Cbt Generalised Anxiety Disorder Case Study

Introduction and Presenting Problem

Generalised anxiety disorder (GAD) is characterised by excessive, difficult-to-control worry about a range of everyday events, accompanied by symptoms such as restlessness, fatigue, difficulty concentrating, irritability, muscle tension and disturbed sleep (American Psychiatric Association, 2013). It is one of the most common anxiety presentations seen in primary and secondary care, and it frequently co-occurs with low mood. This case study presents a model formulation-and-intervention account of a fictional client in order to illustrate how cognitive behavioural therapy (CBT) is applied in routine clinical psychology practice. It is written as reference material for learning purposes only and does not describe a real person; the client, her history and all test scores are illustrative.

The client, referred to throughout by the pseudonym “Hannah”, is a 29-year-old postgraduate student and part-time administrator who was referred to a psychological therapies service by her general practitioner. She described eighteen months of “constant worrying” that had intensified since beginning her Masters programme. Her worries spanned academic performance, finances, her relationship, her parents’ health and a diffuse sense that “something will go wrong”. She reported that the worry felt uncontrollable, occupied several hours of most days, and was accompanied by broken sleep, tension headaches and a persistent feeling of being “on edge”. Crucially, Hannah did not describe discrete panic attacks, intrusive trauma memories or obsessional rituals, which helped to distinguish her presentation from panic disorder, post-traumatic stress disorder and obsessive-compulsive disorder respectively.

The document demonstrates the reasoning that underpins a competent CBT case study: how presenting information is gathered, organised into a shared formulation, used to guide the choice of intervention, and finally measured as an outcome. The intention is to model good practice rather than an idealised, problem-free course of therapy.

Client Background and History

A thorough history is the foundation of any psychological formulation, because the maintaining factors of a disorder in the present are usually easier to understand against the backdrop of how the difficulty developed. Hannah was seen for two assessment sessions before the formulation was agreed.

Developmental and Family History

Hannah was the elder of two children and described her childhood as “comfortable but pressured”. Her father was characterised as a high achiever who valued academic success and reacted to mistakes with disappointment rather than anger; her mother was described as “a worrier” who checked repeatedly that doors were locked and who often warned the children to “be careful”. Hannah recalled learning early that effort and vigilance were how one stayed safe and earned approval. She performed well at school but remembered feeling that good results were expected rather than praised. There was no reported history of abuse, significant loss in childhood, or developmental delay.

Onset and Precipitating Factors

Hannah dated the escalation of her difficulties to the start of her Masters course, which coincided with moving to a new city, taking on part-time work and the beginning of a serious relationship. Each of these changes introduced legitimate uncertainty, and together they removed the familiar structures that had previously contained her anxiety. In cognitive behavioural terms, these events functioned as precipitants: they did not create a vulnerability so much as activate one that had been present for years.

Coping Strategies and Impact

Hannah’s attempts to manage her worry had become part of the problem. She over-prepared for every seminar, sought frequent reassurance from her partner and her mother, avoided checking her bank balance, and repeatedly delayed submitting coursework because it “was not good enough yet”. These behaviours reduced her distress momentarily but prevented her from discovering that her feared outcomes were unlikely or manageable. The impact on her functioning was considerable: her sleep was poor, her academic deadlines were slipping, and she had begun to decline social invitations. Importantly, she did not report any current risk to herself; a brief risk screen was negative, and this was revisited throughout therapy.

Assessment and Measures

Assessment in CBT is both idiographic and nomothetic. The idiographic component is the detailed, individualised picture of the person’s difficulties built through clinical interview, while the nomothetic component uses standardised, validated questionnaires to benchmark severity and to track change over time (Westbrook, Kennerley and Kirk, 2011). Combining the two guards against the twin risks of therapy that is rich in detail but cannot demonstrate change, and therapy that produces numbers without clinical meaning.

Standardised Measures

Three routine outcome measures were administered at assessment and repeated at intervals. The GAD-7 is a seven-item self-report scale of worry severity, with scores of 5, 10 and 15 marking mild, moderate and severe thresholds (Spitzer et al., 2006). The PHQ-9 was included to monitor co-occurring low mood, which is common in GAD (Kroenke, Spitzer and Williams, 2001). The Penn State Worry Questionnaire (PSWQ) provided a trait measure of the tendency to worry excessively and uncontrollably (Meyer et al., 1990). The use of more than one instrument is deliberate: convergent results across measures increase confidence that change is real rather than an artefact of a single scale.

