Generalized Anxiety Disorder (GAD) - Notes Summary
Case Study: Joan's GAD Treatment
Joan sought help for sleep disturbance and anxiety.
She reported difficulty relaxing, constant worries, and overwhelming recent anxiety.
Worries included physical symptoms (tingling), relationship status, supporting friends, and work stress.
Somatic symptoms: muscle tension, aches, difficulty concentrating, irritability, feeling on edge.
Onset traced back to leaving college 9 years prior.
No substance/alcohol issues.
Diagnosed with GAD and major depressive disorder via Structured Clinical Interview for DSM-IV (First et al., 1997).
Beck Depression Inventory (BDI) score: 21 (moderate to severe depressive symptoms).
Depression considered secondary to GAD.
Metacognitive Therapy (MCT) implemented, monitoring depressive symptoms.
Treatment: 10 sessions focused on modifying metacognitive beliefs about worry (Wells, 1995, 2009).
Sessions 1-2: Case formulation based on the metacognitive model and challenging negative metacognitive beliefs.
Homework: Worry-postponement experiments.
Sessions 3-4: Focus on residual uncontrollability beliefs and danger-related metacognitions.
Homework: Loss-of-control worry experiments and mini-survey.
Sessions 5-6: In-session experiments and verbal re-attribution to challenge negative metacognitions.
Homework: Worry-postponement and exposure to worry triggers.
Sessions 7-8: Focus on positive beliefs about worry, using verbal methods and worry contrast technique.
Homework: Worry modulation experiments.
Sessions 9-10: Assess/modify residual metacognitions and relapse prevention.
Progress monitored with self-report measures (Anxious Thoughts Inventory (Wells, 1994), Penn State Worry Questionnaire (Beck et al., 1995), Generalized Anxiety Disorder Scale), Beck Anxiety Inventory (Beck, 1990), and BDI (Beck & Steer, 1987).
After ten sessions, Joan reported reduced distress from worry/anxiety, improved sleep, and challenged erroneous beliefs.
Post-treatment BDI score was 5.
Introduction to Generalized Anxiety Disorder (GAD)
GAD is characterized by worry, a common cognitive activity in various psychological disorders.
MCT techniques developed for GAD have broader applications (Wells, 2009).
Worry is defined as a chain of thoughts with negative affect, difficult to control, verbal rather than imaginal (Borkovec et al., 1983), aimed at problem-solving.
Type 1 worry: worry about non-cognitive events (finances, physical symptoms).
Type 2 worry: worry about one’s own thought processes or worry about worry (Wells, 1994, 1995, 2000, 2009).
Differentiating Worry from Other Intrusive Thoughts
Worry must be distinguished from obsessional thoughts and depressive or obsessional rumination.
Obsessions are egodystonic (senseless, abhorrent, uncharacteristic), while worry is not.
Clinical Features & Diagnostic Criteria
GAD was once a residual diagnostic category (pre-DSM-III-R, APA, 1987).
DSM-III-R: unrealistic/excessive worry about ≥2 life circumstances for ≥6 months, plus ≥6 symptoms of motor tension, autonomic hyperactivity, and/or vigilance.
DSM-IV (APA, 1994) revisions:
Criterion B: Difficulty controlling worry was added.
Criterion C: Worry accompanied by ≥3 symptoms from a list (restlessness, fatigue, concentration difficulty, irritability, muscle tension, disturbed sleep).
DSM-5 (APA, 2013): No major revisions, but criteria were reordered.
Individuals must identify worry as excessive or report distress/impairment due to constant worry; have difficulty controlling worry.
Disturbance not due to substance/medical condition; not exclusively during mood/psychotic/pervasive developmental disorder.
Worry not confined to features of another disorder (e.g., panic attacks or social embarrassment).
DSM-5 criteria:
A. Excessive anxiety and worry occurring more days than not for at least 6 months about a number of events or activities.
B. The person finds it difficult to control the worry.
C. The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms having been present for more days than not for the past 6 months).
Restlessness or feeling keyed up or on edge
Being easily fatigued
Difficulty concentrating or mind going blank
Irritability
Muscle tension
Sleep disturbance
D. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
E. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.
F. The disturbance is not better explained by another mental disorder
ICD-10 criteria:
A. A period of at least six months with prominent tension, worry and feelings of apprehension, about every-day events and problems.
