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SJHH ... / Mental Health & Addiction Services/ Mental Health Services/ Anxiety Treatment and Research Clinic (ATRC)/ Definitions and Useful Links/ Generalized Anxiety Disorder (GAD)

Generalized Anxiety Disorder (GAD)

What is GAD?

GAD is characterized by chronic and excessive worry about a number of different topics. Most of us worry about things from time to time, but people with GAD find themselves worrying most of the time, even when there is little reason to worry. People with GAD also report that their worry feels uncontrollable, so they have trouble pushing it to the back of their minds or doing other things when they are worrying. The worry in GAD often interferes with a person’s day-to-day life, or is bothersome. For example, people with GAD may find themselves having difficulty working, sleeping, socializing, or enjoying themselves as a result of their worries. GAD is also characterized by a number of physical complaints during times of worry such as muscle tension, trouble sleeping, feeling tired, or feeling “keyed up.” People with GAD may also experience symptoms such as dry mouth, nausea, or trouble swallowing.

Official Criteria for GAD

Based on criteria from the Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association, 2013)

Excessive or unrealistic anxiety and worry about a number of events or activities. The anxiety and worry occurs more days than not (i.e., at least every other day) and has lasted at least six months.
The person finds it difficult to control or “turn off” the worry.
The worry is associated with at least three of the following six symptoms, more days than not, for at least six months:

1. feeling restless, keyed up, or on edge
2. feeling tired frequently
3. difficulty concentrating or mind going blank
4. irritability
5. muscle tension
6. difficulty falling or staying asleep

The worry is not exclusively related to another psychological problem (e.g., worry about having a panic attack in panic disorder, worry about being embarrassed in social phobia). If another psychological problem is present, there must be significant worry about things unrelated to the other problem.
The individual’s worry or anxiety causes significant distress (i.e., it bothers the person that he or she worries too much) or significant interference in the person’s day-to-day life. For example, the worry may make it difficult for the person to perform important tasks at work, interfere with relationships, or get in the way of sleep.
The worry and anxiety are not simply due to a substance (e.g., drinking too much caffeine) or medical condition (e.g., an overactive thyroid).

What do People with GAD Worry About?

People with GAD worry about many different things; in fact, some individuals with GAD will report that they worry about “everything.” Studies have shown that GAD worries are similar in content to the types of worries that people without GAD have. However, people with GAD tend to report worrying more frequently, about more topics, and for longer periods of time than do people without GAD. In addition, people with GAD tend to find it more difficult to control their worries, compared to people without GAD. Examples of topics about which people with GAD worry include:

minor matters (e.g., Will I arrive on time? What if I can’t find a parking spot? I will never get all my chores done? What if I get lost while driving?)
health and safety of loved ones
personal health and safety
work or school
money and paying bills
appearance
friendships and relationships
community affairs, politics, the environment
inability to cope

Causes of GAD

Biological Factors

Neurotransmitters – Some studies suggest that neurotransmitters (i.e., chemical messengers that pass information from one nerve cell in the brain to the next) may be important in the experience of generalized anxiety. Specifically, studies have found that anxiety is increased if receptors in the brain for the neurotransmitter gamma aminobutyric acid (GABA) are blocked. So GABA may be important in the chronic anxiety and worry experienced by people with GAD. The neurotransmitter serotonin may also play a role. However, researchers believe that the role of neurotransmitters in the experience of anxiety is complex, and just one of many factors that affect the development and course of GAD.
Nervous System Activity – Studies have found that worry is often associated with a less flexible parasympathetic nervous system, the system that is involved in “calming down” or reducing the anxiety or fear response. This inflexibility means that people with GAD experience elevated and chronic signs of anxiety (e.g., an elevated and stable heart rate) whereas other people experience high levels of anxiety in response to stress, then reduced levels of anxiety once the source of stress is gone. This tendency for more stable physical symptoms is reinforcing in the short term because people with GAD do not experience the ups and downs of the anxiety reaction, but it is not helpful in the long run because it does not allow people to respond in a flexible way to their surroundings and to fully experience the physical aspects of fear and anxiety. The ability to experience more variation in heart rate and physical arousal is thought to be associated over time with the ability to distinguish situations that are truly threatening from those that are not.
Genetics – There is some evidence that GAD runs in families. When identical and fraternal twins are studied, results suggest that there is a genetic contribution to GAD. However, it seems that what is inherited through genes is the tendency to experience anxiety or depression, in general. In other words, genes only pass on a general tendency for anxiety or depression – they do not pass on GAD specifically.

