Understanding Generalized Anxiety Disorder (GAD)

New York, N.Y.  Anxiety disorders are a category of mental disorders characterized by feelings of anxiety and fear , where anxiety is a worry about future events and fear is a reaction to current events. These feelings may cause physical symptoms, such as a racing heart, and shakiness.

There are a number of anxiety disorders: including generalized anxiety disorder , a specific phobia , social anxiety disorder , separation anxiety disorder , agoraphobia , and panic disorder among others. While each has its own characteristics and symptoms, they all include symptoms of anxiety.

Anxiety disorders are partly genetic but may also be due to drug use including alcohol and caffeine , as well as withdrawal from certain drugs. They often occur with other mental disorders, particularly major depressive disorder , bipolar disorder , certain personality disorders , and eating disorders .

The term anxiety covers four aspects of experiences that an individual may have: mental apprehension, physical tension, physical symptoms and dissociative anxiety. The emotions present in anxiety disorders range from simple nervousness to bouts of terror. There are other psychiatric and medical problems that may mimic the symptoms of an anxiety disorder, such as hyperthyroidism .

Common treatment options include lifestyle changes, therapy , and medications. Medications are typically recommended only if other measures are not effective. Anxiety disorders occur about twice as often in females as males, and generally begin during childhood. As many as 18% of Americans and 14% of Europeans may be affected by one or more anxiety disorders.

Generalized

Generalized anxiety disorder (GAD) is a common, chronic disorder characterized by long-lasting anxiety that is not focused on any one object or situation. Those suffering from generalized anxiety disorder experience non-specific persistent fear and worry, and become overly concerned with everyday matters.

According to Schacter, Gilbert, and Wegner's book Psychology: Second Edition , generalized anxiety disorder is "characterized by chronic excessive worry accompanied by three or more of the following symptoms: restlessness, fatigue, concentration problems, irritability, muscle tension, and sleep disturbance."

Generalized anxiety disorder is the most common anxiety disorder to affect older adults. [11] Anxiety can be a symptom of a medical or substance abuse problem, and medical professionals must be aware of this.

A diagnosis of GAD is made when a person has been excessively worried about an everyday problem for six months or more. A person may find that they have problems making daily decisions and remembering commitments as a result of lack of concentration/preoccupation with worry. Appearance looks strained, with increased sweating from the hands, feet, and axillae, and they may be tearful, which can suggest depression. Before a diagnosis of anxiety disorder is made, physicians must rule out drug-induced anxiety and other medical causes.

In children GAD may be associated with headaches, restlessness, abdominal pain, and heart palpitations. Typically it begins around 8 to 9 years of age.

Phobias

The single largest category of anxiety disorders is that of phobic disorders , which includes all cases in which fear and anxiety is triggered by a specific stimulus or situation. Between 5% and 12% of the population worldwide suffer from phobic disorders. Sufferers typically anticipate terrifying consequences from encountering the object of their fear, which can be anything from an animal to a location to a bodily fluid to a particular situation. Sufferers understand that their fear is not proportional to the actual potential danger but still are overwhelmed by it.

Panic disorder

With panic disorder , a person has brief attacks of intense terror and apprehension, often marked by trembling, shaking, confusion, dizziness, nausea, and/or difficulty breathing . These panic attacks , defined by the APA as fear or discomfort that abruptly arises and peaks in less than ten minutes, can last for several hours. Attacks can be triggered by stress, fear, or even exercise; the specific cause is not always apparent.

In addition to recurrent unexpected panic attacks, a diagnosis of panic disorder requires that said attacks have chronic consequences: either worry over the attacks' potential implications, persistent fear of future attacks, or significant changes in behavior related to the attacks. As such, those suffering from panic disorder experience symptoms even outside specific panic episodes.

Often, normal changes in heartbeat are noticed by a panic sufferer, leading them to think something is wrong with their heart or they are about to have another panic attack. In some cases, a heightened awareness ( hypervigilance ) of body functioning occurs during panic attacks, wherein any perceived physiological change is interpreted as a possible life-threatening illness (i.e., extreme hypochondriasis ).

Agoraphobia

Agoraphobia is the specific anxiety about being in a place or situation where escape is difficult or embarrassing or where help may be unavailable. Agoraphobia is strongly linked with panic disorder and is often precipitated by the fear of having a panic attack. A common manifestation involves needing to be in constant view of a door or other escape route.

In addition to the fears themselves, the term agoraphobia is often used to refer to avoidance behaviors that sufferers often develop. For example, following a panic attack while driving, someone suffering from agoraphobia may develop anxiety over driving and will therefore avoid driving. These avoidance behaviors can often have serious consequences and often reinforce the fear they are caused by.

