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Generalized Anxiety Disorder (GAD) is a state of chronic, widespread anxiety about many possible life areas. These people just seem to be always worried about something. Unfortunately, only a third of them will recover without treatment. People with generalized anxiety worry not only about specific things but also as a general defense mechanism. These individuals have difficulty tolerating even small degrees of uncertainty and have a tendency to expect the worst case scenarios about future events that, in reality, are very unlikely.
The worry functions as a kind of safeguard against these events, giving people with this disorder a false sense of control and reducing their degree of perceived danger. This process is self-reinforcing because the predicted events rarely (if ever) pan out as badly as they believe, so the individuals do not have the opportunity to test their predictions. The act of worry, therefore, helps them avoid the discomfort of uncertainty.
Hiding in plain sight
Unless you are close with the person, Generalized Anxiety Disorder can be difficult to notice because, in contrast with other anxiety disorders, there is no single point of anxiety. However, the emotional state of worry does have a few unique outward signs. People may appear tense and can frighten easily. At work they may doze off in meetings and appear sluggish with puffy, tired eyes. They have difficulty concentrating and appear distracted because their minds are preoccupied with repeatedly playing out negative scenarios.
GAD is a significant cause of workplace disability, with over a third of people reporting at least 6 days of reduced functioning in a given month. The rates of impairment are matched only by those in Major Depressive Disorder and are exceeded only when both occur together (almost 50% of these people are impaired for at least 6 days a month).
Causes and Risk Factors
Almost 3% of Americans have generalized anxiety in a given year, and women are about twice as likely to be diagnosed as men. Relative to other anxiety disorders, the age of onset tends to be later, usually in the 30 to 40 age range. The severity of symptoms tend to increase with age, and Generalized Anxiety Disorder is the most common anxiety disorder among the elderly.
Shared genes with depression
About 50% of people diagnosed with Generalized Anxiety Disorder have other pre-existing anxiety disorders, and up to 80% have at least some symptoms of depression. Genetics account for about 30% of the risk for Generalized Anxiety Disorder. Generalized Anxiety Disorder and Major Depressive Disorder share significant genetic risk factors and frequently occur together.
Childhood risk factors for developing Generalized Anxiety Disorder as an adult include low socioeconomic status, abuse, and internalizing (keeping issues bottled up) symptoms. Poor interpersonal relationships (especially marital issues), unemployment, personality disorders, and low life satisfaction impair treatment outcomes.
The brains of people with Generalized Anxiety Disorder process anticipation in a fundamentally different way from others. This involves a part of the brain called the amygdala, that processes fear and anxiety. When people are shown sets of negative and neutral cues followed by corresponding pictures, in both cases, the participants with Generalized Anxiety Disorder had significantly greater responses in the amygdala. People without Generalized Anxiety Disorder only had significant responses to the negative pairs. This suggests that Generalized Anxiety Disorder causes people to have an anxiety response to any sort of anticipatory situation regardless of whether the preceding cue was negative or neutral. This increased activity of the amygdala also appears in people with Major Depressive Disorder and provides a biological explanation for the high likelihood that a person can have both disorders.
Diagnosing Generalized Anxiety Disorder
How is it different from regular anxiety?
A key difference between Generalized Anxiety Disorder and normal anxiety is that the regular anxiety is usually focused on a specific topic. Furthermore, the level of normal anxiety is reasonably proportional to level of risk at hand. In contrast, generalized anxiety pervades multiple areas of a person’s life. Sufferers can agonize over issues such as work performance, financial security, family life, and their own health, even without any evidence that there are problems. They often are aware that their anxiety is irrational, but knowing that doesn’t alleviate it.
Although the focus of a person’s anxiety can change, the apprehension rarely subsides. This person will be in a state of persistent angst. Most people are able to manage anxiety and put their worries aside when they need focus. However, people with GAD often cannot, and this can make daily life unmanageable.
