GENERALIZED ANXIETY DISORDER
As its name implies, Generalized Anxiety Disorder is a chronic (ongoing) state of diffuse, or free-floating, anxiety that is not attached to specific situations or objects. The anxiety may last for months, with the signs almost continually present. Though Anxiety is a normal and adaptive response to threat that prepares the organism for flight or fight response. Persons who seem to be anxious about almost everything, however, are likely to be classified as having Generalized Anxiety Disorder.
Generalized anxiety disorder is defined as:
1. Excessive anxiety and worry about several events or activities for most days at least for six months period.
2. The worry is difficult to control and is associated with somatic symptoms, such as muscle tension, irritability, difficulty sleeping, and restlessness.
3. The anxiety is not focused on features of another disorder i.e. it is not caused by substance use or due to general medical condition, and does not occur only during a mood or psychiatric disorder.
4. The anxiety is difficult to control, is subjectively distressing, and produces impairment in important areas of a person’s life.
For example Radheshyam feels,
1. Emotionally jittery, tense, and constantly on edge.
2. Cognitively, he expects something awful to happen but doesn’t know what.
3. Physically he perspires constantly, his stomach is usually upset, and he is unable to sleep comfortably.
As we might expect, this disorder can markedly interfere with daily functioning, even if the symptoms are not continually present for the 6 months required for a formal diagnosis.
The person may find it hard to concentrate, to make decisions, and to remember commitments. People with this condition (two-thirds are women) they worry continually, and they are often jittery, agitated, and sleep-deprived. Concentration is difficult, as attention switches from worry to worry, and their tension and apprehension may leak out through furrowed brows, twitching eyelids, trembling, perspiration, or fidgeting. One of the worst characteristics of this disorder is that the person cannot identify, and therefore cannot deal with or avoid, its cause. In Sigmund Freud’s term, the anxiety is free-floating. Generalized anxiety disorder is often accompanied by depressed mood, but even without depression it tends to be disabling (Hunt et al., 2004; Moffitt et al., 2007b). Moreover, it may lead to physical problems, such as ulcers and high blood pressure.
Many people with generalized anxiety disorder were maltreated and inhibited as children (Moffitt et al., 2007a).
EPIDEMIOLOGY
Generalized anxiety disorder is the commonest psychiatric disorder in the population with the reasonable estimates for its one year prevalence range from 3 to 8 percent. The ratio of women to men with the disorder is about 2:1, but the ratio of women to men who are receiving inpatient treatment for the disorder is about 1:1. Lifetime prevalence is close to 5 percent with the Epidemiological Catchment Area (ECA) study suggesting lifetime prevalence as high as 8 percent. In anxiety disorder clinics, about 25 percent of patients have generalized anxiety disorder. The disorder usually has its onset in late adolescence or early adulthood, although cases are commonly seen in older adults. As time passes, however, emotions tend to mellow, and by age 50, general anxiety disorder becomes rare (Rubio & López-Ibor, 2007).
COMORBIDITY
Generalized anxiety disorder is the disorder that most often coexists with another mental disorder, usually social phobia, specific phobia, panic disorder, or a depressive disorder. Around 50 to 90 percent of patients with generalized anxiety disorder usually have another mental disorder. As many as, 25 percent of patients; eventually experience panic disorder. An additional high percentage of
patients are likely to have major depressive disorder.
AETIOLOGY
The cause of generalized anxiety disorder is not known. As generalized anxiety disorder affects a heterogeneous group of persons. Certain degree of anxiety is normal and adaptive and, differentiating normal anxiety from pathological anxiety is difficult. Also differentiating biological causative factors from psychosocial factors is a difficult one.
There are however several theories to explain the aetiology, of which more than one may be applicable in a particular patient.
1. Psychodynamic Theory: According to this theory, anxiety is a symptom of unresolved, unconscious conflicts. Sigmund Freud first presented this psychological theory in 1909 with his description of Little Hans.
2. Behavioural Theory: According to this theory, anxiety is viewed as an unconditioned inherent response of the organism to painful or dangerous stimuli. In anxiety and phobias, this becomes attached to relatively neutral stimuli by conditioning.
3. Cognitive Behavioural Theory (CBT): According to cognitive behaviour theory, in anxiety disorders there is evidence of selective information processing (with more attention paid to threat-related information), cognitive distortions, negative automatic thoughts about the person’s own ability to cope.
