Generalized Anxiety Disorder and Worrying A Comprehensive Handbook For Clinicians and Researchers 1St Edition Alexander Gerlach Full Chapter

Generalized Anxiety Disorder and
Worrying : A Comprehensive Handbook

for Clinicians and Researchers 1st
Edition Alexander Gerlach
Visit to download the full and correct content document:
https://ebookmass.com/product/generalized-anxiety-disorder-and-worrying-a-compre
hensive-handbook-for-clinicians-and-researchers-1st-edition-alexander-gerlach/
Generalized Anxiety
Disorder and Worrying
Generalized Anxiety
Disorder and Worrying
A Comprehensive Handbook for
Clinicians and Researchers
Edited by
Alexander L. Gerlach and

Andrew T. Gloster
This edition first published 2020
© 2020 John Wiley & Sons, Ltd
All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or
transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise,
except as permitted by law. Advice on how to obtain permission to reuse material from this title is
available at http://www.wiley.com/go/permissions.
The right of Alexander L. Gerlach and Andrew T. Gloster to be identified as the author of the editorial
material in this work has been asserted in accordance with law.
Registered Offices
John Wiley & Sons, Inc., 111 River Street, Hoboken, NJ 07030, USA
John Wiley & Sons Ltd, The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK
Editorial Office
111 River Street, Hoboken, NJ 07030, USA
For details of our global editorial offices, customer services, and more information about Wiley products
visit us at www.wiley.com.
Wiley also publishes its books in a variety of electronic formats and by print‐on‐demand. Some content
that appears in standard print versions of this book may not be available in other formats.
Limit of Liability/Disclaimer of Warranty

While the publisher and authors have used their best efforts in preparing this work, they make no
representations or warranties with respect to the accuracy or completeness of the contents of this work
and specifically disclaim all warranties, including without limitation any implied warranties of
merchantability or fitness for a particular purpose. No warranty may be created or extended by sales
representatives, written sales materials or promotional statements for this work. The fact that an
organization, website, or product is referred to in this work as a citation and/or potential source of
further information does not mean that the publisher and authors endorse the information or services the
organization, website, or product may provide or recommendations it may make. This work is sold with
the understanding that the publisher is not engaged in rendering professional services. The advice and
strategies contained herein may not be suitable for your situation. You should consult with a specialist
where appropriate. Further, readers should be aware that websites listed in this work may have changed
or disappeared between when this work was written and when it is read. Neither the publisher nor
authors shall be liable for any loss of profit or any other commercial damages, including but not limited
to special, incidental, consequential, or other damages.
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)
Subjects: LCSH: Anxiety disorders. | Worry.
Classification: LCC RC531 G4643 2020 (print) | LCC RC531 (ebook) | DDC
616.85/22–dc23
LC record available at https://lccn.loc.gov/2020000437
LC ebook record available at https://lccn.loc.gov/2020000438
Cover Design: Wiley

Cover Image: © Francesco Carta fotografo/Getty Images
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
Contents
List of Contributors ix
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 43
Thomas Ehring and Evelyn Behar
5 Worry and Other Mental Health Problems 69
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
viii Contents
11 Interpersonal and Emotion‐Focused Therapy (I/EP) for Generalized

Anxiety Disorder (GAD)231
Michelle G. Newman and Nur Hani Zainal
12 Acceptance‐Based Behavioral Therapies for Generalized Anxiety
Disorder (GAD) 245
Lizabeth Roemer and Susan M. Orsillo
13 Short‐Term Psychodynamic Therapy of Generalized Anxiety
Disorder (GAD) 273
Falk Leichsenring, Christiane Steinert, and Simone Salzer
14 Pharmacological Treatment of Generalized Anxiety Disorder (GAD) 297
David S. Baldwin
15 Internet‐ and Computer‐Based Treatments of Generalized Anxiety
Disorder (GAD) 319
Eni Becker and Gerhard Andersson
16 Generalized Anxiety Disorder (GAD) in Children and Adolescents 335
Tina In‐Albon, Tove Wahlund, and Sean Perrin
17 The Road Ahead: What Research Paths Should Be Taken in Order
to Improve Future Treatments? 369
Andrew T. Gloster and Alexander L. Gerlach
Index381
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
x List of Contributors
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

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

List of Contributors xi
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
1
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
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 some-
body 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
Generalized Anxiety Disorder and Worrying: A Comprehensive Handbook for Clinicians and Researchers,
First Edition. Edited by Alexander L. Gerlach and Andrew T. Gloster.
© 2020 John Wiley & Sons Ltd. Published 2020 by John Wiley & Sons Ltd.
2 Alexander L. Gerlach and Andrew T. Gloster
ecessarily result in increased worrying, even in individuals diagnosed with GAD

n
(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, chap-
ter 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; conse-
quently, 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 threaten-
ing 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 dis-
tinguished 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 high-
lighted that a fear image (worry) is usually considered to be acting as an initial ele-
ment 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
Worry, Generalized Anxiety Disorder (GAD), and their Importance 3
(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 wor-
rying 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 rest-
lessness, 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 previ-
ously 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 symptomatol-
ogy, 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
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 suffer-
ing, 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 diag-
nostic 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 recog-
nized 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 gov-
ernment). This study concluded that CBT was more cost‐effective (Heuzenroeder
et al., 2004). The generalizability of this study depends on the modeled costs associ-
ated 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 assump-
tions adequate for the German healthcare system came to a similar conclusion
(Wunsch, Kliem, Grocholewski, & Kröger, 2013). Other aspects that should be con-
sidered 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 comor-
bidly 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 pre-
sent evidence for the overlap of symptoms such as obsessions, rumination, and wor-
rying. 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 cog-
nitive 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
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, empir-
ical 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 differ-
ent classes of pharmacological agents (Baldwin). In addition, the important topic of
digital developments is examined in a chapter on internet and computer interven-
tions, 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).
References
American Psychiatric Association.(1980). Diagnostic and statistical manual of mental disorders

(3rd ed.). Arlington, VA: Author.
(3rd ed., rev.). Arlington, VA: Author.
American Psychiatric Association.(2013). Diagnostic and statistical manual of mental disorders:
DSM‐5. Arlington, VA: Author.
Andor, T., Gerlach, A. L., & Rist, F. (2008). Superior perception of phasic physiological arousal
and the detrimental consequences of the conviction to be aroused on worrying and meta-
cognitions in GAD. Journal of Abnormal Psychology, 117(1), 193–205. doi: 10.1037/
0021‐843X.117.1.193
Barlow, D. H. (2002). Anxiety and its disorders: The nature and treatment of anxiety and panic.
New York, NY: The Guilford Press.
Beekman, A. T. F., Bremmer, M. A., Deeg, D. J. H., Van Balkom, A. J. L. M., Smit, J. H., De
Beurs, E., … Van Tilburg, W. (1998). Anxiety disorders in later life: A report from the
longitudinal aging study Amsterdam. International Journal of Geriatric Psychiatry, 13(10),
717–726.
Beesdo, K., Pine, D. S., Lieb, R., & Wittchen, H.‐U. (2010). Incidence and risk patterns of
anxiety and depressive disorders and categorization of generalized anxiety disorder.
Archives of General Psychiatry, 67(1), 47. doi: 10.1001/archgenpsychiatry.2009.177
Bijl, R., Ravelli, A., & van Zessen, G. (1998). Prevalence of psychiatric disorder in the general
population: Results of the Netherlands Mental Health Survey and Incidence Study
(NEMESIS). Social Psychiatry and Psychiatric Epidemiology, 33(12), 587–595. doi: 10.1007/
s001270050098
Borkovec, T. D. (1994). The nature, function and origins of worry. In G. C. L. Davey &
F. Tallis (Eds.), Worrying: Perspectives on theory, assessment and treatment (pp. 5–33).
Oxford, UK: Wiley.
Borkovec, T. D., & Inz, J. (1990). The nature of worry in generalized anxiety disorder: A pre-
dominance of thought activity. Behaviour Research and Therapy, 28(2), 153–158. doi:
10.1016/0005‐7967(90)90027‐G
Borkovec, T. D., Robinson, E., Pruzinsky, T., & DePree, J. D. (1983). Preliminary exploration
of worry: Some charateristics and processes. Behavior Research and Therapy, 21(1), 9–16.
doi: 10.1016/0005‐7967(83)90121‐3
Craske, M. G. (2003). Origins of phobias and anxiety disorders: Why more women than men?
Oxford, UK: Elsevier Ltd.
Davey, G. C. L., & Levy, S. (1998). Catastrophic worrying: Personal inadequacy and a perse-
verative iterative style as features of the catastrophizing process. Journal of Abnormal
Psychology, 107(4), 576–586. doi: 10.1037/0021‐843X.107.4.576
Fernandez, A., Haro, J. M., Martinez‐Alonso, M., Demyttenaere, K., Brugha, T. S., Autonell, J.,
… Alonso, J. (2007). Treatment adequacy for anxiety and depressive disorders in six European
countries. British Journal of Psychiatry, 190(2), 172–173. doi: 10.1192/bjp.bp.106.023507
Gerlach, A. L., & Stevens, S. (2014). Generalized anxiety disorder: Assessment and treatment.
In P. Emmelkamp & T. Ehring (Eds.), The Wiley handbook of anxiety disorders (pp. 1003–
1037). West Sussex, UK: Wiley. doi: 10.1089/jwh.2014.5150
Haller, H., Cramer, H., Lauche, R., Gass, F., & Dobos, G. J. (2014). The prevalence and bur-
den of subthreshold generalized anxiety disorder: A systematic review. BMC Psychiatry,
14(1). doi: 10.1186/1471‐244X‐14‐128
Heuzenroeder, L., Donnelly, M., Haby, M. M., Mihalopoulos, C., Rossell, R., Carter, R., …
Vos, T. (2004). Cost‐effectiveness of psychological and pharmacological interventions for
generalized anxiety disorder and panic disorder. Australian & New Zealand Journal of
Psychiatry, 38(8), 602–612. doi: 10.1080/j.1440‐1614.2004.01423.x
Kessler, R. C., Berglund, P., Demler, O., Jin, R., Merikangas, K. R., & Walters, E. E. (2005). Lifetime
prevalence and age‐of‐onset distributions of DSM‐IV disorders in the national comorbidity
survey replication. Archives of General Psychiatry, 62, 593–602. doi: 10.1001/archpsyc.62.6.593
Kessler, R. C., & Walters, E. (2002). The national comorbidity survey. In M. T. Tsuang & M.
Tohen (Eds.), Textbook in psychiatric epidemiology (pp. 343–362. doi: 10.1002/0471234311.
ch14). Wiley & Sons.
Lieb, R., Becker, E., & Altamura, C. (2005). The epidemiology of generalized anxiety disorder
in Europe. European Neuropsychopharmacology, 15(4), 445–452. doi: 10.1016/j.
euroneuro.2005.04.010
Ma, X., Xiang, Y. T., Cai, Z. J., Lu, J. Y., Li, S. R., Xiang, Y. Q., … Ungvari, G. S. (2009).
Generalized anxiety disorder in China: Prevalence, sociodemographic correlates,
comorbidity, and suicide attempts. Perspectives in Psychiatric Care, 45(2), 119–127. doi:
10.1111/j.1744‐6163.2009.00212.x
Marten, P. A., Brown, T. A., Barlow, D. H., Borkovec, T. D., Shear, M. K., & Lydiard, R. B.
(1993). Evaluation of the ratings comprising the associated symptom criterion of DSM‐
III‐R generalized anxiety disorder. Journal of Nervous and Mental Disease, 181(11), 676–
682. doi: 10.1097/00005053‐199311000‐00005
Mathews, A. (1990). Why worry? The cognitive function of anxiety. Behaviour Research and
Therapy, 28(6), 455–468. doi: 10.1016/0005‐7967(90)90132‐3
Nutt, D., Argyropoulos, S., Hood, S., & Potokar, J. (2006). Generalized anxiety disorder:
A comorbid disease. European Neuropsychopharmacology, 16, 109–118. doi: 10.1016/j.
euroneuro.2006.04.003
O’Leary, J., & Fisak, B. (2015). Examination of trait stop rules as predictors of worry, perse-
verative thinking, and generalized anxiety disorder symptoms. Journal of Experimental
Psychopathology, 6, 242–252. doi: 10.5127/jep.040714
Olesen, J., Gustavsson, A., Svensson, M., Wittchen, H. U., & Jönsson, B. (2012). The
economic cost of brain disorders in Europe. European Journal of Neurology, 19(1), 155–162.
doi: 10.1111/j.1468‐1331.2011.03590.x
Ruscio, A. M., Hallion, L. S., Lim, C. C. W., Aguilar-Gaxiola, S., Al‐Hamzawi, A., Alonso, J., …
Haro, J. M. letzter genannter Autor nach https://www.ncbi.nlm.nih.gov/pubmed/
28297020 Scott, K. M. (2017). Cross‐sectional comparison of the epidemiology of
DSM‐5 generalized anxiety disorder across the globe. JAMA Psychiatry, 74(5), 465–475.
doi: 10.1001/jamapsychiatry.2017.0056
Slade, T., & Andrews, G. (2001). DSM‐IV and ICD‐10 generalized anxiety disorder: Discrepant
diagnoses and associated disability. Social Psychiatry and Psychiatric Epidemiology, 36(1),
45–51. doi: 10.1007/s001270050289
Stefanopoulou, E., Hirsch, C. R., Hayes, S., Adlam, A., & Coker, S. (2014). Are attentional
control resources reduced by worry in generalized anxiety disorder? Journal of Abnormal
Psychology, 123(2), 330–335. doi: 10.1037/a0036343.
Stein, M. B., Sherbourne, C. D., Craske, M. G., Means‐Christensen, A., Bystritsky, A., Katon,
W., … Roy‐Byrne, P. P. (2004). Quality of care for primary care patients with anxiety dis-
orders. American Journal of Psychiatry, 161(12), 2230–2237. doi: 10.1176/appi.
ajp.161.12.2230
Upatel, T., & Gerlach, A. L. (2008). Appraisal of activating thoughts in generalized anxiety
disorder. Journal of Behavior Therapy and Experimental Psychiatry, 39(3), 234–249. doi:
10.1016/j.jbtep.2007.07.004
Wells, A. (1997). Cognitive therapy of anxiety disorders: A practice manual and conceptual
guide. Chichester, UK: Wiley.
Wittchen, H.‐U. (2002). Generalized anxiety disorder: Prevalence, burden, and cost to society.
Depression and Anxiety, 16(4), 162–171. doi: 10.1002/da.10065
Wittchen, H.‐U., Kessler, R. C., Beesdo, K., Krause, P., Höfler, M., & Hoyer, J. (2002).
Generalized anxiety and depression in primary care: Prevalence, recognition, and manage-
ment. The Journal of Clinical Psychiatry, 63(Suppl 8), 24–34.
World Health Organization. (1992). The ICD‐10 classification of mental and behavioural disor-
ders: Clinical descriptions and diagnostic guidelines. Geneva, Switzerland: Author.
World Health Organization. (2018). International statistical classification of diseases and related
health problems (11th revision). Retrieved from https://icd.who.int/browse11/l‐m/en
Wunsch, E. M., Kliem, S., Grocholewski, A., & Kröger, C. (2013). Wie teuer wird es wirklich?:
Kosten‐Nutzen‐Analyse für Psychotherapie bei Angst‐ und Affektiven Störungen in
Deutschland. Psychologische Rundschau, 64(2), 75–93. doi: 10.1026/0033‐3042/a000154
2
Assessing Worry
An Overview
Marcia T. B. Rinner and
Andrew T. Gloster
Department of Psychology, Division of Clinical Psychology and
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 con-
structs, 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 var-
ies 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 con-
centrating/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,
10 Marcia T. B. Rinner and Andrew T. Gloster
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 devel-
oped 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 worri-
some 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 assess-
ment 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 assess-
ment instruments focus on worry, the key feature of GAD. The Penn State Worry
Assessing Worry 11
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 indi-
vidual’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 bet-
ter 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 dan-
ger; (c) beliefs about cognitive competence; (d) general negative beliefs; and (e) cog-
nitive 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 Scale and no. of items Validation
Self‐report questionnaire of GAD and Worry

