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Generalized anxiety disorder (GAD) is one of the most common mental disorders in the United States (Locke, Kirst, Shultz, 2015) and the most common anxiety disorder for which people see a primary care physician (Ormel et al., 1994; Wittchen et al., 2002]. GAD effects nearly 7 million adults with women more likely to have GAD than men. Overall nearly 6% of the population will experience GAD in their lifetime (Kessler et al., 2005a). Women have a lifetime prevalence rate of more than 7% while men have a lifetime prevalence rate of nearly 5% (Locke, Kirst, Shultz, 2015)
Causes and Etiology
GAD may be familial so that people who have family members with GAD are more likely to also have GAD. Childhood development also plays a role in GAD. Because parents are the primary adult role models, parents play a major role in emotional socialization (Arellano, Gramszlo, Woodruff-Borden, 2018), an essential part of child development. Children mimic their parent(s) in verbalization and in responses to stimuli. (Arellano, Gramszlo, Woodruff-Borden, 2018). Children show more emotional competence whenever a parent expresses more positive emotions as well as discusses emotions and inappropriate and appropriate emotional reactions. (Arellano, Gramszlo, Woodruff-Borden, 2018) .
Parents who have anxiety have more of a chance to disrupt the children’s emotional socialization process (Arellano, Gramszlo, Woodruff-Borden, 2018). Children who experience abuse or trauma have also have a greater chance of developing an anxiety disorder. In addition, people with a family history of alcohol abuse and panic disorder have increased odds of experiencing GAD (Arellano, Gramszlo, Woodruff-Borden, 2018).
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Diagnosis of GAD
People with GAD experience constant worry about different things almost continuously. The person may find it difficult to control the worry. To be diagnosed with GAD, symptoms must be experienced more days than not within a six-month time frame (Generalized Anxiety Disorder, n.d.). The symptoms of GAD are wide ranging and may include restlessness or being on edge. People with GAD are often fatigued, have difficulty concentrating, and have sleep disturbances. (Generalized Anxiety Disorder, n.d.). In addition, GAD also causes irritability and increased muscle tension (Generalized Anxiety Disorder, n.d.). The person must experience at least 3 of symptoms to be diagnosed with GAD. (Generalized Anxiety Disorder, n.d.) GAD effects many lives. Proper diagnoses and treatment offer the potential for people with GAD to live full lives and to decrease the burden of the disorder.
Many theories have been proposed for the etiological basis of GAD; however, the etiology of GAD remains poorly understood (Locke, Kirst, Shultz, 2015). Each theory has some published evidence supporting it but no evidence is causal. In one theory, someone with GAD will experience persistent activation of areas of the brain associated with mental activity and introspective thinking following worry inducing stimuli (Paulesu, 2010). This theory is one of several focused on the ‘dysregulation of worry’ (Paulesu, 2010). A second theory suggests environmental and genetic factors are the primary etiology (Locke, Kirst, Shultz, 2015); however, this study was completed using twins as the primary participants in the study. The use of twins limits the validity of these studies.
Impact on Life
Many people with GAD are impacted both by GAD and by other mental disorders. Major depressive disorder is a common comorbidity with GAD (Massion et al., 1993; Stein, 2001; Wittchen et al., 1994); Additionally, people with GAD also have physical comorbidities. Many of these comorbidities including irritable bowel syndrome while not life-threatening make life unpleasant (Massion et al., 1993; Stein, 2001; Wittchen et al., 1994). Other comorbidities including peptic ulcer disease, diabetes and cardiac diagnoses may be life shortening or life threatening. Some symptoms experienced by people with GAD do not have identified etiology.
Even without comorbidities GAD is often a chronic disease. People with untreated GAD experience exacerbations intermittently and sporadically (Ballenger et al., 2001; Wittchen et al., 2003). GAD decreases overall feelings of well-being with people with GAD having poor overall well-being within the last year and at some other time in their life (Cramer et al, 2005).
Quality of life and personal relationships as well as employment are affected with GAD. People with GAD report dissatisfaction with their main activity ie work or hobby and with family life (Cramer et al., 2005). Moreover, people with GAD report worse overall family and social role functioning (Hoffman et al, n.d.). Person’s with GAD experience between 1.5 and 5.4 impairment days in a month (Hoffman et al., n.d.) making work difficult to manage. People with GAD are more likely than those without GAD to miss at least one day of work per month (Olfson et al., 2000). This number of impairment days is equivalent to other chronic physical diseases including ulcers, arthritis, diabetes and autoimmune diseases (Kessler et al., 2001).
When compared to other mental disorders GAD is less impairing than mood disorders but more impairing than other anxiety disorders including agoraphobia, social phobia, simple phobia and obsessive-compulsive disorder and panic disorder (Hoffman et al, n.d.). GAD is reported as more impairing than substance use disorders, schizophrenia, and bulimia nervosa (Hoffman et al, n.d.). Participants in studies of GAD and major depressive disorder were more likely to report impaired role functioning than pure major depressive disorder patients (Hoffman et al, n.d.).
Treatment
Anxiety doesn’t always need to be treated; however, anxiety should be treated whenever symptoms are affecting day to day life and impairment in social and occupational functions. For a person living with GAD having a trusted physician relationship is essential. The physician can act as a go-between for pharmacological approaches and talk therapies as well as for alternative treatments and education (Locke, Kirst, Shultz, 2015). Primary treatment options for GAD include pharmacological approaches and talk therapies (Bandelow, Michaelis, Wedekind, 2017). In addition to patient education and alternative therapies may help the person living with GAD to make adjustments to improve quality of life (Bandelow, Michaelis, Wedekind, 2017).
