GAD.pdf

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Analysis and Treatment of Generalized Anxiety Disorder

MICHEL J. DUGAS and ROBERT LADOUCEUR

Ecole de Psychologie, Universit~ Laval, Canada

Introduction

Generalized Anxiety Disorder (GAD) is among the most frequent anxiety disorders. Using DSM-III-R diagnostic criteria, Breslau & Davis (1985) found a prevalence of 9% in the general population. However, two large-scale Ameri- can studies yielded more modest rates. The National Institute of Mental Health (NIMH) multi-site study obtained a prevalence of 4% for GAD (cited in Barlow, 1988) and the National Comorbidity Survey (NCS) produced similar numbers, showing a 6-month prevalence of 3.1% and a lifetime prevalence of 5.1% (Kessler, McGonagle, Zhao, Nelson, Hughes, Eshleman, Wittchen & Kendler, 1994). The NCS also revealed a higher lifetime prevalence of GAD in women than in men, 6.6% and 3.6%, respectively.

Despite its prevalence, mental health professionals report that they seldom see GAD patients as compared to other anxiety disorder patients (Barlow, Blanchard, Vermilyea & Di Nardo, 1986; Bradwejn, Berner & Shaw, 1992). This apparent contradiction may be explained in two ways. First, individuals with GAD tend not to seek help for their problem. Compared to other anxiety disorders such as Panic Disorder, GAD is associated with less symptomatic distress and social impairment (Noyes, Woodman, Garvey, Cook, Suelzer, Clancy & Anderson, 1992). Therefore, GAD patients tend to wait many years before seeing a mental health professional (Rapee, 1991). Also, 80% of individuals with GAD do not remember their first symptoms and report having

198 MicheI J. Dugas and Robert Ladouceur

been worried and anxious all their life (Barlow, 1988; Rapee, 1991). For this reason, they often interpret their symptoms as unmodifiable personality traits and do not seek professional help. Second, when these individuals seek help, GAD may not be properly recognized. General practitioners are often seen first and they tend to limit their investigation to GAD somatic symptoms such as fatigue and insomnia (Bradwejn, Berner & Shaw, 1992). Further, GAD patients frequently become depressed, socially anxious and demoralized (Butler, Fennel, Robson & Gelder, 1991). If these consequences become sufficiently severe, they may be seen as the main problem and GAD will again remain undetected.

Classification

GAD was officially recognized in the third edition of the Diagnostic and statistical manual of mental disorders of the American Psychological Associa- tion (APA, 1980). It was originally considered a residual diagnostic category, which meant that it could not be diagnosed in the presence of another disorder. In 1987, DSM-III-R made GAD a primary diagnostic category and defined its main feature as unrealistic or excessive worry. The diagnosis also required 6 out of 18 somatic symptoms, which were divided into three categories, motor tension, autonomic hyperactivity, and vigilance and scanning. Although DSM- III-R improved the diagnostic reliability of GAD, it remained relatively weak as compared to other anxiety disorders (Di Nardo, Moras, Barlow, Rapee & Brown, 1993; Williams, Gibbon, First, Spitzer, Davies, Borus, Howes, Kane, Pope, Rounsaville & Wittchen, 1992).

In order to clarify the definition of GAD and improve its diagnostic reliability, DSM-IV (APA, 1994) made many significant changes. The first diagnostic criteria for GAD is now "Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance)." (APA, 1994, p. 435). The worry must be difficult to control and lead to significant distress or impairment in important areas of functioning (e.g., social, occupational, etc.). To improve the diagnostic specificity of the somatic criterion, DSM-IV changed the diagnostic criterion from six out of 18 to three out of six symptoms: (1) restlessness or feeling keyed up or on edge, (2) being easily fatigued, (3) difficulty concentrating or mind going blank, (4) irritability, (5) muscle tension, and (6) sleep disturbance. Although studies of the diagnostic reliability of DSM-IV GAD have yet to appear, our clinical experience suggests that these changes in GAD criteria will lead to greater diagnostic agreement.

Analysis and Treatment of Generalized Anxiety Disorder 199

Comorbidity

Many studies report very high rates of comorbidity for patients with a principal diagnosis of GAD. Sanderson, Di Nardo, Rapee & Barlow (1990b) report that 91% of their GAD patient sample had an additional DSM-III-R diagnosis. In a similar study, de Ruiter, Ruken, Garssen, van Schaik & Kraai- maat (1989) report a comorbidity rate of 67% for GAD. In these studies, the most common additional diagnoses were Social Phobia, Panic Disorder, Dys- thymic Disorder and Specific Phobia. When comparing GAD and Panic Disor- der, Noyes and colleagues (1992) report that Specific Phobia was a more common secondary diagnosis for GAD subjects. In a large-scale study involving 468 anxiety disorder patients, Moras, Di Nardo, Brown & Barlow (1991, cited in Brown & Barlow, 1992) report that GAD and Panic Disorder with Agoraphobia were the principal diagnostic categories that had the highest comorbidity rates.

High rates of comorbidity for GAD as a secondary disorder have also recently been reported. In their extensive study, Moras et al. (1991, cited in Brown & Barlow, 1992) found that GAD was the most common additional diagnosis (23%) at the clinical level (at least moderate severity). In a study of patients with a principal diagnosis of Major Depression or Dysthymia, Sander- son, Beck and Beck (1990a) report that GAD and Social Phobia were the two most common additional diagnoses. Brown and Barlow (1992) suggest that further research on comorbidity is of the utmost importance for diagnostic classification and treatment outcome. Considering the high rate of comorbidity of GAD, these considerations become all the more important.

The Concept of Worry

The Penn State research team originally defined worry as "a chain of thoughts and images, negatively affect-laden and relatively uncontrollable. The worry process represents an attempt to engage in mental problem solving on an issue whose outcome is uncertain but contains the possibility of one or more negative outcomes." (Borkovec, Robinson, Pruzinsky & DePree, 1983a, p. 10). Following a series of empirical studies, Borkovec and colleagues now suggest that worry is primarily a verbal conceptual activity which may be used as a coping strategy (Borkovec & Lyonfields, 1993; Borkovec, Shadick & Hopkins, 1991; Roemer & Borkovec, 1993). In DSM-IV, worry is also referred to as apprehensive expectation which has been described by the Albany research group as "a future-oriented mood state in which one becomes ready or pre- pared to attempt to cope with upcoming negative events. Anxious apprehen- sion is associated with a state of high negative affect and chronic overarousal,


a sense of uncontrollability, and an attentional focus on threat-related stimuli (e.g., high self-focused attention or self-preoccupation and hypervigilance)" (Brown, O'Leary & Barlow, 1993, p. 139). In both these definitions, worry consists of repeated thoughts about future danger which are experienced as aversive and relatively uncontrollable. Borkovec (1985) also suggests that worry is best described by the phrase "What if...". Thus, high worriers are experts at identifying possible problems while being poor at generating effective solutions or coping responses.

