Generalized Anxiety Disorder

Definition and usual symptoms of Generalized Anxiety Disorder

Generalized anxiety disorder is a psychiatric disorder in which the individual experiences significant anxiety and worry about a number of events or activities and this anxiety occurs repeatedly i.e. it is chronic.

Specific and observable criteria for generalized anxiety disorder are provided in the Diagnostic and Statistical Manual , 4th Edition, (DSM-IV) of the American Psychiatric Society. The DSM-IV criteria include the following:

• Unusually intense anxiety and worry occurring "more days than not for at least six months"

• The person finds it difficult to reduce this worry

• The anxiety and worry are related with three or more of the following symptoms:
  • Restless feeling, being keyed up or on edge
  • Easily fatigued
  • Difficulty concentrating or mind going blank
  • Irritability
  • Muscle tension
  • Disturbed sleep for example difficulty falling or staying asleep or unsatisfying sleep. Nett et al (2002) in their review of generalized anxiety disorder also mention muscle tension and insomnia. They pointed out that an additional characteristic of generalized anxiety disorder is hypervigilance which is abnormal watchfulness for possible dangers.

Lifetime prevalence

A large epidemiological US survey found a lifetime prevalence for generalized anxiety disorder of 5.7% putting it as the tenth most frequent psychiatric disorder and the fourth most frequent anxiety disorder in this study (Kessler et al, 2005).

Causes (Aetiology)

There is considerable evidence for a genetic contribution to the aetiology of generalized anxiety disorder (Fung at al, 2010). My own clinical experience leads me to the conclusion that childhood trauma (codependence, complex PTSD) can also be causative or at least, a contributing factor to the development of generalized anxiety disorder.

Indeed there is research to support this clinical observation (Safren et al, 2002). I have also found clinically, that alcohol abuse and/or dependence is frequently associated with generalized anxiety disorder. While much of alcohol use can be an attempt to reduce the anxiety, the effect is short lived and its long term effect increases anxiety and sensitivity to environmental stressors.

Treatment

There are important reasons to make sure that persons with generalized anxiety disorder receive adequate treatment. Firstly, those with this condition frequently also have other mental disorders and or somatic conditions. That is, pure generalized anxiety disorder is infrequent and it is usually accompanied by various other psychiatric and physical conditions.

This high rate of co-morbidity generally makes generalized anxiety disorder as debilitating as that experienced by those with major depressive disorder (Katzman, 2009).

Secondly, the less obvious and less severe symptoms of generalized anxiety disorder probably caused it to be less recognized and treated.

Thirdly, persons with generalized anxiety may resort to maladaptive strategies to reduce their anxiety e.g. alcohol abuse or dependence, tranquilizer addiction, or a behavioral addiction of some kind e.g. distraction with computer games.

A variety of treatment approaches are available for generalized anxiety disorder including the following:

• Cognitive behavioral therapy (CBT) has been demonstrated to be effective in ameliorating generalized anxiety disorder (Dugas & Koerner, 2005). Dugas and Koerner list six main components: "presentation of treatment rationale (learning to cope with uncertainty); worry awareness training; re-evaluation of the usefulness of worrying; problem-solving training; cognitive exposure; and relapse prevention.”

• Pharmacological approaches to the treatment of generalized anxiety disorder have been used for over 50 years. The long and controversial history of the use of benzodiazepines (tranquillizers) in treating anxiety disorders in general and generalized anxiety disorder in particular has recently been discussed by Lader (2011). Lader ended his review with the following conclusion:
  
  “The practical problems with the benzodiazepines have persisted for 50 years, but have been ignored by many practitioners and almost all official bodies. The risk-benefit ratio of the benzodiazepines remains positive in most patients in the short term(2-4 weeks) but is unestablished beyond that time, due mainly to the difficulty in preventing short-term use from extending indefinitely with the risk of dependence.”
  
  More recently antidepressants have been used with generalized anxiety disorder. In a recent review, Katzman (2009) states “The consensus across current treatment guidelines is that first-line treatment for patients with GAD Generalized anxiety disorder) should consist of an antidepressant, either a selective serotonin reuptake inhibitor (SSRI) such as sertraline, paroxetine or escitalopram, or a selective serotonin noradrenaline (norepinephrine) reuptake inhibitor (SNRI) such as venlafaxine or duloxetine.
  
  Evidence from early clinical studies of the atypical antipsychotics in the treatment of anxiety and GAD indicate that they may have a potential role in the treatment of GAD, either as monotherapy or as augmentation to standard treatment.” The development of drug dependence seems less of a problem for these antidepressant medications.

• Recently exercise training has been shown to be useful in the treatment of generalized anxiety disorder (Herring et al, 2011). Exercise is obviously a relatively safe intervention with a number of positive “side effects” e.g. cardiovascular fitness.

References

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders. (4th ed., text rev.) Washington, DC: Author.

Dugas, M. J., & Koerner, N. (2005). Cognitive-Behavioral Treatment for Generalized Anxiety Disorder: Current Status and Future Directions. Journal of Cognitive Psychotherapy, 19(1), 61-81.

Fung, W. L. A., McEvilly, R., Fong, J., Silversides, C., Chow, E., & Bassett, A. (2010). Elevated prevalence of generalized anxiety disorder in adults with 22q11.2 deletion syndrome. The American Journal of Psychiatry, 167(8), 998.

Herring, M. P., Jacob, M. L., Suveg, C., Dishman, R. K., & O'Connor, P. J. (2011). Feasibility of exercise training for the short-term treatment of generalized anxiety disorder: A randomized controlled trial. Psychotherapy and Psychosomatics, 81(1), 21-28.

Katzman, M. A. (2009). Current considerations in the treatment of generalized anxiety disorder. CNS Drugs, 23(2), 103-120.

Kessler, Ronald C., Berglund, Patricia, Demler, Olga, Jin, Robert, Merikangas, K. R., Walters, Ellen E., (2005). Lifetime Prevalence and Age-of-Onset Distributions of DSM-IV Disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, Vol. 62(6), 593-602.

Lader, M. (2011). Benzodiazepines revisited—Will we ever learn? Addiction, 106(12), 2086-2109.
Nutt, D. J., Ballenger, J. C., Sheehan, D., & Wittchen, H.-U. (2002). Generalized anxiety disorder: Comorbidity, comparative biology and treatment. International Journal of Neuropsychopharmacology, 5(4), 315-325.

Safren, S. A., Gershuny, B. S., Marzol, P., Otto, M. W., & Pollack, M. H. (2002). History of childhood abuse in panic disorder, social phobia, and generalized anxiety disorder. Journal of Nervous and Mental Disease, 190(7), 453-456.