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Library of Congress Cataloging‐in‐Publication Data
Names: Gerlach, Alexander L., 1966– editor. | Gloster, Andrew T., editor.
Title: Generalized anxiety disorder & worrying : a comprehensive handbook for clinicians and researchers / edited by Alexander Gerlach and Andrew T. Gloster.
Other titles: Generalized anxiety disorder and worrying
Description: First edition. | Hoboken, NJ : Wiley-Blackwell 2020. | Includes index.
Identifiers: LCCN 2020000437 (print) | LCCN 2020000438 (ebook) | ISBN 9781119189862 (hardback) | ISBN 9781119189886 (adobe pdf) | ISBN 9781119189893 (epub)
Set in 10/12pt Galliard by SPi Global, Pondicherry, India
Printed and bound by CPI Group (UK) Ltd, Croydon, CR0 4YY
10 9 8 7 6 5 4 3 2 1
To the memory of and moments shared with my father. Andrew T. Gloster
1 Worry, Generalized Anxiety Disorder (GAD), and their Importance 1
Alexander L. Gerlach and Andrew T. Gloster
2 Assessing Worry: An Overview 9
Marcia T. B. Rinner and Andrew T. Gloster
3 Perceptions of Threat 25
Keith Bredemeier and Howard Berenbaum
4 Transdiagnostic View on Worrying and Other Negative Mental Content
Thomas Ehring and Evelyn Behar
5 Worry and Other Mental Health Problems
Markus Jansson‐Fröjmark, Elena Bilevicius, Renée El‐Gabalawy, and Gordon J. G. Asmundson
6 Learning Science and Generalized Anxiety Disorder (GAD) 99
Ian Stewart, Stephan Stevens, Bryan Roche, and Simon Dymond
7 Cognitive‐Behavioral Models of Generalized Anxiety Disorder (GAD): Toward a Synthesis 117
Naomi Koerner, Peter McEvoy, and Kathleen Tallon
8 Structural and Functional Neuroanatomy of Generalized Anxiety Disorder 151
Anne Schienle and Albert Wabnegger
9 Cultural Perspectives in Understanding, Treating, and Studying: Worry and Generalized Anxiety Disorder (GAD) 173 Dong Xie
10 Cognitive‐Behavioral Therapy (CBT) for Generalized Anxiety Disorder (GAD) 203
Michelle G. Newman, Nur Hani Zainal, and Juergen Hoyer
11 Interpersonal and Emotion‐Focused Therapy (I/EP) for Generalized Anxiety Disorder (GAD)
Michelle G. Newman and Nur Hani Zainal
Acceptance‐Based Behavioral Therapies for Generalized Anxiety Disorder (GAD)
Lizabeth Roemer and Susan M. Orsillo
13 Short‐Term Psychodynamic Therapy of Generalized Anxiety Disorder (GAD)
Falk Leichsenring, Christiane Steinert, and Simone Salzer
David S. Baldwin
Eni Becker and Gerhard Andersson 16 Generalized Anxiety Disorder (GAD) in Children and Adolescents
