Monday, February 25, 2008
Generalized Anxiety DisorderDefinition
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Generalized anxiety disorder (GAD) is much more than the normal anxiety people experience day to day. Without provoking, it is chronic and exaggerated worry and tension. This disorder involves anticipating disaster, often worrying excessively about health, money, family or work. Sometimes, though, just the thought of getting through the day brings on anxiety.
People with GAD can't shake their concerns, even though they usually realize that much of their anxiety is unwarranted. People with GAD also seem unable to relax and often have trouble falling or staying asleep. Their worries are accompanied by physical symptoms, especially trembling, twitching, muscle tension, headaches, irritability, sweating, hot flashes and feeling lightheaded or out of breath.
Many individuals with GAD startle more easily than other people. They tend to feel tired, have trouble concentrating and may suffer from depression. GAD may involve nausea, frequent trips to the bathroom or feeling like there is a lump in the throat.
GAD affects about 4 million adult Americans and about twice as many women as men. The disorder comes on gradually and can begin at any time, though the risk is highest between childhood and middle age. It is diagnosed when someone spends at least six months worrying excessively about a number of everyday problems, and it is commonly treated with medications. Evidence shows that genes play a modest role in GAD.
GAD rarely occurs alone; it is usually accompanied by another anxiety disorder, depression or substance abuse. These other conditions must be treated along with GAD.
Symptoms
Generalized anxiety disorder (GAD) is characterized by six months or more of chronic, exaggerated worry and tension that is unfounded or much more severe than the normal anxiety most people experience. People with this disorder usually:
Expect the worst
Worry excessively about money, health, family or work, when there are no signs of trouble
Are unable to relax
Are irritable
Suffer from insomnia
Have physical symptoms, such as fatigue, trembling, muscle tension, headaches, irritability or hot flashes
Causes
Like heart disease and diabetes, anxiety disorders are complex and probably result from a combination of genetic, behavioral, developmental and other factors.
Using brain imaging technologies and neurochemical techniques, scientists are finding that a network of interacting structures is responsible for these emotions. Much research centers on the amygdala, an almond-shaped structure deep within the brain. The amygdala is believed to serve as a communications hub between the parts of the brain that process incoming sensory signals and the parts that interpret them. It can signal that a threat is present, thus triggering a fear response (anxiety). It appears that emotional memories stored in the central part of the amygdala may play a role in disorders involving very distinct fears, like phobias, while different parts may be involved in other forms of anxiety.
By learning more about brain circuitry involved in fear and anxiety, scientists may be able to devise more specific treatments for anxiety disorders. It someday may be possible to increase the influence of the thinking parts of the brain on the amygdala, thus placing the fear and anxiety response under conscious control. In addition, with new findings about neurogenesis (birth of new brain cells) throughout life, perhaps a method will be found to stimulate growth of new neurons in the hippocampus in people with severe anxiety.
Studies of twins and families suggest that genes play a role in the origin of anxiety disorders. However, experience also plays a part. In PTSD, for example, while trauma triggers the anxiety disorder, genetic factors may explain why only certain individuals exposed to similar traumatic events develop full-blown PTSD. Researchers are attempting to learn how genetics and experience interact in each of the anxiety disorders -- information they hope will yield clues to prevention and treatment.
Treatment
Medication and specific types of psychotherapy are the recommended treatments for this disorder. The choice of one or the other, or both, depends on the patient's and the doctor's preference, and also on the particular anxiety disorder.
Before treatment can begin, the doctor must conduct a careful diagnostic evaluation to determine whether your symptoms are due to an anxiety disorder, which anxiety disorder(s) you may have, and what coexisting conditions may be present. Anxiety disorders are not all treated the same, and it is important to determine the specific problem before embarking on a course of treatment. Sometimes alcoholism or some other coexisting condition will have such an impact that it is necessary to treat it at the same time or before treating the anxiety disorder.
If you have been treated previously for an anxiety disorder, be prepared to tell the doctor what treatment you tried. If it was a medication, what was the dosage, was it gradually increased and how long did you take it? If you had psychotherapy, what kind was it, and how often did you attend sessions? Oftentimes people believe they have "failed" at treatment, or that the treatment has failed them, when in fact it was never given an adequate trial.
When you undergo treatment for an anxiety disorder, you and your doctor or therapist will be working together as a team. Together, you will attempt to find the approach that is best for you. If one treatment doesn't work, the odds are good that another one will. And new treatments are continually being developed through research.
Antidepressants
A number of medications that were originally approved for treating depression have been found to be effective for anxiety disorders. These must be taken for several weeks before symptoms start to fade, so it is important not to get discouraged and stop taking these medications before they've had a chance to work.
Some of the newest antidepressants are called selective serotonin reuptake inhibitors, or SSRIs. These medications act on a chemical messenger in the brain called serotonin. SSRIs tend to have fewer side effects than older antidepressants. People do sometimes report feeling slightly nauseated or jittery when they first start taking SSRIs, but that usually disappears with time. Some people also experience sexual dysfunction when taking some of these medications. An adjustment in dosage or a switch to another SSRI will usually correct bothersome problems. It is important to discuss side effects with your doctor so that he or she will know when there is a need for a change in medication. Venlafaxine, a drug closely related to the SSRIs, is useful for treating GAD.