4. Biological Theory:
1) Genetic evidence: About 15-20% of first degree relatives of the patients with anxiety disorder exhibit anxiety disorders themselves. The concordance rate in the monozygotic twins of patients with panic disorders is as high as 80% (4 times more than in dizygotic twins).
2) Chemically induced anxiety states: Infusion of chemicals (such as sodium lactate, isoproterenol and caffeine), ingestion of yohimbine and inhalation of 5% CO2 can produce panic episodes in predisposed individuals.
3) GABA-benzodiazepine receptors: GABA (Gamma amino butyric acid) is the most prevalent inhibitory neurotransmitter in the central nervous system. It has been suggested that an alteration in GABA levels may lead to production of clinical anxiety.
4) Other neurotransmitters: Norepinephrine, 5-HT, dopamine, opioid receptors and neuroendocrine dysfunction have also been implicated in the causation of anxiety disorders.
5) Neuroanatomical basis: Locus coeruleus, limbic system, and prefrontal cortex are some of the areas implicated in the aetiology of anxiety disorders.
6) Organic anxiety disorder: This disorder is characterized by the presence of anxiety which is secondary to the various medical disorders (e.g. hyperthyroidism, phaeochromocytoma, coronary artery disease). If anxiety symptoms can occur secondary to medical disorders, it seems possible than that anxiety has a biological basis.
TREATMENT
The treatment of anxiety disorders is usually multimodal. The most effective treatment of generalized anxiety disorder is probably one that combines psychotherapeutic, pharmacotherapeutic, and supportive approaches.
1. Psychotherapy:
The major psychotherapeutic approaches to generalized anxiety disorder are cognitive behavioural therapy (CBT), supportive, and insight oriented. Psychoanalytic psychotherapy is not usually indicated, unless characterological (personality) problems co-exist. Usually supportive psychotherapy is used either alone, when anxiety is mild, or in combination with drug therapy. Supportive therapy offers patients reassurance and comfort, although its long-term efficacy is doubtful. Insight-oriented psychotherapy focuses on uncovering unconscious conflicts and identifying ego strengths.
2. Relaxation Techniques:
In patients with mild to moderate anxiety, relaxation techniques are very useful. Patient uses these techniques himself as a routine exercise everyday and also whenever there is an anxiety-provoking situation. These techniques include Jacobson’s progressive relaxation technique, yoga, pranayama, self-hypnosis, and meditation.
3. Other Behaviour Therapies:
Other behaviour therapies include biofeedback and hyperventilation. These therapies are also very effective in managing generalized anxiety disorder.
4. Pharmacotherapy:
The two major drugs to be considered for the treatment of generalized anxiety disorder are benzodiazepines and the SSRIs.
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REFERENCES:
· David G. Myers Psychology 9th eds. 2010 by Worth Publishers
· Goldberg, D., & Poulton, R. (2007a). Generalized anxiety disorder and depression:Childhood risk factors in a birth cohort ollowed to age 32. Psychological Medicine, 37, 441–452. (p. 602)
· Hunt, C., Slade, T., & Andrews, G. (2004). Generalized anxiety disorder and major depressive disorder comorbidity in the National Survey of Mental Health and Well-Being. Depression and Anxiety, 20, 23–31. (p. 602)
· KAPLAN & SADOCK S Synopsis of Psychiatry Behavioral Sciences/Clinical Psychiatry eleventh edition ISBN 978-1-60913-971-1
· Moffitt, T. E., Harrington, H., Caspi, A., Kim-Cohen, J., Goldberg, D., Gregory, A. M., & Poulton, R. (2007b). Depression and generalized anxiety disorder: Cumulative and sequential comorbidity in a birth cohort followed prospectively to age 32 years. Archives of General Psychiatry, 64, 651–660. (p. 602)
· Moffitt, T., Caspi, A., & Rutter, M. (2006).: Measured gene-environment interactions in psychopathology: Concepts, research strategies, and implications for research, intervention, and public understanding of genetics. Perspectives on Psychological Science. 1, 5–27.
· Niraj Ahuja 2011, A Short Textbook of PSYCHIATRY Seventh Edition Published by Jaypee Brothers Medical Publishers (P) Ltd
· Passer, Michael W. and Ronald E. Smith: Psychology: the science of mind and behavior (4th ed.), Published by McGraw-Hill 2009
· Rubio, G., & López-Ibor, J. J. (2007). Generalized anxiety disorder: A 40-year follow-up study. Acta Psychiatrica Scandinavica, 115, 372–379. (p. 602)
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