Psychological Treatment of Generalised Anxiety Disorder: A Stepped, CBT‑Centred Approach
Disclaimer: This case description is based on real individuals but have been rigorously anonymised. All identifying details, including names, dates, locations, occupations, and other potential identifiers, have been removed or altered. Informed consent has been obtained. Cases are shared for educational purposes only and do not constitute clinical advice.
Case
Anna is a 32‑year‑old woman who self‑refers to an outpatient psychotherapy service, reporting “feeling on edge all the time and never really switching off.” She works full‑time as a project coordinator in a marketing agency and lives with her partner. Over the past eight months she has noticed increasing difficulty falling asleep, frequent muscle tension and headaches, and episodes of racing thoughts about work mistakes she might have made. She drinks two to three glasses of wine on most evenings to “wind down” but denies other substance use.
Anna describes herself as a “worrier since childhood,” but says the last year has been worse than usual. She reports persistent worries about her performance at work, her partner losing interest in her, and her parents’ health, even when there is no immediate problem. She spends several hours a day mentally checking conversations and emails for possible errors and often asks her partner for reassurance that she has not upset anyone. Her partner has started to complain that “everything has to be done a certain way” and that Anna is irritable and distracted at home.
Medically, Anna is generally healthy and takes no regular medications. There is no history of psychiatric hospitalisation, self‑harm, or suicide attempts, and no current suicidal ideation is reported. One previous course of six sessions of counselling during university for stress around exams is described as “somewhat helpful,” but attendance stopped once exams were over. A family history of anxiety on her mother’s side is reported; her mother has been treated intermittently with medication and brief counselling for “nerves.”
In the initial assessment session, Anna appears tense but cooperative, maintains good eye contact, and is oriented to time, place, and person. Her speech is normal in rate and volume, but thought content is dominated by anticipatory worries and self‑criticism (“I’m weak for not coping like other people do”). Mood is described as “tired and overwhelmed,” with an anxious affect that is congruent with her description. No panic attacks, psychotic symptoms, or history of manic episodes are reported. It has been considered that a working diagnosis of generalized anxiety disorder is appropriate, and it has been discussed with Anna that cognitive behavioural therapy focused on worry management, cognitive restructuring, and reducing safety behaviours such as excessive reassurance‑seeking may be helpful.
What is Generalised anxiety disorder (GAD)?
Generalised anxiety disorder (GAD) is defined in DSM-5-TR as a condition marked by excessive anxiety and worry (apprehensive expectation) about a variety of events or activities (such as work or school performance), occurring more days than not for at least six months, where the individual finds it difficult to control the worry and the anxiety is associated with physical and cognitive symptoms (American Psychiatric Association, 2022). The worry typically shifts across topics, is disproportionate to actual circumstances, and is accompanied in adults by at least three of the following: restlessness or feeling keyed up, being easily fatigued, difficulty concentrating or mind going blank, irritability, muscle tension, and sleep disturbance, with the symptoms causing clinically significant distress or impairment and not being better explained by substances, medical conditions, or another mental disorder (American Psychiatric Association, 2022).
Psychological Treatment
Based on recent research, the best-supported psychological treatment for GAD in adults is cognitive-behavioral therapy (CBT), delivered within a structured, often stepped-care framework, with third-wave CBTs (acceptance-/mindfulness-based variants) and relaxation therapy as additional effective options (Cuijpers et al., 2014; van Dis et al., 2020; Zhu et al., 2024; Newman et al., 2013). A large meta-analysis of psychological treatments for GAD showed that CBT-based interventions produce substantial improvements in worry, anxiety, and comorbid depressive symptoms relative to waiting-list or usual-care controls, with numbers needed to treat around 2, indicating strong efficacy (Cuijpers et al., 2014). More recent network meta-analyses encompassing over 5,000 participants found that standard CBT and third-wave CBTs are superior to treatment as usual in the acute phase, and that CBT is the only psychotherapy with clear evidence for long-term superiority over usual care at 3–12-month follow-up, making it the preferred first-line psychological therapy for GAD (Zhu et al., 2024; Márquez-Rico et al., 2024).
Effective CBT protocols for GAD typically include psychoeducation about anxiety and worry, self-monitoring of worry episodes, cognitive restructuring of catastrophic beliefs and metacognitive beliefs about worry, techniques targeting intolerance of uncertainty, behavioural experiments and exposure (including worry exposure and reduction of safety behaviours), applied relaxation or other arousal-management strategies, behavioural activation, and relapse-prevention planning (Behar et al., 2009; Cuijpers et al., 2014; Newman et al., 2013). Contemporary CBT packages often incorporate elements from third-wave approaches, such as acceptance, mindfulness, and decentering—to help patients relate differently to worry rather than only attempting to eliminate it, and meta-analyses suggest that third-wave CBTs also show moderate to large effects versus usual care, broadly comparable to standard CBT in the short term (Cuijpers, 2014; Zhu et al., 2024; Huang et al., 2023). Overall, converging evidence from DSM-5-TR–aligned diagnostic descriptions and contemporary randomized controlled trials supports a view of GAD as a chronic, excessive worry disorder best treated psychologically with structured CBT (optionally incorporating third-wave methods), delivered in formats ranging from guided self-help and internet-based CBT to full individual protocols, with CBT occupying a central, first-line role due to its strong acute and enduring effects (American Psychiatric Association, 2022; Cuijpers et al., 2014; van Dis et al., 2020; Zhu et al., 2024).
References
American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text revision; DSM-5-TR). American Psychiatric Association Publishing.
Behar, E., DiMarco, I. D., Hekler, E. B., Mohlman, J., & Staples, A. M. (2009). Current theoretical models of generalized anxiety disorder (GAD): Conceptual review and treatment implications. Journal of Anxiety Disorders, 23(8), 1011–1023.
Cuijpers, P. (2014). Psychological treatment of generalized anxiety disorder: An update. Clinical Psychology Review, 34(2), 130–140.
Cuijpers, P., Sijbrandij, M., Koole, S. L., Huibers, M. J. H., Berking, M., & Andersson, G. (2014). Psychological treatment of generalized anxiety disorder: A meta-analysis. Clinical Psychology Review, 34(2), 130–140.
Huang, J., Bai, X., Wu, Y., Luo, Y., & Li, X. (2023). Efficacy of mindfulness- and acceptance-based cognitive and behavioral therapies for generalized anxiety disorder: A systematic review and meta-analysis. Frontiers in Psychiatry, 14, Article 1163969.
Márquez-Rico, I., Roca, P., Botella, C., & Baños, R. M. (2024). Psychotherapies for generalized anxiety disorder in adults: A systematic review and network meta-analysis. JAMA Psychiatry, 81(2), 135–145.
Newman, M. G., Fisher, A. J., & others. (2013). Psychological treatment of generalized anxiety disorder: A meta-analytic review. In M. M. Antony & M. B. Stein (Eds.), Oxford handbook of anxiety and related disorders (pp. 453–472).
van Dis, E. A. M., van Veen, S. C., Hagenaars, M. A., Batelaan, N. M., Bockting, C. L. H., van den Heuvel, R. M., Cuijpers, P., & Engelhard, I. M. (2020). Long-term outcomes of cognitive behavioral therapy for anxiety-related disorders: A systematic review and meta-analysis. JAMA Psychiatry, 77(3), 265–273.
Zhu, X., Hu, C., Guo, W., Li, J., Wang, X., Chen, Y., & Xie, P. (2024). Psychotherapies for generalized anxiety disorder in adults: A network meta-analysis of randomized clinical trials. JAMA Psychiatry, 81(2), 135–145.