For adults
Generalised anxiety disorder (GAD)
Generalised anxiety disorder is persistent worry about several areas of life at once. The worry is hard to stop, and it usually comes with physical tension and poor sleep. It is common in adults, and CBT helps many people with it.
What generalised anxiety is
In generalised anxiety disorder, often shortened to GAD, the worry is not about one thing. It moves between work, money, health, the people you love and small practical matters such as being late, and when one worry is settled another usually takes its place. The common thread is uncertainty. A situation with an unknown outcome feels unsafe until it has been thought through, and most of life has an unknown outcome. The diagnosis applies when the worry has been present on most days for six months or more, is hard to stop, comes with symptoms such as tension, tiredness or poor sleep, and gets in the way of work, relationships or rest.
What generalised anxiety looks like day to day
- Running through what could go wrong tomorrow while you are trying to get to sleep.
- Tight shoulders, a clenched jaw, headaches or an unsettled stomach on most days.
- Asking someone whether things will be all right, rereading emails, or checking that family members have arrived safely.
- Putting off decisions, or handing them to someone else, in case you choose wrongly.
How it differs from OCD and health anxiety
The three problems share doubt, checking and reassurance seeking, and people often have more than one. In OCD the thoughts are usually experienced as intrusive and out of keeping with who you are, and they are followed by compulsions, which can be mental rituals. In health anxiety the worry stays on illness and is fed by bodily sensations and body checking. In generalised anxiety the worries are about ordinary life, they change topic, and they feel like reasonable concerns that you cannot put down. Working out which pattern is driving things is part of the first session, because it changes what treatment concentrates on.
What keeps the worry going
The treatment described here is based on a model developed by Michel Dugas, Melisa Robichaud and colleagues. It puts at the centre the difficulty many people have with not knowing how things will turn out. If not knowing feels unacceptable, then worrying, checking, asking and over-preparing all make sense as attempts to get certainty. They bring brief relief, which is why they are repeated, but you never find out how things would have gone without them, so not knowing stays as difficult to sit with. Adrian Wells has described a second layer, in which believing that worry is uncontrollable or harmful adds worry about the worrying.
- Trigger: A text left unanswered, or a child home late
- What if?: What if something has happened to them?
- Worry: Going over it, and planning for every outcome
- Seeking certainty: Checking, asking, over-preparing or avoiding
- Relief, for now: Brief relief, and not knowing stays as difficult to sit with
- Then back to the first step, and the loop runs again.
- Other situations that now set it off too: An email from your manager, A news story, A bill arriving, A friend going quiet.
Where treatment steps in. You practise small, planned steps, such as sending an email without rereading it, and find out that you can cope with not knowing.
New triggers. Over time, more situations become linked to the trigger and start the loop off too.
What treatment involves
NICE guideline CG113 recommends stepped care for generalised anxiety in adults, starting with information and guided self-help and then offering a choice between individual CBT, applied relaxation or medication. What I offer is the individual CBT. NHS Talking Therapies provides the same steps free of charge, and I will say so if that looks like the better route for you.
What the treatment consists of, in the order I use
Mapping the worry and what you do about it
We record a week or two of worry, including what set it off and what you did next, which is usually where the reassurance seeking, checking and avoidance show up.
Practising not knowing
You choose situations where you would normally make sure, and you deliberately do not, such as sending a message without rereading it or letting a family member travel without asking them to text on arrival. You write your prediction on the behavioural experiment sheet first and record what happened afterwards. Repeated across many small situations, not knowing becomes easier to live with.
Worry postponement, as an experiment
If you believe your worry cannot be controlled, we test that belief. When a worry starts you note it and put it off to a set fifteen minutes later in the day, and we look at what happened to it in between. It is an experiment, not a rule to get right.
Real problems and hypothetical ones
A worry about a problem you can act on, such as a bill that is due, gets structured problem solving with a decision and a date. For a worry about something that may never happen, you write out the feared outcome in detail and read it repeatedly without reassuring yourself, and find that you can think about it and that the distress is manageable.
Cutting down reassurance and checking
Throughout, you reduce the reassurance seeking, checking and over-preparing in steps that you choose. If a partner has become the main source of reassurance, I can help you explain the change to them.
With older teenagers I use the same approach with some adaptation, with parents involved as appropriate, and worry in younger children is covered on the anxiety in children page. CBT helps many people with generalised anxiety, but not everyone, and results vary from person to person.
The aim is to live with not knowing
Treatment does not remove uncertainty, and it does not promise that the things you worry about will turn out well. What changes is that you can leave a question open, make a decision without checking it with anyone, and go to bed without having resolved tomorrow.
Sources
- National Institute for Health and Care Excellence. Generalised anxiety disorder and panic disorder in adults: management. Clinical guideline CG113 (2011; checked 2020). nice.org.uk/guidance/cg113 (opens in a new tab)
- Dugas, M. J., & Robichaud, M. (2007). Cognitive-Behavioral Treatment for Generalized Anxiety Disorder: From Science to Practice. Routledge.
- Wells, A. (1995). Meta-cognition and worry: a cognitive model of generalized anxiety disorder. Behavioural and Cognitive Psychotherapy, 23, 301-320.
Common questions
I have always been a worrier. Is this just my personality?
Some people are more prone to worry than others, and the tendency often goes back to childhood. Treatment does not try to change your personality. It works on the habits that keep worry going, such as seeking reassurance, over-preparing and putting off decisions, and those can change even when the worry has been there for years. The aim is not to stop worrying altogether, because some worry leads to solving a real problem, but for worry to take up less of your day and be easier to step out of.
Should I take medication for generalised anxiety?
That is a decision for you and your GP or psychiatrist. I do not prescribe. NICE guidance for adults offers a choice between an individual psychological therapy, which is CBT or applied relaxation, and an SSRI antidepressant, with sertraline usually considered first. It advises against benzodiazepines except as a short-term measure in a crisis.
How long does treatment take?
There is no fixed number. NICE guidance (CG113) describes 12 to 15 weekly one-hour sessions as usual for CBT for generalised anxiety, with fewer if someone recovers sooner. Worry that has lasted for decades, or that comes with low mood or another anxiety problem, can take longer. I give you an estimate by the end of the first session, and we review progress with a questionnaire as we go.
Free 20-minute call
Not sure whether this is the right fit?
Start with a free 20-minute call. We talk through what is going on, I answer any questions you have, and I tell you whether I think I can help. If I cannot, I will try to point you to someone who can. The call is free and there is no obligation to book.
Weekdays, 9am to 5pm. No GP referral needed.