Worry Themes

Sanderson & Barlow (1990) investigated worry themes in 22 GAD patients and found that they worried most about their family (79% of subjects), finances (50%), work (43%) and illness (14%). All worries that were subjected to interjudge reliability ratings were placed in one of these four categories. Interestingly, GAD patients reported more worry about minor matters than other clinically anxious groups included in the study (Social Phobia, Panic Disorder, Specific Phobia, and Obsessive-Compulsive Disorder).

Craske, Rapee, Jackel & Barlow (1989) compared the worry themes of 19 GAD patients with those of 26 normal subjects. Their results show that GAD subjects worry more about illness/health/injury and miscellaneous issues while worrying less about finances than normal subjects. Worries about family, home and interpersonal relationships were equally reported by both groups. The authors attempted to classify all worries using the four categories identified by Sanderson & Barlow (1990), but they only managed to place 74.8% of GAD worries and 84.8% of normal worries in the family, finances, work and illness categories. Craske et al. conclude that these four categories are clearly insuffi- cient to account for the diversity of worry themes in individuals with GAD.

Shadick, Roemer, Hopkins & Borkovec (1991) assessed worry themes in 31 GAD patients, in 12 non-clinical university students who met GAD diagnostic criteria ("high worriers") and in 13 non-anxious subjects. For all three groups, the most common worry themes were family, home and interpersonal relationships. However, GAD patients and high worriers reported a higher percentage of worries about miscellaneous problems that could not be placed in one of the four pre-established categories (family, finances, work and illness). The authors conclude that GAD patients and high worriers worry about a greater variety of situations, including minor problems, and that these multiple situations must be investigated to better understand excessive worry.

The studies described above suggest that GAD and normal worry themes are relatively similar. These results have lead some researchers to claim that these groups do not differ substantially on the content of worry (e.g., Brown et al., 1993; Wells, 1994). However, two differences have emerged from the literature.

Analysis and Treatment of General&ed Anxiety Disorder 201

First, GAD patients worry about a greater diversity of situations than non- clinical subjects (Craske et al., 1989; Shadick et al., 1991). Second, they also worry more about minor matters than non-anxious subjects (Shadick et al., 1991) and other clinically anxious patients (Sanderson & Barlow, 1990). Indirect support for this claim was provided by Di Nardo (1991, cited in Brown et al., 1993) who showed that a negative response to the question "Do you worry excessively about minor matters?" can effectively rule out a diagnosis of GAD (negative predictive power of .94). Our research group has also shown that worry about minor matters is sensitive as 86% of subjects meeting GAD cognitive and somatic criteria reported worrying about minor things (Dugas, Freeston & Ladouceur, 1994b).

In more general terms, many authors suggest that worry themes have a social evaluative basis (e.g., Sanderson & Barlow, 1990; Borkovec et al., 1991; Eysenck & van Berkum, 1992). Lovibond & Rapee (1993) showed that feared social outcomes, and not feared physical outcomes, correlate with the Penn State Worry Questionnaire. Likewise, our research team found that public self and body consciousness were better predictors of scores on the Penn State Worry Questionnaire than private self and body consciousness (Letarte, Free- ston, Rh~aume & Ladouceur, 1998). In other words, awareness of oneself as an object of public scrutiny is more closely related to worry than awareness of internal states. Recently, we have shown that social worry, as compared to physical or financial worry, is a stronger predictor of the general tendency to worry (Freeston, Dugas & Ladouceur, 1995). It remains to be established if GAD worry and normal worry differ in the degree to which they are rooted in social evaluation.

Worry and Problem Solving

Many studies point to an important relationship between worry and problem solving. Our research team obtained correlation coefficients ranging from 0.31 to 0.51 between measures of worry and problem solving in a non-clinical population (Dugas, Letarte, Rh~aume, Freeston & Ladouceur, 1995d). Sub- scales describing problem-solving skills explained very little or non-significant amounts of variance of worry scores whereas problem orientation subscales, which describe initial affective, cognitive and behavioral reactions to problem situations, were strong predictors of worry scores. These findings were replicated with a clinical sample as GAD patients and high worriers had poorer problem orientation scores than moderate worriers (Blais, Ladouceur, Dugas & Freeston, 1993). As predicted, all three groups were similar on measures of problem-solving skills. These studies suggest that GAD patients and high worriers do not lack knowledge about how to solve problems but have difficulty applying their knowledge because of counter-productive reactions to


problem situations. For instance, one of our GAD patients worried a great deal that his girlfriend would leave him because of ongoing dissatisfaction with the relationship. During pre-treatment evaluation, he spontaneously described behaviors which he could adopt to improve the relationship. He clearly knew that if he could initiate more social activities, explore and pursue new mutual interests, and generally adopt a more proactive attitude, this would go a long way toward improving the quality of the relationship and increasing his girlfriend's satisfaction. Although the patient and therapist both realized that adopting these behaviors would greatly improve the relationship, the patient could not bring himself to act accordingly because of counter-productive reactions to the problem situation. In fact, he expressed great difficulty in perceiving his relationship problems as challenges to be met. As can be expected, 2 months into therapy, the relationship had not changed and the patient's girlfriend decided to leave him.

In a related line of research, three studies have shown that high worriers are slower on categorization tasks when the stimuli are ambiguous and the correct response unclear (Metzger, Miller, Cohen, Sofka & Borkovec, 1990; Tallis, 1989; Tallis, Eysenck & Mathews, 1991). Tallis and colleagues (1991) suggest that worriers, when attempting to solve problems, are hindered by elevated evidence requirements. Our research group hypothesized that elevated evidence requirements may be a component of a cognitive vulnerability factor in high worriers and GAD patients, namely intolerance of uncertainty. In order to test the relationship between worry and intolerance of uncertainty, we devised the Intolerance of Uncertainty questionnaire which evaluates emotional, cognitive and behavioral reactions to ambiguous situations, implications of being uncertain, and attempts to control future outcomes. We then demonstrated that worry is highly related to intolerance of uncertainty and that the relationship is not simply a consequence of shared variance with negative affect (Freeston, RhSaume, Letarte, Dugas & Ladouceur, 1994c). These findings were replicated with a clinical sample as GAD patients and high worriers were more intolerant of uncertainty than were moderate worriers (Ladouceur, Freeston & Dugas, 1993b). Thus, intolerance of uncertainty seems to be an important cognitive vulnerability factor in GAD patients and high worriers.

