Generalized anxiety disorder
General Anxiety Disorder (GAD)
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General Anxiety Disorder (GAD)
Background and Diagnostic Criteria of GAD
The criteria for diagnosing an individual with General Anxiety Disorder (GAD), has undergone various modifications. During the 1980’s GAD was diagnosed as a residual category of anxiety disorders, when other anxiety disorders were not diagnosed. Initially, it was defined as the presence of a persistent and generalized form of anxiety (without any organic cause) which lasted for more than one month. The earlier diagnostic criteria for GAD were the presence of at least three symptoms out of 4 identified as typical to GAD. These symptoms included muscle tension (muscle spasms, tremors), autonomic responses (tachycardia or bradycardia, excess sweating, hyperventilation), unnatural & unnecessary apprehensions and vigilance & scanning (exploratory behavior) (Brown, Barlow, Liebowitz, 1994).
However, in 1994 the definition and domain of GAD was put forward in the Diagnostic and Statistical Manual of Mental Diseases-IV, as per American Psychiatric Association guidelines. DSM-IV defines GAD as a form of anxiety disorder which is presented with excess and uncontrollable worries about different life events/activities, which must be accompanied by three out of six symptoms of negative affective emotion. These six symptoms as per DSM-IV diagnostic criteria for GAD are (Brown, Barlow, Liebowitz, 1994):
a. Excessive anxiety and worry (apprehensive expectations), occurring for some days but less than 6 months, about some events or activities.
b. The individual with the disorder will have extreme difficulty in controlling the worry.
c. The anxiety and worry must be associated with three o more of the following symptoms:
i. Restlessness or feeling keyed up
iii. Difficulty in concentrating or maintaining focus
v. Muscle tension
vi. Disturbances in sleep ( either falling or staying asleep or difficulty in falling asleep)
d. The feature of anxiety and worry should not be confined to features of an Axis 1 disorder( for example, worry should not be accompanied with panic attacks), should not match features of social phobia ( like feeling embarrassed or venturing out alone in new places) , should not any degree or symptoms of obsession or compulsion (lie obsessive-compulsive disorder), should not match the features of separation anxiety disorders ( that arises due to being away from near and dear ones), must not be associated with weight gain due to bulimia nervosa or weight loss due to anorexia nervosa, should not arise from anxiety due to physical disorders.e. The anxiety and worry or the physical symptoms must cause clinically significant distress or impairment to cause a disturbance in their social, occupational or personal life.
f. Moreover, such disturbances must not be linked with any form of physiological effects of a substance (drug abuse or medication abuse) or from any general medical condition and must not be linked to any mood disorder too.
Prevalence of GAD and Burden of Disease
Data from various studies have indicated that the lifetime prevalence of GAD occurs in around 1.4% to 5.4% of the general population, all across the globe. The largest documented data revealed by the National Co-morbidity Survey indicated the prevalence estimates to be 1.6% for current GAD and 5.1% for lifetime GAD. Such data was documented for around 8000 individuals between the age group of 15 to 54 years. GAD is prevalent in a ratio of 2:1 between females and males. GAD is also considered as one of the commonest disorders in the elderly population. The data have been substantiated by examining the consumption of minor tranquilizers. Around 17% to 50%, of the elderly population consumes mild tranquilizers.
Detection of GAD or its history of origin on age is difficult. However, it has been recognized that GAD does not have a late onset like most other anxiety disorders and also GAD is not associated with acute exacerbations, which are common features of anxious or depressive disorders. From the data of National Co-morbidity Survey, it became apparent, that GAD does not manifest in early childhood years and lowest age of individuals presenting with Gad symptoms was 15 years.
Initially, GAD was related to be an independent disorder that was not associated with any comorbid conditions.
However, the NCS data revealed that individuals suffering from GAD reported that such sufferings were strongly associated with past treatment seeking behavior ( usage of drugs or cognitive therapy) or due to substantial interference in lifestyle. Therefore, GAD does not occur independently and must be related with other physical, physiological or even psychological debility. This is because, community surveys indicated, that approximately 90% individuals who suffered from GAD had a history of mental disorder (Witchen et al, 1994).
Moreover, the data from NCS revealed, that around 65% of individuals who suffered from GAD had also another comorbid disorder. Clinical studies have revealed that 75% of individuals suffering from GAD suffered from concurrent mood or anxiety disorders too. Gad was strongly associated with various anxiety and depressive disorders. These disorders are substance abuse disorder, panic disorders, phobia related disorders, and major depressive disorders. Apart from the mood disorders, GAD has been strongly associated with other physical disorders like irritable bowel syndrome and chronic headaches.
Conceptual Model Underlying GAD
GAD is based on the concept of anxious apprehension. Anxious apprehension has been defined as a future-oriented change in mood state of an individual, in which one becomes ready or prepared to negate the impacts of negative consequences or events, which are anticipated and apprehended. The mood state is associated with increased levels of chronic hyperarousal and a feeling of uncontrollability over one’s self-behavior or movements. There is a high self-focused attention towards threatening or uncomfortable stimuli. It was also evident that the anxiety symptoms or apprehensions, which is the genesis of GAD is also the basis for various other mood and anxiety disorders too (Barlow, 1988).
