Anxiety II (Mood Disorders)

Generalized Anxiety Disorder: General Features

Generalized Anxiety Disorder: General Features

• GAD = Generalized Anxiety Disorder.

• Involves chronic, excessive worry across many areas of life.

Age of Onset

• Median onset is around 30 years old.

• This is later than many other anxiety disorders.

• Some people report feeling anxious for most of their lives.

Development

• Rarely begins before adolescence.

• Peaks in middle age.

• Declines in later adulthood.

Key Takeaway

GAD usually develops later than many anxiety disorders and is marked by long-term, excessive worry that is more common in females.

GAD: DSM Criteria

GAD: DSM Criteria

GAD = Generalized Anxiety Disorder.

Main requirements

• Excessive anxiety and worry on more days than not for at least 6 months.

• The person finds it hard to control the worry.

• The worry causes significant distress or impairment.

• Symptoms are not better explained by another disorder.

Must have 3 or more symptoms

• Restlessness or feeling on edge

• Easily tired

• Trouble concentrating or mind going blank

• Irritability

• Muscle tension

• Sleep problems

Key Takeaway

GAD is long-term, hard-to-control worry lasting 6+ months, with physical and mental symptoms that interfere with daily life.

GAD Specifier: With Panic Attacks

GAD Specifier:

With Panic Attacks

• A specifier adds extra detail to a diagnosis.

• “With panic attacks” can be added to many disorders, not just panic disorder.

Panic Attack Specifier

• A panic attack is a sudden surge of intense fear or discomfort.

• It peaks within minutes.

• The person must have 4 or more symptoms.

Symptoms include:

• fast or pounding heart

• sweating

• trembling

• shortness of breath

• choking feeling

• chest pain

• nausea/stomach distress

• dizziness

• chills or heat sensations

• numbness or tingling

• feeling unreal or detached

• fear of losing control

• fear of dying

Why it matters

• If GAD has the “with panic attacks” specifier, it usually means:

  • worse long-term outcome

  • more severe symptoms

  • greater impairment

Key Takeaway

GAD can include panic attacks, but that does not automatically mean panic disorder. It means the diagnosis is GAD with panic attacks.

GAD: Worry

GAD:

Worry

What is worry?

• Worry = apprehensive expectation.

• It is a chain of negative, hard-to-control thoughts.

• It is usually about future threats or possible bad outcomes.

• People with GAD often feel stuck in a future-focused anxious state.

Worry vs. Rumination Worry

• Future-focused

• Linked to anxiety

• About fear or threat

• Focuses on many possible problems

• Often sounds like: “What if…?”

Rumination

• Past or present-focused

• Linked to depression

• About failure or loss

• Focuses on one or a few problems

• Often involves replaying negative thoughts

Key Takeaway

Worry is anxiety-based and future-focused, while rumination is depression-based and focused more on past or present failures/losses.

GAD vs. Normal Anxiety/Worry

GAD vs. Normal Anxiety/Worry

GAD is different from normal worry because it is:

• Excessive and hard to control

• Interferes with daily life and relationships

• Longer-lasting and happens often

• Can occur without a clear trigger

• Often includes physical symptoms, like:

  • restlessness

  • feeling on edge

  • sweating

  • nausea

  • muscle tension

• Makes it harder to do tasks quickly or efficiently

• Usually involves worry about many different things, not just one specific problem

Common Worries by Age Adults

• job

• health

• money

• family

• daily responsibilities

Children

• school performance

• being on time

• competence

• catastrophic events

Key Takeaway

Normal worry is usually manageable and situation-based, while GAD worry is excessive, long-lasting, physically draining, and disruptive to daily life.

GAD: Why Do People Worry?

GAD: Why Do People Worry?

• Theories focus on what keeps worry going in people with GAD.

• Worry may feel useful, even when it becomes harmful.

Common reasons people worry

• Worry helps them cope.

• Worry helps them avoid thinking about bigger fears.

• Worry makes them feel prepared for bad events.

• Worry helps them manage emotions.

• Worry makes them feel in control.

Key Takeaway

In GAD, worry acts like maladaptive problem-solving: it feels helpful, but it actually keeps anxiety going.

GAD: Psychological Causes

GAD: Psychological Causes

1. Cognitive Avoidance Theory of Worry

• Worry helps people avoid deeper emotional distress.

