Generalized Anxiety Disorder

Generalized anxiety disorder 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, work problems, or school 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. 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, hard-to-control 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):

• Tense—feeling keyed up Being easily fatigued Difficulty concentrating Irritability
• Muscle tightness Difficulties with sleep

Generalized anxiety disorder is frequently associated with physical symptoms such as tension headaches, irritable bowel syndrome, high blood pressure, insomnia, and even osteoporosis. However, the presence of any or all of these physical problems does not necessarily imply a diagnosis of generalized anxiety disorder, which is based primarily on the presence of ongoing worry.

You are 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 (alcohol or benzodiazepine withdrawal). Generalized anxiety disorder often occurs together with depression, a condition sometimes referred to as “mixed anxiety-depressive disorder.” In such instances, a careful history will usually reveal which disorder—the generalized anxiety or the depression—came first.

Generalized anxiety disorder can develop at any age. 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 5 percent of the American population and may be slightly more common in females than males (55 to 60 percent of those diagnosed with the disorder are female).

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

Generalized anxiety disorder can be aggravated by any stressful situation that elicits these fears, such as increased demands for performance, intensified marital conflict, physical illness, or any situation that heightens your perception of danger or threat.

The underlying causes of generalized anxiety disorder are unknown. It is likely to involve a combination of heredity, neurobiology, and predisposing childhood experiences, such as excessive parental expectations or parental abandonment and rejection, or parents modeling worry behavior.

Current Treatment

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. Fearful self-talk underlying specific worry themes is 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, such as “If I worry about it, it won’t happen,” as well as fearful beliefs about worry itself, such as “My worries are uncontrollable” or “I’ll go crazy from worrying.” Realistic self-statements 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 (your worst-case scenarios) of what you’re worried about. In these images you include strategies you would use to reduce anxiety and cope with the situation.

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. This means taking 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.

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 using the Internet.

Medication. For moderate to severe cases of generalized anxiety disorder, SSRI medications such as Zoloft, Luvox, Lexapro, or Celexa may be used. The SNRI medication Effexor has also been found to be effective in treating generalized anxiety disorder. Another medication, BuSpar, has been used for fifteen years 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. Benzodiazepines such as Xanax, Ativan, and Klonopin are often used in primary care but are not considered a first-line treatment by psychiatrists because of their potential for tolerance, dependence, and abuse.

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 chapter 18.

Lifestyle and 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.