People with generalized anxiety disorder experience excessive anxiety under most circumstances and worry about practically anything. In fact, their problem is sometimes described as free-floating anxiety. Like the young Web designer Tomas, they typically feel restless, keyed up, or on edge; tire easily; have difficulty concentrating; suffer from muscle tension; and have sleep problems (see Table 5-1). The symptoms last at least 6 months (APA, 2013). Nevertheless, most people with the disorder are able, although with some difficulty, to carry on social relationships and job activities.

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Generalized anxiety disorder is common in Western society. Surveys suggest that as much as 4 percent of the U.S. population has the symptoms of this disorder in any given year, a rate that holds across Canada, Britain, and other Western countries (Kessler et al., 2012, 2010, 2005; Ritter, Blackmore, & Heimberg, 2010). Altogether, more than 6 percent of all people develop generalized anxiety disorder sometime during their lives. It may emerge at any age, but usually it first appears in childhood or adolescence. Women diagnosed with the disorder outnumber men 2 to 1. Around one-quarter of the people who have generalized anxiety disorder are currently in treatment (NIMH, 2011; Wang et al., 2005).

A variety of factors have been cited to explain the development of this disorder. Here you will read about the views and treatments offered by the sociocultural, psychodynamic, humanistic, cognitive, and biological models. We will examine the behavioral perspective when we turn to phobias later in the chapter because that model approaches generalized anxiety disorder and phobias in basically the same way.

According to sociocultural theorists, generalized anxiety disorder is most likely to develop in people who are faced with ongoing societal conditions that are dangerous. Studies have found that people in highly threatening environments are indeed more likely to develop the general feelings of tension, anxiety, and fatigue and the sleep disturbances found in this disorder (Slopen et al., 2012; Stein & Williams, 2010).

Take, for example, a classic study that was done on the psychological impact of living near the Three Mile Island nuclear power plant after the nuclear reactor accident of March 1979 (Baum et al., 2004; Wroble & Baum, 2002). In the months following the accident, local mothers of preschool children were found to display five times as many anxiety or depression disorders as mothers living elsewhere. Although the number of disorders decreased during the next year, the Three Mile Island mothers still displayed high levels of anxiety or depression a year later. Similarly, studies conducted more recently have found that in the months and years following Hurricane Katrina in 2005 and the Haitian earthquake in 2010, the rate of generalized and other anxiety disorders was twice as high among area residents who lived through the disasters as among unaffected persons living elsewhere (Shultz et al., 2012; Galea et al., 2007).

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One of the most powerful forms of societal stress is poverty. People without financial means are likely to live in rundown communities with high crime rates, have fewer educational and job opportunities, and run a greater risk for health problems (Moore, Radcliffe, & Liu, 2014; López & Guarnaccia, 2008, 2005, 2000). As sociocultural theorists would predict, such people also have a higher rate of generalized anxiety disorder (McLaughlin et al., 2012; Stein & Williams, 2010). In the United States, the rate is almost twice as high among people with low incomes as among those with higher incomes (Sareen et al., 2011; Kessler et al., 2010, 2005). As wages decrease, the rate of generalized anxiety disorder steadily increases (see Table 5-2).

Since race is closely tied to stress in the United States (related to discrimination, low income, and reduced job opportunities), it is not surprising that it too is sometimes tied to the prevalence of generalized anxiety disorder (Sibrava et al., 2013; Marques et al., 2011; Soto et al., 2011). In any given year, African Americans are 30 percent more likely than white Americans to suffer from this disorder. Moreover, although researchers have not consistently found a heightened rate of generalized anxiety disorder among Hispanic Americans, they have noted that many Hispanics in both the United States and Latin American suffer from nervios (“nerves”), a culture-bound disorder that bears great similarity to generalized anxiety disorder (López & Guarnaccia, 2005, 2000; APA, 2000). People with nervios experience enormous emotional distress, somatic symptoms such as headaches and stomachaches, so-called brain aches marked by poor concentration and nervousness, and symptoms of irritability, tearfulness, and trembling.

