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Generalized anxiety disorder

Generalized anxiety disorder

Definition

Generalized anxiety disorder, or GAD, is a disorder characterized by diffuse and chronic worry. Unlike people with phobias or post-traumatic disorders, people with GAD do not have their worries provoked by specific triggers; they may worry about almost anything having to do with ordinary life. It is not unusual for patients diagnosed with GAD to shift the focus of their anxiety from one issue to another as their daily circumstances change. For example, someone with GAD may start worrying about finances when several bills arrive in the mail, and then fret about the state of his or her health when it is noticed that one of the bills is for health insurance. Later in the day he or she may read a newspaper article that moves the focus of the worry to a third concern.

A manual commonly used by mental health professionals is the Diagnostic and Statistical Manual of Mental Disorders , also known as the DSM. This manual may also be identified more specifically by edition, such as the DSM, fourth edition text revised, or DSM-IV-TR. The DSM-IV-TR classifies GAD as an anxiety disorder.

Description

Generalized anxiety disorder is characterized by persistent worry that is excessive and that the patient finds hard to control. Common worries associated with generalized anxiety disorder include work responsibilities, money, health, safety, car repairs, and household chores. The ICD-10, which is the European equivalent of DSMIV-TR, 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.

DSM-IV-TR specifies that the worry must occur "more days than not for a period of at least six months"; ICD-10 states only that the patient "must have primary symptoms of anxiety most days for at least several weeks at a time, and usually for several months." The patient usually recognizes that his or her worry is out of proportion in its duration or intensity to the actual likelihood or impact of the feared situation or event. For example, a husband or wife may worry about an accident happening to a spouse who commutes to work by train, even though the worried partner knows objectively that rail travel is much safer than automobile travel on major highways. 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 patient's life.

DSM-IV-TR specifies interference with work, family life, social activities, or other areas of functioning as a criterion for generalized anxiety disorder; ICD-10 does not mention interference with tasks or other activities as a criterion for the disorder. Both diagnostic manuals mention such physical symptoms as insomnia , sore muscles, headaches, digestive upsets, etc. as common accompaniments of GAD, but only DSM-IV-TR specifies that an adult patient must experience three symptoms out of a list of six (restlessness, being easily fatigued, having difficulty concentrating, being irritable, high levels of muscle tension, and sleep disturbances) in order to be diagnosed with the disorder.

Patients diagnosed with GAD have a high rate of concurrent mental disorders, particularly major depression disorder, other anxiety disorders, or a substance abuse disorder. They also frequently have or develop such stress-related physical illnesses and conditions as tension headaches, irritable bowel syndrome (IBS), temporomandibular joint dysfunction (TMJ), bruxism (grinding of the teeth during sleep), and hypertension. In addition, the discomfort or complications associated with arthritis, diabetes, and other chronic disorders are often intensified by GAD. Patients with GAD are more likely to seek help from a primary care physician than a psychiatrist ; they are also 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. In addition, patients with anxiety disorders have higher rates of mortality from all causes than people who are less anxious.

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

Children diagnosed with GAD have much the same anxiety symptoms as adults. The mother of a six-year-old boy with the disorder told his pediatrician that her son "acted like a little man" rather than a typical first-grader. He would worry about such matters as arriving on time for school field trips, whether the family had enough money for immediate needs, whether his friends would get hurt climbing on the playground jungle gym, whether there was enough gas in the tank of the family car, and similar concerns. The little boy had these worries in spite of the fact that his family was stable and happy and had no serious financial or other problems.

GAD often has an insidious onset that begins relatively early in life, although it can be precipitated by a sudden crisis at any age above six or seven years. The idea that GAD often begins in the childhood years even though the symptoms may not become clearly noticeable until late adolescence or the early adult years is gaining acceptance. About half of all patients diagnosed with the disorder report that their worrying began in childhood or their teenage years. Many will say that they cannot remember a time in their lives when they were not worried about something. This type of persistent anxiety can be regarded as part of a person's temperament, or inborn disposition; it is sometimes called trait anxiety. It is not unusual, however, for people to develop the disorder in their early adult years or even later in reaction to chronic stress or anxiety-producing situations. For example, there are instances of persons developing GAD after several years of taking care of a relative with dementia , living with domestic violence, or living in close contact with a friend or relative with borderline personality disorder .

The specific worries of a person with GAD may be influenced by their ethnic background or culture. DSMIV-TR's observation that being punctual is a common concern of patients with GAD reflects the value that Western countries place on using time as efficiently as possible. One study of worry in college students from different ethnic backgrounds found that Caucasian and African American students tended to worry a variable amount about a wider range of concerns whereas Asian Americans tended to worry more intensely about a smaller number of issues. Another study found that GAD in a community sample of older Puerto Ricans overlapped with a culture-specific syndrome called ataque de nervios, which resembles panic disorder but has features of other anxiety disorders as well as dissociative symptoms. (People experience dissociative symptoms when their perception of reality is temporarily altered they may feel as if they were in a trance, or that they were observing activity around them instead of participating.) Further research is needed regarding the relationship between people's ethnic backgrounds and their outward expression of anxiety symptoms.

Causes and symptoms

Causes

The causes of generalized anxiety disorder appear to be a mixture of genetic and environmental factors. It has been known for some years that the disorder runs in families. Recent twin studies as well as 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 susceptibility to generalized anxiety. The role of the family environment (social modeling ) in an individual's susceptibility to GAD is uncertain. Social modeling, the process of learning behavioral and emotional response patterns from observing one's parents or other adults, appears to be a more important factor for women than for men.

Another factor in the development of GAD is social expectations related to gender roles. A recent Swiss study corroborated earlier findings that women have higher levels of emotional distress and lower quality of life than men. The higher incidence of GAD in women has been linked to the diffuse yet comprehensive expectations of women as caregivers. Many women assume responsibility for the well-being and safety of other family members in addition to holding a job or completing graduate or professional school. The global character of these responsibilities as well as their unrelenting nature has been described as a mirror image of the persistent but nonspecific anxiety associated with GAD.