Hannah’s baseline scores placed her worry in the severe range and her mood in the moderate range, consistent with a primary diagnosis of GAD with secondary low mood. The illustrative scores recorded across therapy are summarised below.

Diagnostic Formulation of the Problem

Diagnosis is a starting point rather than an explanation. Using DSM-5 criteria, Hannah met the threshold for GAD: excessive worry occurring more days than not for at least six months, difficulty controlling the worry, and the required cluster of associated symptoms causing clinically significant distress and impairment (American Psychiatric Association, 2013). Differential diagnosis considered and excluded panic disorder, social anxiety disorder, health anxiety and depression as the primary problem, although low mood was recognised as a significant secondary feature to be monitored. A diagnosis is useful here because it connects Hannah’s presentation to an evidence base, but the work of therapy depends on the individualised formulation that follows.

Case Formulation

Formulation is the heart of CBT. It is a shared, provisional hypothesis that links the client’s history, beliefs, triggers and responses into an account that makes the problem intelligible and, crucially, points to where change is possible (Beck, 2011). Two complementary formulations were developed with Hannah: a longitudinal formulation explaining vulnerability, and a maintenance formulation explaining why the worry persisted day to day.

Longitudinal Formulation

The longitudinal formulation located Hannah’s vulnerability in early learning experiences. Growing up in a household that prized achievement and modelled vigilance, she developed core beliefs such as “I must not make mistakes” and “the world is unpredictable and dangerous”. These core beliefs gave rise to dysfunctional assumptions, for example “if I worry about everything, I will be prepared” and “if I relax, something bad will happen”. For years these assumptions were functional enough: Hannah worked hard, achieved, and avoided feared outcomes. The transitions that accompanied her Masters course overwhelmed these strategies, and the latent assumptions became active and distressing.

The Cognitive Behavioural Model of Worry

The maintenance formulation drew on established cognitive behavioural models of GAD. Borkovec’s avoidance theory proposes that worry is predominantly a verbal-linguistic activity that suppresses the vivid imagery and physiological arousal associated with feared outcomes; because worry dampens arousal in the short term, it is negatively reinforced, which explains its persistence despite being distressing (Borkovec, Alcaine and Behar, 2004). Dugas and colleagues emphasise intolerance of uncertainty as a central driver: individuals with GAD find ambiguity threatening and use worry, reassurance-seeking and over-preparation to try to eliminate it, a goal that can never be fully achieved (Dugas et al., 1998). Wells’ metacognitive model adds a further layer, distinguishing “type 1” worry about external events from “type 2” worry about worrying itself, and arguing that positive beliefs (“worry keeps me safe”) and negative beliefs (“my worrying is uncontrollable and harmful”) together sustain the disorder (Wells, 2009).

Maintenance Cycles

Applied to Hannah, these models produced a clear maintenance picture. A trigger, such as receiving an assignment brief, activated the assumption that she must be fully prepared to avoid disaster. This generated a chain of “what if” worries, which raised anxiety and physical tension. To reduce the discomfort, Hannah engaged in safety behaviours: over-preparing, seeking reassurance and avoiding her bank balance. Each behaviour lowered anxiety briefly but prevented disconfirmation of her feared outcomes and reinforced the belief that vigilance was necessary. In parallel, she held the positive metacognitive belief that worry was protective, alongside the negative belief that it was uncontrollable, so that the act of worrying itself became a further source of distress. The following maintaining factors were identified collaboratively and became the explicit targets of therapy:

• Intolerance of uncertainty, driving a search for impossible guarantees;
• Positive beliefs about worry as a form of preparation and protection;
• Negative beliefs about the uncontrollability and harmfulness of worry;
• Safety behaviours (over-preparation, reassurance-seeking, procrastination) that prevented disconfirmation;
• Avoidance of specific triggers, such as finances, that narrowed her life and sustained threat appraisals;
• Physiological tension and poor sleep, which lowered her threshold for further worry.

Intervention and Treatment Plan

The intervention was planned as a time-limited, structured course of individual CBT, broadly consistent with the stepped-care recommendations of the National Institute for Health and Care Excellence for GAD (NICE, 2011). Fourteen sessions were contracted, with the understanding that the number could be reviewed. Each session followed the standard CBT structure of agenda-setting, review of between-session tasks, focused work, and collaborative planning of further tasks. Goals were agreed at the outset and framed in observable terms, so that progress could be judged against them.

