Generalized Anxiety Disorder

What is Generalized Anxiety Disorder?

Generalized anxiety disorder refers to the presence of ongoing, persistent, excessive and irrational worry about daily activities and events, for at least six months before a formal diagnosis is made.

The National Institute of Mental Health describes generalized anxiety disorder (GAD) as persistent and excessive worry about a variety of everyday problems lasting for at least 6 months.

Anxiety disorder is one of the common and serious mental disorders all over the world. According to a WHO report, anxiety disorders were estimated to be 3.6% in 2015 at a global level.

In comparison with depression disorders, anxiety disorders are more common among females than males (4.6% compared to 2.6% at the global level).

What are the Causes of Generalized Anxiety Disorder?

Generalized Anxiety Disorder is likely to result from both biological and emotional factors. The causes or risk factors of GAD include:

• Genetics: Genes play a large role in the etiology of GAD. It may run in families with anxiety disorder. A study reveals that the risk of GAD in first-degree relatives of people with GAD was five times as compared to control groups.
• Stress and Trauma- Recent or prolonged exposure to stressful situations may cause anxiety. Patients with GAD are more likely to report traumatic events. Some findings indicate that that early exposure to serious trauma such as, childhood sexual assault, physical and emotional abuse may lead to a different clinical presentation in GAD patients.
• Excessive consumption of caffeine - Study shows that intake of large amounts of caffeine may increase psychoses and worsen anxiety-like symptoms like heart palpitations, rapid heartbeat, elevated blood pressure, and insomnia.
• Personality trait- People with certain personality traits are more prone to anxiety disorders than others. Neuroticism and extraversion are strongly related with anxiety disorder.

• Gender: Studies suggest that anxiety disorders are more prevalent among women than men. Metacognitive (becoming aware of one's awareness and higher-order thinking skills) beliefs in uncontrollability may contribute to the higher prevalence of anxiety in females than males.
• Diseases Associated- GAD may be an outcome for other diseases such as multiple sclerosis, irritable bowel syndrome and some cardiac events.

What is the Difference between GAD and other Mental Problems?

GAD is different from other mental disorders in a number of ways.

• For example, worrying in GAD is exaggerated, intrusive and persistent which is not common with normal worry.
• The GAD individuals are not likely to have panic attacks in contrast to the symptoms of 'panic disorder'.
• Also, studies show that GAD patients more often have simple phobias, whereas patients with panic disorder commonly are associated with depersonalization and agoraphobia.
• GAD does not involve repetitive behaviors to relieve stress that is caused by any obsession or fear, like what is seen in another anxiety disorder called obsessive compulsive disorder.

What are the Signs and Symptoms of Generalized Anxiety Disorder?

The symptoms of GAD include:

• Difficulty concentrating or focusing
• Trouble falling asleep
• Irritability
• Fatigue/exhaustion
• Muscle tension or body aches
• Restlessness
• Repeated stomach problems or diarrhea
• Sweating palms
• Rapid heartbeat
• Trembling
• Numbness/tingling in different parts of the body

How do you Diagnose Generalized Anxiety Disorder?

In the diagnosis of generalized anxiety disorder the careful observation of individual's symptoms is the initial and crucial step. Patients with GAD should be evaluated for symptoms associated with worry. A patient history helps to categorize the anxiety as acute or persistent in order to get an idea of the severity of the disorder. The history of substance use with careful attention to caffeine, nicotine, and stimulants as well as alcohol and benzodiazepine withdrawal is also very important.

DSM-IV-TR- The Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision describes GAD as excessive anxiety and worry for 6 months about a number of different activities or events. The codes or core features of GAD based on DSM-IV-TR criteria are a standard diagnostic criterion.

The GAD-7 scale- The GAD-7 (The 7-Item Generalized Anxiety Disorder Scale) has been used as a validated diagnostic tool to evaluate severity of condition. It includes seven parameters and has good diagnostic sensitivity and specificity based on DSM-IV criteria. Greater GAD-7 scores are correlated with more degree of severity.

The Hamilton Anxiety Rating Scale (HAM-A)- It is a widely used interview measure designed to assess anxiety. It helps to assess cognitive and affective components of anxious experience (for example, anxious mood, tension, fears, difficulty concentrating), but lack in assessing the central feature of difficult-to-control worry.

The DSM-5 Level 2 (Anxiety-Adult measure)- It is the 7-item PROMIS Anxiety Short Form that mainly assesses the pure domain of anxiety in individuals age 18 and older. Each item on the measure is rated on a 5-point scale with a range in score from 7 to 35 with higher scores indicating greater levels of severity in GAD.