Socioeconomic status may also contribute to generalized anxiety. One British study found that GAD is more closely associated with an accumulation of minor stressors than with any demographic factors. Persons of lower socioeconomic status, however, have fewer resources for dealing with minor stressors and so appear to be at greater risk for generalized anxiety.

One additional factor may be the patient's level of muscle tension. Several studies have found that patients diagnosed with GAD tend to respond to physiological stress in a rigid, stereotyped manner. Their autonomic reactions (reactions in the part of the nervous system that governs involuntary bodily functions) are similar to those of people without GAD, but their muscular tension shows a significant increase. It is not yet known, however, whether this level of muscle tension is a cause or an effect of GAD.

Symptoms

The symptomatology of GAD has changed somewhat over time with redefinitions of the disorder in successive editions of DSM. The first edition of DSM and DSM-II did not make a sharp distinction between generalized anxiety disorder and panic disorder. After specific treatments were developed for panic disorder, GAD was introduced in DSM-III as an anxiety disorder without panic attacks or symptoms of major depression. This definition proved to be unreliable. As a result, DSM-IV constructed its definition of GAD around the psychological symptoms of the disorder (excessive worrying) rather than the physical (muscle tension) or autonomic symptoms of anxiety. DSM-IV-TR continued that emphasis.

According to the DSM-IV-TR, the symptoms of GAD are:

  • excessive anxiety and worry about a number of events or activities, occurring more days than not for at least six months
  • worry that cannot be controlled
  • worry that is associated with several symptoms such as restlessness, fatigue , irritability, or muscle tension
  • worry that causes distress or impairment in relationships, at work, or at school

In addition, to meet the diagnostic criteria for GAD,

the content or focus of the worry cannot change the diagnosis from GAD to another anxiety disorder such as panic disorder, social phobia , or obsessive-compulsive disorder , and the anxiety cannot be caused by a substance (a drug or a medication).

One categorization of GAD symptoms that some psychiatrists use in addition to the DSM framework consists of three symptom clusters:

  • symptoms related to high levels of physiological arousal: muscle tension, irritability, fatigue, restlessness, insomnia
  • symptoms related to distorted thinking processes: poor concentration, unrealistic assessment of problems, recurrent worrying
  • symptoms associated with poor coping strategies: procrastination, avoidance, inadequate problem-solving skills

Demographics

It is difficult to compare present statistics for generalized anxiety disorder with those of the 1980s and early 1990s because of changes in the diagnostic criteria for GAD in successive editions of DSM. The National Institute of Mental Health (NIMH) states that as of 2000, 2.8% of the general United States population, or about four million people, have GAD during the course of a given year. One study that used DSM-III-R criteria concluded that 5% of the United States population, or one person in every 20, will develop GAD at some point in their lives. Another range of figures given for the lifetime prevalence of GAD in the American population is 4.1%6.6%. The figure given for children in the United States is also 5%. Women develop generalized anxiety disorder more frequently than men; the sex ratio is variously given as 3:2 or 2:1. Prevalence across races and ethnic groups is more difficult to determine because of cultural influences on expressions of anxiety.

Some psychiatrists think that generalized anxiety disorder is overdiagnosed in both adults and children. One reason for this possibility is that diagnostic screening tests used by primary care physicians for mental disorders produce a large number of false positives for GAD. One study of the PRIME-MD, a screening instrument for mental disorders frequently used in primary care practices, found that 7% of patients met the criteria for GAD. Follow-up in-depth interviews with the patients, however, revealed that only a third of the GAD diagnoses could be confirmed.

Diagnosis

Diagnosis of GAD, particularly in primary care settings, is complicated by several factors. One is the high level of comorbidity (co-occurrence) between GAD and other mental or physical disorders. Another is the considerable overlap between anxiety disorders in general and depression. Some practitioners believe that depression and GAD may not be separate disorders after all, because studies have repeatedly confirmed the existence and common occurrence of a "mixed" anxiety/depression syndrome.

Evaluating a patient for generalized anxiety disorder includes the following steps:

  • Patient interview. The doctor will ask the patient to describe the anxiety, and will note whether it is acute (lasting hours to weeks) or persistent (lasting from months to years). If the patient describes a recent stressful event, the doctor will evaluate him or her for "double anxiety," which refers to acute anxiety added to underlying persistent anxiety. 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 to assess anxiety disorders in general. The Generalized Anxiety Disorder Questionnaire for DSM-IV (GAD-Q-IV) is a more recent diagnostic tool, and is specific to GAD.
  • Medical evaluation. Nonpsychiatric disorders that are known to cause anxiety (hyperthyroidism, Cushing's disease, mitral valve prolapse, carcinoid syndrome, and pheochromocytoma) must be ruled out, as well as certain medications (steroids, digoxin, thyroxine, theophylline, and selective serotonin reuptake inhibitors) that may also cause anxiety as a side effect. The patient should be asked about his or her use of herbal preparations as well.
  • Substance abuse evaluation. Because anxiety is a common symptom of substance abuse and withdrawal syndrome, the doctor will ask about the patient's use of caffeine, 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 or between GAD and other anxiety disorders.

In some instances the doctor will consult the patient's family for additional information about the onset of the patient's anxiety symptoms, dietary habits, etc.

Treatments

There are several treatment types that have been found effective in treating GAD. Most patients with the disorder are treated with a combination of medications and psychotherapy .

Medications

Pharmacologic therapy is usually prescribed for patients whose anxiety is severe enough to interfere with daily functioning. Several different groups of medications have been used to treat generalized anxiety disorder.

