Pages 266-269 from the Management of Mental Disorders, published by World Health Organization, Sydney. Editions in Australia, Canada, China, Italy, New Zealand and the United Kingdom.
4.6 Generalised Anxiety Disorder
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Generalized anxiety disorder is all about excessive worry and the tension that results from that. Treatment is therefore about teaching people to worry appropriately (structured problem solving is good for this) and enabling them to be less tense (deep muscular relaxation is useful for this). Sedation with an anxiolytic is really not a good treatment, it just reduces the complaints to the clinician.
4.6.1 Description and diagnosis
Description
Generalised anxiety disorder (GAD) is characterised by persistent, generalised, and excessive feelings of anxiety which are not associated with any particular environmental circumstances but are caused by a general tendency to worry excessively. Typical worries may include such things as: the possibility of the individual or a relative becoming ill or having an accident; exaggerated concern about finances; or excessive worries about work or social performance. The anxiety symptoms experienced by individuals with GAD are variable but may include any of the following:
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Diagnosis
According to the World Health Organization's (WHO) International Classification of Diseases (ICD)-10th Edition, for a diagnosis of GAD the individual must have been bothered by symptoms of anxiety on most days for a period of at least several weeks, but usually for a period of 6 months. The anxiety symptoms involve:
- Apprehension (e.g., worry about the future, feeling `on edge', difficulty concentrating)
- Motor tension (restlessness, headaches, trembling, inability to relax)
- Other symptoms of high arousal (e.g., sweating, accelerated heart rate, dry mouth, stomach upsets, dizziness, light-headedness)
Differential diagnosis
A routine medical assessment is required to ensure organic or physical disease is not causing the anxiety symptoms (e.g., hyperthyroidism). Typically, individuals with GAD will already have consulted with a general medical practitioner who would have ruled out an underlying organic disorder. Individuals with organic anxiety syndrome can present with the same symptoms as in GAD, however, laboratory tests and psychiatric history reveal a clearly identifiable endocrine disorder or psychoactive substance abuse problem.
Adjustment disorder
Often involves anxious mood, however, in adjustment disorder there is a clearly identifiable stressor and an absence of anxiety symptoms prior to that stressor.
The major diagnostic issue is that people who meet criteria for GAD have always regarded themselves as worriers and seldom present for treatment for the worrying, rather to be reassured that what they are worrying about - their children's health, the significance of a symptom - is not true. A history of regular medical attendance for such concerns or for tension headaches and other expressions of anxiety should lead the clinician to enquire about excessive worrying.
Epidemiology
GAD is one of the most common anxiety disorders, affecting 2-8% of the population. This disorder is also one of the most common diagnoses at the primary care (general medical practitioner or community health centre) level. The age of onset of GAD is quite variable, ranging from 20-40 years of age. Research into the male to female ratio of the disorder is equivocal, although it is probable that males and females are equally likely to develop GAD.
Course and prognosis
GAD is a chronic disorder that tends to develop gradually and fluctuate in severity over time. The course of the disorder can be either constant, or waxing and waning in nature. Although most individuals appear to be symptomatic for the majority of time since the onset of the disorder, about one quarter of individuals with GAD exhibit periods of remission (three months or longer without symptoms). The anxiety and worry associated with GAD can be made worse by stress.
Assessment
The rationale for assessment is discussed in the section on Panic Disorder. Hopkins Symptoms Checklist is discussed in that section and will also be useful for assessing symptom levels and measuring improvement in GAD.
4.6.2 Management plan for GAD
Management strategies will always vary from one individual to the next depending on the individual's particular problems. Generally, however, the management of GAD usually involves:
- Ongoing assessment of the disorder
- Education about the nature of anxiety, tailored to each individual's needs. Some basic information about anxiety is provided in Section 4.1 and includes:
- The nature of anxiety
- Management of the fight-or-flight response
- The role of hyperventilation in anxiety
- Training in strategies for controlling anxiety and reducing stress:
- Relaxation methods and breathing control to reduce physical symptoms of anxiety
- Planning short-term activities which are relaxing or distracting (particularly those activities that have been helpful in the past).
- Using structured problem solving to help individuals deal with stressors that may contribute to worry (Section 4.6.3).
- If individuals avoid situations or activities because of anxiety, encourage them to gradually confront the things they fear using graded exposure (Section 4.3.4).
