Understanding and awareness of generalized anxiety disorder have been growing in popular culture. This, no doubt, is due in large part to the expansion of the “global mind” that is the internet. With this increasing awareness, more and more people are recognizing themselves in the symptom profile of GAD. What, then, is going on with this particular diagnosis? What are its causes? How does it “live” in everyday experience? And most importantly, how can we treat it effectively?
Statistics about generalized anxiety disorder
First, let’s look at some statistics about generalized anxiety disorder (hereafter referred to as “GAD”). According to the Anxiety and Depression Association of America, the incidence of GAD in the US adult population in a given year is somewhere between 2 and 3.1% (roughly 6.8 million people). Globally, this number is between 4% and 5.7%. Women are twice as likely to suffer from it as men. The most common age range for GAD to appear is between 45 and 59 years, and these numbers decline after age 60. Importantly, only about 43.2% of GAD sufferers are receiving treatment (psychotherapy and/or psychopharmacology). Clearly, there is a need for more understanding of GAD, more outreach to help those in need and more effective treatment options.
Generalized anxiety disorder and the DSM V
Understanding the incidence of GAD, we move on to the next obvious question: What is generalized anxiety disorder?
According to the DSM V (The Diagnostic and Statistical Manual, Fifth edition)*, the list of symptoms included in the generalized anxiety disorder criteria are as follows:
Excessive anxiety about a number of events or activities, associated with three or more of the following:
Restlessness, feeling keyed up or on edge.
Being easily fatigued.
Difficulty concentrating or mind going blank.
Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep).**
Of course, anyone can experience these symptoms…we use the word “stress” as a generic term to cover the same idea. The difference with a clinical diagnosis of GAD is the degree to which such symptoms interfere with, disturb or create distress for the person.
How does generalized anxiety disorder live in everyday experience?
One symptom of generalized anxiety disorder in our list above stands out as most salient. When the DSM talks about “feeling keyed up or on edge”, it is attempting to give further insight into the experience of anxiety itself. This is a good thing, for dry descriptions of the artificially separated components of what is, after all, a living process, don’t give us a real feeling of GAD as an experience.
And this is where the Deconstructing Anxiety model*** can be so helpful. Demonstrating that there is a single “core fear” underneath any anxiety disorder, including GAD, it helps us appreciate the essence of anxiety in a way we can relate to experientially. The Deconstructing Anxiety model says that this core fear, the original interpretation we adopt about how life
can threaten our purposes, is responsible for literally every problem we have. Whenever a situation stimulates an upset, it does so because it triggers the core fear interpretation.
For example, if one’s core fear is of abandonment, every problem will be filtered through the interpretation that a situation is threatening because it could lead to one’s abandonment. The same is true for the other four core fears in our model: loss of identity, loss of meaning, loss of purpose, and the fear of death. All of us have all five of these core fears, but only one can claim responsibility as the ultimate filter through which we interpret our problems, the anxious assumptions we make about what the problems will lead to.****
With regard to GAD, one’s core fear (whichever of the five it may be), generates an interpretation that any and all situations can be perceived as a source of anxiety. This is distinct from the other anxiety disorders (with the possible exception of panic disorder), such as Social phobia, OCD, PTSD, etc.*****, where the core fear interpretation latches on to a specific object or situation, such as spiders in a simple phobia, germs in OCD, a traumatic event in PTSD, or social situations in social phobia.
This means that the lived experience of GAD is of a sort of “free-floating” anxiety, one that is ready to attach to a great variety of situations. It feels more diffuse in that regard, where one is not hypervigilant about a specific set of circumstances, but rather feels “keyed up” and “on edge” about life itself. Health, finances, relationships, etc., can all spark an anxious response, and the sufferer seems always to be on the lookout for the next danger.
An online generalized anxiety disorder test illustrates the point
In our last blog, we listed the ten questions of one informal generalized anxiety disorder test. Here is another:******
Have you worried excessively or been anxious about several things over the past 6 months?