These medications include the following:

  • Benzodiazepines. This group of tranquilizers does not decrease worry, but lowers anxiety by decreasing muscle tension and hypervigilance. They are often prescribed for patients with double anxiety because they act very quickly. The benzodiazepines, however, have several disadvantages: they are unsuitable for long-term therapy because they can cause dependence, and GAD is a long-term-disorder; they cannot be given to patients who abuse alcohol; and they cause short-term memory loss and difficulty in concentration. One British study found that benzodiazepines significantly increased a patient's risk of involvement in a traffic accident.
  • Buspirone (BuSpar). Buspirone appears to be as effective as benzodiazepines and antidepressants in controlling anxiety symptoms. It is slower to take effect (about twothree weeks), but has fewer side effects. In addition, it treats the worry associated with GAD rather than the muscle tension.
  • Tricyclic antidepressants. Imipramine (Tofranil), nortriptyline (Pamelor), and desipramine (Norpramin) have been given to patients with GAD. They have, however, some problematic side effects; imipramine has been associated with disturbances in heart rhythm, and the other tricyclics often cause drowsiness, dry mouth, constipation, and confusion. They increase the patient's risk of falls and other accidents.
  • Selective serotonin reuptake inhibitors. Paroxetine (Paxil), one of the SSRIs, was approved by the Food and Drug Administration (FDA) in 2001 as a treatment for GAD. Venlafaxine (Effexor) appears to be particularly beneficial to patients with a mixed anxiety/depression syndrome; it is the first drug to be labeled by the FDA as an antidepressant as well as an anxiolytic. Venlafaxine is also effective in treating patients with GAD whose symptoms are primarily somatic (manifesting as physical symptoms, or bodily complaints).

Psychotherapy

Some studies have found cognitive therapy to be superior to medications and psychodynamic psychotherapy in treating GAD, but other researchers disagree with these findings. As a rule, GAD patients who have personality disorders , who are living with chronic social stress (are caring for a parent with Alzheimer's disease , for example), or who don't trust psychotherapeutic approaches require treatment with medications. The greatest benefit of cognitive therapy is its effectiveness in helping patients with the disorder to learn more realistic ways to appraise their problems and to use better problem-solving techniques.

Family therapy is recommended insofar as family members can be helpful in offering patients a different perspective on their problems. They can also help the patient practice new approaches to problem-solving.

Alternative and complementary therapies

Several alternative and complementary therapies have been found helpful in treating patients with generalized anxiety disorder. These include hypnotherapy ; music therapy; Ayurvedic medicine; yoga ; religious practice; and guided imagery meditation .

Biofeedback and relaxation techniques are also recommended for GAD patients in order to lower physiologic arousal. In addition, massage therapy, hydrotherapy, shiatsu, and acupuncture have been reported to relieve muscle spasms or soreness associated with GAD.

One herbal remedy that has been used in clinical trials for treating GAD is passionflower (Passiflora incarnata ). One team of researchers found that passionflower extract was as effective as oxazepam (Serax) in relieving anxiety symptoms in a group of 36 outpatients diagnosed with GAD according to DSM-IV criteria. In addition, the passionflower extract did not impair the subjects' job performance as frequently or as severely as the oxazepam.

Prognosis

Generalized anxiety disorder is generally regarded as a long-term condition that may become a lifelong problem. 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 2002, the genetic factors involved in generalized anxiety disorder have not been fully identified. In addition, the many stressors of modern life that raise people's anxiety levels are difficult to escape or avoid. The best preventive strategy, given the early onset of GAD, is the modeling of realistic assessment of stressful events by parents, and the teaching of effective coping strategies to their children.

See also Bodywork therapies; Cognitive-behavioral therapy; Cognitive problem-solving skills training; Stress

Resources

BOOKS

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

"Generalized Anxiety Disorder." Section 15, Chapter 187 in The Merck Manual of Diagnosis and Therapy, edited by Mark H. Beers, M.D., and Robert Berkow, M.D. Whitehouse Station, NJ: Merck Research Laboratories, 2001.

Pelletier, Kenneth R., MD. The Best Alternative Medicine. Part II, "CAM Therapies for Specific Conditions: Anxiety." New York: Simon and Schuster, 2002.

Rowe, Dorothy. Beyond Fear. London, UK: Fontana/Collins, 1987.

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

PERIODICALS

Brown, Timothy A., Laura A. Campbell, Cassandra L. Lehman, and others. "Current and Lifetime Comorbidity of the DSM-IV Anxiety and Mood Disorders in a Large Clinical Sample." Journal of Abnormal Psychology 110 (November 2001): 585-599.

"Clinical Notes from the APA: Treating Generalized Anxiety Disorder." Psychopharmacology Update 12 (June 2001): 22-25.

Gale, Christopher. "Anxiety Disorder." British Medical Journal 321 (November 11, 2000): 1204-1207.

Gamma, A., and J. Angst. "Concurrent Psychiatric Comorbidity and Multimorbidity in a Community Study: Gender Differences and Quality of Life." European Archives of Psychiatry and Clinical Neuroscience 251 (2001): Supplement 2:1143-1146.

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

Hettema, John M., Michael C. Neale, Kenneth S. Kendler. "A Review and Meta-Analysis of the Genetic Epidemiology of Anxiety Disorders." American Journal of Psychiatry 158 (October 2001): 1568-1578.

"Location of Genes Linked to Obesity and Anxiety Found." Pain & Central Nervous System Week. (October 8, 2001).

Magill, Michael K. "Generalized Anxiety Disorder in Family Practice Patients." American Family Physician 62 (October 1, 2000): 1537-1540.

Preboth, Monica. "Paroxetine Approved for Generalized Anxiety." American Family Physician 64 (October 1, 2001): 1280.

Rynn, Moira A., Lynne Siqueland, Karl Rickels. "Placebo-Controlled Trial of Sertraline in the Treatment of Children with Generalized Anxiety Disorder." American Journal of Psychiatry 158 (December 2001): 2008-2014.

Scott, E. L., W. Eng, and R. G. Heimberg. "Ethnic Differences in Worry in a Nonclinical Population." Depression and Anxiety 15 (2002): 79-82.

