Generalized Anxiety Disorder (GAD), Causes, Assessment and Treatment 

By Jorg Thonnissen (2010) Psychologist – Hypnotic Impact | Hypnotherapy Perth

Generalized anxiety disorder (GAD) is a serious problem that affects a large cross section of society. According to Kessler, Chiu, Demler, Merikangas, & Walters (2005) it affects as many as 6.8 million Americans will be diagnosed every year with the condition with twice as many women being diagnosed than man. In Australia a large survey (10641 participants) found that 3·6% of the population experienced GAD for 12-months at the time of the study (Hunt, Issakidis, & Andrews, 2002). The onset of GAD in the American sample is reported as being between the ages of 31- 32 (Kessler, et al., 2005). What follows is a brief outline of the theory, assessment and treatment options used to address GAD and a number of closely linked anxiety disorders. In addition to this I will provide a brief explanation of how I apply some of these findings in my own clinical work as a psychologist in private practice.

Generalized Anxiety Disorder - Causes and Assessment
GAD is characterized by excessive worrying about everyday life events to an extent that can be defined as irrational(Comer, 2013). In GAD the anxiety provoking stimuli might be a lot less defined compared to other anxiety disorders such as:

1. Post-Traumatic Stress Disorder where a specific traumatic event can later on lead to flash backs (Ozer, Best, Lipsey, & Weiss, 2008),
2. Obsessive-Compulsive Disorder where the sufferer employs rituals to control persistent anxiety provoking thoughts (Abramowitz, Taylor, & McKay),
3. Panic Disorder where symptoms are characterized as a sudden attack of terror and the sufferer then worries about that it might happen again (Westen & Morrison, 2001), and
4. Social or specific phobias where the anxiety provoking cause is well defined to a particular stimulus (Comer, 2013)

This means sufferers of GAD usually anticipate the worse possible outcome when it comes to matters of health, work, family or relationships for example and thus find themself in a position where they have lost the ability to effectively control their worry (Comer, 2013; Fricchione, 2004).
The symptoms of generalized anxiety disorder can vary and besides psychological indicators include a whole rafter of physiological signs such as headaches, nausea, issues with breathing, muscle tension, numbness of limbs, irritability, agitation as well as insomnia, difficulties in maintaining focus and concentration (Fricchione, 2004) to name only the most common examples.  If these symptoms persist in excess of 6 months GAD is likely to be diagnosed (American Psychiatric Association, 2000).
To use examples from my own clinical experience, sufferers of GAD usually define themselves as constant worriers – sometimes more, sometimes less- who just can’t relax no matter how hard they try. They may worry about what to wear to a dinner party or what to buy for someone as a birthday present. They may worry about getting sick and then lose their job or that someone they care for will have an accident even though there is no real reason for this right there and the question of “what if?” is a constant chatter in the back of their minds.
Ironically, this constant worry may be so intense that sleep patterns are interrupted and so the elevated stress levels eventually contribute to the development of physiological symptoms described earlier and thus sufferers may indeed need to miss work, thus confirming their fear by living a life of self-fulfilling prophecy. Consequently they find themselves in a nightmarish cycle of negativity that greatly diminishes their pleasure of living a life with a sense that could offer any kind of positive aspiration.
This being said, GAD sufferers are capable of normal social and occupational functioning when their anxiety levels are low, however, when at any given time their anxiety levels are elevated even routine tasks can become an impossible chore due to overthinking and an ominous feeling that a disaster is about to happen at any time (Fricchione, 2004; Westen & Morrison, 2001).
According to statistics the typical demographics where GAD is most prevalent is defined as middle to low income earners with individuals experiencing separation, divorce or loss of partner being at increased risk of developing the disorder (Kessler, et al., 2005).
The diagnosis of GAD is defined by the DSM-IV-TR (American Psychiatric Association, 2000) as follows:

1. Excessive anxiety and worry (apprehensive expectation), occurring more-days-than-not for at least 6 months, about a number of events or activities (such as work or school performance).
2. The person finds it difficult to control the worry.
3. The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms present for more-days-than-not for the past 6 months).
   1. restlessness or feeling keyed up or on edge
   2. being easily fatigued
   3. difficulty concentrating or mind going blank
   4. irritability
   5. muscle tension
   6. sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep)
   7. The focus of the anxiety and worry is not confined to features of other Axis I disorder (such as social phobia, OCD, PTSD etc.)
   8. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
   9. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hyperthyroidism), and does not occur exclusively during a mood disorder, psychotic disorder, or a pervasive developmental disorder (American Psychiatric Association, 2000).