Consequences of Worrying Scale Davey et al. (1996) 5‐point likert scale/29 items Davey et al. (1996)
(COWS)
Generalized Anxiety Disorders Shear et al. (2006) 5‐point scale from “none” to “very Shear et al. (2006)
Severity Scale (GADSS) severe”/6 items
Generalized Anxiety Disorder Newman et al. (2002) Items are mainly dichotomous (yes/no), Newman et al. (2002)
Questionnaire‐IV (GADQ‐IV) 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
7‐item self‐rated Generalized Anxiety Spitzer et al. (2006) 4‐point scale from “not at all” to “nearly Spitzer et al. (2006)
Disorder Scale (GAD‐7) every day”/7 items
The 2‐item shortened GAD‐7 Spitzer et al. (2006) 4‐point scale from “not at all” to “nearly Micoulaud‐Franchi et al.
every day”/2 items (2017)
The Generalized Anxiety Disorder‐ Spitzer et al. (2006) 4‐point scale from “not at all” to “nearly Micoulaud‐Franchi et al.
Single Item (GAD‐SI) every day”/1 item (2017)
Penn State Worry Questionnaire Meyer et al. (1990) 5‐point likert‐scale from “not at all Meyer et al. (1990)
(PSWQ) typical” to “very typical”/16 items
Student Worry Scale (SWS) Davey et al. (1992) 4‐point scale from “almost never” to Davey et al. (1992)
“almost always”/10 items
Why Worry Scale (WW & WW‐II) WW: Freeston et al. (1994) WW: 20 items; WW: Freeston et al. (1994)
WW‐II: Holowka et al. (2000) WW‐II: 5 point likert scale from “not at WW‐II: Holowka et al.
all” to “absolutely true”/25 items (2000)
Worry Domains Questionnaire Tallis et al. (1992) 0–8 point frequency and intensity scales Stöber and Seidenstücker
(WDQ) from “never” to “several times a day” (1997)
and “not upsetting” to “extremely
upsetting”/25 items
Worry Domains Questionnaire Short Stöber and Joormann (2001) 5‐point scale from “not at all” to Stöber and Joormann
Form (WDQ‐SF) “extremely”/10 items (2001)
Worry Inventory for Managers Stöber and Seidenstücker (1997) 5‐point scale from “not at all” to Stöber and Seidenstücker
(WIM) “extremely”/24 items (1997)
Worry Scale for Older Adults (WS) Wisocki (1994) 5‐point scale from “never” to “much of Wisocki (1994)
the time”/35 items
Self‐report questionnaires of related constructs
Anxious Thought Inventory (AnTI) Wells (1994) 3‐factors: social worry, health worry, and Wells (1994)
meta‐worry/22 items
Cognitive Intrusions Questionnaire Romero‐Sanchiz, Nogueira‐ 9‐point likert scale/79 items Romero‐Sanchiz, Nogueira‐
(CIQ‐TV) Arjona, Godoy‐Ávila, Arjona, Godoy‐Ávila,
Gavino‐Lázaro, and Gavino‐Lázaro, and
Freeston (2017) Freeston (2017)
Hamilton Rating Scale for Anxiety Hamilton (1959) 5‐point scale from “absent” to “very Maier et al. (1988)
(HAM‐A) severe, incapacitating”/14 items
Meta‐Cognitions Questionnaire Cartwright‐Hatton and Wells 4‐point likert scale from “do not agree,” Cartwright‐Hatton and
(MCQ) (1997) to “agree very much”/65 items Wells (1997)
Meta‐Cognitions Questionnaire Wells and Cartwright‐Hatton 4‐point likert scale from “do not agree” Wells and Cartwright‐
short version (MCQ‐30) (2004) to “agree very much”/30 items Hatton (2004)
Meta‐Cognitions Questionnaire‐ Cartwright‐Hatton et al. 4‐point likert scale from “do not agree” Cartwright‐Hatton et al.
Adolescent Version (MCQ‐A) (2004) to “agree very much”/30 items (2004)
Meta‐cognitions Questionnaire for Bacow et al. (2009) 4‐point likert scale from “do not agree,” Bacow et al. (2009)
Children (MCQ‐C) to “agree very much”/24 Items
Thought Control Questionnaire Wells and Davies (1994) 4‐point scale from “never” to “almost Wells and Davies (1994)
(TCQ) always”/30 items
(continued on p.14 )
Table 2.1 (Continued )
Clinician Rating of related constructs

Anxiety Disorders Interview Schedule Brown et al. (1994) Silverman, Saavedra, and
(ADIS) Pina (2000)
Composite International Diagnostic Kessler and Üstün (2004) Haro et al. (2006)
Interview (CIDI)
Diagnostisches Interview bei Margraf et al. (2017) Margraf et al. (2017)
psychischen Störungen (DIPS)
Structured Clinical Interviews for First et al. (2002) Lobbestael, Leurgans, and
DSM‐IV (SCID‐I) Arntz (2011)
Structured Clinical Interviews for First et al. (2015) First et al. (2015)
DSM‐5 (SCID‐I)
Assessing Worry 15
are adapted versions of the MCQ for measuring metacognitive belief in children and
adolescents. Finally, the TCQ assesses thought controlling strategies (Wells & Davies,
1994). A description of the items of the presented instruments can also be viewed in
Table 2.1.
Additionally, some studies have presented daily diaries as an instrument for the
assessment of worry. For example, a study from Szabó and Lovibond (2002) used a
worry diary to assess the function of worry. Participants were asked to monitor each
worrisome thought they had by writing it down on a diary for 7 days and then subse-
quently to rate the frequency and the uncontrollability of the worries. Similarly, a
study from Borkovec, Harzlett‐Stevens, and Diaz (1999) asked participants to write
down worries each day for 2 weeks in a Worry Outcome Diary.
Psychophysiological measurements have also been used to measure correlates of
worry. One of the trademark indications of anxiety is physiological arousal. In addi-
tion, some authors believe that the unique physiological findings associated with
worry may serve as biological markers for chronic worry (Campbell & Brown, 2002).
Consistent with psychophysiological assessment of anxiety in general, such research
on worry has concentrated on the rigidity of the autonomic nervous system during
worry. It has been demonstrated that low heart rate variability as a measure of an
inflexible autonomic nervous system is associated with higher trait worry (Chalmers,
Quintana, Abbott, & Kemp, 2014) and daily worry (Brosschot et al., 2007). Also,
individuals with higher intolerance of uncertainty show lower heart rate variability
(Deschênes, Dugas, & Gouin, 2016). In addition to measures of autonomic rigidity,
other physiological correlates identified via physiological assessment include elevated
muscle tension and skin conductance as well as predominant activation of the left‐
frontal cortex as measured by the electroencephalogram (EEG; Borkovec et al., 2004;
Hofmann et al., 2005). Further studies have investigated other related aspects of
worry; for example, the release of cortisol, endocrinological or immunological cor-
relates of worry (Brosschot, Gerin, & Thayer, 2006; Schlotz, Hellhammer, Schulz, &
Stone, 2004).
General concerns about psychophysiological measurements have been raised,
including the enormous inter‐individual variability and numerous potential confounds
in most assessment procedures (Herbert, Rheingold, & Brandsma, 2001), cost and
practicality in clinical settings, and the limited relevant information for treatment
planning. Concerns have also been raised about self‐report measurements, such as
self‐report questionnaires being especially prone to cognitive biases.
Challenges in assessing GAD and worry

