Anxiety

by Daniel Freeman

Affected people go to great lengths to avoid risks, engage in repeated checking, pursue and recommend cautious behaviour, regulate their diet carefully, practice the most hygienic habits, and generally engage in overprotective behaviour. Despite all these attempts they seldom achieve a sense of safety or of contentment.

  How common is GAD?

  Almost everyone worries from time to time. Some of us, though, worry more often and more intensely. In one study:

  • 38% of people reported worrying at least once a day. 19.4% worried once every two to three days. And 15% worried about once a month.

  • For 9% of people, their spells of worrying lasted two or more hours. 11% worried for one to two hours. 18% worried for between ten and sixty minutes; 38% for one to ten minutes; and a happy 24% said they worried for less than a minute at a time.

  About 3% of people suffer from generalized anxiety disorder, and women are twice as likely to be affected as men. Research indicates that around 2% of young people may have experienced GAD by the age of 18, with 0.3% severely affected.

  What causes GAD?

  Generalized anxiety disorder is a relatively new concept, appearing in the Diagnostic and Statistical Manual for the first time in 1980, and only really coming into its own as a diagnostic category in the 1990s. This partly explains why research on worry is a relatively recent development, with no single account dominant.

  That said, several theories of worry have been influential, and we begin this section on the causes of GAD by discussing the four main ones.

  Theories of worry

  The metacognitive model

  The word ‘metacognitive’ means the beliefs we hold about our thoughts. And the theory developed by Adrian Wells puts metacognitive beliefs about worry firmly at the centre of GAD.

  Wells highlights two types of metacognitive beliefs: positive and negative. Like many people, whether they have an anxiety problem or not, individuals with GAD tend to see worry as beneficial. They may believe, for instance, that worrying helps them to anticipate and solve problems; that it provides the motivation necessary to tackle those problems; or that it prepares them for the worst if a solution can’t be found. Despite realizing that it is pure superstition, they may even feel that by worrying about an event they can prevent it occurring.

  Clearly, someone who thinks of worry in such positive terms may do rather a lot of it. But people with GAD, unlike other anxious individuals, also hold a number of negative views of worry: principally, that worry is uncontrollable – once you start, it’s almost impossible to stop; and that worry is dangerous – as a sign of looming insanity, for example.

  It’s this painful combination of positive and negative views about worry that distinguishes GAD – and makes life such a misery for those who suffer from it. These people worry because they feel it’s the right thing to do; and yet worrying is a source of huge distress. Indeed, as this theory has helped reveal, people with GAD even worry about worry.

  The cognitive avoidance theory

  Rather differently, Tom Borkovec of Penn State University argues that worry is principally an avoidance strategy. What we’re avoiding is the present, and we do this when we worry by focusing on the future. Borkovec suggests that this avoidance takes three forms.

  First, we worry because we believe it will help us to prevent disaster occurring or, if it does happen, to cope with it.

  Next, worry about relatively superficial or unlikely threats distracts us from more distressing problems. Borkovec notes, for instance, that people with GAD report more trauma in their lives, and worse relationships.

  Finally, worry suppresses feelings, allowing us to avoid the full emotional impact of a feared event. Worry, argues Borkovec, is essentially verbal thought. And verbal thought is not a good medium for emotions. To really feel something, we need to visualize it, but worry distracts us from such images. Borkovec cites research indicating that worry reduces bodily arousal (such as heart rate) in response to threatening images. He concludes:

  In sum, worriers may escape fearful imagery by focusing on the verbal channel while thinking about the future in more abstract terms, e.g. ‘something awful will happen’, with few concrete details.

  Intolerance of uncertainty

  For Naomi Koerner and Michel Dugas, GAD is founded on intolerance of uncertainty:

  Individuals who are intolerant of uncertainty believe that uncertainty is stressful and upsetting, that being uncertain about the future is unfair, that unexpected events are negative and should be avoided, and that uncertainty interferes with one’s ability to function.

  Worry, almost by definition, is an attempt to anticipate and control uncertain future events. It seems logical, then, that people with a strong intolerance of uncertainty will become persistent worriers.

  Koerner and Dugas speculate that the progression from intolerance of uncertainty to worry may be influenced by three factors. First are the positive beliefs about worry we touched on when discussing the metacognitive model. Second are the forms of cognitive avoidance identified by Borkovec. And third is the belief, held by many people with GAD, that they are poor at solving problems: ‘because some degree of uncertainty is inherent to most problems, it is easy to see how individuals with GAD could become frustrated and overwhelmed with solving even minor problems’ – which only increases their anxiety and fuels their worry.

  The mood-as-input theory

  The mood-as-input theory of worry was formulated by the British psychologist Graham Davey, though it’s nicely demonstrated by an experiment carried out by other researchers a few years earlier. Half of the participants in the experiment were put into a bad mood, and the other half into a good mood. Then they were each asked to come up with a list of birds’ names. Half were told they could stop when they felt like it (the ‘feel like continuing’ stop rule) and half to continue until they could think of no more names (the ‘as many as can’ stop rule).

