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CBT for Generalised Anxiety Disorder

We all experience a degree of Anxiety or Worry at some point in our lives – It’s part of being human.

But what about those times when the anxiety seems to never leave us?  Or when we just can’t seem to put the worry out of our head?

Generalised Anxiety Disorder is the name given to a very common mental health problem in which we spend a lot of time engaged in worry, feel anxious for much of the time and notice our behaviour change in a way to try to minimise bad things happen in the world around us.

This article takes an in-depth look at Generalised Anxiety Disorder and explores how this common problem can be helped by Cognitive Behavioural Therapy.

Anxious girl on her own staring at the floor with generalised anxiety disorder

What is anxiety?

First off, Anxiety on its own is entirely normal.  We all have it on occasion and, in the right circumstances, it can be an incredibly useful emotion to alert us to and enable our response to danger.

Anxiety evolved as an emotional and physical response to danger in the world.  It keeps us safe. It is the product of millions of years of evolution and has been designed via natural selection as a quick fire system to get us out of danger whenever it presents.

When we experience something as being a potential threat to our safety, the parts of the brain responsible for emotional processing trigger off a series of changes within our body which enable us to respond to the threat in a way which increases the possibility of us staying alive.

The brain sends a signal to the adrenal glands, activating what is commonly called the “Fight or Flight” response.  This adrenaline alerts other parts of the body, and the body responds with such changes as increased heartrate, faster, more shallow breathing, increased physical tension and “butterfly” feelings in the stomach, amongst other things.  All of the things that our body can use to effectively deal with the threat – We either fight it or we flight it (escape).

When faced with actual, real danger, Anxiety gives us the physical tools we need to survive.

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Worry and Generalised Anxiety Disorder

For many of us today, it is generally rare to experience a real physical threat – if we’re lucky, we may only experience this maybe a few times in our lifetime – and yet, the experience of anxiety is more prevalent than ever.

Why is this?  Well, unlike other animals, we are gifted with fantastic reasoning and mental problem solving skills.  We are able to respond to problems as they emerge and we can generate solutions based upon our existing knowledge, experiences from the past and our expectations about the future.  These mental skills have served us well, contributing to our highly developed languages, our societies and cultures.

However, it is because of these more highly developed mental skills that that Generalised Anxiety (and other mental health issues) can occur.

Worry (and its counterpart, rumination) is a type of thinking process which moves our attention onto problems which are not happening in the here and now.  When we worry we are casting our mind into the future and attempting to work out and solve any and all possible problems that may occur around a particular theme in the future.

The problem with trying to predict and solve any and all problems in the future is that

a)  Most of these problems will never arise.

b)  Focusing upon future threat (the possible problem) in the here and now, even when the problem is not here, creates stress and anxiety for us in the here and now.

Worry and Anxiety – Mind and Body

People can sometimes get confused between worry and anxiety, occasionally thinking “it’s all anxiety” or “it’s all worry”.  But there is a distinction between the two and it is really helpful to understand this.

First off, Worry is a mental process.  It happens in your head – it’s not an emotion or a feeling.  When you find yourself caught in your head imagining all the possible things that could go wrong in a situation, then you are worrying.

Worry is also more than just a single thought.  It is a repetitive process that stays with us for an extended period of time.

Additionally, Worry is focused upon the future and it is always focused upon potential threatening or difficult outcomes.  We never find ourselves worrying about things turning out fine – it’s always about a potential negative event.

So, our definition of Worry is:  A mental process which is future focused, threat focused (revise this)….

Anxiety is different.  Anxiety is the emotional state which our body uses to notify us of danger and to activate the physical tools necessary for us to tackle it.  Panic, fear, ….. are all types of anxiety.  In generalised anxiety the sense of anxiety is not always experienced in intense peaks (like panic) but is more of a consistent, elevated level of unease.

Our definition of anxiety is:  An emotion that…..definition here.

CBT Treatment for Generalised anxiety disorder

There are a number of different Cognitive Behavioural Therapy approaches to the treatment of generalised anxiety disorder, such as those developed by Craske and Barlow, Wells and Dugas and Robichaud.  Here, I’m going to cover Dugas and Robichaud’s model for dealing with Generalised Anxiety Disorder, so you know exactly what to expect when you choose to enter CBT treatment.

