If you ever tempted to seek anxiety counseling, odds are that you might be struggling with worry. Worry is a mental chain of thinking that is persistent, repetitive, and uncontrollable. Worry mostly focuses on the uncertainty of the future. When we worry constantly about a number of things and cannot stop, this may be a hint that we might be suffering from a legitimate illness called Generalized Anxiety Disorder (GAD).
Worriers tend to predict negative or threatening outcomes. They mentally rehearse various solutions to what they perceive to be a threat. But ironically, rehearsing these solutions doesn’t reduce their sense of uncertainty. In other words, worriers predict that bad things will happen. They have trouble accepting uncertainty, so they try to problem solve in advance. But they still feel uncertain and anxious because they can’t implement the solution immediately.
About 30% of U.S. adults will deal with an anxiety disorder at some point in their lives. Of the entire population of the U.S., about 2% struggle with Generalized Anxiety Disorder.
What Causes Generalized Anxiety?
It’s unclear whether the cause is genetic or environmental. Current research suggests that a combination of genetics and environment contribute to the development of anxiety. However, we do understand a little more of the biology behind anxiety than previous. The amygdala plays a significant role in our experience of fear and anxiety, as does the autonomic nervous system.
The neurotransmitters glutamate, gamma aminobutyric acid (GABA), serotonin (SE), adrenalin (epinephrine), norepinephrine (NE), beta-endorphins (BE), and dopamine (DA) seem to facilitate anxiety, although it is suspected that other currently unknown neurotransmitters may also be involved. Anxiety can be caused by other medical conditions. Substance-induced anxiety from drugs (prescription, over-the-counters, herbals, and illegal) is also possible.
What is it like to have Generalized Anxiety?
There are a few key components that make GAD unique to the other anxiety-related disorders.
Intolerance of Uncertainty
Being intolerant of uncertainty is believed to predispose individuals to have mental health issues with anxiety, also known as Generalized Anxiety Disorder. Being intolerant of uncertainty also helps to maintain the disorder once it has developed. People without an anxiety disorder may not like uncertainty, but they generally tolerate it. They generally believe that if bad things happen, they’ll be able to cope.
People with Generalized Anxiety Disorder are different. They believe it is unacceptable to be uncertain or to experience ambiguity. They are afraid that uncertainty or ambiguity will lead to negative outcomes or cause problems in general. They may also believe that it is irresponsible if they don’t try to resolve the uncertainty or ambiguity.
When people who struggle with anxiety receive ambiguous or uncertain information, they use maladaptive coping strategies to try to guarantee certainty. Their major strategies are worry and avoidance. Another strategy includes using safety behaviors, where they seek reassurance from others, over-prepare, gather excessive amounts of information, or repeatedly check or verify the safety of the information or situation.
For example, if Susan is going to a social event with some new acquaintances, she might be thinking, “What if everyone finds out I’m shy and stops talking to me?” This thought reflects her uncertainty about what might happen. Her attempt to cope involved the use of worry and avoidance in order to try to gain certainty.
Beliefs About Worry
When we have excessive anxiety and worry, we tend to have several strongly held beliefs about worry itself. Some of these beliefs are positive, and others are negative. For example, “Worrying will help prepare me for danger (positive belief)”, or “Worry is uncontrollable and potentially dangerous (negative belief)”.
Even when we experience worries as uncontrollable, we continue to worry. We continue to believe that worrying is helpful. So it’s important to understand our specific beliefs about the advantages and disadvantages of worry. For example, we might feel that worrying keeps us safe and alert. However, it can lead to more worry, make our mood worse, and get in the way of our relationships.
Poor Problem Orientation
When we experience constant anxiety, we tend to view problems as threats. We have low confidence in our ability to solve problems, so we expect a negative outcome if we try. As a result, we overcompensate in trying to create the perfect solution to our problems. Suddenly, instead of solving the real problem (our worry), we end up getting stuck and focused on solving what we are worrying about, and end up not solving the real problem.
In part, this happens because we keep trying to come up with a solution that we are certain will work. But if the problem we are concerned about is still in the future, we can’t immediately implement our solution. This means that we can’t be certain that our solution will work, so we continue to worry and come up with additional solutions without actually choosing one.
