Generalized Anxiety Disorder 389
might perceive her as incompetent or that she would fail and this would reveal
her vulnerability to all.
Rebecca experienced anxiety and worried daily, especially at work when
the demands were greatest. During stressful work periods she experienced chest
tightness, tense muscles, and heart palpitations. Various anxious thoughts
automatically intruded into her mind at such times like “This job is too stress-
ful for me,” “I’m not ‘cut out’ to be a store manager,” “My incompetence will
become obvious to everyone,” and “I don’t have what it takes to do this job.”
She felt tense and on edge much of the work day, but unfortunately the anxious
symptoms followed her home because she would sit and rehearse all the day’s
work activities in order to evaluate her performance (e.g., “Did I make the right
decision?”, “Did I handle that situation well or not?”). She would also think
about her agenda for the next day and worried whether she was about to expe-
rience an unexpected calamity. Rebecca’s sleep was very disrupted by anxiety
and worry. She averaged about 5 hours per night, having great difficulty with
sleep onset due to “racing thoughts.” She found it difficult to relax, and there
were signs of some decline in her physical health as indicated by high blood
pressure and an irritable bowel syndrome. She also experienced periods of deep
dysphoria that met diagnostic criteria for a major depressive episode on at least
two occasions, although both episodes went undetected. Rebecca did not abuse
alcohol nor was she prescribed anxiolytic medication. However, her anxiety
and worry led to procrastination, avoidance, and frequent reassurance seeking
from others about her performance.This chapter presents a modified cognitive model and treatment of generalized anx-
iety disorder (GAD) that is based on an earlier cognitive formulation for chronic anxiety
disorder (Beck et al., 1985). We begin by considering key diagnostic issues and phenom-
enology of GAD, followed by a presentation of the cognitive model and its empirical
status. Cognitive assessment and case conceptualization for GAD is discussed, as well
as a disorder- specific treatment approach based on the cognitive model. The chapter
concludes with a consideration of treatment efficacy and directions for future research.
DiagnostiC ConsiDerationsDSM-IV Diagnosis
In DSM-IV-TR (American Psychiatric Association [APA], 2000) GAD is considered an
anxiety disorder characterized by excessive anxiety and worry that persists for at least
6 months and concerns a number of events or activities. GAD was first recognized as
a separate disorder in DSM-III, and since then a number of diagnostic changes were
made to improve its reliability and to shift from a focus on “free- floating anxiety”
to worry as the central defining feature of the disorder (Mennin, Heimberg, & Turk,
2004). The current DSM-IV-TR conceptualizes GAD as chronic, excessive, and perva-
sive worry (i.e., occurs more days than not about a number of events or activities for at
least 6 months) that is difficult to control. The worry is associated with three or more
symptoms of anxiety and some of these symptoms have to occur more days than not
for at least 6 months. Moreover, the anxiety and worry must cause clinically significant
distress or impairment and it can not be restricted to concerns that characterize another
Axis I disorder. Table 10.1 presents the DSM-IV-TR criteria for GAD.