Making the Diagnosis
People with generalized anxiety suffer from an inordinate amount of worry on the majority of days for at least 6 months. They experience at least three (only one is needed for diagnosis in children) of several types of physical symptoms.
- Low energy
- Attention problems
- Physical tension
- Difficulty sleeping
Their symptoms are difficult to control and significantly impair their work and home lives. The diagnosing physician should make sure the symptoms are not side effects. Look for sources from medications, drugs of abuse, or medical conditions. Stimulants can induce paranoia, and endocrine disorders like hyperthyroidism may cause anxiety and similar physical symptoms.
Generalized Anxiety Disorder worsens in times of physical illness or emotional strife. Though it is not officially part of the diagnostic criteria, people often report vague physical symptoms like headaches, gastrointestinal upset, and nonspecific aches and pains. These in turn can serve as additional sources of anxiety.
Treating Generalized Anxiety Disorder
Cognitive Behavioral Therapy
Cognitive Behavior Therapy (CBT) is the most widely studied psychotherapy for Generalized Anxiety Disorder and is usually the first choice approach. It is at least as effective as medication, and its effects tend to last longer over time. CBT enables people to objectively evaluate the focus of their anxiety in a caring empathic environment. They learn to use reality testing when they encounter anxiety triggers so that they can head off the spirals of worry.
The focus of worry in Generalized Anxiety Disorder can be anything and anywhere. Often the worry is constant, and triggers are difficult to identify. However, mindfulness, the practice of keeping attention on the present, can help manage this chronic pattern of worry. The techniques used in mindfulness help people focus on their real-time emotional processes. They enable people to accept feelings of uncertainty about the future rather than put up a shield of worry.
Medications become necessary when symptoms significantly impair a person’s ability to function in everyday life.
Antidepressants such as selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) are usually the best medications. They are better suited to the chronic nature of General Anxiety Disorder. Zoloft (sertraline) is the first choice among them. They also simultaneously treat the depression that frequently accompanies generalized anxiety. About two thirds of people with GAD will have at least a 50% reduction in symptoms from SSRIs and SNRIs. These medications are the preferred choice because tranquilizers like Xanax (alprazolam) can lead to dependence and are only effective short-term.
Lyrica (pregabalin), a nerve pain medication, can be useful in people who cannot tolerate antidepressants and has the added benefit of a rapid onset of action. A person will usually see anxiety reductions within a week, compared to up to four weeks for antidepressants.
Benzodiazepines like Xanax (alprazolam) or Ativan (lorazepam) start working rapidly. They can be added to SSRIs or SNRIs at the beginning of treatment for a few weeks until the anti-anxiety effects of the antidepressant fully kicks in.
Managing Generalized Anxiety Disorder
Over 80% of people with Generalized Anxiety Disorder initially come to medical attention because of the physical symptoms, especially stomach upset, nausea, vomiting, diarrhea. In fact, roughly half of patients with Irritable Bowel Syndrome also meet criteria for GAD. Many people see their primary care physician with physical symptoms and get a different diagnosis while GAD is completely missed.
Because of the vacillating severity of Generalized Anxiety Disorder, physicians may miss it as the patients’ symptoms do not always meet the exact timing criteria. In fact, by the time of diagnosis, the average person will have already suffered symptoms for 5 to 10 years.
If you think you may have Generalized Anxiety Disorder, your family physician can administer short screening tools like the GAD-2 and GAD-7. These scales cover several of the criteria for Generalized Anxiety Disorder. However, they are not diagnostic by themselves and should be part of an assessment by a mental health professional.
People with Generalized Anxiety Disorder often have disturbed sleep due to persistent hyperarousal . Patients should avoid nighttime alcohol and caffeine and stick to a regular sleep-wake schedule.
Quitting smoking and any other nicotine products will also help reduce anxiety. Patients should also develop a regular exercise routine (half an hour a day, a few times a week is sufficient) as this is a great way to reduce stress.