Generalized Anxiety Disorder

Anxiety disorders differ in both their breadth and their intensity. Panic attacks are notoriously intense, arriving suddenly and sometimes with no apparent trigger. In contrast, Generalized Anxiety Disorder (GAD) probably has the most breadth. The name itself suggests anxiety about many different events or situations or activities.

Anxiety in GAD takes the form of “apprehensive expectation,” or worry. That’s the cardinal symptom of GAD. In addition to excessive worry, a DSM-5 diagnosis of GAD requires three of the following six symptoms. Some of the symptoms must be “present more days than not” for the last six months. Notice that four of these symptoms represent the manifestation of anxiety in the body. Only one is cognitive, and only one is emotional. Note that all of these symptoms appear to be more the result of worry than the cause.

  • Restlessness (physical)
  • Feeling fatigued (physical)
  • Problems with concentration (cognitive)
  • Irritability (emotional)
  • Tension (physical)
  • Sleep issues (physical)

That’s the life of the person with GAD: Worried about everything. Some days are better than others, but even when the worry relents, it always returns. Clients with GAD worry even about the mundane aspects of life that most people manage with occasional fussiness. This includes job or retirement issues, financial situation and spending, existing and possible health issues, bad luck, their relationships, and any current stressors. They may worry not only for themselves but also about people they love. They may even worry more about others than the others worry about their own lives.

Like other anxiety disorders, the diagnostic criteria of GAD emphasize that the anxiety is out of proportion to any objective threat, is hard to control, occurs frequently (more days than not for the previous six months), and causes significant distress or impairment in functioning.

Like other anxiety disorders, GAD exists on a continuum with normality. Everyone worries from time to time, and everyone worries excessively from time to time. If you let the number of things worried about be one dimension, and the frequency or intensity of worry be another dimension, then it becomes possible to locate GAD as a region of the graph where worries are both frequent or intense and about many things.

According to the DSM-5 (p. 223) the course of GAD tends to be chronic, “fluctuating between syndromal and subsyndromal forms of the disorder.” In other words, once you have GAD, you tend to always have some of it, though it may not always reach the level of a diagnosis. The DSM-5 further states (p. 225) that GAD “is associated with significant disability and distress that is independent of comorbid disorders, and most non-institutionalized adults are moderately to seriously disabled.”

The Nature of Worry

Worry is an attempt to control the future, in order to reduce risk and feel safe. In the normal range, anxiety functions to help you anticipate and plan for threats, generally anything that might go wrong. In life, you learn that it’s important to be able to look at a plan or process and discern where there’s a probability that things to go wrong, and what their consequences might be. If the probability is high or the consequences severe, then it’s important to have some kind of contingency plan in place to mitigate risk and put things back on track. That’s just good planning, preparation, or prevention.

In fact, worry in our society is common, and for the most common worries, the antidote is already socially prescribed: Worried about failing your classes? Then study. Worried about your looks? Then diet and start exercising. Worried about a car accident? Don’t speed, drive defensively, and wear your seat belt. Have a medical issue? Go to a doctor, maybe even a specialist. For just about every common problem you might face in life, a solution is already available. You just have to follow through. Knowing that you’re following the well worn path travelled by the rest of humanity helps in letting go. You’re doing what most people do. In this instance, you can realistically think of worrying as a method of protecting yourself and disclosing opportunities. Nothing wrong with that.

Certainly the process of anticipating problems could continue forever, but at some point, the normal person says enough and lets go of the need to have everything planned out in great detail, for every possible contingency, far in advance.

In contrast, pathological worry is an attempt to control risk to the point that safety is absolutely certain. Imagine the forward thinking involved in worry as a kind of branching process, where the mind searches out all possible risks, tries to find some contingency plan that might eliminate the risk, then seeks to assess any risks created by the contingency plan.

So you start studying for your Chemistry final exam, because you’re worried about failing. So far, so good. Healthy worry is motivating you to prepare. But you also worry that your roommate will come home and disturb you—your roommate will resent not being able to watch TV while you study—so maybe the library would be a better place, but the library can be noisy on a Friday night sometimes, and tonight is Friday night, so maybe that’s not such a good idea either. You could study tomorrow, but that means pushing back your studying for your math exam, and when these things pile up, the fatigue is enormous. Remember what happened two years ago, when you didn’t have time to study for your Spanish final. You got a C grade for the class. Your Chemistry professor will be just as disappointed as your Spanish professor if that happens. As you can see, all your contingency plans have their own risks. As the author’s own mother used to say “I just don’t know what I’m going to do.”

In the example above, you can imagine the person constantly asking the question “What could go wrong?” If the answer is anything at all, then risk mitigation thinking swings into action. If the risk can’t be mitigated out of existence, then the person concludes they are not safe, and that another solution must be found. Since there are risks with most everything, worry becomes infinite.

Notice that the person doesn’t ask “What could reasonably go wrong?” They don’t assess the chances, and when they do, they exaggerate the probability. This might be considered an example of magnification, a cognitive distortion. Or, it might be considered black and white thinking: The presence of any risk at all means that the person is not safe or in danger and must continue the search for a better solution. Worry thus represents an exaggerated attempt to control risk out of existence. If anything could go wrong, that option becomes a dead end.

Notice that since worry is an impossible search for safety, worry only stimulates more worry. The person never reaches a point where they feel they can simply let go and endure the risks foreseen.

