420 TREATMENT OF SPECIFIC ANXIETY DISORDERS
goal in key areas of her life such as work/school, family, health, intimate relationships,
finances, leisure, friendships, and the like. For example, in the area of intimacy the
therapist could ask “Where would you like to be in 3 years with regards to an intimate
relationship?”, “What do you see as the greatest barrier to achieving this goal in inti-
macy?”, “How likely is it that you will make this goal?”, and “What would be the worst
possible outcome for you in 3 years?” This type of questioning will provide the therapist
with a better understanding of the motivational features of worry.
One of Rebecca’s primary concerns was to maintain a reputation with her employ-
ees as a fair, competent, and understanding manager. The problem for her was that
any criticism was viewed as a threat to this goal and would trigger a heightened state
of anxiety in which she worried that others viewed her as a weak and incompetent
leader. It is easy to see how Rebecca’s desire to be admired by others (i.e., a major cur-
rent concern) fed into a vicious cycle of worry about how her employees perceived her
managerial style.
Worry Triggers
The Worry Self- Monitoring Form B (Appendix 10.1) will provide an indication of the
type of stimuli that trigger worry episodes. Again this information is critical for com-
pleting a contextual analysis of worry episodes. A variety of external factors may trigger
worry such as when Rebecca received even a slightly negative remark from an employee.
Another client had pathological worry about his finances and was plunged into one of
these episodes whenever there was even a slight decline in his monthly investment state-
ment (a much too common occurrence, as any investor knows!). Martin, an older client
with GAD, would start worrying about mowing his lawn whenever he looked out the
front window of his house. Most clients can generate a list of external cues that trigger
their worry. Sometimes the list of triggers is broad and other times it is very narrowly
focused.
Internal cues such as automatic anxious intrusive thoughts, images, or even physi-
cal sensations are important triggers of a worry episode. Martin would have an intru-
sive thought that tomorrow was garbage day and then he would start worrying about
whether he will have enough energy to move his trash to the curb. Sarah would feel a
slight nausea that she interpreted as a possible sign of the flu, and then worried that
she might be getting sick. Rebecca would remember that she hadn’t visited her parents,
wonder if they were still well, and then start worrying that they might get terribly ill or
soon die before she could spend more time with them. Clients may not be aware of all
the internal or external triggers to their worry but within the first few sessions the main
worry triggers should be identified.
Metacognitive Appraisals of Worry
How individuals appraise or evaluate their worries is another key component of the case
conceptualization. This part of the assessment focuses on how clients evaluate the worry
process associated with each of their primary worry concerns. Here we are emphasiz-
ing individuals’ “online” appraisals of worry episodes rather than the core beliefs about
worry that may underlie the faulty appraisals of worry. The following metacognitive
appraisals should be specified in the case formulation: