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09 September 2010

Worrying all the time?

Do you tend to worry excessively, to such an extent that you fail to enjoy life? If so, you may be suffering from generalised anxiety disorder.

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The term "generalised anxiety disorder" (GAD) refers to a condition characterised by excessive worry. In some ways, the term "tension disorder" is a better one - this is a condition characterised by both mental tension (e.g. worry, irritability) and physical tension (e.g. muscle tension, insomnia).

People with GAD worry about everyday life circumstances (e.g. job responsibilities, finances, the health of family members) or about more minor matters (e.g. household chores, keeping appointments). The worries are experienced as difficult to control, and they are clearly distressing or interfere significantly with work or with social functioning.

The worrying is accompanied by one or more of a range of physical symptoms, such as restlessness, being easily fatigued, difficulty concentrating, irritability, muscle tension and disturbed sleep.

The particular symptoms of GAD may differ somewhat from person to person. For example, some people may experience primarily cognitive symptoms (i.e. worry), while in other people the bodily symptoms (e.g. aches and pains) are experienced as the main problem.

Worries are not exclusive to GAD
Excessive worry is not only a feature of GAD. The worries of generalised anxiety disorder need to be distinguished from the ruminations of depression and the obsessions of obsessive-compulsive disorder (OCD).

The disorder that most closely overlaps with GAD is in fact depression: many people with GAD also have depressed mood, and many people with depression also have significant worries. The obsessions of OCD tend to be relatively senseless in comparison to the more understandable worries of GAD.

There are also a number of different general medical disorders that may present with symptoms of anxiety; it is important not to misdiagnose GAD in these cases. Certain foods (e.g. caffeine), medications (e.g. stimulants) and substances (e.g. alcohol) may also contribute to increased anxiety.

Finally, GAD should be differentiated from normal anxiety. The distinction between normal anxiety and a clinical disorder such as GAD rests on the extent of distress and dysfunction associated with symptoms. The worries of GAD are of course more pronounced, more pervasive, and more likely associated with physical symptoms than are ordinary worries.

Who gets GAD?
Around 5% or more of the general population will suffer from GAD at some point in their lives. The prevalence of the disorder is higher, however, in people who are already visiting a general practitioner.

GAD is also more common in people with another psychiatric disorder, including another anxiety disorder. Finally, GAD is somewhat more common in women than in men.

Most people with GAD say that they have suffered from excessive worrying all their lives; the condition may have an early onset and may continue for many years. Symptoms often worsen during stressful times.

What to do
There are several different medications that can be used for the treatment of generalised anxiety disorder. These include benzodiazepines, buspirone, hydroxyzine and antidepressants.

Benzodiazepines are also known as "tranquilizers". Their major advantage is that they work very quickly to reduce anxious feelings as well as physical symptoms of anxiety. Their major disadvantage is that when people discontinue them, there is often a "rebound" anxiety, with the return of GAD symptoms. Also, benzodiazeoines are not effective for the depressive symptoms that commonly co-occur with GAD. Furthermore, there is an association between the use of benzodiazepines and motor vehicle collisions, due to subtle cognitive impairment.

Buspirone (or Buspar) is the only medication in its particular class. A major advantage of this agent is that it has relatively few side effects; most people with GAD tolerate it very well. Disadvantages of buspirone are that it takes three to four weeks before the agent begins to work, and that it is not effective for the depressive symptoms and other anxiety disorders that are often seen in people with GAD.

Hydroxyzine is a medication that has long been available. Like buspirone, it too can be readily stopped at any point. Hydroxyzine is, however, initially associated with some feelings of sedation. This can be an advantage for some people (e.g. those with insomnia), but it may be a disadvantage for others (e.g. those who need to operate machinery). As in the case of benzodiazepines and buspirone, it is not effective for the depressive symptoms that often co-occur with GAD.

The term "antidepressants" is a very poor one, as these medications are in fact the first choice of medication for many different anxiety disorders. Many of the antidepressants are effective in GAD, and they are also often effective for the depressive symptoms and other anxiety disorders seen together with GAD. Their major disadvantage is that like buspirone, it may take several weeks of daily medication before their positive effect becomes apparent.

Venlafaxine is one of the few antidepressants that is in fact licensed for the treatment of GAD, although other agents are likely to be registered in the future.

Psychotherapy
People with GAD can be seen as viewing the world through a lens which colours everything with negative predictions. Psychotherapy focuses on attempting to change this lens (technically, this is the "cognitive" part of "cognitive-behavioural therapy").

Steps in the cognitive-behavioural therapy of GAD can include self-monitoring and cognitive restructuring. Self-monitoring involves paying closer attention to one's thoughts and feelings. In some ways this is an exposure ("face the fear") technique, but the technique is also useful in demonstrating to oneself the connection between fearful thoughts about the future and feelings of anxiety.

Cognitive restructuring involves providing good counter-arguments which dispel the logic of worry and fear found in GAD. Common cognitive distortions in GAD include probability overestimation, catastrophizing, and all or nothing thinking. Overcoming such distortions may well require the help of a professional.

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