How do you Treat Generalized Anxiety Disorder?

The main treatments for generalized anxiety disorder include psychotherapy or psychological counseling and medications or a combination of both.

Cognitive behavior therapy (CBT) - It is an effective form of psychotherapy for generalized anxiety disorder. In a study conducted on older adults with functional impairment at 6-month follow-up, this therapy was found to be a beneficial tool. CBT significantly improved worry severity, depressive symptoms and general mental health compared with EUC (Enhanced Usual Care).

Use of medications - The neurotransmitters that are mainly targeted in anxiety disorders are gamma-aminobutyric acid (GABA), serotonin, dopamine, and epinephrine. GABAergic inhibition is essential for maintaining a balance between neuronal excitation and inhibition. The serotonin inhibitors also play a major role in treating anxiety disorders.

1. Selective serotonin re-uptake inhibitors (SSRIs)

This drug class includes fluoxetine, sertraline, citalopram, escitalopram, fluvoxamine, paroxetine and vilazodone. They work by inhibiting the serotonin transporter and appear to cause desensitization of postsynaptic serotonin receptors, thus normalizing the activity.

It is generally recommended that the medicine must be taken for another six months at least. Research suggests that this lowers the risk return of anxiety.

2. Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)

Serotonin norepinephrine reuptake inhibitors as a first line choice for comorbid GAD. This drug class includes venlafaxine, desvenlafaxine and duloxetine.

3. Benzodiazepines

Benzodiazepines are also used in treating GAD. They are advantageous treatments for anxiety disorders because they have fast action. Diazepam has been successfully used in treating the symptoms but is used only for temporary basis due to its adverse effects.

4. Anticonvulsant agents

• Gabapentin - It is an effective agent for GAD and shows modest mood stabilizing properties, improves sleep quality, and may prove to be useful for comorbid chronic pain syndromes such as irritable bowel syndrome, fibromyalgia, and interstitial cystitis.
• Buspirone - It is also an effective anxiolytic drug and has been reported to show minimal side effects with minimal withdrawal symptoms.

5. Antipsychotic Medications

Antipsychotic medications have also been used to treat severe anxiety for many years. These include aripiprazole, ziprasidone and risperidone. A review of second-generation antipsychotic drugs shows that quetiapine and risperidone were effective when combined with antidepressants.

How do you Prevent Generalized Anxiety Disorder?

Generalized anxiety disorder can be prevented and anxiety levels kept in check by keeping in mind the following steps to reduce the impact of symptoms caused by worry.

Identify and recognize your worry- An early recognition of cause of anxiety helps you to prevent many other mental health conditions, which can worsen if not identified within time.

Prioritize things- Paying attention to important issues in your life can help you reduce anxiety.

Avoid consuming unhealthy substances- Consuming alcohol and drugs that can cause addiction such as caffeine or nicotine can even worsen anxiety. So, quitting such substances is an effective preventive measure.

Keep yourself physically active- Developing a daily routine and involving few minutes of physical activities keeps you energized and active.

Lifestyle changes to reduce anxiety

Certain lifestyle changes may provide benefit in relieving anxiety and its associated symptoms. They are as follows:

• Get adequate sleep of at least 8 hours.
• Keep professional and personal life separate; never bring work to your home.
• Eat healthy and consume more fruits and green vegetables.
• Socialize yourself; interact with your loved ones or stay connected with important persons in life.
• Meditate or perform yoga daily.
• Quit smoking or alcohol intake.

References:

1. Generalized Anxiety Disorder (GAD) - (https://adaa.org/understanding-anxiety/generalized-anxiety-disorder-gad)
2. Patients with generalized anxiety disorder and a history of trauma: somatic symptom endorsement. - (https://www.ncbi.nlm.nih.gov/pubmed/15920396)
3. Alcohol, nicotine, caffeine, and mental disorders - (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3181622/)
4. Personality and anxiety disorders. - (https://www.ncbi.nlm.nih.gov/pubmed/16879789)
5. What is generalised anxiety disorder (GAD)? - (https://www.beyondblue.org.au/the-facts/anxiety/types-of- anxiety/gad)
6. Generalized anxiety disorder vs. panic disorder. Distinguishing characteristics and patterns of comorbidity. - (https://www.ncbi.nlm.nih.gov/pubmed/1593271)
7. Screening mnemonic for generalized anxiety disorder- (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1479789/)
8. Efficacy of Cognitive Behavioral Therapy for Generalized Anxiety Disorder in Older Adults: Systematic Review, Meta-Analysis, and Meta- Regression. - (https://www.ncbi.nlm.nih.gov/pubmed/27687212)

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