We all feel anxious and nervous sometimes, especially when life becomes hectic, or stressful. We might worry about financial, health, work, and family issues. However, in some cases, anxiety can become excessive and can interfere with everyday functioning and with our daily activities. This excessive worrying can be perceived as uncontrollable, disproportional to the actual dangers, and intolerable. It might be a sign of Generalized Anxiety Disorder, a highly prevalent disorder, which is associated with persistent suffering and considerable impairments.
This article will cover:
- What is Generalized Anxiety Disorder?
- What is excessive worrying and how is it differentiated from normal worrying?
- Why do we keep worrying even though we do not want it?
- Treatment of GAD
What is Generalized Anxiety Disorder?
Generalized Anxiety Disorder (GAD) is a prevalent and disabling disorder characterized by chronic and uncontrollable excessive worry about a number of events or activities. This worry, which is multifocal (e.g., about finances, family, health, and the future), is typically accompanied by other nonspecific psychological and physical symptoms. For instance, in primary care, many people with this disorder often present with physical symptoms such as muscle tension, gastrointestinal symptoms, back pain, and insomnia. However, excessive worry is, indeed, the core feature of GAD. The intensity, duration, or frequency of the anxiety is out of proportion to the actual likelihood or impact of the anticipated event. [1]
The age at onset is highly variable; some cases of GAD begin in childhood, most begin in early adulthood, and another peak of new-onset cases occurs in older adulthood, often in the context of chronic physical health conditions.
Many people report that they have been anxious their whole life. GAD is, by definition, a chronic disorder, and its minimum duration of anxiety for a diagnosis is 6 months, and most patients have had the disorder for years before seeking treatment. [1] This disorder is found to be associated with an impairment in life satisfaction and well-being that is (at least) comparable to that of patients suffering from other prevalent psychological disorders. [3].
DSM-5 CRITERIA FOR GAD
A. Excessive anxiety and worry (apprehensive expectation), occurring more days than not and for at least 6 months, about a number of events or activities (such as work or school performance)
B. The person finds it difficult to control the worry
C. The anxiety and worry are associated with three (or more) of the following six symptoms (1) restlessness or feeling keyed up or on edge (2) being easily fatigued (3) difficulty concentrating or mind going blank (4) irritability (5) muscle tension (6) sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep.
D. The focus of the anxiety and worry is not confined to features of an Axis I disorder. E.g., the anxiety or worry is not about having a panic attack (as in panic disorder), or being embarrassed in public (as in social phobia etch. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. The disturbance is not due to the direct physiological effects of a substance (e.g, a drug of abuse, a medication) or general medical condition (e.g., hyperthyroidism) and does not occur exclusively during a mood disorder.
What is excessive worrying and how is it differentiated from normal worrying?
Truth be told, everyone worries. What is worrying and what distinguishes normal worrying from pathological worrying?
Worry is a chain of catastrophizing thoughts that are predominantly verbal. It consists of the contemplation of potentially dangerous situations and of personal coping strategies. It is intrusive and controllable although it is often experienced as uncontrollable. Worrying is associated with a motivation to prevent or avoid potential danger. Worry itself may be viewed as a coping strategy but can become the focus of an individual’s concern.
The content of normal worrying and GAD-worrying cannot be distinguished. This means that people with GAD and people without GAD can worry about the same minor things in life. However, the motives and sequences that play a role in developing and maintaining the worry are different in normal and pathological worrying. More precisely, it is the way that people with GAD interpret and think about their worrying (their metacognition about worry) that maintains their disorder. They usually perceive it as uncontrollable and persistent. They might think that they will be driven crazy because of their worrying and that they will never stop worrying. As a result, people with GAD usually end up worrying about their worries. For instance, if someone that suffers from GAD is asked the question: if the problem you are worried about was solved, would your complaints be over? They would answer negatively because something else would appear on the surface to worry about. In contrast, normal worrying is usually over, when the problem is solved, and it is not perceived as uncontrollable.
A clinical presentation of a worrying episode of GAD, as described by a patient is described below:
“Last night when I went to bed, I started thinking about the job interview that I have tomorrow. It is so important for me to get this job. And then it all started. I was thinking, what if I am not even able to introduce myself? What if I am not even able to talk and then I start stammering? The employer will definitely think that I am not competent for the job. And what if he asks me about the reasons why I am still unemployed? Then, I will lose the position and again I will be broke and unproductive. And then, my parents will be disappointed again and I should ask for financial support again. And what if my boyfriend thinks that I am not even able to find a job and that I will be like this forever, ending up on my own? Then my heart started bumping quickly and I could not control all these thoughts. I ended up staying awake the whole night and, in the morning, I did not even appear in this job interview. It was vain anyway”.
If we examined the example mentioned above, it can be seen how a minor thought triggered a chain of thoughts. This is a typical way of thinking for someone who suffers from GAD. Because individuals with GAD are highly sensitive to threats in general, they might easily interpret a situation as dangerous. In response, fight-or-flight reactions are activated, and physical symptoms can be triggered at the same time. Moreover, in GAD the threat is more generalized, and it is not clear what needs to be avoided. As a result, people do not have a clear image of their fears and they find it hard to define it and describe it. [3]
Why do we keep worrying even though we do not want it?
A question is: Why and how the worrying is maintained, even though it can be so disabling? The Metacognitive Model describes precisely the ways that the worrying is maintained. As mentioned before, pathological worry is associated with the ways that people interpret their worry (e.g., positive and negative metacognitions) and not with its content of it [4].
