Generalised Anxiety Disorder

Generalised Anxiety Disorder


Anxiety Disorder

Psychological Medicine


What is Generalised Anxiety Disorder?

Generalised Anxiety Disorder (GAD) is a specific form of anxiety disorder

with persistent, overpowering worry and anxiety, lasting at least 6 months

to several years. It is characterised by exaggerated worry and tension, even

though there might not be any major triggers. The person tends to think

the worst of situations and is unduly concerned about health issues, family,

finances and work.


The person with GAD may have the following symptoms

- exaggerated worry and tension - muscle aches

out of proportion to the triggers - difficulty swallowing

- inability to relax - feeling breathless

- restlessness - hot flushes

- difficulty concentrating - trembling

- startle easily - irritability

- insomnia - twitching

- fatigue - nausea

- headaches - going to bathroom frequently

- giddiness


The symptoms may range from mild to

severe. Those with severe GAD symptoms

may not be able to work or carry out daily

activities. This may result in secondary

depression and there is also an increased

risk of substance abuse in attempts to selfmedicate.

Other anxiety disorders can also

accompany GAD.


The exact causes are not fully known, but several factors play a part:

Genetic factors

Research suggests that a family history of anxiety disorders increases the

likelihood of someone developing GAD. However, not all will go on to have

the illness. There are other factors contributing to the onset of the condition,

such as:

Physiological chemical imbalance

Neurotransmitters are special chemicals that carry signals across the nerve

endings. If the neurotransmitters are out of balance, signals cannot get

through the brain properly. This can alter the way the brain reacts in certain

situations, leading to anxiety. It has been found that GAD is associated with

abnormal levels of certain neurotransmitters in the brain.


People of certain personality types may be more prone to developing GAD.

This is related to the way they perceive and handle stress in their lives.

External factors

Stressful events (such as abuse, the death of a loved one, divorce, changing

jobs or schools) may lead to GAD. Symptoms are also worsened during

periods of stress. The use of and withdrawal from addictive substances,

such as alcohol, caffeine and nicotine, can worsen anxiety.

Medical conditions

Specific medical conditions are associated with anxiety symptoms, such

as an overactive thyroid. The symptoms from the illness mimic anxiety

symptoms, and the stress of having the medical illness also contributes to

increased anxiety. Other medical conditions like cardiac arrhythmias, seizures,

diabetes and high blood pressure are also associated with increased anxiety.



Generalised anxiety disorder can be treated with medications, psychological

interventions or a combination of both. Choice of treatment depends on

the severity of symptoms, and the person’s preference.


While medications do not cure GAD, they can

keep the symptoms under control and allow

the person to get back to functional state.

The main types of medications used to treat

GAD are antidepressants, anti-anxiety drugs

and beta-blockers. These medications can help to control some physical

symptoms and improve some aspects of brain functioning.


Antidepressants are used to treat GAD, as well as any associated depressive

symptoms. The commonly used antidepressants include selective serotonin

reuptake inhibitors (SSRIs), tricyclic antidepressants, monoamine oxidase

inhibitors, and some new antidepressants, such as serotonin-norepinephrine

reuptake inhibitor (SNRI). These must be taken regularly for two to four

weeks for significant improvements to occur.


Possible side-effects of antidepressants

Antidepressants may cause mild and, usually, temporary side-effects in

some people. Not everyone will experience the side-effects. The most

common ones and their remedies are:

• dry mouth – drink more water

• constipation – eat bran cereals, prunes, fruits and vegetables

• dizziness – get up slowly from your bed or chair. Walk slowly and

hold on to something stable. If the dizziness continues, sit down

or lie down immediately. Do speak to your doctor if the symptom

does not go away and interfere with your daily activities.

• drowsiness – this will pass soon. Do not drive or operate machinery

if feeling drowsy or sedated

• headache – this is transient and will usually go away

• nausea and stomach discomfort – even when it occurs, it is transient

after each dose; take medicine with food.

• nervousness and insomnia – these may occur in the initial period of

starting medication. Dose reduction or time will usually resolve this.