The causes for GAD are difficult to determine. However, Kendler (1992) believes that the increased propensity of women to suffer twice as much from the condition is due to the fact that they are more likely to be poorer and suffer from higher levels of abuse and discrimination than man. Others believe that the factors that can lead to GAD are linked to influences to do with environmental, genetic and brain chemistry (Etkin, Prater, Schatzberg, Menon, & Greicius, 2009; Fricchione, 2004; Westen & Morrison, 2001).
Thus, there are many causes that can lead to the condition.   For instance higher stress levels as a consequence of living in larger cities, an unsafe political climate, traumatic life experiences or trauma as a consequence of life changes that come with challenging circumstances such as job loss, loss of a significant other, physical illness or having a baby and the subsequent changes that take place can all be causes for GAD (Baker, 2010).  Drug use and withdrawal as well as excessive use of caffeine or other stimulants can also trigger anxiety (Farach et al., 2012). Drugs such as benzodiazepines as well as alcohol dependence have been implicated as anxiety triggers and so has been the dependence on tobacco (Cohen, 1995).
Considering nature versus nurture factors, even though one or any number of these external circumstances outlined above may lead to GAD researchers also found evidence that allows for the assumption that the disorder has a genetic link (Silberg, Rutter, & Eaves, 2001). In other words, a sufferer of the disorder may be biologically predisposed to the condition because of his or her family history. In terms of nurture, behavioral patterns can be learned from significant others (Tammen, Friso, & Choi, 2013).
Neurological research by Etkin, Prater,Schatzberg, Menon, & Greicius (2009) found that certain regions of the brain are linked to the development of anxiety.   The central nucleus of the amygdala especially has been identified as an important part in the regulation of anxiety. On the one hand it has been found that individuals suffering from GAD not only have greater gray matter in that area, but they also have less distinct neurological connections between amygdala, brainstem, cerebellum and hypothalamus which is suggesting a reduction in functionality. On the other hand the same research by Etkin et al. (2009) also found that in those individuals the neurological connectivity  between the amygdala, parietal cortex and prefrontal cortex is more pronounced. By the same token the neurological connectivity between amygdala, insula and cingulate brain regions are also decreased allowing for the assumption that individuals suffering from GAD aim for a reduction in emotional involvement through the utilization of cognitive strategies in an attempt to reduce anxiety (Etkin, et al., 2009).

The Treatment of Generalized Anxiety Disorders
Generally speaking, anxiety disorders are typically treated with psychotherapy, medication or a combination of the two (Comer, 2013). The good news is that GAD can be managed and greatly reduced if effectively treated with the proper methods (Comer, 2013). For example, even though in the initial phases of withdrawal from long term alcohol or benzodiazepines use anxiety levels might be heightened however, shortly thereafter they are likely to decline significantly, however in some cases this process may take up to 2 years (Cohen, 1995).
The treatment choices vary based on the kind of problem a person faces. Nevertheless, it is my view that those suffering from anxiety should make a medical professional their first port of call so that it can be determined whether the symptoms are in fact of psychological and not potentially of physiological origin. As such, the medical practitioner needs to investigate whether intervention in the form of medication might be warranted before referring his patient for psychological treatment to a mental health professional. It is important that the patient explains to the medical health professional whether he or she have had previous treatment for anxiety, and if, which therapeutic methods and type of medications  have been used, as well as how effective the approach has been so that the medical practitioner can determine the next step in therapy.
It is not uncommon that individuals suffering from GAD have to try several different approaches before finding the one that works for them and if coexisting conditions such as alcohol abuse or depression are prevalent for example then, depending on the severity, it may also be possible that such conditions need to be controlled first before the symptoms of the anxiety can be addressed (Evans et al., 2008).