Social anxiety disorder

Social anxiety disorder (SAD; also known as social phobia) describes an intense fear and avoidance of negative public scrutiny, public embarrassment, humiliation, or social interaction. This fear can be specific to particular social situations (such as public speaking) or, more typically, is experienced in most (or all) social interactions. Social anxiety often manifests specific physical symptoms, including blushing, sweating, and difficulty speaking. As with all phobic disorders, those suffering from social anxiety often will attempt to avoid the source of their anxiety ; in the case of social anxiety this is particularly problematic, and in severe cases can lead to complete social isolation.

Social physique anxiety (SPA) is a subtype of social anxiety. It is concern over the evaluation of one's body by others. SPA is common among adolescents, especially females.

Obsessive–compulsive disorder

Obsessive–compulsive disorder (OCD) is a type of anxiety disorder primarily characterized by repetitive obsessions (distressing, persistent, and intrusive thoughts or images) and compulsions (urges to perform specific acts or rituals). It affects roughly 3% of the population worldwide.

The OCD thought pattern may be likened to superstitions insofar as it involves a belief in a causative relationship where, in reality, one does not exist. Often the process is entirely illogical; for example, the compulsion of walking in a certain pattern may be employed to alleviate the obsession of impending harm. And in many cases, the compulsion is entirely inexplicable, simply an urge to complete a ritual triggered by nervousness.

In a slight minority of cases, sufferers of OCD may only experience obsessions, with no overt compulsions; a much smaller number of sufferers experience only compulsions. [20]

Post-traumatic stress disorder

Post-traumatic stress disorder (PTSD) is an anxiety disorder that results from a traumatic experience. Post-traumatic stress can result from an extreme situation, such as combat, natural disaster, rape, hostage situations, child abuse , bullying , or even a serious accident. It can also result from long-term (chronic) exposure to a severe stressor, for example soldiers who endure individual battles but cannot cope with continuous combat.

Common symptoms include hypervigilance , flashbacks , avoidant behaviors, anxiety, anger and depression. There are a number of treatments that form the basis of the care plan for those suffering with PTSD. Such treatments include cognitive behavioral therapy (CBT), psychotherapy and support from family and friends.

Separation anxiety

Separation anxiety disorder (SepAD) is the feeling of excessive and inappropriate levels of anxiety over being separated from a person or place. Separation anxiety is a normal part of development in babies or children, and it is only when this feeling is excessive or inappropriate that it can be considered a disorder. Separation anxiety disorder affects roughly 7% of adults and 4% of children, but the childhood cases tend to be more severe; in some instances, even a brief separation can produce panic.

Situational anxiety

Situational anxiety is caused by new situations or changing events. It can also be caused by various events that make that particular individual uncomfortable. Its occurrence is very common. Often, an individual will experience panic attacks or extreme anxiety in specific situations. A situation that causes one individual to experience anxiety may not affect another individual at all.

For example, some people become uneasy in crowds or tight spaces, so standing in a tightly packed line, say at the bank or a store register, may cause them to experience extreme anxiety, possibly a panic attack. Others, however, may experience anxiety when major changes in life occur, such as entering college, getting married, having children, etc.

Causes

Drugs

Anxiety and depression can be caused by alcohol abuse, which in most cases improves with prolonged abstinence. Even moderate, sustained alcohol use may increase anxiety levels in some individuals. Caffeine , alcohol and benzodiazepine dependence can worsen or cause anxiety and panic attacks. Anxiety commonly occurs during the acute withdrawal phase of alcohol and can persist for up to two years as part of a post-acute withdrawal syndrome , in about a quarter of people recovering from alcoholism .

In one study in 1988–1990, illness in approximately half of patients attending mental health services at one British hospital psychiatric clinic, for conditions including anxiety disorders such as panic disorder or social phobia , was determined to be the result of alcohol or benzodiazepine dependence . In these patients, an initial increase in anxiety occurred during the withdrawal period followed by a cessation of their anxiety symptoms.

There is evidence that chronic exposure to organic solvents in the work environment can be associated with anxiety disorders. Painting, varnishing and carpet-laying are some of the jobs in which significant exposure to organic solvents may occur.

Ingestion of caffeine may cause or exacerbate anxiety disorders. A number of clinical studies have shown a positive association between caffeine and anxiogenic effects and/or panic disorder . [33] [34] [35] Those with anxiety can have high caffeine sensitivity.

Stress

Anxiety disorders can arise in response to life stresses such as financial worries or chronic physical illness. Anxiety among adolescents and young adults is common due to the stresses of social interaction, evaluation, and body image. Anxiety is also common among older people who have dementia . On the other hand, anxiety disorder is sometimes misdiagnosed among older adults when doctors misinterpret symptoms of a physical ailment (for instance, racing heartbeat due to cardiac arrhythmia ) as signs of anxiety.

Genetics

GAD runs in families and is six times more common in the children of someone with the condition.

While anxiety arose as an adaptation, in modern times it is almost always thought of negatively in the context of anxiety disorders. People with these disorders have highly sensitive systems; hence, their systems tend to overreact to seemingly harmless stimuli. Sometimes anxiety disorders occur in those who have had traumatic youths, demonstrating an increased prevalence of anxiety when it appears a child will have a difficult future. [38] In these cases, the disorder arises as a way to predict that the individual’s environment will continue to pose threats.

