Generalized Anxiety Disorder

Background/Definition/Epidemiology

Humans have a natural response to survival, stress and fear. Such responses enable an individual to pursue pertinent objectives and respond accordingly to the presence of danger. The ‘flight or fight’ response in a healthy individual is provoked via a real challenge or threat and is utilized as a means of acting appropriately to the situation. However, when an anxiety disorder manifests in someone, then an inappropriate/excessive state of arousal develops. People then feel symptoms of fear, apprehension, or uncertainty. These feelings or reactions may surface even when no real threat exists.

Generalized Anxiety Disorder (GAD), is a common anxiety disorder that affects roughly 5% of the United States general population. “GAD is commonly associated with psychiatric and medical comorbidities and is often chronic. GAD is associated with extensive psychiatric and medical utilization and, if left untreated, can cause impairment as severe as major depressive disorder (MDD)” (Schlaepfer & Nemeroff, 2012, p. 343). The characteristics of GAD are: a near constant state of anxiety/worry disproportionate to the degree of stress/threat, feeling worried/anxious for the majority of days and such feelings persisting for over six months with a worsening of the condition with stress, lack of ability to control anxiety/worry, and feelings of uncertainty of themselves and displays of confirming and perfectionist attitudes.

For there to be confirmed diagnosis of GAD, patients must display three or more established symptoms for most of the time, during the 6 months or more. These symptoms are:

1. Difficulty with concentration

2. Being irritable

3. Experiencing disturbed sleep

4. Being on edge/restless

5. Feeling tired

6. Having muscle tension (Lader, 2015).

Other than these symptoms other symptoms associated with the heart can occur. “Patients have physical anxiety symptoms (such as tachycardia and tremor) and key psychological symptoms, including restlessness, fatigue, difficulty in concentrating, irritability, and disturbed sleep” (Lader, 2015, p. 1).

Pathophysiology

A defined pathophysiology of GAD or any anxiety disorders has not been established. Nevertheless, research suggests there are some mechanisms within the central nervous symptoms that become disrupted in people with anxiety disorders. One such example is the conditioned fear response evident in those with GAD. “Behavioral and psychophysiological findings demonstrated overgeneralization of conditioned fear among patients with GAD. Specifically, generalization gradients were abnormally shallow among GAD patients, reflecting less degradation of the conditioned fear response as the presented stimulus differentiated from the CS+” (Lissek et al., 2014, p. 909). Adding to the notion of conditioned fear response is disruption in the gamma-aminobutyric acid (GABA) system (Lissek et al., 2014). This is why benzodiazepines remain a somewhat effective treatment for those suffering from GAD and other related anxiety disorders. Other areas of interest in understanding GAD from this perspective is the activity in regions of the amygdala that can signal GAD in an individual.

A 2013 study examining the effects of GAD on the human amygdala noted GAD manifestation created changes in the circuits of that region involved with emotion processing. The researchers also found changes and disruptions when it came to coding of interceptive states as well as the processing of fear. “Adolescents with GAD exhibited disruptions in amygdala-based intrinsic functional connectivity networks that included regions in medial prefrontal cortex, insula, and cerebellum. Positive correlations between anxiety severity scores and amygdala functional connectivity with insula and superior temporal gyrus were observed” (Roy et al., 2013, p. 290).

It seems GAD appears to disrupt certain processes within key regions of the human brain. This then can lead to an altered fear/stress response. It can also generate the physical symptoms associated with GAD.

Natural History

GAD seems to be rare in terms of solely appearing in the case of those suffering from GAD. Comorbidity is far more common with GAD presenting itself alongside other psychiatric disorder and normal anxiety. Most with GAD suffer from alcohol abuse, other anxiety disorders, and/or comorbid depression. These disorders tend to occur over the course of a lifetime. While GAD rarely leads to suicide, because of the higher rate of comorbidities, it can attribute to a lower quality of life and thus a potentially shorter life, especially if drug or alcohol abuse is involved.

While morbidity information does not reveal much in terms of morbidity, one recent study examined the effects of GAD on adults 45 years or older. The discovered the effects of GAD on cardiovascular health seem to form a negative correlation in women. “Current GAD predicted greater cardiovascular mortality (HR-values range from 1.86 to 1.99; p-values ≤ 0.025) independently from MetS and cardiovascular risk factors. In men, the MetS and MDE/GAD were not associated with mortality” (Butnoriene et al., 2015, p. 360). This could be for several reasons. The first is GAD can lead to depression and depression is often associated with lack of activity and poor lifestyle habits (Butnoriene et al., 2015).

