Generalized anxiety disorder (GAD) is one of the most frequent mental disorders all over the world. It belongs to the category of anxiety disorders and is considered to be a “highly prevalent, chronic, costly and disabling mental disorder” (Cuijpers et al., 2014, p. 131). GAD can develop as an independent disorder. In this case, it is diagnosed according to DSM-5 criteria and corresponds to DSM code 300.02 (F41.1). Nevertheless, it frequently develops as a comorbid condition of other mental disorders. Thus, it can accompany such disorders as depression, panic disorder or post-traumatic stress disorder. The prevalence of GAP depends on such factors as gender, age, race or culture, which can both increase or reduce the risk of GAD incidence and development. While not always immediately diagnosed, GAD is a curable disorder. The choice of treatment interventions depends on the patient’s condition and the causes of the disorder. The current paper studies the peculiarities of GAD diagnosing, prevalence of this disorder, and reviews possible beneficial treatment strategies to manage GAD.
Brief Description of Anxiety Disorders
Anxiety disorders in general belong to the most prevalent mental conditions worldwide. According to many researches, anxiety disorders are consistently associated with “increased psychiatric and physical morbidity, use of health care services, and psychosocial impairment” (Black & Grant, 2015, p. 124). Due to similar clinical manifestations that can be misinterpreted, anxiety disorders are frequently not recognized and, consequently, not treated properly. Thus, it important to differentiate anxiety disorders to provide patients with necessary care. On the whole, DSM-5 lists the following anxiety disorders:
- Separation anxiety disorder
- Selective mutism
- Specific phobia
- Social anxiety disorder (social phobia)
- Panic disorder
- Generalized anxiety disorder
- Substance/medication-induced anxiety disorder
- Anxiety disorder due to another medical condition
- Other specified anxiety disorder
- Unspecified anxiety disorder (Black & Grant, 2015, p. 124).
The notion of anxiety itself describes different phenomena. However, in the clinical literature is usually means “the presence of fear or apprehension that is out of proportion to the situation” (Black & Grant, 2015, p. 124). It can be concluded that anxiety comprises diverse sensations that people observe when they feel threat or are in danger. These anxiety sensations can include “racing heart, changes in breathing, stomach problems (ranging from butterflies in the stomach to nausea or diarrhea), sweating, trembling or shaking, hot flushes or cold chills, general feelings of restlessness or jumpiness, and dizziness or light-headedness” (Robichaud & Dugas, 2015, p. 10). Thus, anxiety has mainly physical manifestations. While most of individuals often experience anxiety as a single phenomenon in different life situations, frequent and repetitive cases of anxiety that impair the daily life are the signs of anxiety disorder and a reason to visit a specialist.
Statement of Diagnosis
Despite the title, one of the primary signs of generalized anxiety disorder is not anxiety, but excessive worry about daily events that are difficult to control (Robichaud & Dugas, 2015). GAD is generally characterized by “pattern of frequent, persistent excessive anxiety and worry that is out of proportion to the impact of the event or circumstance that is the focus of the worry” (Black & Grant, 2015, p. 139). Since the majority of patients experience GAD for long periods of time, it is commonly considered to be a chronic disorder. Tyrer and Baldwin (as cited in Cuijpers et al., 2014, p. 131) state that the 12-month prevalence rate of GAD has been estimated to be between 1.2 and 1.9% and the lifetime prevalence between 4.3 and 5.9%.
At present, there are six major diagnostic criteria for GAD.
- Excessive anxiety and worry that is experienced during most of the days within the period of minimum 6 months, concerning some activities or events related to work, studies, and other daily activities.
- The person has difficulties with controlling the worry:
- The anxiety and worry are correlated with at least three (one for children) of the six symptoms (experienced during most of the days within the period of minimum 6 months), such as “restlessness or feeling keyed up or on edge; being easily fatigued; difficulty concentrating or mind going blank; irritability; muscle tension; sleep disturbance” (Black & Grant, 2015, p. 140).
- The experienced anxiety, worry, and the related physical manifestations condition meaningful distress or impairment in different areas of everyday life of a person.
- The disturbance observed by an individual is not connected with any physiological effects of a substance use such as drug of abuse or medication, or another health condition.
- The anxiety cannot be explained by any other mental disorder, such as negative evaluation in social anxiety disorder or memories of traumatic events in posttraumatic stress disorder (Black & Grant, 2015).
