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GAD is characterized by streams of thinking on wide-ranging topics imbued with emotional ambiguity about negative outcomes. Individuals with GAD exhibit automatic emotional-processing biases favoring negative information.

People with GAD and other common mental health conditions tend to interpret ambiguous scenarios (e.g. “You wake with a start in the middle of the night, thinking you heard a noise, but all is quiet”) in a more threatening manner (e.g. “it’s a burglar”) than non-anxious control participants (e.g. “it was the wind”; 42–44). Participants with GAD are also more likely to produce threat-related spellings of homophones (words that sound the same but have two meanings e.g. dye/die) than non-anxious control participants. Interestingly, people in remission from GAD tend not to differ significantly from control groups (45, 46). Interpretation bias is also reduced following anxiolytic medication (46), with greater clinical improvement associated with correspondingly reduced negative interpretations. On a recognition memory test for ambiguous sentences, which assessed interpretation bias while avoiding assessor demand effects, participants with GAD endorsed more threatening interpretations than GAD-recovered and non-anxious participants, who performed similarly (47). The groups did not differ in their rejection of threatening but impossible interpretations (foils), thus ruling out the effects of a general threat-based response bias. Using the same task, Krahé et al. (48) further demonstrated that worry was associated with negative interpretation bias across the general population, and that participants with GAD were biased towards negative interpretations, while community volunteers were biased towards benign (i.e. neutral or positive) interpretations. Hirsch and Mathews' (41) model of worry posits a key role for negative interpretations in triggering negative thoughts and maintaining worry. In contrast, a bias to generate more benign interpretations, evident in non-anxious individuals, would lead to less worry being triggered by negative thoughts and to briefer bouts of worry when it occurs, due to benign interpretations having the potential to terminate streams of worry.

Given that there is a negative interpretation bias in individuals with GAD, the next question that must be addressed is whether it has a causal role in maintaining worry and anxiety. One effective approach to investigating causality is to isolate putative causal processes and modify them experimentally. A secondary benefit to this approach is determining how the mechanism can be modified to inform effective psychological intervention methods. Cognitive bias modification (CBM) of interpretation involves repeated practice with tasks that require generation of benign meanings for ambiguous events, or attending to benign interpretations while ignoring threatening meanings.

The causal role of negative interpretation bias in maintaining worry in GAD was initially established using single-session experiments in which participants were trained to generate benign interpretations of ambiguity. Hirsch et al. (49) showed that training high trait worriers to preferentially access benign meanings of emotionally ambiguous homographs (words with two meanings e.g. hit—record or hit—attack), and ambiguously threatening scenarios, led to reductions in worry. Positive training using the same approach was later demonstrated to be effective in reducing worry in participants with GAD on a behavioral task assessing intrusive thoughts, and showed that this effect was mediated by change in interpretive bias (50). These findings provided initial support for the causal role of interpretation bias in the maintenance of worry in GAD. To investigate the longer-term role of interpretation bias, Hirsch et al. (51) allocated volunteers with GAD to receive 10 home-based CBM sessions. CBM involved listening to either ambiguous worry-related scenarios where the ambiguity was resolved in benign ways, or to an active control condition where ambiguity was not resolved. The active training condition led to reduced negative interpretations post-training and, importantly, to reduced levels of trait worry, anxiety and depression at one-month follow-up. Hence, negative interpretation bias has a causal role in maintaining worry and anxiety in people with GAD in the longer term. Consequently, psychological interventions for GAD should focus on developing more benign interpretations of ambiguous situations.