Dugas model of GAD

The main principle underlying the Dugas model is something that we call “intolerance of uncertainty.”  Studies have shown that when people are experiencing high levels of GAD, they have a low tolerance for uncertainty in the world.  Intolerance of uncertainty is described by Dugas and Robichaud as working like a sort of allergy, a bit like hayfever or a food allergy.  When someone who has hayfever is exposed to even a tiny amount of pollen in the air, their body reacts with a huge response – Sneezing, itchiness, sore, red eyes, etc.  That is, a small amount of the allergen leads to a BIG response.

In GAD, exposure to a small amount of uncertainty, leads to a BIG response – Lots of Anxiety, Excessive worry, Avoidance, Checking, Feeling on edge, Sleeplessness.  If you, or someone that you know, has experienced GAD, then you will know exactly what I’m talking about.  It often feels as though every little thing can be a potential trigger for a huge amount of Anxiety and Worry.

So what do we do about this?  Dugas and Robichaud’s approach to treating GAD highlights the reality that much of the GAD sufferers response to uncertainty in the world is done as a way of reducing the uncertainty.  For instance, when people worry they are working through every possible scenario in their head, just in case it comes true so that they will be prepared – that is, they are attempting to reduce uncertainty in the world by worrying about every possible eventuality.

The problem with this however, is that no matter what we do or how much we worry, there still remains some uncertainty in the world.  There always will be.

And we know that a continued mental focus upon potential threats (the “what ifs?”)  keep our body feeling anxious, even when the threat is not physically in front of us.

So, we have a choice – do we continue the neverending task of reducing all of the uncertainty in the world, or do we do something different?

What if we could increase our tolerance instead?  That is what Dugas’ generalised anxiety model is all about.

This is how we do it.

Dugas and Robichaud (1998) model of Generalised Anxiety Disorder

Dugas Robichaud GAD Model

Step 1 – Worry Training

First off, lets think about how we deal with worry.  As mentioned above, worry is a key feature of generalised anxiety disorder and so it makes sense that we would want to start to get to grips with it as soon as as possible.  Here, we are looking to evaluate individual worries with a view to finding out whether they are “Hypothetical” worries or “Real” problems.  Here are some definitions:

      • Hypothetical worry:  A worry that has not actually happened in the real world as yet and may never happen.
      • Real problem:  The problem has happened.  It is real and out there in front of us.  There is something we can do about it.

For people with generalised anxiety disorder, distinguishing between Hypothetical worries and Real problems can be a challenge.  Often, hypothetical worries can feel as though they are real problems, despite that fact that the only place that they exist are in the minds of the worrier.  This is why we need to train ourselves to notice the difference.

Have a look at the worksheet I’ve presented below:

Worry Diary used in CBT for Generalised Anxiety Disorder (GAD)

This is what we call a worry diary and it is the main tool that we are going to use to begin to “collect” and evaluate our worries.

When we collect our worries, what we are aiming to do is to gather all of the examples of worries that are going on in our head throughout the day.  “But I’m always worrying!”, I hear you say.  If this is the case, then to begin with just use the worry diary to catch your worries 3 times each day.

Here’s how to use a worry diary to do worry training…

              1. In the situation/trigger column, write down where you where or what had just happened before or around the time you were worrying or otherwise decided to catch your thoughts.
              2. In the “Anxiety rating” column, try to think about how intense your feeling of anxiety is at the time you were worrying.  Rate this as a percentage – 100% is equal to unbearable, panic levels of anxiety and 0% represents no anxiety whatsoever.  Thinking about the intensity of the anxiety in this way gets us to notice any subtle differences in our anxiety as we try out the skills in the treatment.
              3. In the “Worry (What if?)” column, we want to write down the actual worry that we catch in our minds at the time we are using the diary.  So we might write, “What if I can’t pay the gas bill?”, “What if my parents become unwell?” or “What if my partner is in an accident?”  It might take some time for us to get used to identifying individual worries but this is fine…remember we are training.
              4. Now for the fun part.  Take a look at your “What if?” and ask yourself if it is a Real, current problem or if it is Hypothetical.  If you struggle with this then think about whether the problem has actually happened and is out there in the real world for you to deal with.  This would mean that it is real – move onto column 5.  If not, then it is Hypothetical – it hasn’t happened and may never will.
              5. If you decide that your worry is Hypothetical then further worrying about something that does not exist will cause you continued feelings of anxiety.  You now have a choice…carry on worrying or refocus upon what is going on around you and the real events that you can actually do something about.  Sometimes people with GAD struggle to refocus into the present moment, to get out of their minds so to speak and so I teach them a grounding technique which can help.
              6. If you decide that your worry is Real – i.e., it has happened, is there in the real world and you have concrete evidence that it exists then you can do something about it.  This links in with a later part of our model, Problem Solving, in which we look at active ways in which we can deal with Real problems, rather than getting caught up in the cycle of worry about it.