B. At least four symptoms out of the following list of items must be present, of which at least one from items (1) to (4).
Autonomic arousal symptoms
Palpitations or pounding heart, or accelerated heart rate.
Sweating.
Trembling or shaking.
Dry mouth (not due to medication or dehydration).
Symptoms concerning chest and abdomen
Difficulty breathing.
Feeling of choking.
Chest pain or discomfort.
Nausea or abdominal distress
Symptoms concerning brain and mind
Feeling dizzy, unsteady, faint or light- headed.
Feelings that objects are unreal (derealization), or that one’s self is distant or “not really here” (depersonalization).
Fear of losing control, going crazy, or passing out.
Fear of dying.
General symptoms
Hot flushes or cold chills.
Numbness or tingling sensations.
Symptoms of tension
Muscle tension or aches and pains.
Restlessness and inability to relax.
Feeling keyed up, or on edge, or of mental tension.
A sensation of a lump in the throat, or difficulty with swallowing.
Other non-specific symptoms
Exaggerated response to minor surprises or being startled.
Difficulty in concentrating, or mind going blank, because of worrying or anxiety.
Persistent irritability.
Difficulty getting to sleep because of worrying.
C. The disorder does not meet the criteria for panic disorder phobic anxiety disorders, obsessive- compulsive disorder or hypochondriacal disorder.
D. Not sustained by a physical disorder, such as hyperthyroidism, anorganic mental disorder or psychoactive substance-related disorder, such as excess consumption of amphetamine-like substances, or withdrawal from benzodiazepines.
Epidemiology and Course of GAD
GAD is a common emotional disorder, frequently seen in primary care.
Lifetime prevalence rate: ~5% (range: 1-6%) (Kessler et al., 2009).
Women are twice as likely to be diagnosed with GAD compared to men.
The US Collaborative Psychiatric Epidemiology Studies (over 20,000 participants): Lifetime prevalence rates of GAD were 7.7% for women and 4.1% for men (McLean et al., 2011).
Approximately 12% of patients attending anxiety clinics meet criteria for GAD.
Age of onset: Bimodal distribution with peaks in adolescence and later life (Dugas & Robichaud, 2007).
GAD runs a chronic, fluctuating course with low remission rates: 15% at 1 year, 25% at 2 years (Yonkers et al., 1996).
Prevalence rates among older adults range from 0.7 to 7.1% in the community (Stanley & Novy, 2000).
US National Comorbidity Replication Study: Lifetime prevalence in cases over 60 was 3.6% (Kessler et al., 2005).
Levels of worry, anxiety, and depression in older adults with GAD are similar to those of younger adults (Beck et al., 1995).
Worry content differences: Younger individuals report more about work, older groups fewer worries about health (Molina et al., 1998).
Comorbidity
High comorbidity between GAD and other psychiatric disorders (depression, other anxiety disorders) (Ouimet et al., 2012).
Impact of comorbidity on clinical outcomes is no greater in GAD than in other anxiety disorders (Hunt, 2002).
Yonkers et al. (1996): 52% of GAD sample met criteria for panic disorder/agoraphobia; 32% had social anxiety disorder; 37% met criteria for major depression.
Judd et al. (1998): Major depression (62%) and dysthymia (39%) were the most common comorbidities.
The pattern of comorbidity may reflect an underlying and generic vulnerability to psychopathology.
Research on Treatment Outcome
Psychological Therapies:
Behavioral treatments:
Focused on symptom control via relaxation methods.
Anxiety management approaches:
Multicomponent packages combining relaxation, coping techniques, and challenging negative thoughts (e.g., Butler et al., 1987, 1991).
Relaxation-focused treatments:
Applied relaxation (introduced in stages, culminating in rapid relaxation skills applied in anxiety-provoking situations).
Applied relaxation (Ost, 1987) and progressive plus applied relaxation (Bernstein & Borkovec, 1973) have been used alone or as components of multi-element treatment programmes.
Cognitive Behavioral Therapy (CBT):
Focused on challenging negative thoughts (Beck et al., 1996).
Varied in the types of thoughts targeted.
Focused on salient danger-related thoughts/beliefs centered on intolerance of uncertainty (Dugas & Ladouceur, 2000).
