Generalised Anxiety Disorder (GAD) is an anxiety disorder
It is characterised by excessive anxiety and worry
It often co-exists with depression, other anxiety disorders and substance abuse
Symptoms tend to grow worse with time if the condition is not treated
It tends to run in families
It is best treated by a combination of medication and psychotherapy
Everybody worries at times. But in the case of Generalised Anxiety Disorder (GAD), an Anxiety Disorder, the person’s worries are much more than normal day-to-day anxiety. They are excessive, unrealistic, chronic and relentless.
People with GAD usually expect the worse and worry excessively about everyday life circumstances (such as their health, job, raising of children or finances), or minor matters (such as household chores or renovations - even just getting through the day becomes problematic).
The focus of worry can shift from one concern to another. At times the source is evident but the reaction is disproportionate to the actual likelihood or impact of the feared event. At other times the source of the anxiety and worry is hard to pinpoint.
It is common for children and adolescents with GAD to worry about their competence and performance at school or in extra-mural activities. They may need more reassurance about their performance than other children.
Individuals with GAD usually suffer physical symptoms as well. These symptoms may include headaches, irritable bowel syndrome, dizziness, sweating, nausea, muscle aches, difficulty swallowing and diarrhoea. They may also need to go to the toilet more frequently.
Sufferers tend to be irritable and complain of feeling on edge, struggling to sleep, being easily fatigued and/or finding it difficult to concentrate. They may also startle more easily than other people.
GAD often coexists with other psychiatric problems such as another anxiety disorder, depression and substance abuse.
People with GAD cannot “snap out of it” and seem unable to relax. They may realise that their worry is excessive but find it difficult to control it.
Unlike people with several of the other anxiety disorders, people with GAD don’t characteristically avoid situations as a result of the disorder.
However, GAD can be distressing and can significantly interfere with a person’s functioning in various aspects of the person’s life. Fortunately, medication and psychotherapy can greatly improve quality of life.
Symptoms usually have an insidious onset. The symptoms may differ slightly from person to person. Some may experience more cognitive symptoms (such as worry or difficulty concentrating), others may be plagued more by physical symptoms (such as restlessness, irritability, muscle tension, and disturbed sleep).
The symptoms are usually worse during stressful times and grow progressively worse if not treated.
Although the exact causes have not been identified, GAD seems to run in families. As in the case of other anxiety disorders, this disorder seems to be underpinned by various brain circuits.
General medical causes of anxiety symptoms, such as endocrine problems, should be excluded. Certain substances such as caffeine, stimulants and alcohol may also contribute to increase anxiety.
Who gets GAD?
About 5% of the general population will suffer from GAD at some point in their lives. GAD is more common in women than in men and often occurs in relatives of affected persons.
GAD usually begins in childhood or adolescence but can also have its onset in adulthood.
GAD is more common in people with another psychiatric disorder, including another anxiety disorder.
A diagnosis is usually made by a general practitioner who may refer the person to a psychiatrist. The psychiatrist should do a thorough assessment, including taking an in-depth history of the patient and of his or her family. The input of people close to the affected person may also be valuable.
The criteria set out in the Diagnostic and Statistical Manual of Mental Disorders (DSMIV) is usually used to make a diagnosis. For a diagnosis to be made, excessive anxiety and worry (“apprehensive expectation”) must be present more days than not for a period of at least six months about a number of events and activities.
In addition, the person must have at least three of the following symptoms:
Restlessness or feeling keyed up or on edge
Being easily fatigued
Difficulty concentrating or mind going blank
GAD must be distinguished from everyday worry and other disorders which can also present with anxiety and worry. Such disorders include the obsessive thoughts and worry about, for example, being contaminated (as seen in Obsessive Compulsive Disorder), worry about having a panic attack (as in Panic Disorder), being embarrassed in public (as in Social Anxiety) and ruminations (often characteristic of depression).
The physiological effects of a substance (medication, drug abuse or exposure to a toxin) or general medical conditions such as hyperthyroidism should also be ruled out.