Worry as Approach-Avoidance Behavior

Although many recent findings concerning worry are compatible with each other, some are more difficult to reconcile. On the one hand, worry is associated with approach behavior. Subjects report that worrying helps them find a solution or a better way of doing things and increases their feelings of control (Freeston et al., 1994c). Worry also leads to selective attention to threatening information (Macleod & Mathews, 1988) which can occur without the indi-


vidual's knowledge (Mathews, 1990). On the other hand, worry is associated with different types of avoidance. GAD patients claim that worrying helps them avoid improbable negative outcomes (Brown et al., 1993; Roemer & Borkovec, 1993) and non-clinical subjects report that worrying distracts them from thinking about worse things (Freeston et al., 1994c). Worry is also related to avoidance of mental images associated with unpleasant somatic experience (Borkovec & Hu, 1990; Freeston, Dugas & Ladouceur,1994a) and to avoidance of threatening material (Roemer, Borkovec, Posa & Lyonfields, 1991a).

Recently, Krohne (1989, 1993) has proposed a general model of anxiety which may be helpful in integrating these findings and understanding worry. Krohne suggests that individual coping patterns are the result of dispositional preferences for vigilance (as a result of intolerance of uncertainty) and for avoidance (as a consequence of intolerance of emotional arousal). High- anxious individuals would have strong tendencies to approach and to avoid which would lead to fluctuating, anxiety-increasing coping behavior in threatening situations.

In order to test the suitability of Krohne's model specifically for worry, our research team examined the relationship between coping patterns on the one hand, and the tendency to worry and GAD somatic symptoms on the other (Dugas, Freeston, Doucet, Provencher & Ladouceur, 1995b). Subject groups were formed according to four types of behavior patterns: (1) high intolerance of uncertainty and high suppression (HU/HS), (2) high intolerance of uncertainty and low suppression (HU/LS), (3) low intolerance of uncertainty and high suppression (LU/HS), and (4) low intolerance of uncertainty and low suppression (LU/LS). As predicted, the HU/HS group scored higher than all other groups on the Penn State Questionnaire and reported more intense somatic symptoms. Therefore, GAD patients may be intolerant of both uncertainty and emotional arousal. As Krohne (1989, 1993) correctly points out, uncertainty and emotional arousal cannot be attenuated simultaneously as vigilance decreases uncertainty but increases emotional arousal whereas avoidance decreases arousal while increasing uncertainty. GAD patients would switch from one coping mode to the other in a futile attempt to deal with a perceived threat. Thus, worry would seem to be approach-avoidance behavior, resulting from the deployment of both vigilant and avoidant coping modes.

Clinical Conception of GAD Worry

Based on the empirical studies described above and our clinical experience with GAD patients, we have elaborated a specific clinical conception of GAD worry. Let us begin with the perception of threat. Considering that everyday life involves numerous ambiguous situations, individuals who are intolerant of

204 Michel J. Dugas and Robert Ladouceur

uncertainty will perceive more threatening situations due to their vigilant mode of coping (Krohne, 1989, 1993). The perception of threat leads to worry and an increase in levels of anxiety (Macleod & Mathews, 1988) and depression (Dugas, Freeston, Blais & Ladouceur, 1994a). The individual will then be particularly attentive to threatening information (Mathews, 1990), detect subjective risk to a greater degree (Butler & Mathews, 1987), perceive ambiguous material as threatening (Eysenck, Macleod & Mathews, 1987; Eysenck, Mogg, May, Richards & Mathews, 1991; Mathews, Mogg, Kay & Eysenck, 1989) and overestimate the probability of negative outcomes (Mac- leod, Williams & Bekerian, 1991). In turn, this biased treatment of environ- mental information increases levels of worry and anxiety.

Even if worry involves a stream of negative thoughts, loss of mental control and is related to negative affect (Borkovec et al., 1983a; Brown et al., 1993), it may nonetheless be evaluated in positive terms. High worriers (Freeston et al., 1994c) and GAD patients (Ladouceur et al., 1993b) claim that worry helps them avoid negative events, find a better way to do things and increase their feelings of control. Further, GAD patients may view their worry as such an important part of them that they wonder how they will be if they no longer worry (Brown et al., 1993). Worry may thus be partially maintained by both positive and negative reinforcement although the benefits of worrying are often overestimated (e.g., high worriers often report that worrying helps them avoid events which are, in fact, highly unlikely). The following two examples illus- trate how GAD patients may perceive worry as a way of preventing negative outcomes. First, a 24-year-old female student involved in our treatment program reported that she had always worried a great deal about school and had always succeeded in her courses. Not only did she believe that if she worried less she would not succeed, she observed that other students who did not seem to worry very much did not perform as well as she did in school, thus "con- firming" her erroneous belief about the usefulness of worry. In the same perspective, a middle-aged woman being treated at our clinic worried about the health of her grandson during her three week vacation in Europe. Upon her return, she was relieved to find him in good health. Unfortunately, two weeks later, her grandson became ill. The patient interpreted this turn of events as follows: "This proves that my worries really did prevent him from becoming ill because when I stopped worrying, he became sick. I should have continued worrying!"

In addition to being intolerant of uncertainty, if an individual is also intolerant of emotional arousal, he will then be vulnerable to becoming excessively worried (Dugas et al., 1995b). Recall that uncertainty and emotional arousal cannot be attenuated simultaneously (Krohne, 1989, 1993). When the individual attempts to decrease uncertainty by using a vigilant coping style, he increases his emotional arousal. Further, when high worriers attempt to use problem solving to deal with the perceived threat, they have difficulty applying


their problem-solving skills due to poor problem orientation (Blais et al., 1993; Davey, 1994; Dugas et al., 1995d).

On the other hand, attempts at decreasing emotional arousal by an avoidant coping mode will lead to increases in uncertainty. Instances of avoidant coping include the avoidance of mental imagery associated with worry. Worries are primarily made up of verbal-linguistic thought activity (Borkovec & Inz, 1990; Borkovec & Lyonfields, 1993; Freeston et al., 1994a) and often do not concern the individual's worst fears. Avoidance of mental images leads to a decrease in peripheral physiological activity (Borkovec & Hu, 1990; Borkovec, Lyonfields, Wiser & Deihl, 1993) and in emotional processing of the threatening material (Butler, Wells & Dewick, 1992; Foa & Kozak, 1986), all of which negatively reinforces and maintains worry (Borkovec et al., 1991).

GAD patients, who are intolerant of both uncertainty and emotional arousal, thus switch from one coping mode to the other in a futile attempt to deal with the perceived threat. Constant shifting from partial problem solving to avoidance of mental images and vice versa prevents GAD patients from adequately dealing with the threat and contributes to the establishment of a downward spiral in which worry and levels of anxiety and depression are maintained or increased.