Tina In‐Albon, Tove Wahlund, and Sean Perrin
17 The Road Ahead: What Research Paths Should Be Taken in Order to Improve Future Treatments?
Andrew T. Gloster and Alexander L. Gerlach
List of Contributors
Gerhard Andersson Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden
Gordon J. G. Asmundson Department of Psychology, University of Regina, Regina, Saskatchewan, Canada
David S. Baldwin Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
University Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
Southern Health NHS Foundation Trust, Southampton, UK
Eni Becker Clinical Psychology, Radboud University of Nijmegen, Nijmegen, the Netherlands
Evelyn Behar Department of Psychology, Hunter College, City University of New York, New York, NY, USA
Howard Berenbaum Department of Psychology, University of Illinois at Urbana‐Champaign, Champaign, IL, USA
Elena Bilevicius Department of Psychology and Pathophysiology, University of Manitoba, Winnipeg, Manitoba, Canada
Department of Anesthesia & Perioperative Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
Keith Bredemeier Center for the Treatment and Study of Anxiety, Philadelphia, PA, USA
Simon Dymond Department of Psychology, Swansea University, Swansea, UK Reykjavík University, Reykjavik, Iceland
Thomas Ehring Clinical Psychology and Psychotherapy, Department of Psychology, University of Munich, Munich, Germany
List of Contributors x
Renée El‐Gabalawy Department of Psychology and Pathophysiology, Department of Anesthesia & Perioperative Medicine, and Department of Clinical Health Psychology, University of Manitoba, Winnipeg, Manitoba, Canada
Alexander L. Gerlach Department of Psychology, Clinical Psychology and Psychotherapy, University of Cologne, Cologne, Germany
Andrew T. Gloster Department of Psychology, Division of Clinical Psychology and Intervention Science, University of Basel, Basel, Switzerland
Juergen Hoyer Department of Psychology, Clinical Psychology and Psychotherapy, Institute Outpatient Clinic and Day Clinic for Psychotherapy, Technical University of Dresden, Dresden, Germany
Tina In‐Albon Clinical Psychology and Psychotherapy of Childhood and Adolescence, Department of Psychology, University Koblenz‐Landau, Landau, Germany
Markus Jansson‐Fröjmark Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
Naomi Koerner Department of Psychology, Ryerson University, Toronto, Ontario, Canada
Falk Leichsenring Department of Psychosomatics and Psychotherapy, Justus‐Liebig‐University Giessen, Giessen, Germany
Peter McEvoy School of Psychology, Curtin University, Perth, Western Australia, Australia
Centre for Clinical Interventions, Perth, Western Australia, Australia
Michelle G. Newman Department of Psychology, The Pennsylvania State University, University Park, PA, USA
Susan M. Orsillo Department of Psychology, Suffolk University, Boston, MA, USA
Sean Perrin Clinical Psychology, Department of Psychology, Lund University, Lund, Sweden
Marcia T. B. Rinner Department of Psychology, Division of Clinical Psychology and Intervention Science, University of Basel, Basel, Switzerland
Bryan Roche Department of Psychology, Maynooth University, Maynooth, Ireland
Lizabeth Roemer Department of Psychology, University of Massachusetts Boston, Boston, MA, USA
Simone Salzer Clinic of Psychosomatic Medicine and Psychotherapy, Georg‐August‐University, Göttingen, Germany and International Psychoanalytic University (IPU) Berlin, Germany
Anne Schienle Institute of Psychology, University of Graz, Graz, Austria
Christiane Steinert Department of Psychosomatics and Psychotherapy, Justus‐Liebig‐University Giessen, Giessen, Germany
Stephan Stevens Department of Psychology, Clinical Psychology and Psychotherapy, University of Cologne, Cologne, Germany
Ian Stewart School of Psychology, National University of Ireland, Galway, Ireland
Kathleen Tallon Department of Psychology, Ryerson University, Toronto, Ontario, Canada
Albert Wabnegger Institute of Psychology, University of Graz, Graz, Austria
Tove Wahlund Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
Stockholm Health Care Services, Region Stockholm, Sweden
Dong Xie Department of Psychology and Counseling, University of Central Arkansas, Conway, AR, USA
Nur Hani Zainal Department of Psychology, The Pennsylvania State University, University Park, PA, USA
Worry, Generalized Anxiety Disorder (GAD), and their Importance
Alexander L. Gerlach1 and Andrew T. Gloster2
1 Department of Psychology, Clinical Psychology and Psychotherapy, University of Cologne, Cologne, Germany
2 Department of Psychology, Division of Clinical Psychology and Intervention Science, University of Basel, Basel, Switzerland
What is Worry—What is GAD?