Another key emotional processing bias proposed in Hirsch and Mathews’ (41) model is selective attention to threatening information (attention bias), which heightens perceived threat in the environment, presumably leading to more worry. A typical paradigm to assess attention bias is the dot probe. This involves one threatening and one non-threatening word being presented briefly on screen and subsequently disappearing, with one word then replaced by a probe. Participants categorize the probe as quickly as possible and faster responses are assumed to indicate that the participant was attending to the location of the word that the target replaced. Numerous studies indicate that individuals with GAD preferentially attend to threatening information when simultaneously presented with both threatening and benign stimuli, including words (52–55) and faces (56, 57). However, some research using emotional face stimuli have failed to identify a negative attentional bias in GAD, and instead found faster shifting away of attention from negative faces in this population (58). Given that worry is a verbal process with infrequent imagery (59–61), verbal material may be more appropriate to assess attentional biases in people with GAD. Furthermore, attention bias may operate more clearly when worry has been primed. In high trait worriers, the tendency to attend to threat operated more strongly when tested after an episode of worry (62), creating a self-maintaining cycle in which worry itself may foster greater attention to threat, which in turn could perpetuate worry bouts. Hence, while an attentional bias to threat in GAD has been established, further research on attention biases in GAD is warranted to understand the boundaries (e.g. verbal material akin to worry) and setting conditions (e.g. once worry is activated) of attentional biases in this population.

Attentional bias does, however, appear to have a causal role in maintaining worry and anxiety in GAD. Cognitive bias modification of attention (CBM-A) has been used to test the causal role of attention bias in maintaining worry. Hayes, Hirsch, and Mathews (63) allocated high worriers to benign training or a control condition for a two-stage training session. Participants in the benign training group completed dot-probe training where a target probe replaced the non-threatening word nearly all the time, thus encouraging attention to non-threatening information. In contrast, the probe for the control group replaced threat and non-threat words equally often. Participants then completed dichotic listening training, where one worry story was played into one channel (ear) and one positive story was played into the other channel simultaneously via headphones. Participants were instructed to listen to a specified story, and at random points the story switched to the other ear so participants had to shift attention to the other channel. Participants in the benign group were always instructed to listen to the positive story across all story pairs, thus training them to attend to positive information and away from worry. In the control condition participants were asked to listen to the positive stories for half of the story pairs, and worry stories for the other half. The benign trained group demonstrated a more benign attention bias following training than the control group and also experienced few negative thought intrusions in a subsequent worry task, suggesting that attention bias has a role in maintaining worry. Longer-term attention training using multiple sessions of dot-probe training reduced attentional bias to threat words and importantly also led to reduced anxiety in people with GAD (64), indicating a causal role of attentional bias in maintaining anxiety in GAD. It should be noted, however, that while important in demonstrating the causal role for attentional bias, multi-session training methods designed to reduce attentional bias have sometimes failed to produce significant change in attention bias in other populations and therefore consequently anxiety (see for example a study in which internet-delivered training at home did not reduce social anxiety; 65). If CBM-A does not change the target process, then its role in maintaining anxiety or worry cannot be assessed. Further refinements to these methods are required to augment home based modification of attention bias. Despite this, evidence of an attentional bias to threat and its causal role in maintaining GAD has been supported, indicating that CBT interventions which facilitate a more benign attentional bias are warranted and may help optimize clinical outcome.

Thoughts can occur in quasi-verbal form (as if talking to oneself), or imagery form (mental representations encompassing different sensory modalities). Evidence suggests that worry tends to occur predominantly in verbal form, with infrequent and brief images when they do occur (59–61). Furthermore, those with GAD have even briefer and fewer images than those without the disorder (61), in contrast to other anxiety disorders where prolonged negative imagery is common (66, 67).

Individuals with GAD sometimes report believing that worrying verbally is helpful in resolving their problems. This belief is misleading, however, as verbal worry has been found instead to increase subsequent negative thought intrusions (68) and prolong negative mood (69). One likely reason for this unhelpful effect is that verbally represented content in worry is typically over-general in nature, and easily moves from one negative topic to another, making positive resolution of specific problems difficult or impossible. Experiments have shown that intrusive thoughts following negative events are substantially more likely to persist if people are instructed to think about the event verbally (as in worry) rather than in the form of mental images (70). Similarly, Hirsch et al. (68) demonstrated that instructed practice in thinking about worry-related content in the form of mental images, which typically have a more specific and concrete focus, reduced the number of subsequent negative intrusive thoughts compared to engaging in worry in verbal form. Hirsch and Mathews (41) therefore propose that the primarily verbal nature of worry in GAD is particularly unhelpful and leads to greater capture of attention by threatening information (62), utilizes high levels of limited-capacity attention control resources (71) and promotes repeated bouts of worry by increasing the likelihood of subsequent negative thought intrusions (68, 72). Given this, CBT for GAD should encompass techniques that enable more imagery-based and concrete and specific thinking.