Are these worries present most days?
Are you able to control your worries or do they interfere with your ability to focus on what you are doing?
I can control my worries.
I cannot control my worries.
When you were anxious during the past six months: were you bothered by one or more of the following?
(If YES then please select an option. It’s possible to select more options).
Restlessness, on the edge, or feeling, keyed up.
Feeling tired, weak or exhausted easily.
Having difficulty concentrating or finding your mind going blank.
Having trouble falling or staying asleep, or having restless and unsatisfying sleep. Have you been diagnosed with:
Post-traumatic stress disorder
Social phobia / social anxiety disorder.
Major Depressive disorder / Major Depressive episode.
Panic disorder (with or without Agoraphobia).
None of the above.
During the last year, has the use of alcohol or drugs:
resulted in your failure to fulfill responsibilities with work, school, or family?
placed you in a dangerous situation, such as driving a car under the influence?
Have gotten you arrested?
continued despite causing problems for you or your loved ones?
None of the above.
Just as with the test in our last blog, it becomes clear from this example that the symptoms of GAD can be about virtually any aspect of life. The questions here simply focus on “excessive worries” that interfere with one’s
ability to function well, and anxiety about “several things”. GAD is, indeed, “generalized” anxiety.
Treating generalized anxiety disorder
But, of course, the most important question we can ask about GAD is quite simply “How do we treat it?”. Generalized anxiety disorder treatment is not usually seen as unique or distinct from other types of anxiety treatment. The research shows that exposure therapy is the most effective approach to the anxiety of any sort, helping the client to safely face (expose themselves to) the threatening circumstance. As a result, there is supposed to be an “extinction” of the fear.
In the Deconstructing Anxiety program, we work with this same principle, adding the essential point that one must first gain insight into the correct fear to face, and this insight must inform the correct action to take. In other words, insight into the real problem (rather than a superficial layer of the problem) must be appreciated in order to design an exposure that can create extinction. One cannot extinguish a fear if they are facing the wrong problem!
In our model, the correct insight is the core fear, the true source of the client’s problem. And the correct action that will extinguish the fear is what we call “doing the opposite of the chief defense”. The chief defense is understood as the primary strategy or behavior one uses to protect themselves from the core fear. While it is meant to give control over that which is feared, the chief defense inevitably backfires, creating more of that fear (see previous blogs for explanations about why this is so).
Therefore, “doing the opposite” of the chief defense, removing that which was meant to keep the fear at bay, necessarily brings our exposure. And because it is an exposure to the core fear (that is what the chief defense was hiding), we can be assured of extinction as we face that fear and find that nothing terrible happens (again, see previous blogs for why we
necessarily find this). Living through the situation we feared, in vivo or in imagination, we discover no catastrophe, nothing ruinous, and we can no longer be fooled by its predictions of doom and gloom. This is the key to healing anxiety!
In summary, when treating GAD, it is incumbent upon the therapist to recognize the ways in which GAD “behaves” (in one’s thoughts, feelings and actions) differently than other anxiety disorders do, to design an appropriate exposure that will reveal the harmlessness of the feared situation. Keeping our eye on the understanding that it is the core fear that must be faced, and that we must face it by “doing the opposite” of the chief defense, our path to healing is clearly laid out before us.
*American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).
**This is only a list of symptoms and not the full diagnostic criteria since our purpose is to present a picture of the experience of GAD. For the complete diagnostic criteria, see the DSM V (reference above).
***Pressman, T. (2019). Deconstructing Anxiety: The Journey from Fear to Fulfillment. Maryland: Rowman and Littlefield.
****This can be readily demonstrated by the “Digging for Gold” exercise in the Deconstructing Anxiety program.
*****In the DSM V, OCD and PTSD have, for the first time, been classified in a category distinct from anxiety disorders, but for our purposes, the experience of both is clearly one of anxiety.