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Generalized Anxiety Disorder

By Olivia Guy-Evans, published Feb 16, 2022

by Saul Mcleod, PhD

Generalized Anxiety Disorder

What is Generalized Anxiety Disorder?

Generalized anxiety disorder (GAD) is a mental health condition which is characterised by uncontrollable and excessive anxiety or worries about common occurrences and situations.

A person with GAD may have worries about things such as finances, health, and safety which is more exaggerated from normal feelings of worry about these things.

People with GAD may worry when there appears to be no reason to and can feel like these feelings are persistent for days, weeks, or months on end.

They may often report feelings that something bad is going to happen or that they just cannot calm themselves down. 

The anxiety being experienced by those with GAD may occur for a specific reason or there may be no known trigger but is disproportionately great or unrealistic to the situation.

The unexplained, trigger-less feelings of anxiety is described as ‘free-floating anxiety’ as is common for people with GAD. Free-floating anxiety is a general sense of uneasiness, discomfort, and nervousness that appears for seemingly no reason. 

How Common Is GAD?

GAD is a relatively recent diagnosis. Before 1980, it was under the label the label of ‘anxiety neurosis’, coined by Sigmund Freud in 1984. The disorder described by Freud included panic symptoms so when panic disorder was identified as a separate disorder, the part of anxiety neurosis that didn’t include panic became known as generalized anxiety disorder. 

GAD is twice as common in women than it is in men. Studies in Europe suggest that GAD has a 12-month prevalence of around 2% and is one of the most frequently (up to 10%) diagnosed mental health disorders (Lieb, Becker, & Altamura, 2005).

People affected by GAD can lead normal lives with productive jobs and social lives but be internally struggling with worry and distress. 

Symptoms of GAD

Symptoms for GAD can vary in intensity and the anxiety can get better or worse depending on the situation.

Occasionally, people with GAS may find that their symptoms decrease then suddenly increase in severity, preventing normal functioning. 

GAD differs from other conditions which have similar symptoms. Those who have social anxiety disorder for instance would only experience intense anxiety in social situations, people with depression may occasionally feel anxious but not as frequent as those with GAD.

Likewise, those with phobia also have intense worries but usually about one particular thing whereas those with GAD worry about a number of different topics but not usually as intense as a phobia. 

Psychological

  • Persistent worrying or anxiety about a number of areas.

  • The persistent worries or anxieties are out of proportion to the impact of the events. 

  • Overthinking plans and solutions to all possible worst-case outcomes. 

  • The inability to control constant worries.

  • Perceiving a lot of situations or events as threatening. 

  • Difficulty dealing with uncertainty.

  • Feeling unable to set aside or let go of worries.

  • Fear of making the wrong decision. 

  • Feeling unable to relax – being irritable. 

  • Feeling as if the mind goes blank.

  • General feeling of being on edge. 

  • Having difficulties concentrating. 

Physical

  • Sweating 

  • Fatigue 

  • Trouble sleeping

  • Nausea

  • Stomach aches

  • Headaches

  • Trembling or feeling twitchy

  • Muscle tension

  • Light-headedness 

  • Frequent need to urinate

GAD in Children and Adolescents

GAD is also common in children and adolescents, and they may experience some of the same symptoms but may have different worries.

They may worry about their performance at school or family member’s (e.g., parent’s) safety. Children and adolescents with GAD may:

  • Feel overly anxious to fit in with their peers

  • Lack confidence

  • Strive for approval 

  • Redo tasks until they are perfected

  • Spent an excessive amount of time of their homework

  • Need lots of reassurance about their performance

  • Experience stomach aches or other physical complaints

  • Avoid school or social situations

Cognitive Distortions

There are some key features to GAD which make it different to normally experienced anxiety. These include three cognitive distortions.

The first being distorted automatic thoughts, which can include catastrophizing (e.g., believing that something terrible is going to happen) and labelling (e.g., labelling themselves as a bad person).

The second cognitive distortion is maladaptive assumptions, which are unrealistic thoughts and attitudes (e.g., ‘all anxiety is bad’, ‘I must get rid of all of my anxiety’).

The last cognitive distortion is dysfunctional schemas which are labels which someone with GAD may give themselves or make negative assumptions about (e.g., ‘people will laugh at me if they can see I am anxious’). 