Those living with GAD sufferers may see lack of energy, lack of interest, and constant worry. GAD sufferers may pose a problem for those taking care of them or living with them. GAD may also pose a problem health wise if the worry and fear prevents people with GAD from doing the necessary, everyday tasks of life needed to function normally. Because GAD can be chronic and can lead to the complication of MDD, it may lead to lifestyle choices that may be isolative in nature and promote unhealthy coping mechanisms such as alcohol abuse or disordered eating (Butnoriene et al., 2015).

Subjective Data

Clinical Presentation of GAD can appear through discovery of specific habits or symptoms in the patient. For example, worry and anxiety must be associated with 50% of the 6 symptoms listed in the first section. If a patient goes in to discuss his or her history with GAD the patient typically would state he or she has sleep disturbances, may be irritable, restless, and/or easily fatigued. Some questions related to flight or fight response may reveal the patient feels afraid in seemingly normal situations like entering a train, or ruminating over past actions. Because GAD frequently exists as a comorbidity, some questions should lean towards asking if the person has a history or social anxiety, depression, or suffered from any traumatic event in the past.

Sufferers of GAD often note experiencing behavior where they may eavesdrop on conversations or feel they need to know as many details as possible of whatever piqued their interest. They may exhibit low-risk taking behavior, avoidance behaviors, and fear mistakes or criticism. Questions may center on whether the person feels over-responsibility over the situations of others, or hearing negative news. Since perfectionism plays a key role in GAD, some events in a patient’s history may reveal unrealistic and unfavorable assessment of their efforts and so forth.

In terms of family medical history, while there is no defined connection of GAD as a potentially inherited, those with GAD tend to have family members suffer from anxiety disorders (Lader, 2015). They also tend to display similar coping mechanisms that their family members have when dealing with anxiety. This leads into social history. Those with anxiety disorders may avoid social situations, especially when the disorder is severe. Avoidant behaviors, negative coping mechanisms like drinking may present in patients with GAD.

Objective Data

In a 2014 study, the researchers examined the clinical presentation of GAD within the human brain. “Generalized social anxiety disorder (GSAD) is characterized by aberrant patterns of amygdala-frontal connectivity to social signals of threat and at rest. The neuropeptide oxytocin (OXT) modulates anxiety, stress, and social behaviors” (Dodhia et al., 2014, p. 2061). They discovered oxytocin played a role in regulating anxiety in patients with GAD.

Higher social anxiety severity in GSAD subjects correlated with lower amygdala-ACC/mPFC connectivity on PBO and higher social anxiety also correlated with greater enhancement in amygdala-frontal connectivity induced by OXT. These findings show that OXT modulates a neural circuit known for social threat processing and emotion regulation, suggesting a neural mechanism by which OXT may have a role in the pathophysiology and treatment of social anxiety disorder (Dodhia et al., 2014, p. 2061).

Oxytocin appears to be an important marker for potential treatment ideas in those suffering from GAD.

Aside from oxytocin, a nurse performing an examination may find other physical positive symptoms may occur like constant worry and worrying to worry. Negative symptoms may be chronic fatigue, a person that easily fatigues, and sleep disturbances. Sleep disturbances are very common among those with anxiety disorders, especially those with GAD. The worrying is a signature aspect of GAD and should be assessed to understand the degree of GAD within the patient.

Since GAD has comorbidity with other disorders, one of which is alcohol abuse, physical symptoms of alcohol abuse may be determined from the examination if it exists in the patient as a comorbidity. Depression and other anxiety disorders like social anxiety disorder may present. This may mean the patient may show positive symptoms like withdrawal or negative symptoms like increased heartrate and sweating.

Assessment and Diagnosis

The five-differential diagnosis associated with GAD can be: alcoholism, Adrenal Crisis, Depression, Schizophrenia, and sleep disorders. Alcoholism is closely tied to GAD and can appear before the development of GAD or after the development of GAD. Some of the symptoms of alcoholism like sweating and anxiety are similar to the presentations seen in GAD. People with GAD often will experience other symptoms that will rule out alcoholism such as constant worrying and potential sleep problems. This leads to the next problem which is sleep disorders.

Sleep disorders mean people can suffer from no sleep like insomnia, or lack of sleep. People suffering from sleep disorders may experience anxiety and moodiness due to lack of sleep and experience fatigue (Chokroverty, 2013). However, sleep disorders can be ruled out as an option because GAD also has symptoms of muscle aches and muscle tension along with constant worrying and stress. Adrenal Crisis can lead to muscle aches and tension, specifically, pain the lower back, legs, or abdomen (Chokroverty, 2013). However, it can be ruled out because it can lead to severe vomiting and diarrhea, not associated with GAD or most other chronic health problems.

