Generalized Anxiety Disorder – Overview and Treatment Options

Diagnostic Criteria for Generalized Anxiety

A. Excessive anxiety and worry, occurring more days than not for at least 6 months, about a number of events or activities.

B. The person finds it difficult to control the worry.

C. The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some present for more days than not for the past 6 months):

• Restlessness or feeling keyed up or on the edge
• Being easily fatigued
• Difficulty concentrating or mind going blank
• Irritability
• Muscle tension
• Sleep disturbance

D. The focus of the anxiety and worry is not confined to features of an Axis I disorder, the anxiety or worry is not about having a panic attack, being embarrassed in public, being contaminated, being away from home or close to relatives, gaining weight, having multiple physical complaints, or having a serious illness, and the anxiety and worry do not occur exclusively during Posttraumatic Stress Disorder.

E. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning

F. 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 and does not occur exclusively during a Mood Disorder, a Psychotic disorder, or a Passive Developmental Disorder.

Associated Features and Disorders

Associated with…

• Muscle tension
• Trembling
• Twitching
• Feeling shaky
• Muscle aches or soreness

Many individuals with GAD also experience somatic symptoms:

• Sweating
• Nausea
• Diarrhea
• Exaggerated startle response
• Accelerated heart rate
• Shortness of breath
• Dizziness

GAD very frequently co-occurs with Mood Disorders (Major Depressive or Dysthymic Disorder), with other Anxiety Disorders (Panic Disorder, Social Phobia, Specific Phobia), and with Substance Related Disorders (Alcohol or Sedative, Hypnotic, or Anxiolytic Dependence or Abuse).

Other conditions that may be associated with stress (irritable bowel syndrome, headaches) frequently accompany GAD.

Specific Culture and Age Features

There is considerable cultural variation in the expression of anxiety in some cultures. It is important to consider the cultural context when evaluating whether worries about certain situations are excessive. In some cultures, anxiety is expressed predominately through somatic symptoms, while in others, it is expressed through cognitive symptoms.

In children and adolescents with GAD, the anxieties and worries often concern the quality of their performance or competence at school or in sporting events, even when their performance is not being evaluated by others.

There may be excessive concerns about punctuality. They may also worry about catastrophic events such as earthquakes or war. Children with the disorder may be overly conforming, perfectionistic, and unsure of themselves and tend to redo tasks because of excessive dissatisfaction with less than perfect performance. They are typically overzealous in seeking approval and require excessive reassurance about their performance and their other worries.

GAD may be over diagnosed in children. In considering this diagnosis in children, a thorough evaluation for the presence of other childhood Anxiety Disorders should be done to determine whether the worries may be better explained by another disorder.

Gender Features

In clinical settings, the disorder is diagnosed somewhat more frequently in women than in men. About 55%-60% of those presenting with the disorder are female. In epidemiological studies, the sex ratio is approximately two-thirds female.

Prevalence

In a community sample, the one-year prevalence rate for GAD was approximately 3%, and the lifetime prevalence rate was 5%. In anxiety disorder clinics, up to a quarter of the individuals have GAD as a presenting or co-morbid diagnosis.

Course and Development

Many individuals with GAD report that they have felt anxious or nervous all of their lives. Although over half of those presenting for treatment report onset in childhood or adolescence, onset occurring after age 20 is not uncommon. The course is chronic but fluctuating and often worsens during times of stress.

Familial Pattern

Anxiety as a trait has a familial association. Although early studies produced inconsistent findings regarding familial patterns for GAD, more recent twin studies suggest a genetic contribution to the development of this disorder. Furthermore, genetic factors influencing risk of GAD may be closely related to those for Major Depressive Disorder.

Differential Diagnosis

GAD must be distinguished from an Anxiety Disorder Due to a General Medical Condition. The diagnosis is Anxiety Due to a General Medical Condition if the anxiety symptoms are judged to be a direct physiological consequence of a specific general medical condition.

A Substance Induced Anxiety Disorder is distinguished from GAD by the fact that the substance is judged to be etiologically related to the anxiety disturbance.

Several features distinguish the excessive worry of GAD from the obsessional thoughts of Obsessive Compulsive Disorder. Obsessional thoughts are not excessive worries about everyday or real life problems, but rather are ego-dystonic intrusions that often take the form of urges, impulses, and compulsions that reduce the anxiety associated with the obsessions.

Anxiety is invariably present in Posttraumatic Stress Disorder. GAD is not diagnosed if the anxiety occurs exclusively during the course of PTSD. Anxiety may also be present in in Adjustment Disorder, but this residual category should be used only when the criteria are not met for any other Anxiety Disorder.