Criteria for Diagnosing GAD

For a diagnosis of GAD, individuals must meet the criteria stated in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

For Generalized Anxiety Disorder, the diagnostic criteria is as follows:

  1. The presence of excessive anxiety and worry about a variety of topics, events, or activities. This worry and anxiety must occur more often than not over a period of at least 6 months.

  2. The experienced worry and anxiety must be very difficult to control. The worry in both adults and children may easily shift from one topic to another.

  3. The worry and anxiety must be accompanied by at least 3 of the following physical or cognitive symptoms (note: in children, only one of the symptoms is necessary):

  • Edginess or restlessness

  • Tiring easily; more fatigued than usual

  • Impaired concentration or feeling as if the mind has gone blank

  • Irritability 

  • Increased muscle aches or soreness

  • Difficulty sleeping

For a diagnosis to be met, the anxiety, worry, and other symptoms may interfere with areas of normal functioning. It can make work, relationships, or other important areas of life difficult.

Symptoms for GAD must also be unrelated to any other medical conditions and cannot be better explained by another mental health disorder or by the effect of substances (e.g., medication, alcohol, or drugs). 

Someone with GAD may spend a high percentage of their waking hours worrying about different things. Specifically in adults, the worries can be related to job responsibilities or performance, the health of themselves or of loved ones, financial matters etc. 

During an assessment of the presence of GAD, the clinician may use a combination of the DSM-5 criteria, standardised assessments, and their clinical judgment.

Sometimes, people may be asked to complete self-report questionnaires to help determine a diagnosis or to identify the severity of the symptoms.

Semi-structured interviews can also be used to help make an accurate diagnosis which can include a standardised set of questions. Some commonly used diagnostic interviews are:

  • Structured Clinical Interview for DSM Disorders (SCID)

  • Anxiety and Related Disorders Interview Schedule for DSM-5 (ADIS-5), including a child version which involves interviewing both the child and the parent.

The Vicious Cycle of Anxiety 

At the core of anxiety is worrying about potential threats. The anxiety is an attempt to cope with a future event that is believed to be negative and threatening. However, anxiety can keep people stuck in an endless loop of more anxiety, and thus it becomes a vicious cycle. 

Avoidance and safety behaviours

People with anxiety may often use avoidance as a coping mechanism. This is where they try to avoid feared situations as much as possible to reduce their anxiety. Avoidance can cause a quick decrease in anxiety, but it can worsen anxiety in the long run.

People with anxiety may also rely on safety behaviours as another way to cope. This can include relying on medications, having an exit plan, excessive use of a phone to distract themselves, or having another person with them that they trust.

Although these safety behaviours can help reduce feelings of anxiety, people can become too dependent on them, and they are not challenging themselves to see that the perceived threat was not that threatening.

Also, safety behaviours may not be available in every anxiety-provoking situation so when not available, more feelings of anxiety may be produced.

The cycle of anxiety

If someone has anxiety, they are more likely to be scanning their environment for potential threats – more attention is being paid to them. This causes physical symptoms of anxiety to intensify.

To cope with the anxiety, individuals may choose to either avoid or escape the situation which brings them short-term and usually instant relief.

Although this relief can make someone with anxiety feel better short-term, in the long-term this can be detrimental. Long-term effects of avoidance and escape can result in an increase of physical symptoms, a loss of confidence about coping, and increased use of safety behaviours.

anxiety avoidance graph

Because of this, this can keep anxiety going and a repetition of the cycle described. The anxiety may even increase or be generalised to other situations.

Reversing the cycle

In order to break the vicious cycle of anxiety, it is important to gradually confront the feared situations whilst dropping safety behaviours.

In the short-term, this can result in increased feelings of anxiety, but after a while, the physical symptoms should decrease as well as the scanning for potential threats.

The use of healthy coping skills can help reduce anxiety to a manageable level. This can build confidence slowly in order to get used to these situations and control responses.

By challenging themselves in structured and repeated ways, there should be a better chance of reducing anxiety overall. 