Similarly, antidepressant medications called tricyclics are started at low doses and gradually increased. Tricyclics have been around longer than SSRIs and have been more widely studied for treating anxiety disorders. For anxiety disorders other than OCD, they are as effective as the SSRIs, but many physicians and patients prefer the newer drugs because the tricyclics sometimes cause dizziness, drowsiness, dry mouth, and weight gain. When these problems persist or are bothersome, a change in dosage or a switch in medications may be needed. Tricyclics are useful in treating people with co-occurring anxiety disorders and depression. Imipramine, prescribed for panic disorder and GAD, is an example of such a tricyclic.
Antianxiety Medications
High-potency benzodiazepines relieve symptoms quickly and have few side effects, although drowsiness can be a problem. Because people can develop a tolerance to them -- and would have to continue increasing the dosage to get the same effect -- benzodiazepines are generally prescribed for short periods of time. People who have had problems with drug or alcohol abuse are not usually good candidates for these medications because they may become dependent.
Some people experience withdrawal symptoms when they stop taking benzodiazepines, although reducing the dosage gradually can diminish those symptoms. In certain instances, the symptoms of anxiety can rebound after stopping medication. Potential problems with benzodiazepines have led some physicians to shy away from using them, or to use them in inadequate doses, even when they are of potential benefit to the patient. Alprazolam is a benzodiazepine that is helpful for panic disorder and GAD.
Buspirone, a member of a class of drugs called azipirones, is a newer antianxiety medication that is used to treat GAD. Possible side effects include dizziness, headaches and nausea. Unlike the benzodiazepines, buspirone must be taken consistently for at least two weeks to achieve an antianxiety effect.
Other Medications
Beta-blockers, such as propanolol, are often used to treat heart conditions but have also been found to be helpful in certain anxiety disorders, particularly in social phobia. When a feared situation, such as giving an oral presentation, can be predicted in advance, your doctor may prescribe a beta-blocker to keep your heart from pounding, your hands from shaking and other physical symptoms from developing.
Psychotherapy
Psychotherapy involves talking with a trained mental health professional, such as a psychiatrist, psychologist, social worker or counselor to learn how to deal with problems like anxiety disorders.
Cognitive-Behavioral and Behavioral Therapy
Research has shown that cognitive-behavioral therapy (CBT), a form of psychotherapy, is effective for several anxiety disorders, particularly panic disorder and social phobia. It has two components. The cognitive component helps people change thinking patterns that keep them from overcoming their fears. For example, a person with panic disorder might be helped to see that his or her panic attacks are not really heart attacks; the tendency to put the worst possible interpretation on physical symptoms can be overcome. Similarly, a person with social phobia might be helped to overcome the belief that others are continually watching and harshly judging him or her.
The behavioral component of CBT seeks to change people's reactions to anxiety-provoking situations. A key element of this component is exposure, in which people confront the things they fear. Another behavioral technique is to teach the patient deep breathing as a relaxation aid.
Behavioral therapy alone, without a strong cognitive component, has long been used effectively to treat specific phobias. Here also, therapy involves exposure. The person is gradually exposed to the object or situation that is feared. At first, the exposure may be only through pictures or audiotapes. Later, if possible, the person actually confronts the feared object or situation. Often the therapist will accompany him or her to provide support and guidance.
If you undergo CBT or behavioral therapy, exposure will be carried out only when you are ready; it will be done gradually and only with your permission, and you will work with the therapist to determine how much you can handle and at what pace you can proceed.
A major aim of CBT and behavioral therapy is to reduce anxiety by eliminating beliefs or behaviors that help to maintain the disorder. For example, avoidance of a feared object or situation prevents a person from learning that it is harmless. Similarly, performance of compulsive rituals in OCD gives some relief from anxiety and prevents the person from testing rational thoughts about danger, contamination, and so forth.
To be effective, CBT or behavioral therapy must be directed at the person's specific anxieties. An approach that is effective for a person with a specific phobia about dogs is not going to help a person with OCD who has intrusive thoughts of harming loved ones. CBT and behavioral therapy have no adverse side effects other than the temporary discomfort of increased anxiety, but the therapist must be well trained in the techniques of the treatment in order for it to work as desired. During treatment, the therapist probably will assign homework -- specific problems that the patient will need to work on between sessions.
CBT or behavioral therapy generally lasts about 12 weeks. It may be conducted in a group, provided the people in the group have sufficiently similar problems. Group therapy is particularly effective for people with social phobia. There is some evidence that, after treatment is terminated, the beneficial effects of CBT last longer than those of medications for people with panic disorder; the same may be true for OCD, PTSD and social phobia.
For many people, the best approach to treatment is medication combined with therapy. As stated earlier, it is important to give any treatment a fair trial. And if one approach doesn't work, the odds are that another one will.
If you have recovered from an anxiety disorder, and at a later date it recurs, don't consider yourself a treatment failure. Recurrences can be treated effectively, just like an initial episode. The skills you learned in dealing with the initial episode can be helpful in coping with a setback.
Sources:
Archives of General Psychiatry
National Institute of Mental Health Anxiety Disorders
British Journal of Psychiatry Supplement
Psychiatric disorders in America: the Epidemiologic Catchment Area Study
Last Reviewed: 2 Nov 2005
Last Reviewed By: Laura Stephens
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