Treatment Outcome Studies

Before presenting a detailed description of our assessment and treatment program, a brief review of treatment outcome studies will be carried out. The review will be restricted in three ways. First, treatment outcome studies that were carried out before DSM-III-R or that do not use DSM-III-R criteria to diagnose subjects will not be described (e.g., Barlow, Cohen, Waddell, Vermi- lyea, Klosko, Blanchard & Di Nardo1984; Butler, Cullington, Hibbert, Klimes & Gelder, 1987; Durham & Turvey, 1987; Jannoun, Oppenheimer & Gelder, 1982). Prior to DSM-III-R, GAD was characterized by a number of somatic symptoms that did not adequately discriminate it from other anxiety disorders. Therefore, to include these studies would add very little to our knowledge of treatment outcome for GAD, as described in DSM-III-R and DSM-IV. The only exception to this first restriction will be the stimulus control treatment study by Borkovec, Wilkinson, Folensbee and Lerman (1983b) because of its pio- neering nature as well as its important theoretical and clinical implications for the treatment of excessive worry.

Second, because this chapter specifically concerns GAD worry, outcome studies of treatments that do not directly target GAD worry will not be described (e.g., Barlow, Rapee & Brown, 1992; Borkovec& Costello, 1993; Butler et al., 1991; Sanderson & Beck, 1991; White, Keenan & Brooks, 1992). Although these treatments indirectly target worry via various forms of cogni-


tive restructuring, they will not be discussed because of the non-specific nature of their cognitive interventions. Finally, outcome studies that include pharma- cological treatments (e.g., Lindsay, Gamsu, McLaughlin, Hood & Espie, 1987; Hoehn-Saric, McLeod & Zimmerli, 1988) are not described because they exceed the scope of this chapter.

Borkovec et al. (1983b) were among the first researchers to apply a treatment that specifically targets worry. In two distinct studies, they demonstrated the effect of a stimulus control treatment for university students who reported worrying for more than 50% of the day. After having identified their main worry themes, students were asked to delay worrying until a predetermined 30 min period of the day, always in the same place. In both studies, results showed a larger decrease in time spent worrying for experimental groups than for waiting list control groups. Considering that worries are related to the avoidance of mental imagery (Borkovec & Inz, 1990; Borkovec & Lyonfields, 1993; Freeston et al., 1994a) and somatic activation (Borkovec & Hu, 1990; Borkovec et al., 1993), a stimulus control treatment which resembles cognitive exposure may be an effective treatment component for GAD worry. However, Borkovec and colleagues did not instruct their subjects to specifically expose themselves to mental images, which may prove to be more efficient for the reduction of worry. Further, the generalizability of these results is limited because the researchers used non-clinical subjects and did not assess treatment maintenance.

O'Leary, Brown & Barlow (1992) applied a form of cognitive exposure (worry control) to three GAD patients in a multiple baseline design across subjects. In worry control, subjects are asked to expose themselves to their worries by conjuring up all possible consequences, including the worst poten- tial outcomes. For two out three subjects, the treatment lead to a significant decrease in the tendency to worry, as measured by the Penn State Worry Ques- tionnaire. Upon inquiry, all subjects reported a decrease in time spent worrying and in worry-related distress as well as an increase in their degree of daily pleasantness. The results reported by O'Leary and colleagues are particularly interesting considering that they applied only one treatment component, which suggests that cognitive exposure is indeed an active treatment component. Further, they used specific measures that assess key GAD dimensions such as tendency to worry and distress associated with worry (DSM-IV, APA, 1994). Although these results are encouraging, the comparative efficacy of this treatment awaits further study.

Recently, Brown et al. (1993) described a multidimensional treatment package for GAD. The treatment involves five components: (1) cognitive restructuring, (2) progressive muscular relaxation, (3)cognitive exposure (worry control), (4) response prevention, and (5) dealing with problems. Although many case histories suggest that this treatment package is effective, empirical comparative studies have yet to be carried out. Considering that cognitive


exposure to the worst image related to worry leads to increased somatic activation (Borkovec & Hu, 1990; Borkovec et al., 1993) and to emotional processing of threatening material (Foa & Kozak, 1986), the inclusion of worry control in this treatment package seems to be a judicious choice. However, two aspects of this multidimensional intervention remain questionable. First, considering that worry is associated with poor problem orientation and not with a lack of knowledge about how to solve problems (Blais et al., 1993; Dugas et al., 1995d), why do the authors suggest applying all sub-components of problem-solving training? It may prove more effective (and less time con- suming) to target problem orientation and briefly review problem-solving skills with GAD patients. Second, which worries should be targeted by the different treatment components? Should worry control and problem solving be applied indiscriminately to all worries? If not, how should the therapist decide which worries are amenable to the different treatment components? In order to facilitate treatment application and increase its effectiveness, we believe that these questions must be addressed.

Types of Worries

At Laval University, we have been fascinated by the different types of worries reported by our GAD patients. We believe that GAD worries can be divided into three distinct categories, each requiring a different treatment strategy. Our GAD patients have described worries that concern: (1) immediate problems which are grounded in reality and modifiable, (2) immediate problems which are grounded in reality but non-modifiable, and (3) highly remote events which are not grounded in reality and therefore non-modifiable. Each one of these types of worries will now be depicted. In addition, we will recommend specific treatment strategies for each type of worry which will be further described in the Process of Treatment section.

The first type of worry concerns immediate problems which are grounded in reality and modifiable. Examples include worries about interpersonal con- flicts, dressing properly for specific situations, and daily hassles such as being on time for an appointment, getting the car fixed or making minor house repairs. Recall that GAD patients, when faced with problem situations, report initial cognitive, affective and behavioral reactions (problem orientation) which are ineffective or counter-productive (Blais et al., 1993). Although problem- solving training has been used in the treatment of excessive worry and GAD, it has either been added as a peripheral element to a pre-existing stimulus control treatment (Borkovec et al., 1983b) or included as a minor and unspe- cific component in a general treatment package (Brown et al., 1993). Consid- ering that worry is associated with poor problem solving, we believe problem- solving training (PST) should be a major component in the treatment of GAD.


We further propose that two important considerations guide the use of PST. First, the therapist should adapt PST by focusing on the patient's initial reaction when faced with a problem, taking into account the cognitive, affective and behavioral dimensions of this reaction. Because GAD patients do not report a lack of problem-solving skills (Blais et al., 1993), extensive training in all phases of problem solving is inappropriate and may in fact decrease patient motivation. Second, PST with problem-focused goals should only be applied to worries about immediate problems which are grounded in reality and modifiable.