Causes and Risk Factors

As with most mental health conditions, there is not thought to be a one direct cause of the development of GAD. GAD is likely to develop from a complex interaction between the environment and the biology of the individual, including: 

  • Differences in brain structure, function, and chemistry

  • Genetics – individuals who have immediate family members with an anxiety disorder or other mental health condition may be more likely to develop GAD

  • Differences in the way that threats are perceived

  • Personality traits – an individual whose temperament is timid, has a pessimistic outlook, or who tend to avoid anything dangerous may be more prone to GAD

  • Experiences – people with GAD may have a history of significant life change, traumatic or negative experiences. They may have had struggles during childhood or been exposed to a recent traumatic event. 

  • Other conditions - people with a chronic medical illness or other mental health disorder may also be at an increased risk of developing GAD

A key brain area which is believed to be involved in GAD is the amygdala. The amygdala is part of the limbic system of the brain and is involved in the processing and regulation of emotions including fear.

In a study investigating young people with GAD, it was found that they had hyperactive amygdala when presented with masked threats, compared to those without GAD (Monk et al., 2008). 

In the brain, there is known to be a presence of threat-related negative connectivity between the right ventrolateral prefrontal cortex and the amygdala, suggesting that the prefrontal cortex (an area involved in critical thinking and reasoning) modulates the amygdala response to threats.

The amygdala is believed to support vigilance to threats through immediate threat processing, whereas the ventrolateral prefrontal cortex facilitates later processes related to emotion regulation.

Thus, if there are disturbed amygdala to ventrolateral prefrontal cortex interactions, these are thought to influence anxiety as the amygdala may be overriding the part of the brain that is providing logical reasoning to perceived threats.

The presence of other mental health disorders could also be a risk factor for developing GAD. In a study which investigated people with anxiety disorders, it was found that 35% of the individuals tested had a comorbid personality disorder.

Specifically, 49% of those with GAD were most often diagnosed with a personality disorder (Sanderson et al., 1994). Whilst other mental health conditions may not be a direct cause of GAD, it could be a contributing factor to putting someone more at risk of developing GAD. 

As previously mentioned, sometimes GAD can develop from environmental experiences that are either stressful or traumatic.

The outbreak of COVID-19, which many consider a stressful or traumatic event, has been investigated for its impact on mental health. It was found in a 2021 study that reported psychological distress regarding COVID-19 was positively correlated to depressive symptoms as well as to GAD (Nikčević et al., 2021).

This makes sense considering many people during the pandemic may have developed more extreme worries over their health, other’s health, work, and financial matters – the major worries that people with GAD tend to have. 

When to Seek Help

It is usually recommended to see a doctor when the individual:

  • Feels as if the worry is excessive and interfering with work, relationships, and other aspects of functioning. 

  • Feels depressed or irritable due to the anxiety or may have issues with substance abuse or have another mental health condition.

  • Is experiencing suicidal thoughts or behaviours. 

  • Feel as if the anxiety is getting worse and is persistent – it’s important to seek help before the anxiety becomes extreme. 

  • Find themselves constantly seeking help and reassurance from others. 

  • Repeatedly tries different methods of anxiety management to no avail.

As the lifetime prevalence of GAD is twice as likely in women than in men, some women’s health professionals have recommended that all girls and women over the age of 13 years old should be screened for anxiety (Gregory et al., 2020). 

Many people may not seek help for GAD since they do not experience the extreme physical symptoms of panic attacks. However, panic is not typically present in people with GAD, so it is still useful to seek help if experiencing physical symptoms of anxiety.

It may also be helpful to make a note of the physical symptoms that are being experienced before attending an appointment with a professional. 

When finding a clinician, it is important to take some time in researching providers who specialise in anxiety treatment.

Since anxiety is present in a lot of mental health conditions such as obsessive-compulsive disorder (OCD), social anxiety disorder, and eating disorders, it will be beneficial to find someone who understands the specific criteria that an individual may meet so that they can be diagnosed and treated accordingly. 

Treatment

Medication

For treating GAD, there are some short-term medications that can be taken to relax some of the physical symptoms of anxiety such as muscle tension and stomach cramping.

Benzodiazepines are the main class of medications used for treating anxiety. Some examples of benzodiazepines are:

  • Alprazolam (Xanax)

  • Clonazepam (Klonopin)

  • Lorazepam (Ativan)

These medications are very strong and so are not always recommended to take long-term. They have side effects of causing high dependence and can be abused. 

