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Generalised Anxiety Disorder

Anxiety is a characteristic feature of most people. In it’s ‘normal’ form, it helps with vigilance, learning and general performance. In short, anxiety is useful. However, in excess it starts to work against us. Extremes of self-focus and apprehension quickly reduce attention and performance, perhaps aggravated by that particular blend of emotions (such as anger, shame, guilt or sadness mixing with a dominating fear) that make up each person’s unique ‘anxiety’.

Generalised Anxiety Disorder (GAD) is characterised by chronic worry about all sorts of life problems and circumstances. It will differ from normal worrying through the intensity, frequency and perceived uncontrollability of the worry thoughts. There might be a biological basis to GAD where some people are more likely to over-respond to life stressors; and studies of families show there is a chance of some genetic influence.

GAD is possibly the most common anxiety disorder, affecting 5-6% of the population.

It seems likely that Separation Anxiety Disorder (SAD) and GAD are related in children and adolescents depending on psychological development. That is ‘life worries’ will present at different levels and will be concerned with different sources according to a child’s physical and emotional age. A child with SAD alignment will probably worry about the attachment figure disappearing and be clingy and focus heavily on help-seeking; while the GAD aligned child will worry excessively about his or her adequacy in many areas and be constantly focused on personal shortcomings. Various studies have shown SAD and GAD as affecting around 6-7% of children with SAD predominating at age 11 and GAD at age 15.

To be defined as a ‘disorder’ GAD must involve unrealistic or excessive worry about two or more life circumstances for six months or more. During this time there will be more worry days than worry free days. This worry should also involve three or more of the following six symptoms in adults but only one for children:

· Restlessness or feeling keyed up or on edge

· Being easily fatigued

· Difficulty concentrating or mind going blank

· Irritability

· Muscle tension

· Sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep)

Additionally, the worry should not be about having a panic attack as in fear of the attack. People with GAD who panic do not fear the symptoms of the attack, (fear they are going to die or go mad); rather they understand that the attack is a symptom of the GAD. To be diagnosed as GAD the disorder should also not involve problems of a social nature that would be included under the classification of Social Anxiety Disorder (SA); or contamination such as in OCD; or being away from home or away from depended-upon people as might be seen in Agoraphobia and Separation Anxiety; or involve irrational fears about having a serious illness (Hypochondriasis [HC]). GAD should also not be the diagnosis if it only occurs during clinical depression; however, it is notoriously difficult to separate GAD and depression.

GAD frequently first occurs in adulthood. One study suggests that being over 24, separated, divorced or widowed, unemployed and a homemaker (and presumably female as the ratio appears to be 2:1 female for this disorder) shows a higher risk of contracting GAD, (Wittchen et al). However, GAD often appears to occur at a very early age and many people have no clear concept of when anxiety began to interfere with their lives. This is very commonly seen within Anxiety Care for all anxiety disorders (perhaps barring agoraphobia), as onset is often slow with no clear line between ‘well and not’.

When the onset is later in life this is likely to be in response to some stressing event and Brown reports the findings of Blazer et al as suggesting that the occurrence of one or more ‘negative life events’ increased by threefold the risk of developing GAD in the following year. In this type of GAD it is obviously important to differentiate between this disorder and post-traumatic stress disorder (PTSD), which should be done by a clinician. Work cited by Brown (Brown et al; Starcevic) suggests that it can also be difficult to separate GAD from various forms of depression as mentioned above.

It might be possible to speculate that early onset of GAD is a different form of the disorder from that occurring in later life, or perhaps is more to do with the person’s personality, life situation and allied anxious tendencies when occurring in childhood. However, concerning onset, there is further research that suggests it can be as far back as a person can remember and that GAD sufferers tend to present with a lifetime history of anxiety, apprehension and physical symptoms (various, Rapee 1991 p78; Sanderson & Wetzler 1991 p131).