Antianxiety drugs

The most commonly used antianxiety drugs are the benzodiazepines. They

are useful not only for daytime anxiety symptoms but also to aid sleep at

night. Although effective, benzodiazepines may cause dependence after

prolonged use, resulting in withdrawal symptoms if the drug is stopped or

reduced in dosage. Hence, benzodiazepines should only be used for shortterm

management of anxiety symptoms, and not for long-term treatment.

Hydroxyzine is an alternative antianxiety drug. It is less addictive than

benzodiazepines, and is also used in other clinical situations, such as itchiness.

Possible side-effects with this drug are sleepiness, hangover the next day,

dry mouth and constipation.

Propranolol is a type of beta-blocker used to treat heart conditions. Used

in GAD, it can lessen the physical symptoms of anxiety, such as heartpounding.

However, those with a history of asthma or low blood pressure

should not be prescribed this medication, as it can worsen the underlying

medical problems.

Be sure to discuss with your doctor and highlight any important medical

history, so that medications can be tailored to your needs.

Psychological interventions

The recommended psychological treatment for GAD is cognitive-behaviour

therapy. This usually involves: relaxation to reduce chronic tension; techniques

for managing unhelpful beliefs about worry; learning to challenge and to

let go of worries; adopting more helpful coping and problem solving

strategies; and learning to be less focused on uncertainty and more focused


on the present. For some individuals, mindfulness training and meditation

may also be helpful to decrease worry and increase ‘present-moment’ focus.

How to help yourself

1. Calming Technique

When you are anxious, you are more likely to hyperventilate. While this

is not dangerous, you are left feeling exhausted or ‘on edge’, which makes

you more likely to respond to stressful situations with intense anxiety

and panic.

Use the calming technique set out in the following steps and you’ll be

on your way to developing a better breathing habit.

Step 1. Sit on a comfortable chair or lie on a bed.

Step 2. Breathe in through the nose for 4 seconds (you can start

with 3 seconds).

Step 3. Hold your breath for 2 seconds.

Step 4. Release your breath for over 6 seconds (through the mouth

if possible), then pause slightly before breathing in again.

Step 5. Practise, practise, practise.


2. Learn to relax

Learning a relaxation technique can

help you to unwind and bring tensions

and anxiety under control. One of the

body’s reactions to fear and anxiety

is muscle tension.

One helpful method of reducing muscle tension is through a technique

called Progressive Muscle Relaxation (PMR). In PMR, you tense up

particular muscles and relax them and practise this technique consistently.

You can read more about PMR in the last section.

3. Postpone your worry

Worry can occur at any time or place, often without you being aware of

its exact triggers. As such, worry can interfere with your daily life. A

strategy to deal with this problem is to postpone your worry to a particular

worry period.

To begin, choose a particular time, place and length of time for worrying.

This time, place and duration should be the same each day (e.g. 6 pm @

Study Room for 20 minutes). Try and select a convenient time, for

regularity, that is not too close to bed time.

The second step is to postpone

a worry as soon as you become

aware of it. Note your worry

briefly down on paper and

remind yourself that you will

have time to think about it later.

Turn your focus to the present

and the activities of the day to

help let go of the worry until the worry period has arrived.

When your worry period comes around, use the time to reflect on the

worries you have written down from that day. Only worry about the

things you have noted down. It may, also, be helpful to write your

thoughts down on paper rather than worrying in your head. By learning

to postpone your worry, it will be less intrusive in your life and you will

be managing your worry effectively, giving you a greater sense of control.



4. Challenge your negative predictions

Worrying involves a type of thought process where you engage in

negative and catastrophic thinking about things you predict could


When such negative thinking style constantly hassles you, emotions

(such as anxiety) may result, and you may experience unpleasant physical

sensations (i.e. nausea, breathlessness, your heart beating fast, tensed

muscles and giddiness) and avoid doing certain things. One way to lift

those negative emotions and unpleasant bodily sensations is to challenge

those bothersome thoughts.

First, write down what is worrying you and what you predict is going to

happen. Next, you can challenge your worries by asking yourself:

• What is the evidence for my prediction?