The agreed objectives were as follows:

1. To reduce the frequency and perceived uncontrollability of worry to a manageable level;
2. To test, and where appropriate modify, beliefs about the usefulness and dangerousness of worrying;
3. To increase tolerance of uncertainty through graded behavioural experiments;
4. To reduce reliance on safety behaviours and reassurance-seeking;
5. To re-establish restorative sleep and a more balanced daily routine;
6. To consolidate skills into a personalised plan for staying well.

Phase 1: Engagement, Psychoeducation and Self-Monitoring

The opening sessions focused on building a collaborative relationship and sharing the formulation. Psychoeducation normalised Hannah’s symptoms, explaining the anxiety response as an overactive but fundamentally protective system rather than evidence of weakness or impending breakdown. This directly addressed her negative beliefs about the harmfulness of worry. Hannah began a worry diary, recording triggers, the content of worries, their intensity, and what she did in response. Self-monitoring served two purposes: it provided data for the formulation and it introduced a small but important degree of distance between Hannah and her worry, encouraging her to observe it rather than be immersed in it.

Phase 2: Cognitive Restructuring and Worry Management

The middle phase introduced techniques to work directly with worry. A distinction was drawn between “practical” worries, which concern current, solvable problems, and “hypothetical” worries, which concern improbable or future events that cannot be solved now. For practical worries, structured problem-solving was taught: defining the problem, generating options, choosing and implementing a plan, and reviewing the outcome. For hypothetical worries, Hannah practised worry postponement, agreeing to defer such worries to a short, scheduled “worry period” later in the day. In practice she found that most postponed worries had lost their urgency by the time the period arrived, which began to erode her belief that worry was uncontrollable.

Cognitive restructuring targeted specific negative automatic thoughts. Using thought records, Hannah learned to identify a hot thought (for example, “if I get a low grade my career is over”), examine the evidence for and against it, and construct a more balanced alternative. The therapist was careful not to replace catastrophic thoughts with implausibly positive ones, which rarely convince; the aim was realistic appraisal, such as “a single low grade would be disappointing but would not end my career, and I have options if it happens”.

Phase 3: Behavioural Experiments and Exposure to Uncertainty

The most powerful change typically comes not from talking about beliefs but from testing them in action (Clark and Beck, 2010). Several behavioural experiments were designed collaboratively. To test the belief “if I do not over-prepare, I will fail”, Hannah deliberately prepared for one seminar to a “good enough” standard and predicted the outcome in advance; the seminar went well, directly contradicting her prediction. To address intolerance of uncertainty, she undertook graded tasks that deliberately introduced small uncertainties: sending an email without re-reading it five times, checking her bank balance once rather than avoiding it, and allowing her partner to make plans without seeking detailed reassurance. Reducing reassurance-seeking was framed as an experiment rather than a prohibition, which helped Hannah to engage with it. Each experiment was reviewed against its prediction, and the results were used to update the formulation and to weaken the belief that vigilance and certainty were necessary for safety.

Phase 4: Relapse Prevention and Consolidation

The final sessions consolidated gains and prepared Hannah for the end of therapy. Together, the therapist and Hannah wrote a “staying well” plan, sometimes called a therapy blueprint, summarising what she had learned, the strategies she had found most useful, her early warning signs, and a concrete plan for responding to setbacks. Importantly, the possibility of future lapses was normalised: a return of worry under stress was framed as an expected event to be managed with established skills, not as evidence that therapy had failed. The frequency of sessions was tapered, and a single follow-up appointment was arranged for three months after the final session.

Outcome Evaluation

Evaluating outcome rigorously is an ethical and professional obligation, not an optional extra. The standardised measures provided the clearest evidence of change. Hannah’s GAD-7 fell from 17 at baseline to 6 by session fourteen, moving her from the severe range to below the clinical threshold. Her PHQ-9 declined from 13 to 5, indicating that her secondary low mood had also improved, which is consistent with the frequently observed relationship between worry and mood. Her PSWQ fell from 68 to 48, a meaningful reduction in trait worry, although the residual score suggests that a tendency to worry remained and would need ongoing management.

Interpreting these numbers requires care. A reduction in scores is encouraging, but clinically significant change is best judged by whether the client has moved out of the clinical range and whether the change is reliable rather than attributable to measurement error or chance. On both counts Hannah’s results were encouraging: her GAD-7 crossed the clinical threshold, and the convergence of change across three separate measures increased confidence that the improvement was genuine. Equally important were the idiographic indicators: Hannah was sleeping better, had submitted her coursework on time, had resumed social activities, and reported that worry no longer dominated her days. She also reported a changed relationship to worry, describing it as “something I notice and can put down” rather than “something that controls me”, which reflected a shift in the metacognitive beliefs identified in the formulation.