Family and finance are usually the most common subject of the worrying. In GAD this worry could concern strong feelings of threat, perhaps misconceptions of situations coupled with a highly sensitive internal readiness to acquire threatening information. That is, GAD sufferers may be expecting to be frightened and they will probably ascribe the most threatening scenarios to these situations and tend to believe that the situation in question is uncontrollable. This will be aggravated by the mentioned focus on the self, which may intensify the emotional experience, and, perhaps, by depression which is often a hidden component of GAD. To a person whose overall energy is lowered by depression, the world is a very anxiety provoking place.

GAD co-occurs with other anxiety disorders, particularly simple phobia and social anxiety, and research also suggests that people with depressive disorders are more likely to have GAD as well than are people with other anxiety disorders. Brown discusses research that suggests that GAD is the most common co-morbid disorder in people seeking treatment for other anxiety disorders and depression (Brown et al; Sanderson et al). Brown also cites research that suggests that GAD may be the ‘most commonly occurring emotional disorder’ in people who go to their doctors with stress-associated disorders such as irritable bowel syndrome and chronic headaches, (Blanchard et al.).

People with GAD feel anxious regardless of the situation they are in. This is in contrast to phobics and most obsessive/compulsives, whose anxiety relates directly to a specific activity or other stimulus. GAD symptoms may vary from mild anxiety (feeling tense and worried), to palpitations, nausea, chest pains, difficulty in breathing, dizziness, vertigo, feeling ’unreal’, having ‘jelly legs’, intense sweating, faintness, restricted vision and hearing and feelings of impending insanity or death (i.e., panic symptoms). GAD sufferers also tend to ‘startle’ more easily than other people. They will often be regular visitors to their family physician and will probably have had tests for physical problems to do with the stomach and chest as most sufferers are likely to present with concern about physical symptoms rather than to understand that their problem is anxiety based. Research by Schweizer & Rickels suggests that GAD is twice as common in people visiting doctors’ offices than is found in community samples.

Like other anxiety conditions, this disorder has nothing to do with insanity. As mentioned above, GAD sufferers also tend not to worry so much about their symptoms as do people with Panic Disorder and similar problems, as they will be aware that they are not harmful. However, worry in GAD seems to be, as well as uncontrollable, a focus on verbal activity, thoughts, rather than images; and is conscious, attention-demanding and difficult to switch off. This may allow GAD sufferers to avoid thinking about the feared situations in a rational manner, so leaving them unable to work through their problems. In this way anxiety is maintained. Worry may also be reinforced by the frequent non-occurrence of feared situations. That is, sufferers may see their worry reaction almost in a superstitious form: as if a lot of worry somehow buys off the terrifying outcomes. GAD sufferers may be ‘chronic worriers’ seeking treatment only as a last resort and relying mainly on self-help or GP prescribed medications.

People with GAD usually manage to face what they fear, but sometimes they find this difficult or even impossible. If their anxiety reaches a panic level, they may easily fear losing control of themselves, which is understandable, as there is no obvious trigger for the panics. If such anxiety or panic remains unfocused, the sufferer's life will not be as pleasant as it might be, but it need not be too restricted. Up to a third of normal young adults report panic attacks from time to time. However, if the anxiety begins to focus on particular situations, such as being far from home or mixing socially, and the person begins to escape from situations where anxiety occurs (i.e. avoidance begins) the GAD is probably changing into an anxiety disorder such as agoraphobia or social anxiety, or perhaps laying fertile ground for the parallel growth of such a disorder.

Most phobic conditions are best treated by some form of ‘exposure’, in the course of which the sufferer learns to face the dreaded situation in a systematic way. People become `sensitised’ to fear by irregular exposure to it, usually coupled with rapid flight. The instant drop in tension that takes place when they flee makes this addictive. ‘Habituation’ is the opposite of this, allowing a person to become used to the anxiety at a level they can manage, by gradually exposing themselves to it, without avoiding or running from the situation.