The second type of worry reported by our GAD patients involves immediate problems which are grounded in reality but non-modifiable. Examples include worries about the illness of a loved one or the state of the world such as pov- erty, war, increasing violence and injustice. Because these problem situations are non-modifiable, PST with problem-focused goals will not lead to desired outcomes. However, as Nezu and D'Zurilla (1989) have pointed out, PST with emotion-focused goals may help patients adapt to a non-modifiable problem situation. Therefore, this type of worry may be dealt with by using PST with emotion-focused goals. The following clinical example illustrates a worry involving an immediate problem which is grounded in reality but non- modifiable. A middle-aged man, who had been working for a well-known and established company over the past 25 years, worried about the direction the company had recently taken. Although he held an important position in the company and did not agree with its new direction, he could not modify the decisions taken at company headquarters. Although the patient's worries about his work originally seemed to concern a modifiable situation, further investigation clearly showed that the situation was in fact beyond his range of influence and thus non-modifiable.

GAD patients also report worrying about highly remote events that are not grounded in reality and consequently non-modifiable. Worries about the possibility of someday going bankrupt or becoming seriously ill (in the absence of immediate financial or health problems) are examples of this type of worry. These worries are not within the reach of PST with either problem-focused or emotion-focused goals because no problem situation actually exists. Recall that the verbal content of worry represents avoidance of fear provoking imagery and that worry is negatively reinforced by a decrease in aversive somatic activation (Borkovec & Lyonfields, 1993; Roemer & Borkovec, 1993). Thus, current accounts of the role of worry as avoidance of fearful images and the existence of a group of worries about problems which do not actually exist (and are not amenable to PST) both point toward the use of functional cognitive exposure to fearful images.

Although the Albany group suggests directing exposure at the fearful imagery component of worry (cf. Brown et al., 1993; Craske, Barlow & O'Leary, 1992; O'Leary, Brown & Barlow, 1992), they seem to apply cognitive exposure


indiscriminately to all worries. In contrast to this view, we believe that exposure to the worst images should only be used with worries concerning highly remote events. Further, Craske and colleagues (1992) recommend using applied relaxation and cognitive restructuring during cognitive exposure while Brown et al. (1993) prescribe the generation of alternatives to the worst image in the final phase of exposure practice. Theoretical accounts of the processes involved in successful exposure (Foa & Kozak, 1986) as well as our own experience using exposure with obsessive ruminators (cf. Ladouceur, Freeston, Gagnon, Thibodeau & Dumont, 1993c; Ladouceur, Freeston, Gagnon, Thibodeau & Dumont, 1994) strongly suggest that exposure to the fearful imagery should be carried out independently of other treatment strategies. Other strategies, whether they be relaxation, cognitive restructuring or the generation alternative scenarios, may be used by the patient in order to neutralize the feared image and thus decrease the beneficial effects of exposure. Now that the different types of worries have been presented, let us turn to a detailed description of our assessment and treatment program.

Assessment

Considering the major changes in GAD diagnostic criteria since DSM-III (APA, 1980), it is not surprising that GAD assessment has also undergone significant change. Originally considered a non-specific disorder often referred to as "free-floating" or "pervasive" anxiety, GAD was assessed with general measures of anxiety. Although these general measures remain important, specific measures of key symptoms should be the mainstay of GAD assessment. We recommend that the complete assessment of treatment outcome for GAD include four levels of measures: (1) structured interviews for the diagnosis and evaluation of treatment outcome, (2) measures of GAD symptoms, (3) measures of key variables associated with GAD, and (4) general measures of anxiety and depression. Considering that GAD assessment has been ne- glected in the past and that poor assessment has contributed to a lack of specificity and effectiveness of treatment interventions, this section will describe in detail each level of measure which is essential to effective treatment planning for GAD.

Structured Interviews

Because of the poor diagnostic reliability of GAD as compared to other anxiety disorders (cf. Di Nardo et al., 1993; Williams et al., 1992), the use of a well established diagnostic structured interview is of the utmost importance. Ideally, the GAD diagnosis should be confirmed by a second independent


diagnostic interview (i.e., a different clinician who administers the same structured interview). In order to properly assess treatment outcome and maintenance, the diagnostic structured interview should also be administered at post- test and at all follow-up assessments. We believe the Anxiety Disorders Inter- view Schedule for DSM-IV (ADIS-IV, Brown, Di Nardo & Barlow, 1994) represents the most practical and informative structured interview presently available for anxiety disorders. Although the ADIS-IV was designed for the anxiety disorders, it also contains items which screen for mood disorders, somatoform disorders, psychoactive substance use disorders, psychotic disorders, and medical problems. The section on GAD includes items which cover DSM-IV diagnostic criteria as well as other items about worry themes, percentage of the day spent worrying, alcohol and drug consumption, physical condi- tion, duration of the disorder, etc. Administration of the ADIS-IV typically takes 1-2 h and yields information on the presence of Axis I disorders with severity ratings.

Measures o f GAD Symptoms

The first measure of GAD symptoms is the Worry and Anxiety Question- naire (WAQ, Dugas, Freeston, Lachance, Provencher & Ladouceur, 1995a). The WAQ contains 16 items and is derived from the Generalized Anxiety Disorder Questionnaire (GADQ, Roemer, Posa & Borkovec, 1991b) which was updated to include all DSM-IV diagnostic criteria for GAD as well as current research questions about worry. GADQ dichotomous items were changed to continuous scale items (rated on a nine-point Likert-type scale) given earlier problems with high and unstable endorsement rates for some items (cf. Freeston et al., 1994a). The WAQ initially asks for a list of up to six worry themes which are then each rated for their excessive and realistic nature. Next, there are eight items about worry and anxiety which include three items from the GADQ (minor worries, percentage of thoughts and images, and percentage of the day spent worrying) and five items for DSM-IV GAD criteria. The WAQ also contains four items which are highly representative of related constructs, namely intolerance of uncertainty, thought suppression, problem orientation and perfectionism. Each one of these items was drawn from existing measures and had the highest corrected item-total correlation. The final item asks about physical health. Although DSM-IV states that worry should not be about another Axis I disorder such as Hypochondriasis, the relationship between worry about health and actual physical illness remains important when assessing GAD.

We also recommend using the Penn State Worry Questionnaire (PSWQ, Meyer, Miller, Metzger & Borkovec, 1990) which consists of 16 items that measure a trait-like tendency to worry. Meyer et al. (1990) have shown that the


PSWQ is unifactorial, has high internal consistency and test-retest reliability, as well as adequate convergent and discriminant validity. Further, scores on the PSWQ distinguish GAD patients from other anxiety disorder patients (Brown, Antony & Barlow, 1992). Because the PSWQ and the WAQ are brief ques- tionnaires which are very informative, we recommend they be administered at regular intervals during treatment in order to assess patient progress. Patients should also complete these measures at pre-test, post-test and at all follow-up evaluations.

