Everyone experiences concerns and worries from day to day. When a problem arises a person might worry about how they will deal with the problem and what the outcome might be. However, some people worry excessively about a number of routine events or activities for a good part of each day for months on end.

Typical worries for people suffering from Generalised Anxiety Disorder (GAD) may include the possibility of a loved one becoming ill or having an accident, excessive concerns about financial circumstances or preoccupying worries about performance at work or in front of others. For these people their worries seem to be uncontrollable and subsequently produce significant anxiety, distress and interfere with everyday living.

Some of the symptoms associated with generalised anxiety include:

Feelings of nervousness or restlessness
Feeling on edge or being easily startled
Becoming easily fatigued
Difficulties in concentration and memory
Increased irritability
Tense and aching muscles
Problems falling and staying asleep

How is GAD different from normal worrying?

As mentioned previously, each person worries from time to time about aspects of their life circumstances. Most people worry about the same sort of things, so it is not the content of the worries that are a distinguishing feature of GAD. The type of worrying that is a core feature of GAD does differ in a variety of ways. For people suffering from GAD:

Worries seem uncontrollable and cannot be put off until a later time (i.e. preoccupying)
Worries are persistent, prominent as well as distressing, and are of longer duration
Worries are accompanied by physical symptoms of anxiety
Worries take up more time than is warranted by their importance or the chances of the event eventuating

The most defining feature of GAD is that it results in a person feeling significantly distressed and can impair their ability to live their daily lives.

What impact can GAD have on life?

Difficulty making decisions
Withdrawal from family and friends
Increased stress at work which can result in time off
Difficulty completing daily tasks
Procrastination which results in feeling overwhelmed
Fatigue due to lack of sleep or exhaustion associated with continual anxiety
Avoidance of situations that generate worry and anxiety

Case Example: Andrew and his worries

Andrew is a single 26 year old studying at university. Andrew, like his mother, has always been a worrier and frequently becomes anxious over what other people seem to consider to be the smallest of things, making him feel hot, sweaty and nervous. However, of late, his anxiety symptoms have become increasingly problematic, particularly since he started university, which he is finding stressful. Andrew often worries that certain misfortunes will happen to him and subsequently he spends much of his time over-planning everything in his life, so as to prevent such a disaster from occurring. He has trouble in making decisions as he worries about the impact his decision will have on other people and what they will think of him. He is currently finding it difficult to concentrate on his university studies as his worries and concerns just go round and round in his head and no matter how hard he tries, he just can’t distract himself from them. His worrying has gotten to the extent where he finds it difficult to get to sleep at night and subsequently is tired all day. He has frequent headaches and his muscles always feel tense.

Who is affected by GAD?

GAD affects 3.1% of people in Australia, making it one of the most common anxiety disorders (ABS, 1997)
GAD appears to affect females at a rate double to that of males (Roemer, Orsillo & Barlow, 2002)
Symptoms of GAD can develop at any age; however, onset usually occurs between the ages of 20 and 30 years
Although GAD can affect people of all cultures, the way in which anxiety manifests itself across specific cultures is different. For example, some cultures express anxiety predominately through physical or somatic symptoms whereas others primarily through their thoughts. The material that people worry about is also likely to vary according to the culture in which they live

The causes

There is no single cause or pathway through which GAD develops. Nevertheless research has implicated a number of important factors that appear to play an important role in the development of generalised anxiety. These include both biological and psychological factors.

Biological factors

Although no single gene has been associated with GAD, familial studies suggest that people may inherit a biological vulnerability to anxiety disorders like GAD.
In addition research suggests that anxiety disorders in general as well as GAD may be linked to the neurotransmitter, serotonin, a chemical in the brain.
Many individuals that are diagnosed with GAD report that they have felt anxious and nervous for most of their lives, suggesting that personality type or temperament is likely to play an important role in the development of this condition.

Psychological factors

Whilst biological factors may increase a person’s vulnerability or risk of developing GAD, life circumstances, such as levels of stress and how a person copes with stress are also important. In particular, worry and subsequent anxiety symptoms appear to be triggered during times of stress.