The Role of Medication in Generalized Anxiety Disorder
The medications that doctors can prescribe for anxiety vary depending on the specifics of the condition. The most commonly prescribed are anti-anxiety drugs, antidepressants and beta blockers to bring the physiological symptoms under control (Rickels & Rynn, 2002) . There are three types of antidepressant medication that are most commonly prescribed, these are called tricyclics, selective serotonin reuptake inhibitors (SSRI’s), and monoamine oxidase inhibitors (MAOIs) and they all work rather uniquely in their own way, however, they usually have to be taken for at least a few weeks before their effectiveness becomes clear. Dosages typically start low and may be increased over time to get the desired effect (Rickels & Rynn, 2002).
For example, the SSRI’s work in the brain by altering the levels of the neurotransmitter serotonin which plays a key role in many aspects of mental health such as in depression, and anxiety which are associated with low levels of serotonin production. By increasing and sometimes decreasing the levels of serotonin these symptoms are counter balanced and anxiety levels should ideally decrease (Pum, Huston, & Müller, 2009). From my own clinical experience I know that typical medications in that class here in Australia would be known by the brands of Zoloft, Prozac and Paxil and there is Effexor which is commonly used to treat anxiety disorder.
Similarly, tricyclics are antidepressants that block the absorption of serotonin and norepinephrine therefore increasing levels of these chemicals available in the brain (Allgulander et al., 2003). However, these antidepressants are of an older generation and thus may have more side effects than the newer class of SSRI’s. Nevertheless, tricyclics may work where SSRI’s have failed to show the desired effects and thus they still have a place in the anxiety treatment arsenal (Allgulander, et al., 2003). From my own clinical experience some commonly prescribed medications for panic disorder and generalised anxiety disorder are known by the names of nortriptyline, desipramine, amitriptyline, doxepin, imipramine and trimipramine for example. Likewise, MAOIs by the brand names of Marplan, Nardil and Parnate are also often used to combat a variety of anxiety disorders such as social anxiety disorder and panic disorder. It is worth noting that medications will potentially have a variety of side effects, hence anxiety sufferers should always ensure observational vigilance when taking psychoactive drugs.
In comparison, anti-anxiety medications such as benzodiazepines have fewer side effects but a user might develop a dependence that could be difficult to manage as ever higher doses are required to get the desired anxiety reducing effect (Shorter & Tyrer, 2003). These drugs work by increasing the effects of what is called gamma-aminobutyric acid (GABA), a neurotransmitter responsible for the reduction of neurons that are associated with anxiety and stress. Benzodiazepines have a sedative effect and are known to be muscle relaxants, anticonvulsant and hence have the desired anxiety reducing effect (Shorter & Tyrer, 2003). Probably the most commonly used benzodiazepines containing brands used in Australia for panic disorder in my experience would be Ativan and Xanax the latter of which is also used to treat generalised anxiety disorder whereas the brand Klonopin is often prescribed for people suffering from social phobia.
The use of beta-blockers is also an option in the fight to reduce anxiety. Beta blockers, work by blocking norepinephrine and adrenaline from binding to beta receptors on nerves (Silvestri et al., 2003) – hence the name. Thus, even when facing an otherwise anxiety producing situation, the physiological responses of anxiety would be suppressed. One of the most commonly prescribed medications here in Australia in my view would probably be known by the brand name of Inderal.
However, utilizing medication alone will not be sufficient in dealing with the various symptoms of anxiety thus, one also needs to understand its causes and the way our perception influences our thoughts which in turn largely determines our behavior and its consequences. For instance, it is not hard to see how our perception gives rise to physiological factors. If we smell something delicious our body readies itself for food by producing saliva. If we believe that we are not able to deal with a situation at work or at home, we feel stressed and that has an effect on our cortisol levels in the blood. These examples show that there really is no disconnect between our belief and our physiology – between mind and body. This is where psychotherapy can make a real difference.

