Generalised anxiety disorder: when worry becomes a way of life

“I know it’s silly. But the moment you stop worrying, that’s exactly when something happens.”

I hear this sentence, in one version or another, more often than I would expect. It is said by someone who, in the morning, thinks about the child who walked to school, over coffee about a meeting that is still a week away, while driving about their mother’s health, in the evening about a bill that might not arrive on time, and at night about all of it together. None of these worries is mad. Each one, taken alone, makes perfect sense. What is exhausting is that they never end — when one falls quiet, the next one starts up, as if a radio station were playing in your head that cannot be switched off.

When this goes on for months and years, we speak of generalised anxiety disorder. In this post I will explain where the line lies between ordinary worry and a disorder, why worry persists even though it clearly does us no good, and what helps. You cannot get a diagnosis from a blog post — nobody can make one without a conversation in person — but you can get a better map of what may be happening to you.

Worry with no fixed address

With most forms of anxiety you can point to the object of fear. In social anxiety it is other people’s eyes, in panic attacks the body, in a phobia the spider or the aeroplane. In generalised anxiety disorder the object keeps changing address. Today it is work, tomorrow health, the day after a child’s friendships. That is why we call it “generalised” — worry spills over the whole of life.

The US National Comorbidity Survey Replication, published in 2005 by Ronald Kessler and colleagues, estimated that around 5.7 per cent of adults have this disorder at some point in their lives. That is roughly one person in seventeen. Women are more often affected than men, and the disorder often begins unnoticed and lasts a long time before anyone gives it a name. Many people have spent their whole lives being known as “the one who just likes to worry”, and never thought it could be any different.

You will find a short explanation of the term in the knowledge base under generalised anxiety. Here I want to go deeper — into how worry works from the inside.

When worry becomes a disorder

Everyone worries. Worry is in fact a useful ability: the brain runs through possible futures so that it can prepare for them. A student worried about an exam will study. A father worried about rain will give his child an umbrella. So when does worry become something professionals call a disorder?

The diagnostic manuals (the American DSM-5 and the international ICD-11) describe roughly this picture:

• The worry is excessive compared with the real likelihood and consequences of what you fear.
• It lasts more days than not for at least six months and concerns several areas of life, not just one.
• It is hard to stop. It is not that you decide to worry — the worry happens on its own and won’t let go.
• It comes with physical signs: restlessness or feeling “on edge”, tiring easily, trouble concentrating, irritability, tense muscles (often neck, shoulders and jaw) and poor sleep.
• It gets in the way of life — at work, in relationships, when resting — or causes a great deal of suffering.

The phrase more days than not matters. In the week before a house move, or the month after losing a job, almost anyone worries too much — that is a response to hard circumstances, not a disorder. Generalised anxiety disorder is a pattern that stays even when circumstances are calm. Then the mind goes looking for a new worry, as if silence itself were suspicious.

Intolerance of uncertainty

When Canadian researchers Michel Dugas, Robert Ladouceur and colleagues set out in the 1990s to find what sets people with generalised anxiety disorder apart, they came to a surprising answer. It was not primarily what people feared, but how they bore not knowing. They called the phenomenon intolerance of uncertainty.

A person with high intolerance of uncertainty experiences an open question as a danger in itself. They are not only afraid the test result will be bad — the fact that it isn’t in yet is already unbearable. They are not only afraid their partner will be angry — not knowing what mood he will come home in is already unbearable. A small chance of a bad outcome feels almost as bad as a large one, because what troubles them is not the probability but the openness.

Research has shown intolerance of uncertainty to be one of the strongest predictors of how much someone worries. On this basis Dugas and colleagues developed a model with three further ingredients: the belief that worry is useful, a negative orientation towards problems (the sense that you won’t be able to solve them) and cognitive avoidance. The model also gave rise to a form of cognitive behavioural therapy that deals less with the content of worries and more with one’s relationship to uncertainty.

This is an important shift. If worry is driven by intolerance of uncertainty, then reassurance — “it won’t happen” — cannot work. Even if someone proves to you that the odds are one in a thousand, the one remains. Worry will not settle because of better evidence, but only once you learn to live a little more easily with what is unfinished.