Another cognitive process proposed to underlie worry is impairment in attentional control (41). Attentional control is a limited capacity resource needed to intentionally ignore distracting information or to shift mental focus (73). Inducing active worry impairs attentional control resources (74). Unfortunately, attentional control is depleted in people with GAD (75, 76), with impairment particularly acute during worry (76, 77). Poor performance on attentional control tasks has also been found to predict subsequent development of GAD (78), further suggesting a causal role. Individuals with GAD may struggle to interrupt streams of worry and refocus onto other topics since worry occupies the same limited attentional control resources needed to refocus attention elsewhere. Furthermore, worry in verbal linguistic form may be particularly problematic for individuals who worry excessively. Leigh and Hirsch (71) found that high trait worriers performed poorly compared with low worriers on an attentional control task when worrying verbally, but not when they worried in imagery form. This suggests that the verbal thinking style typical of worry about negative events may be particularly unhelpful and lead to depleted attentional control, the resource needed to shift mental focus away from worry. Biased cognitive processes may combine with defective attentional control to perpetuate worry. Hirsch et al. (49) showed that cognitive bias modification of interpretation, which was designed to train high worriers to interpret ambiguous information more positively, not only facilitated a more benign interpretive bias and fewer negative thought intrusions, but also led to less impairment of attentional control during worry. Hence, interpretation bias may contribute to worry-specific attentional control problems, since more benign interpretations resulted in less pre-emption of attentional control resources by worry content. Given this, uncontrollable worry in GAD may be maintained in part by interpretive bias per se, but also by its on-going impact on attentional control (41). CBT for GAD needs to employ techniques that enable clients to utilize attentional control resources to focus on the task at hand and encourage them to shift away from worry (i.e. choose to deploy the attentional control resources they have on focusing externally). Furthermore, techniques which encourage imagery-based processing or facilitate benign interpretations are likely to also help clients deploy attentional control resources away from worry.

Client and therapist work collaboratively to develop an idiosyncratic formulation based on a recent bout of worry. The formulation focuses on processes that trigger and maintain worry such as habits (cognitive-emotional processing biases) of attention and interpretation, as well as highlighting the thinking style being predominantly verbal and abstract in nature. By viewing cognitive biases as mental habits, clients can see that it will take time and effort to change their current tendency to worry, but that new habits can be developed to replace old ones, fostering hope of recovery. Furthermore, the role of depleted attentional control is also discussed in relation to the need to re-deploy a “mental-spotlight” onto the task at hand. The challenge for redeploying the “mental spotlight” is that the “mental magnet” of worry tends to keep the “mental spotlight” focused on worry. “Thinking habits” (i.e. cognitive processes that maintain worry) fuel the “mental magnet” keeping clients focused on their worry. In this way, the formulation highlights key cognitive processes of attention and interpretation biases, verbal abstract worry, and the difficulty of shifting attentional control away from worry and deliberately onto the task at hand.

Other information is also incorporated into the formulation. For example, when drawing out the processes that occur during worry, it can be useful to highlight any self-critical thinking. This often fuels worry and has the potential to undermine efforts to develop new CBT techniques, since if they are not deployed effectively on first attempt self-criticism often follows. This then increases emotional distress and promotes further worry. Consequently, having self-critical thinking style as part of the formulation is useful, and can be later countered by using a compassionate voice (88). The worry process itself also elicits physical symptoms of anxiety, lower mood and poor concentration. In turn, these symptoms can be focused on or interpreted negatively and can fuel more worry. Individuals will often try to respond behaviorally or by actively thinking in certain ways in an attempt to stop worry or deal with the situation. However, these behaviors can often lead back to worry or prove futile. The formulation forms the basis of the intervention, and provides a rationale for developing more helpful thinking habits (cognitive processes) and trying to shift focus away from worry and effectively onto the current task. Please refer to Figure 1 for a typical formulation example.

