What Worriers Hear Most
'Don't worry so much.' It's the phrase people with Generalized Anxiety Disorder (GAD) hear most and find least helpful. They want to stop and cannot. Worse, many have a meta-belief that says: 'I have to worry, or something bad will happen.'
Why can't worry stop? The most influential answer came from Penn State's Thomas D. Borkovec, who spent 40 years refining the Cognitive Avoidance Theory of Worry (Borkovec 1994; Borkovec, Alcaine & Behar 2004). Its core claim is deeply counterintuitive: worry is not a tool to manage anxiety — it is the mechanism that maintains it.
GAD: The 'Job' of Worrying
DSM-5 GAD: excessive, hard-to-control worry for ≥6 months, plus 3 of 6 symptoms (restlessness, fatigue, concentration trouble, irritability, muscle tension, sleep disturbance). 12-month US prevalence is about 3.1% (Kessler 2012, NCS-R), women 2:1, with high comorbidity with major depression and other anxiety disorders.
Clinicians often say GAD patients seem to have worrying as a 'job.' Topics shift — exam, job, marriage, kids, health — but the act of worrying does not stop.
Borkovec's Key Experiments
Borkovec asked a simple question: what is actually happening in a worrier's head?
Borkovec & Inz 1990 — Worry is words, not pictures
GAD patients and controls were asked to 'worry as usual' and were randomly interrupted to report what was in mind. Worriers overwhelmingly reported verbal-linguistic thought, not visual imagery. 'What if I fail the exam…' sentences rolled endlessly, but vivid images of the feared scene were rare.
Borkovec & Hu 1990 — Worry quiets the heart
Snake-fearful students were given 5 minutes of (a) worry, (b) neutral thought, or (c) relaxation before imagining a feared scene. The worry group had the smallest heart-rate response to the feared image. Worry had immediately reduced the bodily response — but intrusive thought and anxiety persisted for days after.
Hoehn-Saric 1989 — GAD autonomic nervous systems are 'frozen'
You might expect GAD patients to be chronically aroused. Instead, data showed reduced autonomic flexibility — low heart rate variability, blunted response to stimuli. Borkovec read this as the trace of chronic somatic suppression by worry.
The Theory in One Sentence
Worry, by taking verbal form, suppresses the somatic response to feared imagery, blocking complete emotional processing (Foa & Kozak 1986). Short-term: relief. Long-term: unprocessed emotion intrudes and recurs.
Analogy: rolling 'what if I fail' a hundred times in your head feels safer than imagining 'me failing' once in full. Words are abstract and constrain affect. But emotion is not completed, so it returns tomorrow. Worry becomes a self-reinforcing loop.
The patient feels they are 'preparing.' The nervous system is 'avoiding.'
Worry vs Rumination: Future Threat vs Past Loss
Watkins (2008) groups both under abstract repetitive thought, divided by time:
- Worry — future, threat, 'what if…' (core of GAD)
- Rumination — past, loss, 'why…' (core of depression, Nolen-Hoeksema)
Same abstractness and repetition; different affect. Worry → anxiety; rumination → depression. This is one reason GAD and MDD co-travel.
Stöber (1998) further distinguished productive vs unproductive worry. Productive: concrete, time-bounded, leads to action. Unproductive: abstract, open-ended, no action. GAD worry is overwhelmingly the latter.
Three Theories at a Glance
| Theory | Core mechanism | Treatment focus |
|---|---|---|
| Borkovec cognitive avoidance (2004) | Verbal worry suppresses somatic response to feared imagery → emotion not processed | Imagery exposure to feared outcomes + relaxation |
| Wells metacognitive therapy (MCT, 2005) | 'I must worry to be safe' (positive) + 'worry is dangerous' (negative) → Type 2 worry | Modify meta-beliefs, detached mindfulness, worry postponement |
| Newman & Llera contrast avoidance (2011) | Worry pre-loads negative mood to avoid mood 'drops' if good mood is shattered | Tolerate positive affect; tolerate emotional contrasts |
These complement rather than compete. Cognitive avoidance: what is avoided (imagery). Contrast avoidance: when (just before mood drop). MCT: why (meta-beliefs). Most GAD patients carry pieces of all three.
Why Imagery Exposure Works
Newman & Borkovec built CBT for GAD around imagery exposure. The principle is simple: have the patient look at the most-avoided image, all the way through.
Example. A patient who worries her husband will die commuting:
- 30 minutes vividly imagining the worst scene — the call, the hospital, the funeral, herself a year later. No flinching.
- Allow body responses (heart, tears) to happen.
- Re-rate anxiety after 30 minutes — usually lower than at the start (habituation / completed processing).
- Repeat daily.
If worry is 'rolling it in words to dampen the body,' imagery exposure is 'painting it in full so the body can complete its work.' Patients resist hard at first — 'You want me to feel more anxious?' But after one cycle, they learn: when the image ends, the feeling fades. That re-learning is the engine of recovery.
Wells's MCT — Worry About Worry
Adrian Wells (2005) attacks from another angle. GAD patients hold two meta-beliefs:
- Positive (Type 1): 'Worry keeps me safe.'
- Negative (Type 2): 'I can't stop worrying; I'll lose my mind.'
Type 2 — worry about worry — is the engine. Worry itself is universal; what makes it pathological is fearing it.
MCT does not engage the worry content. It uses detached mindfulness to watch worry as clouds passing, and worry postponement ('I'll worry only 4:00–4:30 PM') to demonstrate controllability. RCTs show MCT equal or superior to standard CBT (Wells 2010).
Newman's Contrast Avoidance — Fearing Good Mood
Newman & Llera (2011) propose a provocation. Worry is not 'avoidance of fear' but 'avoidance of mood drop.' If you are calm and bad news hits, the drop is steep. If you are pre-worried, the drop is shallow. So worriers keep themselves negatively primed.
Llera & Newman (2014): people who worried before watching a negative video showed smaller affective spikes and rated this preferable. Worry is not 'preparation' — it is avoidance of unpleasant surprise.
Clinically: train patients to tolerate good mood — savor positive affect, accept 'something bad may come but right now is good.'
Treatment: Drugs vs Therapy
First-line drugs: SSRIs (escitalopram, sertraline), SNRIs (venlafaxine, duloxetine), buspirone. Effect sizes SD 0.3–0.5 (moderate). Downsides: 4–8 wk onset; sexual/weight/sedation side effects; ~50–60% relapse on discontinuation.
CBT: Cuijpers et al. 2014 meta found g≈0.8 (large) vs control. Equal to or better than drugs and, crucially, gains hold after termination.
NICE/APA recommend CBT first for mild-moderate, drugs combined for severe or with comorbid depression. Patient preference is decisive; 'both' is the most common answer.
Closing: You Must Sit With the End of Worry
Borkovec's 40 years reduce to one line: worry is flight. From a feared image, from a body response, from the drop after a good mood.
So treatment reduces to one line: stop fleeing, look all the way, let the body run. The first try gets worse. But when the first cycle ends with anxiety simply fading on its own, the patient learns — perhaps for the first time — that not worrying was safe. That learning is the curve of recovery.
If worry keeps you awake tonight, try one thing. Take the 'what if…' sentence, render it as the scene, and watch it for thirty minutes. If after those thirty minutes you are still breathing, still alive, with perhaps an oddly flat calm — you hold one piece of evidence that Borkovec was right.
