Don't Worry - Be Happy: Managing Anxiety

Generalized Anxiety Disorder, or GAD, is a chronic condition with a fluctuating but unremitting course. The condition is called generalized or "free-floating" because it occurs across situations. It is characterized by extended periods (> six months) of apprehension or worry about everything - anything that can be perceived by a very creative and imaginative person as a potential danger or threat. This distinguishes GAD from other conditions where the worry is more specific or circumscribed.

WORRY ABOUT	DISORDER
having another panic attack	Panic Disorder
being embarrassed in public	Social Phobia
being contaminated, not checking well enough	Obsessive-Compulsive Disorder
gaining weight	Anorexia Nervosa
having a serious illness	Hypochondriasis
EVERYTHING: minor matters, work/school, family, finances, relationships, and health (self, significant others)	Generalized Anxiety Disorder

This worry is difficult to control, makes it hard to concentrate on other things and is exhausting, quite apart from the fact that it interferes with sleep. It is usually accompanied by motor tension (trembling, restlessness, inability to relax, tension headaches) and autonomic arousal (sweating, racing heart, rapid breathing, stomach discomfort, dry mouth, etc.). Needless to say, GAD can be disruptive to many areas of an individual's life beyond the areas they worry about: educational attainment, success in career, and fulfillment in personal relationships.

GAD vs. Panic
Many symptoms of motor tension and autonomic arousal overlap with the symptoms of panic attacks, so it is important to know the difference between the two. In panic attacks, the motor tension and autonomic arousal is more sudden, extreme and time-limited. In addition, the prevailing emotion during a panic attack is fear. Fear is different from anxiety in the sense that the threat or danger is immediate. Whereas anxiety helps prepare us for a future threat or danger, the purpose of fear is to help us cope with an immediate threat or danger.

Take the example of a person who has to walk home from a friend's house at night through a wooded area. He worries ahead of time about the possible dangers he could face along the way such as being attacked by a cougar or a crazed woodsman. He puts off going as long as he can, until he can wait no longer. His anxious thoughts lead to physical arousal and behavioural changes as he walks slightly crouched, ready for action. This person is experiencing anxiety. Unknown to this person, his "friend" has followed, run ahead and hid behind a tree, ready to leap out at him. As the friend leaps and yells "boo" this person experiences fear.

GAD vs. Stress
Another important distinction is between GAD and stress. Stress is our body's response to some sort of external emotional or physical demand. The big concern with stress is that we will fall prone to stress-related illness such as hypertension, heart attacks, strokes, cancer, diabetes, asthma, and arthritis. This too is a common concern among people with GAD. Will my worry undermine my health and eventually kill me?

The answer has to do with lifestyle. People who suffer from stress are typically preoccupied with responding to challenges in their external environment. They typically respond to these challenges by making lifestyle decisions about the amount of exercise they get, how well they pace themselves, and the food they eat that puts them medically at risk. Anxiety sufferers may also make these same poor choices, but are in my experience less likely to do so. Instead, they are more concerned with challenges from their internal environment, are more tuned into their bodies, and take better care of themselves.

What's Good About it?
A final important consideration is the usefulness of anxiety. Remember, anxious arousal actually serves to prepare us for a perceived future threat or danger. Most of the time we are unable to pinpoint the trigger for this alarm, and simply feel tense and edgy as if something terrible is going to happen. Other times, particularly when we can identify what it is we are worried about and our anxiety is in correct proportion to the threat or danger, anxiety can help us function more effectively. An example is my preparing for this public presentation. If I were to have no anxiety I would be dull and blase, and we could be assured of a mediocre performance. On the other hand, if my anxiety became excessive, my performance would begin to break down.

How Common is it?
Pure GAD is not particularly common compared with other anxiety disorders. About five percent of the population (one in twenty) will suffer from GAD during their lifetime. However, it is one of the most common when considered in combination with other disorders such as depression, alcohol abuse and other anxiety disorders. It is twice as common among women as men, particularly among women over the age of 45, and individuals who are unemployed or working in the home. Although often recognizable in childhood, it is sometimes decades before being diagnosed, and only about 25 percent of individuals with GAD ever receive treatment.

What it's Not:
Care must be taken in diagnosing GAD to distinguish it from a number of physical disorders that mimic its symptoms such as hyperthyroidism, cardiac arrhythmia, pulmonary embolism, congestive heart failure, and hypoglycemia. Your family physician can make this determination.

Excessive and Misplaced
People with anxiety disorders have an enormous capacity to worry about things most people don't even think about. These worries can include such things as being punctual, remembering to call a friend, or wondering about the weather forecast. Their worry seems excessive and misplaced to other people who react by saying "Haven't you got anything better to worry about?"

Difficult to Control
The anxiety sufferer's worries are also different in the sense that they are difficult to control. They occur almost nonstop, like the rapid fire of a machine gun, one worry chained to the next in quick succession. The thoughts rarely stop, and when they do this is cause for the anxiety sufferer to worry about not worrying, concerned that they might not be ready for whatever might happen next. Anxiety sufferers find it difficult to relax as a result.

