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NIH

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Generalized Anxiety Disorder

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Persistent, excessive anxiety and worry about various events or activities, including work and school performance, that the individual finds it difficult to control.

The intensity, duration, or frequency of the anxiety/worry is disproportionate to the event.
(American Psychiatric Association, 2013).

People with GAD often report distress due to constant worry, along with impairments in social, occupational, or other areas of functioning. They also report that they have felt anxious all their lives.

GAD is one of the most common anxiety disorders in the general population
(Spitzer et al. 2006)

The core symptom of GAD is chronic worrying
Smith & Segal, 2020).

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A. Severe anxiety or worry about various events or activities, which occurs most days and lasts for at least 6 months.

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

C. At least three of the following symptoms are associated with anxiety and worry

Muscle tension

Restlessness

Fatigue

Difficulty concentrating

Sleep disturbance

Irritability/on edge

**Only one of these symptoms is required in children

D. The anxiety/worry/physical symptoms cause significant distress or impairments in aspects of life and areas of functioning

E. The disturbance is due to the effects of substance use or another medical condition

D. The disturbance can not be explained by any other mental disorder

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People are generally diagnosed with GAD around age 30.

Some instruments, such as the Hamilton Rating Scale for Anxiety, are useful for recording and quantitating the severity of symptoms but are not diagnostic assessments. A structured clinical interview makes a formal diagnosis.

Symptoms of anxiety are easily detected, but it is the interpretation that is difficult. The relationship between anxiety and depressive symptoms makes it especially challenging for the clinician to form a diagnosis.  (Tyrer &Baldwin, 2006)

One may experience:

Trembling, twitching, shakiness, and muscle aches or soreness associated with muscle tension.

Somatic symptoms such as sweating, nausea, and diarrhea

Exaggerated startle reaction

Autonomic hyper-arousal such as accelerated heart rate, shortness of break, and dizziness are less prominent than other anxiety disorders.

Irritable bowel syndrome, headaches, or other conditions associated with stress

Differential diagnosis can include:

Anxiety disorder due to another medical condition

substance/medication-induced anxiety

Social anxiety disorder

Obsessive-compulsive disorder

Posttraumatic stress disorder

Depressive, bipolar, and psychotic disorders

https://monkeysee.com/diagnosing-generalized-anxiety-disorder/

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GAD usually begins at an earlier age, and symptoms usually manifest slower than in most other anxiety disorders, which is why GAD isn't usually diagnosed until later.

GAD has many manifestations; not all who have GAD experience the same symptoms, but most people experience a combination of emotional, behavioral, and physical symptoms, which overlap with other mental health disorders.

People with GAD may:

Worry excessively about everyday things

Have difficulty controlling their feelings of nervousness or worries

Be easily startled

Have a hard time swallowing/feel a lump in their throat

Sweat a lot/have hot flashes

feel lightheaded or out of breath

Tremble or twitch

Experience headaches, muscle aches, unexplained pain, GI issues

DSM-5 Symptoms:

Restlessness

Easily fatigued

Difficulty concentrating/ drawing a blank

Irritability

Muscle tension

Sleep disturbance

Symptoms tend to be chronic,
but may fluctuate, becoming worse during times of stress.

Onset rarely occurs prior to adolescence
(Beesdo et al. 2010, as cited American Psychiatric Association, 2013).

Expression of worry symptoms differs across cultures. Some people may express more behavioral/emotional symptoms(fear or avoidance), whereas others may experience more physical symptoms(muscle tension or stomach aches).
(American Psychiatric Association,2015).

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According to the DSM-5, "clinical expression of generalized anxiety disorder is relatively consistent across the lifespan."

Children/adolescents generally worry more about the quality of their performance in school or sports(even when no one is evaluating their performance). They may also worry excessively about catastrophes(e.g., earthquakes or war).
Adults tend to worry about everyday situations such as their personal health and the health wellbeing of their family, finances, household responsibilities.

The severity of symptoms is greater in younger adults.

(Wolitzky-Taylor et al. 2010, as cited in by American Psychiatric Association, 2013).

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Generalized anxiety disorder (GAD) - causes, symptoms & treatment

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Children with GAD show symptoms in the following ways.

Overly perfectionist or insecure

Tend to "redo tasks because of excessive dissatisfaction with less-than-perfect performance"(American Psychiatric Association, 2013).