  The participants’ response to those stop rules depended on their mood. For the ‘feel like continuing’ group, those feeling upbeat persevered longer than those in a negative mood. But the situation was reversed in the ‘as many as can’ group: those in a bad mood were more likely to persist with the task.

  Davey argues that this experiment encapsulates two essential features of severe worry. First is the fact that our sense of whether or not we’ve completed a task satisfactorily is often based on our mood, rather than any objective measurement. This is particularly true for tasks which don’t have an obvious end point, such as worrying. A negative mood indicates that the task hasn’t been completed. So someone who feels anxious or unhappy – as people suffering from GAD generally are – is likely to feel that they haven’t yet worried enough.

  The second point is that persistent worriers tend to use the ‘as many as can’ stop rule. This may be partly because there seems to be a natural tendency to opt for such a rule when we’re feeling down, and partly because worriers often hold some fairly rigid beliefs: for example, that worrying is essential if disaster is to be averted; that only perfection will do; and that uncertainty is undesirable. But the ‘as many as can’ stop rule can be a tough one to follow. And with activities as open-ended as worry, an obvious conclusion is rarely in sight.

  Biological perspectives on GAD

  What do we know about what’s happening in the brain when we worry? Neurological research on worry is in its early days, but some insights have already emerged.

  In one study, scientists asked people with GAD and non-anxious individuals to spend time thinking about a variety of faces and sentences, some of which had no emotional resonance while others were designed to induce worry. During the task, the participants’ brain activity was recorded in a functional magnetic resonance imaging (fMRI) scanner.

  For both the anxious and non-anxious groups, the same areas of the brain were activated when they worried. These areas were the medial prefrontal cortex, which plays an important role in our thoughts about our self, and the anterior c
ingulate region, which – among other tasks – is involved in problem-solving and the processing of emotions. But there was a difference between the two groups. In the individuals with GAD, the ‘worrying’ areas of the brain remained active even when they were told to stop thinking about a sentence or face and instead relax. We know that people with GAD find it extremely difficult to stop worrying; this experiment provides neurological confirmation.

  When it comes to genetic influences, the evidence suggests that these are less significant for GAD than for many other anxiety disorders. The disorder seems to run in families, at least to a degree, but this seems to be overwhelmingly the result of environmental factors. No genetic influence at all was found in two twin studies, while three others estimated heritability at around 20%. Moreover, the genetic vulnerability for GAD is very close indeed to that for depression, leading some researchers to suggest that ‘from a genetic perspective, MD [major depression] and GAD seemed to be the same disorder’.

  Social perspectives on GAD

  GAD and depression may appear virtually identical in terms of genetic influence, but if we look at the long-term risk factors for each disorder, greater differences emerge.

  Researchers who followed 1,000 New Zealanders from infancy to age 32 discovered that, although clinical depression and GAD share some risk factors, the differences are much more significant. Depression is linked to a family history of the illness and to problems in adolescence. GAD, on the other hand, is strongly associated with childhood experience, specifically a low socioeconomic background; anxious, hostile, or abusive parenting; inhibited temperament; a tendency to worry, or to be unhappy or fearful; and behavioural problems such as bullying, fighting, stealing, tantrums, and lying.

  Similarly, when psychologists interviewed a group of Dutch primary school children they found that the children who regarded their parents as anxious or rejecting reported higher levels of worry. So too did those who saw themselves as ‘insecurely attached’ – indicating a fundamental problem in their relationship with their parents (for more on attachment styles, see p. 41). Clearly, the researchers were relying on the children’s own accounts. And it’s not impossible that the children who reported difficulties in their parenting did so because they were prone to worry. Nevertheless, the research reinforces the link between worry and childhood experience suggested by the New Zealand study.

  Chapter 9

  Obsessive-compulsive disorder

  Have you ever left the house and then hurried back, maybe several times, to check that you’ve locked the front door or turned off the cooker? Have you ever found yourself unpacking your bag yet again on the way to the airport just to be sure that you haven’t forgotten your passport? And do you sometimes feel the need to wash your hands repeatedly after going to the toilet or touching something dirty?

  How about strange thoughts that pop into your mind as if from nowhere? Do you ever find yourself thinking, for example, that you’re about to hit someone? Or shout or swear in the most inappropriate situations – at a funeral, perhaps, or in a library?

  If you’ve answered yes to any of these questions, don’t worry. Virtually everyone experiences impulses like this occasionally. And they can sometimes seem quite bizarre. Here’s a selection volunteered by members of the general public:

  • Impulse to push someone in front of a train.

  • Wishing a person would die.

  • Thought of throwing a baby down the stairs.

  • Image of being in a car accident, trapped under water.

  • Thoughts of catching a disease from touching a toilet seat.

