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Generalized Anxiety Disorder: Core Features and Treatment Options
Abnormal Psychology · Chapter 11: Anxiety-Based Disorders: Origins and Therapeutic ApproachesSection 11.1 · lesson 39 of 9716 min · free with a free account
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In this lesson
Why worry that is difficult to control is the feature that carries the diagnosis.
- Separate fear, anxiety, and ordinary worry
- Use the three response systems as a framework
- Describe the presentation, its duration and its cost
- State the explanatory models and the treatment targets
Transcript
Everything said in the video, section by section (2,225 words). Read along, or search it.
Anxiety-Based Disorders: Origins and Therapeutic Approaches
Generalized Anxiety Disorder: Core Features and Treatment Options
Almost everyone worries. So what turns worry into a condition? That question runs through this whole section, and the answer is not obvious. It is not the content of the worry, and it is not how unpleasant it feels. We start by separating three words that get used interchangeably. Fear, anxiety, and worry. Then comes a framework used across the whole of this chapter. Anxiety shows up in three systems, and those systems do not always agree. After that, the presentation itself. Its duration, its physical cost, and what it is confused with. We finish with why the worry keeps going, and what treatment actually aims at.
Fear And Anxiety
Two Responses, Two Time Frames
Fear is the response to a threat that is present now. It mobilizes the body for immediate action, it is intense, and it ends when the threat passes. Anxiety is apprehension about a threat that has not occurred, and may not. It is more diffuse, lower in intensity, and it can run for years, because nothing arrives to end it. Here is the part students skip. Both of them are adaptive. Fear produces escape from danger. Anxiety produces preparation. Checking the route, revising the document, rehearsing the difficult conversation. Someone with no capacity for anxiety would prepare for nothing at all. So neither becomes a disorder simply by being present. Each becomes disordered when it is out of proportion to the real likelihood and severity. When it persists with no threat there, and when the person's life narrows around managing it. That last element, functional cost, does most of the work in every judgment in this chapter. One thing before we go further. This material is educational, and not a basis for diagnosis. If you recognize your own experience here, please speak with a qualified professional.
Three Systems
Anxiety Is Not One Thing That Varies In Amount
Anxiety is not a single thing that varies in amount. It appears across three systems that can be measured separately. The physiological system is the body's stress response. Muscle tension, altered breathing, gut symptoms, disturbed sleep. In this condition it shows as tension headache, unrefreshing sleep, and restlessness. And the person may not connect any of that to worry at all. The cognitive system is where attention shifts toward threat, and ambiguous information is read as dangerous. Thinking becomes repetitive and verbal. Chains of what if, reaching forward through unlikely sequences. The behavioral system is avoidance, or approach while doing something to feel safer. Reassurance-seeking, repeated checking, over-preparation, refusing to make plans, delegating decisions. Now the point that makes this framework worth learning. The three systems do not always move together. Someone can report very little subjective worry, while staying physically tense and heavily avoidant. So an assessment that asks about one system will underestimate the other two. And the treatment target differs by system, which is why all three have to be asked about.
The Family
One Mechanism, Different Focus
The conditions in this chapter share one common structure. An overestimation of threat, then an avoidance response that gives short-term relief. And then a failure to meet the information that would correct the overestimation. Avoidance works. That is exactly the problem with it. So if the mechanism is shared, what separates these conditions? The focus of apprehension. In generalized anxiety disorder the focus is diffuse, and it shifts across life domains. In panic disorder, covered in eleven point two, it is the bodily sensations themselves. In the phobias of eleven point three it is a specific object, situation, or social evaluation. Obsessive-compulsive and trauma-related conditions are classified separately, and covered in eleven point four. Establishing the focus is therefore the first step in every differential in this chapter.