Measures of Key Variables Associated with GAD

The first measure of associated variables which should be administered is the Intolerance of Uncertainty scale (IU, Freeston et al., 1994c) which consists of 28 items about uncertainty, emotional and behavioral reactions to ambiguous situations, implications of being uncertain, and attempts to control the future. The sum of these items distinguishes worriers meeting GAD criteria by questionnaire from those who do not and the relationship between measures of worry and the IU are not accounted for by shared variance with negative affect (Freeston et al., 1994c). Factor analyses revealed five factors corresponding to the ideas that uncertainty: (1) is unacceptable and should be avoided, (2) reflects badly on a person, (3) provokes frustration, (4) induces stress, and (5) inhibits action. The internal consistency of the IU is excellent and the scale shows good temporal stability over a five-week period ( r -0 .78) (Dugas, Ladouceur & Freeston, 1995c). Although the IU does not assess GAD symptoms, it does provide valuable information about important cognitive variables. Therefore, we suggest that it be administered before and after treatment, and at follow-up assessments.

The second measure is the Social Problem-Solving Inventory (SPSI, D'Zurilla & Nezu, 1990). The SPSI is a multidimensional self-report measure of social problem solving which consists of 70 items (rated on a five-point Likert-type scale) that are divided into two major scales and seven subscales. The two major scales are the Problem Orientation Scale and the Problem- Solving Skills Scale. The Problem Orientation Scale, which refers to general motivational factors, contains three subscales: Cognition, Emotion, and Be- havior. The Problem-Solving Skills Scale is divided into four subscales: Problem Definition and Formulation, Generation of Alternative Solutions, Decision Making, and Solution Implementation and Verification. The SPSI has sound psychometric properties and is a good multicomponent measure of social problem solving.

As many researchers have pointed out, GAD patients and high worriers believe that worrying has substantial benefits (cf. Brown et al., 1993; Dugas, Ladouceur, Boisvert & Freeston, 1996; Roemer & Borkovec, 1993). The Why


Worry? questionnaire (WW; Freeston et al., 1994c) was developed by our research team in order to assess appraisal of worries. The WW consists of 20 items giving reasons why people say they worry. Based on our clinical experience with GAD patients, a pool of items was developed and empirical criteria were used to select items. Factor analyses identified two types of beliefs: (1) worrying has positive effects such as finding a better way of doing things, increasing control, and finding solutions, and (2) worrying can prevent negative outcomes from happening or provide distraction from fearful images or from thinking about worse things.

Although some WW items deal with avoidance of images or emotional material, the questionnaire was not exclusively designed to assess thought suppression. We recommend using the White Bear Suppression Inventory (WBSI; Wegner & Zanakos, 1992) to complement the WW in assessing thought suppression. The WBSI, which shows good metric properties, measures individual differences in the tendency to suppress unwanted thoughts. Though the WBSI has mainly been used for research purposes, it has proven quite helpful in assessing thought suppression in our GAD patients.

General Measures of Anxiety and Depression

Although general measures of psychopathology are no longer the mainstay of GAD assessment, the Beck Anxiety Inventory (BAI, Beck, Epstein, Brown & Steer, 1988a) and Beck Depression Inventory (BDI, Beck, Rush, Shaw & Emery, 1979) remain valuable because of their proven psychometric qualities and their wide-spread use. The BAI is a 21-item state anxiety scale measuring the intensity of cognitive, affective, and somatic anxious symptoms experienced during the last 7 days. Our research team has confirmed the sound psychometric properties of the BAI on non-clinical, outpatient, and psychiatric samples (Freeston, Ladouceur, Thibodeau, Gagnon & Rh~aume, 1994b).

The BDI consists of 21 items covering the principal depressive symptoms and has been in use for over 25 years. Its psychometric properties have also been extensively studied (cf. Beck, Steer & Garbin, 1988b; Bourque & Beaudette, 1982) and proven to be excellent. Like the WAQ and the PSWQ, these brief inventories should be administered regularly during therapy, at pre- test, post-test and at all follow-up assessments.

Overview of Treatment

The treatment's main objectives are to help the patient recognize his worries as approach-avoidance behavior, discriminate between different types of worries, and apply the correct strategy to each type. Our intervention pro-


gresses over approximately 18 1-h sessions and involves four components: (1) presentation of treatment rationale, (2) behavioral analysis and awareness training, (3) specific worry interventions, and (4) reevaluation of worry appraisal. Although it always involves these four components, the treatment program is tailored to the individual needs of each patient. For instance, for patients who report worrying mostly about problems which are grounded in reality, adapted PST with emphasis on problem orientation would be the principal specific worry intervention. For patients who worry mostly about highly remote events, functional cognitive exposure would be the main specific worry intervention.

Treatment typically lasts 4 months with follow-up sessions over a one-year period. Ideally, the first eight sessions are conducted on a biweekly basis in order to closely monitor the patient's initial progress. Then, eight weekly sessions are followed by two fade-out sessions (usually two to four weeks apart). We also recommend three follow-up sessions over a one-year period, at three, six and 12 months. Although sessions typically last 1 h, those that involve exposure practice may last up to 1.5 h.

Process of Treatment

Presentation of Treatment Rationale

During the first two sessions, the therapist presents the treatment rationale. First, our clinical model of GAD worry is described and all patient questions about the model are dealt with. Right from the first session, the therapist stresses that the patient's perception of uncertainty is an important source of worry and anxiety. Considering that uncertainty is pervasive in everyday life for all individuals, the treatment's goal is not to help the patient attempt to eliminate uncertainty, but rather to recognize, accept and develop coping strategies when faced with uncertain situations. The clinical model, which is an abbreviated version of our model described above (cf. Clinical Conception of GAD Worry), is presented in Figure 7.1.

Although this general model is highly simplified, we believe that it is important initially to present a model which patients can easily grasp and identify with. We have found this model quite adequate for this purpose. The therapist then presents the three following components, namely behavioral analysis and awareness training, specific worry interventions, and reevaluation of worry appraisal. At this point, the different types of worries are introduced and briefly discussed. The therapist also presents the worry interventions and briefly explains why they are used. A highly structured format has proven helpful in presenting the treatment rationale.


1 D. ~ W o r r y ~ ' ~

~~Mood S t a ~

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Figure 7.1. Clinical model of GAD worry.

Behavioral Analysis and Awareness Training

Following the presentation of treatment rationale, the therapist and patient proceed to the behavioral analysis and awareness training of situations related to worries. This treatment component is used to increase patient awareness and allow them to clearly discriminate between the three types of worries. Recall that we have identified worries that concern: (1) immediate problems which are grounded in reality and modifiable (e.g., a current interpersonal conflict with a work colleague), (2) immediate problems which are grounded in reality but non-modifiable (e.g., the illness of a loved one), and (3) highly remote events which are not grounded in reality and therefore non-modifiable (e.g., the possibility of someday going bankrupt). Because most worries relate to situations that may fit into more than one of these categories, a detailed behavioral analysis (cf. Ladouceur, Fontaine & Cottraux, 1993a) of each situation is required. Further, we have developed a series of therapist questions which help patients classify their worries on both critical dimensions.

