The defining feature of Generalized Anxiety Disorder (GAD) is 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 type of generalized anxiety.

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.

To meet the diagnostic criteria for Generalized Anxiety Disorder, there needs to be a few specific things:

• The worry has to be very excessive.
• It has to happen for at least six months more often than not.
• The worry has to be about a number of events or activities, and not just a specific thing.
• It’s incredibly difficult to control the worrying.
• At least three symptoms exist, such as restlessness, being on-edge, fatigue, difficulty concentrating or focusing, irritability, muscle tension, or sleep issues.
• The symptoms cause impairment in one or more important areas of life.

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.

Treatment of Generalized Anxiety

Cognitive-Behavioral Therapy (CBT) is considered to be an effective and reliable treatment for anxiety. It is the “gold standard” and the first line of approach that should be considered for treating anxiety disorders (Hofmann et al., 2012). CBT has been demonstrated to result in a large degree of improvement for generalized anxiety disorder (Cuijpers et al., 2014), as well as to reduce the disorder’s most prominent symptom of worry (Hanrahan, Field, Jones, & Davey, 2013).

CBT has also demonstrated to substantially improve symptoms of anxiety disorders for two or more years after treatment ended (Ishikawa, Okajima, Matsuoka, & Sakano, 2007). Because research studies often exclude individuals based on certain criteria, such as having other diagnoses, studies have also examined the use of CBT in real-world settings and found it to be an effective treatment under those circumstances as well (Stewart & Chambless, 2009).

Worry Awareness

Before clients can evaluate their thoughts, they have to become aware of their thoughts and the difference between Productive Worry and Unproductive Worry. This is called Worry Awareness and is the first step in tailoring CBT for GAD. It’s useful to be able to tell the difference between productive and unproductive worry, and monitor and respond to unproductive and worry responses.

Productive worry allows us to focus on immediate problems that are realistic and which we have some control or influence over. We focus on solving the problem. We accept less than perfect solutions and are willing to tolerate reasonable risk and uncertainty. We recognize the positive, negative, and neutral aspects of the situation and we have self-confidence that we can cope. As a result, our anxiety or distress is relatively low

Unproductive worry is different. We focus on situations in the future, asking ourselves things like, “what if (this) or (that) happened”. We imagine problems that we have little control or influence over. We reflect on how upset we would be if the problem did actually happen. Most interestingly, we reject solutions because success isn’t guaranteed. Instead, we pursue a sense of safety and certainty. We have a narrow and exaggerated focus on the future threat, and have a sense of helplessness about our ability to cope with the situation. As a result, our anxiety or distress is high.

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.

In order to learn about the types of worry we engage in, it’s often useful to write down our worries as soon as possible. Otherwise, life gets in the way and our worries become indistinguishable. By writing your worries down, you are essentially learning the first step of cognitive restructuring, which is to identify thoughts. You’ll have your list of worries written down that you can then more easily evaluate and discover patterns of the typical situations you worry about. Also, in seeing your written list of worries, over time you’ll start to notice that many of your worries have rarely come true. This helps to regain mental balance and encourage the belief that worries are unrealistic and that worry itself isn’t helpful. This information will also help you down the road to test-drive specific worries in real-life scenarios (referred to as in-vivo exposures).

Cognitive Restructuring

Once we can successfully identify and record our worried thoughts, we can being to learn how to evaluate and respond to them. The problem is that one worry tends to lead to the next one, which leads to the next one, and so on. How do you decide which worry/thought to evaluate? I recommend choosing the initial thought that set the chain of worry in motion; if that’s difficult to do, then choose the most anxious-producing worry.

To do this, you can use an informal method of cognitive restructuring. This is just like creating a “pro/con” list, except in the first column you’ll list your thoughts and in the second column you’ll record your responses to your thoughts. It’s helpful to go over multiple thoughts, so write down a list of your worries on the left column. The more specific you can be about your worry, the better; vague worries tend to be difficult to challenge. Then, go over the thoughts in the left column, one at a time. For each thought, ask yourself, “Is this thought true, not completely true, or false?”

Ask yourself what the worst-case scenario, or consequence, would be if your worry ended up happening, or being true. 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.

