Generalized Anxiety Disorder 421
••Tendency to engage in catastrophizing
••Estimates of the probability of threat or catastrophe
••Perceived uncontrollability of worry
••Extent of metaworry (i.e., worry about worry)
••Expected negative consequences of worry
••Expected positive aspects of worryThe client will have already articulated the catastrophic outcome when the primary
worry concerns were assessed. A student with GAD, for example, might frequently
worry about his performance on a test. The therapist would ask, “When you worry
about an exam, how often do you end up convinced you will fail the course and be
put on academic probation” (i.e., the student’s catastrophic outcome)? “Are there other
negative outcomes that you think about more often when you worry about exams?”
“On a scale from 0% (no probability of being put on academic probation) to 100%
(complete probability of being put on academic probation), what is the likelihood of this
catastrophe?” “What is the likelihood of less extreme outcomes such as not passing the
exam or failing the course?” “As you look at this now, do you think you are exaggerat-
ing the likelihood of a bad outcome?” “What do you think is the most likely outcome?”
“How difficult is it to think about the most likely outcome when you are worrying about
exams?”
The cognitive therapist also obtains ratings on the perceived controllability associ-
ated with each primary worry concern. In the previous example the therapist would ask
“how difficult is it for you to stop worrying about the exam once you start the worry
process?” “On a scale from 0 (absolutely no control) to 100 (complete control), what is
the average amount of control you have over worry about exams? “Does this control
vary at all?” “Are there times when you have good control over the worry and other
times when your control is terrible?” “Have you noticed what seems to encourage worry
control and things that interfere in your level of control?”
It is important to determine the extent that metaworry is associated with each of the
primary worry concerns (Wells, 1999, 2006). For example, Rebecca indicated she had
difficulty falling asleep each night because of “racing thoughts” (i.e., worry) about how
she responded to employee problems that day and also what might lie ahead of her tomor-
row. However, she quickly shifted from these “primary worries” to worry about the con-
sequences of not being able to shut down her racing thoughts and fall asleep. A rating from
0 (“no worry about worry”) to 100 (“extremely concerned about being worried”) was
obtained each time Rebecca worried about her managerial performance with employees.
What was interesting is that metaworry was sometimes very strong in certain situations
(e.g., when tr ying to fall asleep at night) but less prominent in others (e.g., worr ying about
how she will handle an employee situation just before the interview). Thus in the case for-
mulation it is important to specify the extent of metaworry associated with each primary
worry content, the situations when metaworry is strong and when it is weaker.
The perceived positive and negative consequences of worry are a related aspect of
metaworry. Again it is important to determine perceived consequences associated with
each worry concern when the individual is engaged in the worry process. It is expected
that the perceived consequences are highly idiosyncratic and will vary greatly between
worry concerns. Rebecca, for example, perceived mainly negative consequences with
her work worries, noting that the worry probably made her less confident and assertive