Everyone worries. Some people worry occasionally or transitorily, while others worry frequently or uncontrollably. The ubiquity of worry makes its study far‐reaching, important, and exciting. Worry—like most concepts in mental health nomenclature— is not a technical term, however, but rather stems from everyday language’s attempt to describe inner‐psychic experiences. This, in turn, makes the study of worry difficult and sometimes messy. For example, if you simply ask a person to worry, will this instruction result in the same type of worry that occurs naturally? Worrying at night, when trying to fall asleep, is probably one of the most common situations in which people worry. However, why do we worry some nights and not others? Is it really simply a question of triggers being responsible for a worry episode starting? Interestingly, in some treatments, asking individuals to worry is used therapeutically. This often results in the new experience that when one actively worries, it is actually less anxiety provoking and much less associated with a feeling of losing control than when worrying occurs spontaneously (compare Gerlach & Stevens, 2014). However, to date, it remains unknown why there are such striking differences in the experience of worry, dependent on circumstances. Nonetheless, this approach (instructing somebody to worry) is one of the most common forms of worry induction used to study, for example, the acute physiological effects of worrying (e.g., Andor, Gerlach, & Rist, 2008; Borkovec & Inz, 1990; Stefanopoulou, Hirsch, Hayes, Adlam, & Coker, 2014). Other examples of worry induction are the use of materials such as film clips about worrisome topics. The use of such materials as triggers, however, does not
necessarily result in increased worrying, even in individuals diagnosed with GAD (e.g., Upatel & Gerlach, 2008). Some authors have attempted to induce worrying by employing the catastrophizing interview technique (e.g., Davey & Levy, 1998; O’Leary & Fisak, 2015). Arguably, all these attempts to induce worry are qualitatively different from the actual experience of worry that occurs spontaneously. Therefore, research looking at worry in its natural environment (e.g., ecological momentary assessment) is of special importance. Definitions of worry usually concentrate on future‐oriented anxiety or apprehension about possible negative events and, in some cases, the reaction of the afflicted individual to this experience (Craske, 2003, chapter 2; Gerlach & Stevens, 2014). Research on worry aims to specify its nature and impact on mental health, and that is also the goal of this book. A number of authors have previously attempted to define worry. We would like to highlight a few different definitions that each contribute to better understanding the concept of worry as it has been studied in recent years. The definition quoted most often was suggested by Borkovec, Robinson, Pruzinsky, and DePree (1983): “Worry is a chain of thoughts and images, negatively affect‐laden and relatively uncontrollable; it represents an attempt to engage in mental problem‐solving on an issue whose future outcome is uncertain but contains the possibility of one or more negative outcomes; consequently, worry is related closely to fear process” (p. 10). Borkovec (1994) has added the notion to this definition that “worry is a predominantly verbal–linguistic attempt to avoid future aversive events” (p. 7). Mathews (1990) highlighted the link between worry and problem‐solving by defining worry as the constant rehearsal of a threatening outcome or threat scenario that may hinder successful problem‐solving. Interestingly, Barlow (2002) argued that worry can be conceptualized as an attempt to solve an upcoming problem and Wells (1997) even argued that worrying is an actively initiated strategy to cope with future threats. Beekman et al. (1998) defined worry somewhat more technically by stating that worries are “cognitions that a state of an object (self, in‐group, society, or world) in one or more domains of life (health, safety, environment, social relations, meaning, achievement, or economic) will become or remain discrepant from its desired state” (p. 778). Importantly, these authors distinguished between worries concerned with self and close others (micro worries) and worries about society or the entire world (macro worries), and only micro worries were shown to be related to poor mental health. Macro worries, in contrast, were positively related to mental health. Finally, Gerlach and Stevens (2014) have highlighted that a fear image (worry) is usually considered to be acting as an initial element within the mental process of worrying. In their view, perceived threats (worries) should be considered the central force driving the act of worrying, which may include self‐soothing or problem‐solving related cognitions.
