Generalized Anxiety Disorder (GAD)

Generalized Anxiety Disorder (GAD)

Generalized Anxiety Disorder (GAD)

Generalized anxiety disorder (GAD) can be hard to diagnose. The symptoms are relatively unfocused; the nervousness is low-key and chronic; panic attacks are not required. Furthermore, it is, after all, just worry, and that’s something that touches all of us. But there are differences. Ordinary worry is somehow less serious; we are able (well, most of the time) to put it aside and concentrate on other, more immediate issues. The worry of GAD often starts of its own accord, seemingly without cause. And GAD worry is at times hard to control. It carries with it a collection of physical symptoms that pile onto the sense of agitated restlessness in a cascade of misery.

ORDER COMPREHENSIVE SOLUTION PAPERS ON Generalized Anxiety Disorder (GAD)

Although some patients with GAD may be able to state what it is that makes them nervous, others cannot. GAD worry is typically about far more issues (“everything”) than objective facts can justify. The disorder typically begins at about 30 years of age; many patients with GAD have been symptomatic for years without coming to the attention of a clinician. Perhaps this is because the degree of impairment in GAD is often not all that severe. Genetic factors play an important role in the development of GAD. It is found in up to 9% of the general adult population (lifetime risk), and, as with nearly every other anxiety disorder, females predominate.

Essential Features of Generalized Anxiety Disorder

Hard-to-control, excessive worrying about a variety of issues—health, family problems, money, school, work—results in physical and mental complaints: muscle tension, restlessness, becoming easily tired and irritable, experiencing poor concentration, and trouble with insomnia.

The Fine Print

The D’s: • Duration (on most days for 6+ months) • Distress or disability (work/educational, social, or personal impairment) • Differential diagnosis (substance use and physical disorders, mood disorders, other anxiety disorders, OCD, PTSD, realistic worry)

Bert Parmalee

For most of his adult life, Bert had been “a worry-wart.” At age 35, he still had dreams that he was flunking all of his college electrical engineering courses. But recently he had felt that he was walking a tightrope. For the past year he had been the administrative assistant to the chief executive officer of a Fortune 500 company, where he had previously worked in product engineering.

“I took the job because it seemed a great way to move up the corporate ladder,” he said, “but almost every day I have the feeling my foot’s about to slip off the rung.”

Each of the company’s six ambitious vice-presidents saw Bert as a personal pipeline to the CEO. His boss was a hard-driving workaholic who constantly sparked ideas and wanted them implemented yesterday. Several times he had told Bert that he was pleased with his performance. In fact, Bert was doing the best job of any administrative assistant he had ever had, but that didn’t seem to reassure Bert.

“I’ve felt uptight just about every day since I started this job. My chief expects action and results. He has zero patience for thinking about how it should all fit together. Our vice-presidents all want to have their own way. Several of them hint pretty broadly that if I don’t help them, they’ll put in a bad word with the boss. I’m always looking over my shoulder.”

Bert had trouble concentrating at work; at night he was exhausted but had trouble getting to sleep. Once he did, he slept fitfully. He had become chronically irritable at home, yelling at his children for no reason. He had never had a panic attack, and he didn’t think he was depressed. In fact, he still took a great deal of pleasure in the two activities he enjoyed most: Sunday afternoon football on TV and Saturday night lovemaking with his wife. But recently, she had offered to take the kids to her mother’s for a few weeks, to relieve some of the pressure. This only resurrected some of his old concerns that he wasn’t good enough for her—that she might find someone else and leave him.

Bert was slightly overweight and balding, and he looked apprehensive. He was carefully dressed and fidgeted a bit; his speech was clear, coherent, relevant, and spontaneous. He denied having obsessions, compulsions, phobias, delusions, or hallucinations. On the MMSE, he scored a perfect 30. He said that his main problem—his only problem—was his nagging uneasiness.

Valium made him drowsy. He had tried meditating, but it only allowed him to concentrate more effectively on his problems. For a few weeks he had tried having a cocktail before dinner; that had both relaxed him and prompted worries about alcoholism. Once or twice he even went with his brother-in-law to an Alcoholics Anonymous meeting. “Now I’ve decided to try dreading one day at a time.”

Evaluation of Bert Parmalee

Bert worried about multiple aspects of his life (his job, being an alcoholic, losing his wife); each of these worries was excessive for the facts (criterion A). The excessiveness of his worries would differentiate them from the usual sort of anxiety that is not pathological. Despite repeated efforts (meditation, medication, reassurance), he had been unable to control these fears (B). In addition, he had at least four physical or mental symptoms (only three are required): trouble concentrating (C3), fatigue (C2), irritability (C4), and sleep disturbance (C6). He had been having difficulty nearly every day for longer than the required 6 months (A). And his symptoms caused him considerable distress, perhaps even more than is usual for patients with GAD (D).

One of the difficulties in diagnosing GAD is that so many other conditions must be excluded (E). A number of physical conditions can cause anxiety symptoms; a complete workup of Bert’s anxiety would have to consider these possibilities. From the information contained in the vignette, a substance-induced anxiety disorder would appear unlikely.

Anxiety symptoms can be found in nearly every category of mental disorder, including psychotic, mood (depressed or manic), eating, somatic symptom, and cognitive disorders. From Bert’s history, none of these would seem remotely likely (F). For example, an adjustment disorder with anxiety would be eliminated because Bert’s symptoms met the criteria for another mental disorder.

It is important that the patient’s worry and anxiety not focus solely on feature of another mental disorder, especially another anxiety disorder. For example, it shouldn’t be “merely” worry about weight gain in anorexia nervosa, about contamination (OCD), separation from attachment figures (separation anxiety disorder), public embarrassment (social anxiety disorder), or having physical symptoms (somatic symptom disorder). Nevertheless, note that a patient can have GAD in the presence of another mental disorder—most often, mood and other anxiety disorders—provided that the symptoms of GAD are independent of the other condition.

The only specifier for GAD is is the optional with panic attacks. Bert’s diagnosis, other than a GAF score of 70, would be a plain vanilla:

It is reasonable to ask this question: Does diagnosing GAD in a depressed patient help with your evaluation? After all, the anxiety symptoms may disappear once the depression has been sufficiently treated. The value, I suppose, is that flagging the anxiety symptoms gives a more complete picture of the patient’s pathology. Also, you may have to treat the anxiety symptoms independently later on.