In GAD, exposure work like this would not be helpful unless the sufferer, and whoever was helping him or her, was prepared to spend a good deal of time recording all the occasions when anxiety rose, in order to discover whether or not there was a particular activity or situation causing it. However, these efforts might well be fruitless, where the problem had no particular focus, as is frequently the case in GAD.

Benzodiazepines (any of them), seem to be the current chemical treatment of choice for GAD although research reported in Gliatto (p,7 Hales et al; Schweizer) suggests that an optimum level and duration of medication is difficult to ascertain, and that 25% of patients relapse within one month after cessation of medication and 60-80% within one year. However, it seems that patients treated for in excess of six months with medication have a lower relapse rate after cessation. Hoen-Saire & Mcleaod suggest that it is rare for a person to become addicted to therapeutic doses of benzodiazepines. However, people can become dependent and withdrawal symptoms tend to occur when the medication is discontinued. These symptoms can be hard to differentiate from a recurrence of anxiety. Withdrawal symptoms are likely to be higher with larger doses, with rapid reduction of doses and with concurrent tobacco usage. Dependency risk increases as the dosage and duration of treatment increases, but can occur even when appropriate doses are used for three months.(Gliatto p9).

Antidepressants are also often used with GAD and these will be most useful where there is a con-current depressive problem. Whether or not the prescribing physician is willing to use a ‘cocktail’ of antidepressants and benzodiazepanes will depend on his or her assessment of the disorder.

Cognitive therapy can also be useful. This focuses on thoughts and the way an individual processes these thoughts; assumptions about life and people; and beliefs. The cognitive therapist tries to help an individual to recognise and change faulty thinking patterns. There is a range of booklets on this site that look at erroneous or damaging thinking; see: ‘Obsessional Thinking’; ‘Guilt and Shame’, ‘I know I’ve got to do it myself, but...?’

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References and source material

Barlow, D.H. (1988) Anxiety and its Disorders. New York: Guildford Press (As seen in Edelmann 1992 p.141)

Barlow, D.H. (1991) The Nature of Anxiety; Anxiety, Depression and Emotional Disorders in Rapee, R.M. & Barlow, D.H. 1991.(Editors)

Barlow, D.H., Blanchard,E.B., Vermilyea, J.A., Vermilyea,B.B. & DiNardo,P.A. (1986a) Generalized Anxiety and generalized anxiety disorder: Description and reconceptualization. American Journal of Psychiatry, 143, 40-44. As seen in Edelmann 1992 p.139)

Blanchard EB, ScharffL, Schwarz SP, Suls JM, Barlow DH,. The role of anxiety and depression in the irritable bowel syndrome. Behav Res Ther 1990;28:401-5

Blazer DG, Hughes D, George LK. Stressful life events and the onset of the generalized anxiety disorder syndrome. Am J Psychiatry 1987; 144:1178-83 (as seen in Brown, Timothy A., 1997)

Brown, Timothy A, PsyD, The Nature of generalized Anxiety Disorder and Pathological Worry: Current Evidence and Conceptual Models. Can J Psychiatry Vol 42, October 1997

Brown TA, Barlow DH. Comorbidity among anxiety disorders: implications for treatment and DSM-IV. J Consul Clin Psychol 1992;60:835-44

Brown TA, Marten PA, Barlow DH. Discriminate valididty of the symptoms constitiuting the DSM-III-R and DSM-III-IV associated symptom criterion of generalized anxiety disorder. Journal of Anxiety Disorders 1995;9;317-28

Diagnostic and Statistical Manual of Mental Disorders 3rd edition revised (DSM-III-R 1987) American Psychiatric Association, Washington D.C. USA (As seen in Edelmann 1992 p.139)

Diagnostic and Statistical Manual of Mental Disorders 4th edition (DSM-IV 1994). American Psychiatric Association, Washington D.C. USA

Edelmann, Robert J. (1992) Anxiety - Theory, Research and Intervention in Clinical and Health Psychology. John Wiley & Sons

Gilbert, Paul (1992) Depression, The Evolution of Powerlessness, Lawrence Erlbaum Associates Ltd, Hove, East Sussex

Greist, J.H. (1989) Obsessive/compulsive Disorder: A Guide. University of Wisconsin.