Shortt, Alison L., Paula M. Barrett, Tara L. Fox. "Evaluating the FRIENDS Program: A Cognitive-Behavioral Group Treatment for Anxious Children and Their Parents." Journal of Clinical Child Psychology 30 (December 2001): 525.

Tolin, D. F., J. Robinson, C. Gruman, and others. "The Prevalence of Anxiety Disorders Among Middle-Aged and Older Puerto Ricans." Gerontologist (October 15, 2001): 33.

Wagner, Karen D. "Children Who Worry Too Much." Psychiatric Times 17 (September 2000): 9.

Young, A. S., and others. "The Quality of Care for Depressive and Anxiety Disorders in the United States." Archives of General Psychiatry 58 (January 2001): 55-61.

ORGANIZATIONS

Anxiety Disorders Association of America. 11900 Parklawn Drive, Suite 100, Rockville, MD 20852-2624. (301) 231-9350. <www.adaa.org>.

Anxiety Disorders Education Program, National Institute of Mental Health. 6001 Executive Blvd., Room 8184, MSC 9663, Bethesda, MD 20892-9663. (301) 443-4513. <www.nimh.nih.gov>.

Freedom From Fear. 308 Seaview Avenue, Staten Island, NY 10305. (718) 351-1717. <www.freedomfromfear.com>.

National Mental Health Association. 1021 Prince Street, Alexandria, VA 22314-2971. (800) 969-6642. <www.nmha.org>.

OTHER

National Institute of Mental Health (NIMH). Anxiety Disorders. NIH Publication No. 00-3879 (2000). <www.nimh.nih.gov/anxiety/anxiety.cfm>.

National Institute of Mental Health (NIMH). Facts About Generalized Anxiety Disorder. NIH publication OM-99 4153, revised edition (2000). <www.nimh.nih.gov/anxiety/gadfacts.cfm>.

Rebecca J. Frey, Ph.D.

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Generalized Anxiety Disorder

Generalized Anxiety Disorder

Definition

Generalized anxiety disorder is a condition characterized by "free floating" anxiety or apprehension not linked to a specific cause or situation.

Description

Some degree of fear and anxiety is perfectly normal. In the face of real danger, fear makes people more alert and also prepares the body to fight or flee (the so-called "fight or flight" response). When people are afraid, their hearts beat faster and they breathe faster in anticipation of the physical activity that will be required of them. However, sometimes people can become anxious even when there is no identifiable cause, and this anxiety can become overwhelming and very unpleasant, interfering with their daily lives. People with debilitating anxiety are said to be suffering from anxiety disorders, such as phobias, panic disorders, and generalized anxiety disorder. The person with generalized anxiety disorder generally has chronic (officially, having more days with anxiety than not for at least six months), recurrent episodes of anxiety that can last days, weeks, or even months.

Causes and symptoms

Generalized anxiety disorder afflicts between 2-3% of the general population, and is slightly more common in women than in men. It accounts for almost one-third of cases referred to psychiatrists by general practitioners.

Generalized anxiety disorder may result from a combination of causes. Some people are genetically predisposed to developing it. Psychological traumas that occur during childhood, such as prolonged separation from parents, may make people more vulnerable as well. Stressful life events, such as a move, a major job change, the loss of a loved one, or a divorce, can trigger or contribute to the anxiety.

Psychologically, the person with generalized anxiety disorder may develop a sense of dread for no apparent reason-the irrational feeling that some nameless catastrophe is about to happen. Physical symptoms similar to those found with panic disorder may be present, although not as severe. They may include trembling, sweating, heart palpitations (the feeling of the heart pounding in the chest), nausea, and "butterflies in the stomach."

According to the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, a person must have at least three of the following symptoms, with some being present more days than not for at least six months, in order to be diagnosed with generalized anxiety disorder:

  • restlessness or feeling on edge
  • being easily fatigued
  • difficulty concentrating
  • irritability
  • muscle tension
  • sleep disturbance

While generalized anxiety disorder is not completely debilitating, it can compromise a person's effectiveness and quality of life.

Diagnosis

Anyone with chronic anxiety for no apparent reason should see a physician. The physician may diagnose the condition based on the patient's description of the physical and emotional symptoms. The doctor will also try to rule out other medical conditions that may be causing the symptoms, such as excessive caffeine use, thyroid disease, hypoglycemia, cardiac problems, or drug or alcohol withdrawal. Psychological conditions, such as depressive disorder with anxiety, will also need to be ruled out.

In June 2004, the Anxiety Disorders Association of America released follow-up guidelines to help primary care physicians better diagnose and manage patients with generalized anxiety disorder. They include considering the disorder when medical causes for general, vague physical complaints cannot be ruled out. Since generalized anxiety disorder often co-occurs with mood disorders and substance abuse, the clinician may have to treat these conditions as well, and therefore must consider them in making the diagnosis.

Treatment

Over the short term, a group of tranquilizers called benzodiazepines, such as clonazepam (Klonipin) may help ease the symptoms of generalized anxiety disorder. Sometimes antidepressant drugs, such as amitryptiline (Elavil), or selective serotonin reuptake inhibitors (SSRIs), such as paroxetine (Paxil), escitalopram (Lexapro), and venlafaxine (Effexor), which also has norepinephrine, may be preferred. Other SSRIs are fluoxetine (Prozac) and sertraline (Zoloft).

Psychotherapy can be effective in treating generalized anxiety disorder. The therapy may take many forms. In some cases, psychodynamically-oriented psychotherapy can help patients work through this anxiety and solve problems in their lives. Cognitive behavioral therapy aims to reshape the way people perceive and react to potential stressors in their lives. Relaxation techniques have also been used in treatment, as well as in prevention efforts.

Prognosis

When properly treated, most patients with generalized anxiety disorder experience improvement in their symptoms.

Prevention

While preventive measures have not been established, a number of techniques may help manage anxiety, such as relaxation techniques, breathing exercises, and distractionputting the anxiety out of one's mind by focusing thoughts on something else.

