Copyright © 2017 AICH – Servier Research Group. All rights reserved 203 www.dialogues-cns.org
Current theoretical foundations
eneralized anxiety disorder (GAD) has been
regarded as a primary diagnosis since 1987 (Diagnostic
and Statistical Manual of Mental Disorders, third revi-
sion [DSM-III-R]). Previously, GAD had been consid-
ered an “anxiety neurosis.” Its speciﬁcation as a singular
disorder has allowed the recognition of factors common
to anxiety disorders, for example, anxious anticipation,
cognitive biases, and excessive concern. Additionally,
GAD has speciﬁc factors that are not shared with other
anxiety disorders, such as intolerance of uncertainty,
and excessive concerns in several important areas. It
is therefore a diagnosis whose conceptualization has
much evolved over the last 2 decades, and recent stud-
ies on the subject suggest that the individualization of
GAD will continue into the future.1
Nowadays, DSM-52 deﬁnes GAD as “the presence
of excessive anxiety and worry about a variety of topics,
events, or activities. Worry occurs more often than not
for at least 6 months and is clearly excessive.” People
suffering from GAD have great difﬁculty in controlling
these worries. They may also present with edginess or
restlessness, difﬁculty sleeping, difﬁculty concentrating,
Keywords: child; cognitive behavioral therapy; generalized anxiety disorder;
practice; transdiagnostic process
Author afﬁliations: Psychologist in private practice, Eschau, France; Institu-
tion La Doctrine Chrétienne, Strasbourg, France; Strasbourg University, Stras-
Address for correspondence: 31A Rue du Couvent, 67114 Eschau, France
As a form of therapy, cognitive behavioral therapy (CBT)
is more than a mere “toolbox.” CBT allows us to bet-
ter understand how the human mind is functioning be-
cause it is based on neuroscience and experimental and
scientiﬁc psychology. At the beginning, the Diagnostic
and Statistical Manual of Mental Disorders (DSM) was
“nontheoretical,” but nowadays (the most recent ver-
sion being DSM-5), it is increasingly based on CBT para-
digms (with the insertion of important notions such as
cognitions and behaviors). This Brief Report presents
what we currently know about generalized anxiety
disorder (GAD) and how we can treat this condition by
nonpharmaceutical means. In the last few years, GAD
theories have evolved, becoming more precise about the
cognitive functioning of GAD sufferers. Here, we look
at current theoretical models and the main techniques
of therapeutic care, as well as the advances in research
about the “transdiagnostic” process and GAD in child-
hood. CBT is an effective treatment for GAD, typically
leading to reductions in worry, and a study has shown
that such therapy is equal to pharmaceutical treatment
and more effective 6 months after study completion.
© 2017, AICH – Servier Research Group Dialogues Clin Neurosci. 2017;19:203-207.
Cognitive-behavioral therapy for generalized
Lucas Borza, PsyM
and an increase in muscle aches or soreness. GAD suf-
ferers are generally burdened by the signiﬁcant conse-
quences the disorder has on their relationships or on
In CBT, evaluation is crucial. Professionals rely on
their clinical judgment, but they will also use standard-
ized assessment tools to evaluate symptoms.3-7 Exces-
sive worry is the main symptom in GAD. Anxiety is
almost always present in the minds of patients. The
themes of concern are relatively similar to those of the
normal population but are experienced in more cata-
strophic ways. The surrounding world is perceived with
apprehension, vigilance, and pessimism (chronic feeling
of insecurity, loss of contact with the experiential).
The search for reassurance is the second core element.
Anxiety levels are therefore higher than in the normal
population, but they are less intense and more diffuse
than in a panic disorder, for example (Figure 1).