• What is the evidence against my prediction?

• How likely is it that what I am predicting will actually happen

(Rate 0–100%)?

• What is the worst that could happen?

• What is the best that could happen?

• What is the most likely think that will happen?

• How helpful is it for me to worry about this?

• How else could I view the situation?

5. Challenge your worrying thoughts

Ask yourself this question: If you believed your worrying has many

benefits, how willing would you be to give it up? A way to challenge

your worrying thoughts is to come up with a list of ‘Evidence For’ and

‘Evidence Against’ the idea that worrying is beneficial.


6. Engage in time management and problem solving

Time Management

As a result of GAD (i.e. anxious apprehension), you are more likely to feel

overwhelmed by obligations and deadlines, in addition to everyday

hassles and stressors. Practice time management strategies, such as

delegating responsibility, being assertive (i.e. saying “no”), and sticking

to your daily agenda of tasks to be done based on their priorities.

Problem Solving

Engaging in problem solving may also help you to think differently and

more realistically about the ‘worrying’ situations. There are some questions

you need to ask yourself before launching into problem solving:

• Is it a real and likely problem that I am worried about?

• Is the problem happening now?

• Is the problem something I have some control over?

If the problem you are worried about is an unrealistic and unlikely

prediction of the future, of which you have little control over, then,

although the problem might appear real, it is not an actual problem that

requires a solution. In these situations, you might find that challenging

your worrying thoughts (Point 5) and letting go (Point 7) might be the

most useful.

However, if it is a real problem in the here-and-now, it would be better

to use problem-solving strategies.

Problem solving involves the following:

Step 1. Identify and try to state the problem as clearly as possible.

Write it down.

Step 2. Work out what possible options are available to deal with the

problem and write them down.


Step 3. List the main advantages and disadvantages of each option,

taking into account what resources are available to you.

Step 4. Identify the best option(s) to deal with the problem.

Step 5. List the steps required for this option to be carried out.

Step 6. Carry out the best option and evaluate the outcome.

7. Acceptance and ‘Letting Go’

To let go of your worries means you are doing the opposite of what you

would normally do with your worries: engage with them, chase them,

react to them, try to control them, and try to reason with them. There

are a number of things you can do to let go of your worries:

Step 1. Be Aware and acknowledge the presence of worries.

You could say to yourself: “Here comes a worry” or “I notice

I’m worrying”.

Step 2. Don’t Respond. Don’t judge or react to your worries.

Just observe your worries with curiosity. Describe to yourself

the thoughts, feelings and sensations you are experiencing

right at that moment. Just allow the worries to be, without

responding to them or trying to change them in any way.


Step 3. Let Go. Only after fully acknowledging, observing, and

describing the worries you have in your mind, can you make

the decision to let the worries go. Think of letting the worries

just pass by like clouds moving slowly across the sky or leaves

floating down a stream. Release the worries and you might

say to yourself: “My worries are not facts, realities, or truths,

they are just thoughts. They aren’t helpful to me. I’ll just let

them go.”

Step 4. Be Present-Focused. Once you have told yourself to let the

worries go, it is important to focus your attention on the present

moment. When you worry, you are focused on the future and

bad things that could happen. If you focus on the simple things

happening in the present, you will be less likely to worry.

Step 5. Deal With A Wandering Mind. Whilst trying to remain

focused on the present, you might get frustrated if you find

your mind wandering back to worrying thoughts. This is natural

and normal. The important thing to do is to recognise that

your mind has wandered and to return your attention to the

present and what it was that you were focusing on. Do this as

many times as you need to.

8. Have a balanced diet and adequate rest

While seemingly simple, taking basic care of the body cannot be

overemphasized. People with high anxiety are also advised to cut down,

or omit, caffeine in their daily diet. This is because caffeine can worsen

the anxiety symptoms. Caffeine is found in coffee, tea, some soft drinks,

and chocolate. Avoid alcohol, as it can cause more psychological and

physical problems with prolonged use, as well as interfere with


9. Talk to someone

Sharing your problem with someone may be helpful. Others may give

you a different perspective to the problem.