Resources

PERIODICALS

"Guidelines to Assist Primary Care Physicians in Diagnosing GAD." Psychiatric Times (July1,2004):16.

Sherman, Carl. "GAD Patients Often Require Combined Therapy." Clinical Psychiatry News (August 2004): 12-14.

ORGANIZATIONS

American Psychiatric Association. 1400 K Street NW, Washington DC 20005. (888) 357-7924. http://www.psych.org.

Anxiety Disorders Association of America. 11900 Park Lawn Drive, Ste. 100, Rockville, MD 20852. (800) 545-7367. http://www.adaa.org.

National Institute of Mental Health. Mental Health Public Inquiries, 5600 Fishers Lane, Room 15C-05, Rockville, MD 20857. (888) 826-9438. http://www.nimh.nih.gov.

KEY TERMS

Cognitive behavioral therapy A psychotherapeutic approach that aims at altering cognitionsincluding thoughts, beliefs, and imagesas a way of altering behavior.

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generalized anxiety disorder

generalized anxiety disorder (jen-er-ă-lyzd) n. a state of inappropriate and sometimes severe anxiety, without adequate cause, that lasts for at least six months. Symptoms include breathlessness, palpitations, sweating, clammy hands, dry mouth, and globus hystericus. Treatment includes cognitive behavioural therapy and antidepressants.

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Generalized Anxiety Disorder

Generalized Anxiety Disorder

Definition

Description

Causes and symptoms

Demographics

Diagnosis

Treatments

Prognosis

Prevention

Resources

Definition

Generalized anxiety disorder (GAD) is a disorder characterized by excessive worry and anxiety concerning a number of events and activities. This anxiety is accompanied by such symptoms as restlessness, fatigue , inability to concentrate, muscle tension, or disturbed sleep. Individuals with this disorder experience symptoms on most days for a period of at least six months, and find the symptoms difficult to control.

Description

Generalized anxiety disorder is characterized by persistent worry that is excessive and that patients find hard to control. Common worries associated with generalized anxiety disorder include work responsibilities, money, health, safety, car repairs, and household chores. Unlike people with phobias or post-traumatic disorders, people with GAD do not have their worries provoked by specific triggers; they may worry about almost anything having to do with ordinary life. It is not unusual for patients diagnosed with GAD to shift the focus of their anxiety from one issue to another as their daily circumstances change. For example, people with GAD may start worrying about finances when several bills arrive in the mail, and then fret about the state of their health when they notice that one of the bills is for health insurance. Later in the day they may read a newspaper article that moves the focus of the worry to a third concern.

Patients usually recognize that their worry is out of proportion in its duration or intensity to the actual likelihood or impact of the feared situation or event. For example, a husband or wife may worry about an accident happening to a spouse who commutes to work by train, even though the worried partner knows objectively that rail travel is much safer than automobile travel on major highways. The anxiety levels of patients with GAD may rise and fall somewhat over a period of weeks or months but tend to become chronic problems. The disorder typically becomes worse during stressful periods in the patient’s life.

The Diagnostic and Statistical Manual, fourth edition, text revision (DSM-IV-TR) specifies interference with work, family life, social activities, or other areas of functioning as a criterion for generalized anxiety disorder. This may be accompanied by such physical symptoms as insomnia , sore muscles, headaches, and digestive upsets. According to the DSM-IV-TR, adult patients must experience three symptoms out of a list of six (restlessness, being easily fatigued, having difficulty concentrating, being irritable, high levels of muscle tension, and sleep disturbances) in order to be diagnosed with the disorder.

Patients diagnosed with GAD have a high rate of concurrent mental disorders, particularly major depression disorder, other anxiety disorders , or a substance abuse disorder. They also frequently have or develop such stress-related physical illnesses and conditions as tension headaches, irritable bowel syndrome (IBS), temporomandibular joint dysfunction (TMJ), bruxism (grinding of the teeth during sleep), and hypertension. In addition, GAD often intensifies the discomfort or complications associated with arthritis, diabetes, and other chronic disorders. Patients with GAD are more likely to seek help from a primary care physician than a psychiatrist; they are also 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. In addition, patients with anxiety disorders have higher rates of mortality from all causes than people who are less anxious.

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

Children diagnosed with GAD have much the same anxiety symptoms as adults. The mother of a six-year-old boy with the disorder told his pediatrician that her son “acted like a little man” rather than a typical first-grader. He would worry about such matters as arriving on time for school field trips, whether the family had enough money for immediate needs, whether his friends would get hurt climbing on the playground jungle gym, whether there was enough gas in the tank of the family car, and similar concerns. The little boy had these worries in spite of the fact that his family was stable and happy and had no serious financial or other problems.

GAD often has an insidious onset that begins relatively early in life, although it can be precipitated by a sudden crisis at any age above six or seven years. The idea that GAD often begins in the childhood years even though the symptoms may not become clearly noticeable until late adolescence or the early adult years is gaining acceptance. About half of all patients diagnosed with the disorder report that their worrying began in childhood or their teenage years. Many will say that they cannot remember a time in their lives when they were not worried about something. This type of persistent anxiety can be regarded as part of a person’s temperament, or inborn disposition; it is sometimes called trait anxiety. It is not unusual, however, for people to develop the disorder in their early adult years or even later in reaction to chronic stress or anxiety-producing situations. For example, there are instances of people developing GAD after several years of taking care of a relative with dementia , living with domestic violence, or living in close contact with a friend or relative with borderline personality disorder.