People with GAD should tell the doctor about when it was first noticed, the course of the disorder and previous treatment received, including what medication was prescribed, the dosage and duration, and how effective it was in relieving symptoms. If the person underwent psychotherapy, it is important to mention the kind of psychotherapy used.
Great progress has been made in the treatment of anxiety disorders. Although treatment cannot cure the disorder, it can greatly relieve the symptoms and improve quality of life.
Together with your attending doctor, a treatment plan should be worked out. The best course of treatment is a combination of medication and psychotherapy.
Any co-existing disorder should also be treated.
Several different medications can be used to treat GAD. These include antidepressants, buspirone and benzodiazepines.
The first line of treatment is certain kinds of antidepressants such as Selective Serotonin Reuptake Inhibitors (SSRI’s) and Selective Serotonin and Noradrenaline Reuptake Inhibitors (SNRI’s).
These antidepressants act on the neurotransmitter serotonin (and noradrenaline in the case of the SNRI’s) and also treat depression which often co-exists with GAD. Examples of SSRI’s are sertraline (Zoloft) and fluoxetine (Lilly-Fluoxetine), while venlafaxine (Efexor) is an example of an SNRI. Venlafaxine and paroxetine (Aropax) are licensed for GAD in some countries.
A person will be started on a low dose which will gradually be increased until a therapeutic dose is reached. The disadvantage of these antidepressants is that, unlike benzodiazepines, they take a few weeks before the person notices a relief of symptoms. Many people therefore stop taking medication prematurely.
Although they have a favourable side-effect profile, side-effects such as headaches and nausea may be experienced. Fortunately they will gradually disappear after a while. If side-effects are difficult to tolerate, a different medication may be prescribed.
Buspirone (or Buspar) has relatively few side effects and is well tolerated. The disadvantage is that, like the SSRI’s and SNRI’s, they take a few weeks before symptoms are relieved. They also don’t treat depression or other anxiety disorders which often co-exist with GAD.
Benzodiazepines (also known as “tranquilizers”) work very quickly and are thus often preferred to antidepressants by patients. However, people may develop tolerance which means that dosages need to be increased to deliver the same effect. The risk of addiction is thus high.
Another disadvantage is that they only treat anxiety and not depression. They also only have an effect while the person is taking them. If they are stopped, symptoms return.
It is important not to stop medication without medical supervision – the doctor will probably taper off the dosage to avoid “rebound” anxiety.
Medication tends to bring about results more rapidly, but the benefits of psychotherapy may be more enduring.
There are many different types of psychotherapy. Cognitive Behavioural Therapy (CBT) is often recommended for the treatment of anxiety. It is short-term, structured therapy which is based on the theory that one’s feelings and behaviour are controlled by how one thinks and perceives the world.
CBT focuses on changing negative thought patterns. The therapist will challenge cognitive distortions such as catastrophising, probability overestimation and all or nothing thinking and encourage the development of a positive mindset.
Self-monitoring is an important part of CBT. The person is encouraged to pay closer attention to thoughts and feelings.
Relaxation and stress management techniques
These techniques can help people to relax and cope with stress. Relaxation techniques used include progressive relaxation and diaphragmatic breathing (a special breathing exercise involving slow, deep breaths to reduce anxiety).
People with GAD often feel isolated. Support groups can help the person to share his or her concerns with others and to learn different techniques to cope with the disorder. In South Africa, the Depression and Anxiety Support Group has helped many people cope with anxiety disorders and depression. There are several groups throughout the country. They can be contacted at (011) 783 1474/5.
This disorder is difficult to prevent as there is no specific factor which triggers the onset. However, early treatment can prevent the level of disability or dysfunction reached. It may also help to prevent the development of co-existing conditions.
For more information on GAD and other anxiety disorders, the book “False Alarm: How to Conquer the Anxiety Disorders” is available from the MRC Unit or the Mental Health Information Centre at (021) 938 9229.
Reviewed by Dr Soraya Seedat, psychiatrist and co-director: MRC Unit on Anxiety Disorders