GAD is the most spread mental disorder. At present, the global prevalence for anxiety disorders is 7.3% that means that one in 14 individuals all over the world has an anxiety disorder 11.6% (one in nine people) is likely to experience an anxiety disorder the following year (Baxter, Scott, Vos, & Whiteford, 2012).
The feeling of anxiety is a normal reaction to stress. However, excessive and repeated anxiety which is difficult to control is a sign to consult a doctor. GAD develops due to an interaction of factors, both environmental and biological (“Generalized anxiety disorder,” 2017). For example, these factors include differences in function and chemistry of brain, genetic reasons, diverse perceptions of threats and stresses, and the peculiarities of personality and the development of an individual (“Generalized anxiety disorder,” 2017). Thus, people with negative temperaments, those who already have GAD in the family history, and those who have experienced negative or traumatic life experiences, are more likely to develop GAD.
Prevalence of GAD can depend on such factors as race, nationality, or be higher or lower in certain demographic groups. Thus, race is considered to be a factor that has an impact on the prevalence of GAD (Bandelow & Michaelis, 2015). For example, European or White individuals are more exposed to this disorder than the representatives of the other races. At the same time, Africans, Asians, Native Americans or Pacific Islanders experience GAD less frequently than the others. However, in the US, African Americans make up the group at high risk of developing GAD. Another idea is that people living in the developed countries are more likely to observe the symptoms of GAD that the citizens of low-income countries. Still, this fact can be probably explained by lower level of diagnosing in less developed countries and generally poor access to healthcare. Thus, nationality as well as the place of living is also a meaningful factor.
As for demographic factors influencing GAD, age and gender can be singled out. There is evidence that GAD is more characteristic of adults. The average age-of-onset for GAD is estimated at 31 years old (“Generalized anxiety disorder (GAD),” n.d.). Thus, GAD prevalence is the highest among people aged 45-59 (7.7%) and 30-44 (6.8%) while only 4.1% of younger individuals (18-29 years old) experience GAD. The prevalence of this disorder after the age of 60 is even lower, only 3.6% (“Generalized anxiety disorder (GAD),” n.d.).
Gender is another factor that influences the prevalence of GAD. Thus, although GAD can affect both males and females, it is twice more often diagnosed in women than in men (Baxter et al., 2012). One of the possible explanations of this fact is that women are more concerned about the daily problems. Moreover, female patients are more attentive to their health and report their symptoms more frequently than males. In addition, although GAD symptoms are similar for men and women, females are more likely to develop GAD as comorbid condition to bipolar depression. At the same time, males’ development of GAD is frequently a comorbid condition to substance use.
Pertinent Information Associated with Diagnosis
Anxiety was treated differently in the course of history. Goodwin and Guze (as cited in Black & Grant, 2015, p. 123) considered anxiety to be significant for several conditions identified already in the nineteenth century. In the end of the nineteenth century, there appeared a notion of “irritable heart syndrome,” characterized by chest pain, palpitations, and dizziness,” which was considered related to a functional cardiac disturbance (Black & Grant, 2015, p. 123). Moreover, neurasthenia as a disorder of nervous exhaustion was discovered and described at that time. Later, Freud distinguished neurasthenia from cases influenced prevalently by anxiety symptoms and defined this condition as “anxiety neurosis” (Black & Grant, 2015, p. 123). He also outlined its clinical manifestations as comprising “general irritability, anxious expectation, pangs of conscience, anxiety attacks, and phobias” (Black & Grant, 2015, p. 123).
There is another issue pertinent to generalized anxiety disorder. It is the global access to information. Different media make available information concerning political, socioeconomic, social or environmental issues that bring more stress and anxiety to people. Moreover, for people with inclination to mental disorders, overall access to information can stimulate the development of anxiety disorders, including GAD. At the same time, information technologies can be used in GAD treatment strategies.
Health and life insurance make a concern for individuals with mental disorders. Most of the anxiety disorders including GAD comply with health or life insurance. Stull, it depends on the patient’s condition and the selected treatment strategy. However, the majority of patients with anxiety disorders can get a traditional life or health insurance.
Beneficial Treatment Interventions
Depending on the severity of symptoms and the condition of the patient, there are several treatment strategies for GAD. Thus, there exist pharmacological and psychological treatment interventions (Andrews, Mahoney, Hobbs, & Genderson, 2016).