Exposure component: Worry as avoidance of distressing emotions; coping skills practice.
Self-Control Desensitisation (SCD) (Borkovec et al., 2002).
Hierarchy of anxiety-provoking situations (least to most threatening).
Desensitization to each situation (starting with the least anxiety-provoking).
Imagine anxious situation, physical reactions, worries, thoughts, and images.
Use relaxation skills to counteract anxious responses.
Positive self-statements.
Systematic reviews and meta-analyses:
CBT is associated with significant clinical improvement, maintained at 6- and 12-month follow-up (Cuijpers et al., 2014; Gonçalves & Byrne, 2012; Ouimet et al., 2012).
Maintenance of gains at 2 years (Borkovec et al., 2002).
Cognitive-behavioral treatments appear to be associated with the largest treatment effects when compared with anxiety management, non- directive psychotherapy, or psychoanalytic psychotherapy (Cuijpers et al., 2014; Durham et al., 1994).
Fisher and Durham (1999) reanalysis of data from six outcome studies assessing recovery rates:
Recovery rate of 40% using trait-anxiety as the outcome criterion.
Individual cognitive therapy & applied relaxation had recovery rates at 6-month follow-up of 50–60%.
Ost and Breitholz (2000):
Applied relaxation and cognitive therapy were effective treatments (53% and 62% of patients significantly improved).
Patients showed little improvement in trait-anxiety and worry.
Arntz (2003):
Compared cognitive therapy with applied relaxation.
Percentage improvement in trait anxiety at post-treatment: 12.8% following cognitive therapy and 18.1% following applied relaxation.
Recovery rates:
Post-treatment: 35% (cognitive therapy) and 44% (applied relaxation).
6-month follow-up: 55% (cognitive therapy) and 53.3% (applied relaxation), based on trait-anxiety.
CBT approaches based on specific models of pathological worry:
Cognitive therapy focused on intolerance of uncertainty (Dugas & Ladouceur, 2000).
Recovery rates of approximately 50% have been achieved in group treatment (Dugas et al., 2003).
Metacognition (Wells, 1995).
Treatment outcomes based on the metacognitive model appear to be greater than those obtained with other CBT approaches.
Wells and King (2006): Large post-treatment effects sizes on measures of trait-anxiety and worry in an uncontrolled trial.
Wells et al. (2010): MCT demonstrated a clear superiority against applied relaxation in a comparative trial.
Van der Heiden et al. (2012): MCT produced superior outcomes compared with intolerance of uncertainty-focused CBT.
Van der Heiden et al. (2013): MCT appears effective when delivered in group format with 71% recovery rates (Penn State Worry Questionnaire) and a post-treatment within-subject effects size of d = 1.86.
Pharmacological Treatment
Four drug groups provide short-term relief for some GAD symptoms: antidepressants, azapirones, anticonvulsants, and benzodiazepines (Baldwin et al., 2011; Roy-Byrne & Cowley, 2007).
Few studies have used long-term follow-up evaluations of drug effects, impact on cognitive symptoms (worry).
Earlier studies were conducted on heterogeneous patient samples with diagnoses such as “anxiety neurosis”.
Few studies have so far evaluated combined psychological and pharmacological interventions.
Mitte et al. (2005) meta-analysis: Azapirones and benzodiazepines were equally effective in the short-term.
Roy-Byrne and Cowley (2007) review: Antidepressants (SSRIs) and azapirones (buspirone) were useful short-term drug treatments for GAD; safer alternatives to benzodiazepines.
Benzodiazepines: Increased risk of sedation and dependence (Tyrer, 1990); adverse effects in neonates (Gale & Oakley-Browne, 2003).
Rebound anxiety on withdrawal of benzodiazepines: 15–30% of people (Tyrer, 1990).
Brawman-Mintzer (2001) and Connor and Davidson (1998): Gradual tapering of medication and careful assessment of client suitability are recommended before pursuing this treatment.
Baldwin et al. (2011) systematic review and meta-analysis of 27 high-quality randomized controlled trials:
Compared effectiveness of nine drugs.
Four SSRIs: sertraline (Lustral), fluoxetine (Prozac), escitalopram (Lexapro) and paroxetine (Paxil).
Two SNRIs: duloxetine (Cymbalta) and venlafaxine (Effexor).