Other medications such as antidepressants are medications that are not as strong and more tolerable so can be taken long-term.

Selective serotonin reuptake inhibitors (SSRIs) which affect serotonin levels in the brain are a frequent choice for many. Some SSRIs that can be prescribed include:

  • Citalopram (Celexa)

  • Fluoxetine (Prozac)

  • Sertraline (Zoloft)

SSRIs can take a few weeks to begin working and they can also have some side effects such as nausea, dry mouth, or some suicidal thoughts, specifically when beginning to take the medication. 

Cognitive behavioural therapy

Cognitive behavioural therapy (CBT) is a popular therapy of choice for many people with anxiety as it has been proven in many instances to be more effective at treating anxiety than medications in the long-term.

CBT involves regular meetups with a therapist with the goal of working together to change negative or maladaptive thinking patterns and behaviours to more realistic and useful ones.

In CBT sessions, people learn how to recognise and control their anxious thoughts through learning specific skills to directly manage worries associated with GAD. 

The cognitive distortions associated with GAD (distorted automatic thoughts, maladaptive assumptions, and dysfunctional schemas) are features which can be targeted in CBT sessions.

With the therapist, individuals with GAD can also learn to challenge themselves and break the vicious cycle of anxiety through identifying and gradually dropping safety behaviours, and challenging negative thoughts. 

Through this process, symptoms improve as one builds on their success. CBT can usually be delivered effectively in around 8-10 sessions. CBT is often prescribed alongside medication to effective treatment.

Since CBT is working to target the core of the problem with GAD, there is less of a chance of a relapse after stopping CBT than there is with stopping medication. 

Lifestyle

Aside from prescribed medications and therapy, there are some lifestyle changes that could help someone who is struggling with GAD:

  • Maintaining a healthy diet and taking up regular exercise

  • Having enough sleep

  • Taking up yoga, meditation, or other relaxing activities

  • Avoiding stimulants such as coffee

  • Avoiding alcohol – alcohol can make people feel less anxious almost immediately which is why many people with anxiety may turn to alcohol. However, they may feel more irritably or depressed after consumption, this can also interfere with some medications. 

  • Having a support network – talking with friends or family about worries or anxieties someone has could be beneficial

Do you need mental health help?

USA

Contact the National Suicide Prevention Lifeline for support and assistance from a trained counselor. If you or a loved one are in immediate danger: https://suicidepreventionlifeline.org/

1-800-273-8255

UK

Contact the Samaritans for support and assistance from a trained counselor: https://www.samaritans.org/; email [email protected].

Availiale 24 hours day, 365 days a year (this number is FREE to call):

116-123

Rethink Mental Illness: rethink.org

0300 5000 927

Fact Checking
Simply Psychology content is rigorously reviewed by a team of qualified and experienced fact checkers. Fact checkers review articles for factual accuracy, relevance, and timeliness. We rely on the most current and reputable sources, which are cited in the text and listed at the bottom of each article. Content is fact checked after it has been edited and before publication.

About the Author

Olivia Guy-Evans obtained her undergraduate degree in Educational Psychology at Edge Hill University in 2015. She then received her master’s degree in Psychology of Education from the University of Bristol in 2019. Olivia has been working as a support worker for adults with learning disabilities in Bristol for the last four years.

How to reference this article:

Guy-Evans, O. (2022, Feb 16). Generalized Anxiety Disorder. Simply Psychology. www.simplypsychology.org/generalized-anxiety-disorder.html

Sources

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https://www.verywellmind.com/dsm-5-criteria-for-generalized-anxiety-disorder-1393147

Government of Western Australia. (n.d.). The Vicious Cycle of Anxiety. Centre for Clinical Interventions. Retrieved 2021, October 12, from: https://www.cci.health.wa.gov.au/~/media/CCI/Mental-Health-Professionals/Panic/Panic---Information-Sheets/Panic-Information-Sheet---03---The-Vicious-Cycle-of-Anxiety.pdf

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Nikčević, A. V., Marino, C., Kolubinski, D. C., Leach, D., & Spada, M. M. (2021). Modelling the contribution of the Big Five personality traits, health anxiety, and COVID-19 psychological distress to generalised anxiety and depressive symptoms during the COVID-19 pandemic. Journal of Affective Disorders, 279, 578-584.

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