Anxiety Disorders traditionally grouped together as anxiety disorders include generalized anxiety disorder, panic disorder and agoraphobia, specific phobia, and social anxiety disorder, as well as two new disorders, separation anxiety disorder and selective mutism. These specific anxiety disorders are complicated by panic attacks or other features that are the focus of the anxiety. But in generalized anxiety disorder, the focus is generalized to the events of everyday life. Therefore, we consider generalized anxiety disorder first.
Generalized Anxiety Disorders.
Is somebody in your family a worrywart or a perfectionist? Perhaps it is you! Most of us worry to some extent. As we have said, worry can be useful. It helps us plan for the future, make sure that we’re prepared for that test, or double-check that we’ve thought of everything before we head home for the holidays. But what if you worry indiscriminately about everything? Furthermore, what if worrying is unproductive? What if no matter how much you worry, you can’t seem to decide what to do about an upcoming problem or situation? And what if you can’t stop worrying, even if you know it is doing you no good and probably making everyone else around you miserable?
These features characterize generalized anxiety disorder (GAD).
The DSM-5 criteria specify that at least 6 months of excessive anxiety and worry (apprehensive expectation) must be ongoing more days than not. Furthermore, it must be difficult to turn off or control the worry process. This is what distinguishes pathological worrying from the normal kind we all experience occasionally as we prepare for an upcoming event or challenge. Most of us worry for a time but can set the problem aside and go on to another task. Even if the upcoming challenge is a big one, as soon as it is over the worrying stops.
The physical symptoms associated with generalized anxiety and GAD differ somewhat from those associated with panic attacks and panic disorder. Whereas panic is associated with autonomic arousal, presumably as a result of a sympathetic nervous system surge (for instance, increased heart rate, palpitations, perspiration, and trembling), GAD is characterized by muscle tension, mental agitation.
Diagnostic Criteria for Generalized Anxiety Disorder.
A. Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months about a number of events or activities (such as work or school performance).
B. The individual finds it difficult to control the worry.
C. The anxiety and worry are associated with at least three (or more) of the following six symptoms (with at least some symptoms present for more days than not for the past 6 months) [Note: Only one item is required in children]:
1. Restlessness or feeling keyed up or on edge
2. Being easily fatigued
3. Difficulty concentrating or mind going blank
5. Muscle tension
6. Sleep disturbance (difficulty falling or staying asleep or restless, unsatisfying sleep)
D. The anxiety, worry or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
E. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hyperthyroidism).
F. The disturbance is not better explained by another mental disorder (e.g., anxiety or worry about having panic attacks in panic disorder, negative evaluation in social anxiety disorder).
Causes of GAD.
As with most anxiety disorders, there seems to be a generalized biological vulnerability. This is reflected in studies examining a genetic contribution to GAD, although Kendler and colleagues confirmed that what seems to be inherited is the tendency to become anxious rather than GAD itself.
Clinicians thought that people who were generally anxious had simply not focused their anxiety on anything specific. Thus, such anxiety was described as “free floating”. But now scientists have looked more closely and have discovered some interesting distinctions from other anxiety disorders.
The first hints of difference were found in the physiological responsivity of individuals with GAD. It is interesting that individuals with GAD do not respond as strongly to stressors as individuals with anxiety disorders in which panic is more prominent.
Individuals with GAD show less responsiveness on most physiological measures, such as heart rate, blood pressure, skin conductance, and respiration rate, than do individuals with other anxiety disorders. Therefore, people with GAD have been called autonomic restrictors.
When individuals with GAD are compared with non-anxious “normal” participants, the one physiological measure that consistently distinguishes the anxious group is muscle tension. People with GAD are chronically tense.
Some people inherit a tendency to be tense (generalized biological vulnerability), and they develop a sense early on that important events in their lives may be uncontrollable and potentially dangerous (generalized psychological vulnerability).
GAD is quite common, and available treatments, both drug and psychological, are reasonably effective. Benzodiazepines are most often prescribed for generalized anxiety, and the evidence indicates that they give some relief, at least in the short term. Benzodiazepines carry some risks.
- First, they seem to impair both cognitive and motor functioning. Specifically, people don’t seem to be as alert on the job or at school when they are taking benzodiazepines.
- The drugs may impair driving, and in older adults they seem to be associated with falls, resulting in hip fractures.
- Benzodiazepines seem to produce both psychological and physical dependence, making it difficult for people to stop taking them.
There is stronger evidence for the usefulness of antidepressants in the treatment of GAD, such as paroxetine (also called Paxil) and venlafaxine (also called Effexor). These drugs may prove to be a better choice. In the short term, psychological treatments seem to confer about the same benefit as drugs in the treatment of GAD. But psychological treatments are more effective in the long term.
Recent reports of innovations in brief psychological treatments are encouraging. Because we now know that individuals with GAD seem to avoid “feelings” of anxiety. And the negative affect associated with threatening images, clinicians have designed treatments to help patients with GAD process the threatening information on an emotional level, using images, so that they will feel (rather than avoid feeling) anxious. These treatments have other components, such as teaching patients how to relax deeply to combat tension.
A cognitive-behavioral treatment (CBT) for GAD in which patients evoke the worry process during therapy sessions and confront anxiety-provoking images and thoughts head-on. The patient learns to use cognitive therapy and other coping techniques to counteract and control the worry process.