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Generalized Anxiety Disorder
This paper has analyzed one of the personality disorder, and which focuses on the anxieties of persons. This problem is the Generalized Anxiety Disorder, and in the discussion, we have noted that this problem starts to occur in underage persons and those who are near adulthood. Some of the major symptoms of this disease include high-level anxieties, feeling of being threatened and extreme worries. The best treatment that is suggested is through guidance and counseling or generally, the Cognitive Behavioral Therapy.
Depression and the anxiety disorders at first were seen to be very similar but generally, the two are not the same. Specifically, depression is capable of generating emotions like despair, hopelessness and anger on where energy of the persons is low; the person suffering from this problem can be overwhelmed by their daily chores. On the other hand, the anxiety disorders bring about the experiences of general anxiety, fear and panic; especially, in situations where it is not expected that persons would feel threatened and anxious. Where there are no triggers for anxiety, these people are seen to be disturbed and threatened. Comparing the two problems, both are treated with antidepressants and many depressions are accompanied by anxieties. Study has shown that 85 percent of the persons with major depression are also diagnosed with problems such as the Generalized Anxiety Disorder, which we will focus in details.
Generalized Anxiety Disorder (GAD)
According to Anxiety Disorders Association of America (AADAA), the Generalized Anxiety Disorder is a problem that is characterized by excessive, persistent and unrealistic worry and this is about everyday things. The persons who are diagnosed with this disease are known as the GAD and they experience exaggerated tension and worry, and more notably, their worries seen unwarranted. This is to mean, other people cannot notice the reason as to why the GAD persons are threatened by the situations bringing about this. AADAA adds that this problem has so far affected a number of adults totaling to 6.8 million representing 3.1% of the United States of America’s population. On its part, the National Institute of Mental Health (NIMH) writes that this problem is concerned with worries that are accompanied with some physical problems.
Particularly, the physical problems that characterize the Generalized Anxiety Disorder are like fatigue, muscle tension, headaches, muscle aches, trembling, and difficulties during swallowing, excessive sweating, twitching and lastly the hot flashes. This problem is often comorbid with the mood disorders and where research has shown that 42% of the persons that are suffering with the Generalized Anxiety Disorder have had a history of major episodes of depression in the past (Heimberg, 2004). As well, he adds that the persons that have been found with the problem are found to have strong relationship with the personality disorders, more than the panic disorder or agoraphobia. However, this is more strengthened when the person with this problem too has a major depression in himself or herself. Additionally, the Generalized is characterized with the hyperactive arousal of the central nervous system; for example, the muscle tension.
According to NIMH, there is also a level of mildness in people and the persons who have this problem can work socially and may hold down a job. They cannot avoid some situations that are due to their problem of this disorder and they have difficulties carrying even the simple daily activities. NIMH quotes a person’s account of how someone feels due to this problem, “When my problems were at their worst, I’d miss work and feel just terrible about it. Then I worried that I would lose my job. My life was miserable until I got treatment.” Portman (2009) writes that there are some researches, which have tended to suggest that the GAD can even run in families, and it is probable to grow worse when the persons are under extreme stress. This problem often begins at an early age and the symptoms starts to show slowly than in a number of other anxiety disorders.
However, some people have reported having GAD at early adulthood, and this is usually in response to a stressor in their lives. Once it develops and becomes persistent, it can turn itself to be chronic, and it can be managed to some extent with proper treatment but not entirely. Portman (2009) is categorical that GAD is prevalent in some primary care setting such as family life and marital status. This is to say that some factors such as stress in life of married persons and those who are under the care of stressed families can be real determinant of occurrence of this disorder in persons underage or near adulthood. According to NIMH (2009), the GAD normally does not occur alone, it is accompanied by other problems, and this is noted in treatments where, while treating, the persons are also diagnosed with the cognitive behavioral therapy and other conditions related to improper actions resulting from their inappropriate cognitive behaviors.
