We are all familiar with the concept of fear in one way or another. We know that everyone deals with it in their own way and that there are different conditions associated with it. One is Generalized Anxiety Disorder.
The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) defines anxiety in several ways, including generalized anxiety disorder.
This disorder is characterized by the presence of anxiety and excessive, persistent worry that is difficult to control (worrying). These concerns can relate to different events or activities and are the result of three or more physiological symptoms.
In addition, for a period of at least six months, patients experience anxiety or worry during most days of this period.
The Development of Generalized Anxiety Disorder
The third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III, APA, 1980) initially introduced Generalized Anxiety Disorder as a single diagnosis. However, experts often used it as a residual diagnosis for individuals who did not meet the diagnostic criteria of other anxiety disorders (1).
This publication defined generalized anxiety disorder as chronic and persuasive worrying (2). Then in the next publication, the DSM-IV-TR, it was characterized as excessive, out-of-control worrying about various things occurring on most days for at least six months.
This undue worry also causes discomfort and/or impairment in functioning. It also consists of at least three of the following aspects:
- restlessness or nervousness
- trouble concentrating
- muscle tension
- sleep disturbances
Psychiatric medications and cognitive behavioral therapy (CBT) are used to treat generalized anxiety disorder (3, 4, 5). Pharmacotherapy can be effective in reducing anxiety symptoms. However, medication does not appear to significantly affect worrying, which is the defining characteristic of this disorder (3).
Current Theoretical Models of Generalized Anxiety Disorder
The avoidance model
The avoidance model (6) is based on Mowrer’s two-factor theory of fear (1974). It also borrows some of its concepts from the emotional processing theory of Foa and Kozak (7, 8).
The avoidance model argues that worrying is a thought-based activity that arises as an attempt to inhibit vivid mental imagery and associated somatic and emotional activation.
In particular, this inhibition avoids the emotional processing of fear, which is theoretically necessary for successful habituation and eradication of fear-provoking stimuli.
Intolerance of uncertainty
According to this model, individuals suffering from Generalized Anxiety Disorder perceive situations of uncertainty as ‘stressful and irritating’. As a result, chronic worrying arises in response to those situations (10).
These people believe that worrying can help them cope better with the events they fear. They may even believe it will prevent such events (11, 12).
This worrying, along with the feelings of anxiety that accompany it, leads to a negative approach to the problem. It also leads to cognitive avoidance, which exacerbates worrying. In particular, people who take a negative approach to the problem experience the following:
- a lack of confidence in their ability to solve problems
- seeing problems as a threat
- frustration when faced with a problem
- pessimism about the outcome of their efforts to solve the problem
These thoughts exacerbate worrying and anxiety (10).
The metacognitive model
The metacognitive model states that people suffering from generalized anxiety disorder experience two types of worry. Wells, the author of the model, defined type 1 worry as worrying about non-cognitive events, such as external situations or physical symptoms (Wells, 2005).
According to Wells, people with generalized anxiety disorder begin to worry about type 1 concerns. They worry that their worrying is uncontrollable or that it could be inherently dangerous. This ‘worry about worry’ (meta-worry) is what Wells calls a type 2 worry.
Wells associated these type 2 concerns with a range of ineffective strategies aimed at avoiding worrying about these type 2 concerns. These strategies mainly consisted of attempts to control behaviour, thoughts and/or emotions (10).
Emotional Instability Model
The emotional instability model is based on the literature on emotion theory and the regulation of emotional states in general. This model consists of four central components: (10)
- The first component states that individuals suffering from Generalized Anxiety Disorder experience emotional hyper arousal. In other words, their emotions are more intense than most people’s. This applies to both positive and negative emotions, but especially to negative emotions.
- The second component states that people with generalized anxiety disorder have a poor understanding of emotions. This includes, for example, deficiencies in describing and labeling emotions. It also concerns access to and application of useful information about emotions.
- Then, in the third component, it is determined that people with generalized anxiety disorder have a more negative attitude about certain emotions than other people.
- Finally, the fourth component states that these individuals have little or no adaptive emotion regulation. They also use management strategies that may make them feel even worse than the feelings they should have been regulating in the beginning.
The acceptance model
According to the authors Roemer and Orsillo, this model consists of four components:
- internal experiences
- a problematic relationship with internal experiences
- avoiding experiences
- behavioral restriction
Therefore, the developers of this model suggest that people suffering from Generalized Anxiety Disorder have negative reactions to their own internal experiences, and are motivated to try to avoid those experiences. They do this both behaviorally and cognitively (by continuing to worry).
Finally, these five theoretical models have an important characteristic in common. They all focus in particular on the consequences of avoiding internal experiences as a coping strategy.
In recent years, research has advanced significantly when it comes to theorizing about this disorder. However, there is a need for more fundamental research into the predictive components of the five models.