The Role of Psychotherapy in Anxiety Reduction
Psychotherapy aims to define the causes of the anxiety disorder and proposes techniques of how to deal with the symptoms. One of the most effective types of therapy in dealing with GAD and anxiety disorders generally has been cognitive behavioral therapy (CBT).  In fact, CBT has been found to be more effective than drug treatment in the treatment of anxiety (Otto, Smits, & Reese, 2004). As the name suggests, CBT involves 2 parts – a person’s cognition, and behavior.
As a therapist trained in CBT I have come to know over the years that people suffering from GAD may have a number of issues that need to be addressed such as for example past traumatic experiences, finding it hard to deal with uncertainty, lack of emotional understanding, interpersonal issues, they may practice cognitive as well as experiential avoidance or lack proper problem solving skills to name only a few. These issues may have to be addressed one by one. As such CBT is designed to challenge the anxiety supporting negative thought patterns a person may have into one that is conducive to a more positive mindset whereas the behavioral part is concerned with changing the way individuals react to anxiety provoking stimuli.
For instance sufferers of anxiety will come to understand the symptoms for what they are and also learn specific techniques such as breathing exercises that will enable them to take control of their fears and develop confidence. These techniques may involve making a person with social anxiety understand that the people they think have judgmental attitudes towards him or her are probably not thinking like this at all or a sufferer of post-traumatic stress might be asked to recall the traumatic disturbance under the guidance of the therapist which in turn will help lessening the negative effects that come from practicing avoidance.
Therapy may also include exposure strategies to the anxiety provoking stimulus so that the client has an opportunity to confront his or her anxieties gradually.  This in turn will not only enable the client to practice the learned techniques but also feel more and more confident in those anxiety-provoking situations.
In essence, the application of CBT for GAD would follow a number of steps and measures. For example the first step is usually psycho-education which basically involves informing the client about the epidemiology of the disorder and how treatment is going to address the various aspects of the condition. This gives the client an overview of how therapy will progress and hopefully enhances motivation to stay the course.
The client will find out that therapy will involve the daily monitoring of the anxiety provoking events and associated levels of anxiety in order to understand the cues that may provoke them. Once identified, the client will learn how to better control the anxiety stimulus with learned techniques such as deferring worrying about the anxiety provoking situation until sometime later where time has been allocated for focusing on problem solving.
Clients will be taught relaxation techniques such as deep breathing exercises that can be utilized in feared situations to shift attention away from worrying. Progressive muscle relaxation can also be introduced as part of relaxation techniques designed to lower the clients’ stress perception.
CBT also entails the use of desensitization techniques whereby clients are encouraged to imagine themselves vividly being in the anxiety provoking situation and then taking charge of it until the anxiety is reduced to manageable levels. This kind of cognitive restructuring teaches the client self-control and will consequently also increase levels of confidence as they become more adaptive to the anxiety provoking events around them. Clients will come to realize that they have the ability to utilize alternative modes of thinking instead of holding on to patterns that encourages negative thoughts that give rise to anxiety. This change of thought pattern will ultimately not only lead to better thinking styles, but more importantly, better feeling.


In conclusion it is my view that the above research is very relevant to my clinical practice as I am dealing daily with clients seeking to control their anxiety. Further to this in my many years of private practice I find the use of hypnotherapy in combination with CBT as outlined here the best approach as the use of hypnotherapy as a technique facilitates progressive muscle relaxation as well as desensitization and positive future projections all in one.  This strategy therefore represents in my view the superior method.
This holds especially true when this approach is supported by the use of client specific instructional hypnotherapy audio recordings to which my clients can listen to daily in their own time as part of their ‘homework’. This is a cost effective way for clients to take part in therapy as they have the added benefit of ‘doing therapy at home’. The ongoing instructional reminder of what needs to be done has shown remarkable success over the years and many of my clients have attested to the success of this method.  Some will need pharmacological support in the form of medication in addition to this method others don’t. It all depends on the individual and the type and duration of anxiety they are facing.

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By Jorg Thonnissen (2010) Psychologist – Hypnotic Impact | Hypnotherapy Perth