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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
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Library of Congress Cataloging‐in‐Publication Data

Names: Gerlach, Alexander L., 1966– editor. | Gloster, Andrew T., editor.
Title: Generalized anxiety disorder & worrying : a comprehensive handbook
for clinicians and researchers / edited by Alexander Gerlach and Andrew
T. Gloster.
Other titles: Generalized anxiety disorder and worrying
Description: First edition. | Hoboken, NJ : Wiley-Blackwell 2020. |
Includes index.
Identifiers: LCCN 2020000437 (print) | LCCN 2020000438 (ebook) | ISBN
9781119189862 (hardback) | ISBN 9781119189886 (adobe pdf) | ISBN
9781119189893 (epub)
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
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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).
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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
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We had given no instructions, only to be silent and remain still.
They seemed to separate and go in different directions. On coming
near the house, some one of their company hailed to the balance,
“come on, boys, here they are!” “There!” said Pool, “I told you so.” So
soon as we heard this, we knew that we had been discovered, and
that it was to kill or be killed.
I made my escape out of the house the first opportunity I saw,
dodged around a big fig tree, and looked back a moment at the
house. Pool was standing in the door with his gun at a poise. Harvey
came round the corner of the house, on Pool’s right, and jumped into
the gallery; Pool immediately fired, and struck Harvey in the left side.
Harvey immediately squared himself and shot the contents of his
whole load in Pool’s side, and fell on the gallery. Pool stepped into
the yard, and another man shot him in the breast, and he
immediately fell dead.
At this moment Stoughton and John Copeland jumped out of the
door and ran; I wheeled immediately as the crowd rushed around the
house, and ran. At the report of the next gun, the shot whistled all
around my head, I then heard several guns. It appeared to me there
must have been five hundred at that moment; and I have no doubt
that I made the best running there that I ever made in my life before.
In fact, it seemed to me that it was no trouble, that I never touched
the ground, but flew over it.
After I had got a sufficient distance from the place, and found I
was not pursued by any of their party, I stopped to reflect to myself,
and wondered what had become of Stoughton and my bother John.
Pool, I knew, must be dead, for I saw him fall, and the blood gush
from the wound. I felt almost certain that Stoughton and my brother
John were both killed also, from the number of guns I heard fired, as
I thought.
It was then that I more seriously meditated on my situation than I
ever had done before, and wondered to myself what I should do for
the best. I felt very sad, and thanked my God for my providential
escape, believing that all the rest of my comrades were in eternity.
But after I had thus meditated and reflected upon the past, I felt that I
deserved death, when all my crimes again stared me full in the face.
I then formed a stern resolution within my own breast, that if God
would permit me ever again to reach my home, that I would refrain
from all my evil ways, and become a Christian, believing that God
had been merciful to me, in preserving me, and hurling my comrades
and associates into another world.
After a while I became more collected and concluded I would go
over to Daniel Brown’s, who, I knew, did not live far from that place. I
had been there but a short time when my brother John came up,
bare-headed, and mud above his knees, where he had run through a
muddy reed-brake. He called me to one side, and in a few words he
told me that Stoughton was not killed, but Pool was, and that our
enemies had left there. He saw them carrying Harvey away, and he
thought Harvey was dead; that we had better go over and do
something with Pool and get Stoughton, and leave.
This was on Sunday, the 15th of July, 1848. Several persons had
accidently happened in at Brown’s that day. I went into the house
and told the company what had happened over to the other house,
since I left; that there had been some shooting done, and that Pool
was killed, and I expected Harvey was; that we were on our way to
Honey Island, and stopped there for the night; and that I had come
over to Brown’s to get some bread baked, and that it had all
occurred since I left; and that I would like to go over and do
something with Pool, and see if Stoughton was killed. A number of
persons went with us to the place, some ladies among the rest.
When we got there we found Pool lying dead. We laid him straight
on his back. I recollected that he had some money, and I soon
sounded his pockets, and obtained one hundred and twenty dollars
of the money I had given him. There was a five dollar gold piece
missing. I took all he had. As he had other means, I knew that the
money would do him no good then. I went into the house and got
John Copeland’s hat, and went down to the side of the swamp and
called Stoughton, and he came out. We were then all together again,
except Pool.
We gathered our guns, returned to Brown’s, eat dinner, and left for
home. But in the affray I had lost my memorandum book, and in that
book was the diagram or map and directions where to find the
money which belonged to Wages, McGrath and myself; I hunted for
it diligently, but could not find it. It certainly went in a very mysterious
way, and I have often since thought that the decree of Justice forbid
me enjoying that money.
After we left Brown’s that day, we traveled on the same route we
had come. We slept in the woods that night, and next day we got
something to eat at Peter Fairley’s, and so continued our journey on
home, where we arrived on Sunday, the 22d of July, having been
gone just fourteen days. When we arrived, old Wages was highly
pleased that Harvey was killed, and he and the old lady very
promptly settled with us. He paid us off with his place on Big Creek,
in part, and the balance in hogs, cattle, pony horses, carts and