Rationale for CBT Treatment

Silverman (2003) postulated that in the past decade, research from randomized clinical trials have produced strong and consistent evidence that cognitive-behavioral therapy (CBT) can play an important role in reducing Social Phobia, Separation Anxiety, and Generalized Anxiety Disorder in Children and Adolescents.

The author proposed therapeutic procedures and strategies used in CBT in three phases:

Education Phase:

In the education phase, children first receive information that anxiety may manifest in three ways:

• Feelings in their bodies
• Certain behaviors such as avoiding or staying away from events that may be anxiety provoking.
• The things we say to ourselves( self talk).

The situations avoided and the anxious thoughts vary among patients. During the education phase, children learn to identify the situations and the nature of their thoughts.

In GAD, children engage in frequent, uncontrollable worry, The worry thoughts vary and may focus on everything and anything, or specific areas such as personal health, parent’s health, their performance in school, or world events. Children with GAD may also show avoidant behaviors, such as not eating in restaurants.

Application Phase:

In the application phase, children (and parents, if they are involved) practice the principles and procedures taught in the beginning sessions. This application occurs in the therapy session and out-of-session as homework assignments. The therapist’s role is similar to a coach in terms of providing feedback, support and encouragement as the child engages in increasingly difficult anxiety provoking exposure tasks.

Relapse Prevention Phase:

As the child meets with continued success, the therapist should begin discussing with the child issues relating to termination, including relapse prevention. Specifically, the importance of continued exposures should be emphasized.

Role of Positive Beliefs

Wells et.al (1999) presented a comprehensive theory regarding the importance of “Meta-Worry” in understanding GAD, positing that individuals who suffer from GAD hold a variety of beliefs about possible benefits of their worrying. Their research suggests a strong argument for the use of CBT as a viable treatment for GAD.

Borkovec, Hazlett-Stevens, & Diaz (1999) asked GAD clients what they believed might be the benefits of worrying?

If I worry about something, I am more likely to actually figure out how to avoid or prevent something bad from happening.

Although it may not actually be true, it feels like if I worry about something, the worrying makes it less likely that something bad will happen.

Worrying about most of the things I worry about is a way to distract myself from worrying about even more emotional things, things that I don’t want to think about.

If I worry about something, when something bad happens, I’ll be better prepared for it.
Worry helps to motivate me to get things done that I need to get done.

Worrying is an effective way to problem solve.

STUDY I
The authors constructed a questionnaire which presented the reasons for worry, and asked GAD and control groups to rate items and asked analog GAD and control groups to rate the extent to which each statement described a reason for why they worried.

In Study I, a small group of college students meeting criteria for GAD was compared to a nonanxious group and a group who met some but not all GAD criteria. The items referring to worry as avoidance, preparation and problem solving were most highly endorsed overall.

Between group differences were limited to use the worry as a distraction from emotional topics, where the GAD group scored significantly higher than the nonanxious group.

STUDY II
In Study II, the same scales were administered to a large sample of GAD participants, non-anxious controls, and controls who met GAD criteria from somatic symptoms but did not experience excessive worry. The same three items were most highly rated by the entire group. The GAD participants were, however, significantly more endorsing of worry as a useful problem solving device, and of the feeling that worry makes bad things less likely to happen than the non-anxious group, and they were significantly more characterized by the use of worry as a distraction than both control groups.

Standard and Enhanced CBT for Late-Life GAD

Mohlman et.al (2004) hypothesized that as the U.S. population ages, mental health professionals are becoming more concerned about effective treatments for late-life anxiety. The authors stated that it is currently unclear whether treatment strategies used successfully with younger adults are appropriate for older adults.

“The efficacy of CBT for anxiety is one promising strategy currently being investigated in elderly population samples.”

The authors further stated that although CBT is an efficacious treatment for GAD in younger adults, little is known about its efficacy in older adults.

Participants and Measures

The authors stated that to their knowledge, their two small pilot studies are the first investigations of CBT delivered in a mental health clinic in individual format. “Study I tested a standard version of CBT, and Study II tested a version that was enhanced with learning and memory aids designed to make the therapy more effective for the elderly.”

STUDY I
Study I participants included 27 adults age 60 to 74, with a mean age of 66.4. Continuous demographic and clinical variables were compared between the groups in Studies I and II using multivariate analyses of variance (MANOVA). “There were no significant differences on variables in either sample.”

ANALYSIS OF STUDY I
At posttreatment, 50% of the CBT group and 31% of the wait list group were free of GAD, and 45% of the CBT group and 23% of the wait list group were free of comorbid diagnosis. “At follow-up, an additional 36% of the CBT group was GAD free and an additional 30% were free of comorbid diagnosis.”

