Running head: GENERALIZED ANXIETY DISORDER 1

Generalized Anxiety Disorder

Ashley Henderson

Portland State University

COUN

GENERALIZED ANXIETY DISORDER 2

Generalized Anxiety Disorder

Overview

“Generalized Anxiety Disorder (GAD) is a condition characterized by ‘free floating’

anxiety or apprehension not linked to a specific cause or situation” (Dinsmoor, R. S. & Odle, T.

G., 2006, p. 1589). Stein, Hollander & Olasov Rothbaum (2009), describe this worry as different

from “normal” worry, by being unrealistic and harder to control (p. 164). They go on to describe

GAD patients as having poorer problem “orientation” skills (difficulties approaching problems),

and more difficulty tolerated ambiguity (p. 165).

History

The Diagnostic and Statistical Manual of Mental Disorders-III (DSM-III) changed its

anxiety category from the previous “anxiety neurosis” to “anxiety states.” Listed under “anxiety

states” were panic disorder, generalized anxiety disorder, and obsessive compulsive disorder (as

cited in Caycedo & Griez, 2001, p. 188). This was the first inclusion of GAD as a diagnostic

category. It was considered a residual category reserved for disorder not meeting criteria for any

other anxiety disorder. The next two revisions of the DSM would include changing criteria for

the GAD diagnosis (Stein, Hollander & Rothbaum, 2009, p. 162).

Diagnosis

The APA’s (2000) DSM-IV-TR diagnostic criteria for GAD is quoted below.

A. Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at

least 6 months, about a number of events or activities (such as work or school performance).

B. The person finds it difficult to control the worry.

GENERALIZED ANXIETY DISORDER 3

C. The anxiety and worry are associated with three (or more) of the following six symptoms (with

at least some symptoms present for more days than not for the past 6 months). Note: Only one

item is required in children.

(1) restlessness or feeling keyed up or on edge

(2) being easily fatigued

(3) difficulty concentrating or mind going blank

(4) irritability

(5) muscle tension

(6) sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep)

D. The focus of the anxiety and worry is not confined to features of an Axis I disorder, e.g., the

anxiety or worry is not about having a Panic Attack (as in Panic Disorder), being embarrassed in

public (as in Social Phobia), being contaminated (as in Obsessive-Compulsive Disorder),

being away from home or close relatives (as in Separation Anxiety Disorder), gaining weight (as

in Anorexia Nervosa), having multiple physical complaints (as in Somatization Disorder), or

having a serious illness (as in Hypochondriasis), and the anxiety and worry do not occur

exclusively during Posttraumatic Stress Disorder.

E. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in

social, occupational, or other important areas of functioning.

F. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of

abuse, a medication) or a general medical condition (e.g., hyperthyroidism) and does not occur

exclusively during a Mood Disorder, a Psychotic Disorder, or a Pervasive Developmental

Disorder. (p. 476).

GENERALIZED ANXIETY DISORDER 4

Trembling, sweating, heart palpitations, and nausea also tend to accompany GAD, even

though they are not listed in the DSM-IV-TR diagnostic criteria for the disorder. (Dinsmoor, R.

S. & Odle, T. G., 2006, p. 1590).

Before making a diagnosis of GAD, Rygh and Sanderson (2004), warn that stimulant

intoxication, exposure to a toxin, or withdrawal from sedatives or alcohol must be ruled out due

to similarities in symptoms (p. 1). Kay and Tasman (2006) add that some endocrine disorders,

gastrointestinal disorders, infectious diseases, cardiovascular disorders, respiratory disorders,

immunological disorders, metabolic conditions, and neurological disorders, and psychological

disorders other than GAD can also mimic symptoms of GAD (p. 644).

Prevalence

Generalized Anxiety Disorder affects 1.6% of the population at any time, and has a

lifetime prevalence rate of 5.8%, with highest risk factors for those over age twenty-four (Rygh

and Sanderson, 2004, p. 3). It accounts for almost one-third of cases referred to psychiatrists by

general practitioners” (Dinsmoor, R. S. & Odle, T. G., 2006, p. 1590). Barlow (2002), notes that

American women are affected twice as often by GAD then American men. He also cites that

Divorcees have higher rates, as well as homemakers, retirees, and those who live in the North

East United States (p. 481-482). Comorbidity is of GAD is high with other psychiatric disorders.

Full GAD is found in 20% of depressed patients and 10% of those with other anxiety disorders.

Two-thirds of GAD patients also have an addition Axis I disorder and 89% of those with GAD

meet criteria for another psychiatric disorder (Stein, Hollander & Olasov Rothbaum, 2009, p.

165).

Course

Rygh and Sanderson (2004) note that the disorder usually starts in childhood and the

suffer only seeks treatment only after becoming disabled from normal functioning by worry.

They add that the disorder is generally resistant to treatment and when remission does happen to

occur, relapse rates are high at 27%. They also note that GAD is sometimes conceptualized by

researcher as a personality disorder due to its chronicity and resistance to treatment (p. 3).

