Generalised Anxiety Disorder

Original Editors - Dana Moorer & Kaelin Hocker from Bellarmine University's Pathophysiology of Complex Patient Problems project.

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Definition/Description

Generalized anxiety disorder GAD) is one of the most common mental disorders. Up to 20% of adults are affected by anxiety disorders each year. Generalized anxiety disorder produces fear, worry, and a constant feeling of being overwhelmed. Generalized anxiety disorder is characterized by persistent, excessive, and unrealistic worry about everyday things.

• This worry could be multifocal such as finance, family, health, and the future.
• It is excessive, difficult to control, and is often accompanied by many non-specific psychological and physical symptoms

GAD can be considered primary or secondary depending on the onset.

1. If GAD occurs early in life without any other diagnosis than it is considered primary.
2. If GAD develops later in life and there are other disorders present, it is considered secondary in nature.

Epidemiology

In the general population, the lifetime prevalence of GAD is 5.1%, with a 12‐month prevalence measured at 3.1%.

• Within the primary care setting, the WHO collaborative study on Psychological Disorders in Primary Health Care studyreported that GAD formed the second largest category of psychological disorders, with a prevalence of just under 7.9%.
• A survey of high utilisers of medical health care found a particularly high prevalence rate of GAD at 22%, and the prevalence of GAD in patients visiting physicians' offices has been shown to be twice that found in the community.
• Women have a higher prevalence rate for GAD than men, with the median age of onset occurring during the early 20s.

Symptoms

GAD can be a challenge to diagnose. People consider panic attacks a hallmark of all anxiety disorders, but GAD is different in that there are generally no panic attacks associated with the condition. As a result of this misconception, without the experience of panic attacks, a person may think they are "just worrying too much." Their struggles with constant worry may be minimized or dismissed and, in turn, not properly diagnosed or treated

The DSM-5 outlines specific criteria to help professionals diagnose generalized anxiety disorder. Having a standard set of symptoms to reference when assessing clients helps them to more accurately diagnose mental health concerns and, in turn, create a more effective plan of care.

Criteria for Diagnosing GAD: When assessing for GAD, clinical professionals are looking for the following:

1. The presence of excessive anxiety and worry about a variety of topics, events, or activities. Worry occurs more often than not for at least six months and is clearly excessive.
2. The worry is experienced as very challenging to control. The worry in both adults and children may easily shift from one topic to another.
3. The anxiety and worry are accompanied by at least three of the following physical or cognitive symptoms (In children, only one of these symptoms is necessary for a diagnosis of GAD):

• • Edginess or restlessness
  • Tiring easily; more fatigued than usual
  • Impaired concentration or feeling as though the mind goes blank
  • Irritability (which may or may not be observable to others)
  • Increased muscle aches or soreness
  • Difficulty sleeping (due to trouble falling asleep or staying asleep, restlessness at night, or unsatisfying sleep)

Causes

There is no singular cause of GAD that has been identified. Evidence has shown that multiple factors are usually at play, influencing the development of GAD. Some of the common factors include things like genetic predisposition, brain chemistry, family background, social influence, and life experiences

The limbic system is a collection of brain structures that, among other functions, is involved in the regulation of many of basic emotional reactions. The amygdala, in particular, is the part of the limbic system involved in the automatic fear response, as well as in the integration of memory and emotion. The amygdala is an important player in people's ability to discern and feel fear, so it may not be a surprise that imaging studies of people diagnosed with GAD show elevated amygdala activity during the processing of negative emotions. It is this heightened activity within the amygdala that researchers believe might influence the inaccurate interpretations of social behavior for patients with GAD.

Life Experiences

Although genetic and biologic factors clearly contribute to the development of GAD, a greater percentage of the risk for GAD lies in complex psychological, environmental, and social factors. Examples given below:

• Experiencing Trauma:Mental health researchers have found that trauma in childhoodcan increase a person's risk of developing GAD. Difficult experiences such as physical and mental abuse, neglect, the death of a loved one, abandonment, divorce, or isolation can all be contributing factors
• Children learn from caregivers and other important people close to them how to handle challenging, stressful situations. When they model less effective methods of stressful management, children tend to do the same. These early social learning experiences can influence the development of long-lasting anxiety.
• Using everyday addictive substances like caffeine can heighten feelings of worry or nervousness, contributing to the development of anxiety.5 Our culture tends to ask more and more of us, pushing us to perform, and leaving us to fear feeling left behind, socially, financially, physically, or otherwise.
• Research has shown that two main factors of anxiety, specifically related to women, were being afraid of and/or humiliated by a current partner or ex-partner. Dangerous and fearful experiences within intimate relationships can also influence the development of anxiety.
• Of people who are on social media, it has been shown that approximately 30% are plugged into social media for 15 hours or more per week. Researchers are finding that the use of social media, particularly in excess, can greatly impact mental health, sometimes resulting in anxiety and depression. Interacting with others through social media can also present us with the same challenges as when we are interacting in people, such as feelings of loneliness, rejection, abandonment, or humiliation..