Evaluating Beliefs about Worrying

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 trim down that worry thought to be more specific?
• What could I respond with when I have this particular worry?

Worry Time and Mindfulness

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.

Mindfulness can be used as a part of this. It’s important that this not be merely a suppression of our thoughts, but more of an acceptance and awareness of our thoughts. Accepting that they are present, and letting them fade on their own. You can begin with a worry induction, followed by a five minute mindfulness/breathing exercise.

Generally, setting worry time in the evening is best, but make sure that it is at least one hour before bedtime to avoid any issues with sleep. Once you get the hang of doing this on a daily basis, it will become habit. At some point, you will notice that you haven’t been worrying as often, or actually skipping worry time altogether. At this point, you can cut down on the frequency of worry time.

In-Vivo Exposures to Uncertainty

Since the central feature of General Anxiety Disorder (GAD) is intolerance of uncertainty,  exposures are specifically designed to induce uncertainty. To find out how to expose yourself to worrisome situations, ask yourself which situations trigger worry. Identify the situations you feel the most anxious or uncertain about, and consider what do you avoid doing or experiencing because of your anxiety.

Alternatively, you can review your worry log from earlier on to identify situations, environments and patterns. Since GAD sufferers have difficulty in making decisions, they believe they need to make the right, or perfect, decision. Reviewing the worry log will help to elicit situations to plan to use.

Regardless of the method you use to generate your list of worries, order them from least-bothersome to most anxiety provoking, on a scale of zero to 100. Start with the least worrisome events and purposefully expose yourself to them, using the techniques you’ve learned so far. As you gain mastery with them, advance up the ladder to the next least anxiety provoking situation, and repeat.

During exposure, make certain to gather your predictions of what will happen. Identify what you tend to do to make sure that these negative conditions don’t occur (safety behaviors). Look for signs that predictions may or may not be accurate. Ask yourself how you will determine if the outcome of your experiment is good or bad.

If you find that you can’t go through with these exposures, it’s important to evaluate what got in the way. Use imagery by closing your eyes and recreating the scene in your mind. Describe where you are and what you’re seeing. Ask yourself what you notice in terms of your emotions, and focus on that feeling. When you focus this emotion, notice what sort of things go through your mind. Finally, identify how dangerous the situation actually was. Take all of this into account in redesigning your exposure experiment.

Imaginal and Emotion Exposures

Interestingly enough, these tend to be more difficult to do than the previous, in vivo exposures so it’s important not to begin these exposures too early. You can tell if you’re ready when you have good success with your in vivo exposures to mild and moderate anxiety levels.

To identify feared images, ask yourself what images (mental picture, daydream, imagery) run through your mind that lead you to worry. Contrast that with what images you try not to think about because it would be too anxiety provoking.

Emotional exposures are similar. Since worry is a strategy to avoid intense emotion, we actually avoid it because of our negative beliefs about emotion. Imaginal and emotional exposures help you to test your predictions about emotions. Mindfulness of emotions teaches us to experience emotions more adaptively, and is an essential component. By eliciting the emotion, you can test any dysfunctional beliefs about emotions you might have. Ask yourself:

• What’s the worst part about anxiety?
• What do I fear might happen if I start to feel anxious?
• What might happen if I don’t try to control my anxiety?
• Can anything bad happen from experiencing anxiety?
• Could emotions or anxiety cause me to do anything that I don’t want to?

You can also learn how to relate to your emotions in a more mindful and accepting manner. Elicit emotions by using imagery and repeating any verbal thoughts. During your imaginal exposure, ask yourself:

• What am I afraid could happen?
• What’s my level of anxiety (0-100%)?
• What did I learn from the experience?

Relaxation Training

Interestingly enough, relaxation training is not a required part of treatment for Generalized Anxiety Disorder. It’s useful in a few key situations. If the anxiety is so intense that you don’t want to engage in real-life (in vivo) exposures, it can help. It’s also useful when you find that your distress doesn’t decrease after working on all of the steps, or if you hold maladaptive beliefs about your emotions. It can be beneficial in situations when you aren’t able to identify your thoughts because your focus is on your physical (somatic) sensations of anxiety.