The other potential differential diagnosis is depression. Depression can cause fatigue, trouble sleeping, moodiness, and worry. However, the level of anxiety felt by those with GAD and the desire to know more about certain situations, with resultant perfectionism traits, rules out depression. The final differential diagnosis is schizophrenia. Schizophrenia can be ruled out as a potential diagnosis because it is usually attributed with positive symptoms like hallucinations and negative symptoms such as lethargy (Chokroverty, 2013).

Diagnostic tests to identify GAD may include a physical examination where the doctor may order urine/blood tests along with other tests to see if any underlying medical condition is present. Psychological questionnaires may be used to assist in determining a diagnosis (Lader, 2015. A key marker for GAD is difficulty in controlling feelings of worry.

Plan for Management

There are some avenues of treatment to help patients manage GAD. The first intervention is psychotherapy. Psychotherapy a.k.a. talk therapy involves a patient having sessions with a therapist to assess and reduce anxiety symptoms. Talk therapy can take on the form of cognitive behavioral therapy or CBT. CBT therapy has been proven effective for a variety of psychological disorders, specifically anxiety disorders like GAD. “Client early in-session statements against change (counter-change talk) were found to be robust predictors of post-treatment worry scores and differentiated treatment responders from nonresponders. Moreover, client motivational language predicted outcomes beyond initial symptom severity and self-report measures of motivation” (Lombardi, Button, & Westra, 2013, p 12).

Other forms of treatment exist in the form of medications. Pregabalin otherwise known as Lyrica, is an anxiolytic agent and has been used to treat GAD in adults living in the EU. Thanks to its rapid onset of effect, those taking the medication can experience a faster relief of symptoms. Some adverse effects are weight gain and dizziness. Though, most tolerate the medication well. People taking such a medication for anxiety, may also take a SSRIs or SNRIs. Pregabalin has been used as a long-term treatment option for sufferers of GAD. “Alongside selective serotonin reuptake inhibitors (SSRIs) and serotonin-noradrenaline reuptake inhibitors (SNRIs), pregabalin is considered a first-line agent for the long-term treatment of GAD by the World Federation of Societies of Biological Psychiatry” (Frampton, 2014, p. 835).

Potential referrals to other services may be a social worker in order to gain awareness of programs or treatments that can help with other potential comorbidities like alcoholism and/or substance abuse problems. This is because identification of key concepts like positive coping mechanisms may only be done through admittance of specific programs.

Facilitators and Barriers

Lifestyle habits can make or break a treatment plan for someone suffering from GAD. Something as simple as keeping physically active can play a vital role in keeping stress at manageable levels. Exercise has also been shown to improve mood and assist people in staying healthy. “Only recently has attention turned to maladaptive and persistent expressions of anxiety, with a growing body of evidence indicating promise for exercise as an effective treatment for some of the anxiety disorders” (Asmundson et al., 2013, p. 362). If a person with GAD has a sedentary lifestyle, this may impede progress, especially if combined with medications that may potentially cause weight gain.

Another potential facilitator or barrier to treatment and recovery is use of alcohol and other sedatives (Asmundson et al., 2013). While substances like alcohol can alleviate anxiety in the short-term, in the long-term it worsens anxiety, reducing the likelihood of recovery. Food can also play a key role.

Eating healthy can help the person with GAD avoid nutritional deficiencies that could lead to negative symptoms related to anxiety. The previous correlation discovered with GAD patients and heart problems could stem from poor eating habits. Anxiety may cause disordered eating. The often-best way to handle such problems is through consistent adoption of healthy habits.

To overcome potential barriers nurses and doctors must educate the patient in the importance of positive coping mechanisms and lifestyle choices when it comes to management of GAD and other anxiety disorders. If patients learn and understand the importance of sound decisions in regards to food and exercise, they may be more inclined to adopt those choices to help their recovery. Patient education is often an important aspect of recovery in relation to lifestyle changes.

Patient Engagement

Patient engagement in GAD is crucial in recovery. If patients do not take the necessary steps every day to alleviate symptoms of GAD and reduce the effects of GAD on the body and the brain, the patient will see a continued occurrence of GAD. As previously mentioned, lifestyle habits can speed up or prolong recovery. If patients do not reveal the kind of habits they have to their nurse or doctor, and do not reveal all of the symptoms or disorders they have, they are missing out on potentially pertinent information that could help them recover.

Because one main treatment option for GAD is talk therapy, patient engagement is key. Imagine a patient in a talk therapy session not engaging with the therapist. The patient does not reveal what he or she does that leads to the constant worrying and refuses to acknowledge if the problems have worsened GAD presentation or not. This can lead to miscommunication and lack of effective treatment options for the patient. Patients need to understand, especially in this setting, that the more they discuss and are open with their problems related to GAD, the more help and education they can receive on their situation.