Worry as an attempt at control

So why do we worry, if worry hurts so much? Because it has a hidden job. Worry is an attempt to control something we cannot control.

People with generalised anxiety disorder often believe — sometimes out loud, sometimes only to themselves — something like this: “If I worry, I’ll be prepared.” “If I worry, the bad thing won’t happen.” “If I didn’t worry, I’d be irresponsible.” “Worrying shows that I care.” Adrian Wells, author of the metacognitive model of the disorder, called these positive beliefs about worry. Alongside them sit negative ones: “Worry will destroy me.” “If I don’t stop, I’ll go mad.” So the person is caught between two forces — they worry because they think they must, and they are frightened because they worry too much. Wells calls this “worry about worry”.

The American researcher Thomas Borkovec noticed something else: worry is mostly verbal. When you worry, you tell yourself sentences in your head — “what if I’m late, what if they fire me, what then” — and only rarely see vivid images. Verbal thinking arouses the body less than images do. Worry is therefore, in a way, an escape from stronger emotions: instead of feeling fear, sadness or helplessness, you think about them. In the short term it works as a buffer. In the long term it means the fear is never really processed, because it is never really felt.

And then comes the trap. Most of what we fear does not happen. When it doesn’t, the brain does not say “look, that was unnecessary”, but “look, worrying worked”. In 2020 Michelle Newman and Lucas LaFreniere published a study in which people with generalised anxiety disorder recorded their worries for ten days and then checked which came true. The great majority of predictions did not, and for those that did, the outcome was often less bad than expected. Without writing it down, nobody notices — and worry takes the credit for a calm that would have come anyway.

Worry, “what if” and overthinking

I have written about related patterns before, so I won’t repeat them here, only place them. The mechanism by which the brain would rather predict a hundred disasters than one calm day is described in “What if …”: why the brain would rather predict a hundred disasters than one calm day. Thoughts that circle without ever concluding are the subject of Overthinking: why thoughts go round in circles and how to step out.

These are all pieces of the same picture, but they are not the same. Catastrophising is the way a thought leaps to the worst outcome. Overthinking and rumination are often turned backwards — chewing over what has already happened. Worry in generalised anxiety disorder, by contrast, faces forwards, is spread across several areas and has become a way of being, not just an occasional episode. The person doesn’t worry about something — they worry because it is their default state, and then find something to worry about.

What it looks like up close

In conversation, generalised anxiety disorder often doesn’t show up as fear. It shows up as tiredness, tension and a kind of constant readiness. The dialogue below (composite, not a real person) is one many people will recognise themselves in.

“I don’t know why I’m so tired. I’m not doing anything special.”
“What has been going round in your head today, from the morning until now?”
“Oh, nothing much. Whether my son will get the scholarship. Whether I said something wrong in the meeting. Whether Mum took her tablets. And that noise in the car.”
“That’s quite a few open questions for one morning.”
“Yes, but I have to think about these things. If I don’t, who will?”
“What do you think would happen if you left one of those questions open for an hour?”
A long pause. “I don’t know. I feel I’d be letting something slip out of my hands.”

That last sentence is the heart of it. Worry here is not a thinking error but a grip — hands that are not allowed to let go. There is often a story behind it: growing up in a family where you had to stay alert because the environment was unpredictable, where the child took on worrying for the adults, or where misfortune really was close. In relational family therapy, which I am training in, we therefore always ask to whom, and why, worry was once necessary. Back then it may have been a sensible adaptation. Today it keeps running, even though life has changed.

Exercise: ten minutes for an open question

This exercise does not try to get rid of worry. It helps you observe it and test what happens if you don’t follow it all the way. It uses two ingredients that are well supported by research: worry postponement and checking predictions. You will find a longer description of the first in the knowledge base under worry postponement and in the post Worries you have no control over: an exercise that helps you set them down.

