Generalized Anxiety Disorder
Generalized anxiety disorder (GAD) is characterized by an excessive number of unmanageable worries that don’t go away by themselves and last for a minimum of six months.1 The concerns that cause the anxiety are usually very numerous and broad in scope, which is why the problem is referred to as “generalized.”
The thoughts that cause the worrying aren’t usually about life-threatening matters. If a person were in immediate danger, his or her emotional and physical reactions would more accurately be described as fear. Fear and anxiety are related emotions, but anxiety more precisely describes a situation where the cause of concern isn’t imminent.
Everyone experiences normal, temporary periods of anxiety in life, such as worrying about a problem at work or worrying about a loved one when he or she is sick. However, a person with GAD worries excessively almost every day and, typically, the worrisome thoughts jump from one cause of concern to the next, making them uncontrollable, time-consuming, and very distracting. Overall, GAD is an intolerable and painful disorder.
When a person is struggling with GAD, he or she has numerous troubling thoughts that can’t be controlled throughout the day. The causes of concern might not even be related to one another. For example, a man with GAD might worry that someone he knows is in danger, have nearly constant thoughts that his car could break down, and be anxious about some task that he’s trying to complete at work. In cases like this, the person is usually afraid of being unable to cope with these future events if the worst outcome should occur. As these worries accumulate, the person begins to think of the world as a very unsafe and unpredictable place. For most people with GAD, this uncertainty and inability to predict what will happen is very disturbing.
Some people with GAD might recognize that their worries are excessive and go beyond what might realistically happen, while others might think that all of their worries are within the realm of possibility. In both cases, the anxious thoughts appear impossible to stop and are extremely troublesome. People with GAD find it very difficult to focus on tasks that require concentration. They also suffer from frequent muscle aches, tension, and difficulties sleeping, as well as general feelings of being uneasy most of the time.
ARE THERE OTHER PROBLEMS RELATED TO GAD?
GAD is often associated with many other problems.9 Some surveys have shown that GAD is equally as burdensome as depression, and unfortunately, many people suffer with both GAD and depression. Many people with GAD also struggle from drug and alcohol problems, specific phobias, social phobias, post-traumatic stress disorder, dysthymia, bipolar disorder, attention-deficit/hyperactivity disorder, and dependent personality problems. Physical illnesses related to stress are also common, such as chest pain, irritable bowel syndrome, frequent headaches, diabetes, and cardiovascular disease.
WHO IS AFFECTED BY GAD?
In 2005, the National Comorbidity Survey Replication surveyed over nine thousand adults in the United States and estimated that 6 percent of them would develop GAD at some point in their lives. Other estimates suggest that in any given year, 3 percent of all adults in the United States are suffering with GAD, with women reporting the disorder twice as frequently as men. By far, GAD and the other anxiety disorders (including phobias, panic disorder, obsessive-compulsive disorder, and post-traumatic stress disorder) are the most common mental health problems in the United States. Other studies have suggested that over the course of a person’s lifetime, the odds of developing GAD are approximately one in twenty.
Many people with GAD report that they’ve been suffering with the illness since they were children, but some sources suggest that GAD often begins during adulthood, especially when stressful events are experienced.
Although the exact causes of GAD are unknown, it’s believed that development of the disorder is influenced by biological, psychological, and social factors. Studies of family members indicate that the odds of inheriting GAD from a parent with the illness are almost one in three. Other research suggests that some people with GAD are born with a natural vulnerability to the illness that makes them more easily irritated and prone to muscle tension, restlessness, sleep problems, and bodily discomfort.
Some researchers believe that the act of excessive worrying has small, temporary benefits for people, which reinforces the behavior; however, it also has long-term emotional drawbacks. Initially, excessive worrying may actually help people avoid feeling sad emotions that they don’t want to experience, and it may help them avoid thinking about images of future negative events. Yet despite these temporary benefits, the excessive worrying that characterizes GAD quickly becomes overwhelming. Often, the person becomes afraid of his or her own emotions and begins avoiding negative experiences. Complicating the situation even more, some evidence suggests that people with GAD pay more attention to the negative emotional stimuli in their lives, such as threatening words and angry faces, than to positive stimuli, even when they aren’t aware that they’re doing it.
