Generalized Anxiety Disorder - the facts
By Dr. Scott Blair-West, Psychiatrist
Introduction
In any discussion of anxiety disorders we need to consider firstly the nature of anxiety. It is now accepted that anxiety is a normal adaptive response to stressful situations, frequently seen in situations where the person's safety or security is threatened and in novel social situations. It could be argued that in these contexts anxiety usually acts in a positive way, helping a person to adapt or cope with the situation. The characteristics of anxiety, which include emotional, physical, cognitive and behavioural components can be seen as an evolutionary adaptation necessary for normal functioning. Certainly most people would accept the value of the "fight or flight response" in certain threatening situations, e.g. trapped in a dead-end street by a snarling dog.The "fight or flight response" (or the normal anxiety response) consists of elements of emotion, i.e. fear and apprehension, physical symptoms which include tension, edginess, irritability and all of the physical symptoms associated with panic attacks, cognitive aspects including worry or catastrophic misinterpretation of physical symptoms leading to fears of death or illness as seen in a panic attack, and finally behavioural components which include escape, avoidance or "freezing" in terrifying situations. It remains important to recognize the similarity between these anxiety symptoms and the symptoms experienced at a time of high motivation or arousal, i.e. prior to exams, job interviews or during sexual intercourse. The point needs to be made again that the physical symptoms of both anxiety and arousal are identical, with the major differences between the two relating largely to the cognitive interpretation one places upon the symptoms.
Anxiety disorders themselves represent an exaggeration of these responses in frequency, intensity and sensitivity to surroundings and triggers. It seems likely that there is a significant genetic or inherited component in the development of anxiety disorders, with the result being an alteration of brain chemistry of such people, making them more vulnerable to excessive anxiety responses in these situations or in situations not normally seen as threatening. Clearly this inherited vulnerability to high levels of anxiety can be combined with the effect of critical life events to precipitate severe anxiety at any particular time and it remains highly debatable whether life events by themselves in a person not prone to developing significant anxiety symptoms can cause major anxiety disorders. Despite this, we must recognize the importance of stress related conditions such as Post traumatic Stress Disorder and the possibility of such anxiety symptoms developing in people previously not describing anxiety symptoms of any note.
Diagnostic considerations:
Generalized Anxiety Disorder (GAD) is now accepted as a diagnosis in its own right as defined by the American Psychiatric Association's Diagnostic and Statistical manual for Mental Disorders 4th Edition (DSM-IV). The hallmarks features of GAD are excessive anxiety and worry about a number of events or activities, worry that has been present for at least six months. Furthermore, the person describes great difficulty controlling this worry and usually describes a vast array of associated physical symptoms, some of which may be restlessness or feeling keyed up or on edge, being easily fatigued, difficulty concentrating, irritability, muscle tension and sleep disturbance involving difficulty falling asleep, staying asleep and remaining restless throughout the night. DSM-IV further demands that these symptoms must cause distress and impairment and not relate to other psychiatric or medical conditions.In the past GAD had been seen as a residual category covering all anxiety disorders not characterised by panic attacks. It is now recognised that GAD exists as an entity of its own characterised by chronic anxiety and excessive worrying. Whereas panic attacks occur episodically and are charaterised by high levels of anxiety, peaking quickly over a few minutes and often settling by 45-60 minutes, GAD anxiety symptoms are spread throughout the day, are usually present on virtually every day of the person's life and occur over many years. GAD therefore describes chronic consistent anxiety symptoms as opposed to Panic Disorder's brief episodes of severe anxiety.
Further differentiation from other anxiety disorders is sometimes difficult, particularly from Obsessive Compulsive Disorder and this is further complicated by the fact that there is often extensive co-morbidity with GAD and including other anxiety disorders and depression. In general the recognition of chronic anxiety and worry about family, finances, work and personal illness are characteristics of GAD, whilst OCD's intrusive thoughts usually occur entirely involuntarily, with the content characteristically relating to specific thoughts such as contamination, disaster, violence etc. Usually these thoughts are recognised as egodystonic, i.e. the patient does not wish to have these thoughts and is distressed by them and would be gladly rid of them, whereas worry in GAD patients is usually related to concerns from the person's everyday life and is regarded as reasonable and understandable.
