Generalized Anxiety Disorder (GAD)

Clinical Feature 

Generalized Anxiety Disorder was earlier mentioned in Freud writing “anxiety neurosis”. He at the time used the term anxiety neurosis (GAD & Panic) to distinguish it from phobic neurosis (Heimberg, et.al, 2004). Generalized Anxiety Disorder shortly known as GAD is a form of anxiety disorder characterized by excessive, irrational, uncontrollable worry and nervousness about future apprehension. The individual is extremely worried about these and other things even though there is little or no reason to be worried about them and they find it little or no help to control their anxiety. Excessive worry means worrying even when there is no specific threat present or in a manner that is disproportionate to the actual risk (Hirsch & Mathews, 2012). 

Comorbidity

Generalized anxiety disorder often co-exists with other anxiety and unipolar depressive disorders.  That means a person who is suffering from GAD is more likely to have another sort of disorder at the same time. Social and specific phobia and panic are common. Similarly, in patients with a lifetime diagnosis of GAD, there is often a history of major depression or dysthymia (Nuta et.al. 2002 & Wittchen, 1994). 

Similarly co-morbidity with substance use is less common (DSM-5). 

Prevalence Rate

6% of general populations are affected by GAD in their lifetime. Females are more vulnerable to GAD than male in the ratio of 2:1 and adults are more likely to develop GAD than adolescents; its  12 month prevalence percentage is 0.9 and 2.9 respectively. Lifetime prevalence varies among countries; various research shows data is in between 5 -11%. The disorder peaks during middle and old age. DSM 5 reports that EU countries are likely to experience GAD more frequently than non EU countries (DSM-5).

In a study conducted by Ahmad, Masalha et.al among 811 patients in Jordan it was found that 36 to 45 years aged individuals were five times more likely to have anxiety than other age groups and patients with asthma or arthritis were more likely to develop GAD than other chronic conditions. 

DSM-5 Diagnostic criteria for Generalized Anxiety Disorder 

A. Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance).

B. The individual finds it difficult to control the worry.

C. The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms having been present for more days than not for the past 6 months); Note: Only one item is required for children.

1. Restlessness or feeling keyed up or on edge.
2. Being easily fatigued.
3. Difficulty concentrating or mind going blank.
4. Irritability.
5. Muscle tension.
6. Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep).

D. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

E. The disturbance is not due to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism).

F. The disturbance is not better explained by another mental disorder. 

Causative factors 

What causes GAD? It has been a great deal of question for the past several years and will be for years to come. Biological perspectives emphasize the role of heredity, brain and neurotransmitter result GAD. Domschke & Gittschalk in 2017 inspected clinical genetic evidence for the familiarity heritability of GAD; they found that children of people with GAD are more likely to develop the condition. Hettema, Kendler, Prescot et.al confirmed that individuals inherited the tendency of becoming anxious rather than GAD itself. 

Difference in brain functioning specifically amygdale and prefrontal cortex increase the risk of developing an anxiety disorder (Patriquin & Mathew, 2017). Imbalances of serotonin (low) present in people with GAD.  

Addictive use of substances namely caffeine also cause heightened feelings of worry contributing to the development of anxiety (Richard & Smith, 2015).

Apart from heredity and brain abnormalities, social cultural perspective believes that GAD is the result of psychological, environmental, and social factors. Traumatic experiences such as death, calamities, pandemic, abuses, negligence and isolation during childhood or adulthood increase its risk. Problem in relationship, Job stress are other sorts of phenomena which cause GAD. 

According to behavioral perspectives, GAD is a learned behavior.  If an individual receives positive reinforcement whenever he/she demonstrates GAD related symptoms during stressful situations, we may tend to do the same next time.  Similarly, GAD is also learned through observation, we tend to mirror the GAD symptoms related behavior from someone else. However this learning happens through unconsciousness.    

