Section Learning Objectives

• Describe how generalized anxiety disorder presents itself.
• Describe the epidemiology of generalized anxiety disorder.
• Indicate which disorders are commonly comorbid with generalized anxiety disorder.
• Describe treatment options for generalized anxiety disorder.

4.2.1 Clinical Description

Generalized anxiety disorder, commonly referred to as GAD, is a disorder characterized by an underlying excessive worry related to a wide range of events or activities (e.g., paying bills on time, being late for appointments, job responsibilities, health, finances, household chores, and other possible misfortunes). While many individuals experience some levels of worry throughout the day, individuals with GAD experience worry of greater intensity and for longer periods of time than the average person. Additionally, they are often unable to control their worry through various coping strategies, which directly interferes with their ability to engage in daily social and occupational tasks. There are six characteristic symptoms of generalized anxiety disorder and in order to be diagnosed with the disorder, individuals must experience at least three of them. These symptoms are: feeling restless or “keyed up”, being easily fatigued, having difficulty concentrating, feeling irritable, having muscle tension, and experiencing problems with sleep.

4.2.2 Epidemiology

The one-year prevalence rate for generalized anxiety disorder is estimated to be 3% of the general population, with nearly 6% of individuals experiencing GAD sometime during their lives. Many people with GAD report that they have felt anxious their entire lives but the mean age of onset is 35, and the disorder rarely occurs before adolescence. Similar to most anxiety-related disorders, females are twice as likely to be diagnosed with GAD as males (APA, 2022).

4.2.3 Comorbidity

There is a high comorbidity between generalized anxiety disorder and other anxiety disorders, as well as major depressive disorder (APA, 2022), suggesting they all share common vulnerabilities, both biological and psychological.

4.2.4 Treatment

4.2.4.1 Psychopharmacology

Benzodiazepines, a class of sedative-hypnotic drugs, originally replaced barbiturates as the leading anti-anxiety medication due to their less addictive nature, yet equally effective ability to calm individuals at low dosages. Unfortunately, as more research was conducted on benzodiazepines, serious side effects, as well as physical dependence have routinely been documented (NIMH, 2013). Due to these negative effects, selective serotonin-reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) are generally considered to be first-line medication options for those with GAD. Findings indicate a 30-50% positive response rate to these psychopharmacological interventions (Reinhold & Rickels, 2015). Unfortunately, none of these medications continue to provide any benefit once they are stopped; therefore, other more effective treatment options such as CBT, relaxation training, and biofeedback are often encouraged before the use of pharmacological interventions.

4.2.4.2 Rational-Emotive Therapy 

Rational emotive therapy was developed by Albert Ellis in the mid-1950s as one of the first forms of cognitive-behavioral therapy. Ellis proposed that individuals were not aware of the effect their negative thoughts had on their behaviors and various relationships and thus, identified a treatment aimed to address these thoughts in an effort to provide relief to those experiencing anxiety and depression. The goal of rational emotive therapy is to identify irrational, self-defeating assumptions, challenge the rationality of those assumptions, and replace them with new more productive thoughts and feelings. It is proposed that by identifying and replacing these assumptions that one will experience relief of GAD symptoms (Ellis, 2014).

4.2.4.3 Cognitive Behavioral Therapy (CBT) 

CBT is among the most effective treatment options for a variety of anxiety disorders, including GAD. In fact, findings suggest that 60% of individuals report a significant reduction/elimination in anxious thoughts one-year post-CBT treatment (Hanrahan, Field, Jones, & Davy, 2013). The fundamental goal of CBT is a combination of cognitive and behavioral strategies aimed at identifying and restructuring maladaptive thoughts while also providing opportunities to utilize these more effective thought patterns through exposure-based experiences. Through repetition, the individual will be able to identify and replace anxious thoughts outside of therapy sessions, ultimately reducing their overall anxiety levels (Borkovec, & Ruscio, 2001).

4.2.4.4 Biofeedback 

Biofeedback provides a visual representation of a client’s physiological arousal. To achieve this feedback, a client is connected to a computer that provides continuous information on their physiological states. There are several ways a client can be connected to the computer. Among the most common is electromyography (EMG). EMG measures the amount of muscle activity currently experienced by the individual. An electrode is placed on the individual’s skin just above a major muscle group- commonly the forearm or the forehead. Other common types of measurement are electroencephalography (EEG) which measures neurofeedback or brain activity; heart rate variability (HRV) which measures autonomic activity such as heart rate or blood pressure; and galvanic skin response (GSR) which measures changes in sweat gland activity.

Once the client is connected to the biofeedback machine, the clinician is able to walk the client through a series of relaxation scripts or techniques as the computer simultaneously measures the changes in muscle tension. The theory behind biofeedback is that in providing a client with a visual representation of changes in their physiological state, they become more skilled at voluntarily reducing their physiological arousal, and thus, their overall sense of anxiety or stress. While research has identified only a modest effect of biofeedback on anxiety levels, clients do report a positive experience with the treatment due to the visual feedback of their physiological arousal (Brambrink, 2004).