Despite the availability of many types of validated assessments of GAD and worry, the
assessment of worry and its associated symptoms is subject to challenges and potential
biases. The fact that worry exists on a continuum (Ruscio, Borkovec, & Ruscio, 2001)
necessitates therapists and researchers to be mindful of dimensional issues rather than
simply assessing for the presence/absence of worry. In terms of determining a GAD
diagnosis, difficulty arises because, according to the DSM‐5 (American Psychiatric
Association, 2013) and DSM‐IV (American Psychiatric Association, 2000) one is
required to determine if a symptom occurs primarily in the context of another disorder.
Such a dichotomous decision is complicated and theoretically questionable given the
pervasiveness of worry across anxiety disorders and the high percentage of comorbidity
(Segerstrom, Tsao, Alden, & Craske, 2000). Indeed, forcing dichotomous decisions
with respect to symptom severity and primary diagnosis has been identified as the two
main causes of poor inter‐rater reliability in the diagnosis of GAD (Brown, 2002).
Stemming from the private nature of worry, matters are further complicated by
virtue of the discrepancy between academic and colloquial usages of the word (Hoyer,
Gloster, & Herzberg, 2009). The imprecise nature of the word can lead to inaccura-
cies and biases in data obtained, inferences drawn from the data, and, in therapeutic
settings, faulty case formulation.
Additionally, worry has mainly been assessed with global self‐report assessments,
which is problematic due to cognitive biases that distort the nature, amplitude, and
frequency of the experience of clinical symptoms (Rinner et al., 2019). Cognitive
biases showing a discrepancy between recalled and actual symptoms have been found
across numerous diagnoses. For example, a study from Stone, Broderick, Shiffman,
and Schwartz (2004) showed that patients with chronic pain reported pain more
intensely and more frequently when recalled retrospectively. Patients with panic
disorders and agoraphobia also retrospectively overestimated panic frequency

before treatment when compared to a self‐monitored diary (De Beurs, Lange, & Van
Dyck, 1992; Margraf, Taylor, Ehlers, Roth, & Agras, 1987). Patients with symptoms
of anxiety, and especially patients with a GAD diagnosis, also report memory distor-
tions. Specifically, individuals with GAD have been shown to have a memory bias
toward threatening stimuli and a general tendency to interpret neutral stimuli as
threatening (MacLeod & McLaughlin, 1995; Mathews, 1990). Consequently, assess-
ing worry through retrospective recall increases the risk of false information due to
cognitive bias.
Assessing worry through global self‐report is further restricted because it can’t
measure daily fluctuations of worry. A study from Verkuil et al. (2007) underlined this
fact by showing that global self‐report measures only account for a fraction of variance
in daily experienced worry.
Assessing worry and GAD with the event sampling methodology (ESM)
Several authors recommend using ESM for the assessment of psychological factors
such as worry (Gloster & Karekla, in press; Gloster et al., 2008; Miron‐Shatz, Stone,
& Kahneman, 2009). Through electronic devices, such as smartphone or electronic
diaries, individuals are asked to report on targeted emotions, cognitions, or experi-
ences as they occur during the exact moment of the survey. This methodology cap-
tures worry close to real time and in a natural environment (Thielsch, Andor, &
Ehring, 2015), thereby reducing recollection biases.
Several studies have been conducted using ESM to assess worry. The procedure of
ESM assessment is similar across the studies. Participants are asked to protocol their
worries on a portable device (e.g., iPod, smartphone) or on paper (e.g., daily diary),
for an average duration of 1 week. In some studies, the participants were asked to
protocol their worries each time they observed themselves worrying (event‐based); in
other studies worry was protocolled at randomized or predefined prompted times
(time‐based). The way worry was operationalized differs between studies from a
broad form of assessment, to more distinct forms. An example of a broad assessment
was used by Kircanski et al. (2015; e.g., “At the time of the beep, I was worried about
things that could happen”). More specific forms of assessment include the time spent
Assessing Worry 17
worrying (Dupuy, Beaudoin, Rhéaume, Ladouceur, & Dugas, 2001; Verkuil et al.
2007); the frequency of worry (e.g., “How often did worries occur since the last
report?”: Thielsch, Ehring, Nestler, Wolte, Kopei, Rist, Gerlach, and Andor, 2015; see
also Szabó & Lovibond, 2002; Thielsch, Andor, et al., 2015; Verkuil et al. 2007), the
intensity (e.g., “How much did you worry in the past hour”: Thielsch, Andor, et al.,
2015), the burden of the worried thoughts (“How much were you bothered by worry
in the past hour”; Thielsch, Andor, et al., 2015), the duration of worry (“How many
minutes did you worry since the last report?”: Thielsch, Ehring, et al., 2015), or the
feeling of uncontrollability (e.g., “My worry is uncontrollable”; Thielsch, Ehring,
et al. (2015) see also Szabó & Lovibond 2002). Some of these ESM studies utilized
items from well‐known self‐report questionnaires, such as the MCQ‐30 (Thielsch,
Ehring, et al., 2015) or the WDQ (Verkuil, Brosschot, Gebhardt, & Korrelboom,
2015) to measure worry.
Measuring worry with ESM has increased knowledge about the variance and natu-
ralistic characteristics, functions, and correlates of worry. As such, ESM studies have
shown individual and day/night differences in the duration of worry. For example,
individuals worry longer during the day than at night. During the day, worrying lasts
on average between 22.51 min (SD = 35.61; Verkuil et al., 2007) and 40.71 min
(SD = 42.35; Verkuil et al., 2015). Mean scores for night worrying vary between
5.52 min (SD = 9.42; Verkuil et al., 2007) and 24.50 min (SD = 20.67; Verkuil et al.,
2015). However, the high standard deviations collected within those studies indicated
high inter‐individual differences: some individuals worry more than others.
The observed increased duration of worry during daytime compared to nighttime
in ESM studies led some to examine the relation between worry and sleep. It has been
hypothesized that daytime durations are a consequence of nighttime worry, as medi-
ated by sleep quality. High nighttime worry might reduce sleep quality and thereby
increase worrying on the next day (Verkuil et al., 2015). Indeed, an association
between worry and perceived sleep quality was found in an ESM study from Thielsch,
Ehring, et al. (2015), lending support to this hypothesis.
In addition to showing inter‐individual differences in worry, recent ESM studies
also report associations between worry and specific groups. For example, Verkuil et al.
(2015) showed that individuals with a high level of work stress worried almost twice
as often compared to a control group, and particularly showed increased worry dur-
ing nighttime. Similar results were shown in individuals with a GAD diagnosis.
Participants in the GAD group spent significantly more time worrying (309.9 min,
SD = 195.46) than a non‐GAD control group (54.93 min, SD = 62.85; Dupuy et al.,
2001). Equivalent levels of worry, however, were found between individuals with a
diagnosis of GAD and/or major depression disorder (MDD; Kircanski et al., 2015).
ESM studies have also investigated further bivariate relationships between worry
and other variables that inform about the nature of worry. For example, associations
between worry frequency and worry duration (r = 0.83; Brosschot et al., 2007) and
between daily worry and goal attainment (Verkuil et al., 2015) have been reported.
A further ESM study also showed that negative metacognitions (i.e., “worry is uncon-
trollable and dangerous”) predicts the intensity and burden of worry in everyday life
and showed that negative cognitions account for an essential proportion of the vari-
ance of daily worry (Thielsch, Ehring, et al., 2015).
ESM has also been used as a therapy tool to reduce worry in individuals with a
GAD diagnosis (LaFreniere & Newman, 2016). Researchers have demonstrated that
ESM is a good tool to assess psychological constructs, such as worry in daily life. The
clinical utility of this approach needs further examination. In sum, the assessment of
worry with ESM has increased knowledge about the nature, variability, function, and
association effects of worry in a naturalistic setting. However, further ESM studies are
needed to increase the understanding of worry and GAD and the use of ESM as a
therapy tool.
Differential Diagnosis of GAD and the Overlap

of Worry with Related Constructs
A difficulty with the diagnosis of GAD is that many GAD‐relevant symptoms overlap
with symptoms of other psychological disorders. Diagnostic criteria for MDD and
GAD both include concentration problems, sleep disturbances, fatigue, and restless-
ness (American Psychiatric Association, 2013). This overlap contributes to difficulties
with differential diagnosis. In addition, patients with depression and GAD both report
negative forms of thinking (rumination and worry, respectively). The content of those
thoughts, however, differs with respect to time reference. GAD patients report future‐
orientated negative thoughts (worrying) compared to patients with depression, who
tend to report intrusive negative thoughts about past experiences (ruminating; Yang
et al., 2014). Thus, one differential aspect that can be considered is the time reference
of the negative thoughts.
The differential diagnosis of GAD is also necessary with other diagnoses. Similar to
depression and GAD, patients with social anxiety and panic attacks report worrisome
thoughts. Patients with social anxiety report, for example, worrying about having
behaved in an embarrassing manner within a social contact, whereas patients with
panic attacks report worrying about the fear of attacks occurring or the fear of losing
control. For the differential diagnosis of depression, panic attacks, social anxiety, and
GAD, this distinction suggests that assessing the content of negative thoughts (e.g.,
fear of losing control, fear of social evaluation, etc.) can give clarity about the diagno-
sis. Another difficulty in the diagnosis of GAD consists in the symptom overlap of
GAD, illness anxiety disorder, and OCD. A study from Romero‐Sanchiz et al. (2017)
assessed the differences and similarities of intrusive thoughts for GAD, illness anxiety
disorder, and OCD and tested the relevance of specific variables as a possibility for
differentiating the three disorders. Specifically, the intrusive thoughts of 125 patients
with either a diagnosis of GAD, OCD, or illness anxiety were evaluated using the
Cognitive Intrusions Questionnaire (CIQ‐TV; Romero‐Sanchiz et al., 2017). The
result showed that a high frequency of body stimuli, as a trigger preceding intrusive
thoughts, was characteristic for patients with illness anxiety and less important for
patients with GAD or OCD. The results further indicated that OCD patients showed
higher levels of responsibility compared to patients with GAD and illness anxiety. The
results of this study provide indications for variables that are important for discrimi-
nating between GAD, OCD, and illness anxiety.
Moreover, an aspect that is worrying in GAD is that it is closely related to cognitive
avoidance. GAD patients show various cognitive avoidance strategies to suppress or avoid
perceived future threats (Borkovec et al., 2004). However, this is not specific to GAD, as
patients with other mental disorders also engage in cognitive avoidance strategies. Indeed,
Assessing Worry 19
experiential avoidance of all types of unwanted internal and external stimuli has been
associated with numerous disorders (Hayes, Luoma, Bond, Masuda, & Lillis, 2006).
Cognitive avoidance has been shown, however, to differ between pathological and non‐
pathological worriers. Therefore, cognitive avoidance has been suggested to discriminate
between adults with and without GAD (Dugas, Gagnon, Ladouceur, & Freeston, 1998).
Conclusion
This chapter reviews the different types of assessments of worry, GAD, and of related
constructs, as well as the challenges in assessing these. For instance, individual varia-
tions in the subjective understanding of the word worry in respondents and biases
associated with its retrospective recollection are consistent challenges in its assess-
ment. Furthermore, when assessing worry, its continuous and private nature should
be considered. Given the difficulty in assessing and identifying worry, it is advisable to
consider a multi‐level, multi‐method approach that coordinates the use of question-
naires, clinical interviews, physiological methods, and ESM to assess worry (Gloster
& Karekla, in press).
References

(4th ed., Text Revision). Washington, DC.
(DSM‐5®). Washington, DC: American Psychiatric Publishing.
Antony, M. M., Orsillo, S. M., & Roemer, L. (2001). Chapter 14: Generalized anxiety disor-
der: A brief overview and guide to assessment. In M. M. Antony, S. M. Orsillo, &
L. Roemer (Eds.), Practitioner’s guide to empirically based measures of anxiety (pp. 189–
195). New York, NY: Springer.
Bacow, T. L., Pincus, D. B., Ehrenreich, J. T., & Brody, L. R. (2009). The metacognitions
questionnaire for children: Development and validation in a clinical sample of children and
adolescents with anxiety disorders. Journal of Anxiety Disorders, 23, 727–736. doi:
10.1016/j.janxdis.2009.02.013
Borkovec, T. D., Alcaine, O. M., & Behar, E. (2004). Avoidance theory of worry and general-
ized anxiety disorder. In Generalized anxiety disorder (pp. 77–108). New York, NY: The
Guilford Press.
Borkovec, T. D., Harzlett‐Stevens, H., & Diaz, M. L. (1999). The role of positive beliefs about
worry in generalized anxiety disorder and its treatment. Clinical Psychological and
Psychotherapy, 6, 126–138.
Borkovec, T. D., Robinson, E., Pruzinsky, T., & DePree, J. A. (1983). Preliminary exploration
of worry: Some characteristics and processes. Behaviour Research and Therapy, 21(I),
9–16.
Brosschot, J. F., Gerin, W., & Thayer, J. F. (2006). The perseverative cognition hypothesis:
A review of worry, prolonged stress‐related physiological activation, and health. Journal of
Psychosomatic Research, 60, 113–124. doi: 10.1016/j.jpsychores.2005.06.074
Brosschot, J. F., Van Dijk, E., & Thayer, J. F. (2007). Daily worry is related to low heart rate
variability during waking and the subsequent nocturnal sleep period. International Journal
of Psychophysiology, 63, 39–47. doi: 10.1016/j.ijpsycho.2006.07.016
Brown, T. A. (2002). Classification of anxiety disorders. In D. J. Stein & E. Hollander (Eds.),