GAD affects approximately 6% of the general
population in France if one considers the entire lifes-
pan.7 The disorder is common and disabling. A recent
review of epidemiological studies in Europe suggests a
12-month prevalence of between 1.7% and 3.75% (be-
ing more common in old age), and the associated func-
tional impairment is similar to that observed with major
depression.8 Comorbidities may be frequent. Indeed,
66.3% of patients present with at least one concomitant
psychopathology9; in 60% of cases, major depression or
another anxious disorder is present10; and 90% of GAD
sufferers are suspected to have a secondary anxious dis-
order, such as social anxiety or panic disorder.11
Concerns described in GAD are considered as a suc-
cession of thoughts in verbal or pictorial form12-14 and not
as a feeling. The emotion of anxiety will be the conse-
quence of these worries and concerns. For instance, one
might think “if I get sick, I will not be able to work any-
more, I can lose my job and cannot support my family, we
will ﬁnd ourselves on the street…” and so on.
In order to understand the pathology, cognitive psy-
chology attempts to represent the functioning of each
disorder through models. Here, we describe two of
these: Barlow’s model and the model of intolerance of
Barlow’s model15 describes a biological and psycho-
logical vulnerability to the negative elements of life.
Focusing attention on potential threats fosters this vul-
nerability and promotes a perceived inability to control
life events. Concerns have also been addressed as a way
to avoid a stronger emotion. This is important from a
therapeutic point of view. It explains how the disorder
can maintain itself over time (maintaining factors) and
which therapeutic techniques could be applied.
The model of intolerance of uncertainty16-18 is also
very important. The point here is to understand that it is
thought that anxiety is related to the difﬁculty to tolerate
doubt about future events and possible negative conse-
quences. However, why then don’t people who realize
that nothing bad happens end up worrying less? This
could be explained by the creation of “false beliefs” or
“positive beliefs” about worries. Indeed, worry is a cog-
nitive attempt to generate ways to prevent bad events
from happening and/or to prepare oneself for their oc-
currence. In addition, the goal of not feeling the “full”
emotion is reached. Patients do not question their beliefs
because they are happy that everything goes well. This
is explained in the avoidance model of worry.19-20 That
model also explains that in each situation, people seek
to eliminate an unpleasant thought, emotion, or memo-
ry. Most often, this leads to the anxious thought ending
up at the center of their attention. In addition, anxiety
promotes the avoidance of mental images that are as-
sociated with greater negative emotion. Thinking about
what could happen makes it possible to not suffer from
emotional images that are more emotionally intense.21
Safety behaviors are then set up (frequent calls to check
if everything goes well, hypervigilance about public an-
nouncement information, etc). So, whereas safety behav-
iors and cognitive avoidance will temporarily decrease
anxiety, they will reinforce worries over time.
0.0 - 1 3 5 10 15 20 25 30 35 40 45 50
Figure 1. Difference of emotion intensity evolution over time in panic
disorder versus generalized anxiety disorder. GAD, generalized
CBT for generalized anxiety - Borza Dialogues in Clinical Neuroscience - Vol 19 . No. 2 . 2017
In summary, in the cognitive approach, worry can be
used as a coping strategy because people believe in its
usefulness. Indeed, some GAD sufferers afﬁrm that it
would not be normal if they didn’t worry about their
family or their jobs, or even that it would increase the
risk that an accident would occur. Sometimes, magical
thoughts are present and very resistant to change.
It is fundamental to explore and evaluate the beliefs
about the function of concerns. They are powerful pre-
disposing and maintaining factors. It is the same with
patients’ perception of their own emotions, which are
often considered intolerable. They feel the need to sup-
press them as fast as they can (short-term strategy).22-26
CBT as treatment for GAD includes the development
of a functional analysis, providing information through
psychoeducation, experimentation with new behaviors
and emotions (exposition, relaxation), and a cognitive
Functional analysis makes it possible to specify where,
when, with what frequency, with what intensity, and
under what circumstances the anxious response is trig-
gered. It is performed with the patient and integrates
the factors maintaining the difﬁculties. This functional
analysis is crucial to the smooth running of therapy
because it gradually introduces important notions of
psychology. It makes it possible to visualize the mental
functioning of the person, which is already therapeutic
in and of itself.
Psychoeducation can easily be the next step. It is gener-
ally crucial because it makes it possible to understand
what the future therapeutic tools will be and facilitates
the increase in motivation to change. Patients begin to
think in a different way about which behaviors could be
the most useful.
