12 October 2005

When worrying becomes too much

Everybody worries at times. But in the case of Generalised Anxiety Disorder (GAD), worries are much more than normal anxiety. They are excessive and relentless.

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.

Physical symptoms
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.

"Snap out of it"
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.

Help is available
Great progress has been made in the treatment of generalised anxiety disorder (GAD). Although treatment cannot cure the disorder, it can greatly relieve the symptoms and improve quality of life.

The best course of treatment is a combination of medication and psychotherapy.

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 (SSNRI’s).

These antidepressants act on the neurotransmitter serotonin (and noradrenaline in the case of the SSNRI’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 SSNRI. 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, 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 SSNRI’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 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).

Support groups
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 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.

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 at (021) 938 9229 or the Mental Health Information Centre at (021) 938 922. - (Ilse Pauw, Health24 writer)


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