Individuals with GAD attend to thoughts around future threat and fail to attend to real benign outcomes for their worries (e.g. worrying about being late for work every day due to traffic, but not registering that they actually always arrive on time). The WHO form is used to record clients worry topics and evaluate whether or not negative outcomes actually occurred. It involves noting the worry topic and date on which the worry occurred, with each topic recorded only once until its outcome is known. In our adaptation of the techniques, clients are also asked to specify the concrete and specific feared outcome of the worry by briefly describing how a film director would set up the scene to show this outcome. This task promotes image-based thinking and ensures that the feared outcome is objective, concrete and specific and testable. Once the event has passed, clients rate whether the outcome was better or worse than expected (i.e. accuracy of the feared prediction) and how well they coped. Hence, the technique targets attention bias by requiring clients to attend to the real, typically positive, outcomes. This process of making an explicit assessment of the specified outcome may in turn provide an opportunity to counter any negative interpretations of the outcome, either at the time the rating is made, or later on reflection with the therapist when reviewing the WHO at subsequent sessions.

Over several sessions the number of worry topics accumulate. Therapists can address clients’ negative interpretations regarding their own performance or other’s responses generated by reviewing the outcomes; guided discovery highlighting perfectionist standards or viewing the situation less critically (e.g. as if it had happened to someone else) can be useful. After several sessions when situations are rated as better than expected, clients are asked to generate an image of the actual benign or positive outcome for thirty seconds. This is then repeated when any outcome is rated positively and provides practice in generating positive imagery.

After about six sessions of using the WHO form, the percentage of positive/benign outcomes (i.e. better than expected) is calculated for all events that have had an outcome. Borkovec et al. (89) cite that outcomes are better than anticipated 85% of the time. In our experience, rates of positive/benign outcomes very often exceed 95%, perhaps because the task was adapted to include a new column where the main concrete and specific feared outcome is explicitly noted on the form, and thus is more testable. For example, the topic may be “performance review” whereas the specific concrete feared outcome may be “John says I am performing poorly.” Personal data around positive outcomes are subsequently built on with a new technique later in treatment (positive outcome imagery—see below). The WHO form is thus used to target attention and interpretation biases, verbal thinking style, generalized and abstract thinking, and attentional control.

Borkovec’s protocol (37, 38) involves clients trying to shift focus externally away from worry and onto the task at hand, which is conceptualized in our adaptation as shifting a “mental spotlight.” Unfortunately, shifting the mental spotlight onto the task at hand early in treatment is particularly difficult since worry utilizes attentional control, which is the very resource needed to shift attention away from worry. If the client manages to focus on the task at hand, they may find themselves drawn back to the “mental magnet” of worry due to cognitive biases. Additionally, stress and anxiety can further deplete attentional control resources already affected by GAD (76, 90). This makes it more difficult to implement CBT techniques for homework when clients feel most anxious or stressed, and yet this is the very time when they would benefit from CBT techniques the most. CBT homework should consequently be set up as repeated practice in developing new “mental muscles” (via more helpful focus of cognitive processes) to shift the mental spotlight. The aim is to practice the shift—not that people will always be able to be focus away from the worry—so any time the focus comes back on the worry or they are unable to shift, they can see it as another opportunity to practice the shift again. Informing clients that this can be challenging from the start will help them to remain engaged in CBT and see that being compassionate about this challenge, while still attempting to shift to the task at hand, will lead to longer term reductions in worry.

Introducing the concept of attentional control as a mental spotlight that can be difficult to shift and introducing CBT techniques as a way of developing new “mental muscles” that require numerous repetitions to develop helps to address potential barriers to progress with CBT. Over treatment, discussions about what clients will shift their mental spotlight to focus on—conceptualized as “hooks” to draw them in the task at hand—helps clients shift to the task at hand and enables them to remain engaged for longer periods of external focus by identifying particular aspects of a task to focus on. This demonstrates how CBT approaches, conceptualized through metaphors, combine to help clients shift focus away from worry by utilizing their attentional control.