The American psychiatric publishing textbook of anxiety disorders (pp. 13–27). Washington,
DC: American Psychiatric Publishing.
Brown, T. A., DiNardo, P. A., & Barlow, D. H. (1994). Anxiety disorders interview schedule for
DSM‐IV (ADIS‐IV). New York, NY: Graywind.
Campbell, L. A., & Brown, T. A. (2002). Generalized anxiety disorder. In M. M. Antony &
D. H. Barlow (Eds.), Handbook of assessment and treatment planning for psychological
disorders (pp. 147–173). New York, NY: The Guilford Press.
Cartwright‐Hatton, S., Mather, A., Illingworth, V., Brocki, J., Harrington, R., & Wells,
A. (2004). Development and preliminary validation of the meta‐cognitions question-
naire — Adolescent version. Journal of Anxiety Disorders, 18, 411–422. doi: 10.1016/
S0887‐6185(02)00294‐3
Cartwright‐Hatton, S., & Wells, A. (1997). Belief about worry and intrusions: The meta‐cog-
nitions questionnaire and its correlates. Journal of Anxiety Disorders, 11(3), 279–296.
Chalmers, J. A., Quintana, D. S., Abbott, M. J., & Kemp, A. H. (2014). Anxiety disorders are
associated with reduced heart rate variability: A meta‐analysis. Frontiers in Psychiatry,
5(July), 1–11. doi: 10.3389/fpsyt.2014.00080
Davey, G. C. L., Hampton, J., Farrell, J., & Davidson, S. (1992). Some characteristics of
worrying: Evidence for worrying and anxiety as separate constructs. Personality and

Individual Differences, 13(2), 133–147.
Davey, G. C. L., Tallis, F., & Capuzzo, N. (1996). Beliefs about the consequences of worrying.
Cognitive Therapy and Research, 20(5), 499–520.
De Beurs, E., Lange, A., & Van Dyck, R. (1992). Self‐monitoring of panic attacks and retro-
spective estimates of panic: Discordant findings. Behaviour Research and Therapy, 30(4),
411–413.
Deschênes, S. S., Dugas, M. J., & Gouin, J. (2016). Intolerance of uncertainty, worry catastro-
phizing, and heart rate variability during worry‐inducing tasks. Personality and Individual
Differences, 90, 199–204. doi: 10.1016/j.paid.2015.11.015
Dugas, M. J., Gagnon, F., Ladouceur, R., & Freeston, M. H. (1998). Generalized anxiety disorder:
A preliminary test of a conceptual model. Behaviour Research and Therapy, 36, 215–226.
Dupuy, J.‐B., Beaudoin, S., Rhéaume, J., Ladouceur, R., & Dugas, M. J. (2001). Worry: Daily
self‐report in clinical and non‐clinical populations. Behaviour Research and Therapy, 39,
1249–1255.
First, M. B., Spitzer, R. L., Gibbon, M., & Williams, J. B. W. (2002). Structured clinical inter-
view for DSM‐IV‐TR Axis I disorders, research version, patient edition(SCID‐I/P)
(November). New York, NY: Biometrics Research, New York State Psychiatric Institute.
First, M. B., Williams, J. B. W., Karg, R. S., & Spitzer, R. L. (2015). Structured clinical interview
for DSM‐5 disorders, clinician version (SCID‐5‐CV). Arlington, TX: American Psychiatric
Association.
Freeston, M. H., Rhéaume, J., Letarte, H., Dugas, M. J., & Ladouceur, R. (1994). Why do
people worry? Personality and Individual Differences, 17(6), 791–802.
Gloster, A. T., & Karekla, M. (in press). A multi‐level, multi‐method approach to testing and
refining intervention targets. In S. C. Hayes & S. G. Hofmann (Eds.), Beyond the DSM.
Oakland, CA: Context Press/New Harbinger.
Gloster, A. T., Richard, D. C. S., Himle, J., Koch, E., Anson, H., Lokers, L., & Thornton, J.
(2008). Accuracy of retrospective memory and covariation estimation in patients with
obsessive‐compulsive disorder. Behaviour Research and Therapy, 46(5), 642–655. doi:
10.1016/j.brat.2008.02.010
Hamilton, M. (1959). The assessment of anxiety states by rating. The British Journal of Medical
Psychology, 32, 50–55.
Haro, J. M., Arbabzadeh‐Bouchez, S., Brugha, T. S., de Girolamo, G., Guyer, M. E., Jin, R.,
… Kessler, R. C. (2006). Concordance of the Composite International Diagnostic
Assessing Worry 21
Interview version 3.0 (CIDI 3.0) with standardized clinical assessments in the WHO
World Mental Health Surveys. International Journal of Methods in Psychiatric Research,
15(4), 167–180.
Hayes, S. C., Luoma, J. B., Bond, F. W., Masuda, A., & Lillis, J. (2006). Acceptance and com-
mitment therapy: Model, processes and outcomes. Behaviour Research and Therapy, 44(1),
1–25.
Herbert, J. D., Rheingold, A. A., & Brandsma, L. L. (2001). Assessment of social anxiety and
social phobia. In S. G. Hofmann & P. M. DiBartolo (Eds.), From social anxiety to social
phobia: Multiple perspectives (pp. 20–45). Boston, MA: Allyn & Bacon.
Hofmann, S. G., Pizzagalli, D. A., Moscovitch, D. A., Litz, B. T., Hyo‐jin, K., & Davis, L. L.
(2005). The worried mind: Autonomic and prefrontal activation during worrying.
Emotion, 5(4), 464–475. doi: 10.1037/1528‐3542.5.4.464
Holowka, D. W., Dugas, M. J., Francis, K., & Laugesen, N. (2000, November). Measuring
beliefs about worry: A psychometric evaluation of the Why Worry‐II Questionnaire. Poster
presented at the annual convention of the Association for Advancement of Behavior
Therapy, New Orleans, LA.
Hoyer, J., Gloster, A. T., & Herzberg, P. Y. (2009). Is worry different from rumination? Yes, it
is more predictive of psychopathology! Research Article, 6, 1–9.
Kessler, R. C., & Üstün, T. B. (2004). The World Mental Health (WMH) survey initiative version
of the World Health Organization (WHO) Composite International Diagnostic Interview
(CIDI). International Journal of Methods in Psychiatric Research, 13(2), 93–120.
Kircanski, K., Thompson, R. J., James, E., Sherdell, L., & Gotlib, I. H. (2015). Rumination
and worry in daily life: Examining the naturalistic validity of theoretical constructs. Clinical
Psychological Science, 3(6), 926–939. doi: 10.1177/2167702614566603
LaFreniere, L. S., & Newman, M. G. (2016). A brief ecological momentary intervention for
generalized anxiety disorder: A randomized controlled trial of the worry outcome journal.
Depression and Anxiety, 33, 829–839. doi: 10.1002/da.22507
Lobbestael, J., Leurgans, M., & Arntz, A. (2011). Assessment Inter‐Rater Reliability of the
Structured Clinical Interview for DSM‐IV Axis I Disorders (SCID I) and Axis II Disorders
(SCID II). Clinical Psychological and Psychotherapy, 18, 75–79.
MacLeod, C., & McLaughlin, K. (1995). Implicit and explicit memory bias in anxiety: A concep-
tual replication. Behaviour Research and Therapy, 33(1), 1–14.
Maier, W., Buller, R., Philipp, M., & Heuser, I. (1988). The Hamilton anxiety scale: Reliability,
validity and sensitivity to change in anxiety and depressive disorders. Journal of Affective
Disorders, 14, 61–68.
Margraf, J., Cwik, J. C., Suppiger, A., & Schneider, S. (2017). DIPS Open Access: Diagnostisches
Interview bei psychischen Störungen. Bochum, Germany: Forschungs‐ und Behandlungszentrum
für psychische Gesundheit, Ruhr‐Universität Bochum. doi: 10.13154/rub.100.89 http://
dips.rub.de
Margraf, M., Taylor, B., Ehlers, A., Roth, W. T., & Agras, W. S. (1987). Panic attacks in the
natural environment. The Journal of Nervous and Mental Disease, 175(9), 558–565.
Mathews, A. (1990). Why worry? The cognitive function of anxiety. Behaviour Research and
Therapy, 28(6), 455–468.
Meyer, T. J., Miller, M. L., Metzger, R. L., & Borkovec, T. D. (1990). Development and validation
of the penn state worry questionnaire. Behaviour Research and Therapy, 28(6), 487–495.
Micoulaud‐Franchi, J.‐A., Bartolomei, F., & McGonigal, A. (2017). Ultra‐short screening
instruments for major depressive episode and generalized anxiety disorder in epilepsy: The
NDDIE‐2 and the GAD‐SI. Journal of Affective Disorders, 210, 237–240. doi: 10.1016/j.
jad.2016.12.038
Miron‐Shatz, T., Stone, A., & Kahneman, D. (2009). Memories of yesterday’s emotions: Does
the valence of experience affect the memory‐experience gap? Emotion, 9(6), 885–891. doi:
10.1037/a0017823
Newman, M. G., Zuellig, A. R., Kachin, K. E., Constantino, M. J., Przeworski, A., Erickson,
T., & Cashman‐McGrath, L. (2002). Preliminary reliability and validity of the generalized
anxiety disorder questionnaire‐IV: A revised self‐report diagnostic measure of generalized
anxiety disorder. Behavior Therapy, 33, 215–233.
Rinner, M. T. B., Meyer, A. H., Mikoteit, T., Hoyer, J., Imboden, C., Hatzinger, M., … Gloster,
A. T. (2019). General or specific? The memory‐experience gap for individuals diagnosed
with a major depressive disorder or a social phobia diagnosis, and individuals without such
diagnoses. Memory, 27(9), 1194–1203. doi: 10.1080/09658211.2019.1640252
Romero‐Sanchiz, P., Nogueira‐Arjona, R., Godoy‐Ávila, A., Gavino‐Lázaro, A., & Freeston,
M. H. (2017). Assessing transdiagnostic intrusive thoughts: Factor structure, reliability and
validity of the Cognitive Intrusions Questionnaire‐Transdiagnostic version in a Spanish sam-
ple. Personality and Individual Differences, 114, 181–186. doi: 10.1016/j.paid.2017.04.008
Ruscio, A. M., Borkovec, T. D., & Ruscio, J. (2001). A taxometric investigation of the latent
structure of worry. Journal of Abnormal Psychology, 110(3), 413–422. doi:
10.1037//0021‐843X.130.3.413
Schlotz, W., Hellhammer, J., Schulz, P., & Stone, A. A. (2004). Perceived work overload and
chronic worrying predict weekend – weekday differences in the cortisol awakening response.
Psychosomatic Medicine, 214, 207–214. doi: 10.1097/01.psy.0000116715.78238.56
Segerstrom, S. C., Tsao, J. C. I., Alden, L. E., & Craske, M. G. (2000). Worry and rumination:
Repetitive thought as a concomitant and predictor of negative mood. Cognitive Therapy
and Research, 24(6), 671–688.
Shear, K., Herbeck Belnap, B., Mazumdar, S., Houck, P., & Rollman, B. L. (2006). Generalized
Anxiety Disorder Severity Scale (GADSS): A preliminary validation study. Depression and
Anxiety, 23(January), 77–82. doi: 10.1002/da.20149
Silverman, W. K., Saavedra, L. M., & Pina, A. A. (2000). Test‐retest reliability of anxiety symp-
toms and diagnoses with the anxiety disorders interview schedule for DSM‐IV: Child and
parent versions. Journal of the American Academy of Child & Adolescent Psychiatry, 40(8),
937–944. doi: 10.1097/00004583‐200108000‐00016
Spitzer, R. L., Kroenke, K., Williams, J. B. W., & Löwe, B. (2006). A brief measure for assess-
ing generalized anxiety disorder. The GAD‐7. American Medical Association, 166,
1092–1097.
Stöber, J., & Joormann, J. (2001). A short form of the worry domains questionnaire: Construction
and factorial validation. Personality and Individual Differences, 31, 591–598.
Stöber, J., & Seidenstücker, B. (1997). Notes and shorter communications: A new inventory
for assessing worry in managers: Correlates with job involvement and self‐reliance. Personal
and Individual Differences, 23(6), 1085–1087.
Stone, A. A., Broderick, J. E., Shiffman, S. S., & Schwartz, J. E. (2004). Understanding recall
of weekly pain from a momentary assessment perspective: Absolute agreement, between‐
and within‐person consistency, and judged change in weekly pain. Pain, 107, 61–69. doi:
10.1016/j.pain.2003.09.020
Szabó, M., & Lovibond, P. F. (2002). The cognitive content of naturally occurring worry
episodes. Cognitive Therapy and Research, 26(2), 167–177.
Tallis, F., Eysenck, M., & Mathews, A. (1992). A questionnaire for the measurement of non-
pathological worry. Personal and Individual Differences, 13(2), 161–168.
Thielsch, C., Andor, T., & Ehring, T. (2015). ScienceDirect do metacognitions and intolerance
of uncertainty predict worry in everyday life? An ecological momentary assessment study.
Behavior Therapy, 46(4), 532–543. doi: 10.1016/j.beth.2015.05.001
Thielsch, C., Ehring, T., Nestler, S., Wolters, J., Kopei, I., Rist, F., … Andor, T. (2015).
Metacognitions, worry and sleep in everyday life: Studying bidirectional pathways using
ecological momentary assessment in GAD patients. Journal of Anxiety Disorders, 33, 53–
61. doi: 10.1016/j.janxdis.2015.04.007
Assessing Worry 23
Verkuil, B., Brosschot, J. F., Gebhardt, W. A., & Korrelboom, K. (2015). Goal linking and
everyday worries in clinical work stress: A daily diary study. British Journal of Clinical
Psychology, 54, 378–390. doi: 10.1111/bjc.12083
Verkuil, B., Brosschot, J. F., & Thayer, J. F. (2007). Capturing worry in daily life: Are trait
questionnaires sufficient? Behaviour Research and Therapy, 45, 1835–1844. doi: 10.1016/j.
brat.2007.02.004
Watkins, E. R. (2008). Constructive and unconstructive repetitive thought. Psychological
Bulletin, 134(2), 163–206. doi: 10.1037/0033‐2909.134.2.163
Wells, A. (1994). A multi‐dimensional measure of worry: Development and preliminary valida-
tion of the anxious thoughts inventory. Anxiety, Stress, & Coping, 6(4), 289–299. doi:
10.1080/10615809408248803
Wells, A., & Cartwright‐Hatton, S. (2004). A short form of the metacognitions questionnaire:
Properties of the MCQ‐30. Behaviour Research and Therapy, 42, 385–396. doi: 10.1016/
S0005‐7967(03)00147‐5
Wells, A., & Davies, M. I. (1994). The thought control questionnaire: A measure of individual
differences in the control of unwanted thoughts. Behaviour Research and Therapy, 32(8),
871–878.
Wisocki, P. A. (1994). The experience of worry among the elderly. In G. C. L. Davey & F.
Tallis (Eds.), Wiley series in clinical psychology. Worrying: Perspectives on theory, assess-
ment and treatment (p. 247–261). John Wiley & Sons.
Yang, M.‐J., Kim, B.‐N., Lee, E.‐H., Lee, D., Yu, B.‐H., Jeon, H. J., & Kim, J.‐H. (2014).
Diagnostic utility of worry and rumination: A comparison between generalized anxiety
disorder and major depressive disorder. Psychiatry and Clinical Neurosciences, 68, 712–
720. doi: 10.1111/pcn.12193
3
Perceptions of Threat
Keith Bredemeier1 and Howard Berenbaum2
1
Center for the Treatment and Study of Anxiety, Philadelphia, PA, USA
2
Department of Psychology, University of Illinois at Urbana‐
Champaign, Champaign, IL, USA
Introduction
A perceived threat involves the subjective recognition of a potential (but uncertain)