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Medical Management

When beginning a treatment program for a patient with generalized anxiety disorder many factors must be considered. These factors include patient education, patient preference, treatment success/failure history, and the patient's comorbidities.

It is important to educate the patient that anxiety is a medical condition that has the ability to be managed.The patient needs to understand how his/her lifestyle and internal thoughts can play a role in the management of anxiety. The patient's preference in the treatment techniques plays a major role in the management and remission of GAD. The patient needs to engage in their treatment and must be willing to make the modification of their lifestyle and internal thoughts. A patient's comorbidities also play a role in treatment, as they might have a pre-existing disorder that can be affecting their anxiety. Anxiety can affect numerous systems throughout the body; therefore it is important to realize that the treatment of anxiety can also help with the associated disorders/pain throughout the body.

There are four different guideline committees that have listed their recommendations for the treatment of patients with generalized anxiety disorder. These committees consist of the World Federation of Societies of Biological Psychiatry (2002), the British Association for Psychopharmacology (2005), the National Institute for Health and Clinical Excellence (2004), and the Canadian Psychiatric Association (2006). The focus of acute treatment for patients who experience GAD is to improve symptoms; with the primary long-term goal of remission ("the complete resolution of both symptoms and functional impairment."). Based on the guidelines for treatment from the committees, the first stage of pharmacotherapy should include an antidepressant, such as a selective serotonin reuptake inhibitor (SSRI) or a serotonin-noradrenalin reuptake inhibitor (SNRI).

First- line treatment:

Selective Serotonin Reuptake Inhibitors

• The two common SSRI used in the treatment of GAD include paroxetine (Paxil) and escitalopram (Lexapro). Sertraline (Zoloft) can be considered a treatment option, however, it is not currently licensed for GAD.
• All of these pharmacological interventions were studied in randomized, double-blinded, placebo controlled environments. As reported by Katzman, each SSRI showed effective treatment of GAD (with paroxetine demonstrating long-term treatment as well). These drugs helped patients achieve greater remission of their anxiety disorder when compared to a placebo.
• How they work: SSRI’s relieve symptoms by blocking the reabsorption, or reuptake, of serotonin by certain nerve cells in the brain. This leaves more serotonin available, which improves mood. An advantage to these drugs is the potential for long-term use for treatment of GAD without the worry of abuse or tolerance.^[10]

Serotonin Noradrenalin (Norepinephrine) Reuptake Inhibitors:

• Two common SNRI used in the treatment of GAD include duloxetine (Cymbalta) and venlafaxine (Effexor).
• The pharmacological intervention was performed on a group of subjects in a double-blind experimental study. It was found that both duloxetine and venlafaxine produced significant improvements in anxiety when compared to those who received placebo only treatment.
  
• However, it was found that adverse side effects were significantly greater in the venlafaxine group, but not found within the duloxetine group.
  
• How they work: this group of medications is for the treatment of anti-depression (and anxiety) that increases the levels of serotonin and norepinephrine. This increase is a result of the inhibition of their re-absorption into the cells within the brain. The mechanism in which this occurs is not fully understood; however, it is believed that these higher levels enhance the neurotransmission (sending of the nerve impulses) and therefore improve and elevate mood.
  

It has been reported that SSRIs and SNRIs have "efficacy limitations, such as lack of response in many patients, a 2- to 4- week delay before the onset of symptom relief, lack of full remission, and risk of relapse."

Second-line treatment:

Benzodiazepines:

• This classification of medication offers a rapid relief of anxiety symptoms for a patient.
• Mechanism of the action occurs by the interaction with the "receptors activated by the neuroinhibitory transmitter, GABA. In doing so, they promote binding of GABA to GABA subunit receptors (GABA A) and enhance chloride ion influx."
• They are not effective in resolving depression that is often associated/accompanied with GAD.
• These medications are highly effective in promoting relaxation and reducing muscular tension and other physical symptoms of anxiety.
• Long-term use is not recommended due to concerns of dependence.^[4] Short to Intermediate-acting agents include oxazepam (Serax), alprazolam, lorazepam (Ativan). Longer-acting agents include diazepam (Valium), chlordiazepoxide (Librium), and clorazepate (Tranxene).

Buspirone:

• The generic name is referred to as Buspar. This drug is an azapirone and has been shown to be effective in the treatment of anxiety over a placebo; however, it may not be as effective as benzodiazepines.^[10]
• The mechanism of action is mediated through serotoninergic activity (specifically as an agonist of the serotonin receptor subtype 5-hydroxytryptamine-1A.)
• It is classified as a non-addictive, non-sedating alternative to the benzodiazepines. It is not considered a first-line treatment due to the one-to three-week delay in relief of symptoms, the short half-life (which results in dose two to three times per day), and the decreased impact on the comorbidity of depression.

Pregabalin:

• This drug is currently only recommended to those patients who are intolerant to SSRIs or SNRIs or who do not receive full remission from SSRIs or SNRIs.
• "The mechanism of action is caused by inhibition of the release of excitatory neurotransmitters" and "the onset of action occurred within the first week".
• In patients, this drug "has been shown to relieve psychic and somatic symptoms of anxiety" in a manner similar to benzodiazepines ( lorazepan and alprazolam) and SNRIs (venlafaxine).
• This drug has not been FDA approved for the treatment of GAD (however it is approved in Europe).