farming tools and utensils. My father and mother, with the family,
removed to the place.
In a very little while after that, the times began to be very squally.
Old Wages and his wife had to pull up stakes, take their negroes and
leave the country, at a great sacrifice of their property. I was already
an outlaw; my brother John now became one with me. Stoughton,
like a fool, as he was, took a yoke of oxen, or some cattle, which he
had received from Wages in part pay for his services, to Mobile for
sale. While there, he was arrested and put in jail, under the
requisition of the Governor of Mississippi, and conveyed from Mobile
to Perry county, where he was tried and convicted twice. The first
conviction was reversed by the Appellate Court, and while in prison,
waiting a second hearing, he died. So went another of our clan to
eternity.
I still continued laying out and hiding myself from place to place,
fully intending to leave the country just as soon as I could settle my
business; and I even made several appointments of times that I
would go, but some way, or somehow, there appeared to be a
supernatural power which controlled my every action, and I could not
leave the vicinity of Mobile.
During that fall and winter my brother John and I made two trips
from Big Creek to Catahoula to hunt for that money, and the last trip
we made I was prepared to leave. Brother John had left the principal
part of his money at home, and had to go back after it, and he
prevailed on me to go with him. We returned to the vicinity of Mobile,
where I loitered away my time for some month or two, and it seemed
that my mind in some way became confused and impaired, and I
took to drinking too much spiritous liquors. One day, some time in
the spring of 1849, my brothers John, Thomas, Isham or Whinn, and
I were at a little grocery store near Dog river, about twelve miles from
Mobile. I drank too much spirits and became intoxicated, and in that
situation I imagined every man I saw was trying to arrest me. I fell in
with a man by the name of Smith, an Irishman, and a difficulty
occurred between us; I concluded that he intended to arrest me. I
drew my double-barrel shot gun upon him and intended to kill him.
He was too quick for me; he threw up my gun, drew his dirk and
stabbed me just above the collar bone. The wound did not quite
penetrate the cavity of the chest, or it would have killed me; I threw
down my gun and ran about two hundred yards and fainted. My
brothers then carried me about two miles, and one of them went
home and got a carriage and took me home. Smith went to Mobile
and told the news. A party came out and tracked me up by the blood,
and arrested and carried me to Mobile jail.
I was now in the worst situation I ever was in in my life. One
indictment against me in Alabama for larceny, and another against
me in Mississippi for murder, and the requisition of the Governor of
Mississippi then in the hands of the officer to carry me there to be
tried. The question was which trial to avoid; if found guilty, as I felt
certain I would be, in both cases, one would be the penitentiary for
not less than four years, and the other would be hanging. I employed
the best counsel that could be procured in Mobile, and on consulting
with him and making him fully acquainted with all the facts, he
advised me to plead guilty of the larceny and go to the penitentiary of
Alabama; “for,” said he, “you may stand some chance after your four
years are out to make your escape from the clutches of the law in
Mississippi. They may not think to file their requisition with the
Governor of Alabama in time, and in that event, when your time
expires, you will be let loose.”
My trial came on before my wound was near well, and I was
brought into court and arraigned, and the indictment read to me in
open court. When asked “are you guilty or not guilty?” I plead guilty,
after which my counsel addressed the court and prayed its
indulgence in passing sentence, and that the term of punishment be
made as short as the law would permit, which was accordingly done,
and sentence of four years at hard labor in the penitentiary of
Alabama was passed upon me.
I accordingly served out my four years at Wetumpka, Ala., and all
to avoid going to Mississippi to be tried for the murder of Harvey.
However, I did not evade the rigor of the laws of Mississippi. The
vigilance of the Sheriff of Perry county threw a guard around me, that
secured to him the possession of my person at the expiration of my
time in the penitentiary of Alabama, and he immediately transferred
me to the county jail of Perry county, Mississippi.
I remained in the jail of Perry and Covington counties upward of
two years before I had a trial. I was found guilty of murder; and the
sentence of death was passed upon me, and the day appointed for
my execution. Within eight days of the time the Sheriff informed me
that my time was only eight days, and that my rope, shroud and
burial clothes were all ready. He then read to me the death warrant!
My tongue nor pen cannot express my feelings on that occasion
during that day and night. However, to my great joy, the next morning
he brought me the glorious news that the clerk of the court had
received a supersedeas and order to respite my execution, and carry
my case to the High Court of Errors and Appeals.
I cannot express my joyful feelings on receiving this intelligence. It
removed that cloud of horror and despair, which was lowering upon
and around me, and renovated anew my whole soul. It was to me as
a refulgent light from the sun of heaven cast upon the dark and
gloomy vale; but, alas, how ephemeral that sunshine of joy and bliss!
That fickle dame, Fortune, upon whose wheel I had so successfully
floated in former days, finally brought me to the same point where I
started.
I was, therefore, conveyed from the Perry county jail to the State
penitentiary at Jackson, to await there a hearing of my case in the
High Court of Errors and Appeals, and remained there about two
years. In the meanwhile my case was argued before this Court, and
the judgment reversed, and the cause remanded for further
proceedings in the Circuit Court of Perry county.
TRIAL OF JAMES COPELAND.
TRANSCRIPT OF THE JUDICIAL PROCEEDINGS.
At the September term of said Court, in the year A. D. 1857, on

