Generalized Anxiety Disorder

Anxiety, worry, and stress are all a part of most people's life today. But simply experiencing anxiety or stress in and of itself does not mean you need to get professional help or you have an anxiety disorder. In fact, anxiety is a necessary warning signal of a dangerous or difficult situation. Without anxiety, we would have no way of anticipating difficulties ahead and preparing for them.

Anxiety becomes a disorder when the symptoms become chronic and interfere with our daily lives and our ability to function. People suffering from chronic anxiety often report the following symptoms:

• Muscle tension
• Physical weakness
• Poor memory
• Sweaty hands
• Fear or confusion
• Inability to relax
• Constant worry
• Shortness of breath
• Palpitations
• Upset stomach
• Poor concentration

These symptoms are severe and upsetting enough to make individuals feel extremely uncomfortable, out of control and helpless.

Anxiety disorders fall into a set of separate diagnoses, depending upon the symptoms and severity of the anxiety the person experiences. The anxiety disorders discussed in this series on anxiety are:

• Generalized Anxiety Disorder (GAD)
• Panic Disorder (including panic attacks)
• Social phobia (also known as social anxiety disorder)
• Specific phobias (also known as simple phobias)

Obsessive-compulsive disorder (OCD) and posttraumatic stress disorder (PTSD) are considered anxiety disorders.

The key feature of Generalized Anxiety Disorder (GAD) is excessive worry.

Everyone worries to some degree at some point about something in their lives. However, the worry experienced by individuals with GAD is clearly out of proportion to the actual likelihood or impact of the feared event. The worry is longstanding.

Themes of worry may include health, finances, job responsibilities, safety of one's children or even being late for appointments. The worry is difficult to control and interferes with the task at hand. For example, students may find it difficult to get their schoolwork done and parents often describe difficulty letting their child get on the school bus. These feelings of worry and dread are accompanied by physical symptoms such as pain from muscle tension, headache, frequent urination, difficulty swallowing, "lump in the throat" or exaggerated startle response.

For some people this chronic anxiety and worry have become the standard approach taken to all situations and health experts recognize this condition as Generalized Anxiety Disorder. While the exact cause for GAD is uncertain, experts feel that it's a combination of biological factors and life events. It's not uncommon for some people with GAD to also have other medical disorders such as depression and/or panic disorder . These may be influenced by the activity certain chemicals systems in the brain.

Symptoms of Generalized Anxiety Disorder

The first sign is chronic, irrational worry that can’t be turned off. This can focus on a variety of topics from health to money to job responsibilities. The worry, while ever present, can peak to the point that it prevents functioning.

Worries can be accompanied by physical symptoms that include trembling, twitching, muscle tension, headaches, sweating or hot flashes. The person might feel lightheaded, out of breath, nauseated or have to go to the bathroom a lot. Some people might feel they have lumps in their throats. Others startle more easily.

GAD comes on gradually and often hits people in childhood or adolescence but can begin in adulthood. According to the Diagnostics Statistics Manual IV, this excessive anxiety occurs more days than not and for at least six months. The person finds it difficult to control the worry.

In addition, there are certain physical conditions associated with GAD. At least three of the following symptoms need to be present for six months:

• feeling keyed up, restless or on edge
• being easily fatigued
• having difficulty concentrating, or having oneÆ mind go blank
• experiencing irritability
• experiencing muscle tension
• having sleep disturbances (difficulty falling or staying asleep; or having restless, unsatisfying sleep)

In addition, the focus of the anxiety and worry is not directed to worrying about a particular occurrence, such as having a panic attack, as in panic disorder or being embarrassed in public as in social phobia or being contaminated as in obsessive-compulsive disorder.

The anxiety, worry and physical symptoms cause significant distress or impairment in social, occupational or other important areas of functioning. ItÆ also important to rule out that the anxiety is not due to drugs, prescription medication, alcohol or another medical condition, such as hyperthyroidism.

What is Panic Disorder?

More than three million Americans will experience panic disorder during their lifetime, and there is no typical victim. According to the American Academy of Child and Adolescent Psychiatry, panic disorder can begin during childhood or before age 25.

While it is not clear what causes the disorder, there is a strong suggestion that the tendency is inherited and runs in families. At one time, researchers believed panic disorder was due primarily to psychological problems. Experts now believe that genetic factors or changes in body chemistry, in combination with stressful circumstances or events, play a pivotal role.

According to the American Psychological Association, each panic attack peaks within about 10 minutes. Sometimes attacks repeat in clusters for up to an hour after the initial attack, with associated fear over the possibility of another attack. Subsequent attacks may occur days and even weeks later.