Seek reassurance and approval

Require excessive reassurance about their performance

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GAD is a relatively new disorder. It was previously classified as anxiety neurosis.
Anxiety neurosis was first explained by Freud in 1894, characterized as “persistent feelings of unattached fearfulness described as free-floating anxiety.”

Anxiety neurosis also included symptoms of panic before panic disorder was identified as a separate disorder.
GAD became the classification for anxiety neurosis that did not include panic; however, since there were not defining features and substantial overlap with other disorders, “it became a residual diagnosis for anxiety disorders that had no other diagnosis.”

Some professionals still argue that GAD is ill-defined, and it was almost excluded from the DSM-IV due to suggested issues with diagnostic reliability.

GAD symptoms have always consisted of generalized, persistent, and excessive anxiety, along with a combination of various psychological and somatic complaints.

(Tyrer &Baldwin, 2006)

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GAD may be over-diagnosed in children. Therefore, to receive a diagnosis, a thorough examination must rule out other childhood anxiety disorders or mental disorders that could explain one's worries.

**separation anxiety, social anxiety, and obsessive-compulsive disorder share similar worries in children (e.g., children with social anxiety may also worry about school performance).

According to DSM-5 criteria, for children to be diagnosed with GAD, they only need to present one of the six symptoms.

(American Psychiatric Association, 2013)

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The risk for developing GAD is highest between childhood and middle age.

There is no known exact cause, but evidence suggests a complex set of risk factors such as genetics, brain chemistry, life experiences, and personality/temperament.
There may be a correlation between the personality trait neurosis and the development of GAD.

One-third of the risk is due to genetic factors
(American Psychiatric Association, 2013).

Researchers have found associated biological processes in the brain, which may play a role in anxiety and fear.

GAD can be considered a precursor for developing other disorders, either associated disorders such as depression or secondary disorders such as alcohol dependence.
(Tyrer &Baldwin, 206)

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Occasional anxiety, worry, or fear are normal aspects of life. Many people may worry about health and finances or an upcoming exam or deadline, but people with GAD may take this to the next level so that their worries become extreme, constant, exaggerated, and difficult to control. People with GAD also anticipate disaster or worry excessively about minor, everyday things, which interferes with daily functioning and impacts relationships.
Just the thought of getting through the day may cause anxiety.

The difference between "normal" worry and GAD is that the worrying associated with GAD is:

Excessive
Intrusive
Persistent
Disruptive

(Smith, M. & Segal, 2020)

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What distinguishes GAD from other Anxiety disorders?

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What distinguishes GAD from other Anxiety disorders?

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Anxiety disorders tend to be comorbid, and GAD symptoms overlap greatly with other disorders.

The median age of onset is 30 years—later than that for other anxiety disorders.

Anxiety disorders can be differentiated based on situations that invoke fear or avoidance behaviors.  The anxiety one with GAD experiences is not as intense as a panic attack(although someone with GAD can experience a panic attack.

The anxiety of GAD is diffused—a general feeling of dread or unease that colors your whole life. (Smith & Segal, 2020).

Adults with GAD often worry about circumstances around everyday life(e.g., health, misfortune to children, job responsibilities, finances) or minor matters (e.g.,  being late for appointments or household chores). In contrast, children with GAD often experience excessive worry about their competence in performance.
Through the duration of the disorder, the focus of concern may shift.
(Tyrer & Baldwin, 2006)

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Scenario 1: a

Patient complains that her whole body aches, her heart beats fast, “Pounds like it's going to burst.”

Can't catch her breath

Chest tightness

Tense for no reason at work and at home

Worries a lot—about everything “never know when something bad is going to happen…like her husband getting hurt or children making a bad choice.”

Gets easily upset

Can't sit still

Finds it hard to work—can’t concentrate.

More than just worries—feels like she is going crazy.

Scenario 2: b

Patient worries excessively: Are the kids dressed right for school or why is her husband late.. “usual things.”

Worries all day long, almost every day

Experiences strong feelings worrying about little things: becomes paralyzed, will “collapse on the couch with fear,” start shaking.

Hasn't been in the office for nine months due to excessive worrying

Acknowledges that she doesn’t worry about big things like cancer or heart attacks.

Restless—can’t sit still.

Feels "on edge."