The specific worries of people with GAD may be influenced by their ethnic background or culture. The DSM-IV-TR cited an observation that being punctual is a common concern of patients with GAD that reflects the value that Western countries place on using time as efficiently as possible. One study of worry in college students from different ethnic backgrounds found that Caucasian and African American students tended to worry a variable amount about a wider range of concerns, whereas Asian Americans tended to worry more intensely about a smaller number of issues. Another study found that a community sample of older Puerto Ricans with GAD overlapped with a culture-specific syndrome called ataque de nervios, which resembles panic disorder but has features of other anxiety disorders as well as dissociative symptoms. (People experience dissociative symptoms when their perception of reality is temporarily altered—they may feel as if they were in a trance, or that they were observing activity around them instead of participating.) Further research is needed regarding the relationship between people’s ethnic backgrounds and their outward expression of anxiety symptoms.

Causes and symptoms

Causes

The causes of generalized anxiety disorder appear to be a mixture of genetic and environmental factors. It has been known for some years that the disorder runs in families. Twin studies as well as the ongoing mapping of the human genome point to a genetic factor in the development of GAD. The role of the family environment (social modeling ) in an individual’s susceptibility to GAD is uncertain. Social modeling, the process of learning behavioral and emotional response patterns from observing one’s parents or other adults, appears to be a more important factor for women than for men.

Another factor in the development of GAD is social expectations related to gender roles. Research findings indicate that women have higher levels of emotional distress and lower quality of life than men. The higher incidence of GAD in women has been linked to the diffuse yet comprehensive expectations of women as caregivers. Many women assume responsibility for the well-being and safety of other family members in addition to holding jobs or completing graduate or professional school. The global character of these responsibilities as well as their unrelenting nature has been described as a mirror image of the persistent but nonspecific anxiety associated with GAD.

Socioeconomic status may also contribute to generalized anxiety. One British study found that GAD is more closely associated with an accumulation of minor stressors than with any demographic factors. People of lower socioeconomic status, however, have fewer resources for dealing with minor stressors and so appear to be at greater risk for generalized anxiety.

An additional factor may be the patient’s level of muscle tension. Several studies have found that patients diagnosed with GAD tend to respond to physiological stress in a rigid, stereotyped manner. Their autonomic reactions (reactions in the part of the nervous system that governs involuntary bodily functions) are similar to those of people without GAD, but their muscular tension shows a significant increase. It is not yet known, however, whether this level of muscle tension is a cause or an effect of GAD.

Symptoms

The symptomatology of GAD has changed somewhat over time with redefinitions of the disorder in successive editions of the DSM. The first edition of the DSM and the DSM-II did not make a sharp distinction between generalized anxiety disorder and panic disorder. After specific treatments were developed for panic disorder, GAD was introduced in the DSM-III as an anxiety disorder without panic attacks or symptoms of major depression. This definition proved to be unreliable. As a result, the DSM-IV constructed its definition of GAD around the psychological symptoms of the disorder (excessive worrying) rather than the physical (muscle tension) or autonomic symptoms of anxiety. The DSM-IV-TR continued that emphasis.

According to the DSM-IV-TR, the symptoms of GAD are:

  • excessive anxiety and worry about a number of events or activities occurring more days than not for at least six months.
  • worry that cannot be controlled.
  • worry that is associated with several symptoms such as restlessness, fatigue, irritability, or muscle tension.
  • worry that causes distress or impairment in relationships, at work, or at school.

In addition, to meet the diagnostic criteria for GAD, the content or focus of the worry cannot change the diagnosis from GAD to another anxiety disorder such as panic disorder, social phobia , or obsessive-compulsive disorder , and the anxiety cannot be caused by a substance (a drug or a medication).

One categorization of GAD symptoms that some psychiatrists use in addition to the DSM framework consists of three symptom clusters:

  • symptoms related to high levels of physiological arousal: muscle tension, irritability, fatigue, restlessness, insomnia.
  • symptoms related to distorted thinking processes: poor concentration, unrealistic assessment of problems, recurrent worrying.
  • symptoms associated with poor coping strategies: procrastination, avoidance, inadequate problem-solving skills.

Demographics

The National Institute of Mental Health (NIMH) estimates that approximately 6.8 million Americans have GAD. Further it is estimated that twice as many women as men develop GAD. One study that used the DSM-III-R criteria concluded that 5% of the United States population, or one person in every 20, will develop GAD at some point.

Some psychiatrists think that generalized anxiety disorder is overdiagnosed in both adults and children. One reason for this possibility is that diagnostic screening tests used by primary care physicians for mental disorders produce a large number of false positives for GAD. One study of the PRIME-MD, a screening instrument for mental disorders frequently used in primary care practices, found that 7 of 10 patients met the criteria for GAD. In-depth follow-up interviews with the patients, however, revealed that only a third of the GAD diagnoses could be confirmed.

Diagnosis

Diagnosis of GAD, particularly in primary care settings, is complicated by several factors. One is the high level of comorbidity (co-occurrence) between GAD and other mental or physical disorders. Another is the considerable overlap between anxiety disorders in general and depression. Some practitioners believe that depression and GAD may not be separate disorders after all, because studies have repeatedly confirmed the existence and common occurrence of a “mixed” anxiety/depression syndrome.

Evaluating patients for generalized anxiety disorder includes the following steps:

  • patient interview. The doctor will ask the patients to describe the anxiety, and will note whether it is acute (lasting hours to weeks) or persistent (lasting from months to years). If the patients describe a recent stressful event, the doctor will evaluate them for “double anxiety,” which refers to acute anxiety added to underlying persistent anxiety. The doctor may also give the patients a diagnostic questionnaire to evaluate the presence of anxiety disorders. The Hamilton Anxiety Scale is a commonly used instrument to assess anxiety disorders in general. The Generalized Anxiety Disorder Questionnaire for DSMIV (GAD-Q-IV) is a more recent diagnostic tool, and is specific to GAD.
  • medical evaluation. Nonpsychiatric disorders that are known to cause anxiety (hyperthyroidism, Cushing’s disease, mitral valve prolapse, carcinoid syndrome, and pheochromocytoma) must be ruled out, as well as certain medications (steroids, digoxin, thyroxine, theophylline, and selective serotonin reup-take inhibitors) that may also cause anxiety as a side effect. Patients should be asked about their use of herbal preparations as well.
  • substance abuse evaluation. Because anxiety is a common symptom of substance abuse and withdrawal syndrome, doctors will ask about patients’ use of caffeine, 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 overlap between GAD and depression or between GAD and other anxiety disorders.