STUDY II
Study II participants were randomly assigned to either 13 50 minute sessions of enhanced CBT (ECBT- n=8) followed by monthly booster sessions for six months, or a 13 week wait list condition (n=7).

ANALYSIS OF STUDY II
At posttreatment, 86% of the ECBT group and 14% of the wait list group were free of GAD, a difference that unlike Study I was statistically significant. “At follow-up, 86% of the ECBT group remained free of GAD, 63% of the ECBT group was free of comorbid diagnosis at posttreatment.

DEMOGRAPHIC AND CLINICAL CHARACTERISTICS OF THE SAMPLE
Study I Study II
wait CBT Wait ECBT
(n=13) (n=14) (n=7) (n=8)
———————————————————————-
Age 65.69 67.14 66.89 68.50
(4.71) (5.30) (9.81) (11.42)
Ethnicity
White 100% 86% 83% 86%
Hispanic O% 14 % 17% 0%

Major 1.78 1.46 1.00 1.25
Health (1.86) (1.27) (1.08) (1.01)

Minor 1.67 0.77 0.87 2.65
Health (1.58) (0.73) (1.13) (0.97)

Comorbid 1.08 0.67 0.87 2.65
(1.04) (0.71) (0.89) (0.70)

Late Onset 38% 50% 50% 70%

The authors stated that Major health problems were defined as those that required inpatient surgery, were life threatening or caused impairment despite ongoing medication. “Minor health problems were those that required outpatient care or those that were effectively controlled with medication.”

Treatment Steps of CBT

In their workbook, Mastery of Your Anxiety and Worry, Craske, Barlow & O’Leary
(1992), proposed a worry record. Participants are asked to list their anxiety symptoms, and rate their level of severity. Symptoms could be rated as none, mild, moderate, strong, or extreme. Furthermore, participants are then asked to list the events which may cause anxiety, as well as the anxious thoughts themselves on a worksheet. They call this worksheet the Worry Record Form.

Symptoms

• TREMBLING
• FATIGUE
• SWEATING
• NAUSEA
• TROUBLE SWALLOWING
• TROBLE SLEEPING
• MUSCLE TENSION
• DIFFICULTY BREATHING
• DRY MOUTH
• HOT FLASHES
• KEYED UP
• DIFICULTY CONCENTRATING
• RESTLESSNESS
• POUNDING/ RACING HEART
• DIZZY
• FREQENT URINATION
• EASILY STARTLED
• IRRITABILITY
• EVENTS
• FAMILY
• FRIENDS
• WORK
• SCOOL
• HOME MANAGEMENT
• FINANCAIL
• HEALTH
• OTHER
• ANXIOUS THOUGHTS

After a person has spent several weeks filling out the Worry Record sheets, they need to examine the patterns from the very beginning of the program to the present. “It is possible that the worry exposure practices could result in a higher level of anxiety. This is normal, because you are being asked to focus on the very things that you worry about.

The next step toward gaining control over your worry and anxiety entails some work in everyday kinds of situations. Preventing worry behavior involves a set of procedures designed to put an end to avoiding certain thoughts or situations.

Instructions for Worry Behavior Prevention Exercises

1. Consider the practical aspects of the task; what you must do or not do, and how you will do or not do the behavior. The tasks may entail some planning, such as asking a friend to let your children sleep over, or arranging a dinner party. In addition, inform your family members or friends of any changes in behaviors that have affected them in the past.

2. Consider the types of worries that will come to your mind and how to counter them. That is, have your realistic thinking strategies prepared to deal with the worry that you feel when practicing.

3. Practice each task the number of times necessary for maximum anxiety levels to reduce to a mild level. Depending on the task, you may be able to repeat the practices quickly, such as one day after another, or over longer periods of time.

4. Spend the next few weeks, or however long it takes, to practice these tasks. The authors recommend that a person attempt to do at least one task each day.

Potential Difficulties with Worry Prevention Exercises

• Procrastination
• Immediate anxiety
• Being unprepared
• Impractical tasks
• You experience little or no anxiety
• Anxiety levels do not decrease

Time Management

Three basic principles for helping you to manage your time:

• Delegating responsibility
• Saying no
• Sticking to agendas

Brainstorming

When you are faced with real life problems or a crisis, do the following:

• Write down what the problem is.
• Let your mind go and write down every possible solution that comes to you.
• Rank order these solutions from best to worst, based on how practical and reasonable they are to do.
• Decide on a specific plan of action in order to carry out each reasonable solution.
• Rate the probability of each solution’s working.

Put the plan for the most reasonable solution into action. If it does not help the problem, move down your list to the next best solution, and try again until you can successfully resolve the problem or make it better.

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