Generalized Anxiety Disorder 441
and metacognition; (3) automatic attentional and interpretation biases for threat when
processing ambiguous stimuli; (4) negative appraisals of worry control and possible reli-
ance on maladaptive mental control strategies; and (5) negative problem orientation and
lack of confidence in problem- solving ability. However, less empirical evidence is avail-
able on the role of metaworry and positive worry beliefs, the ability of chronic worriers
to actually suppress the worry process in the short term, whether individuals with GAD
are overly reliant on ineffective thought control strategies, and whether GAD involves
a failed search for a sense of safety. Overall there is a moderate level of empirical sup-
port for the proposed cognitive model of GAD but numerous gaps remain for further
investigation.
Table 10.5 presents a multicomponent cognitive therapy treatment protocol for
GAD that focuses on shifting from reliance on a pathological avoidant coping strategy
(i.e., worry) to a more controlled, problem- oriented constructive preparatory coping
response to an uncertain future. Cognitive therapy uses cognitive restructuring and
behavioral experiments to counter the GAD patient’s propensity to exaggerate future
threat as well as worry induction and exposure exercises to “decatastrophize” the worry
process. A review of the clinical outcome research indicates that 50–60% of cognitive
therapy/CBT treatment completers will achieve clinically significant recovery at post-
treatment.
Despite the tremendous gains that have been made in our understanding and treat-
ment of GAD, many issues remain unresolved. One of the most fundamental questions
concerns whether GAD is truly an anxiety disorder or should be conceptualized more
broadly as a distress disorder along with depression. Although we understand much
more about the processes that maintain worry, many questions still remain about the
propensity to worry despite its futility and anxiety- inducing qualities. For the cognitive
model, a number of issues require further investigation such as (1) the role of unwanted
intrusive thoughts, (2) whether the information- processing bias is specific to threat or
more broadly related to emotional cues, (3) the role of metaworry and positive meta-
cognitive beliefs in pathological worry, and (4) the nature of worry suppression and
its effects in GAD. In terms of cognitive therapy little is known about the therapeutic
ingredients that are most effective or why cognitive therapy is not more efficacious than
behavior therapy or pharmacotherapy, given the cognitive nature of the disorder. Con-
sistent with other anxiety disorders, the long-term effectiveness of cognitive therapy/
CBT for GAD still remains largely unknown.