Generalized anxiety disorder

Definition

Generalized anxiety disorder, or GAD, is an anxiety disorder differentiated from other anxiety disorders defined by the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) by its characteristic of diffuse and chronic worry. Seniors with GAD may worry about almost anything having to do with ordinary life. Common worries associated with generalized anxiety disorder in older adults include money, physical health, personal safety, ability to keep up with household chores, and the well-being of family members. The International Classification of Diseases, tenth edition (ICD-10), which is the European equivalent of DSM-IV, describes the anxiety that typifies GAD as “free-floating”, which means that it can attach itself to a wide number of issues or concerns in the patient's environment. It is not unusual for a senior with GAD to say that they cannot remember the last time they felt completely relaxed and unworried.

Description

Generalized anxiety disorder is characterized by persistent worry that is excessive and that the patient finds hard to control. The worry must occur frequently over several months. The patient usually recognizes that his or her worry is out of proportion to any actual cause for concern in their present life. For example, a senior may worry about an accident happening to an adult son or daughter who commutes to work, even though the younger adult is a careful driver who has never been involved in an accident and does not have to commute long distances. The anxiety level of a patient with GAD may rise and fall somewhat over a period of weeks or months but tends to become a chronic problem. The disorder typically becomes worse during stressful periods in the senior's life, such as being diagnosed with a physical illness or mourning the death of a pet or loved one.

DSM-IV specifies that the senior's anxiety must be severe enough to interfere with work (if employed), family life, social activities, or other areas of functioning in order to meet the diagnostic criteria for GAD. Such physical symptoms as insomnia , sore muscles, headaches , digestive upsets, diarrhea , difficulty swallowing, trembling, twitching, irritability, sweating, lightheadedness, having to urinate frequently, and feeling out of breath are common accompaniments of GAD in the elderly.

Seniors diagnosed with GAD have a high rate of concurrent mental disorders, particularly major depression , other anxiety disorders, or a substance abuse disorder. They also frequently have or develop stress-related physical illnesses and conditions such as tension headaches, irritable bowel syndrome (IBS), temporomandibular joint dysfunction (TMJ), bruxism (grinding of the teeth during sleep), and high blood pressure . In addition, the discomfort or complications associated with arthritis, diabetes, and other chronic disorders are often intensified by GAD. Seniors with GAD are more likely than patients with other disorders to make frequent medical appointments, to undergo extensive or repeated diagnostic testing, to describe their health as poor, and to smoke tobacco or abuse other substances. Seniors with GAD or other anxiety disorders have higher rates of mortality from all causes than people who are less anxious.

In many cases, it is difficult for a doctor to determine whether the anxiety preceded a physical disorder or followed it; sometimes older people develop GAD after being diagnosed with a chronic physical health problem. In other instances, the wear and tear on the body caused by persistent and recurrent worrying leads to the onset or worsening of physical diseases and disorders. There is an overall “vicious circle” quality to the relationship between GAD and other disorders, whether mental or physical.

Demographics

As of 2008, the National Institute of Mental Health (NIMH) estimates that about 6.8 million Americans have GAD; about two-thirds of these are women. The risk of developing GAD appears to be higher among adolescents and younger adults than among seniors. GAD affects all racial and ethnic groups equally.

Causes and symptoms

The causes of GAD are thought to be a mixture of genetic and environmental factors. It is known that the disorder tends to run in families. Recent twin studies and the ongoing mapping of the human genome point to a genetic factor in the development of GAD. A gene related to panic disorder was identified in late 2001, which increases the likelihood that there is a gene or genes that govern a person's susceptibility to generalized anxiety. The role of the family environment (social modeling) in an individual's susceptibility to GAD is uncertain. Social modeling appears to be a more important factor for women than for men.

Gender appears to be a factor in the development of GAD. Some researchers attribute the 2:1 sex ratio to the demands placed on women in developed countries as caregivers. An older woman who is expected to care for elderly parents or other relatives as well as meet the needs of her own household may find herself feeling increasingly anxious about the many demands on her time, energy, and financial resources.

Other factors that increase a person's risk of GAD include:

• An abusive or otherwise traumatic childhood.
• Having unmet psychological needs, such as being in an unfulfilling marriage or missing one's job after retirement.
• Having a series of stressful events in close succession, such as losing a spouse or sibling shortly after being diagnosed with a serious illness.
• A high level of muscle tension. Several studies have found that patients diagnosed with GAD tend to respond to physiological stress in a rigid, stereotyped manner. It is not yet known, however, whether this level of muscle tension is a cause or an effect of GAD.

Diagnosis

Most seniors are likely to be diagnosed with GAD by their primary care doctor rather than by a psychiatrist, although they may be referred to a psychiatrist for further evaluation.

