Generalized Anxiety Disorder

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Generalized Anxiety Disorder from Patients' Perspectives

“My mom always called me a 'worry wart'. Even though she and my dad never really pushed me in school, I'd always worry about doing well and getting all A's. The night before each test, I always had problems falling asleep and when I did it was restless sleep. I worried - about what would be on the exam, if I had studied enough, what if the teacher threw a curve. It maybe would've been ok if my worries were confined to this one area or if they stopped when the exams were all over, but it seemed almost like my mind would search for the next thing to worry about. My friend hadn't called in a while, was she upset with me? What should I be when I grew up and how come I wasn't sure what I wanted to be yet? Did they say it was going to rain on Saturday - oh no, this would ruin our trip to the beach. All my life, my worries seem to have been endless -- if I'm not worried about one thing, my mind just moves on to the next thing to worry about…“.

“I spend a lot of time talking to my husband about all of my worries. Sometimes he tells me that he is tired of talking about everything in my life and analyzing it in a million different directions. But I feel like I can't help myself. My heart starts to pound, my hands get clammy, and I sometimes pace around the apartment. Primarily, I worry about the future. I worry that the job that I have is not the right one for me. I worry that maybe I should work more hours so that we can buy a house sooner. I worry that maybe I'm getting too old to have a child…My worries will also be triggered by things I see or hear about. Like, if I'm watching a TV show where someone dies, I think about what I would do if my husband suddenly died, how would I get along without him? Maybe we should draw up a will? I think about life without him and worry…“

GAD - Prevalence Rates and Course of the Disorder

GAD affects approximately 4 million adults in the United States. This disorder is about twice as common in women as in men. GAD tends to come on gradually so it is difficult to determine the onset of the disorder. It usually appears between childhood and middle age, and it is not uncommon for many people to report that they have “always been this way“ or that they have been this way for “as long as I can remember“. GAD tends to be a chronic disorder. Symptoms often wax and wane in concert with periods of increased life stress. Most people with GAD are generally able to function relatively well in life and typically don't avoid many situations; however, they do report that their chronic worrying does significantly impact their enjoyment of their life. However, it is possible for GAD to be very severe and to begin impacting even the most ordinary daily activities.

GAD frequently co-occurs with other anxiety disorders and other psychological difficulties (such as depression and substance abuse).

What Causes Generalized Anxiety Disorder (GAD)?

The answer to this question is currently uncertain. Like many of the other anxiety disorders, it is believed that GAD results, in part, from a genetic vulnerability to develop an anxiety disorder (however, there have been no genes identified that lead specifically to GAD). It is believed that this genetic vulnerability interacts with a person's innate temperament (their natural tendency from birth to be more extraverted, introverted, etc.) and developmental experiences to determine who will develop GAD.

What are the Symptoms of GAD?

Everybody worries. But, what distinguishes people with GAD from normal worrying is that people with GAD tend to worry about things that are unlikely to happen (see below) and they tend to underestimate their ability to cope if difficult situations do occur. Most people's worries tend to increase when life stressors arise (e.g., car accident, fired from a job, divorce, death of a loved one). However, people with GAD worry even when no real stressor is present; frequently individuals with GAD report that they feel like they are always playing a “what if“ game in their mind…always worried “what if“ one thing or another happens.

More specifically, the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) specifies the following criteria for GAD.

1. Excessive anxiety, worries, or anticipatory anxiety about several different areas or activities (see below). These types of worries must be predominant (occurring more days than not) for at least 6 months.

2. In addition, individuals with GAD have difficulty controlling the worry and have several physical symptoms associated with anxiety (see general information section of anxiety disorders for common symptoms of anxiety).

3. The worries and/or physical symptoms also cause distress or impairment in social, occupational, or other areas of functioning.

Common Worry Areas for People with GAD

As specified in the Anxiety Disorders Interview Schedule for DSM-IV (ADIS-IV)):

School/work What if there is no one I like in my homeroom next Fall?

This upcoming week is so busy, it seems overwhelming, maybe I can't handle it.

