Worry

Worry is the part of anxiety most people recognise in themselves: the thought that keeps coming back, the what-ifs at two in the morning. It is also where advice can run ahead of the evidence. This lesson is about both.

What the assessment adds

Lesson 1 gave you CG113's two key symptoms of generalised anxiety disorder, or GAD, its six months, and its insistence that a clinician not rely on a symptom count alone. The appendix adds an order. Only once the two key symptoms are present is a clinician told to "ask about the following associated symptoms: restlessness, being easily fatigued, difficulty concentrating, irritability, muscle tension, disturbed sleep."¹

That order matters. Tiredness, irritability and poor sleep have many causes, and on their own they do not point to GAD; they're asked about only after the worry itself has been established as excessive and hard to control. That reading of why the order matters is this course's.⁶ It is also one more reason not to score yourself: the list is not the test.

What NICE offers, and what it does not name

At step 2, for "people with GAD whose symptoms have not improved after education and active monitoring in step 1", CG113 says to "offer 1 or more of the following as a first-line intervention, guided by the person's preference: individual non-facilitated self-help; individual guided self-help; psychoeducational groups."¹ The verb is "offer", NICE's strong grade, and lesson 3 showed what each of those means.

Step 3 is a choice between a high-intensity psychological treatment and a drug treatment, and CG113 does not rank them: "Base the choice of treatment on the person's preference as there is no evidence that either mode of treatment (individual high-intensity psychological intervention or drug treatment) is better. [2011]"¹ This lesson describes the psychological side, because that's what this course researched; the drug side is a conversation with a prescriber, not a course.

If a person chooses a high-intensity psychological treatment: "offer either CBT or applied relaxation." Applied relaxation is a structured treatment, not advice to relax, much as Sleep lesson 6 found CBT-I is not being told to relax. NICE specifies it should "be based on the treatment manuals used in the clinical trials of applied relaxation for GAD", "be delivered by trained and competent practitioners", and "usually consist of 12 to 15 weekly sessions ... each lasting 1 hour."¹ Manualised means delivered from a written protocol. This course didn't read a description of the technique itself.

Now what the page does not say. This course searched CG113's recommendations page, which it read in full. "Mindfulness", "breathing", "yoga" and "physical activity" don't appear on it. "Exercise" appears twice: once as a verb ("exercise caution"), and once in a 2004 recommendation for panic disorder that is health advice, not treatment: "The benefits of exercise as part of good general health should be discussed with all people with panic disorder as appropriate."¹ No recommendation for GAD names exercise, mindfulness or any single worry technique. NG222 lists group exercise and group mindfulness programmes designed for depression among its options for less severe depression, which is a different guideline and a different condition; lessons 5 and 6 come to them.²

What the evidence shows for treating GAD

The evidence that CBT beats waiting lists and usual care for GAD is consistent. Beyond that it is less clear. Every study below was read at abstract level.

The Cochrane review of psychological therapies for GAD, by Hunot and colleagues, is old: its searches ended in 2006, and no newer version was found. It reports that "Based on thirteen studies, psychological therapies, all using a CBT approach, were more effective than TAU/WL in achieving clinical response at post-treatment (RR 0.63, 95%CI 0.55 to 0.73)".³ TAU/WL is treatment as usual or waiting list, and "clinical response" means improving by an amount set in advance, as in lesson 2.

The same review compares CBT with supportive therapy, a talking therapy without CBT's specific techniques, which sits among the active comparisons in lesson 2's list: "No significant difference in clinical response was indicated between CBT and supportive therapy at post-treatment (RR 0.86, 95%CI 0.70 to 1.06), however significant heterogeneity was indicated, which was partly explained by the number of therapy sessions."³ Heterogeneity means the trials disagreed with each other more than chance explains, as in Sleep lesson 3. That gloss of supportive therapy is this course's; the abstract does not define it.⁶

A 2014 meta-analysis by Cuijpers and colleagues included 41 studies; across 28 of them, psychotherapy against a control group gave a large effect, g = 0.84, and "The majority of studies used waiting lists as control condition." It adds: "There were some indications for publication bias."⁴ Lesson 2's question has its answer right there.