Although poverty and various societal and cultural pressures may help create a climate in which generalized anxiety disorder is more likely to develop, socio-cultural variables are not the only factors at work. After all, most people in poor or dangerous environments do not develop this disorder. Even if sociocultural factors play a broad role, theorists still must explain why some people develop the disorder and others do not. The psychodynamic, humanistic-existential, cognitive, and biological schools of thought have all tried to explain why and have offered corresponding treatments.

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Sigmund Freud (1933, 1917) believed that all children experience some degree of anxiety as part of growing up and that all use ego defense mechanisms to help control such anxiety (see pages 63–65). Children feel realistic anxiety when they face actual danger; neurotic anxiety when they are repeatedly prevented, by parents or by circumstances, from expressing their id impulses; and moral anxiety when they are punished or threatened for expressing their id impulses. According to Freud, some children have particularly high levels of such anxiety, or their defense mechanisms are particularly inadequate, and these individuals may develop generalized anxiety disorder.

Psychodynamic Explanations: When Childhood Anxiety Goes UnresolvedAccording to Freud, when a child is overrun by neurotic or moral anxiety, the stage is set for generalized anxiety disorder. Early developmental experiences may produce an unusually high level of anxiety in such a child. Say that a boy is spanked every time he cries for milk as an infant, messes his pants as a 2-year-old, and explores his genitals as a toddler. He may eventually come to believe that his various id impulses are very dangerous, and he may feel overwhelming anxiety whenever he has such impulses.

Alternatively, a child’s ego defense mechanisms may be too weak to cope with even normal levels of anxiety. Overprotected children, shielded by their parents from all frustrations and threats, have little opportunity to develop effective defense mechanisms. When they face the pressures of adult life, their defense mechanisms may be too weak to cope with the resulting anxieties.

Today’s psychodynamic theorists often disagree with specific aspects of Freud’s explanation for generalized anxiety disorder. Most continue to believe, however, that the disorder can be traced to inadequacies in the early relationships between children and their parents (Sharf, 2012). Researchers have tested the psychodynamic explanations in various ways. In one strategy, they have tried to show that people with generalized anxiety disorder are particularly likely to use defense mechanisms. For example, one team of investigators examined the early therapy transcripts of patients with this diagnosis and found that the patients often reacted defensively. When asked by therapists to discuss upsetting experiences, they would quickly forget (repress) what they had just been talking about, change the direction of the discussion, or deny having negative feelings (Luborsky, 1973).

In another line of research, investigators have studied people who as children suffered extreme punishment for id impulses. As psychodynamic theorists would predict, these people have higher levels of anxiety later in life (Busch, Milrod, & Shear, 2010; Chiu, 1971). In addition, several studies have supported the psychodynamic position that extreme protectiveness by parents may often lead to high levels of anxiety in their children (Manfredi et al., 2011; Jenkins, 1968).

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Although these studies are consistent with psychodynamic explanations, some scientists question whether they show what they claim to show. When people have difficulty talking about upsetting events early in therapy, for example, they are not necessarily repressing those events. They may be focusing purposely on the positive aspects of their lives, or they may be too embarrassed to share personal negative events until they develop trust in the therapist.

Psychodynamic TherapiesPsychodynamic therapists use the same general techniques to treat all psychological problems: free association and the therapist’s interpretations of transference, resistance, and dreams. Freudian psychodynamic therapists use these methods to help clients with generalized anxiety disorder become less afraid of their id impulses and more successful in controlling them. Other psychodynamic therapists, particularly object relations therapists, use them to help anxious patients identify and settle the childhood relationship problems that continue to produce anxiety in adulthood (Lucas, 2006).

Controlled studies have typically found psychodynamic treatments to be of only modest help to persons with generalized anxiety disorder (Craske, 2010). An exception to this trend is short-term psychodynamic therapy (see Chapter 3), which has in some cases significantly reduced the levels of anxiety, worry, and social difficulty of patients with this disorder (Bressi et al., 2014; Salzer et al., 2011; Crits-Christoph et al., 2005, 2004).