  • Idea that dirt is always on my hand.

  • Impulse to say something hurtful.

  • Thought of blurting out something in church.

  • Thoughts of ‘unnatural’ sexual acts.

  • Idea of electrical appliances catching fire while I’m out.

  • Idea of my home being broken into.

  • Thought that I haven’t applied my car’s handbrake properly and that the car will crash into traffic while I’m away.

  What is obsessive-compulsive disorder?

  For a small proportion of people, these normal thoughts and urges can spiral out of control, dominating their life and developing into an extremely powerful and distressing set of worries and rituals that is termed obsessive-compulsive disorder (OCD).

  The word ‘obsession’ is often used to denote a keen interest in something, but it has a specific and quite different meaning here. Obsessions in OCD are upsetting and unwanted thoughts, images, and impulses that constantly recur, sometimes throughout the day and night. So distressing are they that people with OCD use a variety of elaborate and time-consuming rituals to try to make them disappear, or to prevent the harm they seem to predict. These rituals are called compulsions and they can be actions (checking that your home is spotlessly clean, for example) or thoughts (for instance, repeating a particular ‘neutralizing’ phrase in your mind).

  (Incidentally, the name ‘obsessive-compulsive disorder’ is the result of a compromise. When the German psychiatric term Zwangvorstellung, literally ‘irresistible thoughts’, was translated into English, the British opted for ‘obsession’ and the Americans for ‘compulsion’.)

  A person is likely to be diagnosed with OCD if:

  • They have regular unwanted and inappropriate thoughts, impulses, or images.

  • These thoughts, impulses, or images are distressing, and are not simply exaggerated worries about real-life problems.

  • They try to ignore or suppress the thoughts.

  • They recognize that the thoughts are the product of their own mind.

  • They engage in repetitive and ritualistic actions or thoughts (i.e. compulsions) in response to their obsessions.

  • The compulsions aim to reduce the distress caused by the obsessions, or prevent some dreaded event, but are excessive and unrealistic.

  • They have recognized that the obsessions or compulsions are unreasonable (this recognition often comes and goes, depending on how the person is feeling).

  • The obsessions or compulsions cause significant distress, take up more than an hour a day, or have a major impact on the person’s normal life.

  In its severest form, OCD can have a devastating effect, taking up so much of the person’s time that they’re unable to carry on normal life. It’s not uncommon for someone with fears about contamination, for example, to spend many hours washing and showering each day. You can get a sense of the potential seriousness of OCD from the fact that it’s the anxiety disorder most likely to cause hospitalization.

  Sometimes there’s a logical connection between a compulsion and an obsession (for example, constant washing resulting from a fear of catching a disease). In other cases, there’s no obvious rhyme or reason (for example, a person might perform counting rituals to prevent their loved ones coming to harm). The vast majority of people with obsessions also have compulsions, but they can each occur independently.

  OCD is a pretty heterogeneous category, encompassing a very broad range of anxieties and symptoms. In an effort to clarify that diversity, scientists have identified five ‘dimensions’:

  Despite this effort to impose order, debate over exactly what should be classified as OCD continues. Some experts, for example, have argued that hoarding is a distinctive form of illness in its own right. Others have argued that certain religious obsessions should be regarded not as a type of OCD but as ‘scrupulosity disorder’.

  How common is OCD?

  Intrusive thoughts, as we’ve seen, are normal, with around 80% of people experiencing them from time to time. It’s been estimated that the average person has around 4,000 thoughts each day, most of them lasting about five seconds. Approximately 13% of these thoughts (i.e. around 500) appear in our minds spontaneously.

  Roughly 2–3% of people develop OCD at some point in their life. The recent US National Comorbidity Survey Replication (NCSR) estimated that 1.2% of the peop
le questioned had suffered from OCD over the past twelve months, with the lifetime figure put at 2.3%. The most common forms of the illness were checking, hoarding, and ordering. On average, obsessions took up 5.9 hours a day, and compulsions 4.6 hours. Given the amount of time consumed by OCD, it’s hardly surprising that almost two-thirds of those who’d experienced the illness in the previous year reported that it had severely interfered with their day-to-day life.

  As we’ve seen, many anxiety disorders seem to be much more prevalent among women than men. The picture is less clear in the case of OCD; the NCSR reported that women were at significantly greater risk than men, yet other studies have found no gender differences.

  OCD can develop at any age, but most usually occurs during late adolescence or early adulthood (in the NCSR, average age for onset was 19.5 years).

  What causes OCD?

  Psychological perspectives

  Up until the 1970s, most mental health professionals looked at OCD through the lens of psychoanalysis, which regarded obsessions as irruptions of deep, instinctive, and principally sexual urges, and compulsions as attempts to control these urges. Persuading a person with OCD to abandon their compulsions was seen as a sure-fire means to propel the individual into psychosis (the technical term for insanity).