The emotional and behavioral approach
The emotional and behavioral approach is generally fa-
vored. The therapist tries to teach relaxation in order to
instruct how to create positive emotions, not to manage
negative ones. There is a double effect as follows: (i) the
provision of a “psychological tool” to prepare for ex-
position exercises; relaxation allows desensitization of
anxiogenic situations; and (ii) a balancing of the gener-
al mood by adding “cognitive break times” in thoughts
The behavioral dimension of CBT is the most im-
portant. Patients will be able to expose themselves
to their own emotions and so will be able to learn
how to fight maintaining factors and avoidance
behaviors that perpetuate the disorder. The cogni-
tive process that is sought is habituation. It is the
acceptance of thoughts as normal and nonblocking
that initiates cognitive work. An example of men-
tal exposition is the instruction “think the worst.”
This strategy allows a rapid and effective reduction
in avoidance. Exposure to anxiety allows patients
to remain in the presence of images related to their
possible concerns (disturbing images that are usu-
ally avoided), in order to encourage emotional ha-
bituation. Patients can learn to tolerate their fears,
which will allow them to think less often and less
intensely about their worries.
The cognitive approach
The cognitive approach often begins with a self-ob-
servation that patients will carry out on their own
thoughts. Can the thoughts be spotted? Can patients
isolate them from emotions? The aim of the cognitive
work is to help patients take a step back from their
automatic thoughts and to be disjointed from those
worries. The third wave in CBT (mindfulness) adopted
this principle to create its therapeutic program with a
In a second step, therapy tends to modify the con-
tent of thoughts to reach a more objective evaluation
of situations. The goal is to struggle against cognitive
biases, such as overgeneralization or maximization of
danger. A second evaluation of situations is possible
by looking for objective indicators that allow relativiz-
ing. It is also possible to evaluate the consequences of
worry and to understand subtle avoidance. The thera-
pist tries to help patients to fully treat anxious antici-
pations, make them aware of danger patterns, and pro-
pose alternatives to catastrophism (overestimation of
GAD in children and the
Children, too, can be worried in a pathological way.
Anxieties are normal during development, but with poor
emotional management they can become problematic.
Always considering the “what if?” they ask a lot of ques-
tions to be sure and certain and sometimes they try to
predict every possible scenario. Attentional focus on
the threat appears to be a bias predisposing to GAD.28,29
Prompt treatment would seem important to prevent this
“cognitive habit” from becoming anchored because in-
tolerance of uncertainty can be the “fuel” of anxiety.30
Children with GAD show difﬁculty concentrating,
and they are always thinking about what’s next. They
need reassurance and approval for small steps and
avoid a lot of uncertain situations. They try to minimize
risks. They can present with perfectionism, a great fear
of making mistakes and a fear of criticism. They also
show metacognitive bias by thinking that worries will
A child with GAD can look like he or she has de-
pression, whereas the real problem is closer to inhibi-
tion and resignation. Psychological work with children
and adolescents requires a lot of imagination. Clinicians
always need to create educational support and adapt
psychiatric classiﬁcation to children.
CBT as a treatment for GAD has been established as
an excellent way to change pathological worries into
normal worries. A lot of research must still be done to
improve therapeutic tools that facilitate distancing one-
self from anxious thoughts. Current science has achieved
a good understanding of psychological mechanisms in
GAD, and further research in transdiagnostic ﬁelds may
provide new approaches to GAD treatment. o
Acknowledgments/Conﬂict of Interest: The author declares no conﬂict
1. Haute Autorite de Santé. Affections psychiatriques de longue durée. Trou-
bles anxieux graves. Paris, France: HAS; 2007.
2. American Psychiatric Association. Diagnostic and Statistical Manual of
Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Association;
3. Brown, TA, Barlow DH. Treatments That Work: Anxiety and Related Dis-
orders Interview Schedule for DSM-5. New York, NY: Oxford University Press;
4. First MB, Spitzer RL, Gibbon M, Williams JB. Structured Clinical Interview
for DSM-IV (SCID). New York, NY: Biometrics Research, New York State Psy-
chiatric Institute; 1998.