Worry remains the definitive feature of GAD and usually affects the four areas noted above. Worry is conscious and attention demanding and is often associated with low perceived levels of control by patients who experience it. It remains the most important feature of the condition and one that needs to be explored thoroughly by psychologists and psychiatrists treating it.
The course of GAD is probably chronic and protracted in many cases and for most people lasts the majority of their life. It would seem from research that GAD often starts in the early twenties but there is certainly evidence that adolescents and even children can develop these symptoms even earlier than this. Given the relative "youth" of the use of this diagnosis and research into GAD, long term prognosis in patients who have been successfully treated is unknown, but we do know that pharmacological treatments have been shown to reduce symptoms in the short term and that cognitive behaviour therapy shows significant and sustained improvement over the longer term, i.e. months to years.
Treatment Strategies
While there are no long term treatment studies of GAD, it would appear reasonable to anticipate that pharmacotherapy treatments would be effective in reducing these symptoms while the patient remains on the medications but that psychological treatments, particularly focusing on cognitive behavioural interventions, are likely to produce more long-term benefit for patients with GAD. Psychological approaches include provision of information regarding the condition, anxiety management techniques, cognitive therapy, structured problem solving and graded exposure. I will focus largely on information regarding these approaches before covering pharmacological management at the end of this article.1. Information and rationale for treatment
An important early intervention in the management of GAD involves the presentation and discussion of a number of details regarding the condition. The links between anxiety and arousal have been discussed above. These need to be reviewed at length as well as the characteristics of the fight/flight response. Causes of increased anxiety such as tiredness, stress, sleep deprivation and medical illness need to be mentioned and the anxiety or panic cycle needs to be discussed in some detail. In addition the relationship between anxiety and level of performance or skill needs to be discussed, noting the inverted U-shared curve. That is to say, at low levels of arousal performance is poor, while arousal levels then increase to an optimal level providing optimal performance and skill. Further increase in arousal levels leads to deterioration in performance as is seen with over anxious people or those who are overly "psyched up". Finally some discussion of the possibility of subtle avoidance in GAD is helpful.
2. Anxiety management techniques
A wide variety of techniques can be useful for simply controlling and reducing anxiety in a wide range of settings. Most commonly used is progressive muscular relaxation which rests on the patient recognising the differences between the tense and relaxed stated as well as progressive training to enable the relaxed stated to occur more readily and more quickly. Isometric relaxation can also be used using similar ideas but the most effective approach involves slow breathing techniques (SBT) which stress the importance of the patient's breathing at a slowed rate (10 respirations/minute) in order to reduce the chronic effects of hyperventilation as well as the acute effects of hyperventilation as seen in panic attacks. This technique, much as with progressive muscular relaxation, requires regular practice and in general all of these techniques require use over two to four weeks before a patient can become skilled at their use and gain continuing benefit.
Other anxiety management techniques that can be particularly beneficial include the use of prescribed exercise, scheduling of pleasant events, time table restructuring to increase efficiency and give more of a sense of control and organisation to a person's general life and activities.
3. Cognitive therapy
The use of cognitive restructuring or cognitive therapy is the cornerstone of treatment of GAD. This relates to recognition that worry is the central feature of GAD and that many of the thoughts and beliefs seen with this worry are exaggerated, irrational and certainly unhelpful. The value of cognitive therapy in changing these thoughts rests on the basic principles of cognitive therapy as espoused by Beck and Ellis which state that excessive emotion including anxiety is not due to the situation in which it arises, but rather the patient's thoughts about that situation. These may be affected by a wide variety of misinterpretations and thinking errors.
Typical cognitions seen with GAD and forming the basis of worrying thoughts include an overestimation of the probability of disaster or threat, an over-estimation of the severity of the feared event, an under-estimation of the person's own coping resources and finally an under-estimation of the outside rescue factors available in the environment to assist the person.
Cognitive therapy aims to recognise these thoughts, note their excessive or irrational nature, practise more rational or reasonable responses and finally test out the old thoughts and the new rational thoughts in appropriate situations in order to disapprove or prove these thoughts respectively. This is commonly done in consultation with a psychologist or psychiatrist, with the first step involving recording thoughts on paper using a dairy or thought record, following this with written practise of more rational responses using appropriate questions and arguments and then setting up specific behavioural tests to confirm the validity of the new thinking. This is a slow process and one described here in a rather simplistic fashion. It usually requires several sessions with a psychologist or psychiatrist to develop these skills although use of a number of the self-help books listed in the appendix at the end of this article can be helpful start and adjunct to treatment.