Treatment 

GAD is quite a common type of anxiety disorder, and treatment for GAD is available. Both psychological therapy and pharmacotherapy or a combination of both, it’s available to the individuals upon severity and complication. Psychologists practice psychological based treatment whereas psychiatrists are responsible for pharmacotherapy. However there is high evidence that individuals will benefit from psychotherapy in the long term (Barlow, Allen & Basden, 2007). Psychotherapy is also recognized as talk therapy which is performed by trained therapists There are various types of psychotherapy; among many cognitive behavioral therapy (CBT) is the most effective treatment for generalized anxiety disorder.

CBT focuses on questioning patient’s negatives or anxious thoughts and asking them to do things that will avoid the anxious feelings and help them to gradually be symptom free. 

Next to CBT, relaxation or medication also significantly aid clients who are expressing anxiety due to GAD.  Relaxation helps patients to relax their muscles, this technique is taught by therapists.  Exercise can only be recommended as adjunctive treatment to standard treatments.

Case Study

Alice, a 48-year-old female dentist, presented to a psychiatrist with a 7-month history of anxiety symptoms, which included persistent feelings of restlessness, irritability, difficulty concentrating; sleep disturbance, fatigue, nausea, diarrhea, muscle cramps, and the sensation of having a lump in her throat. She was suffering from constant worry that her husband could become ill or might have an accident while driving to work. Her symptoms resulted in frequent absenteeism, which caused significant problems at work. Her medical history was unremarkable. The psychiatrist diagnosed her with generalized anxiety disorder. 

(Case adopted form Journal Treatment of Anxiety disorder by Bandelow, et.al. 2017)

References

• Muris, P. (2007). Normal and abnormal fear and anxiety in children and adolescents. Elsevier Inc. 
• Heimberg, R.G., Truk, C.L. & Menin, D.S (2004). Generalized Anxiety Disorder: Advances in Research and Practice. Guliford Press
• Hirsch. C. & Mathews. A. (2012).A cognitive model of pathological worry. Behaviour Research and Therapy. 50(10)
• Nutt, D.J., Ballenger, J.C., Sheehan, D, & Wittchen, H.U. (2002).  Generalized anxiety disorder: comorbidity, comparative biology and treatment.  International Journal of Neuropsycho pharmacology 5.  doi:10.1017/S1461145702003048 
• Ahmand. M.M., & Maslha. A.A. (2018)Prevalence of generalized anxiety disorder in family practice clinics 
• Domschke, K., & Gottschalk, M. G. (2017). Genetics of generalized anxiety disorder and related traits. Dialogues in clinical neuroscience, 19(2) 
• Hattema, J,M., Prescott, C.A., Kendler, K.S., (2006). A Population-Based Twin Study of the Relationship Between Neuroticism and Internalizing Disorders .  American Journal of Psychiatry. 163(5). doi 10.1176/ajp.2006.163.5.857 
• Patriquin, M. & Mathew. S. (2017). The Neurobiological Mechanisms of Generalized Anxiety Disorder and Chronic Stress. Sage Journal. 1. doi.10.1177/2470547017703993 
• Richards. G., Smith. A. (2015). Caffeine consumption and self-assessed stress, anxiety, and depression in secondary school children. J Psychopharmacol.29 (12).  doi:10.1177/0269881115612404
• Barlow, D.H., Allen, L.N., & Basden, S. (2007). Psychological treatment for panic disorder, phobias and generalized anxiety disorders. 3^rd Edition . Oxford University Press.  
• Bandelow, B., Michaelis, S., & Wedekind, D. (2017). Treatment of anxiety disorders. Dialogues in clinical neuroscience, 19(2), 
• Wittchen, H.U., Zhao, S., Kessler, R.C. (1994). DSM-III-R generalized anxiety disorder in the National Comorbidity Survey. Arch Gen Psychiatry. 51(5)  doi:10.1001/archpsyc.1994.03950050015002.