AnxietyFor practitioners110 min read

Treating generalised anxiety disorder in adults: a therapist's manual

A fourteen-session protocol, session by session, targeting worry itself: intolerance of uncertainty, beliefs about the usefulness of worry, the worry outcome diary, imaginal exposure, certainty-seeking behaviours. Diagnostic criteria, assessment, common mistakes, worksheets to hand the patient, and full references.

Reviewed on October 3, 2026
Dr Zayan Al-Falasi, psychiatrist

Topic: Anxiety
Who it's for: For practitioners
Languages: FR · EN · DE · IT · ES · ZH · AR

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The programme

This programme is a treatment manual written for mental health professionals. It assumes clinical training, the ability to make a diagnosis, and access to supervision. It replaces neither your clinical judgement nor your professional responsibility. The diagnostic criteria here are reformulated in our own words and never reproduced: consult the original manuals for the letter of the text.

The notice at the start of the resources is hidden.

1. The programme at a glance

Indication. Generalised anxiety disorder in adults. The programme also suits disabling chronic worry that falls short of the full criteria, which is common and rarely treated.

Reference model. An integrative protocol, assembling three models whose targets are complementary and all evaluated: the intolerance-of-uncertainty model of Dugas, Gagnon, Ladouceur and Freeston (1998), Wells's metacognitive model (1995, 2009) concerning beliefs about worry itself, and Borkovec's avoidance theory (Borkovec, Alcaine & Behar, 2004), extended by Newman and Llera's contrast-avoidance hypothesis (2011); section 4 presents these models. NICE (the National Institute for Health and Care Excellence, 2011), the British body that publishes good-practice guidelines, recommends cognitive behavioural therapy as a first-line treatment at steps 2 and 3 of the stepped-care model in its guideline CG113: under that model, the intensity of care increases with the severity of the disorder and with lack of response to the previous steps.

Format. Fourteen individual sessions of 60 to 90 minutes, weekly, over roughly four months, followed by two booster sessions at one month and three months. Allow 90 minutes for sessions 2, 6, 9, 11 and 12, and 60 minutes for the others (section 12): the formulation, teaching the worry outcome diary, the imaginal exposure, the inventory of certainty seeking, followed where appropriate by a meeting with a relative, and the contrast experiment take time in those sessions.

Target mechanism. Not the disappearance of worry, but four changes: what the patient believes about their worry — that it is useful to them, or that it is uncontrollable and dangerous — their tolerance of not knowing, their ability to tell a problem from a hypothesis, and their contact with the emotion they are avoiding by worrying.

Session	Focus	What the session produces
1	Assessment, measures, frame	Worry record opened
2	Individual formulation	Two-storey diagram, written with the patient
3	Real or hypothetical, and postponement	Sorting done, worry period set
4	Relaxation training	A three-minute release, learnt
5	What worry is supposed to give	Positive beliefs listed and weighed
6	The worry outcome diary	Two weeks of predictions recorded
7	Intolerance of uncertainty	First non-checking experiment
8	Problem solving	One real problem worked in six steps
9	The feared scenario, imaginal	Recording listened to, with no way out
10	Worry judged uncontrollable or dangerous	Deliberate loss-of-control experiment
11	Certainty seeking	Inventory of checking and reassurance
12	Emotional avoidance and contrast	One emotion lived through without prior worry
13	Generalisation, sleep, residues	Final inventory
14	Personal plan, relapse prevention	Summary sheet written by the patient

What the patient takes away. Seven printable worksheets, listed in section 31 and downloadable from this page: worry record, sorting real problems from hypotheticals, worry outcome diary, relaxation record, problem-solving grid, record of certainty seeking, personal plan.

What sets this programme apart from treating anxiety in general. The target is not anxiety, it is worry — the verbal, repetitive, future-oriented mental activity the patient conducts themselves and believes to be useful. A patient with generalised anxiety who is taught only to relax may relax better and worry just as much. That difference of target changes what you measure, what you prescribe, and what counts as progress.