5. Silverman WK, Albano AM. Anxiety Disorders Interview Schedule for
DSM-IV: Child Version, Child And Parent Interview Schedules. San Antonio, TX:
Psychological Corporation; 1996.
6. Spitzer R, Kroenke K, Williams J, Lowe B. A brief measure for assess-
ing generalized anxiety disorder. Arch Intern Med. 2006;166(10):1092-1097.
7. Dugas MJ, Freeston MH, Lachance S, et al. The worry and anxiety
questionnaire: initial validation in nonclinical and clinical samples. Paper
presented at: World Congress of Behavioral and Cognitive Therapies; July
1995; Copenhagen, Denmark.
8. Agence Nationale d’Accréditationale d’Accréditation et d’Evalua-
tion en Santé. Diagnostic et prise en charge en ambulatoire du trouble
anxieux généralisé de l’adulte. Recomm Pour La Prat Clin. 2001:1-9.
9. Wittchen HU, Zhao S, Kessler RC, Eaton WW. DSM-III-R generalized
anxiety disorder in the National Comorbidity Survey. Arch Gen Psychiatry.
10. Nutt D, Argyropoulos S, Hood S, Potokar J. Generalized anxiety disor-
der: a comorbid disease. Eur Neuropsychopharmacol. 2006;16(suppl 2):S109-
11. Barlow DH, Rapee RM, Brown TA. Behavioral treatment of general-
ized anxiety disorder. Behav Ther. 1992;23(4):551-570.
12. Lader M. Generalized anxiety disorder. Encyclopedia Psychopharmacol.
13. Borkovec TD, Robinson E, Pruzinsky T, DePree JA. Preliminary ex-
ploration of worry: some characteristics and processes. Behav Res Ther.
14. Macleod AK, Williams JM, Bekerian DA. Worry is reasonable: the role
of explanations in pessimism about future personal events. J Abnorm Psy-
15. Barlow DH, Di Nardo PA. The diagnosis of generalized anxiety
disorder: development, current status, and future directions. In Rap-
ee RM, Barlow DH, eds. Chronic Anxiety: Generalized Anxiety Disorder,
and Mixed Anxiety–Depression. New York, NY: Guilford Press; 1991:95-
16. Mogg K, Mathews A, Weinman J. Memory bias in clinical anxiety. J
Abnorm Psychol. 1987;96(2):94-98.
17. Dugas MJ, Freeston MH, Ladouceur R. Intolerance of uncertainty and
problem orientation in worry. Cogn Ther Res. 1997;21(6):593-606.
18. Dugas MJ, Gagnon F, Ladouceur R, Freeston MH. Generalized anxi-
ety disorder: a preliminary test of a conceptual model. Behav Res Ther.
19. Borkovec TD. The nature, functions, and origins of worry. In Davey
GC, Tallis F, eds. Worrying: Perspectives on Theory, Assessment and Treatment.
Oxford, UK: Wiley; 1994:5-33.
20. Borkovec TD, Alcaine O, Behar ES. Avoidance theory of worry and
generalized anxiety disorder. In Heimberg R, Mennin D, Turk C, eds. Gen-
eralized Anxiety Disorder: Advances in Research and Practice. New York, NY:
Guilford press; 2004:77-108.
21. Hoyer J, Becker ES, Roth WT. Characteristics of worry in GAD patients,
social phobics, and controls. Depress Anxiety. 2001;13(2):89-96.
22. Mennin DS, Turk CL, Heimberg R, Carmin C. Focusing on the regula-
tion of emotion: a new direction for conceptualizing and treating gener-
alized anxiety disorder. In: Reinecke MA, Clark DA, eds. Cognitive Therapy
Across the Lifespan: Evidence and Practice. New York, NY: Cambridge Univer-
sity Press; 2004:60-89.
23. Cisler JM, Olatunji BO, Feldner MT, Forsyth JP. Emotion regulation
and the anxiety disorders: an integrative review. J Psycopathol Behav Assess.
CBT for generalized anxiety - Borza Dialogues in Clinical Neuroscience - Vol 19 . No. 2 . 2017
24. ThayerJF, Lane RD. A model of neurovisceral integration in emotion
regulation and dysregulation. J Affect Disord. 2000;61(3):201-216.