Humanistic theorists propose that generalized anxiety disorder, like other psychological disorders, arises when people stop looking at themselves honestly and acceptingly. Repeated denials of their true thoughts, emotions, and behavior make these people extremely anxious and unable to fulfill their potential as human beings.

The humanistic view of why people develop this disorder is best illustrated by Carl Rogers’ explanation. As you saw in Chapter 3, Rogers believed that children who fail to receive unconditional positive regard from others may become overly critical of themselves and develop harsh self-standards, what Rogers called conditions of worth. They try to meet these standards by repeatedly distorting and denying their true thoughts and experiences. Despite such efforts, however, threatening self-judgments keep breaking through and causing them intense anxiety. This onslaught of anxiety sets the stage for generalized anxiety disorder or some other form of psychological dysfunctioning.

Practitioners of Rogers’s treatment approach, client-centered therapy (also called person-centered therapy), try to show unconditional positive regard for their clients and to empathize with them. The therapists hope that an atmosphere of genuine acceptance and caring will help clients feel secure enough to recognize their true needs, thoughts, and emotions. When clients eventually are honest and comfortable with themselves, their anxiety or other symptoms will subside. In the following excerpt, Rogers describes the progress made by a client with anxiety and related symptoms:

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Despite such optimistic case reports, controlled studies have failed to offer strong support for this approach. Although research does suggest that client-centered therapy is usually more helpful to anxious clients than no treatment, the approach is only sometimes superior to placebo therapy (Prochaska & Norcross, 2013, 2006, 2003). In addition, researchers have found, at best, only limited support for Rogers’ explanation of generalized anxiety disorder and other forms of abnormal behavior. Nor have other humanistic theories and treatment received much research support.

Followers of the cognitive model suggest that psychological problems are often caused by dysfunctional ways of thinking (see PsychWatch below). Given that excessive worry—a cognitive symptom—is a key characteristic of generalized anxiety disorder (see Figure 5-2), it is not surprising that cognitive theorists have had much to say about the causes of and treatments for this particular disorder.

Maladaptive AssumptionsInitially, cognitive theorists suggested that generalized anxiety disorder is primarily caused by maladaptive assumptions, a notion that continues to be influential. Albert Ellis, for example, proposed that many people are guided by irrational beliefs that lead them to act and react in inappropriate ways (Ellis, 2014, 2002, 1962). Ellis called these basic irrational assumptions, and he claimed that people with generalized anxiety disorder often hold the following ones:

“It is a dire necessity for an adult human being to be loved or approved of by virtually every significant other person in his community.”

“It is awful and catastrophic when things are not the way one would very much like them to be.”

“If something is or may be dangerous or fearsome, one should be terribly concerned about it and should keep dwelling on the possibility of its occurring.”

“One should be thoroughly competent, adequate, and achieving in all possible respects if one is to consider oneself worthwhile.”

(Ellis, 1962)

When people who make these assumptions are faced with a stressful event, such as an exam or a first date, they are likely to interpret it as dangerous, to overreact, and to feel fear. As they apply the assumptions to more and more events, they may begin to develop generalized anxiety disorder.

Similarly, cognitive theorist Aaron Beck argued that people with generalized anxiety disorder constantly hold silent assumptions (for example, “A situation or a person is unsafe until proven to be safe” or “It is always best to assume the worst”) that imply they are in imminent danger (Clark & Beck, 2012, 2010; Beck & Emery, 1985). Since the time of Ellis’ and Beck’s initial proposals, researchers have repeatedly found that people with generalized anxiety disorder do indeed hold maladaptive assumptions, particularly about dangerousness (Clark & Beck, 2012, 2010; Ferreri et al., 2011).

New-Wave Cognitive ExplanationsIn recent years, several new explanations for generalized anxiety disorder, sometimes called the new-wave cognitive explanations, have emerged. Each of them builds on the work of Ellis and Beck and their emphasis on danger.