At present, benzodiazepines such as valium tor alprazolam that were used in previous decades as pharmacological treatment for GAD are no longer prescribed. However, “escitalopram, paroxetine, and sertraline (SSRIs: selective serotonin reuptake inhibitors); duloxetine and venlafaxine (SNRIs: serotonin and norepinephrine reuptake inhibitors); and pregabalin (an anticonvulsant)” were proved to be clinically efficient and considered more beneficial than harmful (Andrews et al., 2016, p. 24). Thus, these medications are among the primary pharmacological treatments for GAD. A meta-analysis revealed the highest effectiveness of duloxetine, followed by sertraline; the most significant remission was achieved due to the use of escitalopram, followed by venlafaxine; and the best tolerability rated were recorded for sertraline, followed by pregabalin (Andrews et al., 2016). Still, pharmacological treatment is only recommended to individuals who did not benefit from psychological interventions.
For the majority of GAD patients, psychological treatments are recommended. One of the widespread psychological treatments for GAD, for adults in particular, is cognitive behavior therapy (CBT). The studies investigating the effectiveness of CBT revealed that these treatments better cope with worrying, anxiety and depression. Moreover, in some cases CBT showed higher efficiency at the longer term if compared to applied relaxation (Andrews et al., 2016). In addition, there is some evidence that CBT provides longer-lasting effects in comparison to the use of usual care (Cuijpers et al., 2014). At present, Internet-based cognitive behavior therapy is gaining more popularity for treatment of diverse anxiety disorders including GAD.
It is provided by means of computer over the internet. It is popular among patients due to the opportunity to be applied at home or at any other comfortable location that also contributes to the treatment compliance. It should be mentioned that CBT as the treatment intervention for GAD, both usual and internet-based, “demonstrates equivalent or superior outcomes compared to other forms of psychotherapy (both inactive and active control conditions) and to pharmacotherapy (due to increased tolerability)” (Andrews et al., 2016, p. 33). Still, internet-based CBT is considered to have more benefits if compared to face-to-face CB. Moreover, it is cost-effective and convenient for patients. Another type of intervention is transdiagnostic cognitive behavioral treatments, both face-to-face and internet-based (Andrews, 2016). They are aimed at managing pathologies similar in mood and anxiety disorders. In addition, transdiagnostic cognitive behavioral treatment is effective in addressing comorbidities.
Despite the effectiveness of all the mentioned interventions, every case of general anxiety disorder is unique due to the factors that caused it and the peculiarities of patient. Consequently, treatment should be selected individually with the consideration of the patient’s needs and comorbid conditions. Moreover, it is important to evaluate the efficiency of the selected treatment intervention and make changes in the strategy in case of necessity.
Helpful Resources for Managing GAD
There are some resources that are useful for patients diagnosed with GAD or just observing its symptoms. For example, Robichaud and Dugas (2015) suggest self-assessment tests and provide a guide for coping with uncertainty, worries, and fears in their generalized anxiety workbook. Moreover, Anxiety and Depression Association of America runs support groups throughout the country aimed at people with diverse anxiety disorders including GAD (“Support groups,” 2016). Also, there are programs provided by colleges of medicine at universities. Thus, department of psychiatry at the University of Illinois suggests Mood and anxiety disorders program aimed at treating adults with mental disorders (“Mood and anxiety disorders program,” 2017).
It can be concluded that generalized anxiety disorder is a mental disorder with complex roots. Despite its curability, it is one of the most prevalent mental disorders. Being one of the anxiety disorders, it has some typical symptoms that are frequently misinterpreted and the disorder is diagnosed later. Thus, worries and anxiety are common to many disorders, but in case of GAD they are excessive, repetitive, and difficult to control. Moreover, they interfere with the daily activities of a person. Although GAD can develop as an independent disorder, it is a frequent comorbid condition to other mental disorders such as depression or substance use. In addition to such factors as brain peculiarities or genetic susceptibility, GAD prevalence can be influenced by age, race, nationality, age or gender. The treatment for GAD is selected individually, with the consideration of patient’s peculiarities. While there is a choice between pharmacological and psychological treatment interventions, psychological is preferable unless it is not effective. Thus, there are opportunities to diagnose the disorder and treat it or at least minimize its negative consequences.
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