25. Dugas M, Ladouceur R. Treatment of GAD. Targeting intolerance
of uncertainty in two types of worry. Behav Modif. 2000;24(5):635-
26. Dugas MJ, Letarte H, Rhéaume J, et al. Worry and problem solv-
ing: evidence of a specific relationship. Cogn Ther Res. 1995;19:109-
27. Cottraux J. Les Thérapies Comportementales et Cognitives. 3rd ed. Paris,
France: Masson; 1998.
28. Waters AM, Bradley BP, Mogg K. Biased attention to threat in pae-
diatric anxiety disorders (generalized anxiety disorder, social phobia, spe-
ciﬁc phobia, separation anxiety disorder) as a function of “distress” versus
“fear” diagnostic categorization. Psychol Med. 2014;44(3)607-616.
29. Armstrong T, Zald DH, Olatunji BO. Attentional control in OCD and
GAD: speciﬁcity and associations with core cognitive symptoms. Behav Res
30. Einstein, Danielle A. Extension of the transdiagnostic model to focus
on intolerance of uncertainty: a review of the literature and implications
for treatment. Clin Psychol Sci Pract. 2014;21(3):1468-2850.
Terapia cognitiva-conductual para la ansiedad
La terapia cognitiva-conductual (TCC), como una forma
de terapia, es más que una mera “caja de herramien-
tas”. La TCC permite una mejor comprensión de cómo
funciona la mente humana ya que se basa en las neu-
rociencias y en la psicología experimental y cientíﬁca. El
Manual Diagnóstico y Estadístico de los Trastornos Men-
tales (DSM) inicialmente fue “ateórico”, pero actual-
mente (la versión más reciente, el DSM 5) se basa cada
vez más en paradigmas de TCC (con la inserción de im-
portantes nociones tales como cogniciones y conductas).
Este reporte breve presenta el conocimiento actual so-
bre el trastorno de ansiedad generalizada (TAG) y cómo
puede ser tratada esta condición a través de medios no
farmacológicos. En los últimos años, las teorías del TAG
han evolucionado, llegando a ser más precisas acerca
del funcionamiento cognitivo de quienes lo padecen.
En este artículo se revisan los modelos teóricos actuales
y las principales técnicas de manejo terapéutico, como
también los avances en la investigación sobre el proce-
so “transdiagnóstico” y el TAG en la niñez. La TCC es
un tratamiento efectivo para el TAG y lo característico
es que reduzca las preocupaciones. Un estudio ha mos-
trado que dicha terapia es equivalente al tratamiento
farmacológico y más efectiva a los seis meses de haber
completado el estudio.
La thérapie cognitivo-comportementale pour
Mode de traitement, la thérapie cognitivo-comporte-
mentale (TCC) est plus qu’une simple «boîte à outils ».
Basée sur les neurosciences et sur la psychologie scien-
tiﬁque et expérimentale, la TCC nous permet de mieux
comprendre le fonctionnement cognitif chez l’homme.
A ses débuts, le DSM (Diagnostic and Statistical Manual
of Mental Disorders) était “non théorique”, mais au-
jourd’hui (la version la plus récente étant le DSM-5), il
se base de plus en plus sur des modèles de TCC (avec
l’insertion de notions importantes comme la cognition
et le comportement). Nous présentons ici brièvement
nos connaissances actuelles sur l’anxiété généralisée
(AG) et ses moyens de traitement non médicamenteux.
Ces dernières années, les théories sur l’AG ont évolué
en se précisant sur le fonctionnement cognitif des per-
sonnes qui en souffrent. Nous examinons ici les modèles
théoriques actuels et les principales techniques de soin
thérapeutique, ainsi que les avancées de la recherche
sur le processus « transdiagnostique » et l’AG dans l’en-
fance. La TCC est un traitement efﬁcace de l’AG, dimi-
nuant typiquement l’inquiétude excessive et une étude
a montré qu’un tel traitement est équivalent à un trai-
tement médicamenteux et plus efﬁcace 6 mois après la
ﬁn de l’étude.