Worry
Ordinary Worry and Clinical Worry
Worry is a chain of verbal thought about possible negative future outcomes. Almost everyone worries, and worry is not a symptom in itself. Four dimensions separate ordinary worry from clinical worry, and no single one is sufficient. Excessiveness. Ordinary worry is roughly proportionate to what might actually happen. Clinical worry treats small or improbable risks as though they were likely and serious. Judge that against realistic probability, not against whether the worrying is understandable. Controllability. Ordinary worry can be set aside once the concern has been addressed. Clinical worry resists that. Attempts to redirect attention fail, and the chain resumes. Ask what happens when the person tries to stop. Uncontrollability, not content, is the most discriminating feature. Breadth. Ordinary worry attaches to a specific concern, and ends when it resolves. Clinical worry moves across work, health, family, finances, and minor logistics. Ask what was worried about a year ago. If the content changed and the worry did not, the worry is the stable element. Functional cost. Ask what the person no longer does, or does differently, because of it. Breadth is the row most often overlooked. A genuinely reasonable current worry does not rule this condition out.
The Presentation
Five Components, Then a Threshold
Now the condition itself. Generalized anxiety disorder is persistent, excessive, difficult-to-control worry across a range of areas. It comes with physical and cognitive symptoms of sustained arousal. It sits among the anxiety disorders in the text revision of the fifth edition of the manual. There are five components, and then a threshold all of them have to pass. One, the worry is excessive relative to the actual risk. Two, it occurs on more days than not, across an extended period. The threshold is months, not weeks. That is what separates this from a reaction to a situation. Three, it spans multiple domains. Four, the person finds it difficult to control. Five, it brings arousal features. Restlessness, fatigue, poor concentration, irritability, muscle tension, disturbed sleep. And now the threshold. The presentation must cause marked distress, or interfere with functioning. Without that it is not a disorder, however uncomfortable it is. Two composite cases show what that threshold does. Farida is thirty-eight, referred after eighteen months of tension headaches with normal investigations. She has worried for at least four years, declined two promotions, and telephones her adult son daily. Tobias is twenty-six, worried and sleeping badly for seven weeks, after his role was put under review. Seven weeks falls short of the required period, and his worry has not shifted across domains. The outcome he fears is genuinely likely, so his worry is proportionate. His distress is real, and that alone is not a disorder.
Body And Course
Why It Arrives at the Wrong Door
The physical features deserve their own treatment, because they drive where people go for help. Sustained muscle tension produces aching shoulders, jaw and neck pain, and tension headache. Fatigue follows from disturbed sleep, and from the metabolic cost of prolonged arousal. Sleep difficulty comes typically at the start of the night, when worry has the least competition. So many people present first to medical services rather than to mental health services. Headaches, gut symptoms, chest tightness, exhaustion. Those get investigated. The worry is not asked about, because the person does not present it as the problem. That is one of the main reasons this condition is recognized late. Asking whether someone worries usually produces only about normal things. Asking whether they can stop, and what happens when they try, is far more informative. Onset is gradual and often early, and many describe having been a worrier for as long as they remember. Which is exactly why they treat it as character rather than as a condition. The course is chronic and fluctuating, and periods of ease get mistaken for resolution. Co-occurrence is the rule rather than the exception, and someone presenting with low mood may have had this for years. One caution. New or unexplained physical symptoms need proper medical assessment in their own right.
Differential
What Else Produces This Picture
Four things produce a similar picture, and each is separated by a different question. First, depressive rumination. It shares the repetitive thought that cannot be set aside. But rumination is past-directed and self-focused. Why did this happen, what does it say about me. Worry is future-directed, and concerns what might happen. So ask about temporal direction. Second, health-related worry. It shares apprehension, physical symptoms, and reassurance-seeking. But the concern stays confined to illness, and does not shift across unrelated domains. Ask what was worried about before health became the focus. Third, a medical cause of the anxiety symptoms themselves. Restlessness, palpitations, tremor, disturbed sleep, and a sense of being on edge. Here the physical symptoms may come before any worry, and thyroid and cardiac conditions can present this way. This must be considered rather than assumed away, especially where onset is sudden or late. Fourth, substance-related anxiety, where the pattern tracks use or withdrawal. That includes caffeine, and alcohol used to manage the anxiety itself. Take a careful history, without judgment. The pattern matters, not the quantity alone. Notice the shape of that table. The shared features are what a person reports spontaneously, so the rest has to be asked for.
