Generalized Anxiety Disorder
Generalized anxiety disorder (GAD) is characterized by chronic anxiety that persists for at least six months but is unaccompanied by panic attacks, phobias, or obsessions. You simply experience persistent anxiety and worry without the complicating features of other anxiety disorders. To be given a diagnosis of generalized anxiety disorder, your anxiety and worry must focus on two or more stressful life circumstances (such as finances, relationships, health, or school/job performance) a majority of days during a six-month period. It's common, if you're dealing with generalized anxiety disorder, to have a large number of worries, and to spend a lot of your time worrying. Yet you find it difficult to exercise much control over your worrying. Worry interferes with your ability to solve realistic problems. Moreover, the intensity and frequency of the worry are always out of proportion to the actual likelihood of the feared events happening.
In addition to frequent worry, generalized anxiety disorder involves having at least three of the following six symptoms (with some symptoms present more days than not over the past six months):
- Restlessness—feeling keyed up
- Being easily fatigued
- Difficulty concentrating
- Irritability
- Muscle tension
- Difficulties with sleep
Finally, you're likely to receive a diagnosis of generalized anxiety disorder if your worry and associated symptoms cause you significant distress and/or interfere with your ability to function occupationally, socially, or in other important areas. If a doctor tells you that you suffer from generalized anxiety disorder, he or she has probably ruled out possible medical causes of chronic anxiety, such as hyperventilation, thyroid problems, or drug-induced anxiety. Generalized anxiety disorder often occurs together with depression: a competent therapist can usually determine which disorder is primary and which is secondary. In some cases, though, it is difficult to say which came first.
Generalized anxiety disorder can develop at any age, though often it occurs later than other anxiety disorders, with quite a few people developing problems with it after age 30. In children and adolescents, the focus of worry often tends to be on performance in school or sports events. In adults, the focus can vary. This disorder affects approximately 4-5 percent of the American population and appears to be more common in females than males, which may be due to females seeking treatment more frequently.
Although there are no specific phobias associated with generalized anxiety disorder, one view propounded by Aaron Beck and Gary Emery suggests that the disorder is sustained by "basic fears" of a broader nature than specific phobias, such as
- Fear of losing control
- Fear of not being able to cope
- Fear of failure
- Fear of rejection or abandonment
- Fear of death and disease
The underlying causes of generalized anxiety disorder are unknown. It is likely to involve a combination of heredity and predisposing childhood experiences, such as excessive parental expectations or parental abandonment and rejection.
Neurological bases of generalized anxiety disorder are being investigated. Brain scans of people with severe GAD or any type of anticipatory anxiety sometimes show an overactivation of certain parts of the brain (including the hypothalamus, amygdala and prefrontal cortex).
Relaxation Training
Abdominal breathing and deep relaxation techniques are practiced on a regular basis to directly reduce anxiety. A physical exercise program may also be included in the treatment.
Cognitive Therapy
Specific worry thoughts and underlying worry themes are identified, challenged, and replaced with more realistic thinking. When you worry, you overestimate the odds of something negative happening and underestimate your ability to cope if something bad did, in fact, happen. Cognitive therapy aims to correct both types of distorted thinking. You would also work on changing negative beliefs or "metabeliefs" about worry itself. These include both beliefs that worry will help you avoid something negative, for example, "If I worry about it, it won't happen," as well fearful beliefs about worry itself such as "My worries are uncontrollable" or "I'll go crazy from worrying." Realistic self-statements to counter these metabeliefs are consistently practiced and internalized over time. Guided imagery may also be used to help redirect your mind from preoccupation with worry to more optimistic themes.
Worry Exposure
In worry exposure, you do repeated and prolonged exposure to fearful images or thoughts (your worst case scenarios) of what you're worried about. In these images or thoughts, you include strategies you would use to reduce anxiety and cope with the situation. Worry exposure is often done by writing down the worry thoughts and/or images in detail as they occur. You carry a notepad with you during the day and write down each worry thought/image as it occurs. After awhile, the act of repeatedly writing down the thoughts helps you to recognize how senseless and useless they are, enabling you to take a step back from them.
Reducing Worry Behaviors
You identify overly cautious "safety behaviors" that tend to reinforce worrying. For example, if you tend to call your spouse or child several times a day to check on them, you would reduce the frequency of this behavior.
Problem Solving
You take systematic action to solve the problem you're worried about. In short, you focus on solutions to the problem that worries you instead of the worry itself. If there is no practical solution, you work on changing your attitude toward the situation, that is, learning to accept what you can't change.
Thought Stopping
In thought stopping, you disrupt the chain of worrisome thoughts in four steps: 1) Notice the worries running through your mind, 2) Mentally decide you are going to stop them, 3) Shout to yourself or (if possible) out loud "Stop!" and 4) Practice abdominal breathing for at least one minute. Repeat the process of thought stopping several times, every few minutes, even if the worries keep coming back. Thought stopping followed by abdominal breathing serves to both disrupt worrying and distract you from it for at least a few moments. Repetition of the process may stop the worry altogether.
Distraction
A variety of distraction techniques can be helpful for worries that do not lend themselves easily to cognitive therapy or problem solving. Common diversionary activities include talking to a friend, journaling, listening to music, gardening, exercise, puzzle solving, arts and crafts, cooking, and the Internet.
Medication
For moderate to severe cases of generalized anxiety disorder, SSRI medications such as Lexapro, Zoloft, Luvox (fluvoxamine), or Celexa may be used. The SNRI medication Effexor has also been found to be effective in treating generalized anxiety disorder. Another medication, Buspar, is sometimes used to treat worry and generalized anxiety. It is no longer considered a first-line medication, however, as the SSRIs appear to be slightly more effective. Buspar may sometimes be combined with an SSRI to enhance the SSRI's effectiveness.
Mindfulness Practice
Mindfulness is an attitude of simply witnessing the ongoing stream of your thoughts and feelings in the present moment without judgment. It originated in Buddhist meditation practice but is now being used as a common treatment for stress, depression, and generalized anxiety. For further information about mindfulness practice, see the chapter on meditation in The Anxiety & Phobia Workbook.
Lifestyle & Personality Changes
Such changes are basically similar to the methods described for panic disorder: stress management, increased downtime, regular exercise, eliminating stimulants/sweets from your diet, resolving interpersonal conflicts, and changing attitudes toward perfectionism, an excessive need to please others, or the excessive need to control.