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The metacognitive theory, developed by the researcher Adrian Wells (2014, 2011, 2005), suggests that people with generalized anxiety disorder implicitly hold both positive and negative beliefs about worrying. On the positive side, they believe that worrying is a useful way of appraising and coping with threats in life. And so they look for and examine all possible signs of danger—that is, they worry constantly.

At the same time, Wells argues, people with generalized anxiety disorder also hold negative beliefs about worrying, and these negative attitudes are the ones that open the door to the disorder. Because society teaches them that worrying is a bad thing, they come to believe that their repeated worrying is in fact harmful (mentally and physically) and uncontrollable. Now they further worry about the fact that they always seem to be worrying (so-called meta-worries) (see Table 5-3). The net effect of all this worrying: generalized anxiety disorder.

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This explanation has received considerable research support. Studies indicate, for example, that people who generally hold both positive and negative beliefs about worrying are particularly prone to developing generalized anxiety disorder and that repeated metaworrying is a powerful predictor of developing the disorder (Wells, 2014, 2011, 2005; Ferreri et al., 2011).

According to another new explanation for generalized anxiety disorder, the intolerance of uncertainty theory, certain individuals cannot tolerate the knowledge that negative events may occur, even if the possibility of occurrence is very small. Inasmuch as life is filled with uncertain events, these individuals worry constantly that such events are about to occur. Such intolerance and worrying leave them highly vulnerable to the development of generalized anxiety disorder (Dugas et al., 2012, 2010, 2004; Fisher & Wells, 2011). Think of when you meet someone you’re attracted to and how you then feel prior to texting or calling call him or her for the first time—or how you feel while you’re waiting for that person to contact you for the first time. The worry that you experience in such instances—the sense of sometimes unbearable uncertainty over the possibility of an unacceptable negative outcome—is, according to this theory, how people with generalized anxiety disorder feel all the time.

Proponents of this theory believe people with generalized anxiety disorder keep worrying and worrying in their efforts to find “correct” solutions for various situations in their lives and to restore certainty to the situations. However, because they can never really be sure that a given solution is a correct one, they are always left to grapple with intolerable levels of uncertainty, triggering new rounds of worrying and new efforts to find correct solutions. Like the metacognitive theory of worry, considerable research supports this theory. Studies have found, for example, that people with generalized anxiety disorder display higher levels of intolerance of uncertainty than people with normal degrees of anxiety (Dugas et al., 2012, 2010, 2009, 2002; Daitch, 2011).

Finally, a third new explanation for generalized anxiety disorder, the avoidance theory, developed by researcher Thomas Borkovec, suggests that people with this disorder have greater bodily arousal (higher heart rate, perspiration, respiration) than other people and that worrying actually serves to reduce this arousal, perhaps by distracting the individuals from their unpleasant physical feelings (Newman et al., 2011; Borkovec, Alcaine, & Behar, 2004). In short, the avoidance theory holds that people with generalized anxiety disorder worry repeatedly in order to reduce or avoid uncomfortable states of bodily arousal. When, for example, they find themselves in an uncomfortable job situation or social relationship, they implicitly choose to intellectualize (that is, worry about) losing their job or losing their friend rather than having to stew in a state of intense negative arousal. The worrying serves as a quick, though ultimately maladaptive, way of coping with unpleasant bodily states.

Borkovec’s explanation has also been supported by numerous studies. Research reveals that people with generalized anxiety disorder experience particularly fast and intense bodily reactions, find such reactions overwhelming and unpleasant, worry more than other people upon becoming aroused, and successfully reduce their arousal whenever they worry (Hirsch et al., 2012; Aldao & Mennim, 2012; Fisher & Wells, 2011).

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Cognitive TherapiesTwo kinds of cognitive approaches are used in cases of generalized anxiety disorder. In one, based on the pioneering work of Ellis and Beck, therapists help clients change the maladaptive assumptions that characterize their disorder. In the other, new-wave cognitive therapists help clients to understand the special role that worrying may play in their disorder and to change their views about and reactions to worrying.