In this connection, it can therefore be argued that the treatment of diagnosis for this disorder can be correlated to that which is administered on persons who have problems with their socialization, have cognitive component, the behavioral component and the physiological components. According to Rygh (2004), some of the treatments that are administered on such persons are like on how to improve the image of these persons, and trying as much as possible to remove the worries them. There is also the self-directed kind of continuation treatments in addition to ensuring that the cognition of the persons with this problem are tackled properly and shown how to deal with the worries of life. In addition, there is also a high need of guiding the persons towards applied relaxation and the self control measures that can see the person judging his or her own environment and evaluating it positively.
NIMF notes that the best way is to seek the help of a mental doctor, simply because the element of having unstable mind cannot be ruled out in this disorder. The practitioners should be competent on matters to do with the cognitive therapies, and some suggestions being given on persons who have special qualities on guidance and counseling. Goldberg (2010) adds that the cognitive behavioral therapy is studied to be more effective in the long term which should always be the concentration, and this is even more than the pharmacological kind of treatment; for example, SSRIs (Selective Serotonin Reuptake Inhibitors). Even though all the treatments are aimed at reducing anxieties in the person, the Cognitive Behavioral Therapy reduces this better as well as the depression; which is a major characteristic of persons suffering from the problem.
One of the most feared medical problems are the problems that are affecting the brain, and this is because they are capable of paralyzing any other kind of functioning in a person’s body. In this regard, it is better that people evaluate themselves early enough to know as to whether or not they are suffering from any kind of ailments that are concerning this problem. One of such problem, which we have discussed, concerns the personality disorder, and particularly, we have looked at the Generalized Anxiety Disorder. This problem starts at an early age and near adulthood, and has symptoms that are connected to worries even when the situation cannot compel the person to be threatened. This problem has been studied to persist when there are other factors like low socialism, low family life and marriage that is not working for the parents of the persons. Some of the treatments require that some drugs be administered; however, as we have noted, the best form is to tackle the cognitive behavior of the person.
Goldberg, D. (2010). Diagnostic issues in depression and generalized anxiety disorder: Refining the research agenda for DSM-V. Arlington: American Psychiatric Publishing Inc.
Heimberg, R. (2004). Generalized anxiety disorder: Advances in research and practice. New York: The Guilford Press.
NIMH. (2009). Anxiety disorder. NIH Publication, Vol. 09 (3879), pp 2-26.
Portman, M. (2009). Generalized anxiety disorder across the lifespan: An integrative approach. Cleveland: Springer Science + Business Media LLC.
Rygh, J. (2004). Treating generalized anxiety disorder: Evidence-based strategies, tools and techniques. New York: The Guilford Press.
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Generalized Anxiety Disorder General Anxiety …
[. . .] Some common symptoms of GAD include:
Sudden feelings of panic, fear and unease
Obsessive thoughts which can’t be suppressed
Constant nightmares and problems in sleeping
Dry mouth, muscle tensions, nausea
Constant nervousness and unable to stay calm
Numb body parts
Recurring memories of horrifying or traumatizing memories
Treatment for Generalized Anxiety Disorder:
Psychotherapy: One of the treatments and cures for General Anxiety Disorder include Psychotherapy. This treatment when used for curing GAD should be aimed at combating against the person’s lowest level of anxiety that is present (Grohol, 2010). The first step towards doing this is identification of the reason why this disorder occurs in the first place. It may be due to poor planning skills, extreme levels of stress, difficulty in relaxation and calming down. The ability to calm a person down and help him relax is the key element that plays an important role in the therapy and overcoming the disorder.
The patient can be taught relaxation tips either in isolation or in the way of giving a feedback. There is education given on the ways in which the person can increase the levels of relaxation and they are usually given exercises which enable the deep breathing where the person is able to perceive their own self and can assess their own selves. It is not necessarily practiced in all the cases but may prove to be quite helpful in some cases. Some therapeutic techniques involve the teaching of muscle relaxations and imageries which help the person calm down his nerves. There are some instances where the person is fully taught how to avoid the stressing out in particular situations and then taught how to apply to a variety of situations (Books, 1997). The people who effectively learn the skill to calm their nerves down and think logically and calmly often make good use of it and it comes in handy. This can also be learnt by brief counseling sessions and are quick in handling the disorder.