For example, if we’re not certain how to solve a problem, we might ask a friend what we should do. If we are given more that one solution to the problem, we might end up worrying about which one is the best solution. Even if we end up deciding what to do, we will continually second guess ourselves.
Cognitive & Emotional Avoidance
Worrying can serve as a way to avoid threatening images, “Worst Case Scenario” thoughts, and distressing emotions. Worry is usually composed of verbal thoughts, such as, “What if my mind goes blank?” Worry tends not to be composed of images or visual pictures in the mind. We may try to think about something positive if we become aware of a negative thought or emotion, or attempt to “push” it away.
We may tell ourselves not to think about certain worries or criticize ourselves for worrying or having anxious thoughts. We may try to distract ourselves from our anxiety or negative emotions. These techniques tend to backfire and actually reinforce our worry and anxiety. We end up becoming addicted to avoiding the unpleasant emotions that stem from our worries at all cost. We fear that if we get too anxious, we’ll fall apart. Or we mentally tell ourselves not to worry over and over, and it’s no surprise that we end up worrying more, because we are still thinking about what we are worried about.
Cognitive-Behavioral Therapy (CBT) is often used for treating and dealing with anxiety. CBT has been successful in treating generalized anxiety. It is also very effective in reducing worry, one of anxiety’s more prominent symptoms.
CBT Step 1: Worry Awareness
The goal here is to learn the difference between productive and unproductive worry:
- Productive worry allows us to focus on problems which we have some control or influence over. As a result, our focus is on solving the problem. In doing this, we accept the trade-off of solving the problem in lieu of seeking a perfect solution and avoiding risk and uncertainty. As a result, our anxiety or distress is relatively low
- Unproductive worry is different. We focus on the uncertain future, specifically on things we can’t control. Our fears may be exaggerated. We also worry about how upset we would be if something bad actually did happen. If we try to come up with solutions, we reject them because our success isn’t guaranteed. Instead, we use the coping strategy of seeking safety and certainty, which can’t happen, so we end up feeling helpless.
For example, imagine we have a worry about not being likable. We might start thinking, “What if people don’t like me?” This is an abstract problem that we have little control over. We can’t directly control how others view us. We could end up catastrophizing that the people we meet might talk amongst themselves about how much they don’t like us. We end up trying to figure out how to be certain of the outcome that we are likable. We end up rejecting any solutions we come up with because there’s no guarantee of success. So, our worrying continues. We become more anxious, and as time goes on, we become overly focused on how anxious we feel. This is an example of unproductive worry.
Here’s a more productive worry scenario: Imagine driving on your way to an important job interview when you get a flat tire, and there’s no spare in the trunk. You worry that you’re not going to be able to make your appointment on time. The possibility that you might leave a bad impression and not get the job enters your mind. But then you engage in Active Problem Solving. You call your potential employer and explain the situation. You reschedule for a later time the next day, and call a tow truck for help in the meantime. You resolve to email your potential employer to let them know that you appreciate their willingness to work with you and that you look forward to meeting with them tomorrow. This is a great way of using productive worry.
CBT Step 2: Cognitive Restructuring
Once we can successfully identify and notice our anxious and worried thoughts, we can being to learn how to evaluate and respond to them.
You can start with a simple method of cognitive restructuring by creating a “pro/con” list where you’ll list your thoughts in the first column and put down your responses to your thoughts in the second column. The more specific you can be about your worry, the better.
For each item in the left column, ask yourself what the worst-case scenario, or consequence, would be if your worry ended up happening. Determine what the percentage of likelihood that this worry might come true is. Be curious and ask yourself if there is a meaning behind this thought; is it truly a “what if” thought, or are you just predicting a negative outcome?
Then ask yourself what the best-case scenario would be, and what you think the most probably or likely outcome might be. The reason for asking yourself about the best case scenario is that when you’re constantly telling yourself the worst is going to happen, you start to believe it. By going for the best case scenario, it can move your prediction to be slightly more accurate.
