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Objectives:

1. Examine Generalized Anxiety Disorder.

2. List emotional, behavioral, and physical signs and symptoms of Generalized Anxiety Disorder.

3. Discuss non-pharmacological treatment options for Generalized Anxiety Disorder.

4. Discuss pharmacological treatments and their side effects for Generalized Anxiety Disorder.

5. Indicate the prognosis for the disease of Generalized Anxiety Disorder.

 

Overview:

Generalized Anxiety Disorder

Generalized anxiety disorder (GAD) is a psychiatric condition that is the most common of the category of anxiety disorders. GAD begins gradually, usually in childhood or adolescence, but can also begin in adulthood. It is more common in women and is genetic, often occuring also in relatives of those affected. Each year, 3.1 percent of people ages 18 and 54 are affected by GAD, and approximately 6.8 million American adults have it.

The key traits are: worrying, anxiety, and fear. A person with GAD is excessively thinking and dwelling on what can be referred to as, "what if’s". This means someone suffering from GAD might have a tendency to dwell excessively on the past and what might have been, things he or she considers have gone wrong in his or her life, or other problems that exist in the past he or she wishes could be corrected. As a result, the person can feels that there is no way out of the vicious cycle of anxiety and worry, and then becomes depressed about life and the state of anxiety he or she find one’s self in.

Whereas some anxiety disorders causes people to avoid certain situations and have panic attacks, this does not happen with GAD. GAD involves the constant thinking and dwelling on anxieties and the inability to shut the mind off of these anxieties. At other times, thoughts seem almost non-existent because the anxious feelings are so dominant. Feelings of worry, dread, lack of energy, and a loss of interest are common. Usually there is no trigger or reason for these feelings and the person can even realize that these feelings being experienced are essentialy irrational. Nevertheless, the feelings are very real. At this point, there is no "energy" or "zest" in life and no desire to want to do much.

Often times the emotional fear and worry is extremely strong as the person’s mind runs through “worst case scenarios”. For example, if someone is suffering from GAD and her husband is ten minutes late, the person with GAD will fear the very worst and think something’s dreadfully wrong. She could think there has been a car accident and the husband is injured or dead. Feelings of fear and anxiety come from these thoughts and the vicious cycle of anxiety and depression never ends.

People with GAD can have anxiety and mood fluctuations that can change from hour to hour or from day to day. Others do better in the morning, and others find it easier at the end of the day. These anxiety feelings and moods feed on themselves, leading the person to continue in the pattern of worry and anxiety unless something breaks the cycle.

People with GAD feel their worries come from the outside—from triggers such as other people or situations. In reality, the worrying is self-generated and the triggers come from inside the patient’s brain causing the patient to worry. When patients worry, they are talking to themselves about things they are afraid of or negative events that they suppose might happen. They run over the feared situation in their mind and think about all the ways they might deal with it. They are trying to solve problems that haven’t happened yet, or worse, simply obsessing on worst-case scenarios. All this worrying may give them the impression that they are protecting themselves by preparing for the worst or avoiding bad situations. But more often than not, worrying is unproductive—sapping mental and emotional energy without resulting in any concrete problem-solving strategies or actions. The way to tell if the patient is experiencing productive or unproductive worrying is if by asking the patient if he or she is running over “what if” scenarios. If they are, the worrying is considered unproductive.

Diagnosing GAD

GAD is diagnosed by a doctor or mental health professional, who can determine if the signs and symptoms are related to an anxiety disorder or another medical condition.

Signs and Symptoms

The symptoms of generalized anxiety disorder (GAD) fluctuate. Symptoms can be better or worse at certain times of the day or the person may have better or worse days. And while stress doesn’t cause generalized anxiety disorder, it can make the symptoms worse. A person with GAD probably will not experience all of these symptoms listed below. Most experience a combination of emotional, behavioral, and physical symptoms.

Emotional Symptoms

• Worrying constantly
• Feeling like the anxiety is uncontrollable; there is nothing you can do to stop the worrying
• Trying to avoid thinking about the worries but you can’t
• Worrying about what’s going to happen in the future
• Strong feelings of apprehension or dread

• Need for frequent reassurance and approval
• Normal life stresses aggravate generalized anxiety
• Inability to stay focused

Behavioral Symptoms

• Inability to relax, enjoy quiet time, or be by yourself
• Difficulty concentrating or focusing
• Putting things off because you feel overwhelmed
• Avoiding situations that make you anxious

Physical Symptoms

• Feeling tense; having muscle tightness or body aches
• Sleep disturbances, having trouble falling asleep or staying asleep because your mind won’t quit
• Feeling edgy, restless, or jumpy
• Stomach problems, nausea, diarrhea
• Headaches, trembling, twitching, irritability, frustration, inability to concentrate, quick to startle
• Lack of ability to fully relax
• Inability to be peaceful, tranquil, and reflective

Non-Pharmacological Treatment for GAD

• Cognitive-behavioral therapy (CBT) has been shown to respond best to GAD. This form of active therapy involves gradually learning to see situations and problems in a different perspective. It also helps a person learn new methods and techniques to use to alleviate and reduce anxiety. Research indicates that generalized anxiety is fully treatable and can be successfully overcome over the course of about three to four months if the person is motivated and works toward recovery. Once patients have given up the idea that worrying somehow helps them, they can start to deal with their worry and anxiety in more productive ways. This may involve challenging irrational worrisome thoughts, learning how to postpone worrying, and learning to accept uncertainty in their lives.
• Self-soothing uses one or more of the physical senses: vision, hearing, smell, taste, and touch. When anxieties increase view something pretty or interesting; listen to soothing music or enjoy sounds of nature; enjoy smells from candles, perfumes, flowers or baked goods; eat or drink favorite meals or beverages; and use of touch by petting an animal or getting a massage.