future undesirable outcome. Such perceptions can be further subdivided into two key
components: (a) the predicted likelihood, or probability, that the undesirable out-
come will occur; and (b) the expected impact, or cost, to the individual if it does.
One’s awareness of a negative outcome that may occur and appraisal of it as threaten-
ing reflects these expectations as well as other factors, including their current mood/
arousal, comfort with distress, and perceived ability to control or cope with the out-
come (see Bandura, 1988; Beck & Clark, 1988; Berenbaum, 2010; Smith & Lazarus,
1990, 1993; Upatel & Gerlach, 2008).
We conceptualize worrying as a form of repetitive thinking that is negatively
valenced and future‐oriented. Thus, there is a clear conceptual connection between
worry and perceptions of threat. Indeed, threat perceptions have long played a central
role in cognitive theories of worry and anxiety. Beck and Clark (1988) argued that
anxiety states differ from depression in that they involve “the theme of perceived
physical or psychological threat to one’s personal domain” (p. 23). They later pro-
posed that anxiety is initiated by the registration of a threat stimulus, which triggers a
“primal threat mode” (Beck & Clark, 1997). Borkovec, Alcaine, and Behar (2004)
echoed this proposal, stating that “it is the perception of threat that initiates the anxi-
ety process” (p. 81). More recently, Berenbaum (2010) developed a two‐phase, pro-
cess model of worrying, in which perceptions of threat play a central role. Specifically,
Berenbaum proposed that the development or activation of a perceived threat initiates
worrying, whereas accepting that the threat exists is what allows an individual to ter-
minate the worrying process.
Taking this idea one step further, we propose that a perceived threat is necessary for
worrying to occur. In other words, we believe that an individual can only have the
experience of worrying if there is an undesirable outcome that may occur sometime
26 Keith Bredemeier and Howard Berenbaum
in the future for them to worry about.1 If accurate, this suggests that understanding
the nature, origins, and consequences of these threat perceptions has critical implica-
tions for theories of, and treatment for, excessive worry and generalized anxiety
disorder (GAD). Although this chapter focuses on research about the general ten-
dency to worry, along with GAD, there is emerging evidence that worrying is a trans-
diagnostic problem (e.g., Kertz, Bigda‐Peyton, Rosmarin, & Björgvinsson, 2012;
McEvoy, Watson, Watkins, & Nathan, 2013). In line with this idea, there is certainly
evidence that more circumscribed threat perceptions (e.g., of physical harm after a
traumatic event; about being evaluated negatively by others) play a prominent role in
other anxiety pathology (e.g., post‐traumatic stress disorder (PTSD)—see Gil &
Caspi, 2006; White, McManus, & Ehlers, 2008; social phobia—see Rapee, 1997;
Uren, Szabo, & Lovibond 2004).
Measuring Perceptions of Threat
Perceptions of threat are typically measured in psychological research by describing a