CHANGING MALADAPTIVE ASSUMPTIONSIn Ellis’ technique of rational-emotive therapy, therapists point out the irrational assumptions held by clients, suggest more appropriate assumptions, and assign homework that gives the clients practice at challenging old assumptions and applying new ones (Ellis, 2014, 2008, 2005). Studies suggest that this approach and similar cognitive approaches bring at least modest relief to those suffering from generalized anxiety (Clark & Beck, 2012, 2010). Ellis’ approach is illustrated in the following discussion between him and an anxious client who fears failure and disapproval at work, especially over a testing procedure that she has developed for her company:

BREAKING DOWN WORRYINGAlternatively, some of today’s new-wave cognitive therapists specifically guide clients with generalized anxiety disorder to recognize and change their dysfunctional use of worrying (Wells, 2014, 2010; Newman et al., 2011; Ritter et al., 2010). They begin by educating the clients about the role of worrying in their disorder and have them observe their bodily arousal and cognitive responses across various life situations. In turn, the clients come to appreciate the triggers of their worrying, their misconceptions about worrying, and their misguided efforts to control their lives by worrying. As their insights grow, clients are expected to see the world as less threatening (and so less arousing), try out more constructive ways of dealing with arousal, and worry less about the fact that they worry so much. Research has begun to indicate that a concentrated focus on worrying is indeed a helpful addition to the traditional cognitive treatment for generalized anxiety disorder (Wells, 2014, 2011, 2010; Ritter et al., 2010).

Treating individuals with generalized anxiety disorder by helping them to recognize their inclination to worry is similar to another cognitive approach that has gained popularity in recent years. The approach, mindfulness-based cognitive therapy, was developed by psychologist Steven Hayes and his colleagues as part of their broader treatment approach called acceptance and commitment therapy (Roemer & Orsillo, 2014; Hayes et al., 2013; Hayes & Lillis, 2012). Here therapists help clients to become aware of their streams of thoughts, including their worries, as they are occurring and to accept such thoughts as mere events of the mind. By accepting their thoughts rather than trying to eliminate them, the clients are expected to be less upset and affected by them.

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Mindfulness-based cognitive therapy has also been applied to a range of other psychological problems, such as depression, posttraumatic stress disorder, personality disorders, and substance use disorders, often with promising results (Roemer & Orsillo, 2014; Hayes et al., 2013). As you’ll see in the next chapter, this cognitive approach borrows heavily from a form of meditation called mindfulness meditation, which teaches people to pay attention to the thoughts and feelings that flow through their mind during meditation and to accept such thoughts in a nonjudgmental way (See InfoCentral below).

Biological theorists believe that generalized anxiety disorder is caused chiefly by biological factors. For years this claim was supported primarily by family pedigree studies, in which researchers determine how many and which relatives of a person with a disorder have the same disorder. If biological tendencies toward generalized anxiety disorder are inherited, people who are biologically related should have similar probabilities of developing this disorder. Studies have in fact found that biological relatives of persons with generalized anxiety disorder are more likely than nonrelatives to have the disorder also (Schienle et al., 2011; Domschke & Deckert, 2010). Approximately 15 percent of the relatives of people with the disorder display it themselves—a much higher prevalence rate than that found in the general population. And the closer the relative (an identical twin, for example), the greater the likelihood that he or she will also have the disorder.

Of course, investigators cannot have full confidence in biological interpretations of such findings. Because relatives are likely to share aspects of the same environment, their shared disorders may reflect similarities in environment and upbringing rather than similarities in biological makeup. And, indeed, the closer the relatives, the more similar their environmental experiences are likely to be. Because identical twins are more physically alike than fraternal twins, they may even have more similarities in their upbringing.