Therefore, the theoretical framework and the conceptual models impose a great difficulty in the diagnosis. This becomes very pertinent on other anxiety disorders also. Various mood and anxiety disorders often present with similar symptoms of GAD. Such situation may either lead to overestimation or underestimation of GAD. There are various postulates regarding the genesis of GAD. Some apprehend that GAD is also related to hereditary traits, just like other mood and depressive disorders. Moreover, GAD is believed to be caused by various biological and psychosocial factors. Anxious apprehension is quite common in certain diseases like major depressive disorder, or other emotional disorders (Barlow, 1988).
A study conducted on 1033 female twins reflected hereditability accounted for 30% of GAD incidences. On the other hand, GAD was strongly associated with environmental factors, which may not have been shared equally by both the twins. It was also noted that although GAD and major depressive disorder share the same familial genetic history, however on environmental influences they widely differed (Kendler et al, 1992).
Moreover, GAD might also have a psychosocial basis of origin. In a study done by Borkovec (1995), it was reflected that GAD was associated with childhood experiences of psychosocial trauma. Such trauma could have evoked from the death of near and dear ones might have been a victim of physical or sexual assault and the level of insecurity to which they were exposed in their childhood days. Borkovec(1994) was introduced the concept of “Pathological worry”, to explain the genesis of GAD. Pathological worry was designated as a negative affective situation, in which diffuse perceptions arose in the mind of an individual. For example, he or she might have to think that the whole world is threatening or abusing him or her. Borkovec (1994) demonstrated that such pathological worry was a negative reinforcing factor, which led to the genesis of GAD.
Management and Treatment of GAD
From the above discussion regarding the signs and symptoms of GAD, it becomes quite apparent that the targets of pharmacological therapy in GAD are to reduce the incidences of worry and hyperarousal phenomenon. These somatic expressions are best managed by cognitive therapy, which forms the major basis of non-pharmacological interventions. A mode of therapy called exposure based paradigm has been applied. As GAD is associated with worry (Pathological worry), such worry will lead to the impaired physiological functioning of the body (Barlow, Rapee & Brown, 1992).
Thus, worry will be a detrimental factor in the normal homeostatic control of physiological processes and will impair such thoughts that improve the functioning of the body. Therefore cognitive theory or exposure based paradigm tries to build on the realization of reduction of the pathological worry, which an individual is reflected to notice on improvement in his or her physiological or cognitive functions. This mode of approach is referred to as biofeedback mechanism of treatment. For the biofeedback mechanisms to be successful, the individuals should be aware of their benefits through their perceptions of well-being. This can happen, either by a sense of well-being in the physical and physiological health or the aspect of mental health (Barlow, Rapee & Brown, 1992).
Other techniques that are commonly applied to treat GAD include relaxation techniques and training on anxiety management. An important finding that translates the success of the non-pharmacological intervention is the decreased need for anxiolytic medications. Individuals, who were on a benzodiazepine, could able to become less dependent on the medicine, with success cognitive coping strategies.
However, if such worries are unable to be driven away by cognitive or behavioral therapy, then it will alleviate the condition of GAD, instead of managing it. Hence, the necessity of pharmacologic interventions arises (Barlow, Rapee & Brown, 1992).
The pharmacological interventions implicated to treat GAD depends upon the physical and psychological symptoms expressed by such patients. The most common medications used for the treatment of GAD include tranquilizers and anxiolytics. However, GAD is also treated in context to the presence of other comorbid psychiatric disorders. For example, an individual who presents with underlying symptoms of Major Depressive Disorder, are prescribed selective serotonin reuptake inhibitors to cause mood elevation in the individual. Such treatments are in jeopardy to the treatment of worry or anxiety that is typically associated with GAD. Anxiolytics or tranquilizers are prescribed for managing the “worry,” while the serotonin reuptake inhibitors are administered for elevating the mood in the same patient (White & Keenan, 1992).
GAD is a form of anxiety disorder which has specific manifestations like other psychiatric disorders. However, often the symptoms of GAD are under-diagnosed because such symptoms remain common to various psychiatric diseases too. Hence, proper management of GAD can only be successful if the differential diagnosis of GAD is robust and focused.
ReferencesBrown, T. A., Barlow, D. H., & Liebowitz, M. R. (1994). The empirical basis of generalized anxiety disorder. American Journal of Psychiatry, 151, 1272–1280.Barlow, D. H. (1988). Anxiety and its disorders: The nature and treatment of anxiety and panic. New
York: Guilford Press
Barlow, D. H., Rapee, R. M., & Brown, T. A. (1992). Behavioral treatment of generalized anxiety disorder. Behavior Therapy, 23, 551–570
Borkovec, T. D. (1994). The nature, functions, and origins of worry. In G. Davey & F. Tallis (Eds.),Worrying: Perspectives on theory, assessment, and treatment (pp. 5–33). New York: Wiley.
Borkovec, T. D., Abel, J. L., & Newman, H. (1995). Effects of psychotherapy on comorbid conditions in generalized anxiety disorder. Journal of Consulting and Clinical Psychology, 63, 479–483.
Kendler, K. S., Neale, M. C., Kessler, R. C., Heath, A. C., & Eaves, L. J. (1992). Generalized anxiety disorder in women: A population-based twin study. Archives of General Psychiatry, 49, 267–272.
White, J., & Keenan, M. (1992). Stress control: A controlled comparative investigation of large group therapy for generalized anxiety disorder. Behavioral Psychotherapy, 20, 97–114.
Wittchen, H. -U., Zhao, S., Kessler, R. C., & Eaves, W. W. (1994). DSM-III-R generalized anxiety disorder in the National Comorbidity Survey. Archives of General Psychiatry, 51, 355–364.