Helping the patient fight the overall stress levels and teaching them how to combat that extreme emotion will also prove to be beneficial. The people suffering from this disorder tend to have very busy schedules and hectic days which give them these attacks of panic and pressure. By helping these people maintain a kind of balance in their life and devoting time to family, work, leisure, etc., the person may be able to perform better and avoid over thinking things (Erlbaum, 2007). The people suffering from this disorder eventually become so accustomed to the constant panic and worrying that they probably don’t imagine a life without those stressful thoughts. Helping the person realize their full potential and what they can accomplish by staying calm will come in handy.
To cure GAD, Individual therapy may be recommended in order to help the person open up because they may feel awkward and the patients don’t open up that easily so individual and private help is quite effective. This also helps to distinguish between whether it is a general anxiety disorder that the person is suffering from or if it is any phobia in particular that may be scaring the person. Often the people suffering from GAD retreat themselves and avoid having to face groups or confrontations so it is often proffered to give them the isolation of individual treatment whereby they can escape their fears (Grohol, 2010).
The non-specific elements in these therapeutic methods are essential to these individuals as they gain an environment which is supportive of their problem and helps them overcome it so they become more comfortable and accept different environments The person may feel better after venting out their problems to someone and getting the required feedback to cope up with the situation. There are certain modeling techniques that may be extended towards the sufferer and thus they escape their traumatic symptoms. Hence these psychotherapies may prove to be one of the essential aiding techniques of treating the sufferers of psychotherapy.
Book, W Sarah. (1997). Social Anxiety Disorder and Alcohol Use.
Botts, R Sheila. (1998). Managing Generalized Anxiety Disorder.
Erlbaum, Lawrence. (2007). Anxiety and Anxiety Disorders.
Graske, G Michelle. (1999). Anxiety Disorders: Psychological… [END OF PREVIEW]
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Generalised anxiety disorder
Generalised anxiety disorder is a syndrome of ongoing anxiety and worry about many events or thoughts that the patient generally recognises as excessive and inappropriate. However, the nature of “generalised worry” has been hard to describe in a categorical manner. The criteria required for making a diagnosis are evolving: these criteria clearly increase or decrease markedly the threshold for diagnosis. 1
- Generalised anxiety disorder is a syndrome of ongoing anxiety and worry about many events or thoughts that the patient generally recognises as excessive and inappropriate
- Most people with generalised anxiety disorder also have other mood and anxiety disorders
- Several treatment efficacy trials have been conducted but few effectiveness trials with generally representative samples
- Cognitive behaviour therapy is more efficacious than non-directive psychotherapy or no treatment
- Anxiety management treatment is also better than no treatment and its efficacy may equal that of cognitive behaviour therapy
- Antidepressants, benzodiazepines, buspirone, and kava are efficacious but often have clinically significant adverse effects
About 1%-5% of the general population report having generalised anxiety disorder. Many of these people also have other disorders, and those with generalised anxiety disorder report a considerable level of disability. Long term follow-up studies suggest that generalised anxiety disorder is a condition that worsens the prognosis for any other condition, and that people who have only generalised anxiety disorder are likely to develop further conditions. The availability of and evidence for efficacious treatments has increased in the past five years.
Sources and selection criteria
We used the Clinical Evidence database 2 then searched for community surveys, randomised controlled trials, and systematic reviews—using the term “generalised anxiety disorder”—in Medline, Embase, and the Cochrane Library up to June 2006.
Who is likely to get generalised anxiety disorder?
Most of the recent literature uses DSM-IV criteria for generalised anxiety disorder; the ICD-10 criteria place greater weight on somatic symptoms and explicitly limit comorbidity (box).