Two anticonvulsants: pregabalin (Lyrica) and tiagabine (Gabitril).
One benzodiazepine: lorazepam (Ativan).
Fluoxetine (response and remission) and sertraline (tolerability) seem to have advantages.
Among five UK licensed treatments, duloxetine, escitalopram, and pregabalin might offer some advantages over venlafaxine and paroxetine.
Psychological vs Drug Treatments
Gould et al. (1997) meta-analysis:
Psychological and pharmacological treatments were equally effective in alleviating anxiety symptoms post-treatment.
At follow-up, psychological therapies had better maintenance of gains compared to medication.
Lindsay et al. (1987):
Outcomes for CBT, anxiety management, and benzodiazepine treatments in patients with GAD were comparable post-treatment (better than waiting-list control).
At 3 months, only CBT and anxiety management treatments maintained improvement.
Power et al. (1989):
Compared CBT, benzodiazepine, and placebo treatments for GAD.
Post-treatment: CBT was superior to the other two conditions.
12-month follow-up: Smaller proportion of CBT group (30%) sought further treatment than benzodiazepine (70%) or placebo groups (55%).
Power et al. (1990):
Compared CBT, benzodiazepines and placebo conditions alone and in combination (CBT plus benzodiazepine, and CBT plus placebo).
CBT alone or in combination was superior to diazepam alone or placebo on most measures at post-treatment and at 6-month follow-up.
Studies of combined psychological/pharmacological interventions are criticized for small sample sizes, short duration, fixed drug doses and differing CBT components without GAD-specific models.
The Metacognitive Model of GAD
Wells (1995, 1997, 2000, 2009): Erroneous metacognitive beliefs about worry are central in pathological worry.
A distinction is made between:
Type 1 worry: General worry (similar to normal worries).
Type 2 worry: Negative thoughts about worry itself (worry about worrying).
Normal worries develop into GAD when Type 2 worrying is activated in response to worry and associated anxiety.
Type 2 worry is the negative interpretation of thinking, a manifestation of underlying negative metacognitive beliefs about worrying。
Negative metacognitive beliefs about worrying:
Beliefs about the uncontrollability of worry.
Beliefs about the dangerous consequences of worrying for mental, physical, and/or social functioning.
Individuals with GAD also have positive metacognitive beliefs about worrying.
They believe worrying is a helpful coping strategy, providing a means of anticipating/avoiding/dealing with potential threats.
Positive beliefs sustain Type 1 worry for coping.
Negative metacognitive beliefs and resulting Type 2 worry lead to GAD.
Episodes are triggered by an intrusive thought (image or verbal “what if…” question).
Triggers prime positive metacognitive beliefs.
Individuals with GAD activate negative beliefs about worrying and negatively appraise worry and its associated responses during the worry episode.
For example, they may think that loss of mental control and a mental breakdown is imminent.
This leads to an intensification of anxiety depicted by the feedback cycle between Type 2 worry and anxiety.
Because worrying is predominantly a verbal conceptual activity that focuses on danger, it may block other processes necessary for emotional processing and the resolution of stress and other emotional reactions.
The use of Type 1 worry may lead to an increase of other symptoms such as intrusive thoughts as symptoms of failed emotional processing following stress.
People with GAD have conflicting beliefs about worry, leading to unhelpful vacillations in mental control attempts.
Individuals fail to discover that worrying does not lead to catastrophic outcomes such as mental breakdown.
The conflicting motivations to disrupt worry once it is activated means that the individual rarely has experiences of discontinuing their worry episode, which would provide evidence of control.
Overt behaviours are used to avoid worry and the threat it carries, (e.g., reassurance-seeking).
Problems with behavioral strategies include: increased uncertainty/ambiguity, and failure to challenge metacognitions and opportunities to discover worries are controllable or that worry is not harmful.
Empirical Support for the Metacognitive Model
Studies have explored worry in non-patients with high levels of pathological worry, non-patients meeting diagnostic criteria for GAD and patients with GAD.
Borkovec and Roemer (1995) showed that motivation, preparation, and avoidance were the most characteristic reasons given for worrying.
Cartwright-Hatton and Wells (1997):
Developed the metacognitions questionnaire (MCQ) to measure metacognitive dimensions.
Both positive and negative beliefs about worrying were positively associated with worry in students.
