Generalized Anxiety Disorder: Psychological Mechanisms

Psychological Mechanisms

Cognitive–Behavioral Model

Psychological models, which emphasize the cognitive–behavioral processes involved in the onset and maintenance of GAD, have emerged in recent years. Individuals’ thoughts, cognitive style and behaviors are thought to instigate and maintain episodes of anxiety. In support of cognitive theories of GAD, anxious indi-viduals with GAD are more likely to perceive ambiguous infor-mation as threatening and/or negative, and to perceive that they are more likely than others to experience threatening situations. Patients with GAD also pay more attention to the detection of po-tentially threatening information and incorporate this informa-tion into highly elaborate cognitive schemas, thus lowering their threshold for activation of an anxiety response. The threatening information then elicits anxious affect and the individual begins to worry in an attempt further to define the problem.

Patients with GAD are likely to be characterized by a per-ception of lack of control over threatening. In addition, these pa-tients are likely to believe that they have little control over their emotions, especially their worrying, leading to further distress. It has been suggested that the interaction between perceived uncon-trollability and a cognitive focus on negative/threatening stimuli may amplify the general worry to pathological.

Psychodynamic Theories

Freud’s concept of signal anxiety followed the development of Freud’s structural model of the mind, which proposes three inter-acting psychological functions: ego (which mediates between the demands of primitive drives, the social and parental prohibitions, and reality), superego (representing the internalized parental and social prohibitions) and id (representing the primitive drives and urges). Freud believed that anxiety serves as a signal to the ego of a threat (in the form of an unconscious drive or wish arising from the id), which, if enacted, may be dangerous to the ego, signaling the potential punishment by the superego or the external world. According to this model, the ego can activate defense mecha-nisms, such as repression, and prevent the actualization of the forbidden urge either by preventing the expression of the wish or by avoiding the life situations in which the wish might be poten-tially expressed. Ideally, repression into the unconscious (i.e., out of subject’s awareness) should successfully contain the drives. However, if the defenses fail, one may experience symptomatic anxiety and other distressing psychological symptoms. Implicit in this model is the concept that the individuals themselves are not consciously aware of these processes. Therefore, the promo-tion of subjects’ insight into unconscious conflicts and the uncov-ering of the unconscious origins of anxiety through interpreta-tion and other techniques is the primary goal (and method) of the psychoanalytic treatment approach.

Sullivan developed a theory of anxiety based on the im-portance of interpersonal relationships. He viewed affects (such as anxiety) as forms of interpersonal communication. According to this model, anxiety communicates the sense of insecurity in interpersonal relationships. For example, a mother who is inse-cure in her role may communicate her insecurity to the infant when she is anxious in her child’s presence. The child in turn identifies her anxiety and expresses anxious affect himself. An-other approach to the understanding of the origins of anxiety was offered by object relations theorists such as Klein and Bowlby. They believed that anxiety reflects a fear of the loss of the nurtur-ing object or fear of being hurt by the antagonistic object.

Finally, self-psychology theorists, such as Kohut, believed that the individual strives to achieve and maintain an integrated, cohesive sense of self. Beginning in early age, the individual devel-ops this sense of self through idealization of important others, such as important caregivers (called self-objects), and through a proc-ess of positive interaction with caregivers (called mirroring). He believed that inadequate provision of these experiences can lead to anxiety (fear of disintegration) and the loss of the cohesive self.