In some instances the doctor will consult the patient’s family for additional information about the onset of the patient’s anxiety symptoms, dietary habits, etc.

Treatments

There are several treatment types that have been found effective in treating people with GAD. Most patients with the disorder are treated with a combination of medications and psychotherapy.

Medications

Pharmacologic therapy is usually prescribed for patients whose anxiety is severe enough to interfere with daily functioning. Several different groups of medications have been used to treat generalized anxiety disorder.

These medications include the following:

  • benzodiazepines. This group of tranquilizers does not decrease worry, but lowers anxiety by decreasing muscle tension and hypervigilance. They are often prescribed for patients with double anxiety because they act very quickly. The benzodiazepines, however, have several disadvantages: they are unsuitable for long-term therapy because they can cause dependence, and GAD is a long-term disorder; they cannot be given to patients who abuse alcohol; and they cause short-term memory loss and difficulty in concentration. One British study found that benzodiazepines significantly increased a patient’s risk of involvement in a traffic accident.
  • Buspirone (BuSpar). Buspirone appears to be as effective as benzodiazepines and antidepressants in controlling anxiety symptoms. It is slower to take effect (about two-three weeks), but has fewer side effects. In addition, it treats the worry associated with GAD rather than the muscle tension.
  • tricyclic antidepressants. Imipramine (Tofranil), nortriptyline (Pamelor), and desipramine (Norpramin) have been given to patients with GAD. They have, however, some problematic side effects: imipramine has been associated with disturbances in heart rhythm, and the other tricyclics often cause drowsiness, dry mouth, constipation, and confusion. They increase the patient’s risk of falls and other accidents.

KEY TERMS

Anxiolytic —A preparation or substance given to relieve anxiety; a tranquilizer.

Ataque de nervios —A culture-specific anxiety syndrome found among some Latin American groups in the United States and in Latin America. It resembles panic disorder in some respects but also includes dissociative symptoms, and frequently occurs in response to stressful events.

Autonomic nervous system —The part of the nervous system that governs the heart, involuntary muscles, and glands.

Double anxiety —Acute anxiety from a recent stressful event combined with underlying persistent anxiety associated with generalized anxiety disorder.

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

Insidious —Proceeding gradually and inconspicuously but with serious effect.

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.

Temperament —A person’s natural disposition or inborn combination of mental and emotional traits.

Temporomandibular joint dysfunction —A condition resulting in pain in the head, face, and jaw. Muscle tension or abnormalities of the bones in the area of the hinged joint (the temporomandibular joint) between the lower jaw and the temporal bone are usually the cause.

Trait anxiety —A type of persistent anxiety found in some patients with generalized anxiety disorder. Trait anxiety is regarded as a feature (trait) of a person’s temperament.

Twin study —Research studies that use pairs of twins to study the effects of heredity and environment on behavior or other characteristic.

  • selective serotonin reuptake inhibitors (SSRIs). Paroxetine (Paxil), one of the SSRIs, was approved by the U.S. Food and Drug Administration (FDA) in 2001 as a treatment for GAD. Venlafaxine (Effexor) appears to be particularly beneficial to patients with a mixed anxiety/depression syndrome; it is the first drug to be labeled by the FDA as an antidepressant as well as an anxiolytic. Venlafaxine is also effective in treating patients with GAD whose symptoms are primarily somatic (manifesting as physical symptoms or bodily complaints).

Psychotherapy

Some studies have found cognitive therapy to be superior to medications and psychodynamic psychotherapy in treating GAD, but other researchers disagree with these findings. As a rule, patients with GAD who have personality disorders , who are living with chronic social stress (e.g., caring for a parent with Alzheimer’s disease ), or who do not trust psychotherapeutic approaches require treatment with medications. The greatest benefit of cognitive therapy is its effectiveness in helping patients with the disorder to learn more realistic ways to appraise their problems and to use better problem-solving techniques.

Family therapy is recommended insofar as family members can be helpful in offering patients a different perspective on their problems. They can also help patients practice new approaches to problem solving.

Alternative and complementary therapies

Several alternative and complementary therapies have been found helpful in treating patients with generalized anxiety disorder. These include hypnotherapy , music therapy, Ayurvedic medicine, yoga , religious practice, and guided imagery meditation.

Biofeedback and relaxation techniques are also recommended for patients with GAD in order to lower physiologic arousal. In addition, massage therapy, hydrotherapy, shiatsu, and acupuncture have been reported to relieve muscle spasms or soreness associated with GAD.

One herbal remedy that has been used in clinical trials for treating GAD is passionflower (Passiflora incarnata). One team of researchers found that passionflower extract was as effective as oxazepam (Serax) in relieving anxiety symptoms in a group of 36 outpatients diagnosed with GAD according to DSM-IV criteria. In addition, the passionflower extract did not impair the subjects’ job performance as frequently or as severely as the oxazepam.

Prognosis

Generalized anxiety disorder is generally regarded as a long-term condition that may become a lifelong problem. 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

The best preventive strategy, given the early onset of GAD, is the modeling of realistic assessment of stressful events by parents, and the teaching of effective coping strategies to their children.

See alsoBodywork therapies; Cognitive-behavioral therapy; Cognitive problem-solving skills training; Stress.

Resources

BOOKS

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed., Text rev. Washington, D.C.: American Psychiatric Association, 2000.

Dugas, Michel J., and Melisa Robichaud. Cognitive-Behavioral Treatment for Generalized Anxiety Disorder: From Science to Practice. New York: Brunner-Routledge, 2006.

Heimberg, Richard G., Cynthia L. Turk, and Douglas S. Mennin, eds. Generalized Anxiety Disorder: Advances in Research and Practice. New York: The Guilford Press, 2004.