Proneness to pathological worry remained positively associated with positive beliefs about worry, and negative beliefs about worry when trait anxiety and other metacognitive factors were controlled.
Wells and Papageorgiou (1998) tested the metacognitive predictors of pathological worry and obsessive-compulsive symptoms:
Both positive beliefs about worry and negative beliefs concerning uncontrollability and danger were independently associated with pathological worry, and negative beliefs made the strongest contribution.
Wells (2005) developed the meta-worry questionnaire to assess danger-related appraisals of worry while eliminating circularity:
Negative danger-related appraisals of worry were positively correlated with pathological worry, and ratings were significantly higher in students meeting criteria for DSM-IV GAD compared with individuals with somatic anxiety or no anxiety.
Wells and Carter (1999) found that Type 1 and Type 2 worry were positively correlated with pathological worry:
However, only Type 2 worry and not Type 1 remained as a significant positive predictor of pathological worry when trait-anxiety and overlaps between worry types were statistically controlled.
Wells and Carter (2001) compared patients with GAD, panic disorder, social phobia, depression, or non-patient controls:
Patients with GAD showed significantly higher negative metacognitive belief and Type 2 worry scores than the other groups.
In a discriminant function analysis, patients with GAD were significantly discriminated from the other groups in terms of negative metacognitions, while the content of Type 1 worry was the best discriminator of patients with panic or social phobia.
Nassif (1999):
The level of negative metacognitive beliefs assessed at time 1 was a significant predictor of the presence of GAD at time 2 when the presence of GAD at time 1 was controlled.
Purdon (2000):
During a worry episode, positive and negative beliefs about worry predicted conflicting motivations to engage in or control worrying thoughts.
Butler et al. (1995) found that brief periods of worry following exposure to a gruesome film were associated with a significantly higher frequency of intrusive images about the film over a subsequent 3-day period compared to brief periods of imagery or “settling down.”
Holeva et al. (2001):
The tendency to use worry in the first few weeks after being a victim in a road traffic accident was associated with a greater incidence of subsequent post-traumatic stress disorder.
Assessment of GAD and Worry
Structured interview schedules: the Structured Clinical Interview for DSM-IV (SCID; First et al., 1997), and the Anxiety Disorders Interview Schedule (ADIS; DiNardo et al., 1994).
The Generalized Anxiety Disorder Questionnaire (GAD-Q; Roemer et al., 1995) is a self-report instrument for the identification of GAD that can be scored in accordance with DSM-III-R or DSM-IV criteria. This instrument has been used to identify GAD cases in research on non-patient samples.
Self-report measures of worry used in clinical and research settings are the Penn State Worry Questionnaire (PSWQ; Meyer et al., 1990) and the Anxious Thoughts Inventory (AnTI; Wells, 1994).
The Generalized Anxiety Disorder Scale (GADS: Wells, 1997) and a revised version (GADS-R: Wells, 2009) have been used in the context of implementing MCT for GAD.
Additional measures of anxiety symptoms and mood:
the Beck Anxiety Inventory (BAI; Beck et al., 1988).
the Beck Depression Inventory (BDI; Beck et al., 1961) or the Beck Depression Inventory II (BDI-II; Beck & Steer, 1987).
At pre-treatment and post-treatment additional measures are administered and include the trait-anxiety subscale of the State-Trait Anxiety Inventory (Spielberger et al., 1983), PSWQ and AnTI.
Metacognitive Therapy (MCT) for GAD
Treatment sessions are typically administered once a week for a period of 12 weeks. However, it is common for treatment to be successfully completed in a range of 6–12 sessions, and the number of sessions provided depends of the speed of therapeutic progress.
Treatment focuses on modifying negative beliefs about the uncontrollability of worry first, then negative beliefs about the danger of worry, and finally positive beliefs about worry.
Formulation and treatment begins with case conceptualisation comprising the construction of an idiosyncratic version of Figure 14.1.
Questioning about the episode should aim to elicit the triggering thought for worry, anxious symptoms and negative beliefs about worry.
Type 2 worry is typically the situational readout of negative beliefs, and so the theme in Type 2 worry should mirror negative beliefs.
A useful line of questioning is to ask about the content of Type 1 worry, then ask about the anxiety symptoms associated with this, and then question the patient about negative thoughts about the anxiety symptoms and worry process itself.