What if I don't get all A's this semester?

What if I didn't write down all of my homework assignments?
Performance What if I don't play my best in the basketball game this weekend?

What if I should have put more time and effort into my presentation for work?
Minor Details What if I said something to my friend that upset her?

What if I should have taken a more advanced math class rather than the one I took?

What if I should have attended the other party last weekend - maybe I would have had more fun there?

Maybe should have bought the other brand of tuna?
Perfectionism What if I didn't leave early enough and I won't get to work on time?

What if I made a grammar mistake on that report I gave to my boss?
Family issues and finances What if my parents got a divorce?

What if we don't have enough money and shouldn't be treating ourselves to this dinner out?
The future What if I don't chose the right life paths?

What if I die before I get a chance to do everything I want to in life?

What if I don't get into a good college or get a good job?
Health (self and others) What if my husband gets into an accident?

What if I get cancer?
Safety What if burglars broke into the house?

What if I was kidnapped?

What if we go to Disneyland and I get lost and can't find my mom?
Things going on in the world What if there is an earthquake?

What if terrorists come to my school?

* Often, evaluation by a professional is needed to help determine whether performance worries are due to GAD or social anxiety disorder (social phobia). Frequently, those with GAD worry primarily about “being the best“ that they can be and the quality of their performance is important to them even if other people wouldn't even know about their successes or failures. However, in social phobia, anxieties are primarily driven by worries about evaluation from others and worries about what others will think about their performance (rather than an intrinsic need to “be the best“ for themselves).

Treatment for GAD

Both medications, Cognitive-Behavioral Therapy (CBT), and a combination of the two have been found to be effective for GAD. The most common medications used for GAD are benzodiazepines (these usually provide only short-term relief, but are quick acting) and selective serotonin reuptake inhibitors (SSRIs; these provide longer-term relief but usually take about 3 weeks before they begin to be effective). It is not uncommon for people who take medications to report that it helps to “take the edge off“ of their anxiety, but that they are still left with many worries. These people frequently seek therapy as an adjunct to their medication regimen.

CBT for GAD typically involves the following steps. First, patients are further educated about the function of anxiety, and they are also asked to monitor and record their worries when they occur. This helps to determine what types of worries are present and if they tend to occur more frequently at certain times of the day.

People with GAD are also taught muscle relaxation techniques (e.g., progressive muscle relaxation). This strategy helps to reduce the general muscular tension that often accompanies GAD; in addition, this specific muscle relaxation strategy also helps to actively redirect one's mind from their worries onto more relaxing thoughts.

CBT also teaches cognitive restructuring techniques - or ways to analyze the worries to determine what exactly is feared, if that is a realistic worry or not, and how one would cope in the event that the worst scenario actually happens. In particular, patients are taught how to recognize probability overestimations (e.g., thinking that a bad outcome is much more likely than it really is) and catastrophizing errors (e.g., thinking that there would be no way that they could cope if the worst happened). These types of cognitive “errors“ are very common in GAD. In addition, it is also valuable for patients to explore their beliefs about worry itself - as it is common for some people to believe that worrying prevents bad things from occurring and worrying about one thing may help them from worrying about something else.

In addition to learning how to better relax and look at the reality of their thoughts, “worry exposure“ techniques are also frequently very helpful. In this strategy, certain worry thoughts or scenarios are rehearsed repeatedly in a very structured and specific way. Confronting these fears gives individuals with GAD an opportunity to practice the other skills that they have learned in therapy (e.g., muscle relaxation, cognitive restructuring). Additionally, this technique has an interesting effect - after having these worries repeatedly (in this structured way), when these thoughts later spontaneously arise on their own, they are often accompanied with a far lower level of anxiety.

If there are any situations that are avoided due to worry, patients are also taught how to confront these situations in a gradual, structured way. Additional techniques, such as time management and goal setting are also implemented to help tackle any realistic worries that may be present.

If you are interested in learning more about anxiety disorders and their treatment, and you live in the Los Angeles area, contact Dr. Nelson at (310) 963-4891 or e-mail her at