2. Before you start

How to use it

Read the whole thing before the first session. Sections 3 to 12 lay down the frame; sections 13 to 26 are worth rereading the day before each session.

Every session is described on the same frame: the objective, a step-by-step run-through (which includes the sentences to say), the common mistakes, and the criterion for moving on. That last point sets the pace: the programme advances by acquisition, not by calendar.

One warning specific to this disorder. The patient with generalised anxiety is a good patient: they come, they are pleasant, they fill in their worksheets, and they talk readily. The session can pass very agreeably reviewing the week's worries, one after another, examining each with sympathy. That drift is the most frequent of all, and it does not treat anything: it is worrying together. The agenda is your main means of protection.

3. The clinical picture

What the patient describes

Patients rarely talk about worry. They talk about tiredness, tension, poor sleep, aches, irritability. They often see their general practitioner first, for years, about physical symptoms. Asked whether they worry, they usually say yes, but that they have always been like that, and that this is not the point.

That last sentence matters: these patients regard their worry as a character trait, not a symptom. It is an obstacle and it is also information — it tells you that the positive beliefs about worry are firmly held.

The three components

Excessive worry that is hard to control, across several domains: work, money, health, the health of family members, the children, small everyday things, being late, decisions. The content is plausible — that is what distinguishes it from an obsession — and it moves: a worry that is resolved is replaced by another.

The physical and cognitive symptoms: muscle tension, fatigue, difficulty concentrating, irritability, unrefreshing sleep or delayed sleep onset. Muscle tension is the most specific symptom of this disorder, and the patient does not connect it to their anxiety.

The behaviours, often neglected in assessment and yet direct targets: reassurance seeking, checking, phoning to make sure everything is all right, excessive planning, over-preparation, lists, refusing to delegate, repeatedly checking the news or results, and avoiding decisions.

What keeps the disorder going

Worry is experienced as useful. That is the starting point. The patient believes it prepares them, that it prevents nasty surprises, that it shows they are serious, that it protects the people they love, or that it stops things from happening. These beliefs are never absurd: they contain a grain of truth, and that is what makes them robust.

Worry is never disconfirmed. Since most feared events do not happen, every day without catastrophe reinforces the idea that the worry did some good. It is a perfect negative reinforcement, and it operates several times a day.

Uncertainty is treated as a danger. Not knowing becomes intolerable in itself, independently of the actual risk. The patient then seeks certainty — by checking, by asking, by planning — which makes uncertainty momentarily less unbearable, and certainty lastingly more necessary.

Worry avoids something. Two complementary mechanisms. Borkovec proposed, on the basis of experimental work (Borkovec & Inz, 1990), that worry, a verbal and abstract activity, avoids the images and the emotional activation that go with them: one thinks about the misfortune without feeling it. Newman and Llera added that worry maintains a continuous negativity which avoids contrast — the sharp fall from a neutral state to bad news. The patient worries in order never to be caught out by an emotion.

The patient worries about worrying. Wells calls this type 2 worry. The patient comes to believe that their worry is uncontrollable, that it will make them ill, that it is damaging their brain. That adds a whole extra storey to the disorder, and that storey is treated separately.

Epidemiology, in two useful figures

Twelve-month prevalence is about 2 %, and lifetime prevalence about 4 %; it is higher in high-income countries, at 2.3 % and 5 % (Ruscio et al., 2017). The disorder is twice as common in women.

Onset is insidious and often long-standing: many patients cannot date theirs. The delay before adequate treatment is among the longest in psychiatry, and most patients are first treated for physical symptoms.

4. The model that guides this programme

Why three models and not one

None of the three available models (reviewed, along with others, by Behar et al., 2009) covers the disorder on its own, and the trials that compare them cannot separate them cleanly. This programme therefore bets that a protocol attacking several targets covers the disorder better; the bet is reasonable, but it has not been tested as such.