Biological Explanations: GABA InactivityIn recent decades, important discoveries by brain researchers have offered clearer evidence that generalized anxiety disorder is related to biological factors (Bergado-Acosta et al., 2014; Craig & Chamberlain, 2010; Martin & Nemeroff, 2010). One of the first such discoveries was made in the 1950s, when researchers determined that benzodiazepines, the family of drugs that includes alprazolam (Xanax), lorazepam (Ativan), and diazepam (Valium), provide relief from anxiety. At first, no one understood why benzodiazepines reduce anxiety. Eventually, however, the development of radioactive techniques enabled researchers to pinpoint the exact sites in the brain that are affected by benzodiazepines (Mohler & Okada, 1977). Apparently certain neurons have receptors that receive the benzodiazepines, just as a lock receives a key.

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Investigators soon discovered that these benzodiazepine receptors ordinarily receive gamma-aminobutyric acid (GABA), a common neurotransmitter in the brain. As you read in Chapter 3, neurotransmitters are chemicals that carry messages from one neuron to another. GABA carries inhibitory messages: when GABA is received at a receptor, it causes the neuron to stop firing.

On the basis of such findings, biological researchers eventually pieced together several scenarios of how fear reactions may occur. A leading one began with the notion that in normal fear reactions, key neurons throughout the brain fire more rapidly, triggering the firing of still more neurons and creating a general state of excitability throughout the brain and body. Perspiration, breathing, and muscle tension increase. This state is experienced as fear or anxiety. Continuous firing of neurons eventually triggers a feedback system—that is, brain and body activities that reduce the level of excitability. Some neurons throughout the brain release the neurotransmitter GABA, which then binds to GABA receptors on certain neurons and instructs those neurons to stop firing. The state of excitability ceases, and the experience of fear or anxiety subsides (Atack, 2010; Ator, 2005; Costa, 1985, 1983).

Some researchers have concluded that a malfunction in this feedback system can cause fear or anxiety to go unchecked (Bremner & Charney, 2010; Roy-Byrne, 2005). In fact, when investigators reduced GABA’s ability to bind to GABA receptors, they found that animal subjects reacted with a rise in anxiety (Costa, 1985; Mohler et al., 1981). This finding suggested that people with generalized anxiety disorder might have ongoing problems in their anxiety feedback system. Perhaps they have too few GABA receptors, or perhaps their GABA receptors do not readily capture the neurotransmitter.

This explanation continues to have many supporters, but it is also problematic. First, according to recent biological discoveries, other neurotransmitters may also play important roles in anxiety and generalized anxiety disorder, either acting alone or in conjunction with GABA (Baldwin et al., 2013; Martin & Nemeroff, 2010; Burijon, 2007). Second, biological theorists are faced with the problem of establishing a causal relationship. The abnormal GABA responses of anxious persons may be the result, rather than the cause, of their anxiety disorders. Perhaps long-term anxiety eventually leads to poorer GABA reception, for example.

In fact, research conducted in recent years indicates that the root of generalized anxiety disorder is probably more complicated than the activity of a single neurotransmitter or group of neurotransmitters. Researchers have determined, for example, that emotional reactions of various kinds are tied to brain circuits—networks of brain structures that work together, triggering each other into action with the help of neurotransmitters and producing a particular kind of emotional reaction. It turns out that the circuit that produces anxiety reactions includes the prefrontal cortex; the anterior cingulate cortex; and the amygdala, a small almond-shaped brain structure that usually starts the emotional ball rolling. Recent studies suggest that this circuit often functions improperly in people with generalized anxiety disorder (Lang, McTeague, & Bradley, 2014; Schienle et al., 2011; McClure et al., 2007) (see Figure 5-3).

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Biological TreatmentsThe leading biological treatment for generalized anxiety disorder is drug therapy (see Table 5-4). Other biological interventions are relaxation training and biofeedback.

ANTIANXIETY DRUG THERAPYIn the late 1950s, benzodiazepines were originally marketed as sedative-hypnotic drugs—drugs that calm people in low doses and help them fall asleep in higher doses. These new antianxiety drugs seemed less addictive than previous sedative-hypnotic medications, such as barbiturates, and they appeared to produce less tiredness. Thus, they were quickly embraced by both doctors and patients.