Explanation
Four Contributions to One Presentation
Four contributions, and none of them explains the condition alone. The biological contribution comes from chapter three, and is not re-taught here. Neurotransmitter systems involved in inhibitory regulation are implicated, along with serotonergic and noradrenergic function. There is a moderate heritable contribution, but it is to anxiety proneness generally, not to this condition. Now the cognitive account, where three components carry most of the weight. Intolerance of uncertainty is experiencing not knowing as itself threatening. It was proposed as a central vulnerability by Michel Dugas, Robert Ladouceur and colleagues. That work developed from the nineteen nineties onward, and it explains why reassurance relieves so briefly. Reassurance answers the current question, and leaves the intolerance exactly where it was. Threat overestimation is the systematic inflation of both likelihood and severity. Metacognitive beliefs are beliefs about worry itself, running in two contradictory directions at once. Positive, that worrying protects and prepares. Negative, that it is uncontrollable and harmful. So the person is simultaneously trying to stop, and unwilling to. Then the avoidance account, from Thomas Borkovec and colleagues. Worry is verbal and abstract, and that quality suppresses vivid imagery and its physiological accompaniment. On this account worry is a strategy that works, briefly, by keeping the fear at a distance. That explains a puzzling finding. People with this condition often show less reactivity during worry than expected.
The Engine
Why Worry Persists
Why does the worry not simply burn out over time? The maintaining mechanism is negative reinforcement, introduced back in five point one. A behavior is strengthened because it is followed by the removal of something aversive. Here the sequence has a peculiar feature. Follow it round. A trigger arrives, and the person worries about an outcome. The outcome, being improbable, does not occur. Relief arrives, and the worry takes the credit. The non-occurrence is read as confirmation that worrying did its job, so the habit is strengthened. Here is the counter-intuitive part. Feared outcomes almost never occur, so the belief is reinforced almost every time. It is reinforced by exactly the evidence that ought to disconfirm it. Time alone does not resolve this. Two behaviors accelerate the cycle. Reassurance-seeking, and checking. Both are covert avoidance. They look like engagement, and they function as escape. Each reassurance teaches that the distress was intolerable and had to be removed. It also transfers the judgment to someone else, so the person gets no practice deciding under uncertainty. Relatives usually reassure out of care, and are often exhausted by it. Explaining the mechanism to them is part of treatment. Blaming them is not.
Treatment
What Is Targeted, and What Is Known
What follows is treatment at the level of principle and rationale. None of it is a protocol, and none of it is to be attempted without a trained clinician. Cognitive-behavioral approaches have the strongest evidence base, and their components follow from the models above. Work on worry beliefs targets the positive belief that worrying is protective. As long as that belief is held, the person has a reason not to stop. Work on uncertainty tolerance aims at the capacity to act without knowing. Not at obtaining more certainty, which is precisely what the person has been attempting. Work on avoidance means dropping reassurance-seeking, checking, and over-preparation. That lets the person discover what actually happens, following the exposure principles of five point four. Applied relaxation targets the physiological system, and is taught by a clinician. Acceptance-based approaches change the person's relationship to worry rather than its content. Medication is described by class only. Several classes of antidepressant medication have evidence here. No drug names, doses, or regimens appear anywhere in this course. Response to cognitive-behavioral treatment is generally good, and gains are typically maintained. It should also be said plainly that a substantial proportion retain residual symptoms. Response rates are somewhat lower than in some other anxiety conditions, and the chronic course is part of why.
What To Carry
Durable Claims From This Section
Gather this into claims worth keeping. Fear answers a threat that is present. Anxiety anticipates one that is not. Anxiety appears in three systems, and they do not always move together. The anxiety conditions share a mechanism, and differ in the focus of apprehension. Clinical worry is marked by excessiveness, uncontrollability, breadth, and cost. Uncontrollability is the most discriminating single feature of those four. Distress and impairment alone do not establish a disorder. Check duration, breadth, and proportionality. And where the worry is proportionate to a real threat, say so rather than diagnosing. Worry persists because feared outcomes almost never occur, and worry takes the credit. Treatment targets worry beliefs, uncertainty tolerance, and avoidance. One question is left honestly open. The evidence for combining psychological treatment with medication is less clear-cut than often assumed.
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