Introduction
As a psychodynamically trained therapist, I am deeply committed to understanding the unconscious processes that shape our emotions, behaviours, and overall mental health. Psychoanalytic theory provides invaluable insights into how early life experiences, unresolved conflicts, and internalised patterns can give rise to conditions such as Generalised Anxiety Disorder (GAD). It enables us to uncover the “why” behind the anxiety—the hidden fears, defence mechanisms, and relational dynamics that contribute to chronic worry.
However, while exploring the roots of GAD is essential for fostering long-term emotional growth and self-awareness, it is equally important to address the immediate, often overwhelming symptoms that individuals face in their daily lives. This is where structured, evidence-based interventions like Exposure Response Prevention (ERP) come into play.
ERP, a specialised tool within Cognitive Behavioural Therapy (CBT), offers practical and effective strategies for controlling and reducing the effects of GAD. By helping individuals confront their fears and break the cycle of avoidance, ERP empowers them to reclaim a sense of agency over their anxiety.
This article aims to bridge the gap between these two perspectives, demonstrating how psychodynamic understanding and ERP can work together to provide a holistic approach to managing GAD. While psychoanalytic insights illuminate the origins of anxiety, ERP offers actionable tools to mitigate its impact. Together, they offer individuals the opportunity not only to control their symptoms but also to cultivate deeper emotional healing and resilience.
Generalised Anxiety Disorder (GAD) is one of the most common mental health conditions, affecting millions of people worldwide. It is characterised by persistent and excessive worry about a variety of everyday issues, ranging from work and relationships to health and finances. While Cognitive Behavioural Therapy (CBT) and Exposure Response Prevention (ERP) are well-established tools for reducing the effects of GAD, understanding its underlying causes often requires delving into the psychodynamic perspective. By exploring both the origins of GAD and the tools to manage it, we can take a comprehensive approach to treatment.
What is Generalised Anxiety Disorder (GAD)?
GAD is a mental health condition defined by chronic and excessive worry about multiple areas of life. Unlike situational anxiety, which is triggered by specific events or challenges, GAD involves a pervasive sense of unease that is difficult to control. Symptoms include:
• Persistent worry that is disproportionate to the actual likelihood or severity of feared events.
• Physical manifestations such as muscle tension, fatigue, headaches, and sleep disturbances.
• Difficulty concentrating and a sense of restlessness or being “on edge.”
For individuals with GAD, everyday life can feel like a minefield of potential catastrophes, leading to a constant state of hypervigilance. The condition can interfere with work, relationships, and overall quality of life.
The Psychodynamic Perspective on GAD
The psychodynamic approach to mental health focuses on unconscious processes, childhood experiences, and the interplay of internal conflicts. From this perspective, GAD is not merely a result of cognitive distortions but is deeply rooted in unresolved emotional conflicts and relational patterns formed in early life.
1. Early Attachments and Fear of Separation
Psychodynamic theory often highlights the importance of early attachment relationships in shaping emotional development. For individuals with GAD, a history of insecure attachment—whether anxious, avoidant, or disorganised—may contribute to chronic anxiety. A child who experienced inconsistent caregiving, where love and support were unpredictably available, may grow into an adult with a heightened need for certainty and control. The chronic worry in GAD can be seen as a defence mechanism against deeper fears of abandonment or rejection.
2. Unresolved Childhood Conflicts
Early experiences of criticism, neglect, or overprotection can create internalised beliefs of inadequacy, danger, or vulnerability. For example, a child whose parents had excessively high expectations might develop a deep-seated fear of failure, which later manifests as a constant drive to pre-empt mistakes and catastrophes. These unresolved conflicts often remain unconscious but continue to influence emotional regulation and behaviour into adulthood.
3. The Role of Repression and Defence Mechanisms
From a psychodynamic standpoint, anxiety often arises when unconscious conflicts threaten to surface. For instance, an individual might repress feelings of anger or resentment towards a parent or partner due to a fear of confrontation or rejection. The energy required to suppress these emotions can manifest as free-floating anxiety, which attaches itself to various external concerns.
4. Perfectionism and the Inner Critic
The psychodynamic perspective also considers the role of the “superego”—an internalised critical voice that enforces societal and parental expectations. For individuals with GAD, the superego may be particularly harsh, creating a relentless sense of not being “good enough.” This can drive the perfectionism and overthinking often seen in GAD, as the individual constantly strives to meet impossible standards to avoid imagined consequences of failure.