The intolerance-of-uncertainty model (Dugas et al., 1998; Dugas & Robichaud, 2007; Robichaud & Dugas, 2015) holds intolerance of not knowing to be the central factor. It produces three consequences: positive beliefs about worry, a negative problem orientation — the patient can solve problems but believes they cannot — and cognitive avoidance, that is, everything the patient does in their head so as not to picture what they fear: pushing distressing thoughts away, distracting themselves, or staying with words rather than images (section 3). It is the best-evaluated model, and the one that organises most of this programme.

The metacognitive model (Wells, 1995, 2009) shifts the target: it is not the worries that matter, it is the beliefs about worry. Positive beliefs set it off; negative beliefs — that it is uncontrollable, that it is dangerous — turn it into a disorder. Treatment then addresses those beliefs, never the content of the worries.

The avoidance theory (Borkovec, Alcaine & Behar, 2004; Newman & Llera, 2011) explains the function of worry: it keeps image and emotion at a distance. It provides the rationale for imaginal exposure, without which a purely cognitive treatment leaves the emotional core intact.

The five levers of the programme

Beliefs about worry. First those that credit it with a use: without this work, everything else is heard as a request to lower one's guard. Then those that call it uncontrollable or dangerous, and that turn it into a disorder.

The distinction between a problem and a hypothesis. A worry about a real problem can be solved; a worry about a hypothesis cannot, and is left alone. This distinction, banal to state, is the one that changes the patient's daily life fastest.

Tolerance of uncertainty. It is built by behavioural experiments, never by reasoning.

Exposure to the feared image. It treats what verbal worry avoids.

Certainty-seeking behaviours. In this disorder, they are the main form of safety behaviour — what the patient does to protect themselves from a feared outcome: checking, asking, looking things up, planning. They have to be removed one by one, like rituals.

What the model implies you should not do

Do not discuss the content of the worries one by one. This is the central mistake. Examining whether the patient is right to fear redundancy produces an hour of relief and a new worry the following week. The content moves; the mechanism stays.

Do not reassure. "Your tests are normal, everything is fine." You have just performed the patient's behaviour for them.

Do not centre the treatment on relaxation. It has its place, a minor one. A relaxed patient who worries just as much has not been treated.

Do not let the session follow the week's worry. The patient will arrive with an urgent subject, every week, and they will be sincere. The agenda holds regardless.

5. The DSM-5-TR criteria, reformulated

The criteria below are a reformulation in our own words, as an aide-memoire. They do not replace the manual: consult the DSM-5-TR (American Psychiatric Association, 2022) for the letter of the text and the application notes.

Generalised anxiety disorder requires the following.

Excessive anxiety and worry, present most days for at least six months, about a number of subjects or activities.

Difficulty controlling that worry.

At least three associated symptoms out of six: restlessness or feeling on edge, being easily fatigued, difficulty concentrating or mind going blank, irritability, muscle tension, and sleep disturbance. One is enough in children.

Clinically significant distress or impairment of functioning.

Exclusion of other causes: the effect of a substance or a medical condition.

Exclusion of another mental disorder that would better account for the worry: fear of judgement in social anxiety, fear of attacks in panic disorder, fear of being ill in health anxiety, obsessions in obsessive-compulsive disorder, reminders of the trauma in post-traumatic stress disorder.

What these criteria do not say, and what you must assess

They list no behaviours. Yet checking, reassurance seeking, excessive planning and avoidance of decisions are targets of treatment, and the assessment must ask about them explicitly.

They say nothing about beliefs concerning worry, which are the metacognitive target.

They do not measure intolerance of uncertainty, which is one of the best predictors of the severity of worry.

The six-month threshold excludes patients who need treatment. A patient disabled for four months is treated.

This programme is for practitioners

It is written for mental health professionals and requires proof of professional status, then a professional subscription.

