Generalized Anxiety Disorder (GAD) And Worry
Everybody worries from time to time, but some people worry excessively and uncontrollably about daily life events and activities. Such severe worry can make you feel physically exhausted and leave you with other physical symptoms. When people experience worry (and other accompanying symptoms) to a clinically significant degree psychologists call it Generalized Anxiety Disorder (GAD). It is thought that between 2 and 6 people out of every 100 will experience GAD every year [1, 2]. The good news is that psychologists’ understanding of what keeps GAD going is improving and several effective CBT treatments for GAD are widely available.
What is it like to have GAD and worry?
Roshi’s allergy to uncertainty
Roshi described herself as always having been a worrier. Her father left home when she was young and her mother has chronic health problems. As a result she has always felt quite responsible for people around her. Roshi worries often about her mother’s health and how she is feeling. She also worries about whether her boyfriend is happy. She often worries that she isn’t doing a good enough job and tries extra hard to be conscientious. Roshi reports that she feels tense, and finds it hard to relax and ‘switch off’. She finds it hard to get to sleep and will often lie awake for hours. She also suffers from irritable bowel syndrome. Roshi copes with her worry by telephoning her mother three times a day to check that she is ok, seeking reassurance from boyfriend that he is happy, making plans and checking for obstacles. At work Roshi doesn’t delegate and often takes extra responsibility: she is a good employee but always worries about how she is doing. She believes that worrying helps her to be prepared, and feels that worrying is such a part of her that she isn’t sure who she would be if it wasn’t there.
Aspects of treatment that Roshi found helpful
Roshi found it helpful to think about her reactions to uncertainty: she was able to recognize that a lot of what she does is attempts to ‘pin down’ uncertainty and make things certain. Her therapist set a ‘worry postponement’ task which made her realize that her worries were not as uncontrollable as she had thought. Roshi’s therapist suggested two things that she found difficult, but which she later reflected had really helped her. One was to try things with the goal of increasing her tolerance of uncertainty: she deliberately did more things where the outcome was uncertain and although she found these exercises uncomfortable they did show her that she was able to ‘think on her feet’ and cope without having to control everything. The other task that Roshi found helpful was to expose herself to some of her worries instead of avoiding them: again, to begin with this was very anxiety-provoking but became less so with practice.
What is generalized anxiety disorder?
The primary symptom of generalized anxiety disorder (GAD) is excessive worry. Some of the signs and symptoms that you may experience if you suffer from GAD include:
- Excessive feelings of worry or anxiety, or feelings of apprehension and tension about daily events.
- Restlessness and an inability to relax.
- Difficulty concentrating because of worry or anxiety.
- Feeling irritable.
- Muscle tension or aches and pains.
- Difficulty sleeping.
- Worry or anxiety that is difficult to control.
- Feeling easily fatigued.
We can separate the effects of GAD into thoughts, feelings, and behaviors:
|How you might think||How you might feel||How you might act|
What is worry?
To worry means to think about problems that might happen in a way that leaves you feeling anxious or apprehensive. Worry is experienced as a chain of thoughts and images and can progress in increasingly catastrophic and unlikely directions. It is often experienced as uncontrollable and seems to take on a life of its own. A leading psychologist Tom Borkovec has provided some helpful descriptions of worry:
“Worry is a chain or thoughts and images, negatively affect-laden and relatively uncontrollable; it represents an attempt to engage in mental problem-solving on an issue whose outcome is uncertain but contains the possibility of one or more negative outcomes; consequently, worry relates closely to the fear process.” 
“Worriers spend much of their time in a theoretically possible, but as yet non-existent future.” 
“The world is potentially dangerous, and I may not be able to cope with whatever comes from the future, so I must anticipate all bad things that might happen so that I can avoid them or prepare for them” 
Is it bad to worry?
Not all worry is problematic – we all foresee problems in our lives and spend at least some time thinking about what we could do to manage them. The difference between normal and problematic worry tends to be one of degree – people with excessive worry just do more of it. Psychologists tend to make a distinction between ‘real’ and ‘hypothetical’ worries.
- Real-event worries are about actual problems that are affecting you right now (e.g. “That car is coming towards this crossing quite quickly”, “My toddler is reaching for something dangerous”).
- Hypothetical worries are about things that do not currently exist, but which might happen in the future (e.g. “What if my husband crashes the car on his way to work?”, “How would I cope if I got ill again?”).
What do people with GAD worry about?
People with GAD tend to worry about the same things as other people, the main difference is that they worry more and worry more often. Common worry themes in GAD include worries about friends, family and relationships:
- What if my child gets hurt playing at the playground?
- What if my partner stops loving me and leaves me?
Worries about health:
- What if this headache turns out to be brain cancer?
- What if I get really ill and I’m not able to take care of my children?
Worries about your future and the world:
- What if I were to lose my job and were made homeless?