Using ERP to Manage the Effects of GAD
While psychodynamic therapy provides insight into the origins of GAD, managing its symptoms in the present often requires structured tools like Exposure Response Prevention (ERP). ERP, a subset of CBT, is an evidence-based method that focuses on confronting anxiety triggers and breaking the cycle of avoidance that perpetuates anxiety.
How ERP Works
ERP involves two key components:
1. Exposure: Gradually facing situations, thoughts, or sensations that provoke anxiety.
2. Response Prevention: Resisting the urge to engage in avoidance or “safety” behaviours that temporarily reduce anxiety but reinforce it in the long term.
By repeatedly confronting feared situations without engaging in avoidance, individuals learn that anxiety diminishes over time—a process known as habituation.
Applying ERP to GAD
1. Identifying Triggers and Avoidance Behaviours
The first step in ERP is to identify the specific situations, thoughts, or sensations that trigger anxiety. Common triggers for GAD might include:
• Uncertainty about the future.
• Fear of making mistakes at work or in relationships.
• Physical sensations such as a racing heart, which can be misinterpreted as signs of illness.
Avoidance behaviours, such as over-preparing, seeking reassurance, or procrastinating, are then identified. For example, someone who worries excessively about financial security might compulsively check their bank balance multiple times a day.
2. Gradual Exposure
Once triggers are identified, the therapist works with the individual to create a hierarchy of feared situations, starting with those that provoke mild anxiety and gradually progressing to more challenging exposures. For example:
• Starting with delaying checking emails for 10 minutes instead of doing so immediately.
• Progressing to leaving an email draft unchecked and sending it without overthinking.
3. Preventing Safety Behaviours
Safety behaviours—such as over-researching, seeking reassurance, or avoiding decisions—offer short-term relief but reinforce the belief that anxiety can only be managed through avoidance. ERP encourages individuals to resist these behaviours. For instance:
• Instead of double-checking an email repeatedly, the individual is encouraged to send it after a single review.
• Instead of asking a partner for constant reassurance about their feelings, the individual is encouraged to tolerate the uncertainty.
4. Sitting with Anxiety
ERP helps individuals learn that anxiety, while uncomfortable, is not dangerous and will naturally subside over time. Through repeated exposures, the brain becomes desensitised to triggers, reducing the intensity and frequency of anxiety responses.
Integrating Psychodynamic Insight with ERP
While ERP is highly effective for reducing the effects of GAD, integrating psychodynamic insights can provide a more holistic approach to treatment. Understanding the unconscious origins of anxiety can help individuals make sense of their emotional patterns, fostering greater self-awareness and compassion.
For example:
• An individual who discovers that their chronic worry stems from a fear of disappointing a critical parent may use ERP to challenge the behaviour patterns that reinforce this fear.
• Someone who recognises their intolerance of uncertainty as a defence against childhood feelings of powerlessness can use ERP to confront this fear more consciously and constructively.
By combining psychodynamic exploration with the practical tools of ERP, individuals can address both the root causes and the symptoms of their anxiety.
The Role of Mindfulness
Mindfulness is a valuable adjunct to both ERP and psychodynamic therapy. It teaches individuals to observe their thoughts and emotions without judgment, fostering greater tolerance for discomfort. Mindfulness can also help individuals stay present during exposure exercises, reducing the urge to catastrophise or overanalyse.
Final Thoughts
Generalised Anxiety Disorder is a complex condition that requires a multifaceted approach to treatment. The psychodynamic perspective helps us understand the deeper emotional roots of anxiety, including unresolved childhood conflicts, attachment patterns, and defence mechanisms. Meanwhile, ERP provides practical tools to confront and reduce the symptoms of anxiety in daily life.
By combining these approaches, individuals can achieve a deeper sense of self-awareness and develop the skills needed to manage their anxiety effectively. While the journey requires effort and commitment, the rewards—greater emotional resilience, improved relationships, and a sense of inner peace—are well worth it.
If you are struggling with GAD, consider seeking help from a therapist trained in both psychodynamic therapy and CBT/ERP. With the right support, it is possible to break free from the cycle of chronic worry and rediscover a calmer, more balanced way of living.
By Ari Sotiriou
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