variety of hypothetical outcomes and asking respondents to indicate how likely they
are to occur (typically using a forced choice rating scale; e.g., from 0 = “not at all
likely” to 6 = “almost certain”), and the expected cost should they occur (also using
a rating scale; e.g., 0 = “not at all bad” to 6 = “horrific”). For example, Berenbaum,
Thompson, and Bredemeier (2007)) presented research participants with 39 out-
comes (e.g., “your health deteriorating,” “making a mistake at work”) that represent
the major domains that people tend to worry about (e.g., interpersonal, achievement,
financial, health). The goal of aggregating across a large number of varied outcomes
is to measure the individual’s general propensity to perceive threat, in a way that is not
idiosyncratic to any particular outcome (and psychometrically, to promote reliability).
Nevertheless, one can also measure (and aggregate) perceptions of threat within a
particular life domain, such as negative social performance outcomes pertinent to
social phobia (e.g., “during a job interview, you will freeze”—Foa, Franklin, Perry, &
Herbert, 1996; “you will do something foolish in public”—Uren et al., 2004).
Although researchers have almost always measured perceptions of threat nomo-
thetically (as just described), idiographic approaches are also possible. For example,
Berenbaum, Thompson, and Pomerantz (2007) asked research participants to list the
five undesirable outcomes that they thought about most often, after which they were
asked to indicate how likely and costly they thought each outcome was. Recently,
Berenbaum et al. (2018) used an ecological momentary assessment strategy to study
worrying. Participants were prompted six times per day (at a random point in time
during each of six consecutive 2‐h blocks) and asked whether they had been worrying.
If they reported worrying, they were asked to indicate how likely and costly the out-
come was about which they had been worrying (findings from this study are discussed
in the next section).
Nomothetic and idiographic approaches have complementary strengths and weak-
nesses. Idiographic approaches have the advantage of asking about outcomes that will
necessarily be realistic and meaningful to the respondent; thus they have strong eco-
logical validity. In contrast, nomothetic approaches may require respondents to esti-
mate the likelihood and cost of outcomes that are unfamiliar. On the other hand,
comparisons across people are more easily interpretable when their likelihood and
Perceptions of Threat 27
cost estimates are about the same set of outcomes, as is the case using a nomothetic
approach. In contrast, if using an idiographic approach, comparisons across people
can be misleading if they concern very different kinds of outcomes. For example, if
Adele reports she is very likely to contract a minor illness whereas Bill reports he is
unlikely to die of cancer, it is difficult to judge whether Adele or Bill is more likely to
overestimate threat.
Thus far we have discussed explicit (self‐report) measures of threat perception,
which share the same potential shortcomings as virtually all other self‐reports (e.g.,
inaccuracies due to impression management). Despite their shortcomings, it is our
opinion that they are superior to the alternatives, which we will discuss very briefly.
For example, there is an extensive literature examining attentional biases to threaten-
ing information (see Bar‐Haim, Lamy, Pergamin, Bakermans‐Kranenburg, & Van
Ijzendoorn, 2007). Although we expect attentional biases to be associated with per-
ceptions of threat (as will be discussed more later), we propose that behavioral meas-
ures of these biases are at most an indirect index of perceived threat. Furthermore, a
measure of attentional bias would not enable the decomposition of perception of
threat into perceptions of probability and cost, which research suggests is important
(discussed in detail in the next section). One might also consider behavioral avoid-
ance/approach to be an indirect index of perceived threat. For example, the degree
that someone is very willing to approach a snake is an indication that they do not
perceive snakes as being as threatening, in contrast to someone who takes great pains
to avoid snakes. One problem with using behavioral avoidance/approach to measure
perceived threat is that this risks conflating perception of threat with anxiety (worry
and/or fear). Similarly, such measures may be confounded by general coping tenden-
cies/strategies (e.g., experiential avoidance).
Research Linking Perceptions of Threat and Worrying
Despite consistent claims by theorists of a close link between perceived threat and wor-
rying, still relatively few studies have directly tested this. Nevertheless, among those
studies that have, greater levels of perceived threat have consistently been associated
with higher levels of worry (Berenbaum, Thompson, & Bredemeier, 2007; Berenbaum,
Thompson, & Pomerantz, 2007; Bredemeier, Berenbaum, & Spielberg, 2012; Butler
& Mathews, 1983; Constans, 2001; MacLeod, Byrne, & Valentine, 1996; MacLeod,
Williams, & Bekerian, 1991). Specifically, several studies have shown that probability
estimates for future negative outcomes (e.g., “your health deteriorating,” “making a
mistake at work,” “doing something foolish in public”) are positively correlated with
levels of worry (Berenbaum, Thompson, & Bredemeier, 2007; Berenbaum, Thompson,
& Pomerantz, 2007; Bredemeier et al., 2012; Butler & Mathews, 1983; Constans,
2001; MacLeod et al., 1991; MacLeod et al., 1996), and some have also shown that
perceived cost estimates are positively associated with worry (Berenbaum, Thompson,
& Bredemeier, 2007; Berenbaum, Thompson, & Pomerantz, 2007; Bredemeier et al.,
2012; Butler & Mathews, 1983). Some additional (but indirect) support for a link
between worry/anxiety and elevated threat perceptions comes from experimental
studies showing that: (a) anxious and fearful/phobic individuals exhibit “online expec-
tancy biases” (e.g., higher expectations of harm) when presented with feared stimuli
(e.g., pictures of snakes; see Aue & Okon‐Singer, 2015); (b) individuals with GAD rate
negative events as more plausible when engaging in “episodic future thinking” (i.e.,
imagining future events; Wu, Szpunar, Godovich, Schacter, & Hofmann, 2015); and
(c) changes in perceived threat occur during cognitive‐behavioral therapy (CBT) for
anxiety disorders, which in turn predicts symptom improvement (e.g., Espejo, Gorlick,
& Castriotta, 2017).
But is perceived threat associated specifically with worry or, alternatively, is it associ-
ated just as strongly with other facets of emotional distress? It turns out that the
answer appears to depend on the specific aspect of the perception of threat, namely
the distinction between the perceived probabilities and the perceived costs. Andersen,
Spielman, and Bargh (1992) found that people who were depressed judged undesir-
able outcomes as more likely to occur than did non‐depressed individuals; they did
not examine worry and did not examine cost estimates. MacLeod et al. (1996) found
that depression was as strongly associated with (elevated) probability estimates for
unpleasant outcomes as was worry; they also did not examine cost estimates.
Berenbaum, Thompson, and Bredemeier (2007) examined both worry and depres-
sion, and both probability and cost estimates. They found that elevated probability
estimates were associated with symptoms of depression in addition to worry, whereas
elevated cost estimates were uniquely linked with worry (i.e., were not associated with
depression). Taking this finding one step further, we hypothesize that the tendency to
overestimate the likelihood of a negative outcome may be a common etiological fac-
tor in different forms of distress (and, thus, will be associated with any form of psy-
chopathology, and likely also elevated levels of general negative affect/neuroticism).
Conversely, the tendency to overestimate the cost of a negative outcome if it does
occur may be a specific factor driving worry, comparable to other biases that have
been found to be uniquely associated with other symptoms/disorders (e.g., underes-
timating positive outcomes in depression; see MacLeod & Byrne, 1996 and Miranda
& Mennin, 2007).
Carr (1974) proposed that perception of threat is “some multiplicative function of
the subjective cost of an event and its subjective probability” (p. 315). To our knowl-
edge, the potential multiplicative effect of probability and cost (which can be quanti-
tatively tested by examining whether the interaction of probability and cost predicts
worry over and above their independent predictive utility) was first evaluated by
Berenbaum, Thompson, and Pomerantz (2007). As predicted, they found that prob-
ability and cost estimates interactively predict worrying. More specifically, the link
between probability estimates and worrying was stronger among those with elevated
cost estimates, relative to those with lower cost estimates. However, Berenbaum,
Thompson, and Bredemeier (2007) failed to replicate this finding. A potential expla-
nation for this discrepancy emerged from a study by Bredemeier et al. (2012), which
explored differential associations between worry and expected negative outcomes
across different timeframes. This study found that the interactive effect of probability
and cost estimates predicting levels of worry was stronger when participants were
considering outcomes far into the future (i.e., the next 10 years) than when consider-
ing more proximal outcomes (i.e., the next month or year). Conversely, the direct
relationship between probability estimates and worry was strongest when participants
were considering the closest timeframe (i.e., the next month). A similar three‐way
interaction between perceived probability, perceived cost, and timeframe was found
within‐subjects in the ecological momentary assessment (EMA) study conducted by
Berenbaum et al. (2018). Specifically, the impact of high cost estimates was stronger
when perceived probability was high, particularly when the anticipated outcome was
further in the future. What is particularly important about this result is that it was
found within‐subjects, which means it cannot be accounted for by individual differ-
ences between subjects (e.g., in neuroticism, depression, intolerance of uncertainty).
Results from these studies highlight the importance of proximity in evaluating the
potential impact of threat perceptions, consistent with other theoretical models/
perspectives (e.g., the threat‐immense model; see Fanselow, 1994). The differential
relations between worry and perceptions of threat across timeframes may reflect ten-
dencies of those who are prone to worrying to: (a) view threats as increasing (see
Riskind, 1997), possibly leading to greater distortions over time; and/or (b) avoid
thinking concretely about potential negative outcomes (see Borkovec et al., 2004;
Stober & Borkovec, 2002), which undermines corrective information processing as
well as active problem‐solving (for further discussion of potential mechanisms, see
Bredemeier et al. (2012)).
Collectively, these findings provide strong empirical support for the proposed link
between perceived threat and worrying. Also, these findings support the critical dis-
tinction between probability and cost estimates in research on threat perceptions.
The importance of this distinction is further supported by work exploring hypothe-
sized antecedents (and, thus, potential causes) of elevated perceptions of threat, dis-
cussed next.
Formation of Threat Perception: Potential Antecedents
Understanding the factors that contribute to elevated perceptions of threat has impor-
tant clinical implications (e.g., for developing alternative targets for treatment, and
possibly even prevention). Unfortunately, only a few studies have directly explored
correlates of perceived threat (Berenbaum, Thompson, & Bredemeier, 2007;
Berenbaum, Thompson, & Pomerantz, 2007; Bredemeier & Berenbaum, 2008). In
those that have, the distinction between probability and cost estimates again emerged
as critical, as different factors have been linked with each. In addition, a number of
studies, not necessarily concerned with worry or perceptions of threat, have examined
factors that influence likelihood estimations.
Negative Beliefs
Negative views of the self are linked with anxiety and worrying (e.g., low self‐efficacy—
Bandura, 1988), and are considered a key factor that can foster stronger expectations
of negative outcomes (see Beck & Bredemeier, 2016; Beck & Emery, 1985). In line
with this idea, Berenbaum, Thompson, and Bredemeier (2007) found that individuals
who perceived themselves as less competent reported higher probability estimates of
negative outcomes. Likewise, holding negative views about the world arguably should
foster negative expectations. In line with this idea, Berenbaum, Thompson, and
Bredemeier (2007) found that perceiving others as more malevolent is also associated
with higher probability estimates. Importantly, elevated probability estimates were
found to (partially) mediate the relationship between both perceptions of one’s own
competence and the benevolence/malevolence of others with increased worry
(Berenbaum, Thompson, & Bredemeier, 2007).
Intolerance of Uncertainty
Another key (cognitive) factor linked to worrying is intolerance of uncertainty, which
can be conceptualized as the tendency to experience negative reactions in response to
uncertain situations (e.g., see Dugas, Buhr, & Ladouceur, 2004; Koerner & Dugas,
2006). Importantly, intolerance of uncertainty seems to be multidimensional (see
Birrell, Meares, Wilkinson, & Freeston, 2011). Specifically, research supports the
importance of distinguishing individuals’ tendencies to: (a) desire predictability (i.e.,
“prospective anxiety”); and (b) feel paralyzed in the face of uncertainty (i.e., “uncer-
tainty paralysis” or “inhibitory anxiety”). Dugas et al. (2004) proposed that one way
in which intolerance of uncertainty may lead to excessive worry is by contributing to
overestimation of threat. In line with this proposal, Bredemeier and Berenbaum (2008)
found that both of these facets of intolerance of uncertainty are linked with perceived
probabilities of negative outcomes, but differentially. Specifically, uncertainty paralysis
was associated with probability estimates in a positive and linear fashion, such that
higher probability estimates were linked with greater feelings of paralysis when uncer-
tain about the future. Perhaps this tendency is linked with lower perceptions of control
(which in turn could foster more negative expectations), or even objectively greater
risk in certain situations (e.g., when immediate action is needed). Conversely, desire for
predictability was not associated with probability estimates for negative outcomes in
general, but was negatively associated with probability estimates for those outcomes
with relatively low base rates (e.g., being in a natural disaster, your home being robbed).
These findings are consistent with work on a related trait, referred to as the “need for
cognitive closure” (i.e., the desire for definite knowledge, to end further information
processing and judgment), which is linked with biases in information processing and
decision‐making that seem to foster increased certainty (see Berenbaum, Bredemeier,
& Thompson, 2008; Kruglanski & Webster, 1996). In a recent experimental study,
Chen and Lovibond (2016) found that intolerance of uncertainty was positively associ-
ated with expectations and post hoc covariation estimations of an unpleasant event
(seeing an aversive picture) under ambiguous circumstances (when the objective likeli-
hood was not known). The proposed causal link between intolerance of uncertainty
and probability estimates is further supported by a study showing that manipulating
beliefs about uncertainty influences estimations of the likelihood that feared conse-
quences will occur (Deschenes, Dugas, Radomsky, & Buhr, 2010).
People who are more intolerant of uncertainty are also thought to expect negative
outcomes to be more costly (Dugas et al., 2004), perhaps because the uncertainty inher-
ent when considering the future adds to their distress, and/or because the desire to know
what will happen in the future leads them consider the worst possible scenario/conse-
quences (i.e., “catastrophize”). In line with this proposal, Bredemeier and Berenbaum
(2008) found that both desire for predictability and uncertainty paralysis were positively
associated with estimated costs of negative outcomes. Further, cost estimates partially
mediated the relationship between intolerance of uncertainty and worrying.
High Performance Standards

The link between perfectionism and anxiety is well established (e.g., see Egan, Wade,
& Shafran, 2011; Frost & DiBartolo, 2002). In line with this finding, Berenbaum and
colleagues have proposed that having higher standards for oneself (a key component
of perfectionism; see Frost & DiBartolo, 2002; Stöber & Joormann, 2001) may
contribute to the tendency to perceive negative outcomes as more costly (as opposed
to more likely). One reason to expect this is that the higher one’s standards, the
greater the discrepancy will be between actual outcomes and the outcomes people
think ought to occur, which in turn will increase the perceived cost of the outcome.
This hypothesis is based in part on work rooted in self‐discrepancy theory (Higgins,
1987) which suggests that actual–ought discrepancies are associated with anxiety
(Strauman, 1992). Consistent with this proposal, a unique association between higher
standards and cost estimates has been shown and replicated (Berenbaum, Thompson,
and Bredemeier, 2007). Further, Saw, Berenbaum, and Okazaki (2013) found links
between standards and worrying in specific life domains (e.g., academics, family rela-
tions). In addition, they found that cross‐cultural differences (between Asian
Americans and White Americans) in standards within particular life/performance
domains explained cross‐cultural differences in levels of worry within those same
domains. Also, findings from this study suggest that personal standards may in part
reflect perceived expectations of significant others (e.g., parents), as these were highly
correlated within several domains.
Goal investment
Finally, there is some evidence that individuals who are more invested in their goals
(measured by asking research participants to indicate how important it is to them to
achieve a specific goal) tend to worry more (Pomerantz, Saxon, & Oishi, 2000). We
hypothesize that this is the case because greater investment in goals will lead to increased
cost estimates. Further, there is some evidence for a specific link between particular goals
and worries—that is, the more an individual is invested in a certain goal (e.g., doing well
in school), the more likely he or she is to worry about possible negative outcomes within
that domain (e.g., failing an exam). For example, Eaton and Pomerantz (1999) found
that parents who were more personally invested in their children’s academic success wor-
ried more about their children’s school performance. Likewise, Pomerantz and Shim
(2008) found that day‐to‐day variability in children’s academic worries and school invest-
ment were associated, such that children worried more about their academic perfor-
mance on days that they were more invested in school. There is some evidence that the
link between goal investment and worrying is mediated by cost estimates, at least as
indicated by reports of how upset people think they would be should the undesirable
outcome come true (Eaton & Pomerantz, 1999; Pomerantz et al., 2000). Additional
work is needed to determine whether these findings will generalize to other domains of
life/functioning (e.g., physical health). More importantly, more research is needed to
directly test the link between goal investment and cost estimates.
Moderators of the Relationship Between

Perceived Threat and Worry
Although perceptions of threat have been proposed as a proximal cause of worrying,
this link may be modulated by other individual differences. For example, Berenbaum
et al. (2008) found that the desire for predictability as well as positive beliefs about
Another random document with
no related content on Scribd:
“And now, my child,” continued Mr. Robinson, “let us turn our
inquiries upon our own hearts.
‘Does no dark sign, no ground of fear,
In practice or in thought appear?’
“How strange it is that we, who have such high notions of integrity
in our intercourse with our fellow-creatures, should so often fail in our
transactions with Him before whom all things are naked and open,
and who will accept only the worship of the heart. O, my child, when
our prayers, our praises, our duties, are laid in the balance, what
must be said of them all?”
“They are found wanting,” replied Emma, with deep and solemn
feeling.
“Most wanting,” said her father emphatically; “corrupt fruits from a
wild and poisonous tree. Let us then take those hearts which God’s
word and our own experience declare to be deceitful above all
things, and desperately wicked—let us take them to the fountain
opened for sin and uncleanness, even the blood of Christ, which
cleanseth from all sin. Without his precious atonement and perfect
obedience to the divine law, how ruinous must have been our guilt;
how utterly naked and destitute our souls! But can we hope that they
are pardoned and accepted? Let us seek, also, their daily renewal;
continuing instant in prayer, and watching thereunto with all
perseverance, let us unsparingly detect all their crooked ways, and
pray that the spirit of holiness and truth would work in us to will and
to do of his good pleasure. O, how can we sufficiently magnify that
complete and great salvation, which redeeming mercy offers to our
fallen race? Blessed be the Lord God of Israel, for He hath visited
and redeemed his people! And blessed be his glorious majesty
forever; let the earth be filled with his glory, and let the whole world
say, Amen!”
“I do say Amen, papa,” rejoined Emma, fervently; “and I do hope I
am truly thankful for those instructions which have shown me the
value of spiritual blessings, and taught me also that in simplicity and
godly sincerity I ought to have my conversation in the world.”
S. S. S.
“That’s a very bad cough you’ve got, friend Smith.”

