Do you worry? Of course you do, we all worry. Perhaps you worry about your health, or about whether you’ll have enough money to retire. Perhaps you worry about whether your kids will get into a good college or whether they’ll get home safely from a party. Perhaps you race to and fro because you worry about being late, or about getting things done. So if day-to-day worries like these are normal, when is worry a problem? When it is chronic, excessive, and significantly interferes with an individual’s personal or professional life.
What is Generalized Anxiety Disorder (GAD)?
Generalized anxiety disorder (GAD) is characterized by chronic and excessive worry about health, money, family, or work. Approximately 3-4% of the population suffers with GAD, with the condition more prevalent in women than men (2.5:1). On the average, individuals with GAD have experienced excessive worry for at least 25 years. More than half of those with GAD also have a mood disorder, such as depression, and many have another anxiety disorder. People with GAD suffer with the triple whammy of anxious thinking. They tend to overestimate the likelihood of something bad happening. If they go on vacation, they believe the house will burn down while they are away. They believe they are more likely than others to have a health problem or to be fired. And, when they encounter problems, even small ones, they tend to overestimate its severity. If they have a headache, it means they have a brain tumor. If they have an argument with their partner, it means they are headed for divorce. Additionally, people with GAD tend to under estimate their ability to cope. They believe that they, far more than others, lack the resiliency to weather a downturn in their health, or the skills to find themselves a new job if they are fired.
People with GAD also have beliefs about worry itself. They believe if they stop worrying that more bad things will happen to them. They believe that by worrying they prevent a bad thing from happening. Although worry protects us to some degree by preparing us to deal effectively with bad things, chronic worriers believe that worrying might actually prevent the bad thing from happening all together. In addition, chronic worriers believe that they have absolutely no control over their worry, and that unless they find a way to control it, that the worry itself will kill them or make them seriously ill.
Because they see worry as the solution to their problems, people with GAD have trouble resolving potential problems effectively, or managing time or achieving goals because they worry instead. They experience persistent and distressing physical symptoms too. They become fatigued easily, and are irritable, keyed up, and tense, and have trouble concentrating. They can experience headaches and gastrointestinal distress and can have great trouble falling or staying asleep. Unlike people with other anxiety disorders, chronic worriers do not typically avoid situations, but do engage in safety behaviors, such as being on time at all costs, or cleaning their home thoroughly every day in case someone pops in unexpectedly, or insisting their partners call immediately when they arrive at work. They seek repeated reassurance from others, such as calling their physicians when they are worried about their health. They ask their friends and family members, “Do you think he’s the right guy for me?” “Do you think it’s safe to fly this summer?” “Do you think I’ll get fired?” Chronic worriers also tend to be overcautious. They put off starting tasks, such as balancing their checkbooks or returning telephone calls, or become paralyzed if they have to make major decisions, such as getting married or changing jobs.
People with GAD are caught in a vicious cycle of escalating worry and physical distress that leads to maladaptive ways of coping that leads to more worry. An attorney worries that he will perform poorly in the courtroom the next day unless he gets enough sleep, and then tosses and turns all night long. The next day he postpones the court date, which causes him to worry more because now his supervisor is complaining that he is falling further behind in his work. The attorney begins to postpone working on other trials thinking that once he gets several nights of rest under his belt, he’ll be able to clear things up at work. The attorney starts to get headaches and has trouble concentrating so that now, even when he does work, he is less effective. This worries him even more until finally, he resigns from his job thinking that trial work is too stressful for him. He takes a new job, which pays less money, so now he is worried about paying his bills. His sleep further deteriorates and now he fears that his sleep problems are affecting his health.
Cognitive Therapy of GAD. Cognitive therapy for GAD includes two primary components: cognitive restructuring and relaxation training.
Cognitive restructuring aims to alter the thinking patterns that contribute to the process of chronic worry. Clients learn that certain patterns of thinking contribute to feeling keyed up and on edge. Cognitive therapists begin by asking clients to record the content, frequency, and intensity of their worry episodes, often using a Dysfunctional Thought Record (DTR). Clients are taught to use the DTR to evaluate situations more realistically and alter their thinking pattern so that they can effectively solve day-to-day problems and manage their time better. For example, a chronic worrier might note on his DTR that he began to feel anxious after his boss told him that he wanted to meet with him later in the afternoon. He recorded on the DTR the following automatic thoughts:
· “He’s upset with me about my report.” “This it -- he’s going to fire me.”