The doctor usually takes the following steps when making the diagnosis:

• Patient interview. The doctor asks the patient to describe the anxiety, and notes whether it is acute (lasting hours to weeks) or persistent (lasting from months to years). The doctor may also give the patient a diagnostic questionnaire to evaluate the presence of anxiety disorders. The Hamilton Anxiety Scale is a commonly used instrument for evaluating anxiety in seniors. The Generalized Anxiety Disorder Questionnaire for DSM-IV (GAD-Q-IV) is a more recent diagnostic tool, but is specific to GAD.
• Medical evaluation. This step is necessary because new-onset anxiety in an older adult is frequently caused by such physical disorders as hyperthyroidism, Cushing's disease, mitral valve prolapse, carcinoid syndrome, and pheochromocytoma. Certain medications (steroids, digoxin, thyroxine, theophylline, and selective serotonin reuptake inhibitors) may also cause anxiety as a side effect. The senior should be asked about his or her use of coffee, tea, and herbal preparations as well, since beverages containing high levels of caffeine can cause jitteriness and anxious feelings in older adults.
• Substance abuse evaluation. Because anxiety is a common symptom of substance abuse and withdrawal syndrome, the doctor asks about the patient's use of nicotine, alcohol, and other common substances (including prescription medications) that may be abused.
• Evaluation for other psychiatric disorders. This step is necessary because of the frequent overlapping between GAD and depression in older adults or between GAD and other anxiety disorders.

Treatment

Most seniors with GAD are treated with a combination of medications and psychotherapy. Seniors do not respond as well to anti-anxiety medications as younger people; they usually experience some symptom relief but not the complete elimination of anxiety. Seniors are usually managed on lower doses of these medications than younger patients.

Medications generally given to seniors whose anxiety is severe enough to interfere with their daily life are:

• Benzodiazepines. This group of tranquilizers does not decrease worry, but lowers the senior's anxiety by decreasing muscle tension. The benzodiazepines have two major disadvantages: they carry a high risk of dependence; and they cannot be given to seniors who abuse alcohol.
• Tricyclic antidepressants. These drugs include imipramine (Tofranil), nortriptyline (Pamelor), and desipramine (Norpramin) and have been given to patients with GAD. Their major drawback for seniors is that they increase the patient's risk of falls and other accidents.
• Selective serotonin reuptake inhibitors (SSRIs). Paroxetine (Paxil) was approved by the Food and Drug Administration (FDA) in 2001 as a treatment for GAD. Venlafaxine (Effexor) is effective in treating patients with GAD whose symptoms are primarily somatic. It is important for seniors taking an SSRI not to discontinue the drug abruptly, as it increases the risk of suicide.

QUESTIONS TO ASK YOUR DOCTOR

• Can the senior's GAD be managed without prescription medications?
• What possible side effects might the drugs have? What precautions are needed for their safe use?
• What is your opinion of cognitive therapy in treating an older person with GAD?
• Would you recommend any alternative treatments or therapies? If so, which ones?
• What can other family members do to help with the senior's treatment?

A newer drug, pregabalin (sold under the trade name Lyrica in the United States), has been approved by the FDA for the treatment of fibromyalgia and partial seizures. It is also approved in Europe (though not in the United States as of early 2008) for the treatment of GAD. Early trials indicate that pregabalin is effective in treating seniors with GAD; it has a low rate of interactions with other drugs, a low risk of dependence, and relieves anxiety symptoms more rapidly than SSRIs.

Nutrition/Dietetic concerns

The senior's eating patterns should be evaluated for adequate nutritional balance, regular mealtimes (no skipping meals), and high levels of caffeine intake. In some cases, a vitamin B12 supplement may help, as a deficiency of this vitamin causes anxiety and depression in some older people. Seniors who smoke should be encouraged to quit, as the nicotine in tobacco has a stimulant effect.

Therapy

A number of evidence-based studies have found cognitive therapy to be effective in treating GAD. Relaxation training is another psychological intervention that has been shown to help seniors with GAD. The greatest benefit of cognitive therapy is its effectiveness in helping seniors with the disorder to learn more realistic ways to appraise their problems and to use better problem-solving techniques. As a general rule, patients with GAD who have personality disorders ; who are living with chronic social stress (e.g., caring for a spouse with Alzheimer's disease ); or who do not trust psychotherapy require treatment with medications.

Family therapy is sometimes recommended for seniors who are living with an adult son or daughter and whose GAD is causing stress for other members of the household.

Group therapy or informal anxiety support groups are also recommended for seniors diagnosed with GAD. In many cases, social contact with others eases the isolation that often reinforces the senior's anxiety, and group members often have helpful tips about coping with the stresses that cause worry as well as with the worry itself.

Alternative and complementary therapies

Several alternative and complementary therapies have been found helpful in treating patients with GAD. These include hypnotherapy; music therapy; yoga ; t'ai chi; religious practice; and guided imagery meditation. One herbal remedy that has been used in clinical trials for treating GAD is passionflower (Passiflora incarnata). The researchers reported that passionflower extract was as effective as a benzodiazepine tranquilizer in relieving feelings of anxiety without the side effects of the prescription medication.