Wednesday of the term, it being the 16th day of the month, James
Copeland was taken to the Bar of the Court and arraigned upon an
indictment, found by the following Grand Jury at the March term,
1857, to-wit: John McCallum, Lemuel Strahan, John W. Carter, Allen
Travis, Lewis H. Watts, James Chappell, G. W. Rawls, Wm. Jenkins,
Peter McDonald, Malachi Odom, Joseph G. Young, James M.
Bradler, Sr., Stephen Smith, Wm. Hinton, Edmund Merritt, Sidney
Hinton, Joseph T. Breeland, Henry Dearman, Lorenzo Batson and
John Fairley, Foreman—which indictment was as follows:
STATE OF MISSISSIPPI,
Perry County. }
In the Circuit Court of Perry County—At March Term, 1857.
The Grand Jurors for the State of Mississippi, summoned,
empanneled, sworn, and charged to inquire in and for the State of
Mississippi, and in and for the body of the county of Perry, upon their
oath, present, that James Copeland, late of said county, on the 15th
day of July, Anno Domini, one thousand eight hundred and fifty-
eight, with force and arms in the county of Perry aforesaid, in upon
one James A. Harvey, then and there being in the peace of God and
the said State of Mississippi, feloniously, wilfully and of his malice
aforethought, did make an assault; and that the said James
Copeland, a certain shot gun, then and there loaded and charged
with gun powder and divers leaden shot, which shot gun, so loaded
and charged he, the said James Copeland, in both his hands, then
and there, had and held, to, at, against and upon the said James A.
Harvey, then and there feloniously, wilfully and of the malice
aforethought of him, the said James Copeland, did shoot off, and
discharge; and that the said James Copeland, with the leaden
aforesaid, out of the shot gun aforesaid, then and there by force of
the gun powder, shot and sent forth as aforesaid, the said James A.
Harvey, in and upon the left side of him the said James A. Harvey,
then and there feloniously, wilfully and of the malice aforethought of
him, the said James Copeland, did strike, penetrate and wound,
giving to the said James A. Harvey, then and there, with the leaden
shot so as aforesaid, discharged and sent forth, out of the shot gun
aforesaid, by the said James Copeland, in and upon the left side of
him, the said James A. Harvey, a little below the left shoulder of him
the said James A. Harvey, divers mortal wounds of the depth of
three inches, and of the breadth of one quarter of an inch, of which
the said mortal wounds, the said James A. Harvey, from the fifteenth
day of July in the year aforesaid, until the twenty-fifth day of July in
the year aforesaid, languished, and languishing did live; on which
said twenty-fifth day of July in the year aforesaid, the said James A.
Harvey in the county of Perry aforesaid, of the mortal wounds
aforesaid, died; and the jurors aforesaid, upon their oaths aforesaid,
do further present, that John Copeland, late of the county aforesaid,
on the day and year first aforesaid, in the county of Perry aforesaid,
feloniously, wilfully and of his malice aforethought, was present,
aiding, abetting and assisting the said James Copeland the felony
and murder aforesaid to do and commit; and the jurors aforesaid
upon their oath aforesaid do say, that the said James Copeland and
John Copeland him the said James A. Harvey, in manner and form
aforesaid, feloniously, wilfully and of their malice aforethought did kill
and murder, against the peace and dignity of the State of Mississippi.
George Wood, District Attorney.
Upon this indictment was indorsed “A true bill signed, John Fairley,
foreman.”
At the September Term the following proceedings were had in the
case: “Be it remembered that there was begun and held a regular
Term of the Circuit Court in and for the county of Perry and State of
Mississippi, at the Court House of said county, in the town of
Augusta, the place designated by law for holding said court, on the
second Monday of September, in the year of our Lord one thousand
eight hundred and fifty-seven, it being the 14th day of said month,
present the Hon. W. M. Hancock, presiding Judge of the 8th Judicial
District of Mississippi, George Wood, Esq., District Attorney for the
said 8th Judicial District, James R. S. Pitts, Sheriff of Perry county
and James Carpenter, Clerk of said Court.”
State of Mississippi,
vs.
James Copeland.
} Murder.
This day comes George Wood, District Attorney, who prosecutes
for the State of Mississippi, and the prisoner is brought to the bar in
custody of the Sheriff, and upon notice of the District Attorney, a
special venue for thirty-six free-holders, or house holders, of Perry
county, and liable to jury service therein, ordered returnable to-