See professional access I already have an account

What the rest contains

6. The ICD-11 criteria, reformulated
7. Differential diagnosis
8. Comorbidity, and what it changes
9. Assessing before treating
10. What the research says
11. The goals of therapy
12. The frame of the programme
13. Session 1 — Assess, measure, set the frame
14. Session 2 — The individual formulation
15. Session 3 — Real or hypothetical, and postponing worry
16. Session 4 — Relaxation training
17. Session 5 — What worry is supposed to give
18. Session 6 — The worry outcome diary
19. Session 7 — Intolerance of uncertainty
20. Session 8 — Problem solving
21. Session 9 — The feared scenario, imaginal
22. Session 10 — Worry judged uncontrollable, or dangerous
23. Session 11 — Certainty-seeking behaviours
24. Session 12 — The avoided emotion, and the question of contrast
25. Session 13 — Generalise, and what is left
26. Session 14 — The personal plan and relapse prevention
27. The two booster sessions
28. Presentations that call for adjustment
29. When it is not enough
30. The family
31. The worksheets to give the patient
32. Treatment fidelity
33. Conclusion
34. Frequently asked questions
35. References

Frequently asked questions

The patient says they have always been like that, and that it is their character. What do I say?

Do not contradict them head on: they are probably right about how long it has gone on. Move the question. "You may always have been attentive and forward-thinking, and that will not change. What we are talking about is the time it takes you today, and the fact that you are sleeping badly." Then measure the daily time spent worrying: the figure does more than any argument, because it turns a character trait into a quantity.

How do I stop the session becoming a review of the week's worries?

By the agenda, written and announced. And by one sentence, to be used without embarrassment when the session drifts: "we are currently doing together exactly what we are trying to reduce." Give the urgent subject a bounded and named amount of time — ten minutes — and hold the boundary. If a subject comes back three weeks in a row, apply the session 3 sorting to it: if it is a real problem, work it in six steps; if it is a hypothesis, it belongs in the period.

What do I do when worry postponement is not working and the patient says they cannot wait?

First check what they are actually doing. Most often, they are trying not to think about it, which is suppression and not postponement. Go back over the distinction: the instruction is not to push the thought away, it is to put off dealing with it. Then check that the period is genuinely being used: postponement without a period being kept becomes an avoidance and stops working within two weeks.

Should the worry period really be kept to the end?

Yes throughout the programme, then as they wish. It is the tool patients keep longest, often for years, and the one they reopen of their own accord at the first sign of relapse.

What do I say to a patient who worries about their children and says that a good mother worries?

Do not argue with the value they are defending, care for their children: you would lose, and rightly. Move onto two other grounds. Effects: what does the child see, what do they learn from a parent who phones four times, what relationship to risk does that give them. And behaviours: the calls, the prohibitions, the checking can be treated without having to settle the question of what a good mother is.

What do I do when the worry concerns something objectively serious — a sick relative, a job at risk, debt?

Do not treat that as a symptom. Part of that worry is justified, and the patient knows it; denying it costs you their trust. Do the sorting finely: what admits of a possible action is treated by problem solving, and sometimes by concrete help — social or legal — that is not your remit but that you can point them towards. What is hypothetical — the outcome of the illness, the future in three years — is left alone. This is often the most delicate work in the programme. When the worry concerns the climate and environmental crisis, Eco-anxiety: a therapist's manual helps you place the case: if the climate is only one of several subjects of worry, this programme applies; if the distress is concentrated on it, that manual offers work that does not dispute the reality of the threat.

Relaxation: yes or no?

Yes, in one session, as a somatic tool, with its rule of use. It reduces muscle tension, which is the most unpleasant and most specific symptom, and it gives the patient something concrete in the first month. No as the heart of the treatment: a relaxed patient who worries just as much has not been treated, and relaxation easily becomes a safety behaviour.

Should imaginal exposure be done with every patient?

With everyone who has a dominant worry with an identifiable core (session 9, step 2) — that is, the great majority. It is the session most often left out, because it is unpleasant for the therapist as much as for the patient, and it is the one whose absence is most felt when the result is partial. The exceptions: an ongoing depressive decompensation, or a patient whose alliance is not yet sufficient — in which case defer, do not delete.

The patient says their worry is uncontrollable. How do I contradict them without putting their back up?