Worry as Distraction

Some authors suggest that worry distracts the person from emotional experiences even more negative than worry. From this perspective, you need not face the real source of your worries, simply because—as long as you’re worrying—a solution is in process. Worry thus becomes a distraction, without which your anxiety or other negative emotion would be worse.

Contrast with Catastrophic Thoughts

Notice further that worries are similar to catastrophic thoughts in that they anticipate what could go wrong. However, catastrophic thoughts have a feeling of inevitability and doom about them, whereas with worry, the person is literally turning the situation or event around in their mind, assessing it from many different directions and perspectives, insofar as their cognitive ability allows, so that worry becomes more of an active search for safety. Outcomes featured in worry are probabilistic, based on the particular course of events. In contrast, catastrophic thoughts quickly target the absolute worst-case scenario.

Contrast with Rumination

Worry is not the same things as rumination. Both involve an excessive preoccupation, constant mulling over of fine details, but worry is more future-oriented and has more cognitive flexibility. Ruminations are singular thoughts or themes that repeat over and over again.

Concentration Issues

At a pathological level, the worry of GAD begins to interfere with cognitive functioning. Obviously, pathological worry is on a continuum with normality, like all the anxiety disorders. In the normal-range, you may have things you’re concerned about, but most of the time, you can set your concern aside and think about something else or do something else. You have enough control over your own cognitive processes to do that. Your worries are put away, and you can return to them later. So-called ordinary worry is not intrusive, it does not insert itself into your stream of consciousness and demand your attention. In GAD, worries do insert themselves, displacing other thoughts and activities to such an extent that they interfere with and disrupt ongoing activities.

Here are some examples: You’re chatting with your friend, and what happens? You can’t keep your mind on the conversation. She’s sharing something about a new restaurant, and you’re worrying about the condition and safety inspections of restaurants in general. She’s sharing something about her spouse, and you’re worried they’re headed for divorce, as so many people you know seem to be these days. She’s sharing the details of a possible new car purchase, and you’re worried that your own car is on the edge of a breakdown. When it comes your turn to talk, it becomes impossible to share the joy, because you have only worries to announce.

Or maybe you’re trying to study, and when you reach the end of a paragraph, you can’t remember anything you just read. You did well for a few sentences, then your mind jumped the tracks and you landed back in “worry mode” again. Then you worry that worrying will get in the way of your assignments. You can’t even organize your thoughts, because your thoughts always come back to worries.

Or maybe you’re on a date and you suddenly can’t remember what your date was saying about her family. You’re just too distracted to be emotionally present for the encounter. Or maybe it’s your turn to talk and your mind suddenly goes blank.

Or maybe you’re at work and it’s impossible to focus your mind enough to sequence your activities toward the accomplishment of a goal. You want to work, but in reality, you’re just spinning your wheels, because your can’t concentrate long enough to determine your priorities in the situation and think them through realistically. Not being able to plan and focus, you begin to worry that your boss is catching on, because your productivity is suffering. You consider taking work home to keep up, but you’re already so tired because you’re not sleeping well that you know it’s pointless. You feel defeated.

Worry about Worry

All anxiety disorders generate a certain level of anxiety about anxiety. In the case of GAD, this takes the form of worry about worry. You might be having a relatively better day, because you find you’re not worrying so much, then wonder why that is, then start worrying that you might start worrying. Ironic, but true.

Just as anxiety about anxiety marks an advanced level of severity, so does worry about worry. Given the concentration problems described above, it’s likely that worry about worry follows impairments in concentration, attention, problem-solving, and other executive skills with which “ordinary pathological worry” interferes.

Self-Doubt

Across the anxiety disorders, clients compare themselves to the situation they face. In GAD, the person makes a sustained heroic effort to prevail, but consistently encounters problems, day after day. As as result, people with GAD feel that life is too hard, or that their problem-solving skills are deficient, or both. They have little confidence in their ability to persevere life’s obstacles and overcome. Instead, what they encounter over and over are threats upon threats, with every possible escape route a dead end. So of course they don’t feel confident. Interestingly, the DSM-5 does not mention the consequences of GAD for the client’s self-image.

Irritability

The irritability of GAD suggests exhaustion and frustration. Some of this derives from the issues at hand, which are vexatious precisely because they resist any good solution, but instead only provoke more worries.

Irritability could also derive from a competition between values. If you’re caught between working hard to build a nest egg and wanting to spend more time with your children, that’s a no win situation, particularly if you feel enormous pressure both ways. Most situations in life have both positive and negative aspects. When you have to choose between several options, all of which have both attractive and unattractive features, that’s called double approach-avoidance conflict. Being caught up in this complexity can deplete coping resources, leaving the person feeling frustrated and overwhelmed.

Physical Manifestations

Normal range worries don’t usually result in sustained physical symptoms. Sure, you might have a few nights of disturbed sleep, but it doesn’t become a lifestyle, as it does with GAD.

Pathological worry, however, has extraordinary physical symptoms. Among other things, the body exists in a constant state of tension and exhaustion. Sleep issues abound. The person may have problems falling asleep due to nighttime worries, or wake up worrying after a few hours of sleep, or wake up early and be unable to return to sleep. Lack of sleep then feeds back in order to amplify other fatigue, irritability, and poor concentration.