The definition of GAD is somewhat more straightforward, if not less controversial. The diagnosis “generalized anxiety disorder” was first introduced with DSM-III (American Psychiatric Association [APA], 1980). In this original conceptualization, generalized anxiety disorder was considered to encompass persistent anxiety of at least 1 month’s duration. This state of persistent anxiety was suggested to generally entail motor tension, autonomic hyperactivity, apprehensive expectation, vigilance, and scanning. In other words, originally, generalized anxiety disorder was a diagnosis with only a few specific symptoms in mind. In the description of the disorder, it was even stressed that patients should not exhibit specific symptoms that characterize phobic disorders (phobias), panic disorder (panic attacks), or obsessive‐compulsive disorder
(obsessions or compulsions). With DSM‐III‐R (American Psychiatric Association [APA], 1987) unrealistic or excessive anxiety and worry (apprehensive expectation) about two or more life circumstances was highlighted as criterion A of generalized anxiety disorder. Thus, for the first time, worry, accompanied by 18 symptoms of motor tension, autonomic hyperactivity, and vigilance and scanning, was considered to be at the core of this debilitating disorder. In addition, the necessary duration for the disorder was extended from 1 to 6 months in order to exclude transient anxiety reactions. This version also stipulated that the symptoms of GAD were not to occur exclusively during a mood or psychotic disorder (i.e., during an episode of major depression). With DSM-IV, criterion A changed such that only excessive anxiety and worry were required. Unrealistic worries were no longer necessary to allow diagnosis of GAD. In addition, criterion B was added stipulating that the person must find it difficult to control their worries. Also, the number of symptoms accompanying worrying was considerably shortened to the list still in place in the current DSM‐5. This decision was mainly based on 1 interview study with 204 subjects by Marten et al. (1993), who found that most of the 18 symptoms were reported by less than 60% of participants, which therefore led to the suggested removal of these symptoms. Note, that in ICD‐10 autonomic arousal symptoms still are highlighted in the definition of the disorder. ICD‐10 (World Health Organization [WHO], 1992) defines GAD as follows: “Anxiety that is generalized and persistent but not restricted to, or even strongly predominating in, any particular environmental circumstances (i.e., it is ‘free‐floating’). The dominant symptoms are variable but include complaints of persistent nervousness, trembling, muscular tensions, sweating, lightheadedness, palpitations, dizziness, and epigastric discomfort. Fears that the patient or a relative will shortly become ill or have an accident are often expressed.” According to DSM‐5 (American Psychiatric Association [APA], 2013), GAD consists of: (a) anxiety and worry that is excessive and occurs more days than not about a number of events or activities for at least 6 months; (b) the worry afflicted individual find it difficult to control the worry, which is associated with at least three of the following symptoms (c) restlessness, fatigue, difficulty concentrating or mind going blank, irritability, muscle tension, sleep disturbance; (d) the anxiety, worry, or the physical symptoms associated with it cause distress; and (e) the disturbance is not better explained by a different disorder. Note, that in DSM‐5 it is no longer required that the symptoms of GAD do not occur exclusively during a mood or psychotic disorder. Finally, in ICD‐11, a combination of the ICD‐10 variant of GAD and the DSM‐5 variant was suggested by defining GAD as follows: “Generalized anxiety disorder is characterized by marked symptoms of anxiety that persist for at least several months, for more days than not, manifested by either general apprehension (i.e. ‘free‐floating anxiety’) or excessive worry focused on multiple everyday events, most often concerning family, health, finances, and school or work, together with additional symptoms such as muscular tension or motor restlessness, sympathetic autonomic over‐activity, subjective experience of nervousness, difficulty maintaining concentration, irritability, or sleep disturbance” (World Health Organization, 2018). Thus, worries are much more strongly highlighted than previously in the ICD. At the same time, sympathetic autonomic over‐activity (such as heart palpitations or sweating) is still considered a relevant part of the symptomatology, contrasting the DSM‐5 operationalization of GAD.
In summary, diagnostic criteria for GAD have changed substantially during the last 40 years. This poses a challenge when one attempts to summarize findings with regard
Alexander L. Gerlach and Andrew T. Gloster
to this condition. In addition, people diagnosed with GAD as defined by DSM‐IV or DSM‐5, in contrast to ICD‐10 or ICD‐11, cannot be directly compared (compare Slade & Andrews, 2001) given the differences between these two diagnostic systems. Given that almost all research on GAD has been conducted using DSM criteria, in this handbook, DSM diagnostic criteria will be used when looking at specific features of the disorder.
Epidemiology
Epidemiological studies of GAD generally estimate the lifetime prevalence of GAD as between 3 and 5% (Bijl, Ravelli, & van Zessen, 1998; Kessler et al., 2005; Ma et al., 2009; Wittchen, 2002). These rates are relatively consistent across cultures (Ruscio et al., 2017). GAD is associated with high costs to both the individual and society (Olesen, Gustavsson, Svensson, Wittchen, & Jönsson, 2012; Wittchen, 2002). Some studies have examined subclinical GAD by relaxing one or more of the diagnostic criteria from the standardized diagnostic manuals (DSM‐III‐R, DSM‐IV, or ICD‐10). These studies estimate the lifetime prevalence at 12% and document significant suffering, impairment, and healthcare costs in afflicted individuals (Haller, Cramer, Lauche, Gass, & Dobos, 2014). Epidemiology studies further suggest that the age of onset occurs later in GAD than other anxiety and depressive disorders (Beesdo, Pine, Lieb, & Wittchen, 2010; Lieb, Becker, & Altamura, 2005). Furthermore, some evidence points to an increased prevalence of GAD in older age groups (Beekman et al., 1998). Equally important, epidemiological studies document high levels of comorbidity, with an estimated 83.3% of individuals with GAD suffering from at least one other anxiety, mood, or substance use disorder (Kessler & Walters, 2002). GAD is most often comorbid with any mood disorder (71.6%), followed by any anxiety disorder (57.8%) and any substance use disorder (34.3%).