The cognitive therapist then worked with the worrier to evaluate how likely it was that his boss was unhappy with his performance and would fire him. They examined the evidence that might confirm and disconfirm the assumption, and developed a more balanced adaptive response:
· “I don’t really know why my boss wants to speak with me. It’s not likely that he’s dissatisfied with me because just yesterday he told me he was very pleased with how I had turned around my business unit. Even if he was dissatisfied with me, it’s very unlikely that he would fire me because my last performance review was very positive.”
This therapy work lead to a productive discussion about the worrier’s tendency to assume that bad things are very likely to happen and that he might want to remind himself of this tendency to jump to catastrophic conclusions when he begins to worry.
In addition, cognitive therapists assist clients to test the assumptions or beliefs they have about worry itself -- that worry leads to greater certainty and thereby control; that they have no control over their worry, or that worry decreases the likelihood of bad events. For example, take the belief many chronic worriers have:
· “I have no control over worrying”
A cognitive therapist might ask the client to schedule worry time, usually a half-hour at an agreed upon time during the day, and then to continue to monitor and record their worry as they have been doing previously. The client and cognitive therapist then compare previous worry records to those completed during the week they scheduled worry time. Many clients discover that while they still worried, they actually worried a bit less by scheduling worry time, thereby disconfirming that their worry is completely out of their control. Similarly, many chronic worriers believe that by worrying about a particular outcome it is less likely to occur. For example, take the client who worries every weekday morning that her husband will not arrive safely to work. With the help of her cognitive therapist, she might try going out with a friend one morning so that she is less likely to worry about her husband and see whether he arrives safely to work or not.
Relaxation training is intended to decrease the persistent physical over arousal that contributes to the maintenance of the worry process, as well as many of the symptoms the person with GAD worries about (gastrointestinal distress, sleeplessness, fatigue). Relaxation training focuses on helping clients to incorporate regular relaxation into their lives as well as teaching them to bring on the relaxation response quickly. Typically, clients are taught to relax by progressively tensing and then relaxing a series of muscle groups. With practice, clients can learn to bring on the relaxation response by imagining feeling relaxed or by saying to themselves a word or phrase, such as “relax my mind and body now.” A cognitive therapist might ask clients to practice bringing on the relaxation response in situations that tend to trigger worry. For example, a client who tends to worry about his work performance, particularly prior to and during weekly team meetings, might practice the relaxation exercise in the conference room at work where the meetings are usually held.
Usually, chronic worriers have a lifelong pattern of worrying about problems rather than implementing concrete strategies that might help manage the problem. For this reason, chronic worriers often have trouble managing their time, being assertive with others, or effectively solving day-to-day problems. As clients gain greater control over their worry, cognitive therapists might focus on teaching clients more effective life-strategies such as these and helping them practice these strategies in a variety of real-life situations.
Role of Medication in the Treatment of GAD
A number of medications can help to control GAD symptoms. Antidepressant medications called selective serotonin reuptake inhibitors (SSRIs) (e.g., fluoxetine, sertraline, paroxetine, venlafaxine) can decrease the symptoms of GAD, while also decreasing the depressive symptoms that chronic worriers typically experience. Tricyclic antidepressant medications are as effective for treating GAD as the newer classes of antidepressants but because many individuals experience quite uncomfortable side-effects, such as dizziness, drowsiness, dry mouth, and weight gain, physicians tend to avoid prescribing them. High-potency anti-anxiety medications, known as benzodiazepines (e.g., alprazolam) are another class of medications that are typically prescribed for GAD. Benzodiazepines work quickly and have few side effects. However, when taken daily for over an extended period of time, some people can become dependent on the medication, particularly if they have had problems with drugs or alcohol. Buspirone is another anti-anxiety medication that is used to treat GAD. Unlike the benzodiazepines, individuals must take buspirone consistently for at least two weeks to achieve a benefit and, like the benzodiazepines, it does not diminish the depressive symptoms of chronic worriers.
Outcome Studies.
Although GAD is a difficult condition to treat, there is growing evidence that GAD can be treated successfully. Cognitive therapy, using a combination of interventions such as relaxation training, cognitive restructuring, and graded exposure has been shown to decrease anxiety and depressive symptoms more than anxiety management training alone, relaxation training alone, or nondirective psychotherapy. Those who complete cognitive therapy exhibit significant improvement in their symptoms. In addition, it appears that people with GAD who receive cognitive therapy tend to maintain their recovery longer.
by Michael A. Tompkins Ph.D.
Founding Fellow, Academy of Cognitive Therapy
Director of Professional Training
San Francisco Bay Area CCT