• It can feel like worry prevents bad things from happening.

• People may think worrying helps them prepare or cope.

• Worrying about small things can distract from bigger fears.

• It gives a false sense of control.

Main idea: Worry works like an avoidance strategy, but it keeps anxiety going.

2. Emotional Dysregulation Model

• GAD may come from difficulty managing emotions.

• People with GAD may:

  • feel emotions quickly and intensely

  • struggle to calm down after negative emotions

  • misunderstand or react negatively to emotions

  • fear sudden mood changes

Main idea: People may prefer constant low-level worry over sudden emotional shifts because it feels more predictable.

Key Takeaway

GAD is maintained by worry that helps people avoid deeper emotions and by difficulty regulating intense emotional states.

GAD: Psychological Causes Continued

GAD: Psychological Causes Continued

3. Metacognitive Model

• Metacognition = thinking about your own thoughts.

• In GAD, people may start worrying about worrying.

Two types of worry

Type 1 worry

• Worry about everyday problems.

• Example: school, health, money, relationships.

Type 2 worry

• Worry about your own thoughts.

• Example: “Why can’t I stop worrying?” or “My worry is dangerous.”

Main idea

• People may believe worry is helpful but also uncontrollable.

• Trying to suppress worry can make it worse.

• Type 2 worry is what keeps anxiety going.

4. Intolerance of Uncertainty Model

• Anxiety is maintained by reacting badly to uncertainty or unclear situations.

• Uncertainty feels stressful, unfair, upsetting, or threatening.

How it works

• Worry feels like it reduces uncertainty.

• People may prefer a bad outcome over an unknown outcome.

• This leads to more worrying instead of actual problem-solving.

Key Takeaway

GAD can be maintained by worrying about worry itself and by feeling unable to tolerate uncertainty.

GAD: Psychological Treatment — ACT

GAD: Psychological Treatment — ACT

Acceptance and Commitment Therapy

• ACT focuses on increasing psychological flexibility.

• This means accepting unpleasant thoughts and feelings without letting them control you.

• The goal is to stay present and choose helpful behaviors based on your values.

Main Features

• Acceptance-based, not always focused on changing thoughts.

• Rooted in:

  • mindfulness

  • self-acceptance

• Can be done:

  • individually

  • with couples

  • in groups

• Can be short-term or long-term.

• Often includes exercises or homework.

• Tailored to the individual client.

ACT’s 6 Core Processes

• Acceptance

• Cognitive defusion

• Being present

• Self as context

• Values

• Committed action

Key Takeaway

ACT helps people with GAD accept anxiety and worry while still making choices that match their values and improve their life.

ACT Core Processes for GAD

ACT Core Processes for GAD

1. Acceptance

• Notice emotions and body sensations without judging them.

• Allow uncomfortable feelings to come and go.

• Accept what cannot be changed instead of fighting it.

2. Cognitive Defusion

• Learn to see thoughts as just thoughts.

• Do not get trapped or consumed by worry.

• Example: instead of “I am stupid,” notice “I am having the thought that I am stupid.”

3. Being Present

• Stay grounded in the current moment.

• Focus on breathing, body sensations, and surroundings.

• Similar to mindfulness.

4. Self as Context

• You are more than your thoughts and emotions.

• Negative thoughts about yourself are not facts.

Key Takeaway

ACT helps people with GAD notice worry without being controlled by it, stay present, and separate themselves from negative thoughts.

ACT Core Processes Continued

ACT Core Processes Continued

5. Values

• Identify what is important and meaningful to you.

• Focus on the kind of person you want to be.

• Example: kindness, honesty, growth, family, health, learning.

6. Committed Action

• Take steps that match your values.

• The action matters, not just the outcome.

• Focus on small, doable tasks that align with what matters to you.

Key Takeaway

ACT helps people with GAD move toward a meaningful life by identifying values and taking real actions, even when anxiety is present.

GAD Treatment: Self-Control Desensitization

GAD Treatment: Self-Control Desensitization

• Self-control desensitization reduces anxiety through repeated exposure.

• The goal is to make anxiety-provoking situations feel less intense over time.

Main Idea

• Based on counter-conditioning.

• Uses reciprocal inhibition:

  • a person cannot be fully relaxed and highly anxious at the same time.