• Biofeedback or Progressive muscle relaxation can help release muscle tension and take a “time out” from worries. The technique involves systematically tensing and then releasing different muscle groups in the body. As the body relaxes, the mind will follow.
• Deep breathing slows down breathing. When people get anxious, they breathe faster which can cause symptoms such as dizziness, breathlessness, lightheadedness, and tingly hands and feet. These physical symptoms are frightening, leading to further anxiety and panic. But by breathing deeply from the diaphragm, you can reverse these symptoms and calm one’s self down.
• Meditation (specifically mindfulness meditation) has been shown to reduce anxiety. Research shows that mindfulness meditation can actually change the function of the brain. With regular practice, meditation boosts activity on the left side of the prefrontal cortex, the area of the brain responsible for feelings of serenity and joy.
• Leading a Healthy Lifestyle such as eating a well balanced meal including complex carbohydrates to keep blood sugars stable, thereby reducing drops in blood sugar which can cause anxiety. Stop drinking or cut back on caffeinated beverages, as they can increase anxiety, interfere with sleep, and even provoke panic attacks. Reduce the amount of refined sugar eaten that would cause blood sugar to spike and then crash. This will leave a feeling of being drained, which can lead to anxiety. Exercise is a natural way to decrease anxiety. Aerobic exercise relieves tension and stress, boosts physical and mental energy, and enhances well-being through the release of endorphins, the brain’s feel-good chemicals. Avoiding alcohol also may temporarily reduce anxiety and worry, but it actually causes anxiety symptoms as it the effects of alcohol, especially long-term use or abuse, wears off. Alcohol can also cause dependence. Nicotine in cigarettes may seem like it calms but it is actually a powerful stimulant which leads to higher levels of anxiety, so it should be avoided. Lack of sleep can contribute to anxiety as one’s ability to handle stress decreases the less sleep is received.

 

Pharmacological Treatment for GAD

Medication has been very successful as a stand-alone treatment for GAD and in conjunction with other therapies and self-help remedies. Medication can be short term or long term depending on individual circumstances. The physician should be contacted if side effects are experienced. None of the following medications should be discontinued abruptly as they may cause health risks.

• Selective Serotonin Reuptake Inhibitors (SSRIs)
  SSRIs relieve symptoms by blocking the reabsorption, or reuptake, of serotonin by certain nerve cells in the brain. This leaves more serotonin available, which improves mood. SSRIs (citalopram, escitalopram, fluoxetine, paroxetine, and sertraline) generally produced fewer side effects when compared with tricyclic antidepressants.  Side effects include: insomnia or sleepiness, sexual dysfunction, and weight gain. They are considered an effective treatment for all anxiety disorders.
• Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)
  Serotonin-norepinephrine reuptake inhibitor (SNRI) such as venlafaxine and duloxetine is notable for a dual mechanism of action. It increases the levels of the neurotransmitters serotonin and norepinephrine by inhibiting their reabsorption into cells in the brain. Side effects may include: stomach upset, insomnia, headache, sexual dysfunction, and minor increase in blood pressure. These medications are considered as effective as SSRIs, so they are also considered a first-line treatment, particularly for the treatment of generalized anxiety disorder.
• Benzodiazepines
  Benzodiazepines are frequently used for the short-term management of anxiety. Examples include: alprazolam, clonazepam, diazepam, and lorazepam and are highly effective in promoting relaxation and reducing muscular tension and other physical symptoms of anxiety. Long-term use may require increased doses to achieve the same effect, which may lead to problems related to tolerance and dependence.
• Tricyclic Antidepressants
  Examples of tricyclic antidepressants include: amitriptyline, imipramine, and nortriptyline. Although they are effective treatment options, they can cause significant side effects such as: orthostatic hypotension, constipation, urinary retention, dry mouth, and blurry vision.

Prognosis

In general, the outlook is good. With appropriate treatment, about 50% of patients improve within 3 weeks of starting treatment, and 77% improve within 9 months. However, the condition itself can last from a short time to years and even a lifetime.

References

White, H. (2013). Generalized Anxiety Disorder. American Journal of Psychiatry, 170(5), 563-564.

Hidalgo, R. B., & Sheehan, D. V. (2012). Generalized anxiety disorder. Handb Clin Neurol, 106, 343-362.

Torpy, J. M., Burke, A. E., & Golub, R. M. (2011). Generalized anxiety disorder. JAMA: The Journal of the American Medical Association, 305(5), 522-522.

Ravindran, L. N., & Stein, M. B. (2010). The pharmacologic treatment of anxiety disorders: a review of progress. The Journal of clinical psychiatry,71(7), 839-854.

Newman, M. G., Castonguay, L. G., Borkovec, T. D., Fisher, A. J., Boswell, J. F., Szkodny, L. E., & Nordberg, S. S. (2011). A randomized controlled trial of cognitive-behavioral therapy for generalized anxiety disorder with integrated techniques from emotion-focused and interpersonal therapies. Journal of consulting and clinical psychology, 79(2), 171.

Wetherell, J. L., Petkus, A. J., White, K. S., Nguyen, H., Kornblith, S., Andreescu, C., ... & Lenze, E. J. (2013). Antidepressant medication augmented with cognitive-behavioral therapy for generalized anxiety disorder in older adults. American Journal of Psychiatry.

Hanrahan, F., Field, A. P., Jones, F., & Davey, G. C. (2012). A meta-analysis of cognitive therapy for worry in generalized anxiety disorder. Clinical psychology review.

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