Studies of environmental and psychological factors suggest that childhood experiences can also make a person vulnerable to developing GAD. These early, influential experiences include trauma, abuse, or unstable and insecure relationships with parents. And, of course, these same types of stressful events can cause GAD later in adulthood.
The development of GAD is also often associated with poverty and minority status. For example, in 1991, it was estimated that the rates of GAD were twice as high among people whose yearly income was below ten thousand dollars, when compared to people with incomes above that amount. Furthermore, when women under thirty years old were compared, African-American women were almost twice as likely as white American women to develop GAD, as were Hispanic-American women between the ages of forty-five and sixty-four when compared with white American women of the same age.
Unfortunately, many people with GAD don’t seek treatment when they’re first affected by the disorder, often waiting as long as nine years before doing so. This is regrettable, especially considering that there are many effective treatments for GAD. Cognitive behavioral therapy for GAD has received much research support. In some treatment studies, cognitive behavioral therapy was helpful for approximately 50 percent of the participants. This treatment for GAD helps people relax, assess the potential risks of the things they fear, and then safely confront those fears. Sometimes, the relaxation techniques alone can lead to a significant reduction of GAD symptoms.
Recently, acceptance and commitment therapy, a behavioral therapy, has also been suggested as a treatment for GAD and other anxiety disorders. Acceptance and commitment therapy uses mindfulness techniques to help people with GAD stop fighting their thoughts and start making decisions in life based on their values.
Personal reports of patients suggest that treatments such as psychodynamic therapy, control mastery therapy, interpersonal therapy, humanistic therapy, and many of the other forms of therapy can also be very effective for treating GAD. However, there has been little research done to support these treatments for GAD.
Antianxiety medications such as alprazolam (Xanax), diazepam (Valium), lorazepam (Ativan), and buspirone (BuSpar) have all been shown to be effective, short-term treatments for GAD. However, some of these medications can lead to dependence, as well as withdrawal symptoms if they’re abruptly discontinued after long-term use. So if people are prescribed any of these medications, it’s very important that they follow the dosage recommendations of the prescribing medical professional. Some antidepressant medications, such as escitalopram (Lexapro), paroxetine (Paxil), sertraline (Zoloft), and venlafaxine (Effexor), have also been shown to be effective treatments, especially to relieve accompanying depressive symptoms.
COGNITIVE BEHAVIORAL THERAPY FOR GENERALIZED ANXIETY DISORDER
Cognitive behavioral therapy (CBT) is a form of treatment that combines elements of both cognitive therapy and behavior therapy. Cognitive therapy examines the way people’s thoughts about themselves, others, and the world affect their mental health. Behavior therapy investigates the way people’s actions influence their own lives and their interactions with others. By combining the two, CBT examines the way people can change their thoughts and behaviors in order to improve their lives.
The cognitive behavioral treatment for GAD is usually composed of ten steps:
- Conduct an assessment and provide education
- Schedule worry time
- Develop relaxation skills
- Develop risk assessment skills
- Develop problem-solving skills
- Conduct worry exposure
- Reduce safety behaviors
- Stop unwanted thoughts
- Revise core beliefs
- Prevent relapse
1. Conduct an Assessment and Provide Education
The first step in the cognitive behavioral treatment for GAD is to conduct an assessment of the person’s symptoms in order to verify that he or she is struggling with GAD and not some other similar problem. Once people have been diagnosed with the disorder, it’s important that they understand the basic nature and causes of the problem (as highlighted above), as well as the demands of the treatment for GAD, particularly that cognitive behavioral therapy is an interactive treatment that requires the person to do work outside of the therapy session.