morrow morning, at 8 o’clock; the prisoner, in his own proper person,
waiving two days’ service of a list thereof and a copy of the
indictment, consenting that it be returned at said time; and upon
suggestion that the prisoner is insane, it is ordered that the Sheriff of
Perry county summons twelve good and lawful men of said county,
to be and appear before said Court on Tuesday morning at 8 o’clock
a.m., to take inquisition as to the case of lunacy, and try whether the
prisoner be of sound mind and understanding.
Tuesday Morning, 8 o’clock.
Court met pursuant to adjournment. Present as on yesterday.
vs.
James Copeland.
} Murder.
This day comes George Wood, the District Attorney, who
prosecutes for the State of Mississippi, and the prisoner is brought to
the bar, in custody of the Sheriff, whereupon comes a jury of good
and lawful men, to wit: Porter J. Myers, Malachi Odom, Sr., J. M.
Bradley, Jr., Darling Lott, Malcolm McCallum, Angus McSwain, Q. A.
Bradley, J. M. Bradley, Sr., Wm. H. Nicols, W. C. Griffin, D. S. Sapp
and James Edwards, who are regularly summoned, elected and
sworn, and well and truly to try an issue joined, ore tenus, whether or
not the prisoner be of sound mind, and whether he possesses
sufficient intellect to comprehend the cause of the proceedings on
the trial, so as to be able to make a proper defense; or whether the
appearance of insanity, if any such be proven, is feigned or not; and
the evidence having been submitted to them in the presence of the
prisoner, they retired to consider of their verdict, and in his presence
returned the following, to-wit: “We, the jury, on our oaths, find the
prisoner sane; that he possesses sufficient intellect to comprehend
the cause of the prosecution on the trial, so as to be able to make a
proper defense, and that the appearance of insanity which he has
exhibited, is feigned.”
And thereupon the prisoner is arraigned on the charge of murder,
as preferred by the bill of indictment; and upon said arraignment,
says that he is not guilty in manner and form as therein and thereby
charged, and for the truth of said plea he puts himself upon the
country; and the District Attorney in behalf of the State of Mississippi
doeth the like.
And thereon come the following good and lawful men of Perry
county, to-wit: Zebulon Hollingsworth, J. J. Bradley, John A. Carnes,
Francis A. Allen, Wm. W. Dunn, Adam Laird, who were regularly
summoned on the special venue returned in this case, and who in
the presence of the prisoner are regularly tried and chosen between
the prisoner and the State; and the special venue being exhausted
the Sheriff proceeded to call the regular jurors in attendance at this
term, and Daniel S. Sapp, Seaborne Hollingsworth and Francis
Martin were in the presence of the prisoner tried, and chosen
between the State and the prisoner; and the regular jury being
exhausted, the Sheriff is directed to summon thirteen bystanders as
jurors, and from the number so summoned as last aforesaid, Milton
J. Albritton was in presence of the prisoner duly tried and chosen
between the State and the prisoner; and the said thirteen persons so
last summoned being exhausted, it is ordered that a venue issue,
commanding the Sheriff to summon twenty good and lawful men of
Perry county, to be and appear before the court to-morrow morning
at 8 o’clock, A. M., to serve as jurors in the trial of the issue
aforesaid, and the prisoner is remanded to jail, and John W. Carter is
sworn as bailiff to take charge of the jury.
Wednesday Morning, 8 o’clock, September 16, 1857.
vs.
James Copeland.
} Murder.
This day comes George Wood, District Attorney, and the prisoner
is again brought to the bar, in custody of the Sheriff, and also comes
the jury whom yesterday were duly tried, chosen and taken between
the parties; and thereupon comes James M. Pitts and John H.
Holder, who were this day returned as jurors in the case, in
obedience to the command of the venue, last issued on yesterday;
who in presence of the prisoner are regularly tried, chosen and taken
between the parties; and the jury so chosen, as aforesaid, are
empaneled and sworn, in the presence of the prisoner, well and truly
to try the traverse upon the issue joined between the State and the
prisoner aforesaid, and a true deliverance make according to the
evidence; and the evidence is submitted to them in the presence of
the prisoner, and the opening argument is heard, on the part of the
District Attorney and the further consideration of the cause is
continued until to-morrow morning, and the prisoner is remanded to
jail.
Thursday Morning, 8 o’clock, September 17, 1857.