Socialisation to the MCT model consists of sharing the case formulation with the patient.
The therapist proceeds by describing the key elements in the formulation.
The central messages to convey are that most people experience worry and that worry only becomes a problem when unhelpful beliefs develop about worry and associated behaviour.
If it was not effective, and this is typical, then it is evidence of how trying not to think thoughts is counterproductive.
Challenging metacognitive beliefs.
Uncontrollability
The first step is challenging metacognitive beliefs about uncontrollability.
Initially verbal methods are used to explore and weaken these beliefs.
The therapist obtains a rating in belief about uncontrollability on a scale from 0 to 100 at the beginning and throughout this procedure of re-attribution.
After challenging the belief verbally, a worry postponement experiment is introduced as a means of testing beliefs in uncontrollability as a homework assignment.
I don’t want you to confuse this technique with the idea of trying not to think a thought. I’m not asking you to use the blue elephant strategy.
One strategy for illustrating different ways of reacting to thoughts is to introduce an experiential exercise of detached mindfulness in the session.
The therapist then introduces further discussion of the evidence and counter-evidence for the belief that worry is uncontrollable and then introduces the “loss of control experiment.”
Following this exercise, beliefs in uncontrollability should be re-rated.
Danger-related metacognitions
Once belief in uncontrollability is at zero, treatment focuses on modifying metacognitive beliefs concerning the dangers of worrying.
The three broad classes of danger are: physical (e.g. worrying can damage my body), psychological (e.g. worrying can make me lose my mind) and social (e.g. worrying is abnormal and will lead people to reject me).
Initial weakening of metacognitions concerning danger can be obtained by emphasising the dissonance that exists between the patient’s negative and positive beliefs about worry. (The Dissonance Technique)
Five Verbal Techniques for Challenging Danger Metacognitions These will be reviewed here: questioning the evidence, questioning the mechanism plus education, questioning the normality of worry, reviewing counter-evidence and decoupling. The aim is not to obtain a definitive challenge to the patient’s negative belief with every question, but to apply the questions and techniques fluidly.
Behavioural Experiments.
Various experiments involving the manipulation of worry can be used to challenge belief in danger- related metacognitions.Mini-Surveys. Mini-surveys can offer an effective means of normalising worry and providing a basis for challenging negative beliefs about its dangerous consequences.
Modifying positive metacognitive beliefs.
In the last third of treatment, attention shifts to modifying positive beliefs about worry as a means of setting the foundations for increased flexibility in cognitive strategies for dealing with threat.
The range and strength of positive beliefs varies across cases, and these are tackled using verbal re-attribution methods involving (1) questioning the evidence, (2) reviewing the counter-evidence, (3) use of the mismatch technique and (4) worry modulation experiments.
Questioning the evidence and reviewing counter-evidence needs little further discussion as these techniques were described previously to challenge negative beliefs about worry.
Mismatch technique.
The mismatch technique (Wells, 1997) consists of asking a patient to write out a detailed summary of a recent worry narrative.Worry modulation. Worry modulation experiments (Wells, 1997) involve asking patients to engage in activities normally associated with worrying whilst deliberately increasing and then decreasing the intensity of worry.
Strategy shifts
In the last couple of sessions of treatment, the therapist introduces alternative strategies for dealing with and thinking about threat.
Relapse preventionIn the last two sessions, relapse prevention focuses on reviewing level of belief in metacognitions (worries about the worrying process) and determining if there is residual avoidance of situations that might trigger worrying.
Applying metacognitive therapy to other disorders
GAD involves some of the core basic psychological processes and factors that are conceptualised as underpinning most forms of psychopathology and emotional vulnerability.
In a meta-analysis of MCT, the treatment approach was found to be more effective than control conditions and CBT with large between- group effect sizes (Normann et al., 2014).
Summary
GAD is a chronic and lifelong condition if untreated. It is one of the most common anxiety disorders. It is of special interest as a potential marker for basic pathological processes associated with psychological vulnerability.
MCT based on the model follows a sequence that can be implemented within 12 weekly sessions.
MCT has applications outside the realm of treating GAD, and offers the possibility that metacognitive treatment techniques may be effectively applied to problems of repetitive, persistent, and difficult-to- control thinking processes across a range of disorders.