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Generalized Anxiety Disorder
Behavioral Health Update
BHSI Newsletter Vol. 1, No. 1
Generalized Anxiety Disorder
Patricia Kraemer, MA, LP

Generalized anxiety disorder (GAD) is marked by excessive, uncontrollable, and unrealistic worry about a number of events or activities. Diagnosis requires that the person has worried more days than not for at least 6 months and that the worry has been associated with significant distress or impaired functioning. Moreover, while the person is worrying, he or she must be typically experiencing three of six symptoms (restless/keyed-up/on-edge, easily fatigued, difficulty concentrating, irritability, muscle tension, and sleep disturbance). GAD is a common and disabling problem that has a lifetime prevalence rate of about 5%.

Anxiety and worry are a normal part of life and most people will worry at least a little bit about how things will turn out. Not only is anxiety a common human emotion, but moderate amounts of anxiety can be helpful by motivating people to prepare for an exam, complete a work assignment, or deliver an energized speech. But excessive anxiety is more than butterflies in your stomach. It is a real, medical illness that can disrupt people’s lives, interfere with performance, and trigger physical discomforts. When persistent and unrealistic worry becomes a habitual way of approaching situations, an individual may be suffering from GAD. Experts believe GAD is probably caused by a combination of biological factors and life events. In fact, many people who have GAD also have other medical disorders, such as depression and/or panic disorder, that seem to be influenced by certain neurotransmitters in the brain, such as serotonin. Some researchers believe that its early onset, chronicity, and resistance to change provide evidence that GAD may be the basic anxiety disorder out of which additional anxiety disorders commonly arise.

Assessment and Associated Features?

GAD can be hard to diagnose. It lacks the obvious symptoms of a panic attack or an anxiety response to a traumatic experience or specific stimulus. Its physical symptoms are typical of many other disorders, and these individuals often suffer from other physical ailments and concomitant symptoms. As a primary diagnosis, GAD has a high rate of concurrence with axis I and II conditions. The most common comorbid axis I conditions are social phobia, simple phobia, panic disorder, major depression, dysthymia, and somatoform disorders. The most common comorbid axis II conditions occur in clusters B and C.
Persons with GAD report that they have been worriers their whole lives. As a result, they may fail to fully process the negative impact of their current worry-related symptoms. Clients with GAD often initially deny that worrying impairs their functioning. Such clients are so used to worrying that they are able to function fairly well and accomplish various tasks throughout their day. Therefore, when assessing impaired functioning, it is often helpful to ask about the impact of specific GAD symptoms such as sleep disturbance, diminished concentration, muscle tension, and feeling tired all the time. Such a focus often reminds clients that they could probably function much better in the absence of these symptoms.

Another feature that may contribute to low diagnostic reliability is a desire to be perfect, which is common?
in persons with GAD.

Complications and Treatment Implications?

One secondary effect of GAD symptomatology is avoidance of the experience and expression of emotions. Research suggests that worry (the central feature of GAD) may actually function to help clients avoid processing their emotions, and such avoidance may negatively reinforce the worry process. In fact, many GAD clients report discomfort with their emotions and a desire to avoid them. For this reason, clinicians may want to view avoidance of emotions as similar to other types of avoidance; working with clients experientially to help them process their emotions. The mechanism of change is believed to be similar to that of exposure to other feared situations.
Another effect of GAD symptoms is problematic interpersonal functioning. Persons diagnosed with GAD tend to have a high rate of comorbid axis II disorders and interpersonal problems. Clinical experience suggests that many of these interpersonal problems arise from the tendency of persons with GAD to continually focus on and avoid any and all perceived potential threats. Potential threats may include feeling that others do not like them and feeling emotionally vulnerable in front of others. Attempts to avoid such threats typically lead to withdrawn, self-absorbed, and distracted interpersonal behavior. Moreover, because their attention is focused primarily on subtle avoidance to keep them safe, persons with GAD fail to notice the impact of their behavior on others. This tendency can lead to the appearance that the person suffering from GAD is devoid of empathy.

Treatment Conceptualization?

GAD is a disorder that is believed to result from a hypervigilance toward external threat. Such hypervigilance leads to habitual cognitive, behavioral, and physiological responses to internal and external cues. Each response feeds on the response before it escalating into intensified anxiety and worry. To reverse this process, cognitive-behavioral therapy (CBT) for GAD targets cognitive, behavioral, and physiological responses by teaching clients new adaptive strategies to replace maladaptive ones. Such strategies include cognitive restructuring, breathing retraining or respiratory control, progressive muscle relaxation, self-control desensitization, and targeting any subtle behavioral avoidance. CBT is considered the gold standard treatment for GAD and is the only therapy that is empirically supported. CBT leads to clinically significant change in about half to two-thirds of those treated. When CBT is combined with an appropriate anti-anxiety medication, 75 to 90 percent of GAD sufferers are helped by treatment.