vs. } Murder.
James Copeland.
This day comes the District Attorney, and the prisoner is again
brought to the bar in the custody of the Sheriff, and the argument is
resumed and concluded; and the jury are instructed by the Court at
the request of the counsel, in writing, and the jury retire to consider
their verdict. And in the presence of the prisoner return the following,
to-wit: “We, the jury, on our oaths, find the prisoner guilty in manner
and form as charged in the bill of indictment;” and the prisoner is
remanded to jail to await his sentence.
SENTENCE OF THE COURT.
Friday Morning, 8 o’clock, September 18, 1857.

vs.
James Copeland.
} Murder.
This day comes the District Attorney, and the prisoner, who was on
yesterday convicted of the crime of murder, is again brought to the
bar. And thereupon the prisoner by his counsel moves the Court for
a new trial, which motion was fully heard and understood by the
Court; and is by the Court here overruled. And to the opinion of the
Court in overruling said motion, the prisoner by his counsel here
excepts:
State vs. James Copeland.
Motion for New Trial of the Collateral. } Murder.
Issue joined as to the sanity of the defendant, and his capacity to
make defense in the charge of murder.
1st. Because the Court erred in refusing instructions asked by
defendant and in granting those asked by the State.
2d. Because said verdict is contrary to law and evidence.
Taylor & Wilborn, for Motion.
And the prisoner being asked what further he had to say why the
sentence of death should not be passed upon him, says nothing in
bar or preclusion. “It is therefore considered by the Court, here, and
is so ordered and decreed, that the prisoner be taken hence to the
jail from whence he came, and there safely kept until the thirtieth day
of October, in the year of our Lord one thousand eight hundred and
fifty-seven; and that the Sheriff take him thence on the said day,
between the hours of ten o’clock in the forenoon and four o’clock in
the afternoon of said day, to the place appointed by law, for
execution; and that he, the said James Copeland, on the said day,
between the hours aforesaid, be hung by the neck until he be dead.”
THE DEATH WARRANT.
THE STATE OF MISSISSIPPI,
To the Sheriff of Perry County—Greeting:

Whereas, at the September term, A. D. 1857, of the Circuit Court
of said county, on the fourth day of said term, James Copeland was
duly convicted of the murder of James A. Harvey, by a verdict of a
Jury chosen and sworn between the parties; and whereas, on Friday,
the fifth day of said term, by the order and decree of said Court, the
said Copeland was sentenced to be hung by the neck until he be
dead, on the thirtieth day of October, in the year of our Lord one
thousand eight hundred and fifty seven, between the hours of ten
o’clock, a. m., and four o’clock, p. m., at the place appointed by law.
These are therefore to command you, in the name, and by the
authority of the State of Mississippi, to take the body of the said
James Copeland, and him commit to the jail of said county, and him
there safely keep, until the said thirtieth day of October, and that on
the said thirtieth day of October, between the hours of ten o’clock, a.
m., and four o’clock, p. m., of said day, at the place appointed by law,
you hang him by the neck until he be dead, dead, dead.
Given under my hand and seal, this, the 18th day of September, A.
D. 1857.
[Seal.] W. M. Hancock, Judge.
THE EXECUTION.
The day arose clear and beautiful on which the sentence of the
law and of outraged humanity was to be executed on the man who
had so often violated their most sacred behests. The sky was blue
and serene; the atmosphere genial; all nature was calm and
peaceful; man alone was agitated by the various strong emotions
which the execution of the fatal sentence of retributive justice on a
fellow-man could not but create.
The place of execution was distant from the city of Augusta one-
quarter of a mile. The gallows was erected on a beautiful elevation
that was surrounded by the verdure of shrubby oak and the tall, long-
leaf pine. The ground was everywhere occupied by thousands of
spectators, gathered from Perry and the surrounding counties, to
witness the solemn scene. It was indeed one that they will long
remember.
About the hour of noon, the prisoner, after being neatly clad, was
led from the jail by the officers of the law, placed in the ranks of the
guard formed for the occasion, and the procession moved slowly
toward the fatal spot.
Soon the doomed man appeared on the gallows. The death
warrant was then read to him, and he was informed that he had but a
short time to live.
He proceeded to address the awe-struck and silent multitude. He
especially urged the young men present to take warning from his
career and fate, and to avoid bad company. His misfortune he
attributed principally to having been misled while young.
When he had concluded, a number of questions were asked by
the immediate spectators, in relation to crimes which had transpired
within their knowledge; but he would give no direct answer—
shrewdly eluding the inquiries.
Execution of James Copeland.—[See Page 118.
The Sheriff then asked him, in hearing of many lookers-on, if the

details of his confession, previously made to that officer, were true.
He replied that they were.
His hands were then tied and the cap pulled over his face, and he
was told that he had but a few moments to live. He exclaimed, “Lord,
have mercy on me!” and he was praying when the drop fell, and a
brief struggle ended his blood-stained career.
GRAND JURY.
John McCullum,
Lemuel Strahan,
John W. Carter,
Allen Travis,
Lewis H. Watts,
James Chappell,
G. W. Rawls,
Wm. Jenkins,
Peter McDonald,
Malachi Odom,
Joseph G. Young,
Jas. M. Bradley, Sr.,
Stephen Smith,
Wm. Hinton,
Edmund Merritt,
Sidney Hinton,
Jos. T. Breeland,
Henry Dearman,
Lorenzo Batson,
John Fairley, Foreman.
WITNESSES.
Wm. Johnson,
Chancey B. Stevens,
Wm. Laudman,
Gibson Waley,
John Anderson,
Wm. C. Griffin,
Moses Fullingam,
Laoma Batson,
Jas. Batson,
David Dubusk, Sr.,
Jefferson Williams,
David Dubusk, Jr.,
Wm. Griffin,
Peter Fairley, Sr.,
Peter Fairley, Jr.,
Alexander Fairley,
Sampson Spikes,
Westley Spikes,
W. H. Nicols,
John Fairley, Prosecutor.
MEMBERS OF THE COPELAND AND WAGES CLAN.
J. Baker,
C. W. Moore,
W. W. Ratlief,
G. Buskings,
J. Harper,
J. Bowings,
J. W. Westly,
J. Whitfield,
J. Whitlom,
J. Porter,
J. Butler,
J. Hopkins,
J. Harper,
W. P. Hobs,
W. C. Whelps,
Jasper Whitlow,
E. Sharper,
T. Powell,
J. Doty,
D. Doty,
S. S. Shoemake,
J. Gillet,
W. Brown,
J. Taylor,
S. Teapark,
J. Pool,
John Copeland,
T. Copeland,
Henry Copeland,
Wm. Copeland,
J. Elva,
H. Sanford,
R. Cable,
J. Hevard,
G. Daniels,
G. H. Wages,
C. H. McGraffin,
Chas. McGrath,
J. Welter,
G. Welter,
A. Brown,
D. Brown,
N. McIntosh,
E. Myrick,
J. F. Wright,
J. Dewit,
W. Ross,
W. Sanferd,
J. McClain,
S. Harden,

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Generalized Anxiety Disorder and

Worrying A Comprehensive Handbook

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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

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

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

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

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