Where Do GAD Patients Present and at What Cost for the Health System?
As is often the case with mental disorders, patients with GAD receive care more often from general practitioners than specialized mental health providers. Population data suggest that less than half of patients receive minimally adequate care (Fernandez et al., 2007). For GAD, only 44% of individuals with GAD were judged to receive minimally adequate care in university affiliated outpatient clinics where care is arguably more stringent than in non‐academic treatment centers (Stein et al., 2004). Within primary care, patients with GAD have been found to utilize healthcare at a higher prevalence rate (8%) than the estimated population rates (2–5%) (Wittchen, 2002). Given diagnostic overshadowing and the general difficulty in recognizing GAD when patients present primarily with somatic symptoms, primary care practitioners are often left with ambiguous clinical pictures. This is reflected in the fact that although physicians recognized emotional problems in over 75% of patients with GAD, they correctly diagnosed GAD only in approximately a third of patients (34.4%) compared to nearly two‐thirds of patients with a major depressive episode (64.3%) (Wittchen et al., 2002).
With respect to specialized mental healthcare, studies have begun to examine the cost–benefit of treating GAD with either Cognitive Behavioral Therapy (CBT) or pharmacology. One study based on assumptions of the Australian health care system modeled a 12‐session CBT vs. pharmacology (serotonin‐norepinephrine reuptake Inhibitor [SNRI] with nine office visits with either a GP or a psychiatrist) with respect to the total cost to the healthcare system (i.e., cost to the patient and cost to the government). This study concluded that CBT was more cost‐effective (Heuzenroeder et al., 2004). The generalizability of this study depends on the modeled costs associated with psychotherapy in each country and whether practitioners would indeed see their patients nine times per year. The degree to which these assumptions vary would affect the relative cost savings in each healthcare system. An analysis based on assumptions adequate for the German healthcare system came to a similar conclusion (Wunsch, Kliem, Grocholewski, & Kröger, 2013). Other aspects that should be considered when examining the cost–benefit of a treatment are the availability, tolerability (e.g., side‐effects, stigma, etc.), and effect size of the treatment both at the end of active treatment and in the extended follow up phase after the termination of treatment.
Introduction and Overview of the Handbook
Nutt, Argyropoulos, Hood, and Potokar (2006) suggested 23 years ago that GAD scientifically is a somewhat neglected disorder, although research into worry and GAD is important given it is one of the most common conditions occurring comorbidly with other disorders. We believe the research presented in the present book is a fine representation of the profound headway research has made towards a better understanding of this mental disorder in recent years. The first section of the book addresses the basic science foundation of worry and GAD. The next chapter (Rinner & Gloster) gives an overview on self‐report instruments developed to assess worry and related constructs. Furthermore, specific challenges in assessing GAD and worry are highlighted as well as possible solutions to these challenges, such as the use of momentary assessment methodologies. Bredemeier and Berenbaum link the research on perception of threat to worry, GAD, and related constructs and illustrate a novel strategy to treat pathological worrying based on this analysis. Ehring and Behar take a transdiagnostic view on worrying and relate it to other forms of negative mental content. Moreover, they summarize research on repetitive negative thinking and present evidence for the overlap of symptoms such as obsessions, rumination, and worrying. Jansson‐Fröjmark, Bilevicius, El‐Gabalawy, and Asmundson extend the view on worry and GAD by looking at the link between worry and other health problems, such as health anxiety and insomnia disorder. A large number of theoretical models explaining GAD and pathological worrying have been developed in the realm of cognitive behavior therapy. Koerner, McEvoy, and Tallon detail these models and take the reader on a journey from the historical beginnings of research into GAD to a synthesis and discussion of the most modern perspectives on this long misunderstood disorder. Stewart, Stephens, Roche, and Dymond focus on yet another aspect, namely learning science. Starting from basic conditioning theory and avoidance learning, they extend their view toward relational frame theory and illustrate how these concepts help understand worry and GAD better. Schienle and Wabnegger summarize research on
Alexander L. Gerlach and Andrew T. Gloster
the structural and functional neuroanatomy of Generalized Anxiety Disorder and give a comprehensive overview on the complex findings within this realm. Finally, Xie extends these theoretical and empirical overviews by adding a cultural perspective on the understanding and treatment of pathological worry and GAD.