This element of fearfulness is called anticipatory anxiety. People fear having another attack while performing the same activity or being in the same situation as when a previous attack occurred. Anticipatory anxiety can be so extreme that people turn away from the outside world for fear that another attack will be set off.

For example, if an attack occurred while driving on the freeway, a person may fear that repeating this type of driving will cause panic again. He will, then, limit himself to driving only on secondary roads. If panic was experienced while sleeping in bed in the dark, a person might sleep on the couch with the light on to try to prevent another attack.

If an attack was experienced outside while walking through a park or shopping at a mall, a fear of having a future attack in public can occur. This can lead to complete avoidance of any outside activity, which can result in a condition called agoraphobia-the inability to go beyond known and safe surroundings because of intense fear and anxiety.

While a great deal of research has been conducted on panic disorder, the exact cause is unclear. Research does suggest that panic disorder is more prevalent in women than in men.

According to the National Institute of Mental Health (NIMH), panic disorder can also happen with other disorders. Depression and substance abuse commonly occur simultaneously with panic disorder. About 30 percent of people with panic disorder abuse alcohol and 17 percent abuse drugs, such as cocaine and marijuana. This drug abuse can be attributed to unsuccessful attempts by a person with panic disorder to alleviate the anguish and distress caused by his condition.

Major advances have been made through research funded by the NIMH to produce effective treatments to help people with panic disorder. Treatment includes medication and a type of psychotherapy known as cognitive-behavioral therapy.

Appropriate treatment by an experienced professional can reduce or prevent attacks in 70 to 90 percent of people with panic disorder. Most people show significant progress after a few weeks of treatment. Relapses can occur, but they can often be treated effectively.

Symptoms of Panic Disorder

There are more than a dozen physical or emotional sensations that a person can experience during a panic attack. Not everyone experiences all of them, and people with panic disorder may report different feelings when having an attack.

If not recognized and treated, panic disorder can be devastating because it can interfere with relationships, schoolwork, employment and normal development. It is not uncommon for a person with panic disorder to experience an anxious feeling even between attacks. People with panic disorder will begin to avoid situations where they fear an attack may occur or situations where help might not be available. This happens with both adults and children with panic disorder.

For example, a child may be reluctant to go to school or be separated from her parents. Not all children who express separation anxiety do so because they have panic disorder, and it can be very difficult to diagnose. But when properly evaluated and treated with a combination of medication and cognitive-behavioral therapy, children with panic disorder usually respond well. It is recommended that a family physician or pediatrician first evaluate children and adolescents with suspected panic. If no other physical illness or condition is found as a cause for symptoms, a comprehensive evaluation by a child and adolescent psychiatrist should be obtained.

Brain scans and blood tests are not effective in diagnosing panic disorder.

Questions formulated by The Anxiety Disorders Association of America can help an individual determine whether he is experiencing panic disorder. These include:

1. Are you troubled by repeated and unexpected “attacks” of intense fear or discomfort for no apparent reason?
2. During such attacks, do you experience at least four of the following symptoms?
   • pounding heart
   • sweating
   • trembling or shaking
   • shortness of breath
   • choking
   • chest pain
   • nausea or abdominal discomfort
   • “jelly” legs
   • dizziness
   • a feeling of unreality or being detached from yourself
   • fear of losing control
   • going crazy
   • fear of dying
   • numbness or tingling sensations or chills or hot flashes
3. Do you have a fear of places or situations where escape or getting help might be difficult, such as a crowded room or traffic jam?
4. Do you have a fear of being unable to travel without a companion?
5. For at least one month following an attack, have you felt persistent:
   • concern about having another attack?
   • worry about going crazy?
   • need to change your behavior to accommodate the attack?

In summary, panic disorder results from having panic attacks. Panic attacks are episodes that come “out of the blue.” They peak within a few minutes and cause feelings of terror and alarming physical symptoms.

People often are convinced during the attack that they are dying and describe a panic attack as the most distressing experience that they have ever had. As a natural response, people dread the next attack and often avoid places or situations where they have had panic attacks.

Social Phobia/Anxiety Disorder

Exposure to social situations can produce physical symptoms, such as sweating, blushing, muscle tension, pounding heart, dry mouth, shaky voice or trembling. These symptoms can become a source of added concern�orry that they will result in unwanted and embarrassing attention. People with social phobia either avoid social or performance situations, or endure them with intense anxiety or stress.