Nutt, David J., Karl Rickels, and Dan J. Stein. Generalized Anxiety Disorder: Symptomatology, Pathogenesis and Management. Oxford: Informa Healthcare, 2002.

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

Rygh, Jayne L., and William C. Sanderson. Treating Generalized Anxiety Disorder: Evidence-Based Strategies, Tools, and Techniques. New York: The Guilford Press, 2004.

VandenBos, Gary R., ed. APA Dictionary of Psychology. Washington, D.C.: American Psychological Association, 2006.

PERIODICALS

Allgulander, Christer. “Generalized Anxiety Disorder: What Are We Missing?” European Neuropsychopharmacology 16, Suppl. 2 (July 2006): S101-S108.

Allgulander, Christer, Ioana Florea, and Anna K. Trap Huusom. “Prevention of Relapse in Generalized Anxiety Disorder by Escitalopram Treatment.” International Journal of Neuropsychopharmacology 9.5 (Oct. 2006): 495–505.

Angst, Jules, and others. “Varying Temporal Criteria for Generalized Anxiety Disorder: Prevalence and Clinical Characteristics in a Young Age Cohort.” Psychological Medicine 36.9 (Sept. 2006): 1283–92.

Baldwin, David S., Anna Karina Trap Huusom, and Eli Maehlum. “Escitalopram and Paroxetine in the Treatment of Generalised Anxiety Disorder: Randomised, Placebo-Controlled, Double-Blind Study.” British Journal of Psychiatry 189.3 (Sept. 2006): 264–72.

Connor, Kathryn M., Victoria Payne, and Jonathan R. T. Davidson. “Kava in Generalized Anxiety Disorder: Three Placebo-Controlled Trials.” International Clinical Psychopharmacology 21.5 (Sept. 2006): 249–53.

Goldston, David B., and others. “Reading Problems, Psychiatric Disorders, and Functional Impairment from Mid- to Late Adolescence.” Journal of the American Academy of Child & Adolescent Psychiatry 46.1 (Jan. 2007): 25–32.

Gosselin, Patrick, and others. “Benzodiazepine Discontinuation Among Adults With GAD: A Randomized Trial of Cognitive-Behavioral Therapy.” Journal of Consulting and Clinical Psychology 74.5 (Oct. 2006): 908–19.

Hoge, Elizabeth A., and others. “Cross-Cultural Differences in Somatic Presentation in Patients with Generalized Anxiety Disorder.” Journal of Nervous and Mental Disease 194.12 (Dec. 2006): 962–66.

Kim, Tae-Suk, and others. “Comparison of Venlafaxine Extended Release Versus Paroxetine for Treatment of Patients with Generalized Anxiety Disorder.” Psychiatry and Clinical Neurosciences 60.3 (June 2006): 347–51.

Kopecek, Miloslav, Pavel Mohr, and Tomas Novak. “Sedative Effects of Low-Dose Risperidone in GAD Patients and Risk of Drug Interactions.” Journal of Clinical Psychiatry 67.8 (Aug. 2006): 1307–1308.

Labrecque, Joane, and others. “Cognitive-Behavioral Therapy for Comorbid Generalized Anxiety Disorder and Panic Disorder With Agoraphobia.” Behavior Modification 30.4 (July 2006): 383–410.

Lyddon, William J. “Review of Generalized Anxiety Disorder: Advances in Research and Practice.” Journal of Cognitive Psychotherapy 20.4 (Winter 2006): 463–64.

Mennin, Douglas S. “Emotion Regulation Therapy: An Integrative Approach to Treatment-Resistant Anxiety Disorders.” Journal of Contemporary Psychotherapy 36.2 (June 2006): 95-105.

Montgomery, Stuart A., and others. “Efficacy and Safety of Pregabalin in the Treatment of Generalized Anxiety Disorder: A 6-Week, Multicenter, Randomized, Double-Blind, Placebo-Controlled Comparison of Pregabalin and Venlafaxine.” Journal of Clinical Psychiatry 67.5 (May 2006): 771–82.

Nutt, David, and others. “Generalized Anxiety Disorder: A Comorbid Disease.” European Neuropsychopharmacology 16, Suppl. 2 (July 2006): S109-S118.

Skopp, Nancy A., and others. “Investigation of Cognitive Behavior Therapy.” American Journal of Geriatric Psychiatry 14.3 (Mar. 2006): 292.

Weems, Carl F., and others. “Predisaster Trait Anxiety and Negative Affect Predict Posttraumatic Stress in Youths After Hurricane Katrina.” Journal of Consulting and Clinical Psychology 75.1 (Feb. 2007): 154–59.

ORGANIZATIONS

Anxiety Disorders Association of America. 11900 Parklawn Drive, Suite 100, Rockville, MD 20852-2624. Telephone: (301) 231-9350. <www.adaa.org>.

Anxiety Disorders Education Program, National Institute of Mental Health. 6001 Executive Boulevard, Room 8184, MSC 9663, Bethesda, MD 20892-9663. Telephone: (301) 443-4513. <www.nimh.nih.gov>.

Freedom From Fear. 308 Seaview Avenue, Staten Island, NY 10305. Telephone: (718) 351-1717. <www.freedomfromfear.com>.

National Mental Health Association. 1021 Prince Street, Alexandria, VA 22314-2971. Telephone: (800) 969-6642. <www.nmha.org>.

OTHER

National Institute of Mental Health (NIMH). Anxiety Disorders. NIH Publication No. 00-3879 (2000). <www.nimh.nih.gov/anxiety/anxiety.cfm>.

National Institute of Mental Health (NIMH). Facts About Generalized Anxiety Disorder. NIH publication OM-99 4153 (2000). <www.nimh.nih.gov/anxiety/gadfacts.cfm>.

Rebecca J. Frey, PhD
Ruth A. Wienclaw, PhD

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Generalized Anxiety Disorder

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

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