Ineffective
Lastly, the worry of people with anxiety disorders is often ineffective as a tool for getting ready or preparing to face the threat. Either it's a threat we can't possibly have any control over, or the nervous arousal is far in excess of what we need for optimal performance.

Clinical Features of the Anxiety Prone
There are several plausible personality theories that attempt to explain why some people suffer from anxiety more than others. One such theory is that of Hans Eysenck who proposed anxiety sufferers tend to be cortically over-aroused, and to have especially sensitive autonomic nervous systems. There is even some support to suggest that this predisposition for having anxiety runs in families. People with this predisposition are often described as "high strung", "nervous," or "overly emotional."

Drawing on my own clinical experience, and a simple checklist published by the Midwest Center for Stress and Anxiety (Open Harbor, Ohio) I have arrived at a similar set of predisposing personality characteristics.

difficulties saying "no" or asserting oneself
easily taken advantage of
easily made to feel guilty
need to analyze, figure things out, know why
need to believe in a fair and reasonable world
perfectionistic, unrealistic expectations of self
desire for greater self control
super responsible and self-sacrificing
concern about what others think
sees self differently (less capable) than others do

Getting Strung Out and Staying Strung Out
How to people develop anxiety problems? It does seem as though anxiety sufferers are predisposed toward anxiety by being more easily physically aroused and by being more sensitive emotionally. Some of this is inherited and some of it is learned behaviour.

Nervous arousal in turn narrows our focus of attention to look only for further signs of danger. It results in a danger-laden view of the world whereby we interpret all events, even relatively neutral ones, as overly threatening and as further evidence justifying our need to worry.

This world view may be based on actual life experiences - not just experiences of adversity, but also learning of faulty coping styles from caregivers. Lastly, episodes of anxiety are often triggered through some disruption (positive or negative) in the anxiety sufferer's life.

Once started, a state of nervous arousal can take on a life of its own because of the effects it has on our thinking. One of these is the deterioration in our problem-solving ability. We tend to either over-estimate the probability of terrible things happening, or underestimate our ability to cope.

These thinking errors can then become habitual through thought skimming, whereby our minds are unable to settle on any one thought long enough to question it or explore alternative explanations.

Resistance is futile! Unfortunately, telling ourselves to stop is like trying not to think about a pink elephant - it doesn't work. It doesn't work because we are attempting to apply a "try harder" solution to a "let it be" problem.

In fact, the harder we try, the more worry intrudes on us. What we really need to do is challenge our worries and replace them with more adaptive ways of thinking.

Cognitive behavioural therapy is a highly effective, research-proven treatment for anxiety that starts by breaking anxiety into its three main components: physical arousal and symptoms, anxious thoughts, and behavioural effects. Each of these components is then targeted separately. The treatment itself is a form of talking therapy that guides the client into new ways of thinking and behaving by teaching them the necessary techniques, and having them practice extensively through homework exercises.

Managing Physical Arousal and Symptoms
Clients are taught relaxation techniques for managing physical arousal and symptoms. The principal techniques are diaphragmatic breathing and progressive relaxation. Changing Your Thinking Clients are encouraged to challenge the beliefs that cause them anxiety by questioning the supporting evidence. This is done by teaching them to identify common forms of dysfunctional beliefs, dispute these beliefs using dispute handles, and replace these beliefs with healthier, more adaptive ones.

Changing Your behaviour
Clients are taught to interrupt thought skimming by exposing themselves to one worry at a time for up to 30 minutes each, until they no longer find them disturbing. They are shown how to eliminate safety checking and avoidance behaviours, and they are instructed in time management, goal setting and problem solving skills.

While cognitive behavioural therapy is certainly available on an individual basis, there are some compelling reasons to consider the group option. First, there is a sense of universality clients get in group from realizing they are not alone in suffering from their problems. Participants enjoy meeting other people with similar problems, and participating in group learning experiences.

Second, the group provides opportunities for vicarious learning from witnessing other people solve similar problems e.g., working together on disputing irrational thoughts. Third, the client's attendance in group for he first time is like a public declaration of their commitment to change. Last but not least, although group cognitive behavioural therapy is in many cases as effective as individual therapy, its cost is roughly one third.

If you or someone you care about is suffering from excessive and uncontrollable worry, and would like more information about cognitive behavioural treatment programs, call me at 881-1206. A complimentary, 20-minute consultation with Dr. Cook is available on request. You may also wish to participate in the National Anxiety Disorder Screening Day at Dr. Cook's Broadmead office year round.

Recommended Reading
Barlow, D. H. (1988). Anxiety and its disorders. The nature and treatment of anxiety and panic. New York: The Guilford Press.

Craske, M. C., Barlow, D. H. and O'Leary, T. A. (1992). Mastery of your anxiety and worry. New York: Graywind Publications.

Roth, W. T. (1997). Treating anxiety disorders. San Francisco: Jossey-Bass Publishers.