It is difficult to say how many people suffer from the disorder. Scholarly studies have used a variety of definitions for social phobia, but such reports put the incidence in the United States at anywhere from five to 13 percent of the population experiencing it during their lifetime. Interestingly, research in Korea has put the incidence much lower, at just one half of one percent of the Korean population.

US surveys have indicated that women and girls outnumber men and boys three to two among those with symptoms of social phobia. Men, however, have been more likely to seek treatment. A variety of studies have demonstrated that social phobia is most likely to develop in the teenage years, though it can start earlier or later. Mental health professionals report that many people suffer quietly for years, looking for help only when their fears have precipitated a major life crisis.

While definitive data are still to be collected, social phobia is considered to be a chronic condition that requires ongoing treatment. About half of the people with social phobia are thought to experience other psychiatric problems at the same time. These typically have included panic disorder, substance abuse and depression.

Types of Social Phobia

For some people, almost any social circumstance is a cause for fear and anxiety. These individuals are said to have generalized social phobia. People for whom just one or two situations produce anxiety are considered to have the nongeneralized form of the disorder.

A number of researchers have suggested that another way to group people with social phobia is based on the kind of situation that evokes dread. Two primary categories or groups are performance and interactional.

The performance grouping includes people who have strong anxiety at the idea of doing something in front of, or in the presence of, other people. Such situations include dining out, working, giving a speech or using a public restroom.

The interactional grouping includes people whose fears center on circumstances where they have to converse or otherwise engage with others, such as meeting new people.

Mental health professionals also have recognized that some people develop symptoms of social phobia as an outgrowth of other medical or physical problems. Individuals with Parkinson’s disease, obesity, disfigurement or other conditions sometimes can have severe anxiety that their physical appearance or actions will attract attention and disdain. While sharing similar symptoms, the Diagnostic and Statistical Manual for Mental Disorders specifically excludes a diagnosis of social phobia if the fears exhibited can be tied to these medical or physical conditions.

Specific Phobias

Many people experience specific phobias, intense, irrational fears of certain things or situations--dogs, closed-in places, heights, escalators, tunnels, highway driving, water, flying, and injuries involving blood are a few of the more common ones. Phobias aren't just extreme fear; they are irrational fear. You may be able to ski the world's tallest mountains with ease but panic going above the 10th floor of an office building. Adults with phobias realize their fears are irrational, but often facing, or even thinking about facing, the feared object or situation brings on a panic attack or severe anxiety.

Specific phobias strike more than 1 in 10 people. No one knows just what causes them, though they seem to run in families and are a little more prevalent in women. Phobias usually first appear in adolescence or adulthood. They start suddenly and tend to be more persistent than childhood phobias; only about 20 percent of adult phobias vanish on their own. When children have specific phobias--for example, a fear of animals--those fears usually disappear over time, though they may continue into adulthood. No one knows why they hang on in some people and disappear in others.

Specific Symptoms of Specific Phobias:

Marked and persistent fear that is excessive or unreasonable, cued by the presence or anticipation of a specific object or situation (e.g., flying, heights, animals, receiving an injection, seeing blood).

Exposure to the phobic stimulus almost invariably provokes an immediate anxiety response, which may take the form of a situationally bound or situationally predisposed Panic Attack. (In children, the anxiety may be expressed by crying, tantrums, freezing, or clinging.)

For adults, the person recognizes that the fear is excessive or unreasonable.

The phobic situation or situations are avoided or else are endured with intense anxiety or distress.

The avoidance, anxious anticipation, or distress in the feared situation(s) interferes significantly with the person's normal routine, occupational (or academic) functioning, or social activities or relationships, or there is marked distress about having the phobia.

In individuals under age 18 years, the duration is at least 6 months.

The anxiety, Panic Attacks, or phobic avoidance associated with the specific object or situation are not better accounted for by another mental disorder.

Treatment of Anxiety Disorders

Anxiety disorders are readily treated by a number of modern techniques, usually including a combination of time-limited psychotherapy and anti-anxiety medications. Both approaches can be effective for most disorders. The choice of one or the other, or both, depends on the the particular anxiety disorder, and the severity of the symptoms. For example, only psychotherapy has been found effective for specific phobias.   When choosing a therapist, you should find out whether medications will be available if needed.

Treatments are specific to the type of anxiety disorder a person is diagnosed with.

• Generalized Anxiety Disorder Treatment
• Panic Disorder Treatment
• Social Phobia Treatment
• Specific/Simple Phobia Treatment

You can also learn a lot more about how psychotherapy is used to treatment anxiety disorders, and what techniques are commonly employed.