1. Set a “worry time”. Every day at the same hour, for ten to fifteen minutes, not right before bed. This is the only time you are allowed to really worry.
2. During the day, just write the worry down. When it appears, note it in a few words on a slip of paper or in your phone and tell yourself: “I’ll come back to you at six.” Then return, with your full attention, to what you were doing.
3. At the agreed time, read the list. For each worry ask: is this something I can solve? If yes, write down one concrete step. If not, mark it as an “open question”.
4. Write a prediction for each worry. What exactly do you expect to happen, and by when? In a week or two come back and check what actually happened.
5. When the time is up, stop. Even if you haven’t finished. Notice what it is like to leave something unfinished, and do something that brings you back into your body — a short walk, a shower, tidying up.

For the first few days it will probably go badly. Worries will slip out of the agreed time and you will feel it isn’t working. That is to be expected. What matters is not that you succeed, but that you begin to notice worry can wait — and that the world doesn’t fall apart in the meantime.

What helps: psychotherapy, CBT and medication

The good news is that generalised anxiety disorder is well researched and that effective forms of help exist. A meta-analysis published in 2014 by Pim Cuijpers and colleagues showed that psychological treatment clearly reduces symptoms compared with waiting lists or no treatment.

The best researched is cognitive behavioural therapy (a short explanation is in the knowledge base under cognitive behavioural therapy). With this disorder it focuses on intolerance of uncertainty, beliefs about worry, avoidance and physical tension. Metacognitive therapy, which does not test the content of worries but one’s relationship to them, is also well supported. Approaches based on mindfulness and acceptance help worries to be noticed without having to be followed.

Relational and psychodynamic approaches are about understanding where the worry came from and what keeps it going in relationships. It often turns out that worry doesn’t circle only in one person’s head, but in the whole system — in a couple where one worries for both, or in a family where worry is the language of love. Once this is understood, space opens up for other ways of connecting.

Medication is part of the guidelines for generalised anxiety disorder and helps many people a great deal, especially when symptoms are severe or therapy alone is not enough. Decisions about medication, its type, dose and duration, belong with a doctor — in Slovenia, first with your GP, who can refer you to a psychiatrist. Even with sedatives that relieve anxiety quickly, it matters that you take them only as your doctor directs. Never stop medication on your own, even when you feel better. Therapy and medication do not exclude each other; they often work together.

One more thing matters here: the physical symptoms of anxiety — a pounding heart, digestive trouble, headaches, fatigue — can overlap with physical illnesses, for example thyroid problems. So it makes sense to be examined by a doctor before treatment begins. Not because anxiety is “all in your head”, nor because it must be something else, but so that both possibilities have been checked.

When it isn’t generalised anxiety disorder

I want to be careful here, because labels stick quickly.

Not every big worry is a disorder. Someone caring for a sick parent, in insecure employment or living in a dangerous relationship worries for good reason. Then worry isn’t excessive — it is a response to real circumstances. What helps here is not working on intolerance of uncertainty, but support, a change of circumstances and sometimes practical help. If you live in a relationship where you are afraid, call the SOS helpline for women and children victims of violence on 080 11 55 in Slovenia, or 113 in an emergency.

Worry can be part of another difficulty. In depression, thoughts often circle around guilt and hopelessness. In obsessive-compulsive disorder, intrusive thoughts are of a different kind and come with compulsions. In post-traumatic stress, the readiness is a consequence of something that has already happened. Telling these apart is not the job of a blog post, but of a professional who sees you in person.

Temperament counts too. Some people are more cautious and alert to danger from childhood. That is not an illness, but the way their nervous system is built. It only becomes a disorder when that caution starts taking more than it gives. I have written more about what happens in the body during anxiety in What happens in the brain during anxiety.

And finally: if, alongside the worries, thoughts come that life isn’t worth living, don’t wait. Call the mental distress line Klic v duševni stiski on 01 520 99 00 in Slovenia (7 pm to 7 am) or the Samaritans helpline on 116 123 in Slovenia (every day, 24 hours), and in an emergency 112.

What to remember

• In generalised anxiety disorder worry changes subject, lasts most days for at least half a year and comes with physical tension.
• The core is often not the content of the worry but intolerance of uncertainty — difficulty staying in an open question.
• Worry is an attempt at control; because most worries don’t come true, it wrongly takes the credit.
• Cognitive behavioural therapy and other forms of psychotherapy help; talk about medication with a doctor or psychiatrist.
• Only a professional who sees you in person can make a diagnosis — a blog post can only give you a better map.