After evaluating your thoughts, if the worry is false or not completely true, ask yourself, “What’s another way to look at this thought?” (alternative explanation). If it is, however, likely to be true, ask yourself, “What can I do about it?” (active problem solving). This is important for worries that could happen, even if it’s very unlikely. This allows you to normalize your thoughts and accept the fact that we can have crazy thoughts at times. You can also compare these worries to all the things we do every day without absolute, 100% certainty, but we do them anyway.
CBT Step 3: Evaluating Beliefs
After evaluating the content of your worries and thoughts, it’s time to evaluate your beliefs about your worries. This is also referred to as Evaluating Beliefs about Worry as a Process. Evaluating beliefs about the worry process helps to reduce worry across different areas of life. Otherwise, once we have specific solutions to reduce worry about just one area of life, we can’t apply it to worry in other areas.
Conducting a Cost-Benefit Analysis is a good way to identify beliefs about worry. To do this, you should focus on beliefs that worry is helpful, uncontrollable, or dangerous. This helps us to gain insight into how beliefs about worry fuel more worries in Generalized Anxiety Disorder.
Remember, worrying often begins when we are presented with ambiguous or uncertain information. We worry because we believe it’s helpful in resolving uncertainty. We often hold additional, positive beliefs about worry being helpful. We end up having difficulty in stopping worry because we believe that our worry is uncontrollable, and we never come to a solution that fully resolves our uncertainty.
You can also evaluate how you approach worry by asking yourself:
- What do my worries tell me about my behavior?
- Does worrying actually help me prepare?
- What do I think a response to this belief, “worry helps me be prepared”, could be?
- Could I narrow down that worrisome thought to be more specific?
- What could I respond with when I have this particular worry?
CBT Step 4: Worry Segmentation
You can start segmenting your worry in 10-30 minute periods in which you can worry about anything you would like. When it’s not “worry time”, the rule of thumb is that you must postpone worrying.
Using a worry time can be especially useful when suffering from Generalized Anxiety Disorder, as we have typically spent a lot of time worrying on a daily basis. It can be difficult to go from frequently worrying to not worrying, so worry-time can act as a bridge. Worry time also provides evidence to us that our belief about worrying being uncontrollable is untrue.
During worry time, we can test our belief that worry is dangerous by doing behavioral experiments. Since we are actually trying to worry, we can find out through experience whether the outcome happens or not. But we need to know how to actively disengage from our worried thoughts first, which is why this step doesn’t occur earlier. When we can evaluate and respond to our thoughts, it’s easier to delay worrying for this task.
CBT Step 5: Exposure Therapy
We’ve all heard about the story where someone jumps right into a snake pit to cure their fear of snakes. While we don’t want to overwhelm our senses, we do want to introduce an element of uncertainty in these “real life” scenarios. Since the central feature of GAD is the intolerance of uncertainty, this makes sense. exposures are specifically designed to induce uncertainty. To find out how to expose yourself to worrisome situations,
Ask yourself which situations cause you to feel the most anxious, worried, or uncertain. The goal is to understand what you normally and automatically do when this happens, and to “relive” these situations slowly and deliberately. Start with the least anxiety-producing situation and purposefully expose yourself to them, using the techniques you’ve learned so far. As you gain mastery with this, you can up the level of exposure to something more provoking, and repeat.
Don’t worry about doing this perfectly. Instead, remember that this is merely another symptom of GAD: Having difficulty in making decisions, and believing you need to make the right, or perfect, decision.
If you find that you can’t go through with this type of exposure therapy, it’s critical to identify what got in your way. Recreate the scene in your mind, describe where you are and what you’re seeing. Focus on each emotion that is evoked, and notice what goes through your mind. This will give you some clues as to what type of thoughts, beliefs, rules, or conditional assumptions might be getting in the way.
You can also do the same thing with your emotions. Recall that worry is a strategy we use to avoid intense emotions that we fear. In part, this is because we have unhealthy beliefs about these emotions.
The goal in all of this is to help you test your predictions and to experience emotions in a more productive and positive way.
Optional Final Step: Relaxation
Interestingly enough, relaxation training is not a required part of treatment for GAD. It’s useful if your anxiety is extremely intense, isn’t responding to treatment, or if you hold unrealistic beliefs about your emotions. It can also helpful when it’s difficult to focus on your anxious thoughts because your focus is on your physical (bodily) sensations.