Prognosis

GAD is generally regarded as a long-term condition that may persist for the rest of the senior's life. Patients frequently find their symptoms resurfacing or getting worse during stressful periods in their lives. It is rare for patients with GAD to recover spontaneously.

Prevention

As of 2008, the genetic factors involved in GAD have not been fully identified. In addition, the many stressors of modern life that raise anxiety levels in older adults are difficult to escape or avoid. The best preventive strategy, given that GAD often starts early in life, is for parents to model realistic assessment of stressful events and teach effective coping strategies to their children.

KEY TERMS

Free-floating —A term used in psychiatry to describe anxiety that is unfocused or lacking an apparent cause or object.

Social modeling —A process of learning behavioral and emotional response patterns from observing one's parents or other adults. Some researchers think that social modeling plays a part in the development of generalized anxiety disorder in women.

Caregiver concerns

Caregivers of seniors diagnosed with GAD should be concerned about:

• The long-term effects of the disorder on the senior's physical health.
• The impact of the disorder on other family members. Many books on caring for seniors note that chronic worrying on the part of the older person can be stressful for others sharing a home with them.
• Suicidal ideation or completed suicide. GAD is not a common trigger of suicide by itself; however, seniors suffering from depression along with GAD are at increased risk of self-harm.
• Proper use of any medications prescribed for GAD. Sudden discontinuation of an SSRI may increase the senior's risk of suicide.

Resources

BOOKS

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed., text revision. Washington, DC: American Psychiatric Association, 2000.

Beers, Mark H., and Thomas V. Jones. Merck Manual of Geriatrics, 3rd ed., Chapter 34, “Anxiety Disorders.” Whitehouse Station, NJ: Merck, 2005.

Pelletier, Kenneth R. The Best Alternative Medicine, Part II, “CAM Therapies for Specific Conditions: Anxiety.” New York: Simon & Schuster, 2002.

World Health Organization (WHO). The ICD-10 Classification of Mental and Behavioural Disorders. Geneva: WHO, 1992.

PERIODICALS

Ayers, C. R., et al. “Evidence-Based Psychological Treatments for Late-Life Anxiety.” Psychology and Aging 22 (March 2007): 8–17.

Bandelow, B., D. Wedekind, and T. Leon. “Pregabalin for the Treatment of Generalized Anxiety Disorder: A Novel Pharmacologic Intervention.” Expert Review of Neurotherapeutics 7 (July 2007): 769–781.

Caudle, D. D., A. C. Senior, J. L. Wetherell, et al. “Cognitive Errors, Symptom Severity, and Response to Cognitive Behavior Therapy in Older Adults with Generalized Anxiety Disorder.” American Journal of Geriatric Psychiatry 15 (August 2007): 680–689.

Gliatto, Michael F. “Generalized Anxiety Disorder.” American Family Physician 62 (October 1, 2000): 1591–1600, 1602.

Kroenke, K., R. L. Spitzer, J. B. Williams, et al. “Anxiety Disorders in Primary Care: Prevalence, Impairment, Comorbidity, and Detection.” Annals of Internal Medicine 146 (March 6, 2007): 317–325.

Mantella, R. C., M. A. Butters, M. A. Dew, et al. “Cognitive Impairment in Late-Life Generalized Anxiety Disorder.” American Journal of Geriatric Psychiatry 15 (August 2007): 673–679.

OTHER

Generalized Anxiety Disorder. [cited Fenruary 8, 2008]. Anxiety Disorders Association of America (ADAA). http://www.adaa.org/bookstore/Brochures/GAD_adaa.pdf.

“Generalized Anxiety Disorder.” MayoClinic.com September 11, 2007 [cited April 7, 2008]. Mayo Foundation for Medical Education and Research. http://www.mayoclinic.com/health/generalized-anxiety-disorder/DS00502/DSECTION=4.

National Institute of Mental Health (NIMH). Anxiety Disorders. NIH Publication No. 06-3879. Bethesda, MD: NIMH, 2006.

Yates, William R. “Anxiety Disorders.” eMedicine August 23, 2007 [cited April 6, 2008]. WebMD. http://www.emedicine.com/med/topic152.htm.

ORGANIZATIONS

American Psychiatric Association, 1000 Wilson Boulevard, Suite 1825, Arlington, VA, 22209, (703) 907-7300, [email protected], http://www.psych.org.

Anxiety Disorders Association of America (ADAA), 8730 Georgia Avenue, Suite 600, Silver Spring, MD, 20910, (240) 485-1001, (240) 485-1035, http://www.adaa.org.

National Alliance on Mental Illness (NAMI), Colonial Place Three, 2107 Wilson Blvd., Suite 300, Arlington, VA, 22201, (703) 524-7600, (800) 950-NAMI (6264), (703) 524-9094, http://www.nami.org.

National Institute of Mental Health (NIMH), 6001 Executive Boulevard, Room 8184, MSC 9663, Bethesda, MD, 20892, (301) 443-4513, (866) 615-6464, (301) 443 4279, [email protected], http://www.nimh.nih.gov.

Rebecca J. Frey PhD