- What if I fail to maintain my garden fence and it blows down in a storm?
Worries about work and school:
- What if I get a bad appraisal and am kicked out?
- What if I fail my exams and don’t get into university?
People with problematic worry tend to worry more about unlikely or remote future events. They often experience worries that ‘chain together’, for example:
- Notices husband is late home from work
- What if he’s been in a car crash?
- Maybe he’s been badly injured
- What if he’s bed-bound for the rest of his life?
- We won’t be able to pay for our house
- What if I resent caring for him and we break up?
- I couldn’t bear to be alone
What causes generalized anxiety disorder and worry?
There is no single cause for generalized anxiety disorder. Some of the factors that are thought to make it more likely that a person will experience GAD include:
- High intolerance of uncertainty. Many situations have an uncertain outcome – you are not able to be 100% sure what is going to happen. People with GAD are more likely to find these situations distressing. They will often avoid them, or engage in behaviors designed to make them feel more certain.
- Positive beliefs about worrying. People who have strong beliefs that worrying is beneficial are more likely to suffer from GAD. Positive worry beliefs might include “worrying helps me to find solutions to my problems”, and “worrying can prevent bad things from happening”.
- Genetic factors. There may be genes which predispose people to developing emotional problems in general, but no specific genes which predispose people to developing generalized anxiety disorder.
What keeps GAD and worry going?
CBT is always very interested in what keeps a problem going. This is because if we can work out what keeps a problem going then we can treat the problem by acting to break the vicious cycle. Some of the factors that psychologists think are important in keeping GAD going are:
- intolerance of uncertainty,
- having positive beliefs about worry,
- negative problem orientation, and
- cognitive avoidance.
Intolerance of uncertainty
Life is uncertain and we can never be 100% sure what is going to happen. Some people are OK with this uncertainty and find it easy to embrace new experiences. Other people struggle with uncertainty: it’s almost as if they are ‘allergic’ to situations where the outcome is uncertain. For these people uncertainty is experienced as stressful and something to be avoided. This is tricky because uncertainty is a normal part of life – it is not optional. People with GAD try to reduce uncertainty by ‘thinking three moves ahead’ and asking “what if”questions – this is worry. Unfortunately this strategy doesn’t work as it is intended to – one problem of worry is that it ‘branches’: for every “what if” question there are multiple answers, each of which trigger more questions, and more answers… Other ways that people with GAD try to feel more certain include:
- Information-gathering and planning. For example, doing lots of research on a product before making a purchase, refusing to go shopping without a list, excessive planning before going on holiday, planning detailed routes in advance and making contingency plans.
- Refusing to delegate tasks to other people. For example, taking on too much work and finding it hard to delegate in case others do things ‘wrong’.
- Checking. For example, calling a loved one repeatedly throughout the day to check that they are alright, re-reading an essay multiple times for spelling mistakes.
- Avoidance and procrastination. For example, avoiding making a decision in case it is the wrong one, or avoiding situations where the possibilities are too uncertain such as a party.
- Seeking reassurance excessively. For example, repeatedly asking for other people’s opinion, or asking for reassurance that a decision is the right one.
Having positive beliefs about worry
Psychologists have found that people who worry a lot often implicitly hold positive beliefs about worry. Five types of positive beliefs about worry are particularly common [6, 7]:
- Worrying helps me to find solutions to problems.
- Worrying increases motivation to get things done.
- Worrying about something in advance can decrease my negative reaction should the event actually occur.
- Worrying can actually prevent bad things from happening.
- Worrying shows that I am a responsible and caring person.
These beliefs often make it difficult for people to stop worrying, and lead to more worry about hypothetical situations. Sometimes a focus in therapy is on the helpfulness of these beliefs.
Negative problem orientation
Psychologists have found that people who worry a lot often have an ineffective approach to solving problems, or they have low expectations that they will be able to solve problems. Researchers have shown that people with worry are actually very good at solving problems, it’s just that they don’t think they are good problem solvers – and as a consequence they sometimes try to avoid problematic situations. Some difficulties of this avoidance are that worriers have fewer opportunities to learn how well they are actually able to cope, and their problems can remain unsolved.
Cognitive avoidance and suppression
Cognitive avoidance describes the strategies that people who worry use to avoid anxiety-provoking thoughts and feelings. Dugas and Robichaud [8, 9] identify the following cognitive avoidance strategies in GAD. Do you recognize yourself in any of these?
- Suppressing worrisome thoughts.
- Substituting neutral or positive thoughts for worries (e.g. telling myself it’s going to be ok).
- Using distraction as a way to interrupt worrying.
- Avoiding situations that can lead to worrisome thinking.
We all avoid things to some extent, but the problem of using cognitive avoidance a lot is that they are tiring, and these strategies can unintentionally lead us to experience more of the thing that we are trying to avoid or suppress.