Do not contradict them: show them their own data. They have postponed dozens of worries to the period since session 3. Ask the question and let them answer: "something you can put off until five o'clock — is it out of control?" Then run the deliberate-worry experiment: almost nobody manages to lose control on command, and that discovery is theirs.

What do I say to a patient who fears worry will make them ill or drive them mad?

Give the information once, factually: worry is tiring, it tenses the body and damages sleep; it does not cause madness. Then move to the experience, which is stronger: "the test has been running for twenty years. How is it going?" And above all, do not repeat the information every week: it would become the patient's reassurance, performed by you.

How long before a change is visible?

The sorting and the period often produce an effect within two to three weeks, and that is what supports engagement. Belief change is slower and requires the outcome diary, kept for at least four weeks, in practice from session 6 to the end of the programme. Warn the patient of that timetable in session 1: it prevents the second-month discouragement.

Should medication be added?

Therapy and medication are equivalent first-line options according to NICE, and the combination has not shown a clear advantage. It is justified by severity, by associated depression, or when the patient is too symptomatic to engage in the work. One important point: benzodiazepines taken as needed are a safety behaviour and hamper learning; they are dealt with in session 11 through a rule of use agreed with the prescriber, and reducing a medication taken regularly is planned with the prescriber, after session 12.

What do I do when the patient improves, a life event happens and everything comes back?

This is the most frequent relapse scenario, and it does not mean the treatment failed. A bereavement, a birth, a diagnosis, a job loss reactivate the mechanism in someone who has all the skills to treat it. Three or four targeted sessions are usually enough. Warn them at session 14: a patient who has been warned comes back early, a patient taken by surprise comes back at square one.

Are fourteen sessions enough?

For a majority of patients, yes, with the two boosters. If improvement is partial at session 14, extend by four to six targeted sessions, naming what remains, rather than running the whole programme again. If you only have eight sessions, keep sessions 1 to 3, 5 to 7, 9 and 14 intact, and fold into session 7 the inventory and the three rules from session 11, which aim at the same target. No shortened version of this programme has been evaluated. This choice covers the three causes of failure in section 9, and it keeps intolerance of uncertainty, which mediates change (Bomyea et al., 2015), as well as imaginal exposure. On the other hand, you give up the relaxation (session 4), problem solving (session 8) and the work on uncontrollability and danger (session 10), part of which the postponement in session 3 already provides: it shows that worry can be controlled. You also give up session 13 and the contrast session (session 12). This is the only case in which you do without the latter, because the specific contribution of emotion-focused work, added to cognitive behavioural therapy, has not been demonstrated (Newman et al., 2011). Do it knowing what you are leaving out.

Can this programme be run in a group?

Yes, and group results are respectable. The sorting, the period, problem solving and the work on beliefs all lend themselves to it. Imaginal exposure and the non-checking experiments require an individualisation that a group does not easily allow: a mixed format is the best compromise.

What do I do when the patient fills in every worksheet, does everything, and nothing changes?

Two hypotheses. Either the experiments are too easy — look at the anxiety ratings, they will tell you: if nothing has gone above 40 out of 100, nothing has been tested. Or the patient is complying without believing, because the positive beliefs are intact: go back to session 5. A third hypothesis, rarer and not to be dismissed: the patient's life situation is genuinely bad, and what they need is not here.

Printable worksheets

The exercises from this programme, as printable PDFs. Members only.

See the plansThe printable worksheets are included with access.

01What is on my mindThree times a day, at fixed times, for the first week.
02A problem, or a hypothesisThe sorting, and the worry period. For use throughout.
03What I predict, what happensThe most important worksheet. Photocopy it, and keep it to the end.
04RelaxationA week of training, then in everyday use.
05Solving a problemOne worksheet per problem. Thirty minutes, stopwatch in view.
06Not checkingThree things given up each week, with a prediction written beforehand.
07My planTo write yourself, at the last session.

Every worksheet in one file, with a table of contents.

generalised anxietyGADworryintolerance of uncertaintyCBTmetacognitive therapyDugasWellsBorkovecprotocolmanualprofessionalsDSM-5ICD-11

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