The second section of the book addresses the applied science of treating worry and GAD. These chapters examine the phenomenology, etiology, and maintenance of worry and GAD as applied to treatment. Each chapter describes a therapy that can be derived when combining the basic understanding of worry and GAD with various therapy assumptions. The chapters include detailed descriptions of techniques, empirical reviews, and case examples. The different therapies include the most widely researched approach to date of CBT (Newman, Zainal, & Hoyer) as well as relatively newer psychotherapy approaches: Interpersonal and Emotion‐focused Therapy (I/ EP; Newman & Zainal); Acceptance and Mindfulness treatments (Roemer & Orsillo), and current approaches of psychodynamic therapies as applied to GAD (Leichsenring, Steinert, & Salzer). Pharmacological treatments are also reviewed, with attention paid to comparative efficacy, treatment duration, and current recommendations of different classes of pharmacological agents (Baldwin). In addition, the important topic of digital developments is examined in a chapter on internet and computer interventions, including cognitive bias modification (Andersson & Becker). One chapter was dedicated specifically to the treatment of children and adolescents (In‐Albon, Wahlund, & Perrin). Finally, the last chapter examines the current state of research on worry and GAD and looks forward to further developments (Gloster & Gerlach).
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Assessing Worry An Overview
Marcia T. B. Rinner and Andrew T. Gloster
Department of Psychology, Division of Clinical Psychology and Intervention Science, University of Basel, Basel, Switzerland
Introduction
Valid and reliable assessments are important for both the research and treatment of generalized anxiety disorder (GAD) and its key feature: worry. As with most constructs, the assessment of worry and its associated effects presents several challenges. This chapter provides an overview of the different types of assessments that exist for GAD and worry and options for dealing with current challenges.
What Is Worrying?
Worrying is an everyday phenomenon that is experienced by most people (Szabó & Lovibond, 2002). However, the frequency and the intensity of worry vary within and between individuals. Several definitions have been formulated for worry. At its core, worrying is a chain or a repetition of negatively valenced thoughts and images that are future orientated (e.g., “what if”) and are related to concerns about negative outcome in the future (Watkins, 2008; also see Brosschot, Van Dijk, & Thayer, 2007; Borkovec, Robinson, Pruzinsky, & DePree 1983). The exact theme of the worried thoughts varies by person. For example, someone might worry about financial concerns (“will I be able to pay my rent next month?”), whereas others might worry about the health of someone they love. In many cases worrying leads to stress and anxiety, which is associated with physiological reactions. Worrying, among other symptoms, has been associated with muscle tension, restlessness/feeling keyed up on edge, difficulty concentrating/mind going blank, being easy fatigued, irritability, and sleep disturbance (Antony, Orsillo, & Roemer, 2001).
Worry has been conceptualized as a mental attempt to solve problems, as well as an attempt to prevent the occurrence of negative events (Borkovec, Alcaine, & Behar,
2004). By anticipating problems, the individual believes he is preparing to react in an adaptive way to problems in the future (Kircanski, Thompson, James, Sherdell, & Gotlib, 2015; see also Borkovec et al., 1983). Other theories, such as the Intolerance of Uncertainty Model or the Metacognitive Theory (Chapter 7), have been developed to explain the mechanism and concept of worry. These different theories of the function of worry partially explain why several conceptually distinct assessment tools have been developed to assess GAD and worry.
Assessments of GAD and Worry
Due to the private nature of worrying (thoughts are not visible for others), the direct assessment of GAD and worry necessitates some form of self‐report.