For internet treatment of GAD specifically, a 2021 meta-analysis by Eilert and colleagues found "large effect sizes for primary outcomes of anxiety (g = 0.79) and worry (g = 0.75), favoring treatment", with a note that matters for this lesson: "Considerable heterogeneity between studies appeared moderated by variability in the interventions themselves".⁴ The abstract does not name the control conditions, so this course can't say what those figures were measured against.

On CBT against applied relaxation, Cuijpers 2014 first says "The number of studies comparing CBT with other psychotherapies (e.g., applied relaxation) or pharmacotherapy was too small to draw conclusions about comparative effectiveness or the long-term effects", then "There were some indications that CBT was also effective at follow-up and that CBT was more effective than applied relaxation in the longer term." A 2022 review by Flückiger and colleagues found "negligible relative efficacy differences" between applied relaxation and CBT without applied relaxation "at each assessment time".⁴ NICE offers both at step 3. Contested, and small either way.

A technique, tested alone

Now the technique a reader is most often handed for worry. It goes by several names: worry postponement, or stimulus control for worry. In the trials below it meant setting aside a fixed time, and in one trial a fixed place, for worrying, and putting worry off until then. That is a description of what the studies tested, not an instruction. "Stimulus control" here is the same name as the insomnia component in Sleep lesson 6, applied to worry instead of to the bed, and the insomnia grade doesn't carry across. The method traces back to a 1983 paper by Borkovec and colleagues, which this course hasn't read.⁵

Four trials of it, each with what its comparison group got. All were read at abstract level.⁵

"High trait worry" means a standing tendency to worry, not a diagnosis. "Focused worry" was an active comparison: its group got instructions too. Versluis's 361 finishers were barely more than a third of the 996 who started, so its result describes the people who stayed. And the McCarrick abstract doesn't describe the augmented version or report postponement against control on worry.

Read each trial's own words, and the picture is mixed and small. McGowan and Behar: "Results provide preliminary support for the use of SC training techniques in larger treatment packages for individuals who experience high levels of worry."⁵

Versluis and colleagues explain their null result by the delivery: "In contrast to previous studies using pen-and-pencil versions of the worry postponement intervention, this study suggests that a direct online implementation was not effective in reducing SHC and worry." SHC means subjective health complaints. They add: "Overall, participants had high trait worry levels and reported difficulty with postponing worrying."⁵

Krzikalla and colleagues describe the field before their trial: "Worry postponement (WP) with a stimulus control rationale appears to be effective in non-clinical samples. However, preliminary research in participants with generalized anxiety disorder (GAD) does not support its efficacy in reducing negative metacognitions or worry." Negative metacognitions are beliefs about one's own worrying, such as that it is uncontrollable. Their trial used a different rationale, a metacognitive one, and concludes: "WP with a metacognitive rationale seems to be effective in reducing worry in participants with GAD."⁵

Small trials, mostly positive, one null online, no meta-analysis this course found, and two different rationales under one name. Contested, at the level of single small trials.⁶

When a single technique has been tested properly

Now the second worked case, which shows what the first one is missing.

Worry exposure is another component of CBT for GAD. Hoyer and colleagues, in 2009, set out to test it on its own, in their words because "Its efficacy as a stand-alone treatment method (without further cognitive-behavioral therapy interventions) has never been tested." They allocated "73 outpatients meeting DSM-IV criteria for GAD as primary diagnosis ... to either WE or AR or a waiting list control group", in treatment that "was manualized (15 sessions with WE or AR)". WE is worry exposure and AR is applied relaxation.⁵

"The proportion of patients reaching high end state functioning was 48% (WE) and 56% (AR). WE and AR did not differ with regard to dropout rate or treatment effects." Their conclusion: "This is the first study to show that a stand-alone exposure in sensu technique--WE--is efficacious in the treatment of GAD."⁵

Sleep lesson 6 met a similar problem with sleep hygiene, with a difference worth noticing. Sleep hygiene alone was graded against, as a stand-alone treatment, by a guideline panel. Worry postponement has no guideline grade either way: NICE simply doesn't name it.