Psychological Factors

Biases in Thinking and Reasoning – People with GAD tend to pay more attention to signs of potential threat than others do. For example, people with GAD notice unhappy or critical facial expressions on other people more than they notice neutral facial expressions. By noticing these critical expressions, they may overestimate the degree of threat (e.g., rejection by another person), making it seem is though there is much more to worry about than there is in reality. People with GAD also have a tendency to interpret ambiguous situations as dangerous, even when there is not enough information to support such a judgement. In other words, if they received a phone call late at night, they would be more likely to think this was a phone call with bad news than would people without GAD. People with GAD also rate the possibility of a negative outcome as more likely than others. For example, people with GAD would estimate the likelihood of a car accident involving their loved ones as much more likely that people without GAD. All of these biases in thinking are thought to contribute to the worry seen in GAD.
Worry as avoidance – An interesting and perhaps surprising finding regarding excessive worry is that worry may actually reduce people’s physical signs of arousal (e.g., heart rate). Researchers have wondered whether this occurs because worrying often takes the form of thoughts (e.g., “what if” questions), rather than unpleasant images (e.g., the image of your loved one in an accident). It appears to be much less arousing to wonder whether something bad has happened than to actually picture the unwanted event. Scientists believe that one of the functions of worry is to distract the individual from frightening images, thereby actually decreasing symptoms of arousal. Although worry can be an effective way of managing fear in the short term, it can make the problem worse over time. By avoiding the frightening images, worriers never get to fully deal with their fears and realize that the bad things they are worrying about probably will not happen.
Beliefs about Worry – Worry may persist because some people believe that worry is helpful to them in some way. For example, some people believe that worry helps them to prepare for things (e.g., “worrying about a test will make me more likely to study”) or to prevent bad things from happening (e.g., “if I worry about my loved ones, they may be less likely to get into trouble”). However, worry does not prevent bad things from happening or increase preparedness. In fact, worry may interfere with a person’s ability to solve problems. Another factor that is associated with worry is the intolerance of uncertainty. People with GAD report being unable to tolerate not knowing what will happen in the future. As a result of this, they may worry in an attempt to predict the future and gain some control. Of course, worry does not actually help people to control the future. Finally, some people with GAD will worry not only about things in their life, but also about the worry itself. For example, some people fear that they are going crazy or will lose control when they are worrying excessively about things. As a result of these concerns, people may try and control or suppress their worry. However, trying to suppress or push away worry may actually make worry more likely to return.

Effective Treatments for GAD

Biological Treatments

A number of medications have been shown to be useful for treating generalized anxiety disorder, and more medications are currently being studied. Drugs that seem to be useful include antidepressant drugs as well as drugs that are traditionally used for treating anxiety. Examples of medications that are often helpful for generalized anxiety disorder include:

Type of Medication	Generic Name	Brand Name
SSRI Antidepressants	Citalopram Fluoxetine Fluvoxamine Paroxetine Sertraline	Celexa Prozac Luvox Paxil Zoloft
Other Antidepressants	Venlafaxine	Effexor
Antianxiety Medications	Alprazolam Lorazepam Buspirone	Xanax Ativan Buspar

The decision of whether to take medication for GAD, and which medication to take should be based on the individual’s past treatment history, the individual’s medical history, possible interactions between the medication and other drugs that person may be taking, potential side effects, and other factors. Studies have suggested that the antianxiety medications often work more on the uncomfortable physical sensations (e.g., muscle tension, difficulty sleeping) while the other medications work more on the experience of feeling tense, anxious or worried.