Causes & Theories

Biological.

There is evidence for a genetic factor. Kay and Tasman (2006) estimate the heritability of

the disorder at 30% (p. 640).

Cognitive-Behavioral.

In the cognitive-behavioral model of Generalized Anxiety Disorder, “individuals’

thoughts, cognitive style and behaviors are thought to instigate and maintain episodes of anxiety

(Kay and Tasman, 2006, pg. 641). They go on to describe this theory by noting that individuals

with GAD are more likely to interpret ambiguous stimuli and information as threatening and/or

negative (pg. 641).

Well’s Metacognitive Theory.

Knowledge, beliefs, and appraisals about cognition has been named “metacognition.”

This model describes GAD as the result of ‘interaction between the motivated use of worry as a

coping strategy, negative appraisal of worry, and worry control attempts” (Rygh & Sanderson,

2004, p. 14). Wells separates worry into two types. Type 1 refers to worry about external events

and stimuli, as well as noncognitive internal events. Phobias would be considers Type 1 worry.

Type 2 worry, is worrying about one’s own thinking or worry about worry, “metaworry.” Well’s

suggests that the basis of GAD is metaworry (Gygh & Sanderson, 2004, p. 14).

Treatment

As one of the leading causes of work place disability, the functioning of those with GAD

is greatly effected. GAD sufferers take more disability days and have higher dysfunction at work.

In addition, one-third of those with GAD seek medical attention for somatic symptoms. Rygh

and Sanderson (2004) argue that the high costs and the chronic nature of the disorder “clearly

indicate the necessity for effective treatments of this disabling disorder” (p. 5).

Psychopharmacological Treatment.

Benzodiazepines.

Originally, and sometimes still, the first-line of defense by clinicians in treating GAD is

benzodiazepines, primarily alprazolam and clonazepam. Benzodiazepines causes sedating,

muscle relaxation, anxiety reduction and decreased physiologic arousal (Kay and Tasman, 2006,

p. 647). Kay and Tasman note that benzodiazepine treatment of GAD has decreased due to

discouragement of their use because of potential abuse and addiction.

Antidepressants.

A decade ago, research on tricyclic antidepressants showed promise for their use in

treatment of GAD, but now serotonin reuptake inhibitors are becoming more used for treatment

(Kay and Tasman, 2006, p. 649). Kay and Tasman explain that this is because SSRIs have much

less side effects than TCAs (p. 649).

Other Pharmacological Treatments.

Psychological Treatments.

Cognitive-Behavioral Therapy.

Kay and Tasman (2006) note in recent years, specific cognitive-behavioral therapies for

patients with anxiety disorders have been developed. The therapies involve “teaching patients to

identify and label irrational thoughts and to replace them with positive self-statements or modify

them by challenging their veracity” (p. 649). The treatment can also involve exposure and/or

relaxation training. CBT is the leading psychotherapeutic intervention of GAD and was

measured to have equal efficacy to pharmacotherapy, but with benefits lasting past

discontinuation of therapy. (Kay and Tasman, 2006, p. 649-670).

Other Therapies.

Supportive psychotherapy, where the patient talks about their difficulties and gets insights

about their illness, has been shown to be helpful for those with milder GAD (Kay and Tasman,

2006, p. 650).

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References

American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders: Dsm-iv-tr.

Washington, D.C.: American Psychiatric Association.

Barlow, D. H. (2002). Generalized Anxiety Disorder. In Eowmwe, L.; Orsillo, S. M.; & Barlow, D. H. (Second Ed),

Anxiety and its disorder: The nature and treatment of anxiety and panic (pp. 477-515). Guilford Press: New

York, NY.

Caycedo, N. & Griez, E.J.L. (2001). Generalized Anxiety Disorder. In Griez, E.J.L.; Faravelli, C.; Nutt, D.; & Zohar,

D. Anxiety Disorders: A Clinical Introduction to Management and Research. (pp. 189-204). West Sussex,

England: John Wiley & Sons:

Dinsmoor, R. S. & Odle, T. G. (2006). Generalized Anxiety Disorder. In Longe, J. (Third Ed), The Gale

Encyclopedia of Medicine (pp. 1589-1591). Detroit, MI: Gale.

Kay, J. & Tasman, A. (2006). Anxiety disorders: Generalized Anxiety Disorder. Essentials of Psychiatry (pp.

639-653). West Sussex, England: John Wiley & Sons, Ltd.

Papp, L. A. (2009). Phenomenology of Generalized Anxiety Disorder. In Stein, D.J.; Hollander, E.; & Olasov

Rothbaum, B. (Second Ed), Textbook of anxiety disorders (pp. 159- 171). American Psychiatric Publishing,

Inc: Washington, D.C.

Rygh, J. L. & Sanderson, W. C. (2004). Treating Generalized Anxiety Disorder: Evidence-based strategies, tools,

and techniques. Guilford Press: New York, NY.