2 Main Steps

1. Create an anxiety hierarchy

• List anxiety-provoking situations from least scary to most scary.

• Rate each situation by intensity.

2. Pair anxiety with relaxation

• Use relaxation techniques while imagining anxiety-provoking situations.

• Examples:

  • breathing

  • visualization

  • muscle relaxation

  • meditation

How It Works

• Start with relaxation.

• Imagine an anxiety-provoking situation.

• Signal when anxiety rises.

• Stop imagining and return to relaxation.

• Repeat until anxiety decreases.

• Move to the next situation on the hierarchy.

Key Takeaway

Self-control desensitization teaches the person to face anxiety gradually while using relaxation until the fear response weakens.

GAD: Biological Causes Genetics

GAD: Biological Causes

Genetics

• GAD has a minimal to moderate genetic link.

• About 30–40% of GAD risk may be related to genetics.

Fear / Anxiety / Stress Network

GAD may involve dysfunction in the brain’s threat-detection system.

Key brain areas

• Amygdala: detects fear and anxiety.

• BNST: helps with vigilance and long-lasting stress responses.

  • Connected to the hypothalamus.

  • Worry can increase cortisol/stress hormones.

• Cortex: involved in thinking, judgment, decision-making, and worry.

  • In GAD, worry thoughts may keep the brain activated.

• Hippocampus: stores learned emotional responses and fear memories.

Neurotransmitters involved

• GABA: calming system

• Serotonin: mood/anxiety regulation

• CRH: stress hormone system

Key Takeaway

GAD may come from genetics plus an overactive fear/stress network that keeps the brain stuck in worry and threat-detection mode.

GAD Treatment: Pharmacotherapy

GAD Treatment: Pharmacotherapy

Buspirone / Buspar

• Buspirone is an anxiolytic used to treat anxiety.

• It is a minor tranquilizer that can reduce tension.

• Takes about 2–4 weeks to show improvement.

Benefits

• Safer and better tolerated than benzodiazepines.

• Causes fewer side effects than benzos:

  • less sedation

  • less muscle relaxation

• Does not cause physical dependence.

• May help boost SSRI antidepressant effects.

Downsides

• Usually less preferred than SSRIs.

• Does not work immediately like benzodiazepines.

Mechanism

• Acts on serotonin 5-HT1A receptors.

• Blocks/inhibits dopamine D2 receptors.

• Unlike benzodiazepines, it does not act on the GABA system.

Key Takeaway

Buspirone is a slower but safer anxiety medication for GAD because it does not cause dependence and has fewer sedating effects than benzodiazepines.

GAD Treatment: SSRIs

GAD Treatment: SSRIs

SSRIs

• SSRIs = selective serotonin reuptake inhibitors.

• Often considered a first-line treatment for GAD.

Benefits

• Do not cause physical dependence like benzodiazepines.

• Can also help with depressive symptoms.

• Overall have a good benefit/risk balance.

Downsides

• Take about 2–6 weeks to show effects.

• May briefly increase anxiety during the first couple weeks.

• Side effects are usually mild but can affect treatment compliance.

Mechanism

• SSRIs block the serotonin reuptake transporter.

• This leaves more serotonin available in the synaptic cleft.

• Long-term effects are still not fully understood.

Key Takeaway

SSRIs are commonly used for GAD because they are safer long-term than benzodiazepines, but they take weeks to work and may initially increase anxiety.

GAD Treatment: Benzodiazepines

GAD Treatment: Benzodiazepines

Benzodiazepines

Examples:

• Xanax

• Klonopin

• Valium

• Ativan

Effects

• Work very quickly, often within minutes.

• Can reduce anxiety.

• Cause sedation and muscle relaxation.

Risks

• Can cause side effects like:

  • cognitive problems

  • aggression

  • increased suicide risk

• Can lead to physical dependence, sometimes after 4–8 months.

• Stopping can cause:

  • withdrawal

  • relapse of anxiety symptoms

• Do not treat depression symptoms that may occur with GAD.

Mechanism

• Bind to GABA-A receptors.

• Make GABA’s calming effect stronger.

• Increase chloride ion flow into neurons.

• This makes neurons less likely to activate/fire.

Key Takeaway

Benzodiazepines can quickly reduce anxiety, but they are risky for long-term use because of dependence, withdrawal, side effects, and poor treatment of depression symptoms