As  with a lot of things in Cognitive Behavioural Therapy, the emphasis upon learning new, sometimes abstract skills around our thinking processes can seem a little strange and challenging at first.  It’s important to remember that this is to be expected and that’s why I place such emphasis upon the “training” part of “Worry training.”  This is a marathon, not a sprint.  Keep practicing at catching and reflecting upon your worries and you will quickly begin to experience the benefits.

Step 2 – Intolerance of uncertainty

As mentioned earlier, studies suggest that people who experience high levels of generalised anxiety have a low ability to tolerate uncertainty in the world.  Because of this this treatment approach places a big emphasis upon teaching you how to notice when you are changing your behaviour in relation to Intolerance of uncertainty and how to then increase your tolerance.

What is meant by Intolerance of Uncertainty?  Intolerance of uncertainty can be thought of as being a little bit like an allergy.

Consider a peanut allergy for example.  When someone with a Peanut allergy is exposed to even a tiny piece of peanut, what happens?  Typically they will have an allergic reaction – runny nose, itchiness, possibly even going into anaphylactic shock.  So a small amount of Peanut leads to a Big response.

Similarly, in someone who is Intolerant to Uncertainty, when they are exposed to even a small amount of uncertainty, they have a big response – Worry, Anxiety, needing reassurance, avoidance, etc.

People who then develop GAD use mental processes like Worry and behaviours such as Avoidance, Reassurance Seeking, Checking and Overcompensating as a way of managing their intolerance to uncertainty.  They are trying to use these strategies as a way of reducing the uncertainty in the world.  For instance, if they avoid uncertain situations then they will not have to worry about the uncertainty of how the situation may develop.  If they seek reassurance from people, they can reduce the uncertainty that they may or may not have made a correct decision.

There are couple of problems with this strategy however.  Firstly, the behaviours themselves become problematic – the GAD sufferer may be constantly seeking reassurance or checking, or they may be avoiding so much that it has a real negative impact upon their lives.

The second problem with this strategy is that the individual with generalised anxiety disorder never escapes or reduces uncertainty in the world entirely.  In fact, this would be impossible.  Despite all of their best efforts (both consciously and unconsciously) the world remains uncertain.

There are still things that will come out of the blue.  There will always be problems.

So, we need to develop a different strategy.  Rather than trying to reduce uncertainty in the world, we instead need to increase our tolerance.  Returning to our Peanut allergy metaphor again, modern treatments for Peanut allergy help people develop tolerance to Peanuts by exposing them to really, really tiny pieces of Peanut protein.  This happens again and again, with gradually larger and larger pieces of Peanut until the sufferer’s body has gotten used to it.  Until their body can tolerate it.  This is exactly what we do with uncertainty – We expose you to little pieces of uncertainty and gradually turn the dial up.  Week by week, your tolerance of uncertainty increases and there is less and less need to respond with avoidance, checking and reassurance seeking, etc.

Here’s how we treat intolerance of uncertainty:

        1. Think about all of the things that you currently do to minimise uncertainty or to cope with things that trigger your anxiety.  You may find that you avoid things like certain situations or people, or avoid making decisions.  You might look for reassurance from other people or procrastinate (put off) things because you are uncertain about how they may turn out.  Because some of these behaviours may not be obvious to begin with, your therapist should be able to support you to identify some of your own manifestations of Intolerance of uncertainty.
        2. Choose one of these behaviours.  Now, bearing in mind that this is a behaviour that you do to minimise uncertainty in the world, and as such, changing it is likely to result in some degree of increased uncertainty and as a result anxiety, we want to choose a behaviour that is relatively small and inconsequential to begin with.  So for instance, we might choose a behaviour like “not asking for reassurance about choosing where to go for lunch” or to “send a text to a friend without double checking it.”  These examples, although small, are perfect to get the ball rolling and in setting you up for success as you continue to develop tolerance to uncertainty.
        3. Set up an experiment to see what happens when you carry out the new behaviour.  So, if the new behaviour was to not seek reassurance about where to go for lunch, we might agree to meet a colleague or friend for lunch and then ourselves make the decision about where to go.   We would be keen to not ask the friend if they were happy with our decision or to look for any other signs that we had made the “right” choice – Instead we would be tolerating the uncertainty that we had.  Typically this might be a trigger for some of our worries – “What if the food’s no good?”, “What if it’s too expensive?”, “What if my friend doesn’t like it?” and so on.  Expect this to happen but as much as you can carry out the experiment as agreed with your therapist.
        4. Write down what happens.  How did you feel to begin with?  Did this change over time?  How did things go in general?  What did you learn about your worries, your anxiety and yourself?  What does this mean for the future?  What will your next experiment be?