Current diagnostic criteria for generalised anxiety disorder
Diagnostic and statistical manual of mental disorders (DSM-IV-TR)
- • Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least six months, about a number of events or activities (such as work or school performance)
- • The person finds it difficult to control the worry
- • The anxiety and worry are associated with three or more (only one for children) of the following six symptoms, with at least some symptoms present for more days than not for the past six months): restlessness or feeling keyed up or on edge; being easily fatigued; difficulty concentrating or mind going blank; irritability; muscle tension; and sleep disturbance
- • Anxiety and worry owing to panic disorder, social phobia, obsessive compulsive disorder, and separation anxiety disorder are excluded
International statistical classification of disease and related health problems, 10th revision (ICD-10)
The patient must have experienced at least six months with predominant tension, worry, and feelings of apprehension about everyday events and problems. At least four of the symptoms below must be present (at least one of which from the first group)
Autonomic arousal symptoms
- Palpitations or pounding heart, or accelerated heart rate; sweating; trembling or shaking; dry mouth (not due to medication or dehydration)
Symptoms involving chest and abdomen
- Difficulty breathing, feeling of choking, chest pain or discomfort, nausea or abdominal distress (such as churning in stomach)
Symptoms involving mental state
- Feeling dizzy, unsteady, faint, or light-headed; feeling that objects are unreal (derealisation) or that the self is “not really here” (depersonalisation); a feeling of losing control, “going crazy,” or passing out; fear of dying
- Hot flushes or cold chills; numbness or tingling sensations; muscle tension or aches and pains; restlessness and inability to relax; feeling keyed up, on edge, or mentally tense; a sensation of a lump in the throat or difficulty in swallowing
Other non-specific symptoms
- Exaggerated response to minor surprises or being startled; difficulty in concentrating or mind “going blank” because of worrying or anxiety; persistent irritability; difficulty in getting to sleep because of worrying
- Panic disorder, phobic anxiety disorder, obsessive-compulsive disorder, or hypochondrical disorder criteria must not be met. If the symptoms are due to a physical disorder or organic mental condition or a substance related disorder, generalised anxiety disorder is excluded
The table table lists recent community surveys using DSM-IV. These have shown that 1%-5% of the population have reported generalised anxiety disorder in the past 12 months. The disorder is more common in women, and often occurs alongside mood disorders, anxiety disorders, somatoform disorders, and medical conditions. 3 4 5 6 7 8
Prevalence of generalised anxiety disorder* in previous 12 months, and comorbidity, according to national community surveys. Values are percentages unless stated otherwise
|Age (years) (No of participants)||20-59 (n=2847)||18-64 (n=7124)||>18 (n=10641)||>18 (n=9282)||>18 (n=2657)||>18 (n=21425)|
|Instrument||SCAN||M-CIDI||CIDI 2.1||CIDI 3.0||AUADIS||CIDI 3.0|
|Proportion of participants with GAD||3.0||1.5||3.6||3.1||4.1||1.0|
|Proportion of men (women)||1.0 (3.6)||1.0 (2.1)||3.2 (4.0)||Not reported||2.8 (5.3)||0.5 (1.3)|
|Of those with a diagnosis of GAD:|
|Proportion with any comorbidity||Not reported||93.1||67.8||85||69.4|
|Mood disorder||Not reported||70.6||44.9||Not reported||Not reported||Not reported|
|Anxiety||Not reported||55.9||37.4||Not reported||Not reported||Not reported|
|Somatoform||Not reported||48.1||Not reported||Not reported||Not reported||Not reported|
|Substance misuse||Not reported||Not reported||13.3||Not reported||23.0||Not reported|
|Medical condition||53.9||Not reported||Not reported||Not reported||Not reported||Not reported|
CIDI=Composite international diagnostic interview; M-CIDI was based on CIDI; 2.1 and 3.1 were later versions of CIDI.
AUADIS=Alcohol use associated disorder interview schedule.
SCAN= Schedule of clinical assessment in neuropsychiatry.