Figure: Vicious cycles of generalixed anxiety disorder
Treatments for generalized anxiety disorder (GAD)
Psychological treatments for generalized anxiety disorder (GAD)
Two psychological treatments for generalized anxiety disorder (GAD) which have a good empirical support include cognitive behavioural therapy (CBT) and applied relaxation. Guidelines recommend 12-15 weekly sessions, each lasting 1 hour (NICE, 2011).
Medical treatments for generalized anxiety disorder (GAD)
The National Institute for Health and Care Excellence (NICE) recommends that if a person with GAD chooses drug treatment they should be offered a selective serotonin reuptake inhibitor (SSRI) in the first instance, or a serotonin-noradrenaline reuptake inhibitor (SNRI) if SSRIs are ineffective . The NICE guidelines recommend against offering benzodiazepines for the treatment of GAD except as a short-term measure during crises.
How can I overcome my generalized anxiety disorder and worry?
There are lots of things that you can do for yourself that will help you to overcome generalized anxiety disorder. These include:
- understanding more about how worry is an attempt to cope with uncertainty,
- worry awareness training,
- increasing your tolerance of uncertainty,
- worry postponement,
- effective problem solving,
- examine your rules and assumptions concerning uncertainty,
- exposure to hypothetical event worry.
Understand that worry is an attempt to cope with uncertainty
Worry is an attempt to project forward to try to ‘pin down’ uncertain situations. If you worry a lot you need to understand that the unintended consequence of asking “what if …?” questions is that you are generating further uncertainty. The Psychology Tools information handout What Is Worry? is a clear description of worry and how it operates in GAD.
Worry awareness training
A very important early step when treating GAD is to practice worry awareness training.
Worry awareness training teaches you to notice whether you are worrying, and then to identify whether your worry is ‘real’ or ‘hypothetical’ . You can then practice behaving differently towards these different kinds of worries. The Psychology Tools Worry Diary worksheet and the Worry Tree are designed for worry awareness training.
Increasing your tolerance of uncertainty
Even if you find uncertainty uncomfortable at the moment, your ability to tolerate it isn’t set in stone – there are lots of things that we can do to increase our tolerance of uncertainty:
- Deliberate exposure to uncertainty. This involves engaging in lots of tasks that ‘chip away’ at our intolerance of uncertainty. You can use the Psychology Tools worksheet Challenging Intolerance Of Uncertainty for a helpful guide to challenge your intolerance of uncertainty.
- Testing your predictions, beliefs, and assumptions about confronting uncertainty. Behavioral experiments are a fantastic way of testing how accurate and helpful our automatic predictions are. They can help us to find out what the consequences are of doing uncertain things. Use the Psychology Tools guide to behavioural experiments to learn more about how to test your beliefs and predictions.
Many people with GAD experience their worry as uncontrollable. Does it feel as though you are powerless to stop your worrying? If you do, this presents a wonderful opportunity to carry out an experiment on your worry. Worry postponement can be treated as an experiment in which you notice when worry occurs, make the conscious decision to postpone the worry until later that day, and then notice what happens. Use the Psychology Tools Worry Postponement worksheet to learn more about how to postpone your worries, and how to make the most from this exercise.
Effective problem solving
Worry is an attempt to resolve uncertainty. Our intention when we worry is protective – to foresee and pre-empt danger – but worry is often inadvertently paralysing because it ‘branches’, increases uncertainty, and leads to inaction. One way around this is to use simple rules which prompt you to take action: If the thing you worry about can be acted on right now, then act on it. If the thing you are worrying about is a hypothetical worry then it’s probably not helpful and can be postponed or dismissed. Many people find the Worry Decision Tree a helpful tool for understanding this decision process.
Examine your rules and assumptions concerning uncertainty
Some people’s rules and assumptions about uncertainty lead them to behave in uncertainty-reducing ways, which can maintain their GAD. For example, Tim believed “If I don’t prepare for every eventuality then I’ll run into trouble”. Reflecting on our rules and assumptions is a helpful first step in modifying them. You can use the Psychology Tools worksheet Modifying Rules and Assumptions to examine the origins, advantages, and disadvantages of your underlying assumptions.
Exposure to hypothetical event worry
Some people find that the things they worry about are extremely distressing: this explains why many people with GAD use the strategy of trying to avoid parts of their worry content. As with many forms of avoidance this tends to lead to some unintended consequences. Exposing ourselves to hypothetical worry content is a helpful treatment technique in this case. Exposure is one of the most effective psychological treatments for many kinds of anxiety and is based on the principle of ‘facing your fears’. When applied to GAD worry exposure consists of writing a ‘worry script’ which is written in detail and from which an audio recording is made. The audio recording is then listened to daily until it no longer produces significant increases in distress.
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About this article
This article was written by Dr Matthew Whalley (clinical psychologist). It was reviewed by Dr Hardeep Kaur (clinical psychologist) on 2019-10-30.