Ideally, you will find that that your anxiety eases as your practice your experiment.  This means that you are building up your tolerance to uncertainty.  As you do this, you will be encouraged by your therapist to undertake additional experiments, each slightly more anxiety provoking than the first but each gradually eating away at the behavioural consequences that generalised anxiety disorder has upon your life.

Step 3 – Positive beliefs about worry

This stage of treatment aims to understand and change the individual’s positive beliefs about worry.  When suggested to client’s that they have positive beliefs about worry, this can sometimes create a bit of confusion.  They know that their worry and anxiety is causing them problems – surely they don’t believe that this is a positive thing?  Well, this is not always the case.  Dugas and Robichaud propose in their GAD treatment model that people with GAD can have a number of different types of positive beliefs about worry which serves to maintain their use of worry as a strategy for dealing with the world.  Here are some examples or positive beliefs about worry:

      1. The belief that worry can protect us from negative emotions.
      2. The belief that worry motivates us to resolve problems.
      3. The belief that worry helps us to resolve problems.
      4. The belief that worry can actually prevent bad things from happening.
      5. The belief that worry is a positive personality trait.

At this stage, we aim to understand if the GAD sufferer has any degree of belief in these positive beliefs about worry and if so work to evaluate their true costs and benefits.  For instance, somebody who believes that worry is a positive personality trait (e.g., “I worry because I’m a caring person”) can be supported to explore whether they would still be a caring person whether they worried or not.  We may look at examples of people who appear to be caring and yet worry very little and consider whether it is the worry that makes someone caring, or whether it is an example of their values.  We would evaluate any other positive beliefs about worry in a similar way.

The aim in this part of the treatment is not necessarily to do away with the client’s positive beliefs about worry completely.  There may even be an element of truth in the positive belief.  But rather, we are aiming to consider and explore the strength of belief and consider if the costs of the belief outweigh the benefits.

Step 4 – Negative problem orientation

We’ve established that people with generalised anxiety disorder tend to have big responses whenever they’re exposed to uncertainty in the world.  This part of the treatment model looks at how being exposed to uncertainty through everyday problems can be helped in a proactive way.

Problems are a part of life.  You have them, I have them, your neighbour’s dog has them.  There’s no escaping from the fact that we are always going to have to deal with different degrees and types of problem as we progress through our lives.  The Dugas GAD treatment model suggests that people who have high levels of GAD are generally as good at solving problems as the general population.  If we think about it this makes sense – Worry is a form of mental problem solving (although many of the problems that we are solving are possibly never going to materialise).  The difference in GAD is the individuals’ perception of what a problem means for them.  Quite often, when faced with a new problem, people with GAD will catastrophise, avoid.

Step 5 – Cognitive avoidance and Imaginal exposure

We talked earlier about what Worry is and we have looked at how we can make the distinction between Hypothetical Worries and Real problems as part of the Worry Training intervention.  We’ve also looked at how our Positive Beliefs about Worry can make us believe that Worry is a useful way of dealing with life.

But this next intervention is, in my opinion, probably the part of the treatment which creates the biggest benefit.  This part of the treatment really gets to the nuts and bolts of Worry and renders it powerless.

If you’ve ever really paid attention to worry (and if you’ve followed the steps above then hopefully by now you have!) then you may have noticed that worry is a verbal, word-based process.  We worry in words.

Now, the theory is that we worry in word form because it is less anxiety provoking than worrying in the form of images.  That is, our What ifs? actually protect us from the far more anxiety provoking form of Imagery.

So, worry is what we call Cognitive Avoidance.  Verbal Worry is a Cognitive Process that enables us to avoid imagining the worst possible fears and outcomes.  Based upon this idea, we can then begin to think about what would happen if we were to stop using Worry as a form of Cognitive Avoidance and dig a bit deeper to face, and get used to, our true imagined fears.  To do this we use something called Imaginal Exposure.