Stressful, traumatic and uncontrollable life events can lead some people to believe that the world is dangerous and unpredictable. Therefore as a way of coping people tend to worry about possible future negative events, believing this will help them to be more prepared should the event occur.
People also develop anxiety as a result of information passed on by other people regarding what is threatening and ways to cope with such threats. For example, as a child, a person may have observed a parent constantly worrying about life circumstances. In addition, a person may have been brought up with the message that dwelling on potential problems is a good thing in that it is part of being a prepared person.

How might GAD change over time?

The symptoms of GAD are considered to be chronic in that they can last for long stretches of time, sometimes with short periods of remission.
Most people that suffer from GAD report continuous symptoms from the initial time of onset; however, 25% of people experience periods of remission for three months or more (DSM-IV, 2000).
GAD appears to develop gradually with fluctuations of severity over the course of a person’s life. These fluctuations are often associated with periods of stress.

What does treatment involve?

Both pharmacological and psychological treatments have been proven to be effective in the treatment of GAD; however, they target different components of the illness. Whilst pharmacological treatments are useful in reducing the physical symptoms, psychological treatments address the abnormal thought processes of GAD. For this reason these treatments may be useful in combination. Different psychological approaches to treatment of GAD is discussed further below.

Psychological Treatment

Cognitive Behavioural Therapy (CBT)

Scientific research indicates that CBT is an effective treatment for GAD (Brown & Schulberg, 1997). Specifically, individuals that have engaged in CBT have been reported to achieve greater symptom relief than those that have not engaged in CBT, or are receiving a non-directive type of therapy e.g. supportive, non-directed counselling. Additionally, the effects produced by CBT are comparable to the symptoms relief provided by some anti-anxiety medications for some people.

As GAD is characterised by excessive worry and the symptoms that result from such, the focus of CBT therefore is on reducing these disabling thought processes and enabling the person to reduce hyperarousal and muscle tension.

CBT for GAD consists of five basic components:

Education specifically related to GAD and detailed treatment information.
Cognitive restructuring of unhelpful thinking styles related to the nature, process and consequences of anxiety and worry to achieve more balanced thought processes.
Individuals are also taught skills in the assessment of risk, probability checking and problem solving.
Relaxation training and controlled breathing targets the physical effects of anxiety including physiological arousal and muscle tension.
Gradual and repeated exposure to worries provides individuals with the opportunity to implement the new skills they have learnt to control anxiety and gain confidence in doing so.

The length of Cognitive Behavioural treatment is highly individual and depends upon a number of factors including symptom severity. Generally, CBT consists of 12 to 20 one hour sessions. The specific time frame for therapy, as well as individual goals, are discussed with the individual during their first CBT session. Group treatment is also an option, rather than individualised treatment.

Pharmacological Treatment

Benzodiazepines

The drugs that belong to this category are more commonly known as tranquilisers or anti-anxiety (anxiolytic) agents. Valium (diazepam) is one of the more well-known types of benzodiazepine, but the category also includes Xanax, Ativan and Serepax, to name a few. Despite the effectiveness of benzodiazepines, these should be considered to be a source of short-term support rather than a long term solution. Although benzodiazepines are effective in providing short term relief from symptoms, they are highly addictive and damaging if used on a long-term basis.

Azapirones

Azapirones are thought to reduce anxiety symptoms by enhancing the activity of serotonin, a chemical found in the brain that has been linked to anxiety disorders. Azapirones such as BuSpar have produced impressive results in the treatment of GAD without many of the negative consequences associated with benzodiazepines, including less sedation as well as reduced potential for dependence. Having said this, as with virtually all medications, side effects do occur.

Antidepressants

Antidepressant medications such as the Selective Serotonin Reuptake Inhibitors (SSRI’s) and tricyclic antidepressants (TCAs) are commonly used in the treatment of GAD. These medications are believed to work by altering the concentration and activity of a particular neurotransmitter, serotonin, a chemical in the brain which has been linked to anxiety disorders (as well as depression and schizophrenia). Like the azapirones, their effects are not as rapid as those produced by benzodiazepines; however, they are equally effective in reducing anxiety symptoms.