On the one hand, it is not rare for many people to think that worrying will help them in hard situations (e.g., positive metacognitions about worry). For instance, they might think that worrying will help them solve their problems, straighten their thoughts, or even be prepared for the worst-case scenario. As a result, their worrying is positively reinforced by their beliefs that it is a helpful strategy to be prepared or to even solve their problems. As a consequence, beliefs about worrying as a helpful strategy result in increased use of worrying as a strategy to cope with anticipated danger. However, most of the time the anticipated dangers that people worry about never happen, and hence, they keep on worrying.
On the other hand, once they start worrying about a topic, a chain of worrying thoughts is usually triggered, and then, they start perceiving the worrying as uncontrollable. More precisely, they start worrying about their worrying (e.g., negative metacognitions about worry). This is usually the reason why someone seeks treatment. It is common for people to start thinking that their worrying will drive them crazy, that it will never stop, and that they cannot control it [4].
Many times, constantly worrying about different topics serves the same purpose as avoidance. When people with GAD worry, their emotional and physiological responses to aversive imagery and to negative feelings are suppressed. This suppression reinforces the process of worrying because it prevents the person from fully experiencing or processing the topic they’re worrying about. Moreover, many people avoid places, situations, and people that they think will trigger their worrying. For instance, they might avoid watching the news, going out to a crowded place, and saying their opinion. Last, they might use safety behaviors (actions someone takes to make a hard situation manageable and easier to deal with). For instance, they might keep track of where everyone is, call every day with important people for reassurance, and check everything multiple times [7]. All these actions end up maintaining their worrying, because in this way they are never exposed to fearful situations, and hence, they do not realize that the things they are worrying about will not happen [4].
An example of the Metacognitive Model is pictured below:
Maintaining factors
- Asking reassurance
- Seeking distraction
- Checking everything multiple times
Treatment of GAD.
GAD is often treated with Cognitive Behavioral Therapy (CBT), which is an evidence-based type of psychotherapy. In CBT, evaluation is crucial. Professionals rely on their clinical judgment, but they also use standardized assessment tools to evaluate symptoms. Excessive worry is the main symptom of GAD and anxiety is almost always present in the minds of patients. The themes of concern are relatively similar to those of the normal population but are experienced in more catastrophic ways. CBT as a treatment for GAD includes the development of functional analysis, providing information through psychoeducation, behavioral experiments with new behaviors and emotions (exposition, relaxation), and a cognitive evaluation and restructuring. CBT uses functional analysis, which makes it possible to specify where, when, with what frequency, with what intensity, and under what circumstances the anxious response is triggered. It is performed with the patient and integrates the factors maintaining the difficulties [5].
The treatment is not focused on the content of worrying, but on the credibility and uncontrollability of worrying. It is crucial to detect, analyze, understand and change the positive and negative beliefs that people have about worrying (positive and negative metacognitions about worrying, e.g., worrying helps me deal with the worst-case scenario, worrying will drive me crazy). The cognitive approach often begins with a self-observation that patients will carry out on their own thoughts. Can the thoughts be spotted? Can patients isolate themselves from emotions? The aim of the cognitive work is to help patients take a step back from their automatic thoughts and to be disjointed from those worries. Moreover, behavioral experiments are useful and necessary in the treatment in order to expose people to their fears, suppressed emotions, and avoided situations. Behavioral experiments usually lead to a mismatch of the initial fearful expectations, since most of the time the things people fear never happen, leading to an actual change of beliefs. Moreover, new functional coping mechanisms are taught in order to learn how to cope with fearful situations and worrying, leaving behind the dysfunctional ones and the safety behaviors [5], [6].
Additional sources
Generalized Anxiety Disorder: When Worry Gets Out of Control (nih.gov)
Treating generalised anxiety disorder and panic disorder in adults (nice.org.uk)
References
[1] Andrews, G., Hobbs, M. J., Borkovec, T. D., Beesdo, K., Craske, M. G., Heimberg, R. G., Rapee, R. M., Ruscio, A. M., & Stanley, M. A. (2010). Generalized worry disorder: A review of DSM-IV generalized anxiety disorder and options for DSM-V. Depression and Anxiety, 27(2), 134–147. https://doi.org/10.1002/da.20658
[2]. Olatunji, B. O., Cisler, J. M., & Tolin, D. F. (2010). A meta-analysis of the influence of comorbidity on treatment outcome in the anxiety disorders. Clinical Psychology Review, 30(6), 642–654. https://doi.org/10.1016/j.cpr.2010.04.008
[3]. Van Der Heiden, C., Methorst, G., Muris, P., & Van Der Molen, H. T. (2011). Generalized anxiety disorder: Clinical presentation, diagnostic features, and guidelines for clinical practice. Journal of Clinical Psychology, 67(1), 58–73. https://doi.org/10.1002/jclp.20743
[4]. Wells, A. (2005). The metacognitive model of GAD: Assessment of meta-worry and relationship with DSM-IV generalized anxiety disorder. Cognitive Therapy and Research, 29(1), 107–121. https://doi.org/10.1007/s10608-005-1652-0
[5]. Borza, L. (2017). Cognitive-behavioral therapy of generalized anxiety - Current theoretical foundations. Dialogues in Clinical Neuroscience, 19, 203–208.
[6]. Topper, M., Emmelkamp, P. M. G., Watkins, E., & Ehring, T. (2017). Prevention of anxiety disorders and depression by targeting excessive worry and rumination in adolescents and young adults: A randomized controlled trial. Behaviour Research and Therapy, 90, 123–136. https://doi.org/10.1016/j.brat.2016.12.015
[7]. Wells, A. (1999). A Metacognitive Model and Therapy for Generalized Anxiety Disorder. Clinical Psychology and Psychotherapy, 6(2), 86–95. https://doi.org/10.1002/(SICI)1099-0879(199905)6:2<86::AID-CPP189>3.0.CO;2-S