To help determine if a worry concerns a problem which is grounded in reality, the therapist can investigate the following. (1) Does the patient have any real proof that the worry is about an immediate problem?, (2) Does he have any proof that the problem he is worried about will appear in the near future?, and (3) Does the worry reflect the patient's tendency to worry even when no


real problem exists?. The patient may then be asked if, based on his previous answers, he thinks his worry concerns a problem which is grounded in reality. Because patients are often reluctant to answer this question in dichotomous terms, we recommend it be answered on a continuous scale. We have found that a nine-point Likert-type scale (0 - Not at all; 8 - Completely) is adequate for this purpose.

Next, the therapist and patient determine if the worry concerns a modifiable problem. The following questions may then be helpful : (1) Has the patient ever solved a problem similar to this one? (2) If he reacted better to the problem, could he solve it? and (3) Does he know someone who could solve this problem (because he reacts better or has better skills)? Finally, based on his answers to these questions, does the patient believe that his worry concerns a modifiable problem? Again, we recommend this final question be answered on a continuous scale.

Although this procedure helps patients to be more objective when assessing their worries on both critical dimensions, the choice of treatment strategy applied to the worry must be agreed upon by both patient and therapist. If the therapist does not agree with the patient's assessment, he should discuss this openly with him in order to come to a mutual agreement. In the course of treating GAD patients, we have noticed that they tend to overestimate the extent to which they can modify problem situations. Although this clinical observation was not originally expected, further reflection upon the consequences of intolerance of uncertainty has led us to the following conclusion. Problem situations which cannot be solved by instrumental problem solving (with problem-focused goals) may involve more uncertainty than those which can be modified by direct action. For instance, if other individuals must be counted on to solve a problem, their actions cannot always be predicted in advance, thereby adding to the uncertainty of the desired outcome. Further, when random effects such as natural phenomena are involved in solving a problem, the outcome becomes all the more uncertain. Therefore, problem situations which are non-modifiable by instrumental problem solving involve a greater degree of uncertainty and are more threatening to GAD patients who are intolerant of uncertainty. Their biased assessment of problem situations as being more modifiable than they actually are may be a consequence of their desire to subjectively decrease levels of uncertainty in non-modifiable situations. It is extremely important that therapists help patients reevaluate the extent to which problems that are grounded in reality are modifiable. For instance, patients can be asked to assess the impact of other individuals and random effects on solving a particular problem before evaluating their own impact. Not only is evaluating the extent to which a problem is modifiable the first step in applying the correct treatment strategy, it is therapeutic in itself as patients begin to clearly perceive and possibly accept the uncertainty involved in problem situations.


The behavioral analysis and awareness training component of our treatment typically lasts two to four sessions. All major worries are assessed on both critical dimensions before initiating the worry interventions. Though the following interventions may be applied in any order, we recommend that adapted PST with problem-focused goals (for worries about problems which are grounded in reality and modifiable) or adapted PST with emotion-focused goals (for worries about problems which are grounded in reality and non- modifiable) be employed first to increase patient motivation and compliance. We strongly suggest that worries about highly remote events which are not grounded in reality be dealt with last as functional cognitive exposure can be frightening for some patients and should be applied once they have already dealt with other worries successfully.

One final point should be stressed by therapists before moving on to the specific worry interventions. When a target worry has been agreed upon and a specific intervention has begun to be applied, the intervention should be carried out to its logical conclusion before targeting another worry. Because GAD patients typically worry about many topics, therapists should expect their patients to want to deal with a different worry when the target worry begins to decrease in intensity. Therefore, therapists should "warn" their patients that when an intervention is applied to a particular worry, it will be carried through to its conclusion even if other worries may eventually seem more important than the one originally agreed upon.

Specific Worry Interventions

Adapted problem-solving training. Adapted problem-solving training (PST) is applied to worries about problems which are grounded in reality. As described above, adapted PST with problem-focused goals is used for modifiable problems whereas adapted PST with emotion-focused goals is applied to non- modifiable problems. Although each type of adapted PST involves a different set of problem-solving goals, both types involve the same problem-solving process. Therefore in both cases, the treatment strategy involves two major components:

Problem orientation. The patient's problem orientation includes his cognitive, affective, and behavioral reactions to problems. Poor problem orientation is highly related to excessive worry and on a more specific level, perception of lack of personal control, which is a constituent of problem orientation, is associated with excessive worry. Because problem-orientation deficits seriously hinder the application of problem-solving skills, it is clearly the focal point of adapted PST. The therapist must stress the importance of recognizing counter- productive reactions to problems and correcting them by using cognitive reevaluation techniques (cf. Beck & Emery, 1985) and behavioral homework


assignments (e.g., daily record keeping of reactions to problems). The patient should be made aware that his counter-productive reactions to problem situations are often expressions of intolerance of uncertainty (Dugas, Ladouceur & Freeston, 1995c). For example, when faced with an ambiguous situation, he may tend to interpret it as threatening (Butler & Mathews, 1983).

Problem-solving skills. This component includes all problem-solving behaviors and involves the following four steps: (1) defining the problem, (2) generating alternative solutions, (3) making a decision, and (4) applying and assessing the solution. Because poor problem orientation affects all problem-solving phases (Nezu & D'Zurilla, 1989), the behavioral steps are reviewed with emphasis on the patient's reaction to the problem situation. For instance, perceiving a problem as a threat rather than a challenge may impede the patient's attempts at defining it in an operational way, discourage him from generating possible solutions, prevent him from making a decision, and keep him from applying a solution.

The therapist should briefly present the key elements of each behavioral step. The first step, defining the problem, includes the description of problems and personal goals with objectivity, specificity, and clarity. Problem definition must provide information that will maximize performance in the following stages of problem solving but exclude information that is related to intolerance of uncertainty or arousal. Next, the generation of alternative solutions involves the following brainstorming rules: criticism is ruled out, "free-wheeling" is welcomed, quantity is wanted, and combination and improvement are sought. Expressions of intolerance of uncertainty or arousal must not restrict the generation of alternative solutions. The third behavioral step, decision making, consists of realistically rating likely consequences of each generated solution in order to determine the best strategy for the particular situation. The final decision must not simply reflect the patient's desire to avoid emotional arousal or situations related to uncertainty. Finally, applying and assessing the solution involves verifying to what extent the outcome prediction was accurate. As- sessment primarily involves observing and recording consequences of actions. If the outcome is unsatisfactory, the patient begins again and attempts to find a better solution. If the outcome is satisfactory, the problem-solving process is terminated. The assessment of the solution must be made against criteria defining optimal outcome and not against criteria reflecting a decrease in uncertainty or emotional arousal.