Izard, C.E. (Ed.) 1977, Human Emotions, New York: Plenum Press - as seen in Rapee, R. M. and Barlow, D. H. (Editors) 1991 p.2

Hales RE, Hilty DA, Wise MG. A treatment algorithm for the management of anxiety in primary care setting. J Clin Psychiatry 1997;58(suppl 3):76-80

Hoehn-Saire R, Mcleod DR. Clinical management of generalized anxiety disorder. In: the clinical management of anxiety disorders. Coryell W, Winokur G, eds. New York: Oxford University Press, 1991;79-100 (as seen in Gliatto, MF)

Gliatto, MF,M.D. Generalized Anxiety Disorder. American Family Physician.

Izard, C.E. & Blumberg, M.A. (1985) Emotion theory and the role of emotions inanxiety in children and adults. In A.H. Tuma & J.D. Maser (Eds.): Anxiety and the anxiety disorders. Hillsdale, NJ: Erlbaum. As seen in Rapee, R. M. and Barlow, D. H. (Editors) 1991. p.2

Marks, I.M. (1981) Cure and care of neurosis. New York: Wiley (As seen in Current Approaches- Obsessive/compulsive Disorder p.27 (1990) Duphar Laboratories Limited.)

Marks, I.M. (1987) Fears, Phobias and Rituals. Oxford University Press

Mathews, A., & Macleod, C. (1987). An information-processing approach to anxiety. Journal of Abnormal Psychology, 98 236-40. As seen in Rapee, R. M., and Barlow, D. H., (Editors) 1991 p.79

Rapee Ronald M. Psychological Factors Involved in Generalized Anxiety, in Rapee, R.M. & Barlow D.H. (Editors) (1991)

Rapee, Ronald M. and Barlow, David H. (Editors) (1991), Chronic Anxiety, Generalized Anxiety Disorder and Mixed Anxiety Depression, The Guildford Press, New York , U.S.A.

Salkovikis, P.M. (1990) Cognitive Factors in Obsessive/compulsive Disorder. Current Approaches - Obsessive Compulsive Disorder. Duphar Laboratories Limited.

Sanderson WC, Beck AT, Beck J. Syndrome comorbidity in patients with major depression or dysthymia: prevalence and temporal relationships. Am J Psychiatry 1990;147;1025-8

Sanderson William C. and Wetzler, Scott (1991) Chronic Anxiety and Generalized Anxiety Disorder : Issues in Comorbity in Rapee, R.M. & Barlow D.H.,(Editors) (1991).

Schweizer E, Generalized anxiety disorder. Longitudinal course and pharmacologic treatment, Psychiatr Clin North Am 1995;18:843-57

Schweizer E, Rickels K. Strategies for treatment of generalized anxiety disorder in the primary care setting. J Clin Psychiatry 1997;58(suppl 3):27-33 (As seen in Brown Timothy 1997)

Starcevic V. Pathological worry in major depression: a preliminary report. Behav Res Ther 1995;33:55-6 (as seen in Brown Timothy, 1997)

Witchen, Hans-Ulrich and Esau, Cecilia A (1991) The Epidemeology of Panic Attacks, Panic Disorder, and Agoraphobia (Chapter3) Panic Disorder and Agoraphobia, A comprehensive guide for the Practitioner, ed. John R. Walker, G. Ron Norton and Colin A. Ross. California : Brooks/Cole Publishing Company

Wittchen ,HU, Zhao S., Kessler RC, Eaves WW. DSM-III-R generalized anxiety disorder in the National Comorbidity Survey. Arch gen Psychiatry 1994; 355-64 (as seen in Brown, Timothy A, PsyD, 1997).

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