As a rule, medications must be titrated carefully and slowly to decrease side effects. To determine effectiveness the medication must be taken at least 4 weeks and at the high end of the dose range. Medication should be continued for at least one year. Many people with GAD require longer treatment (Locke, Kirst, Shultz, 2015).
The pharmacological options to treat GAD include selective serotonin re-uptake inhibitors (SSRI’s), traditional tricyclic antidepressants and benzodiazepines (Bandelow, Michaelis, Wedekind, 2017). SSRI’s and selective serotonin norepinephrine reuptake inhibitors (SNRIs) are usually the first drugs prescribed (Bandelow, Michaelis, Wedekind, 2017). Neither SSRI’s or SNRI’s have an immediate effect (Bandelow, Michaelis, Wedekind, 2017). In fact, both classes of medications require at least 2 weeks and as many as 6 weeks before the person with GAD receives any benefit from the medications. With SNRI’s and SSRI’s cause increased effects during the first two weeks of usage. These effects include jitters and increase of anxiety as well as GI issues. These side effects can reduce compliance with taking the medications. If patient’s experience negative side effects and discontinue SSRI’s or SNRI’s withdrawal may occur and symptoms may sharply increase (Bandelow, Michaelis, Wedekind, 2017).
While not used as often since the release of SSRI’s or SNRI’s, traditional tricyclic antidepressants (TCAs) imipramine and clomipramine are also prescribed for GAD (Bandelow, Michaelis, Wedekind, 2017). This class of drugs has a higher frequency of adverse events than SSRIs (Bandelow, Michaelis, Wedekind, 2017). The dosage must be increased slowly until levels reach those used in the treatment for depression (Bandelow, Michaelis, Wedekind, 2017). TCA’s have a high potential of fatal toxicity if the person overdose on the medication (Bandelow, Michaelis, Wedekind, 2017).
Cognitive behavior therapy (CBT) is an important treatment for GAD and is a first line of treatment (Bandelow, Michaelis, Wedekind, 2017). CBT works because it teaches skills to manage anxiety. These skills have a more long-term benefit than medication without side-effects. Patients with anxiety disorders benefit from supportive talks and attention to the emotional problems associated with anxiety disorder (Bandelow, Michaelis, Wedekind, 2017). CBT sessions are most often individual sessions sixty minutes in length. Patients may need twelve to sixteen sessions to reach maximum effectiveness (Stein, 2015).
Benzodiazepines have the potential to take effect nearly immediately. The effects of benzodiazepines begin soon after oral or parenteral application. Benzodiazepines do not lead to increased jitteriness and insomnia; however, benzodiazepine may be associated with central nervous (CNS) depression (Bandelow, Michaelis, Wedekind, 2017). This CNS depression may result in fatigue, dizziness, increased reaction time, and impaired driving skills (Bandelow, Michaelis, Wedekind, 2017). Benzodiazepines do not improve long term outcomes, and, in fact, long term treatment may result in dependency (Bandelow, Michaelis, Wedekind, 2017). Benzodiazepines are recommended only to achieve control during a crisis and are not typically not prescribed for long periods of times because of the potential for abuse and addiction. Of note, benzodiazepines with a long onset of action have less potential for abuse and thus may be use for long term treatment. The most well-known of these drugs is Klonopin (Locke, Kirst, Shultz, 2015).
In addition to CBT, many other therapies are effective and available to at least some people with GAD. One type of therapy is called psychodynamic therapy which helps to address underlying conflicts that can be the reason for anxiety (Stein, 2015). Another therapy is called applied relaxation therapy which teaches different approaches to initiating a relaxed state (Stein, 2015). Group based sessions of CBT or psychodynamic therapies are also an option (Stein, 2015) Group therapies and information about self-help aren’t as common in the United States because of their lack of availability (Locke, Kirst, Shultz, 2015).
While GAD is a physical illness created by a confluence of childhood development, genetics and the living environment and the impact on the brain, the way people experience it is influenced by cultural and social norms in popular culture. This has consequences for how both medical providers and patients explain and understand the symptoms and for how patients experience GAD.
Popular Culture
People with mental illness are portrayed in many ways in popular media. Often symptoms are exaggerated. People are considered geniuses or incredibly mentally incapacitated. This is often seen in both old and newer movies. In sit-coms anxiety disorders are often trivialized and the punch of a joke. This trivializes anxiety disorder and may make it more difficult for people with GAD to seek help.
People with GAD as well as other disorders may not show outward signs of illness; thus, it is easy for symptoms to be dismissed as “all in the head”. Politicians often infer in press conferences and statements that people who do not have obvious physical ailments are “faking” and, if the person only worked harder or wanted to get well, they would, indeed, get well. This negative stereotyping creates barriers to people with GAD and other disorders to get treatment. Thirty second sound bites are often used to elect politicians who have little or no understanding of disorders including GAD. These politicians, then, become responsible for passing laws and allocating money for treatment of mental illness and because of their lack of knowledge often vote against programs that would benefit people with GAD and other illnesses.
Sometimes anxiety disorders are portrayed as an “interesting quirk of character”. This happens in both print and movies. The difficulties with family relationships and work are rarely portrayed. Rarely if ever is a person seen recovering or becoming stable on medications. And love often conquers all. As soon as a love relationship is engaged in the anxiety disorder magically disappears.
Conclusion
Despite GAD being common it often goes unrecognized and untreated for long periods of time. In part this is because of the popular portrayal of mental illness in our culture. GAD is treatable and does not have to be life changing. Seeking treatment early and remaining in treatment for a enough time will provide the greatest benefits to people with GAD. More research and advocacy is needed for all types of mental illness as well as for GAD.