Only years later did investigators come to understand the reasons for the effectiveness of benzodiazepines. As you have read, researchers eventually learned that there are specific neuron sites in the brain that receive benzodiazepines and that these same receptor sites ordinarily receive the neurotransmitter GABA. Apparently, when benzodiazepines bind to these neuron receptor sites, particularly those receptors known as GABA-A receptors, they increase the ability of GABA to bind to them as well, and so improve GABA’s ability to stop neuron firing and reduce anxiety (Griebel & Holmes, 2013; Treit, Engin, & McEown, 2010; Dawson et al., 2005).

Studies indicate that benzodiazepines often provide relief for people with generalized anxiety disorder (Islam et al., 2014; Hadley et al., 2012). However, clinicians have come to realize the potential dangers of these drugs. First, for many people, when the medications are stopped, anxiety returns as strong as ever. Second, we now know that people who take benzodiazepines in large doses for an extended time can become physically dependent on them. Third, the drugs can produce undesirable effects such as drowsiness, lack of coordination, memory loss, depression, and aggressive behavior. Finally, the drugs mix badly with certain other drugs or substances. If, for example, people on benzodiazepines drink even small amounts of alcohol, their breathing can slow down dangerously (Chollet et al., 2013).

In recent decades, still other kinds of drugs have become available for people with generalized anxiety disorder. In particular, it has been discovered that a number of antidepressant medications, drugs that are usually used to lift the moods of depressed persons, and antipsychotic medications, drugs commonly given to people who lose touch with reality, are also helpful to many people with generalized anxiety disorder. In fact, a number of today’s clinicians are more inclined to prescribe antidepressants or antipsychotics to treat generalized anxiety disorder than the GABA-enhancing benzodiazepines (Chollet et al., 2013; Comer et al., 2011).

RELAXATION TRAININGA nonchemical biological technique commonly used to treat generalized anxiety disorder is relaxation training. The notion behind this approach is that physical relaxation will lead to a state of psychological relaxation. In one version, therapists teach clients to identify individual muscle groups, tense them, release the tension, and ultimately relax the whole body. With continued practice, they can bring on a state of deep muscle relaxation at will, reducing their state of anxiety.

Research indicates that relaxation training is more effective than no treatment or placebo treatment in cases of generalized anxiety disorder (Hayes-Skelton et al., 2013). The improvement it produces, however, tends to be modest (Leahy, 2004), and other techniques that are known to relax people, such as basic meditation, often seem to be equally effective (Bourne et al., 2004). Relaxation training is of greatest help to people with generalized anxiety disorder when it is combined with cognitive therapy or with biofeedback (Cuijpers et al., 2014; Lang, 2004).

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BIOFEEDBACKIn biofeedback, therapists use electrical signals from the body to train people to control physiological processes such as heart rate or muscle tension. Clients are connected to a monitor that gives them continuous information about their bodily activities. By attending to the signals from the monitor, they may gradually learn to control even seemingly involuntary physiological processes.

The most widely applied method of biofeedback for the treatment of anxiety uses a device called an electromyograph (EMG), which provides feedback about the level of muscular tension in the body. Electrodes are attached to the client’s muscles—usually the forehead muscles—where they detect the minute electrical activity that accompanies muscle tension (see Figure 5-4). The device then converts the electric energy, or potentials, coming from the muscles into an image, such as lines on a screen, or into a tone whose pitch changes along with changes in muscle tension. Thus clients “see” or “hear” when their muscles are becoming more or less tense. Through repeated trial and error, the individuals become skilled at voluntarily reducing muscle tension and, theoretically, at reducing tension and anxiety in everyday stressful situations.

Research finds that, in most cases, EMG biofeedback, like relaxation training, has only a modest effect on a person’s anxiety level (Brambrink, 2004). As you will see in Chapter 10, biofeedback has had its greatest impact when it plays an adjunct role in the treatment of certain medical problems, including headaches and back pain (Flor, 2014; Young & Kemper, 2013; Astin, 2004).