Generalized Anxiety Disorder (GAD) DSM-5 300.02 (F41.1)

DSM-5 Category: Anxiety Disorders

Introduction

Patients with GAD may make statements such as: “I was always a worrier: I’d feel keyed up and unable to relax. It could go on for days and days at a time, sometimes constantly.” Others report trouble sleeping, waking in the middle of the night, unable to fall back asleep. Concentration can be a problem, making reading almost impossible. Patients with GAD often imagine the worst, handicapping many aspects of their lives.

Symptoms of Generalized Anxiety Disorder

People with GAD experience chronic, constant and often unsubstantiated worry. Some of the more common topics or worries include work, family, health or money. Such worries can continue throughout the day, in some cases every day, disrupting social activities, family, work or school. Physical symptoms of GAD include, but are not limited to the following:

• Muscle tension
• Gastrointestinal discomfort or diarrhea
• Irritability
• Fatigue
• Edginess
• Restlessness
• Sleep difficulties

It is critical to note that many of the symptoms of GAD overlap with depression, complicating the diagnosis of either disorder (ADAA 2014). In a primary care setting, 45% of anxiety disorders are not properly identified, and are often mis-diagnosed due to somatic complaints. The primary symptom is not anxiety, but rather pain or a difficulty in sleeping. Since the diagnosis is so often incorrect, many patients with GAD do not receive proper treatment (Bandelow, et al 2013).

Diagnostic Criteria

All of the below features must be present in order to make a proper diagnosis of GAD:

• Excessive anxiety and worry, occurring more days than not for at least 6 months, concerning a number of events;
• The individual finds it difficult to control the worry;
• The anxiety and worry are associated with at least three of the following six symptoms (only one item required in children):
• Restlessness, feeling keyed up or on edge.
• Being easily fatigued
• Difficulty concentrating
• Irritability
• Muscle tension
• Sleep disturbance
• The anxiety, worry or physical symptoms cause clinically significant distress or impairment in important areas of functioning;
• The disturbance is not due to the physiological effects of a substance or medical condition;
• The disturbance is not better explained by another medical disorder (American Psychiatric Association, 2013).

Prevalence

Surveys of the general population suggest that during a person’s lifetime, somewhere between 4 to 6% of people will experience GAD. Women seem to be more susceptible to GAD then men, occurring approximately twice as frequently in females. The most common age range for the symptoms of GAD to appear is 45-59 years with a decline in diagnosis after age 60. If GAD is left untreated, it becomes chronic and usually remains, with most patients still suffering from the disease years after the diagnosis. Unfortunately, statistics suggest that only about 40% of patients with GAD are able to receive appropriate treatment (Bandelow, et al 2013).

Comorbidities

GAD tends to coexist with a number of other psychiatric disorders, including, but not limited to major depression, bipolar disorder, other anxieties and substance abuse problems. So many similarities exist between depression and GAD that many experts have even suggested re-categorizing GAD as a mood disorder. In cases where GAD does coexist with other psychiatric disorders, there is a heightened risk of impairment, suicide and disability. Unfortunately, most clinical trials evaluating GAD along with other most likely disorders do not take comorbidity into account, resulting in a paucity of data available to help guide treatment selection. As a result, there is a strong current need to push for additional research examining the comorbidities of GAD (Simon 2009).

Treatment for Generalized Anxiety Disorder

GAD is typically treated using either psychotherapy, medication or a combination of both. In terms of psychotherapy, cognitive behavioral therapy (CBT) tends to be especially useful in the treatment of GAD. This approach works by teaching different ways of thinking, behaving and reacting to certain situations. If successful, the result is that the patient is then able to feel less anxious and/or worried (NIMH 2014).

A variety of CBT interventions have shown promising results. These approaches vary widely in the type and combination used. Some examples include: self-monitoring, relaxation training, cognitive therapy, worry exposure and the practice of newly learned relaxation and coping skills. A review of the scientific literature showed that nearly half of patients treated with CBT showed a positive clinical response to treatment. Further to that, patients undergoing CBT were more likely to show a reduction in anxiety and depression. So, although CBT is generally accepted as the most effective treatment, there is not consensus on which specific CBT approach is most effective in the treatment of GAD (Olatunji, et al 2010).

Although CBT has been shown to work, the effect sizes for GAD are lower than those observed for other anxiety disorders. This finding reinforces the need to develop additional techniques to augment standard CBT methodology. Whatever treatment is chosen, clinicians should consider an approach that provides patients with the tools to (1) identify, differentiate and describe their emotions; (2) enhance their acceptance of affective experience and ability to adapt their emotions, as needed; (3) decrease their dependence on worrying as an emotional avoidance strategy; (4) increase their ability to use emotional information to identify needs, making decisions, guiding their thinking, motivating their behavior and managing their interpersonal relationships (Olatunji, et al 2010).

If medication is used, prescribers typically rely on either anti-anxiety medications or anti-depressants. Anti-anxiety medications are potent, and although they may begin to work immediately, they should not be relied on for long term relief. Anti-depressants may also be helpful in the treatment of GAD. Patients who are prescribed these medications should be aware that they can take several weeks to begin working and can lead to side effects such as difficulty sleeping, headache or nausea (NIMH 2014).

Strategies for living with GAD

If a patient feels that they suffer anxiety, the initial step is to consult with their general practitioner. Such professionals have the training to determine if the symptoms observed might be due to an anxiety disorder or be the result of a medical condition, or both. If an anxiety disorder is suspected, the patient should consult with a mental health professional. A clinician with a background in cognitive-behavioral therapy is likely the best choice. Whoever is chosen, it is key that the patient is at ease with the practitioner, and a team approach to treatment is possible (NIMH 2014).

In addition to seeking out a mental health professional, many patients may experience additional benefit from joining a self-help or support group. Further to that, some may benefit from discussions with a trusted friend or clergy member. Stress management, meditation or exercise can also be helpful. Lastly, support from the family can be very important in facilitating the recovery of a person with GAD, so long as they do not further perpetuate the symptoms. Families need to remember that the disorder is very real to the patient, and it is critical that they not trivialize the disorder or demand instant improvement (NIMH 2014).

References

American Psychiatric Association. 2013. Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

Anxiety and Depression Association of America (ADAA) 2014. Generalized Anxiety Disorder (GAD). adaa.org. Retrieved 24 February 2014 from http://www.adaa.org/understanding-anxiety/generalized-anxiety-disorder-gad

Bandelow, B., Boerner R., Kasper, S., Linden, M., Wittchen H.U., Moller, H.J. The diagnosis and treatment of generalized anxiety disorder. Deutsches Arzteblatt 2013, 1110, 300-310. DOI: 10.3238/arztebl.2013.0300

National Institute of Mental Health (NIMH) 2014. Generalized Anxiety Disorder (GAD). nimh.nih.gov. Retrieved 24 February 2014 from http://www.nimh.nih.gov/health/topics/generalized-anxiety-disorder-gad/index.shtml

Olatunji, B.O., Cisler, J.M., Deacon, B.J.. Efficacy of cognitive behavioral therapy for anxiety disorders: a review of meta-analytic findings. Psychiatric Clinics of North America 2010, 33, 557-577. doi:10.1016/j.psc.2010.04.002

Simon, N.M. Generalized anxiety disorder and psychiatric comorbidities such as depression, bipolar disorder, and substance abuse. Journal of Clinical Psychiatry 2009, 70 Suppl 2: 10-14. doi: 10.4088/JCP.s.7002.02

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