Persistence of anxiety

At a low level, anxiety is not a bad thing. In fact, the hormonal response to anxiety has evolved as a benefit, as it helps humans react to dangers. Researchers in evolutionary medicine believe this adaptation allows humans to realize there is a potential threat and to act accordingly in order to ensure greatest possibility of protection. It has actually been shown that those with low levels of anxiety have a greater risk of death than those with average levels. This is because the absence of fear can lead to injury or death.

Additionally, patients with both anxiety and depression were found to have lower morbidity than those with depression alone. The functional significance of the symptoms associated with anxiety includes: greater alertness, quicker preparation for action, and reduced probability of missing threats. In the wild, vulnerable individuals, for example those who are hurt or pregnant, have a lower threshold for anxiety response, making them more alert. This demonstrates a lengthy evolutionary history of the anxiety response.

Evolutionary mismatch

It has been theorized that high rates of anxiety are a reaction to how the social environment has changed from the Paleolithic era. For example, in the Stone Age there was greater skin-to-skin contact and more handling of babies by their mothers, both of which are strategies that reduce anxiety.

Additionally, there is greater interaction with strangers in present times as opposed to interactions solely between close-knit tribes. Researchers posit that the lack of constant social interaction, especially in the formative years, is a driving cause of high rates of anxiety.

Many current cases are likely to have resulted from an evolutionary mismatch , which has been specifically been termed a “psychopathogical mismatch.”

In evolutionary terms, a mismatch occurs when an individual possesses traits that were adapted for an environment that differs from the individual’s current environment. For example, even though an anxiety reaction may have been evolved to help with life-threatening situations, for highly sensitized individuals in Westernized cultures simply hearing bad news can elicit a strong reaction.

An evolutionary perspective may provide insight into alternatives to current clinical treatment methods for anxiety disorders. Simply knowing some anxiety is beneficial may alleviate some of the panic associated with mild conditions. Some researchers believe that, in theory, anxiety can be mediated by reducing a patient’s feeling of vulnerability and then changing their appraisal of the situation.

Treatment

Treatment options available include lifestyle changes, therapy , and medications. Medication are only recommended if other measures are not effective. Stopping smoking has benefits in anxiety as large as or larger than those of medications.

Therapy

Cognitive behavioral therapy (CBT) is effective for anxiety disorders. CBT, as its name suggests, has two main components: cognitive and behavioral. In cases of social anxiety, the cognitive component can help the person question how they can be so sure that others are continually watching and harshly judging him or her. The behavioral component seeks to change people's reactions to anxiety-provoking situations.

CBT appears to be equally effective when carried out via the internet.

As such it serves as a logical extension of cognitive therapy, whereby people are shown proof in the real world that their dysfunctional thought processes are unrealistic. A key element of this component is gradual exposure, in which the patient is confronted by the things they fear in a structured, sensitive manner. Gradual exposure is an inherently unpleasant technique; ideally it involves exposure to a feared social situation that is anxiety provoking but bearable, for as long as possible, two to three times a week. Often, a hierarchy of feared steps is constructed and the patient is exposed to each step sequentially.

The aim is to learn from acting differently and observing reactions. This is intended to be done with support and guidance, and when the therapist and patient feel they are ready. Cognitive-behavioral therapy for social phobia also includes anxiety management training, which may include techniques such as deep breathing and muscle relaxation exercises, which may be practiced ' in-situ '. CBT can also be conducted partly in group sessions , facilitating the sharing of experiences, a sense of acceptance by others and undertaking behavioral challenges in a trusted environment (Heimberg).

Mindfulness based programs also appear to be effective for managing anxiety disorders.

Caffeine

Caffeine can cause anxiety, along with more minor effects such as muscle twitching, hand tremors, and headaches. The best way to prevent caffeinism is to either wean off caffeine completely or reduce consumption. For some people, anxiety can be reduced by coming off caffeine . Anxiety can temporarily increase during caffeine withdrawal.

Alternative medicine

Regular exercise and reducing caffeine are often useful in treating anxiety. There is tentative evidence that yoga may be effective. In 2006 a Cochrane review found evidence was insufficient regarding meditation to make any conclusions. A 2010 review concluded the evidence was promising.

Epidemiology

Globally as of 2010 approximately 273 million (4.5% of the population) had an anxiety disorder. It is more common in females (5.2%) than males (2.8%).

In Europe, Africa and Asia, lifetime rates of anxiety disorders are between 9 and 16%, and yearly rates are between 4 and 7%. In the United States, the lifetime prevalence of anxiety disorders is about 29% and between 11 and 18% of adults have the condition in a given year. This difference is affected by the range of ways in which different cultures interpret anxiety symptoms and what they consider to be normative behavior. In general, anxiety disorders represent the most prevalent psychiatric condition in the United States, outside of substance use disorder .

From Wikipedia.

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