*As diagnosed according to the DSM-IV criteria.
A review found that the rate of generalised anxiety disorder was significantly higher (odds ratio 3.3 (95% confidence interval 2.0 to 5.5)) in those who had been invloved in civilian trauma (such as a dam collapse or toxic chemical spill). 9 Reviews have linked the disorder with bullying (or peer victimisation) 10 and an increase in the number of life events. 11 Two reviews of family studies show an increased risk of the disorder in first degree relatives of patients. 12 13
The incidence of generalised anxiety disorder in men is half that in womenw1 and is lower in older people.w2 A review of 20 observational studies in younger and older adults suggested that autonomic arousal to stressful tasks was lower in older people and that older people became accustomed to stressful tasks more quickly than younger people.w3
How do people with the disorder pesent?
Anyone presenting with a mood or anxiety disorder may have generalised anxiety disorder. Most screening questionnaires for the condition ask if the person is a worrier, if they worry overmuch about many things, and then ask if they have somatic symptoms of anxiety. As people with generalised anxiety disorder may develop other mood and anxiety syndromes over time, it is important to screen for these too, particularly depressive disorder.
How can the effect of treatment be measured?
In clinical trials the most commonly used clinician rating scales are the Hamilton anxiety scale,w4 a 14 item instrument that places an emphasis on somatic symptoms. The most used self report measures are the state trait anxiety inventory,w5 the Beck anxiety inventory,w6 and the Penn state worry questionnairew7; the first and last of these four scales are in the public domain.
Treatment response is generally defined as a 50% reduction in baseline score. Clinical recovery is often defined as a score of less than 7 on the Hamilton anxiety scale or a score of 1 or 2 on the clinical global impression scale.w8
What is the outcome for patients?
Evidence on long term prognosis is sparse. At 12-year follow-up of adults at an anxiety clinic, 42% of patients had recovered from generalised anxiety disorder, but the disorder was a marker for poor outcome for those patients who had another anxiety disorder. 14 In a similar cohort of 68 people with generalised anxiety disorder alone (as defined by DSM-III criteria) at initial assessment and followed over 12 years, two had the disorder alone after 12 years, 28 no longer had a diagnosis, 12 had developed dysthymic disorder, and 10 had developed depression; the rest had been lost to follow up. 15
Which psychological treatments can help?
Both cognitive therapy and anxiety management therapy are efficacious, and cognitive behaviour therapy may be more efficacious than anxiety management therapy alone.
Anxiety management therapy is a structured therapy involving education, relaxation training, and exposure but does not include cognitive restructuring; cognitive behaviour therapy adds to this a cognitive restructuring element. Relaxation involves practising techniques that lead to muscular or bodily relaxation. Exposure entails (over a period of time) graded, repeated confrontation (through visualisation, image, or the stimulus) with a stimulus that causes anxiety. Cognitive restructuring involves challenging the dysfunctional thought processes and the underlying assumptions that may be related to the symptoms.
Systematic reviews and subsequent randomised trials found that cognitive behaviour therapy significantly improved anxiety and depression over four to 12 weeks compared with the waiting list control group, anxiety management alone, relaxation alone, or non-directive psychotherapy. 16 17 w9 w10 w11 Patients randomised to anxiety management therapy also fare better than waiting list controls, and the efficacy of this treatment may equal that of cognitive therapy. 2 w12 w13
Which drug treatments can help?
Two systematic reviews found that antidepressants (imipramine, paroxetine, and venlafaxine) improved symptoms over four to 28 weeks compared with placebo. 18 19 Clinical trials have found no significant differences among clinical responses to these antidepressantsw14 or between antidepressants and benzodiazepinesw15 or antidepressants and buspirone.w16 In a systematic review buspirone improved symptoms over four to nine weeks compared with placebo. 20 One systematic review found that benzodiazepines reduced symptoms over two to nine weeks compared with placebo. 21 A clinical trial found no significant difference in symptoms over three to eight weeks between benzodiazepines, between benzodiazepines and buspirone, hydroxyzine, or abecarnil (not available in the United Kingdom or New Zealand).w17w18 In a systematic review Kava extract significantly reduced symptoms compared with placebo (according to scores on the Hamilton anxiety scale). 21 There have been some case reports, however, of severe hepatic compromise in patients receiving kava.w19 w20 Evidence from clinical trials indicates that hydroxyzinew21 w20 and pregabalinw23 may be efficacious.