2. Schedule Worry Time
The second step is to schedule worry time. This may sound strange considering that GAD is a problem in which the main complaint is too much worrying. The point, however, is that not all worrying is bad and not all worrying can be controlled. Scheduling worry time, and recording its results on a worry record, allows the person to worry during specific times of the day that have been set aside for this purpose. With consistent practice, this can lead to less interference from worry in the rest of the person’s life. It can also lead to less worrying in general. The steps for scheduling worry time include picking a meaningful topic to worry about, setting aside five minutes to worry, focusing on the worrisome topic without getting distracted, and not dwelling on the topic after worry time has ended.
3. Develop Relaxation Skills
The third step of the treatment for GAD is to learn relaxation skills. People with GAD often experience physical tension in addition to their mental stress. Learning relaxation skills can help relieve both problems, and there are a variety of different techniques that a person can learn. Included here are four of the most important. All of these techniques include focusing on slow, rhythmic abdominal breathing, which often produces a feeling of calmness.
The first relaxation skill that’s taught is progressive muscle relaxation. It involves a seven-second tightening and releasing of specific muscle groups from head to toe, with emphasis on noticing the difference between the tense feeling and the relaxed feeling.
The second relaxation skill is learning how to release muscle tension without first tensing the muscles. This is done by focusing attention on the muscles and visualizing the tension being released.
The third skill is cue-controlled relaxation, in which a person is taught to relax his or her body by saying a relaxing word, such as “peace” or “relax,” with each slow exhalation.
And, finally, the fourth relaxation skill is special-place visualization. This skill teaches the person to envision a place of safety and comfort in his or her imagination. The person can go to this “mental safe place” during the GAD treatment if he or she is overwhelmed by distressing feelings.
4. Develop Risk Assessment Skills
The fourth step in the cognitive behavioral treatment of GAD is to develop risk assessment skills. People with GAD frequently believe that their lives are very dangerous and anticipate that the worst possible outcomes will always occur, no matter what the events. This type of catastrophic thinking is usually caused by automatic thoughts. These are critical thoughts that people think and say to themselves that sabotage safety and happiness. Two examples of automatic thoughts might be “If anything can go wrong, it will” and “The world is unsafe.” A person can be either aware or completely unaware of having a thought like this. However, in both cases the result is that the person feels afraid or anxious.
A risk assessment helps people with GAD identify their automatic thoughts and clarify the likelihood that specific feared events will take place. The goal is to help the person identify healthier thoughts, as well as safer outcomes he or she hadn’t considered. The steps of risk assessment include naming the triggering situation, rating the associated anxiety level, describing the related emotions, identifying the automatic thoughts, imagining the worst possible outcome, predicting a better outcome, and, finally, rating the anxiety level once again.
5. Develop Problem-Solving Skills
The fifth step of the CBT treatment for GAD is to learn problem-solving skills. People with GAD often feels like they don’t know what to do in many situations. Problem-solving skills help them identify and select healthy solutions to difficult, anxiety-provoking situations. The steps to problem solving include defining the problem, outlining the desired goals, brainstorming possible solutions, evaluating the possible consequences, putting the chosen plan into action, and evaluating the results.
6. Conduct Worry Exposure
GAD is a self-reinforcing set of behaviors. When people avoid anxiety-provoking situations instead of coping with them they temporarily decrease their anxiety, but in the long run, they actually increase the strength of their fears. Avoiding the situation robs them of the opportunity to learn how to successfully deal with their anxieties and reinforces their avoidance behaviors in the future. For example, a woman who worries about driving on the freeway will avoid it in order to temporarily decrease her anxiety, even if it means driving great distances on smaller roads. However, until she confronts her fear and learns how to cope with it, she will still feel anxious every time she’s presented with the possibility of driving on the freeway.
Avoidance is a difficult problem to resolve in GAD, and confronting it in a safe and systematic manner is the only way to overcome it. Therefore, the sixth step of the CBT treatment for GAD is to conduct worry exposure, which means safely confronting feared situations, beginning with a situation that’s only moderately worrisome and working upward in difficulty. These exercises begin with relaxation techniques and then proceed to imagining the feared event occurring. Over time, the person will recognize that his or her anxious thoughts and physical sensations peak in intensity and then decrease.
