“I am an old man and have known many troubles, but most of them never happened”
- Mark Twain
I’m postponing the blog on Vicious Cycles for another week, because I’ve had the topic of Worry on my mind (because it’s World Mental Health Awareness Week, and anyway there’s no shortage of worry around these days…)
Worry is common and normal - we all worry sometimes. In other words, we anticipate what could go wrong, we imagine a range of possible negative scenarios, we speculate “What if...” in every possible variety. But usually we snap out of it (at least until the next time...)
This is not pleasant, and most of us could probably benefit from doing less of it, but it doesn’t destroy our lives. Some people, however, develop a major worry problem – they become worriers. When does worry become a serious problem?
When worry is compulsive, hard to control, excessive, inappropriate (i.e. usually about minor things), circling around the same anxious predictions again and again, then we have a real mental health issue. This type of compulsive worry is called Generalized Anxiety Disorder (GAD). People with this problem worry excessively about a variety of things (e.g., job, money, family, health), and as the problem develops, more and more of the worry is about hypothetical scenarios, rather than about real challenges. Along with persistent feelings of anxiety, physical symptoms also tend to develop, such as muscle tension, headaches, and difficulty sleeping
4-7% of the population will develop GAD at some point in their lives, women slightly more than men. In terms of remission, GAD symptoms rarely abate naturally over time.
From a Cognitive-Behavioural perspective, GAD has four main features:
1. Intolerance of uncertainty
2. Positive beliefs about worry
3. Negative problem orientation
4. Cognitive avoidance.
1. Intolerance of uncertainty:
Understandably, we mostly worry about things where the outcome is uncertain. Worry is a natural reaction to uncertainty and it can be seen as a way of trying to predict the future and manage the experience of uncertainty. People with a worry problem tend to be especially uncomfortable with uncertainty. Some would even prefer bad things to happen rather than live with the sense of not knowing what will happen next.
However, worrying generates more uncertainty, which in turn fuels more worry.
Behavioural experiments (see last week’s blog) are one Cognitive-Behavioural technique for working to increase tolerance of uncertainty; here the client deliberately does something more uncertain than usual, to test if it is actually as intolerable as they fear, for example:
• Going to see a film they know nothing about
• Going to a different shop for their groceries
• Ordering something they have never had before in a restaurant
• Making opportunities to meet new people
• Breaking routines
2. Positive beliefs about worry:
Compulsive worriers tend to believe that worry helps in some way, though they may not be fully conscious of this. Some common beliefs they may have are:
• Worry finds solutions to problems
• Worry motivates me to do things
• Worry protects me from possible dangers
• Worry prevents possible dangers from happening
• Worry shows I care
Once people become fully aware of these beliefs, they usually begin to see that there is little evidence to support them.
3. Negative problem orientation:
Worriers tend to use unhelpful strategies to try to solve problems, for example:
• Seeking reassurance for decisions (which keeps worry going, as the worrier never learns to trust their own judgement)
• Seeking out excessive information before making a decision
• Making lists as a substitute for actions
• Being overly busy, throwing oneself into activity rather than solving problems (e.g. cleaning)
• Post-mortem worry: “What if I have made the wrong decision?”
GAD sufferers need to be taught more helpful strategies of problem-solving and decision-making, such as realistic risk-assessment, cost-benefit analysis, trial-and-review, etc.
4. Cognitive avoidance:
Because excessive worry is distressing, many GAD sufferers become worried about their worrying, so they try to go to the other extreme, and push all upsetting ideas out of their mind. This is not a helpful strategy either, as real concerns and issues do need to be faced, and “fearing fear itself” does not improve the situation.
Sufferers are often invited to write down their worries so that they can be faced squarely, and even to set aside a specific “Worry Time” every day, for which they save all their worries. During the specified Worry Time, they are encouraged to worry as hard as they possibly can – this tends to change their relationship with worry as a habit, and can sometimes even be an amusing experience!