The Generalized Anxiety Disorder Questionnaire‐IV (GADQ‐IV; Newman et al., 2002) is a commonly used questionnaire. The GADQ‐IV assesses the experience of worry as part of a screening to identify GAD and corresponds to the DSM‐IV criteria. The GADQ‐IV allows for dimensional assessment on numerous items and results in a total score. The GADQ‐IV shows 89% specificity and 83% sensitivity with respect to DSM‐IV diagnosis and demonstrates good test–retest reliability. To further evaluate the severity of GAD symptoms, Shear, Herbeck Belnap, Mazumdar, Houck, and Rollman (2006) developed the Generalized Anxiety Disorder Severity Scale (GADSS). Within the GADSSS, individuals are asked to report about: the frequency of worrisome thoughts, distress due to worrying, frequency of associated symptoms, severity and distress of associated symptoms, impairment in work, and experienced impairment in their social function. The GADSS has high internal consistency (α = 0.90) and sensitivity to change within 12‐month follow‐up. Furthermore, the GADSS shows good construct validity showing significantly different scores for individuals with a GAD diagnosis and individuals with a panic disorder. Another widely used instrument for the measure of severity of anxiety symptoms is the Hamilton Rating Scale for Anxiety (HAM‐A; Hamilton, 1959). The HAM‐A assesses both psychic anxiety and somatic anxiety and is frequently used in clinical and research setting for the assessment of GAD. The reliability and concurrent validity of this instrument is acceptable (Maier, Buller, Philipp, & Heuser, 1988). Further, shorter, screening instruments are also used for the assessment of GAD such as the 7‐item self‐rated Generalized Anxiety Disorder Scale (GAD‐7; Spitzer, Kroenke, Williams, & Löwe, 2006), the 2‐item shortened GAD‐7, and the Generalized Anxiety Disorder‐Single Item (GAD‐SI; Micoulaud‐Franchi, Bartolomei, & McGonigal, 2017; Spitzer et al., 2006).
GAD has furthermore been measured in a broader sense within clinical interviews. Clinician ratings in general are the most prevalent form of assessment, if not the most researched. The most researched clinical diagnostic interview is the fully structured Composite International Diagnostic Interview (CIDI; Kessler & Üstün, 2004). Semi‐structured clinical ratings include the Structured Clinical Interviews for DSM‐IV (SCID‐I; First, Spitzer, Gibbon, & Williams, 2002) and the Structured Clinical Interviews for DSM‐5 (First, Williams, Karg, & Spitzer, 2015), the Anxiety Disorders Interview Schedule (ADIS; Brown, DiNardo, & Barlow, 1994) and the Diagnostisches Interview bei psychischen Störungen (DIPS; Margraf, Cwik, Suppiger, & Schneider, 2017).
Besides instruments conceptualized to measure GAD specifically, a range of assessment instruments focus on worry, the key feature of GAD. The Penn State Worry
Questionnaire (PSWQ; Meyer, Miller, Metzger, & Borkovec, 1990) and the Worry Domains Questionnaire (WDQ; Tallis, Eysenck, & Mathews, 1992) are most often used. The PSWQ was created to measure an individual’s tendency to worry with respect to excess and intensity; however, it does not measure the content of the individual’s worry (Antony, Orsillo, & Roemer, 2001). In contrast, the WDQ (Tallis et al., 1992) was created to ascertain how much an individual worries about five separate domains: relationships, lack of confidence, aimless future, work, and finance. The WDQ has been recommended for non‐pathological worry, whereas the PSWQ is better suited to measure pathological worry (Verkuil, Brosschot, & Thayer, 2007). However, it is possible that the WDQ simply measures a different aspect of worry as opposed to a different quality. This supposition, however, awaits empirical validation. The WDQ was further refined and also exists in a short version (Worry Domains Questionnaire Short Form; Stöber & Joormann, 2001) and was adapted for managers (Worry Inventory for Managers; Stöber & Seidenstücker, 1997) and elderly adults (Worry Scale for Older Adults; Wisocki, 1994). Next to the PSWQ and the WDQ, other self‐report questionnaires of worry have been reported in the literature, as for example the Consequences of Worrying Scale (COWS; Davey, Tallis, & Capuzzo, 1996), the Student Worry Scale (SWS; Davey, Hampton, Farrell, & Davidson, 1992), and the Why Worry Scale (WW and WW‐II; Freeston, Rhéaume, Letarte, Dugas, & Ladouceur, 1994; Holowka, Dugas, Francis, & Laugesen, 2000). A short description of those instruments can be viewed in Table 2.1.