7. Reduce Safety Behaviors
The seventh step of the CBT treatment for GAD is to reduce safety behaviors. People with GAD often perform certain safety behaviors that they believe prevent them from being harmed. Some of these behaviors might appear very strange or superstitious, like checking a stove five or more times to ensure that it’s been turned off, while other behaviors might appear more realistic, like calling a relative frequently to check on her safety. However, people with GAD often tend to rely on these behaviors for their own well-being or peace of mind, even if the connection to their safety is unproven. The goal of reducing safety behaviors is to examine the true effect of these actions. To reduce safety behaviors, the person first imagines the consequences of not performing a safety behavior and then tests that prediction against what actually happens when he or she resists doing it in real life. The goal is to stop safety behaviors that limit the person’s freedom and enjoyment of life.
8. Stop Unwanted Thoughts
The eighth step of the CBT treatment for GAD is called thought stopping. This refers to the skill of stopping unwanted, unpleasant thoughts by choosing to challenge them or disengage from them, rather than being entangled in them. To begin, the person chooses pleasant thoughts to replace the unwanted thoughts, such as thinking about a vacation instead of problems at work. Next, the person relaxes, thinks about the unwanted thought, shouts “stop” out loud, and then returns to the more pleasant thoughts.
9. Revise Core Beliefs
The ninth step of the cognitive behavioral treatment for GAD is to identify and revise the core beliefs the person has about himself or herself and the world. These core beliefs are the equivalent of the engine that drives GAD; they create the automatic thoughts that produce the person’s fears and avoidance behaviors. Core beliefs can often be identified by noticing similarities in automatic thoughts. For example, a person with GAD might have core beliefs such as “I’m incompetent,” or “I’m defective,” which make the person doubt his or her ability to function effectively in the world. These types of core beliefs create rules by which a person lives his or her life, such as “If I offer my opinion, I’ll be criticized.” In this step of the CBT treatment, the person learns to challenge those rules to see if they are accurate or not.
10. Prevent Relapse
Finally, the last step of the cognitive behavioral treatment for GAD is preventing relapse after treatment is complete. The key to relapse prevention is for the person to continue using the cognitive and behavioral skills learned in treatment and to recognize the early signs of recurring GAD, such as avoiding feared situations, in order to take steps to prevent relapse.
ACCEPTANCE AND COMMITMENT THERAPY FOR GENERALIZED ANXIETY DISORDER
Acceptance and commitment therapy (ACT) incorporates elements of behavior therapy, meditation and mindfulness practices, and scientific research on how humans think and learn.
ACT (pronounced “act”) is based on the principle that many psychological problems are caused by efforts to control, avoid, or get rid of emotions and thoughts that are undesirable. Often, people try to get rid of feelings and thoughts that make them sad or anxious, just as they get rid of other things they don’t want, such as old clothes. However, as ACT points out, feelings and thoughts can’t be controlled. A person can’t throw them out like an unwanted pair of shoes. In fact, the harder a person tries to control his or her thoughts and feelings, the more powerful they often become and the longer they stick around.
The ACT treatment for generalized anxiety disorder typically includes eight steps:
- Educate about GAD, anxiety, and ACT
- Develop creative hopelessness
- Clarify values
- Commit to taking action
- Develop acceptance
- Focus on contact with the present moment
- Utilize cognitive defusion
- Stay committed to values and actions
1. Educate About GAD, Anxiety, and ACT
The initial step of the ACT treatment for generalized anxiety disorder is to educate the person about GAD and the nature of anxiety. It’s especially important for the person to understand the nature of anxiety from an ACT point of view. According to this treatment, anxiety and fear themselves are not the causes of GAD. Rather, it’s the person’s avoidance of anxious and fearful emotions and thoughts that make GAD an overwhelming problem. Starting with the early stages of treatment, it’s also important for people to understand that ACT is an active, participatory treatment designed to help them live a more fulfilling life, not necessarily a “happier” one.
