I have been researching and treating Generalized Anxiety Disorder (GAD) for the past 20 years in diverse settings. Without indulging in too much self-promotion, I have written one book on the topic, another one is in process, a book chapter, several articles and been a guest editor on the subject for a prestigious psychiatric journal. Having achieved these milestones, I have also presented on GAD and treated many individuals in my clinical practice with this anxiety disorder. However, what continues to amaze me is that more individuals with GAD do not present for treatment and when they do it is not until many years after the symptoms first present. In this restless and anxious age, in both private practices and workplace settings, there is an epidemic of “silent sufferers” who are not entering treatment and are suffering from what is becoming a much more treatable condition.
In the present article, I plan to discuss some of the potential reasons behind the disparity that exists between the roughly five to seven percent of the population affected with GAD (this translates into millions of people), and the reality that a much smaller number, percentage-wise, seek treatment. In addition, I will spell out some strategies that should be helpful in managing the symptoms of GAD and potentially lead to a more settled and less anxiety/worry-ridden life. However, before accomplishing either of these goals, a brief summary of what GAD constitutes is in order. It is also important to caution the reader that this article is not a substitute for actual treatment by a professional, ideally, one trained in cognitive-behavioral therapy for generalized anxiety disorder. The intensity, duration and level of impairment GAD causes are the main determining factors that should guide an individual in their choice to pursue therapy and/or psychopharmacology to ameliorate the distress caused by this unrelenting angst and worry.
Generalized Anxiety Disorder was first brought to the attention of professionals and the larger public by Freud. It was called neurasthenia and lumped together with panic, but not classified as an independent diagnosis until the third edition of the Diagnostic Statistical Manual of Mental Disorders was published (DSM III). It is marked by chronic anxiety or worry about any number of events, topics or situations (e.g. fiscal, professional status, work, welfare of self or others, etc.) lasting at least six months, and it is considered excessive. The anxiety or worry are also hard to control and impairing in nature. Other criteria are the following, and the individual must meet three of the six symptoms to meet the diagnostic threshold: 1) restlessness or being keyed up, 2) poor concentration or mind going blank, 3) muscle tension, 4) disturbed sleep, 5) irritability and 6) fatigue. There are often other accompanying symptoms such as sweating, gastrointestinal pain such as constipation or diarrhea and nausea to name a few. The individual with GAD is anxious and worried about future-oriented threats that are often remote and quite unlikely to occur. Nonetheless, the threats feel real and can preoccupy many hours of the person’s time, sapping vital energy that could be harnessed for more productive and meaningful endeavors. One caveat that will be discussed, in more detail, is to never dismiss these threats as trivial and not significant.
There have been a number of reasons for the delay and even completed lack of pursuing any type of therapeutic modality in those struggling with GAD. The most common one given is that many individuals with GAD do not know that their chronic worry and anxiety is non-adaptive. In addition, it is often hard to tease out realistic worries from those who are pathological in nature. And, those with GAD often find the thought of therapy and medication another source of worry to be avoided regardless of the costs. Finally, when GAD patients present to primary care doctors (often their first contact), their condition is often not diagnosed accurately, symptoms are minimized as being due to stress and they are often viewed as the “worried well.” In summary, these patients are not taken seriously and many in the healthcare field, including mental health professionals, do not understand the debilitating effects of GAD nor how to treat it effectively. Anxiety, more broadly, is on the rise, but ironically not receiving the attention it so urgently deserves.
There are a plethora of treatment strategies to overcome the deleterious effects caused by GAD. Without being exhaustive, these are some of the most helpful ones based on my clinical experience and cutting-edge evidence;
Increase tolerance for uncertainty and assist those with anxiety/worry to learn to deal more effectively with ambiguity. Life is in shades of gray, not black and white, so challenging dichotomous thinking assists with living with greater uncertainty.
Decrease the tendency to catastrophize. Most events, situations and topics are not nearly as threatening as those with GAD make them out to be. Helping individuals weigh the threat(s) allows them to challenge their propensity to look at things with a negative mindset. Often things work out better than anticipated in life.
Acceptance of the unalterable and coming up with an “action plan” to help resolve the seemingly alterable can go a long way in building hope.
Differentiate between Type 1 worries that everyone has, versus Type 2 worries that are perceived as dangerous, uncontrollable and even confer advantages. Type 2 worries from this approach are misconstrued and not viewed with objectivity.
Exercise, good sleep, hygiene, healthy eating habits and general positive self-care can ease anxiety and lead to a more positive mindset.
Schedule “worry time.” This technique consists of allotting a certain amount of time each day for all one’s worries, anxieties and fears and only thinking about the litany of these threats during that period of time.
Consider cognitive-behavioral therapy and/or medication(s) if symptoms are intense, persistent and contribute to functional impairment in multiple areas of life.
Some individuals find solace in the developing or deepening of their spiritual and religious identity and connection. This can offset thinking they are alone, provide meaning and help connect to a higher power. This is consistent with Dr. Viktor Frankl’s theory that we are meaning-oriented beings and that self-transcendence—finding causes beyond ourselves— can ultimately help us discover our true purpose in existence. We can do this on many levels, which Frankl referred to as: 1) attitudinal (our attitude towards our place in the world), 2) experiential (how we experience the challenges facing us) and 3) creating (e.g. a work or deed).
Those who struggle with GAD experience their thoughts and emotions more intensely than others. It is important to normalize their sensitivities and work on emotional regulation through the use of self-compassion and soothing.
Generalized Anxiety Disorder has been considered by many authorities in the field as the “step-child” of the psychiatric world. It has been misunderstood, neglected, misdiagnosed and relegated to insignificance compared to other psychological maladies. One prominent psychiatrist called GAD a “God awful diagnosis” and offered some other less-than-generous words to describe it. In reviewing my first book, this very same person remarked he did not like GAD, but liked my book. I guess it is the small consolations in life that can bring on greater vindication in the future. And this is especially true for GAD. I remain passionate, in spite of the residual criticism and devaluing attached to GAD and those who can suffer unknowingly with the disorder for decades, in bringing it to the attention of the larger public. I also believe in fighting for the underdog, and GAD is in that camp. Some of my colleagues have attempted unsuccessfully to reduce its criteria by calling it simply a “worry disorder,” adding specious behavioral modifiers that lack empirical support and even considering computer-assisted therapy, which would dispense with both the need for a therapist and building the centrality of the much needed therapeutic alliance.
We have come a long way since Freud brought GAD into the vista of the mental health landscape, but we still have a long road to travel towards reaching and successfully treating those who live with this painful and distressing mental health challenge. Cautious optimism has always been my mantra, and the hope is that GAD receives more attention at the personal and societal level, where it exacts a huge toll. The future is looking brighter for GAD sufferers and their support systems, which is encouraging in this age of anxiety.
One important note to cap off this offering on GAD: Children and adolescents often present with more physical/somatic symptoms than adults (e.g. headaches, stomach aches). My wife and I treat GAD in our joint practice across the lifespan, and the earlier GAD is detected and treated, the more the prognosis is significantly enhanced. This point cannot be underestimated or overstated enough to curb the tide of anxiety in our current restless climate.
Dr. Michael E. Portman, LCSW, ACT can be reached at [email protected]. Anna Ostro-Portman, LCSW can be reached at [email protected].