Functional Cognitive Exposure. Functional cognitive exposure is used for worries concerning highly remote events which are not grounded in reality and therefore non-modifiable. For the purposes of this chapter, we will discuss the exposure component which is specific to our treatment program for GAD worry, namely the downward arrow technique, and briefly review the notion of covert response prevention.


The first step in cognitive exposure for GAD worry is identifying the worst image related to the worry by using the downward arrow or catastrophizing technique (cf. Beck & Emery, 1985; Burns, 1980; Vasey & Borkovec, 1992). Considering that worry serves to avoid threatening images, the identification of the worst image is a crucial step in worry exposure. Essentially, catastrophizing is accomplished by asking the patient a series of questions analogous to "If ...... were true, what would that lead to?" or "What would that mean to you?". The process is repeated until the patient is unable to generate another response or repeats the same response three consecutive times. Once the final image for each relevant worry has been described, the therapist helps the patient arrange them in hierarchical order, from the least threatening to the most threatening image. Because functional exposure is often difficult to achieve initially, we recommend starting with the least threatening image until the patient masters the exposure technique.

Once the first target has been identified, the therapist helps the patient develop the image until there is sufficient detail. Next, the threatening image is described by the patient and recorded on a looped tape for repeated exposure with a Walkman tape recorder. The patient is then exposed to the anxiety provoking image with covert response prevention. As we have described in detail elsewhere (Ladouceur et al., 1994), covert response prevention involves the identification and proscription of all effortful or voluntary activity used by the patient to control the image, including normal coping strategies. Because subjects expose themselves to mental images which provoke anxiety, cognitive exposure primarily addresses cognitive and emotional avoidance.

Reevaluation of Worry Appraisal

Because GAD patients tend to overestimate the advantages and underesti- mate the disadvantages of worrying (Brown et al., 1993; Ladouceur et al., 1993b; Roemer & Borkovec, 1993), their appraisal of the usefulness of worrying is examined and reevaluated for all types of worries. Although this suggestion is not a new one, specific therapy guidelines for identifying and correcting inappropriate appraisal of worries have yet to be outlined. First, therapists should carefully examine their patients' responses to items on the Why Worry? questionnaire to identify beliefs which may contribute to specific worries. GAD patients may believe that worrying can (1) prevent negative outcomes, (2) decrease guilt, (3)avoid disappointment, (4)distract them from thinking about worse things, (5) help them find a solution or a better way of doing things, and (6) help them increase control over their lives (cf. Ladouceur et al., 1993b). Beliefs such as these may be negatively reinforced, for instance by the non-occurrence of a feared event. Therefore, the appraisal of worry as a useful cognitive activity may make a significant contribution to maintaining


worry. Clinicians should begin with items which are scored highest on the Why Worry? questionnaire. Next, they should help patients determine which one of the beliefs identified on the questionnaire apply to each specific worry. Thera- pists may also wish to ask patients about other beliefs about the usefulness of each worry.

Once beliefs about the usefulness of each specific worry are identified, reevaluation of beliefs may begin. Cognitive techniques should then be used to correct faulty beliefs about the advantages and disadvantages of each specific worry. Socratic questioning and behavioral hypothesis testing are particularly useful in helping GAD patients reevaluate the usefulness of worrying. Because a different set of faulty beliefs may contribute to each worry, therapists should help patients examine and correct worry appraisal independently for each worry. Since beliefs about the usefulness of each worry may overlap to some extent, generalization of more appropriate worry appraisal is not uncommon. However, it remains important to examine beliefs about the usefulness of each specific worry as various combinations of beliefs may require different cognitive interventions.

For instance, one of our GAD patients reported that his two most uncontrollable and distressing worries were the following: (1) becoming seriously ill (e.g., stroke, cancer, etc.), and (2) a family member becoming seriously ill (e.g., multiple sclerosis, cancer, etc.). He believed his worries about his own health were useful because they would help him detect the first signs of illness. If he were to worry less about his health, he may miss the first symptoms of a serious disease and by then it would be too late to treat the illness. In order to effectively treat these worries, the therapist used various cognitive techniques to help the patient reevaluate the usefulness of being constantly worried about his health as way of preventing illness. As for the patient's concerns that a family member may become seriously ill, these were also appraised as very useful but not for the same reasons. He believed that if a family member were to become ill, he would feel extremely guilty if he had not worried about this turn of events ahead of time. Hence, the patient believed these worries would help him decrease future feelings of guilt and shame. He also claimed that not worrying about this eventuality meant that he did not care enough about his family members. Therefore, although the patient's two main specific worries were both related to illness, his beliefs about the usefulness of each worry were quite different. As opposed to worrying about his own health, the patient did not believe that worrying about the health of family members would prevent them from becoming seriously ill by early detection of symptoms. He did believe however that worrying about their health proved that he cared for his family and would also help him decrease eventual feelings of guilt.

In conclusion, reevaluating the advantages and disadvantages of each specific worry is an important treatment component. Although the reevaluation of the beliefs contributing to one worry may generalize in some cases to other


worries, therapists should not take this for granted and should examine specific beliefs related to each worry in order to maximize treatment effectiveness. As common sense dictates, if GAD patients believe that a specific worry is useful, they will be more reluctant to let it go.

T r e a t m e n t Eff icacy

Treatment packages for GAD have generally produced variable and limited gains (Dugas et al., 1996). Patients do improve, but worry often remains excessive and somatic symptoms are not entirely eliminated. We believe that treatment packages that directly target GAD worry may offer important advantages. Further, recent theoretical and clinical developments point to two central treatment strategies. First, adapted problem-solving training seems essential to address the approach component of worry, resulting from intolerance of uncertainty. Second, functional cognitive exposure would allow clinicians to decrease intolerance of emotional arousal by targeting the avoidance component of worry. Initial evaluation of our treatment package is presently underway and results will be available shortly.

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Further Reading

Barlow, D. H. (1988). Anxiety and its disorders: The nature and treatment of anxiety and panic. New York: Guilford Press.

Borkovec, T. D., Shadick, R. N., & Hopkins, M. (1991). The nature of normal and pathological worry. In R. M. Rapee & D. H. Barlow (Eds.), Chronic anxiety: Generalized anxiety disorder and mixed anxiety-depression. New York: Guilford Press.

Brown, T. A., O'Leary, T. A., & Barlow, D. H. (1993). Generalized anxiety disorder. In D. H. Barlow (Ed.), Clinical handbook of psychological disorders, 2nd edition. New York: Guilford Press.

Craske, M. G., Barlow, D. H., & O'Leary, T. (1992). Mastery of your anxiety and worry. Albany, NY: Graywind Publications.

Rapee, R. M. (1995). Trastorno por ansiedad generalizada. In V. E. Caballo, G. Buela-Casal & J. A. Carrob|es (Eds.), Manual de psicopatologia y trastornos psiqui~tricos, Vol. 1. Madrid: Siglo XXI.

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