Generalized Anxiety Disorder 423
sense of safety could be achieved with the worry concern. In other words, what would
have to happen for worry to cease? Louise was a single woman in her mid-30s who was
highly successful in her career and had recently become romantically involved with a
man she met over the Internet. However, she was racked with worry over whether he
really liked her and whether he would drop her at any moment. Her catastrophic think-
ing was “This is my last chance at happiness. If this relationship doesn’t work, I’ll be
left alone the rest of my life.” When asked what needed to happen for her to feel safe
or confident about the relationship, Louise answered that she needed some sign of his
undying commitment to her. But the more she thought about this, the more she real-
ized there was nothing he could do to eradicate her uncertainty about the relationship.
It is the nature of intimate relationships that a spouse or partner can always leave. It is
important for the clinician to determine what constitutes safety for each of the primary
worry concerns, what cues would signal the attainment of safety, and whether individu-
als can recall a time when a sense of peace or safety was attained in this area of their
life. It may be that, like Louise, a client will discover that the search for safety is futile,
maybe even impossible to achieve.
Worry always involves efforts toward problem solving, often with the goal of achiev-
ing a sense of safety and certainty of outcome. It is important to determine the range
of problem solutions that the client generated around a particular worry topic. “What
solutions have you come up with for this particular problem (i.e., the worry concern)?”
“Are you able to generate any good solutions for this problem?” “On a scale from 0 (no
confidence) to 100 (extremely confident), how confident are you that a good solution
will be found for this problem?” “How frustrated do you feel with your problem- solving
efforts?”, “Do you expect to eventually resolve this problem or will it continue unre-
solved indefinitely?”
Pierre was a retired government worker who worried excessively about his retire-
ment income and whether he had enough saved to see him through to old age. He
decided that the best solution to his anxiety and worry was to start a small part-time
business to supplement his retirement income. Unfortunately, this did little to relieve
his anxiety because he now worried about the uncertainties of business and whether
he could sustain a steady income over many years. When he eventually decided to seek
treatment, he was discouraged and convinced there was no solution to his worry. He
had done the most logical thing, which was to earn more money, and yet this only inten-
sified his worry about finances. He adopted a most extreme negative problem orienta-
tion, believing there was no solution to his chronic financial worries.
Dysfunctional GAD Schemas
A cognitive assessment should culminate with an identification of the core maladaptive
schemas of threat, personal vulnerability, intolerance of uncertainty, and metacognitive
beliefs about worry that are responsible for the individual’s chronic worry. Table 10.2
provides a summary of the types of beliefs that will be prominent in GAD. Different
beliefs may be associated with different primary worry concerns, so it is important in
the case formulation to identify the core maladaptive beliefs that underlie each worry
concern.
Rebecca’s primary worry involved her managerial skills when relating to her employ-
ees. Cognitive assessment revealed that a core threat belief was that “her employees
thought she was a weak, passive leader—a real pushover.” She believed this was part of