A patient’s perspective
As a child, I was excessively worried and nervous. I tended to over-analyse situations, was fidgety, and found it difficult to relax. At age 18, I had my first intense anxiety experience, after which my anxiety became significantly worse. Fearful of social and physical situations, I avoided potential anxious situations and often used alcohol to deal with social situations.
My anxieties could change overnight and manifest into a seemingly unsolvable problem. I often worried about my mental state and felt I had to hide my emotions and thoughts from strangers, friends, family, and doctors.
I forced myself to talk to my general practitioner as my anxiety would not subside. For over two years I used medication, which helped significantly. However, I also wished to seek psychological advice to understand what the future might hold for me. I was told by a clinical psychologist that with the right tools and training I would probably be able to change my thought patterns, which had became irrational and negative, and my coping behaviour. It was a great relief to know there could be a better future.
Understanding the errors in my thinking and implementing better coping strategies has reduced my anxiety levels considerably. And this has therefore enabled me to live a much more balanced and normal life.
Martin, aged 37
What further research should be done?
The evidence base for generalised anxiety disorder has grown in recent years. The development of standard methods for conducting and reporting such trials means that the newer trials are of a higher quality and are reasonably comparable.
There are still, however, few trials of clinical effectiveness. More are needed because most patients with generalised anxiety disorder have other mood and anxiety disorders too and are affected for a prolonged period 14 and because the nature of comorbid conditions can change over time. 15 These trials should compare the following: the efficacious psychotherapies; the efficacious medications; and psychotherapies versus medications. Any such trial design should be sufficiently powered to allow for analysis of comorbid conditions and be designed to run over a longer period of time than previous trials. Furthermore, some treatment options such as benzodiazepines, should be examined by meta-analysis of efficacy before further trials are considered.
ADDITIONAL EDUCATIONAL RESOURCES
Resources for health professionals
- • Treatment Protocol Project. Management of mental disorders. 4th ed. Darlinghurst, NSW: World Health Organization Collaborating Centre for Evidence in Mental Health Policy, 2004.
- • Clinical Research Unit for Anxiety and Depression ( www.crufad.com/cru_index.htm )— Contains information on anxiety plus a computerised intervention, which currently needs to be prescribed by a general practitioner
- • British Association for Behavioural and Cognitive Psychotherapies ( www.babcp.com )—Has a list of therapists, training resources, and general information for patients about anxiety and cognitive behaviour therapy
- • Gale C. Generalised anxiety disorder. Clin Evidence. www.clinicalevidence.com/ceweb/conditions/meh/1002/1002.jsp
Resources for patients
- • Bourne E. The anxiety and phobia workbook. 4th ed. Oakland, CA: New Harbinger, 2005. (For use as a supplement for anxiety management training.)
We thank our patient, Martin (see “A patient’s perspective” box), for his description of his generalised anxiety disorder.
Contributors: CG was involved in the development of the search strategy, the resource selection, and the drafting of the paper; he is also the guarantor. OD helped with resource collection, the patient description, and drafting the paper. Kate Thompson helped to develop the search strategy. Keren Skegg and Richard Mullen reviewed the paper before publication.
Competing interests: CG has given talks for Lilly Pharmaceuticals and has attended conferences paid for by Lilly and Jannsen Pharmaceuticals. He has no shares, has not been a consultant to, or an investigator in clinical trials funded by, any pharmaceutical company.
Provenance and peer review: Commissioned and peer reviewed.
Articles from The BMJ are provided here courtesy of BMJ Publishing Group
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