Let’s say that I spend a lot of time worrying about my finances.  I get a letter through the door and straight away this triggers a What if?

“What if that’s a bill?”  I then start to worry about about what would happen next if that was a bill.  “What if I can’t pay it?”  “What if I do pay it and then I’ve got no money for food?”,  “What if it leaves me with no money for rent?”, “What if?…What if?…Etc.”

What happens in this process is that we have a worry, we briefly solve it in our minds and this then leads to another worry, and so on.  But in this process, we are cognitively avoiding imagining the deeper, core fear.  To find out what the core fear is we can use a technique which we call the downward arrow.  The downward arrow helps us to find the deeper meanings we give to things by simply asking, “and if that were true, what would be the worst thing about that?”

The image below shows how the downward arrow technique can help us to find the deeper fears.

Here we see how, with just a few questions we can go from the surface worries all the way down to the deeper fear of becoming homeless, not being able to feed the children and living on the streets.

Of course, your particular anxieties may not be about finances.  They could be about the safety of your children, your performance at work or something entirely different, but the downward arrow technique enables us to get all the way down to the deeper fear, ready for us to work on imaginal exposure.

So, now that we have identified the deeper fear, we want to create a way in which we can expose ourselves to it.  To do this we create an “exposure script”.  The exposure script is a written piece of work in which we write down exactly what happens if the feared scenario were to occur.  The exposure script deliberately provokes our physical anxiety feelings using explicit imagery so that we can get used to thinking about these deeper fears without reverting back to endless verbal worry and also learn that we can tolerate the physical sensations associated with the image.

This is how to write out and use an imaginal exposure script in generalised anxiety disorder treatment:

      1. Having used the downward arrow to identify the deeper concern that our everyday worries relate to, write out a narrative of what it would be like if that event were to happen.  So if our concern was about not being able to pay our bills and then being evicted from our home then we would write about that.
      2. We are interested in activating as much imagery as possible in this script as as possible so remember to write down everything we can see in the script, everything we can hear, taste, smell, feel and think.  This is really important.  Remember that our everyday worry is a verbal word based process because worrying in words is less distressing for us than imagining.  As such, for this intervention to be effective we want to imagine as much as possible in our worry scenario.  It’s also important to remember that, because we are still interested in increasing your intolerance to uncertainty, the script needs to end at an uncertain point – the point at which we are uncertainty reaches its peak.
      3. Write from the first person perspective and as though the event is actually happening in the here and now.  “I open up the brown envelope and peer inside…I take out the piece of white paper and one word jumps out at me…’Eviction’…My heart sinks for a moment and then begins to race…I start to panic.”  Remember: first person perspective as though it is happening right now.
      4. Be aware of anything you do within the script that might “neutralise” the anxiety or distress.  Neutralising in the worry script can be thought of as anything that reduces our anxiety or makes it less distressing and is unhelpful because this is the opposite of exposure.  So, if we write anything like, “I see the words ‘Eviction’, but then I remember that my friend said that he would help me with rent” or “The doctor looks at me and says, it’s serious…but that I’ll probably be ok” then we are using neutralising language and the imaginal exposure with be much less effective.
      5. After you have read through the script with your therapist and it’s agreed that there is no neutralising and that it is appropriate, then its time to record it.  This will typically be an audio recording – most modern mobile phones have a recording app – and it is done so that you can listen to the script at home for practice.  This is the exposure bit.
      6. On a daily basis listen to your audio recording, and rate your anxiety levels as a percentage at the start, middle and end points.  Exposure to our imaginal fears reduces our anxiety over time, so we need to make sure that you listen to the audio for a prolonged period – at least 45mins and perhaps even over an hour.  What you will find, if done properly, is that your anxiety will reduce, the script creates less fear and we no longer need to engage in worry as a method of cognitive avoidance.  We worry less!

Take the next steps…

So there we have a basic overview of what to expect from CBT treatment for Generalised Anxiety Disorder.  It’s not easy, if it was we wouldn’t have a problem.  But we do have a plan of treatment that has been shown to work and is recommended as a first line treatment for Generalised anxiety disorder.  

So, now you know what to expect from the treatment you can decide when to take the next steps when you’re ready.

If you want to get help from us then please feel free to contact us on 07887 701 176 or

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