The limits of the evaluation should also be acknowledged. The outcomes rest on self-report, which can be influenced by a wish to please the therapist, although corroborating behavioural evidence such as timely submission of work partly offsets this. A single case cannot establish that CBT caused the improvement, since the passage of time, the natural fluctuation of symptoms and life changes could all have contributed. These caveats temper any claim that the result is attributable to the therapy alone.

Critical Discussion

This case illustrates both the strengths and the boundaries of a CBT approach to GAD. The principal strength is coherence: assessment fed a formulation, the formulation specified maintaining factors, and the intervention targeted those factors directly, with measured outcomes closing the loop. The evidence base for CBT in anxiety disorders is substantial, with meta-analytic reviews reporting moderate-to-large effects across the anxiety disorders (Hofmann and Smits, 2008), and the present case is broadly consistent with that literature.

Nonetheless, several points warrant critical reflection. First, Hannah was a motivated, psychologically minded client with no major social adversity, few comorbidities and a supportive relationship; such clients tend to respond well, and therapy would likely have been more complex for someone with entrenched beliefs, significant comorbidity or ongoing adversity (Butler, Fennell and Hackmann, 2008). The transferability of this case should therefore be treated with caution. Second, the treatment integrated elements from different models of GAD, including Borkovec’s avoidance account, Dugas’s intolerance-of-uncertainty model and Wells’s metacognitive approach. While pragmatic integration is common, it can blur which mechanism is responsible for change; a purely metacognitive protocol, for example, would have placed less emphasis on the content of worries and more on beliefs about worrying. Third, the decision not to pursue work at the level of core beliefs reflected the time-limited contract; with a longer course, schema-level work might have reduced the residual vulnerability suggested by her PSWQ score.

Ethical considerations also shaped the work. Informed consent was treated as an ongoing process rather than a single event, with the rationale for each new technique explained and agreed. Confidentiality and its limits were discussed at the outset, risk was monitored throughout, and the formulation was shared transparently so that Hannah was an active collaborator rather than a passive recipient. Cultural and individual factors, including the family context in which Hannah’s beliefs about achievement developed, were attended to rather than treated as background noise.

Recommendations

On the basis of this case, several recommendations follow for Hannah and, more generally, for practice.

• Consolidation and self-management. Hannah should continue to use her therapy blueprint, applying worry-postponement and problem-solving independently and reviewing her early warning signs periodically.
• Booster sessions. Given the residual trait worry indicated by her PSWQ, one or two booster sessions within the following year would be a proportionate way to protect her gains without prolonging dependence on therapy.
• Attention to lifestyle maintaining factors. Sleep hygiene and a balanced routine should be sustained, since fatigue lowers the threshold for worry and can act as an early relapse signal.
• Stepped-care logic. Had Hannah not responded, the formulation would have supported escalation in line with NICE guidance, for example a lengthened course of CBT, a shift to a more purely metacognitive protocol, or discussion of pharmacological options with her general practitioner (NICE, 2011).
• Ongoing evaluation. Routine outcome monitoring should continue at the follow-up appointment, so that any deterioration is detected early and addressed.

Conclusion

This model case study has traced a complete episode of CBT for generalised anxiety disorder, from assessment and standardised measurement, through a shared longitudinal and maintenance formulation, to a phased intervention and a transparent evaluation of outcome. The fictional client, Hannah, moved from the severe to the sub-clinical range on a validated measure of worry, with corroborating improvements in mood and daily functioning, while the discussion acknowledged the limits of a single, favourable case and the value of theoretical precision. For students of clinical psychology, the central lesson is that effective CBT is not a collection of techniques applied in isolation but a reasoned sequence in which formulation links understanding to action, and measurement keeps that action honest. This document is provided solely as a model and reference example to support learning, and the client, her history and all scores are illustrative rather than real.

References

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Spitzer, R.L., Kroenke, K., Williams, J.B.W. and Löwe, B. (2006) ‘A brief measure for assessing generalized anxiety disorder: the GAD-7’, Archives of Internal Medicine, 166(10), pp. 1092–1097.

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Westbrook, D., Kennerley, H. and Kirk, J. (2011) An Introduction to Cognitive Behaviour Therapy: Skills and Applications. 2nd edn. London: Sage.