How can relatives and friends help?

Relatives and friends can help by

offering a supportive attitude

towards the person. A person with

anxiety experiences their

symptoms as acutely as someone

with physical pain or discomfort.

Do not dismiss their symptoms as

trivial. Listen to them patiently

and try putting yourself in their

shoes. You can respond by saying, “That must be difficult for you.” An anxious

person may, also, be repetitive about their worries. Try not to express your

frustration at the person.

You can also help the person realise that they have a medical condition

and that anxiety is not a weakness or character flaw. Encourage them to

seek help for their symptoms and inform them that skills can be learnt to

lessen the effects of stress and anxiety.

Seeking professional help

CGH’s Division of Psychological Medicine offers comprehensive psychiatric

services. If you wish to book an appointment for psychiatric consultation,

please contact our Appointment Centre at tel: 6850 3333.

Progressive Muscle Relaxation

When preparing to begin this exercise, make yourself comfortable by

wearing loose clothing and taking off your shoes. Minimise the distraction

to your five senses, such as turning off the TV and radio, and use soft lighting.

Choose a comfortable place to sit while doing this exercise.


General Procedure

1. Once you’ve set aside the time and place for relaxation, slow down your

breathing and give yourself permission to relax.

2. When you are ready to begin, tense the muscle group described. Make

sure you can feel the tension, but not so much that you feel a great deal

of pain. Keep the muscle tensed for approximately 5 seconds.

3. Relax the muscles and keep it relaxed for approximately 10 seconds. It

may be helpful to say something like “Relax” as you relax the muscle.

4. When you have finished the relaxation procedure, remain seated for a

few moments allowing yourself to become alert.

Relaxation Sequence

1. Right hand and forearm. Make a fist with your right hand.

2. Right upper arm. Bring your right forearm up to your shoulder to

‘make a muscle’ like a body-builder.

3. Left hand and forearm. Make a fist with your left hand.

4. Left upper arm. Same as for your right upper arm.

5. Forehead. Raise your eyebrows as high as they will go, as though

you were surprised by something.

6. Eyes and cheeks. Squeeze your eyes tight shut.

7. Mouth and jaw. Open your mouth as wide as you can, as if you’re


8. Neck. Be careful as you tense these muscles. Face forward and then

pull your head back slowly, as though you are looking up to the ceiling.

9. Shoulders. Tense the muscles in your shoulders as you bring your

shoulders up towards your ears.

10. Shoulder blades / back. Push your shoulder blades backwards,

trying to almost touch them together, so that your chest is pushed


11. Chest and stomach. Breathe in deeply, filling your lungs and chest

with air.

12. Hips and buttocks. Squeeze your buttock muscles.



13. Right upper leg. Tighten your right thigh by lifting your thigh and

bending your knee as much as you can. You can also use both hands

to pull your knee towards your body.

14. Right lower leg. Do this slowly and carefully to avoid cramps. Pull

your toes towards you to stretch the calf muscle.

15. Right foot. Curl your toes downwards.

16. Left upper leg. Same as for the right upper leg.

17. Left lower leg. Same as for the right lower leg.

18. Left foot. Same as for the right foot.

Practice means progress. Only through practice can you become more

aware of your muscles, how they respond to tension, and how you can relax

them. Training your body to respond differently to stress is like any training

– consistent practice is the key. Once you have mastered the principles of

progressive muscle relaxation, you can also do this exercise while lying



For appointments and enquiries,

please call CGH Appointment Centre at

Tel: (65) 6850 3333

CGH Appointment Centre operating hours:

8.30 am to 8.00 pm (Monday to Friday)

8.30 am to 12.30 pm (Saturday & Sunday)

Closed on Public Holidays

For more information, please visit

2 Simei Street 3 Singapore 529889

Tel: 6788 8833 Fax: 6788 0933

Reg No 198904226R

All information is valid at the time of printing (August 2009)

and subject to revision without prior notice.

Organisation Accredited by

Joint Commission International

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