GAD is a disease that can be chronic and can lead to MDD. Depression is a serious and often hard to deal with mental disorder. If patients with GAD want to avoid complications like GAD, they must be willing to reduce their unwillingness to share with their healthcare provider and show them the kinds of situations and stressors they face on a daily basis. In addition, they must also reveal the kinds of coping mechanisms they have that are either prolonging the onset of GAD or reducing the symptoms.

Five evidence-based strategies

There are evidence-based strategies that can help a patient with GAD improve self-management and help their healthcare provider assist them in recovery. These five communication strategies are setting a shared agenda, setting self-management goals, ask-tell-ask, closing the loop, and assessing readiness to change (Wittenberg et al., 2015). Setting a shared agenda is a critical step in communicating effectively with a healthcare provider. By setting a shared agenda, a patient can cover important topics and even put in questions that may be forgotten otherwise. This can help patients visualize what they need to be education on in terms of treatment.

The next is ask-tell-ask and allows a healthcare provider to tailor information to the specific needs of the patient. This can make patient education more effective and keeps the patient engaged, allowing a higher level of self-management. To assess readiness to change, this means to really explain the situation and understand the motivations and reasons for wanting to get better. People with GAD may want to recover in order to get back to hobbies or interests that they may have neglected in the past due to the onset of GAD (Wittenberg et al., 2015).

Self-management goals, again, provide visualization of what is needed to recover. Without goals, patients may feel lost in what to do or what to accomplish to get closer to recovery. The last strategy is closing the loop. This is for patients to understand towards the end of a doctor appointment what is going to happen in terms of treatment and self-management efforts. This is a simple means of communicating more effectively, by allowing a chance for further clarification.

References

Asmundson, G. J., Fetzner, M. G., DeBoer, L. B., Powers, M. B., Otto, M. W., & Smits, J. A. (2013). LET’S GET PHYSICAL: A CONTEMPORARY REVIEW OF THE ANXIOLYTIC EFFECTS OF EXERCISE FOR ANXIETY AND ITS DISORDERS. Depression and Anxiety, 30(4), 362-373. doi:10.1002/da.22043

Butnoriene, J., Bunevicius, A., Saudargiene, A., Nemeroff, C. B., Norkus, A., Ciceniene, V., & Bunevicius, R. (2015). Metabolic syndrome, major depression, generalized anxiety disorder, and ten-year all-cause and cardiovascular mortality in middle aged and elderly patients. International Journal of Cardiology, 190, 360-366. doi:10.1016/j.ijcard.2015.04.122

Chokroverty, S. (2013). Sleep Disorders Medicine: Basic Science, Technical Considerations, and Clinical Aspects. Elsevier Science.

Dodhia, S., Hosanagar, A., Fitzgerald, D. A., Labuschagne, I., Wood, A. G., Nathan, P. J., & Phan, K. L. (2014). Modulation of Resting-State Amygdala-Frontal Functional Connectivity by Oxytocin in Generalized Social Anxiety Disorder. Neuropsychopharmacology, 39(9), 2061-2069. doi:10.1038/npp.2014.53

Frampton, J. E. (2014). Pregabalin: A Review of its Use in Adults with Generalized Anxiety Disorder. CNS Drugs, 28(9), 835-854. doi:10.1007/s40263-014-0192-0

Lader, M. (2015). Generalized Anxiety Disorder. Encyclopedia of Psychopharmacology, 699-702.

Lissek, S., Kaczkurkin, A. N., Rabin, S., Geraci, M., Pine, D. S., & Grillon, C. (2014). Generalized Anxiety Disorder Is Associated With Overgeneralization of Classically Conditioned Fear. Biological Psychiatry, 75(11), 909-915. doi:10.1016/j.biopsych.2013.07.025

Lombardi, D. R., Button, M. L., & Westra, H. A. (2013). Measuring Motivation: Change Talk and Counter-Change Talk in Cognitive Behavioral Therapy for Generalized Anxiety. Cognitive Behaviour Therapy, 43(1), 12-21. doi:10.1080/16506073.2013.846400

Roy, A. K., Fudge, J. L., Kelly, C., Perry, J. S., Daniele, T., Carlisi, C., . . . Ernst, M. (2013). Intrinsic Functional Connectivity of Amygdala-Based Networks in Adolescent Generalized Anxiety Disorder. Journal of the American Academy of Child & Adolescent Psychiatry, 52(3), 290-299.e2. doi:10.1016/j.jaac.2012.12.010

Schlaepfer, T. E., & Nemeroff, C. B. (2012). Neurobiology of Psychiatric Disorders E-Book: Handbook of Clinical Neurology (Series Editors: Aminoff, Boller and Swaab). Vol. 106. Burlington: Elsevier Science.

Wittenberg, E., Ferrell, B., Goldsmith, J., Smith, T., Gladchen, M., & Handzo, J. (2015). Textbook of palliative care communication. Oxford University Press.