Numerous other self‐report questionnaires assess the facet of worry within the domain of related constructs (i.e., intrusive thoughts and diagnosis of GAD). For example, the Meta‐Cognitions Questionnaire (MCQ; Cartwright‐Hatton & Wells, 1997) measures beliefs about worry and intrusive thoughts. The MCQ consists of five subscales labeled: (a) positive worry beliefs; (b) beliefs about controllability and danger; (c) beliefs about cognitive competence; (d) general negative beliefs; and (e) cognitive self‐consciousness. The MCQ subscales demonstrated adequate to good internal consistency and good 5‐week test–retest reliability. The first three subscales were shown to predict levels of worry and resulted in significant differences between individuals with GAD and obsessive‐compulsive disorder (OCD). The clinical utility of this measure lies in its ability to identify beliefs that may increase the frequency and persistence of worry. In addition, the Intolerance of Uncertainty Scale (IUS; Freeston et al., 1994) measures emotional and behavioral reactions to ambiguous situations. The IUS is reported to possess excellent internal validity and adequate 5‐week test–retest reliability in an English‐speaking student sample. The IUS has demonstrated convergent validity (with other measures of worry) and discriminant validity (between a GAD sample and non‐anxious controls; as reported in Antony, Orsillo, & Roemer, 2001). Further related constructs are, for example, the Anxious Thought Inventory (AnTI; Wells, 1994) and the Thought Control Questionnaire (TCQ; Wells & Davies, 1994). The AnTI (Wells, 1994) is an instrument measuring generalized worry on three factors (level of worry about health, worry about social relationships and meta worry). The MCQ short version (MCQ‐30; Wells & Cartwright‐Hatton, 2004) assesses individual metacognitive beliefs on five subscales: (a) cognitive confidence; (b) positive beliefs about worry; (c) cognitive self‐consciousness; (d) negative beliefs about uncontrollability of thoughts and danger; and (e) beliefs about need to control thoughts. The MCQ for children (MCQ‐C; Bacow, Pincus, Ehrenreich, & Brody, 2009), as well as the MCQ for adolescents (MCQ‐A; Cartwright‐Hatton et al., 2004),
Table 2.1 Common Assessments of GAD, Worry, and Related Constructs.
Authors and year of publication
Self‐report questionnaire of GAD and Worry Consequences of Worrying Scale (COWS)
The Generalized Anxiety Disorder‐Single Item (GAD‐SI)
Penn State Worry Questionnaire (PSWQ)
Student Worry Scale (SWS)
Why Worry Scale (WW & WW‐II)
Worry Domains Questionnaire (WDQ)
Davey et al. (1996)
Shear et al. (2006)
Scale and no. of items
5‐point likert scale/29 items
5‐point scale from “none” to “very severe”/6 items
Newman et al. (2002) Items are mainly dichotomous (yes/no), one item is in an open‐ended format and two items are an 0–9‐point likert scale from “none” to “very severe”/9 items
Spitzer et al. (2006)
Spitzer et al. (2006)
Spitzer et al. (2006)
Meyer et al. (1990)
Davey et al. (1992)
WW: Freeston et al. (1994)
WW‐II: Holowka et al. (2000)
Tallis et al. (1992)
4‐point scale from “not at all” to “nearly every day”/7 items
4‐point scale from “not at all” to “nearly every day”/2 items
4‐point scale from “not at all” to “nearly every day”/1 item
5‐point likert‐scale from “not at all typical” to “very typical”/16 items
4‐point scale from “almost never” to “almost always”/10 items
WW: 20 items;
WW‐II: 5 point likert scale from “not at all” to “absolutely true”/25 items
0–8 point frequency and intensity scales from “never” to “several times a day” and “not upsetting” to “extremely upsetting”/25 items
Validation
Davey et al. (1996)
Shear et al. (2006)
Newman et al. (2002)
Spitzer et al. (2006)
Micoulaud‐Franchi et al. (2017)
Micoulaud‐Franchi et al. (2017)
Meyer et al. (1990)
Davey et al. (1992)
WW: Freeston et al. (1994) WW‐II: Holowka et al. (2000)