Worry free zones (WFZ) are introduced as the first opportunity to help clients practice focusing their mental spotlight externally onto the task at hand at times when they worry. WFZ were first introduced by Borkovec and Sharpless (80) but have been adapted to highlight the role of cognitive processes that maintain worry. During the first week, WFZ are short (e.g. 5 min) periods of time where clients try to focus away from worry externally onto the task at hand. The zones can be a specified task (e.g. making a cup of tea), place (e.g. bathroom) or time period (e.g. from waking until going downstairs). Clients should be prepared to expect that worry will naturally come back into their mind and to be compassionate with themselves when this happens and re-focus back on the current task. Later, the duration and number of worry-free zones can be increased. WFZ target attention control redeployment actively onto the clients’ current task, helping to override prepotent cognitive biases that will focus clients back onto worry. WFZ may also promote attention bias to benign information.

Once clients can shift focus away from worry during WFZ, they could move on to worry timetabling. Worry timetabling requires the client to postpone worries until a specified time later in the day (e.g. 15 min at 5pm) when they catch themselves worrying, and then re-focus their mental spotlight onto the task at hand. Again, clients may need to be reminded of the importance of using their compassionate voice when they notice the worry returning to their mind. Initially worry may return very quickly, but with practice will return less often and with longer worry-free intervals. If clients forget to use the worry period, then they are asked to timetable any subsequent worries to the next day’s worry period.

During the first week, the worry period is just left as a time when clients can worry. However, during the following session the therapist will enquire about how the client found the experience of postponing worry, whether the worry returned immediately, and if they persevered with the technique, whether the time between worry bouts about that topic grew longer. The therapist should also enquire about when it was harder and easier to postpone worry to help tailor techniques to facilitate greater ability to shift from worry and remain focused on the task at hand. Clients may subsequently choose to not worry in the worry period, but think about worries in more objective ways, or not at all. The worry timetabling technique utilizes attentional control, which is deployed onto the task at hand, and consequently also helps develop a new attention bias to benign information since most tasks are benign in nature.

While not part of Borkovec’s protocol (37, 38), keeping a positive data log can help to develop more adaptive thinking habits. Padesky (91) introduced the technique to help develop more adaptive core beliefs by having clients attend to and note down evidence in day to day life that is in keeping with their new alternative (adaptive) core belief. While the current protocol does not focus on core beliefs per se, worry is often driven by a sense that the individual is “not good enough” and so working with the client to collect evidence that they are “OK” in terms of what they do and how others respond to them is useful. The positive data log involves writing down evidence in day-to-day-life that they are OK. Clients can aim to write down a few pieces of evidence on their log each day. It also has the function of getting the client to be a “detective for positive outcomes” and thus helps develop a more benign attentional bias. Furthermore, when identifying potential information for the positive data log, this may also provide an opportunity to generate positive interpretations of ambiguous events in day-to-day life.

Imagery techniques can be used when people are worrying, and the outcome is unknown. Clients identify a current worry topic and specify a concrete and specific feared outcome and rate the percentage likelihood that this outcome will occur. Given that their WHO collation conducted earlier in treatment will indicate that worry topics very often have benign or positive resolutions (85% of the time; 89), clients are requested to brainstorm different ways that this situation could turn out well. This task develops a new habit to generate multiple positive outcomes, rather than multiple negative outcomes characteristic of worry. Clients are then requested to select an outcome or combination of outcomes to think about further in a positive, concrete way. Clients are asked to set-up the scene as if they were a film director, making the outcome concrete and specific. Clients then close their eyes and generate a vivid image of the scenario unfolding, tuning into the different sensory modalities for 2 min. Finally, they re-rate the likelihood the feared outcome would happen. This technique promotes attention to positive information, positive interpretations and concrete and specific positive outcome imagery of future worries.