Never had a panic attack

Low energy—exhausted

Mind goes blank

a Generalized anxiety disorder. (2012).[Video/DVD] Symptom Media.

b Core video: Generalized anxiety disorder, part 1. (2018).[Video/DVD] Symptom Media.

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There is a high comorbidity of anxiety and depressive disorders.

When someone meets the criteria for GAD, they are likely to meet the criteria for other anxiety disorders and unipolar depressive disorders, which all share patterns of neurosis and emotional lability.

GAD and depression symptoms co-occur but have “differing but independent effects on functional impairment and disability.”
(Spitzer, Kroenke, Williams & Löwe, 2006, pg. 1092)

GAD and major depression share social, occupational, and economic burdens. (Tyrer & Baldwin, 2006)

In females, comorbidity includes anxiety disorders and unipolar depression.
In males, comorbidity includes substance use disorders in addition to anxiety disorders and depression.

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Coping strategies

Get plenty of sleep

Eat healthy, well-balanced meals

Limit consumption of alcohol and caffeine

Count to 10, slowly and repeat if necessary

Embrace humor--laughing is healing.

Learn the triggers

Talk to someone

Accept what you cannot control.

Exercise daily

Replace negative thoughts with positive ones

Look at your worries from a different perspective--engage in realistic thinking.

Do your best, without aiming for perfection (since it is not possible)

Learn how to calm down quickly by  making use of one or more of your physical senses

1. Sight

2. Sound

3. Smell

4. Taste

5. Touch

6. Movement

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According to the Anxiety and Depression Association of America,
Anxiety disorders are the most common mental illness in the U.S., affecting 18.1% of U.S adults and 25.1% of children ages 13-18 years old.

GAD affects an estimated 6.8 million adults(3.1% of the population). Only 43.2% of those affected receive treatment.

GAD is more prevalent among adults and the most common anxiety disorder among older adults.

Females are 2x more likely to experience GAD compared to their male counterparts.

Prevalence and diagnosis peaks in middle age.

Those of European descent are more likely to experience GAD than individuals of non-European descent.

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A wonderful talk by Olivia Remes about anxiety: she explains why it is important to differentiate between normal anxiety and an anxiety disorder.

"They way you cope, or handle things, has a direct impact on how much anxiety you are experiencing"

She offers some coping skills that can lower anxiety:

1. Feeling in control of your life.

2. Forgiving yourself

3. Having purpose and meaning in life-- "you will know the why for your existence and will be able to bear almost and how."

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How to cope with anxiety | Olivia Remes | TEDxUHasselt

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We can't control our anxiety but we can control how we react to it

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We can't control our anxiety but we can control how we react to it

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Neil Hughes provides some humor as he speaks about his life with GAD and how he overcomes his daily anxiety. He explains how our habits are are invisible to us, which may account for why many people with anxiety don't seek help. It is important to observe our patterns of thinking and behavior so we can choose how we are going to react. He calls this mind management.

"we have to do the work ourselves to understand what is going on inside of us"

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A new plan for anxious feelings: escape the custard! | Neil Hughes | TEDxLeamingtonSpa

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GAD is treatable!

Treatment for anxiety disorders usually consists of therapy or medications, or a combination of both.

Therapies work on altering one's relationship with their symptoms, helping people understand the nature of their anxiety, reducing the associated feelings of fear, and learning coping mechanisms.

Psychotherapy(talk therapy)

Cognitive Behavioral Therapy (CBT): targets thoughts, physical symptoms, and behavior

Mindfulness-related Therapy

Acceptance Commitment Therapy

Medication

Antidepressants: Selective serotonin reuptake inhibitors(SSRIs) and Serotonin-norepinephrine reuptake inhibitors (SNRIs)

Anti-anxiety: Benzodiazepines(for severe, paralyzing anxiety) and Buspirone.

Relaxation and healthy lifestyle habits
Yoga, meditation, massage, and exercise

There is no cure for GAD. According to Tyrer & Baldwin(2006), since GAD has a "relapsing course," CBT and pharmacological treatment helps in the short and medium-term but do not completely resolve symptoms. Relapse may be less common after stopping CBT than drug treatments.