If you are currently taking medication it is important that you continue to take the prescribed dose at the appropriate times, on good days and bad days. This medication will help you to prevent future episodes and relapse.

If you are concerned about medication side effects and wish to change or stop taking you medication it is important that you discuss this with your doctor before taking any action. This is important as some medications must be stopped gradually in order to protect the person from dangerous side effects.

What can I do to help myself?

If you have read this brochure and feel that the information in it is relevant to you then it is important that you seek the appropriate help. This can be done by:

Arranging to see a clinical psychologist at Sentiens where a thorough assessment can be conducted and an individual treatment plan developed.
Talking to one of the Mental Health Professionals at Sentiens about Sentiens Group Programs that are most suitable for you.
Organising a consultation with your doctor or psychiatrist.
You may consider local support groups running in your community where you can meet other people experiencing similar difficulties to yourself.
Some people find self-help books to be a valuable resource. Self help books can be used in isolation or in combination with another form of treatment. Some self-help resources that are relevant for people with GAD are listed below.

Expectations for the future

Every person has ups and downs in their lives. This also applies to the recovery process from GAD. After engaging in treatment a person may feel like they have put their worries and anxiety behind them. However, later down the track these symptoms may re-emerge. In reality, research indicates that 60 to 80% of people who have received drug treatment for GAD will experience a relapse in symptoms within 1 year (Gliatto, 2000). As discussed earlier in the brochure this is more likely occur at times of intense stress. This statistic indicates the need for continuing treatment, with an emphasis on continual monitoring and psychological therapy. In severe cases, medication may need to be continued indefinitely, especially if the person has had several major episodes of anxiety.

CBT for GAD is devoted to developing a plan to put in place in which early warning signs of returning anxiety are identified earlier, and responded to, with a predetermined plan for managing these symptoms, with the aim of preventing their escalation. However, sometimes a person may feel that they need some assistance in managing their symptoms. At this stage the person may contact their clinician and request CBT “booster sessions” in which they can gain some extra support and polish up on the skills they learnt previously.

Websites

Mental Health Association - http://www.mentalhealth.asn.au

Gliatto, M. (2000). Generalised anxiety disorder. American Family Physician, 62 (7), 1591-1602.

Government HealthInsite - http://www.healthinsite.gov.au

Clinical research unit for anxiety and depression http://www.crufad.com/cru_index.htm

Anxiety Disorders Alliance - http://ada.mentalhealth.asn.au/

References

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed.) Text revision. Washington, DC: American Psychiatric Association.

Andrews, G. (2003). Worry and Generalised Anxiety Disorder. Retrieved 13 December, 2005 from, http://www.curfad.com/self_help/generalanxiety.htm.

Australian Bureau of Statistics. (1997). Mental health and well-being: Profile of adults. Canberra: Australian Bureau of Statistics.

Brown, C., & Schulberg, H. C. (1997). Depression and anxiety disorders: Diagnosis and treatment in primary care practice. In S. J. Gallant, & G. P. Keita (eds.). Healthcare for women: Psychological, social and behavioural influences. Washington, DC: American Psychiatric Association.

Thompson, R. J., & Van Loon, K. J. (2002). Mental disorders. In T. J. Boll, & S. B. Johnson (eds.). Handbook of clinical health psychology – Volume 1: Medical disorders and behavioural applications. Washington, DC: American Psychiatric Association.

Roemer, L., Orsillo, S. M., & Barlow, D. H. (2002). Generalised Anxiety Disorder. In D. H. Barlow (Ed.). Anxiety and its disorders: The nature and treatment of anxiety and panic. NY: Guilford Press.

World Health Organisation. (2000). Management of mental disorders: Volume 1 (3rd ed.). Sydney. World Health Organisation.

Sentiens Health

Generalized Anxiety Disorder