“Yes, neighbor Jones, but it’s the best I’ve got!”
The man who is guilty of the theft is frequently the first to cry,
“Stop thief!”
The Hyena.
I am a very good-natured person; apt to see things in a favorable

light; fond of picking out pleasant objects to contemplate, and am
usually able to find agreeable qualities in every body and every
thing. But I must confess, that, with all my disposition to be pleased, I
can see very little that is pleasant in the countenance of the hyena.
What a horrid fierce look he has! His countenance seems to bespeak
perpetual hunger and thirst for blood; he looks as if his supper would
taste all the better if it were attended by the agonized struggles and
cries of the victim upon which he feasts! He really looks as if pain
and distress would be but as pepper and spice to his meal.
But the fact is, no animals are cruel; that is, fond of inflicting pain
from mere malice. Even the tiger slays but to eat, and the hyena, ill-
favored as he is, has his part assigned to him by nature, and this is a
useful one to man and beast. He is a native of the warm parts of
Africa, and the southern part of Asia. He seldom kills an animal
except when pressed by want, preferring to feed upon the carcasses
of those he may find slain. It is a horrid part of the story of this
creature, that he will sometimes go into a grave-yard and dig up the
remains of people buried there; and he will, also, follow the march of
an army to feast upon the slain after a battle.
Living in hot countries, and feeding upon the decayed flesh of
animals, the hyena is useful by removing putrid masses of flesh that
would otherwise infect the air with pestilence. He is thus a
scavenger, and shares with the vulture the task of delivering the
countries they inhabit from fruitful causes of fatal disease. Though
we may not admire the face of the hyena, still we perceive that the
world could not well do without him.
There is a common notion that the hyena is so wild in his nature
as to be untamable; but this is a mistake. The creature is frequently
tamed in India, and then lives quietly about the house like a dog. He
is attached to those who are kind, but is spiteful and revengeful to
those who abuse him.
This change in the character made by training, is a strong proof of
the force of education; for not only is the tamed hyena made gentle
in reality, but his countenance is actually rendered mild and
inoffensive. This shows that the character is written in the face, and
bids young people beware how they let their passions mark
themselves upon their countenances.
Jewish Women.
We do not read that a Jewess was to be seen among the crowds

of priests and the rabble who insulted the Son of man, scourged him,
crowned him with thorns, and subjected him to ignominy and the
agony of the cross. The women of Judea believed in the Savior; they
loved, they followed him; they assisted him with their substance, and
soothed him under afflictions. A woman of Bethany poured on his
head the precious ointment which she kept in a vase of alabaster;
the sinner anointed his feet with a perfumed oil, and wiped them with
her hair. Christ, on his part, extended his grace and mercy to the
Jewesses; he raised from the dead the son of the widow of Nain,
and Martha’s brother Lazarus; he cured Simon’s mother-in-law, and
the woman who touched the hem of his garment. To the Samaritan
woman he was a spring of living water. The daughters of Jerusalem
wept over him; the holy women accompanied him to Calvary—
brought balm and spices, and, weeping,
sought him at the sepulchre. His first appearance, after his
resurrection, was to Mary. He said unto her, “Mary!” At the sound of
that voice, Mary Magdalene’s eyes were opened, and she answered,
“Master!” The reflection of some very beautiful ray must have rested
on the brow of the Jewesses.
Story of Philip Brusque.
CHAPTER VI.
Serious Adventures.
It might seem that, under the circumstances described, Emilie

would have been surprised and alarmed as the dark figure emerged
from the shadow of the rock, and stood forth in the full light of the
moon; but she betrayed no such emotion. On the contrary, she
proceeded directly towards the person, and was soon clasped in his
arms. The meeting was evidently one of affection; yet apparently
there was more of grief than joy—for sobs and sighs seemed to
choke the utterance of both. When at last they spoke, it was in
broken sentences, yet in a low and subdued voice, as if they were
apprehensive of discovery.
After remaining here for nearly half an hour, Emilie bade her
companion a hasty farewell, and climbing up the rock, with a light
and hurried step proceeded toward the tent which had now become
her home. She was still at some distance, however, and as she was
passing through a thicket of orange trees, she was abruptly accosted
by a man, who placed himself in her path, and calling her by name,
took hold of her arm, as if to arrest her progress. Emilie saw at a
glance that it was Rogere, and her eye did not fail to remark, at a
little distance, a dark group of men, whom she readily conjectured to
be his companions.
Emilie felt that she was in danger, but she lost not her self-
possession. Shaking off the grasp of Rogere, and standing aloof,
she said—“Is it possible that this rudeness is offered by M. Rogere?
It is a poor occupation for a gentleman to insult a woman, because
she is alone and unprotected!”
“A gentleman!” said Rogere, sneeringly. “I am no gentleman,
thanks to the gods—no, no, fair Emilie—I am something better—I am
a freeman and a lover!”
“Indeed!” said Emilie. “Is he a freeman who takes advantage of
the strength that nature has given him, to injure and distress one
who is weaker than himself? Is he a lover, who wounds and insults
the pretended object of his regard?”
“Nay, fair lady,” said Rogere; “this sounds mighty pretty, and in
France would be heroic; but remember that we are not now under
the tyranny of artificial laws and despotic fashion. We are now
restored to the rights and privileges of nature. There is no
government here, save that which is established by the God of
nature.”
“I will not stay to hear you,” said the young lady, indignantly.
“Every word you utter is an insult, every moment you detain me you
are guilty of insolence and wrong. Shame, shame upon a
Frenchman who can forget to be woman’s protector, and become
woman’s tyrant!”
“Mighty fine all this, certainly; but remember that I repudiate
France and the name of Frenchman: I am a man, that is enough,
and I shall assert man’s privileges. You must listen; you shall hear
me. Look around, and everywhere you see that in the dynasty of
nature all is regulated by force. There is a power of gravitation, which
controls matter, and bids the earth roll round in its orbit. Even matter,
then, the very soil, the inanimate clod, the senseless stones, obey
the law of force. And it is so with the animal tribes: among birds, the
eagle is master of the raven; with quadrupeds, the lion is lord of the
forest; with fishes, the whale is monarch of the deep.
“Then, in communities of animals, we see that everything is
regulated by power; even among a band of wolves, the strongest
has the first choice: privileges are exactly proportioned to power. It is
so throughout nature—might is right. It is on this universal principle
that I claim you as my own. I am the strongest man on the island; I
have therefore a right to whatever I desire. Nay, lady, start not! you
must, you shall listen! I have those near at hand who can and will aid
me, if I do but utter the word. You shall listen—you shall obey! Why
is woman made weaker than man, but that she is to be the servant
of man?”
“M. Rogere,” said Emilie, sternly, “it is humiliation for me to be
obliged to remain for one moment in your presence; it is degradation
to be obliged to speak with you. For all this you will be made to
answer.”
“By whom, pray? Who is there that can call me to account? There
is no law here, remember, that can restrain or punish me. Nature has
given me power, and I shall use it for my own pleasure.”
“I fear not that power; I fear neither you nor your menaces; and if I
remain a moment here, it is not from respect to your strength. You
dare not lay your hand upon me, for there is another power than that
of limbs and muscles. If you are a man, you have a soul, and that
soul has power over the body. Before you can, like the wolf, become
a mere creature of selfishness, before you can act upon the principle
that might is right, you must rid yourself of that soul, that thing within
called conscience. Even now it is at work; it is this which makes you
resort to false philosophy and shallow argument to justify an act that
your humor dictates, but which your soul and conscience condemn.
The wolf stops not to reason, but M. Rogere, who pleads the
example of the wolf, cannot wholly shake off reason. He cannot
imitate the brute, without offering an apology. The wolf is no coward,
but M. Rogere is a coward; there is something within that tells him
that he must not, shall not, dare not exert his strength against a
woman!”
As Emilie uttered these words, she rose to her full height, her eye
flashing with indignation. Rogere looked upon her with astonishment.
As she moved to depart, his feet seemed riveted to the ground, and
it was not till she had already proceeded a considerable distance
towards her home, that he recovered his self-possession. He then
set out in pursuit, and had no difficulty in soon overtaking the
fugitive; but at the moment he was about to lay his hand upon her
shoulder, his arm was arrested, and the well-known form of Brusque
stood before him. “Hold!” said the latter, fiercely; “touch not that
gentle being, or, by heaven, your audacity shall be punished. I have
been near, watching over the safety of this lady, and I have heard
your unmanly words to her. I now know your designs. Beware, or
even your boasted strength shall be insufficient to protect you from
the chastisement which an insolent coward deserves!”
Brusque waited not for reply. Leaving Rogere fixed to the spot and
overwhelmed with confusion, he hastened forward, drew Emilie’s
arm within his own, and proceeded with her to her house. The poor
girl was almost fainting with agitation, and Brusque could do no less
than enter the tent. After leaving her in her mother’s charge, and
giving a few words of explanation, he departed. On the morrow he
called to see her, but he found her feverish, and unable to leave her
bed.
The next day, Emilie sent for Brusque, and the two friends had a
long interview. She thanked him tenderly for his protection from the
rudeness of Rogere; and although something seemed to weigh
heavily upon his mind, he still seemed cheered and softened by her
tenderness. “It is indeed most welcome to me, Emilie,” said he, “to
hear you say these things—would that I were more worthy of your
esteem.”
“Nay, dear Philip,” said Emilie, “do not be forever indulging such a
feeling of humility—I might almost say of self-abasement. What is it
that oppresses you? Why are you always speaking in such terms? It
was not so once, my dear friend.”
“It was not indeed,” said Brusque. “Let me speak out, Emilie, and
unburthen my bosom. I was at St. Adresse your happy lover. I then
dared not only to love you, but to speak of my affection, and seek its
return and reward. But I am changed.”
“Changed! how? when? what is it? changed? Yes, you are
changed; for you are distant and reserved, and once you were all
confidence and truth.”
“Listen, Emilie, for I will make you my confessor. I left our village
home and went to Paris, and engaged with the ardor of youth in the
Revolution; so much you know. But you do not know that I shared in
the blood and violence of that fearful frenzy, and which I now look
back upon as a horrid dream. You do not know that I was familiar
with the deeds of Robespierre, and Danton, and Marat. Yet so I was.
These hands have not indeed been dyed in the blood of my fellow-
men, but yet I assisted in many of those executions, which now
seem to me little better than murders. It is in your presence, Emilie,
that I most deeply realize my delusion. There is something in your
innocence and purity, which rebukes and reproaches my folly, and
makes it appear as unpardonable wickedness. I once loved—nay, I
love you still, Heaven only knows how truly; but I should ill act the
part of a friend by allying your innocence to my degradation.”
Emilie was now in tears, and Brusque became much agitated.
“Speak to me, my friend,” said he; “dry up those tears, and let your
sense and reason come to our aid. I will be guided in all things by
you; if you banish me, I will depart forever.”
“No, no indeed,” said the weeping girl. “You must stay—you must
stay and protect my poor parents; you must stay and be my protector
also, for Heaven only can tell how soon I shall stand in need of
protection from violence and wrong.”
Brusque was evidently touched by this appeal, but the gleam that
seemed to light up his face for a moment was instantly followed by a
cloud upon his brow. Emilie saw it, and said, “Why this doubt? Why
this concealment? What is it, Philip, that disturbs you?”
“I will be frank,” said he. “Since we have been upon this island, I
may have seemed distant and indifferent towards you; but my heart
has ever been with you, and indeed often, when you knew it not, I
have been near you;—this night, I was on the rocks by the sea-
shore, and witnessed your meeting with some one there. Tell me,
Emilie, who was that person?”
Emilie was evidently disconcerted, but still she replied, firmly,
“That is a secret, and must remain so for the present. It shall be
explained in due time; but I pray you, do not seek to penetrate the
mystery now.”
“Well, Emilie, it is not for one like me to dictate terms. My
confidence in you is so complete, that I believe you are right,
however strange it may seem, that, on this lone island, you are in the
habit of meeting a man, and a stranger, upon the solitary sea-shore,
and with marks of affection that seem only due to a brother!” Emilie
started at these words, but she made no reply. Brusque went on. “I
submit to your law of silence; but, my dear Emilie, as you have
appointed me your protector, and given me a right to consider myself
as such, let me tell you that events are approaching which will
demand all our courage, as well as our wisdom; and I cannot but feel
the most anxious fears as to the result.”
“You allude to the state of the island.”
“I do. The anarchy is now at its height. Rogere has rallied round
him the rough and the ignorant, and taught them that license is
liberty. While he cajoles them with dreams of freedom, he is seeking
his own object, which is to become sole master and despot of this
island; and I fear these deluded men will be his dupes and
instruments. It is always the case that the ignorant and degraded
portion of the community are disposed to run after those who flatter,
only to cheat them.
“The condition of the island is in every respect becoming
alarming. The fruits, that were lately so abundant, are fast
diminishing, because they belong to no one in particular; and no one
has any power or interest to preserve them. We have no fields tilled,
for the lands are common to all. If a man were to cultivate a field, he
has no right to it, and if he had, there is no government which can
secure to him the product of his toil. Everything is therefore going to
waste and ruin. We shall soon be in danger of starving if this state of
things continues. Nor is this the worst. Rogere will soon bring
matters to a crisis, and try the law of force.”
“And what is your plan?”
“I intend to procure, if possible, a meeting of all the men of the
island to-morrow, and after showing them the actual state of things,
and the absolute necessity of established laws to save us from
famine and from cutting each other’s throats, I shall appeal to them
once more in behalf of settled government. I have hopes as to the
result—but still, my fears outweigh them. It is impossible to yield to
the demands of Rogere. Nothing but giving up all to him and his
brutal followers, will satisfy him. If we cannot obtain the consent of a
majority to the formation of some settled laws, we must come to the
question of necessity and determine it by blows. If it comes, it will be
a struggle of life and death.”
“I know it, dear Philip; I have long foreseen it.”
“I am glad that you take it so calmly. I should be flattered if your
quiet were the result of confidence in me.”
“Well, well, but you are fishing for a compliment, and I will not tell
you that I depend on you alone! I may have hopes from another
source.”
“Will you tell me from whom?”
“Nay—I shall keep my secret; but be assured that in the hour of
danger, should it come, Heaven will send us succor. Good night.”
“Good night, dear Emilie—good night.” And so the lovers parted.
Brusque sought his home, but with mingled feelings of pleasure
and pain. The restoration of former relations between him and
Emilie, was a source of the deepest satisfaction; but many
circumstances combined to cloud his brow, and agitate his heart with
anxiety.
An Incident from Ancient History.
About 470 years before Christ, Xerxes, king of Persia, was