2. Develop Creative Hopelessness
In order to develop what ACT calls “creative hopelessness,” a person must conduct a thorough evaluation of the strategies that he or she has already used to cope with fear and anxiety. After doing this, the person often recognizes that all of these strategies have been unsuccessful or actually made the problem worse. This is because these strategies are actually attempts to avoid and control feelings of fear and anxiety, which can never be successful. For example, a man who attempts to control his anxiety by drinking alcohol actually develops a worse problem, as does a woman who tries to avoid her anxious feelings by choosing not to talk to her loved ones about them. But rather than just being hopeless, this stage of treatment is also creative because it allows the person to begin exploring new, more successful ways of coping with fear and anxiety.
3. Clarify Values
ACT acknowledges that life is often lived on autopilot, without much sense of what a person really cares about. Clarifying and establishing what a person values can often help that person live a more fulfilling life, despite having occasional feelings of anxiety or fear. Values are the elements of life that give it meaning and importance, like “maintaining a loving relationship with my spouse or partner” or “being an active member of my community.” These values are like compass headings that guide a person through life. They are not destinations at which a person can ever arrive. A person can never stop maintaining a loving relationship and still have a loving relationship. Values are concepts that point a person in the direction of a fulfilling life, and ACT uses many types of values clarification tools to help people identify their values.
4. Commit to Taking Action
After a person has determined his or her values, it’s important to establish goals that support those values and then commit to taking actions that fulfill those goals. For example, if a person’s value is to be an active member of her community, she might list a number of different goals to fulfill that value, such as “attend community meetings twice a month.” This is something that can be completed and thereby create a sense of valued living. The ACT treatment for generalized anxiety disorder includes development of skills and goals that lead to taking committed action.
5. Develop Acceptance
In ACT, learning to accept feared situations and anxious emotions is the alternative to trying to control or avoid them. Acceptance can be hard, but it’s often the only way people can reclaim control of their lives. Many situations cannot be altered, no matter how much a person wishes them to be changed. Accepting this fact is often the first step in reengaging with life. Accepting what cannot be changed frees a person from struggling against it and allows that person to start taking actions based on what he or she values in life.
In order to cultivate acceptance, people are encouraged to experience the anxious emotions that they have been avoiding, to cease fighting things that cannot be altered, and to engage in situations that have been evaded.
6. Focus on Contact with the Present Moment
Focusing on what’s happening in the present moment can help people develop more flexible coping strategies for handling fear and anxiety. When people dwell on the past, they often become sad, and when they anticipate the future, they often become anxious. In both cases, they miss what’s happening at the present time. Paying attention to what’s happening in the moment gives people more control over the decisions they’re making and allows them to see more possibilities in life. This skill is often developed with present-focused mindfulness skills, such as focusing on the rising and falling of the breath or on physical sensations in the body.
7. Utilize Cognitive Defusion
Cognitive defusion is a mindfulness technique that helps people observe their anxious and fearful thoughts without becoming attached to them. “Defuse” is an invented word that means to unstick or to unfuse one’s self from the words that arise in thoughts. The goal of this stage of treatment is to allow people with GAD to function more freely without judging themselves, their feelings, or their thoughts. Thoughts and emotions often arise haphazardly, so it’s easy to see that GAD could worsen over time if a person were to follow or believe every thought and emotion that arose.
Cognitive defusion is often accomplished using meditation or mindfulness techniques, such as imagining thoughts floating by on a cloud, repeating the words of a thought over and over until they lose meaning, or imagining a thought as something outside of oneself. By observing the process of thinking and feeling, the goal is to create space between the person and his or her experience. This gives the person more control over decisions made based on those thoughts and feelings.
8. Stay Committed to Values and Actions
In order to create a fulfilling life, it’s crucial for people to continue making decisions based on what they value in life, rather than based on the thoughts and feelings they have tried to avoid in the past.