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
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
The exact causes are not fully known, but several factors play a part:
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,
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.
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.
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.
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
Be sure to discuss with your doctor and highlight any important medical
history, so that medications can be tailored to your needs.
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
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
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
• 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
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.
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
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
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
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.
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.
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
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 www.cgh.com.sg
Reg No 198904226R
All information is valid at the time of printing (August 2009)
and subject to revision without prior notice.
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Joint Commission International