leading an immense army against the Greeks. It is said that it
consisted of a million of men. When they were all gathered in a vast
plain, the king mounted a throne on the brow of a hill to review them.
It was a splendid spectacle! There were the young, and the strong,
and the ambitious, and the enterprising; and some were richly
attired, and gallantly mounted on fine horses, and armed with shields
and swords of glittering steel. It was, indeed, a proud army. But
suddenly the thought came across the mind of the king—“In the
space of one hundred years; all these living and breathing men will
be in their graves!” It was a solemn thought; and it is said that even
Xerxes shed tears.
Effects of Prohibition.
Mankind have seldom a strong desire for any thing lawful, that is
easily obtained. We are not driven to our duty by laws so much as by
ambition. If it were enacted that persons of high rank only should
dine upon three dishes, the lower grade would desire to have three;
but if commoners were permitted to have as many dishes as they
pleased, whilst the rich were limited to two, the inferior class would
not exceed that number. If gaming were reckoned ungenteel, cards
and dice would lose half their attraction. In the history of the Duke of
D’Ossuna, there is a remarkable instance given of this perverse
nature in man.
A rich Neapolitan merchant prided himself upon not having once
set his foot out of the city during the space of forty-eight years. This
coming to the ears of the duke, the merchant had notice sent him
that he was to take no journey out of the kingdom, under the penalty
of 10,000 crowns. The merchant smiled at receiving the order; but,
afterwards, not being able to fathom the reason of the prohibition, he
grew so uneasy that he paid the fine, and actually took a short trip
out of the kingdom.—English paper.
Saturday Night.
“Oh! it is Saturday night!” exclaimed Ellen; “I had forgotten that. A

Bible story, then. I am sure I think the story about Joseph, or that
about Isaac, or the prodigal son, or Lazarus and his sisters, as
interesting as a fairy story.”
“They are a hundred times more interesting,” said Charles.
It was the custom of Ellen’s mother to tell her children a short
story every night after they were in bed. She was very glad to find
that the true and instructive histories from the good book, interested
her children as much as those stories that were contrived to delight
them.
“My dear children,” she said, “I shall not tell you a story from the
Bible to-night, but I am going to relate an anecdote—which, you
know, means a short story—of some little children of our
acquaintance.
“There are two children who have a great and kind Friend, who is
always taking care of them, whether they are awake or asleep.”
“I suppose you mean their mother,” said little Charley, who was
always impatient to get at the story.
“No, my love; this Friend gave them their father and mother.”
“Oh, you mean God,” whispered Ellen.
Her mother did not reply to her, but proceeded,—
“This bountiful Friend has given to them the most beautiful and
wonderful gems in the world.”
“Gems! what are gems, mother?” asked Charles.
“Precious jewels, my dear. Those I am speaking of are very small,
but so curiously formed that as soon as the casket which contains
them is opened, there is immediately painted on them a beautiful
picture of all the objects toward which they are turned. If it be a
landscape, like that which you see every morning from your chamber
window, there appear on the gems those beautiful mountains that
rise one above another; the mist that curls up their sides; the bright
lake that glistens in the depth of the valley, and which you call the
mountain mirror, Ellen; the large orchards, with their trees gracefully
bending with their ruddy and golden fruit; the neat house opposite to
us, with its pretty curtain of vines hanging over the door, and rose-
bushes clustering about the windows.”
“What, mother!” exclaimed Charles; “all these things painted on a
little gem?”
“Yes, Charles, all; the high mountains, and the rose-bushes, every
leaf and bud of them. And then, if the gems are turned towards the
inside of the house, the landscape disappears, and all the furniture is
painted on them, and the perfect pictures of their friends; not such
pictures as you see done by painters, looking grave and motionless,
but smiling, speaking, and moving.”
“Oh, mother, mother,” exclaimed Ellen, “this is a fairy story, after
all.”
“Are there, in reality, any such gems?” asked Charles, who did not
like that the story should turn out a fairy story.
“There are, my dear Charles; and the same Friend who gave the
children these gems has given to them many other gifts as
wonderful. He has given to them an instrument by which they can
hear the music of the birds, the voices of their friends, and all other
sounds; and another by which they can enjoy the delicious perfume
of the flowers; the fragrance you so often spoke of, Ellen, when the
fruit trees were in blossom, and the locust trees in flower, and the
clover in bloom.”
“Oh, what a generous friend that must be,” said Charles, “to give
such valuable presents, and so many of them. Are there any more,
mother?”
“Yes, Charles, more than I can describe to you if I were to talk till
to-morrow morning. There is a very curious instrument by which they
can find out the taste of everything that is to be eaten; and another
that, by just stretching out their fingers, they can tell whether a thing
is smooth or rough, hard or soft.”
“Why, I can tell that by my fingers,” exclaimed Charles.
“Yes, my dear,” said his mother; “and cannot you taste by putting
food into your mouth? and is there not an instrument set in your
head by which you can hear?”
“My ear, mother?” asked Charles.
“Yes, my dear,” said his mother.
“And do you mean the eyes by those wonderful gems?” asked
Ellen.
“Yes.”
“But I am sure there is no painting in the eyes.”
“Yes, Ellen; every object you behold is painted upon a part of the
eye called the retina; but that you cannot understand now, and you
must let me go on with my anecdote of the two children. When they
arose in the morning, they found that their Friend had taken such
good care of them when they slept that they felt no pain; that their
limbs were all active, and they could every moment receive pleasure
from the precious gems and instruments I have mentioned. They
both looked out of the window, and exclaimed, ‘What a beautiful
morning!’ The little girl turned her gems toward the multiflora, now
full of roses and glistening with dew-drops, and she clapped her
hands, and asked her brother if he ever saw anything so beautiful;
and he turned his gems to a pair of humming-birds, that were
fluttering over the honey-suckle, and thrusting their tiny pumps into
the necks of the flowers; and as their bright images shone on his
gems, he shouted, ‘Did you ever see anything so handsome?’”
“You mean, mother,” said Charles, “that he looked at the
humming-birds, when you say he turned his gems?”
“Yes, my dear; and when he heard the pleasant humming they
make with their wings, it was by the instrument set in the head which
you call the ear. There was not a moment of the day that the children
did not enjoy some good thing their Friend had given to them. They

Generalized Anxiety Disorder and Worrying A Comprehensive Handbook For Clinicians and Researchers 1St Edition Alexander Gerlach Full Chapter

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Generalized Anxiety Disorder and Worrying A Comprehensive Handbook For Clinicians and Researchers 1St Edition Alexander Gerlach Full Chapter

Uploaded by

Copyright:

Available Formats

Generalized Anxiety Disorder and

Worrying : A Comprehensive Handbook

Alexander L. Gerlach and

Limit of Liability/Disclaimer of Warranty

Library of Congress Cataloging‐in‐Publication Data

Cover Design: Wiley

Set in 10/12pt Galliard by SPi Global, Pondicherry, India

1 Worry, Generalized Anxiety Disorder (GAD), and their Importance 1

11 Interpersonal and Emotion‐Focused Therapy (I/EP) for Generalized

Gerhard Andersson Department of Behavioural Sciences and Learning, Linköping

Gordon J. G. Asmundson Department of Psychology, University of Regina, Regina,

David S. Baldwin Clinical and Experimental Sciences, Faculty of Medicine, University

Eni Becker Clinical Psychology, Radboud University of Nijmegen, Nijmegen, the

Evelyn Behar Department of Psychology, Hunter College, City University of New

Howard Berenbaum Department of Psychology, University of Illinois at Urbana‐

Elena Bilevicius Department of Psychology and Pathophysiology, University of

Simon Dymond Department of Psychology, Swansea University, Swansea, UK

Thomas Ehring Clinical Psychology and Psychotherapy, Department of Psychology,

Renée El‐Gabalawy Department of Psychology and Pathophysiology, Department

Alexander L. Gerlach Department of Psychology, Clinical Psychology and

Andrew T. Gloster Department of Psychology, Division of Clinical Psychology and

Juergen Hoyer Department of Psychology, Clinical Psychology and Psychotherapy,

Tina In‐Albon Clinical Psychology and Psychotherapy of Childhood and Adolescence,

Markus Jansson‐Fröjmark Centre for Psychiatry Research, Department of Clinical

Naomi Koerner Department of Psychology, Ryerson University, Toronto, Ontario,

Falk Leichsenring Department of Psychosomatics and Psychotherapy, Justus‐Liebig‐

Peter McEvoy School of Psychology, Curtin University, Perth, Western Australia,

Michelle G. Newman Department of Psychology, The Pennsylvania State University,

Susan M. Orsillo Department of Psychology, Suffolk University, Boston, MA, USA

Sean Perrin Clinical Psychology, Department of Psychology, Lund University, Lund,

Marcia T. B. Rinner Department of Psychology, Division of Clinical Psychology and

Bryan Roche Department of Psychology, Maynooth University, Maynooth, Ireland

Lizabeth Roemer Department of Psychology, University of Massachusetts Boston,

Simone Salzer Clinic of Psychosomatic Medicine and Psychotherapy, Georg‐August‐

Anne Schienle Institute of Psychology, University of Graz, Graz, Austria

Christiane Steinert Department of Psychosomatics and Psychotherapy, Justus‐

Stephan Stevens Department of Psychology, Clinical Psychology and Psychotherapy,

Ian Stewart School of Psychology, National University of Ireland, Galway, Ireland

Kathleen Tallon Department of Psychology, Ryerson University, Toronto, Ontario,

Albert Wabnegger Institute of Psychology, University of Graz, Graz, Austria

Tove Wahlund Centre for Psychiatry Research, Department of Clinical Neuroscience,

Dong Xie Department of Psychology and Counseling, University of Central Arkansas,

Nur Hani Zainal Department of Psychology, The Pennsylvania State University,

What is Worry—What is GAD?

­ ecessarily result in increased worrying, even in individuals diagnosed with GAD

(obsessions or compulsions). With DSM‐III‐R (American Psychiatric Association

to this condition. In addition, people diagnosed with GAD as defined by DSM‐IV or

Where Do GAD Patients Present and at What Cost

Introduction and Overview of the Handbook

American Psychiatric Association.(1980). Diagnostic and statistical manual of mental disorders

Worrying is an everyday phenomenon that is experienced by most people (Szabó &

2004). By anticipating problems, the individual believes he is preparing to react in an

Assessments of GAD and Worry

Authors and year of publication Scale and no. of items Validation

Self‐report questionnaire of GAD and Worry

Authors and year of publication Scale and no. of items Validation

Clinician Rating of related constructs

Challenges in assessing GAD and worry

Differential Diagnosis of GAD and the Overlap

American Psychiatric Association.(2000). Diagnostic and statistical manual of mental disorders

Brown, T. A. (2002). Classification of anxiety disorders. In D. J. Stein & E. Hollander (Eds.),

A perceived threat involves the subjective recognition of a potential (but uncertain)

Measuring Perceptions of Threat

1 Worry, Generalized Anxiety Disorder (GAD), and their Importance 1

ecessarily result in increased worrying, even in individuals diagnosed with GAD