Other Possible Medical Management:

Beta Blockers:

• Beta Blockers are used to treat patients with certain heart conditions. However, this drug can also be used to help prevent the physical symptoms of certain anxiety disorders (usually a type of phobia).
• An example is propranolol (Inderal) is used to lower the heart rate that is often accompanied by anxiety.

Physical Therapy Management

Physical therapists cannot directly cure anxiety, as is it thought to be caused by neurotransmitters within the brain. However physical therapists need to be aware of the symptoms of anxiety due to the fact that more and more patients are being diagnosed with generalized anxiety disorder. Based on the research, there are no specific physical therapy interventions that relate directly to GAD.

Anxiety can cause many clinical symptoms that may mimic a musculoskeletal disorder including muscle tension/ muscle aches. It is important to distinguish what is the source of this muscle tension. This is when a thorough history is important in gathering the necessary information and determining if this is true within the scope of practice.

An important role of a physical therapist is within patient education. It is important for the patient to understand what brings on their anxiety. Explaining that keeping a diary of their anxiety and rating it on a scale of 0-10 can be helpful for the patient. Physical therapists can also teach the patient relaxation techniques and deep breathing exercises.

A physical therapist can also provide massage techniques in order to help decrease muscle tension.

Another way that physical therapists can help in reducing anxiety is through exercise. Research on anxiety and exercise has shown that benefits of exercise include the reduction of anxiety and improved mood. This relationship is not clearly understood; however, it has been found that working out can help increase relaxation and keep the anxiety symptoms from returning once the patient is feeling better. According to the Mayo Clinic, exercise can help anxiety by releasing "feel-good brain chemicals (which include neurotransmitters and endorphins)." Exercise can also increase the body temperature and in turn produce calming effects. There are also psychologic and emotional benefits of exercise that include increased confidence, taking the mind of worries, increased socialization (within a gym setting), and coping in a healthy way. Aerobic exercise is best for the management of anxiety; however, any exercise to get the patient moving is a positive. Workplace physical activity and yoga programmes are associated with a significant reduction in depressive symptoms and anxiety, respectively.

It is also the job of the physical therapist to refer the patient to his/her primary physician in order for the patient to have the proper medical/pharmacological management of their disorder.

Alternative/Holistic Management

Psychological Counseling:

• Cognitive Behavioral Therapy ( CBT): involves addressing the irrational thinking patterns in how patients behave and feel. In many patients, CBT has been shown to decrease the symptoms associated with GAD. CBT treatment includes numerous sessions with a trained mental health professional as well as an awareness of the principles of this therapy.^[10]
• According to an article written by Kavan in the American Academy of Family Physicians, "CBT addresses the role of irrational thinking in how patients feel and behave. CBT for GAD typically includes patient self-monitoring of worrying or related symptoms; cognitive restructuring, including evaluating and reconsidering interpretive and predictive thoughts/worries; relaxation training; and rehearsal of coping skills." This will in turn help patients understand the triggers of their anxiety and patterns of counterproductive thinking. In these therapy interventions, patients try to exchange the unnecessary worrying and thoughts with a more practical problem-solving approach. These patients should also incorporate self-calming techniques (including deep breathing, relaxation, and exercise) into their daily life. This will help reduce arousal and give them a sense of control over their anxiety symptoms.

Additional Management of Generalized Anxiety Disorder:

• Stress management techniques can help people with anxiety disorders calm themselves and may enhance the effects of therapy. Some of these techniques can include deep breathing exercises, progressive muscle relaxation, and meditation. Research suggests that Mindfulness-Based Stress Reduction program  (MBSR) may have a beneficial effect on anxiety symptoms in GAD, and may also improve stress reactivity and coping as measured in a laboratory stress challenge. It comprises breath-awareness, a body-scan, and gentle Hatha yoga which are used to cultivate awareness of internal present-moment experiences with an accepting, non-judgmental stance.
• Deep breathing- When you’re anxious, you breathe faster. This hyperventilation causes symptoms such as dizziness, breathlessness, lightheadedness, and tingly hands and feet. These physical symptoms are frightening, leading to further anxiety and panic. But by breathing deeply from the diaphragm, you can reverse these symptoms and calm yourself down.^[16]
• Progressive muscle relaxation can help you release muscle tension and take a “time out” from your worries. The technique involves systematically tensing and then releasing different muscle groups in your body. As your body relaxes, your mind will follow.
• Meditation. Research shows that meditation boosts activity on the left side of the prefrontal cortex, the area of the brain responsible for feelings of serenity and joy.
• Other stress management techniques could include yoga, music therapy, massage, and counselling services. Also, incorporating a well-balanced diet and making sure to get adequate amounts of sleep each night can help to manage stress and anxiety.

Case Reports

Generalized anxiety disorder and clinical worry episodes in young women

http://www.physio-pedia.com/Generalized_Anxiety_Disorder_Case_Study_2017

Resources

National Institue of Mental Health

Mayo Clinic

RxList: The Internet Drug Index