Panic, briefly

For panic disorder, CG113 says: "For people with mild to moderate panic disorder, offer or refer for 1 of the following low-intensity interventions: individual non-facilitated self-help; individual facilitated self-help."¹ That's close to GAD's step 2, with two differences: "facilitated" where GAD says "guided", and no psychoeducational groups. Lesson 1 has the rest: one attack isn't a disorder, and chest pain is a medical question first.

Four things people get wrong

"Postponing worry is proven." It's popular and sounds sensible, so it's easy to take as settled. Its trials are few and small, mostly positive, one null online, and no meta-analysis pools them.

"Applied relaxation means being told to relax." The name suggests it. NICE specifies a manualised treatment of usually 12 to 15 weekly hour-long sessions with a trained practitioner.

"NICE recommends exercise and mindfulness for anxiety." NG222 lists group programmes of both for less severe depression. For GAD, neither appears as a treatment.

"If one technique didn't help my worry, nothing will." A tip done alone at home isn't the treatment that trials test. Step 3 is therapy or medication, the person's choice with a clinician, and CG113 says it's for "an inadequate response to step 2 interventions or marked functional impairment".¹

Practice

Connections

Back. Lesson 1's line between ordinary and clinical. Lesson 2's question, what the comparison group got, is the whole of the first worked case. Lesson 3's specification of self-help is what NICE means by step 2. Sleep lessons 3 and 6 gave you relative risk, heterogeneity and the sleep-hygiene problem.

Forward. Lesson 5 is exercise, which NICE lists for depression and not for GAD, and where one question gets three different answers.

Go deeper

• NICE CG113, recommendations 1.2.12 to 1.2.20. The specification of applied relaxation is worth reading, because it's so unlike the popular idea.
• Krzikalla and colleagues, 2024, free at PubMed Central. Abstract only here. Its abstract sets the field's earlier results beside its own, which point the other way.

Sources

1. National Institute for Health and Care Excellence, CG113, 2011, updated 2020. Read: the Recommendations chapter, and the appendix on assessing GAD. Supports: the associated symptoms and their order, step 2, the choice at step 3 (1.2.17), applied relaxation's specification, the panic recommendation, the 2004 exercise line, and what the recommendations page does not contain.
2. National Institute for Health and Care Excellence, NG222, 2022, Table 1. Read. Supports: group exercise and group mindfulness among options for less severe depression.
3. V. Hunot and colleagues, "Psychological therapies for generalised anxiety disorder", Cochrane Database of Systematic Reviews 2007, CD001848, doi 10.1002/14651858.CD001848.pub4. Read: the abstract. Supports: the risk ratio against usual care or waiting list, and the comparison with supportive therapy with its heterogeneity.
4. Further GAD reviews, each read at abstract level: P. Cuijpers and colleagues, Clinical Psychology Review 34(2), 2014; N. Eilert and colleagues, Depression and Anxiety 38(2), 2021; and C. Flückiger and colleagues, Journal of Consulting and Clinical Psychology 90(4), 2022. Supports: g = 0.84 with its waiting-list controls and publication bias, the internet-treatment figures and heterogeneity, and the two readings of CBT against applied relaxation.
5. Worry-technique trials, each read at abstract level: S. K. McGowan and E. Behar, Behavior Modification 37(1), 2013; A. Versluis and colleagues, British Journal of Health Psychology 21(2), 2016; C. Krzikalla and colleagues, Clinical Psychology in Europe 6(2), 2024; D. McCarrick and colleagues, Psychology & Health, 2025, online ahead of print; and J. Hoyer and colleagues, Psychotherapy and Psychosomatics 78(2), 2009. The 1983 Borkovec paper is named as the method's origin and was not read. Supports: the table and every quotation from the trials.
6. This course's own constructions, labelled where they appear. The reading of why the order of assessment matters, the gloss of the risk ratio and of supportive therapy, the reading of the trials against each other, the classification, and the reading of package and component are this course's.