Psychological Treatments

The most well studied treatment of generalized anxiety disorder is cognitive behavioural therapy (CBT), though researchers are working on new psychological treatments for GAD to help those people who do not benefit from CBT or medications. CBT involves several strategies:

Cognitive Techniques – these include strategies to challenge “anxious” or “worrisome” thoughts that may not necessarily reflect reality. For example, if someone is worried about failing an exam and never being able to get a job as a result of this, it might be helpful to look at the evidence that he or she will fail the exam and to consider possible alternative outcomes (e.g., if the person has written many exams and failed only one, the probability of failing this time may not be as high as he or she thinks). Further, the therapist would work with the person on examining how bad it would really be if he or she did fail the exam (e.g., does this mean that the person will never find a job, or is it more accurately thought of as a minor setback in school). Cognitive techniques may also target beliefs that people have about worry, including beliefs that worry is helpful in preparing people for things and preventing bad things from happening. Evidence for these ideas is examined to figure out whether worry has really helped the person, by preventing negative outcomes, for example. New approaches to cognitive therapy have also included exercises designed specifically to target intolerance of uncertainty, by helping individuals to recognize, accept, and cope with uncertainty in life.
Relaxation Training – The most commonly used form of relaxation training is progressive muscle relaxation, in which various muscle groups are progressively tensed, then relaxed. Combined with controlled breathing or pleasant imagery, these exercises can be used to combat the physical tension that often accompanies worry. Practice often starts in nonstressful environments, and is later transferred to more stressful situations.
Imaginal Exposure – this technique involves having people expose themselves to the worrisome images that are thought to underlie worry. By repeatedly exposing oneself to images that are feared and avoided, people can begin to habituate or get used to these images. In other words, after repeated exposure these images become less frightening, which, in turn, means that there will be less reason to worry about this topic the next time it arises. In imaginal exposure, fear-provoking images are identified, and then the person begins exposure with a moderately fearful image, gradually working his or her way up to the highly fearful images. For example, if someone worries about the safety of a loved one, they might expose themselves to the image of receiving a phone call about a bad accident involving their loved one. There is still relatively little research on the effectiveness of imaginal exposure for GAD, but studies on this technique are currently ongoing.
Exposure and Prevention of Worry Behaviours – This strategy involves exposing oneself to situations or activities that have been avoided as a result of unrealistic worry. For example, if someone has stopped reading the newspaper for fear of worrying about all the bad events in the world, he or she would be encouraged to begin reading the newspaper again. In addition, individuals with GAD are encouraged to stop using the overprotective or safety behaviours that they rely on to protect themselves from imagined danger. These may include behaviours such as phoning loved ones repeatedly to make sure they are okay, or leaving two hours early for an appointment to prevent being late. These kinds of behaviours prevent the individual from learning that their worries are exaggerated.
Training in other Skills – Treatment for GAD may involve learning other specific skills. For example, some individuals with GAD appear to benefit from learning new strategies for solving problems, or how to manage their time more effectively. In addition, researchers are now studying the use of mindfulness meditation for reducing worry in GAD. This treatment involves teaching the individual to accept their unwanted thoughts and feelings, rather than fighting these experiences or focusing on the meaning of these thoughts and feelings. Preliminary findings on mindfulness meditation are promising.

Combined Treatments

Both medication and CBT seem to be effective in treating GAD, though more research is needed to see if they are more effective in combination than on their own. For many people, the combination of medication and CBT does not work any better than either approach alone, although some individuals respond best to combination treatment. Preliminary studies suggest that CBT, which targets symptoms of anxiety and depression, may have a broader effect on symptoms than the antianxiety medications, which target only symptoms of anxiety. In addition, the effects of CBT appear to last longer than the effects of medication, once treatment has stopped.

Did you know ...?

Generalized Anxiety Disorder affects 2 to 5% of the population and affects more women than men.
Generalized Anxiety Disorder is one of the most common anxiety disorders in older adults.
Many people with GAD report that they have felt anxious or have worried for all their lives. However, GAD can also start in adolescence or adulthood, and may be linked to stressful life events when it occurs during these time periods.
Worry seems to involve more verbal activity as opposed to images. In other words, when people worry they seem to have fewer pictures or images in their minds than words and thoughts.
People with GAD sometimes experience panic attacks (a rush of fear and physical sensations) when they are worrying.