Since GAD is a chronic illness, treatment should be given long-term. Current guidelines recommend CBT and SSRI as first-choice treatments and regular monitoring.

https://monkeysee.com/treatment-for-generalized-anxiety-disorder/

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Treatment for Generalized Anxiety Disorder

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A 2007 longitudinal study suggests that “work stress was related to a twofold risk of major depression or generalized anxiety disorder compared to those with tout the same job demands, even in people who were previously healthy.” Therefore, it is helpful to learn coping mechanisms to minimize stress from work.

People with GAD are generally good at gathering information and investigating problems, and the best careers for people with GAD should build on these strengths.

Ideal careers involve work that:

Engages you mentally so that your mind doesn't wander and worry

Separates you from the causes of your anxiety

Employs your information-gathering skills

While the following careers are not exactly low stress, they will keep you interested, engaged, and may even serve as "good stress."

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CBT is an evidence-based treatment that is particularly effective in the treatment of GAD.
CBT is a form of psychotherapy that focuses on helping an individual change their thinking and behavior patterns by examining "distortions in our ways of looking at the world and ourselves"(smith & Segal, 2020)

For example, if one worries excessively about making lunch for their child and "catastrophize" by imagining the worst possible outcome, you can learn to challenge this thought by answering questions such as:
"What is the likelihood that this worst-case scenario will actually happen?"
"What will happen if this worst-case scenario were to happen? Is it the end of the world?"
"What are some positive outcomes that are most likely to happen?"

Upon a clinical assessment and diagnosis, a provider will create short and long-term objectives and a plan of action to help reduce worry and improve thinking habits.
CBT includes five components:

1. Education

2. Monitoring

3. Physical control strategies

4. Cognitive control strategies

5. Behavioral strategies

CBT can include self-monitoring thoughts/feelings/behaviors, relaxation training, visualization, exposure therapy, breathing exercises, and strategies to refocus worries, challenge negative thoughts, and engage in self-worth building activities.

(Cynthia Kay and Company, 2011; Smith & Segal, 2020).

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There is a high prevalence of anxiety disorders.

Kessler et al. (2012) determined a 12-month prevalence in the U.S to be 0.9% among adolescents and 2.9% among adults or 6.8 million people.
(American Psychiatric Association, 2013)

According to the National Institute of Mental Health(NIH):
Past year Prevalence(2001-2003)

2.7% of US adults  18 years or older had GAD

Prevalence higher in females(3.4%) than males (1.9%)

Degree of impairment ranged from mild to serious with an estimated 32.3% serious impairment, 44.6% moderate impairment, and 23.1% mild impairment

Lifetime Prevalence

2.2% of U.S adolescents aged 13-18 have had GAD

0.9% had severe impairment(determined by DSM-IV)

Higher prevalence among adolescent females (3%) than for males(1.5%)

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Children will experience many of the same symptoms as adults, along with the following "red flags" for GAD in children.

“What if” fears about situations far in the future

Perfectionism, excessive self-criticism, and fear of making mistakes

Feeling that they’re to blame for any disaster, and their worry will keep tragedy from occurring.

The conviction that misfortune is contagious and will happen to them

Need for frequent reassurance and approval

(Smith & Segal, 2020)

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Behavioral, Emotional, Physical symptoms of GAD

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Behavioral, Emotional, Physical symptoms of GAD

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BEHAVIORAL

Difficulty relaxing or sitting still/enjoying quiet time.

Difficulty focusing

Putting things off/avoiding things due to feeling overwhelmed

Avoiding situations that trigger anxiety

EMOTIONAL

Neverending worries

Uncontrollable anxiety--feeling there is nothing you can do to stop worrying.

Intrusive thoughts

Difficulty tolerating uncertainty

A pervasive feeling of apprehension or dread

PHYSICAL

Muscle tightness, body aches, tension

Difficulty falling asleep or staying asleep.

Feeling on edge/jumpy.

Stomachaches, nausea, diarrhea

Palpitations, dry mouth, sweating

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There is a lack of valid and brief measures for anxiety compared with the various measures for depression. While GAD is one of the most common mental disorders, there isn't a brief clinical measure for assessing it. In a 2004-2005 study, Spitzer et al. (2006) developed a brief self-report scale to identify cases of GAD and assess the severity of symptoms.  There study concluded that GAD-7 is a valid and efficient screening and assessment tool.

GAD-7 is a 7-item anxiety scale.

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References

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A brief and effective screening tool for GAD