4. Structured problem solving
This relatively simple approach, again involving pen and paper has been an important part of the management of anxiety and depression for some time. It is particularly helpful for those with little formal psychiatric training including counselors, social workers and general practitioners. It is a recent and integral part of treatment of GAD given the frequent worries, life stressors and everyday problems faced by people with this condition.
It involves six simple steps as follows:-
- 1. Specify problem or key threat.
- 2. List all possible solutions.
- 3. Evaluate consequences of each solution.
- 4. Agree on best strategy.
- 5. Plan and implement (on paper).
- 6. Review results and if necessary, implement alternate strategy or solution.
5. Graded Exposure
Avoidance behaviour is common in all patients with anxiety and GAD is no exception. GAD patients' avoidance is often a little more subtle than those seen in the classic phobic disorders and may involve subtle avoidance of responsibility for decisions and decision making, avoidance of relationships or dating and avoidance of situations that might lead to anxiety or physical symptoms of anxiety. In general, distraction from anxiety and excessive reassurance seeking should be generally discouraged and patients should be encouraged to face these situations using the strategies described above to improve their abilities to cope. In general the key aim in most of these circumstances is confrontation of anxiety and increasing tolerance of any remaining anxiety symptoms.
6. Medications for anxiety
Discussion regarding medications for anxiety in many ways merits an article itself. Put simply, there is no doubt that a variety of psychotropic medications have been proven to be effective in the management of anxiety but there remains concern about various side effects specific for each family of drugs. For example, whilst the benzodiazepine drugs are very effective anti-anxiety agents, they are sometimes complicated by problems with dependence, addiction and escalating use, as well as major difficulties experienced during withdrawal from the medications and some ongoing side effects including sedation, poor coordination and poor concentration if the dose is too high.
Similarly the SSRI medications (Fluoxetine, Sertraline, Paraxetine, Fluvoxamine and Citalopram) are all effective long-term treatments for many anxiety disorders and there is emerging research to show the effectiveness of SSRIs in GAD. A similar drug, Venlafaxine (Efexor) has also been shown to be effective in GAD in a research trial and one of these six drugs is probably preferable for the long-term medication treatment of GAD. Whilst the side effect burden is considerably lower than with benzodiazepines, there are still some concerns with short term problems of nausea, agitation and insomnia and long term problems of sleep disturbance, sexual dysfunction and excessive sweating complicating their use. Having said this, there is little doubt that these medications can be very effective in the long term management of anxiety disorders including GAD and are certainly a reasonable choice for patients unable to use CBT strategies, those who gain inadequate benefit or relief from CBT and sometimes even in combination with CBT in order to boost effectiveness of treatment.
A range of other antidepressant medications have been tried for anxiety disorders and GAD including tricyclic antidepressants, Nefazodone, Moclobemide and the irreversible monoamine oxidase inhibitor drugs. Whilst these drugs may be effective in some patients, the drugs mentioned above are probably preferable given their generally more favorable effectiveness and better tolerability due to lower side effect profile.
The main issue for many people who take these medications for GAD, however, relates to the fact that these drugs only reduce anxiety symptoms during the time they are taken and cessation of the medication will virtually always lead to a recurrence of symptoms. It is for this reason that the CBT strategies are regarded as the treatment of choice given their potential to increase patients' ability to manage their symptoms over the longer term and so consistently improve their quality of life in the long term.
Summary
GAD is a recognised anxiety disorder marked by chronic anxiousness, excessive worry and frequent physical symptoms of anxiety. It has a long-term course and can be effectively treated with cognitive behavioural strategies such as information provision, anxiety management techniques, cognitive therapy, structured problem solving and graded exposure. Medication treatments are also available and can be used by themselves or in combination with CBT. The prognosis for GAD sufferers is now improved given the development of these effective treatments.References
- "Feeling Good" - David Burns
- "An End to Panic" - Elke Zuercher-White
- "Overcoming Shyness and Social Phobia" - Ronald Rapee
By Dr. Scott Blair-West, Psychiatrist.