- Regular physical activity or exercise is often helpful.
- Individuals are to be encouraged to avoid using sedative medication or alcohol to control their anxiety.
- Referral or specialist consultation if symptoms persist for longer than three months despite the above measures.
4.6.3 Structured problem solving
When faced with difficult life problems, many individuals do not have adequate coping skills and consequently feel that they are not able to control what is happening to them. They may therefore feel threatened by the stresses around them.
These feelings of threat and lack of control contribute greatly to the development of anxiety and stress. Everybody has problems in their lives, however, these problems can become more apparent and more difficult to deal with if anxiety is high. For individuals who have high anxiety and difficulty coping with life problems, training in structured problem solving may be extremely useful. Effective problem solving skills can reduce, minimise, control, or even prevent stress and anxiety in daily living.
Detailed information about the use of the structured problem solving technique which is very important in the treatment of GAD is provided in Chapter 1: Core Management Skills.
4.6.4 GAD case study
Ben Walters, an unmarried 24 year old post-graduate university student, was referred to your centre by his supervisor. His psychiatric history reveals the following information:
Psychiatric history
Presenting problem
Ben reported that he has been feeling anxious for a long time but that of late his anxiety has been a lot worse. He says his anxiety is more severe than it used to be.
History of present illness
Ben described himself as having always been a worrier and could not recall a time when he had not experienced some degree of anxiety. He reported that he tends to overplan everything to prevent disaster, which results in tension and frequent headaches. This problem was particularly bad during the last three years of high school. He said he has always had trouble making decisions for fear of making mistakes and upsetting others, and now worries a lot about what his supervisor will think of him. However, he does not get anxious about engaging in social situations. For the past several weeks he has begun to experience bouts of fearfulness upon waking in the morning, and feels nervous, agitated, light-headed, and his heart pounds. He finds it difficult to concentrate on his study with his thoughts going "round and round like a record" - thoughts from which he has difficulty distracting himself. He has become frightened of going to university, worries about what misfortunes might befall him, or becomes anxious if he feels he has nothing planned for the day. His sleep and appetite are normal and he does not appear to avoid any specific situations.
Personal and Family History
Ben remembers having lots of friends at school. He also has childhood memories of his father being abusive and constantly telling him that he is stupid. He worked extremely hard at school to counter this criticism and was academically above average. He moved out of home when he started a degree in economics and is now in his second year of a Ph.D. He has had a long-term relationship in the past but currently has no girlfriend.
Previous Psychiatric and Medical History
Ben was prescribed diazepam by his general practitioner four weeks previously but has only taken this medication on three occasions because it makes him too sleepy. He has had no significant medical or psychiatric problems in the past. He does not smoke, drinks only a small amount of alcohol on social occasions, and does not use illicit drugs. He has avoided caffeine for the past month as he has noted that caffeine increases his anxiety symptoms.
Premorbid Personality
He presented as a cheerful and sensible individual, with a positive outlook on life despite his current difficulties. He does, however, have obsessional personality traits as indicated by his need to do everything perfectly. He also reports that he was quite moody when he was younger and that he has never had a great deal of self confidence.
Mental State Examination
Ben was appropriately dressed, neatly groomed, well spoken, and appeared to be in control. His mood was normal and there was no evidence of formal thought disorder, abnormal perceptions, or delusional ideas. Cognitive function was normal and insight was good.
Management
You ask Ben to fill out the Hopkins Symptom Checklist (HSC) so as to obtain an overall rating of his level of distress. He obtains a score of 60 with the highest scores being for items 1, 2, 3, 10, 31, 35, 44, 46, 48, 55, and 57 (all relating to feelings of worry, uncertainty, or physical complaints such as headaches or breathing difficulties). You find that he does not experience panic attacks.
From the information you have obtained you decide that Ben has generalised anxiety disorder. The following management plan is devised (the number of sessions will vary for each person):
- Ben will receive education about the key features of anxiety and generalised anxiety disorder. Ben's responses to the HSC will be discussed. He will also be given the hyperventilation questionnaire and taught breathing control. He will take home the handouts in Section 4.14.4, 4.14.5, and 4.14.6. Ben will then be taught about structured problem solving.
- Each new session will begin with a discussion of any problems or questions that may have arisen since Ben's last visit. Ben will be taught about the importance of relaxation and given a copy of the handout in Section 4.14.7. Training will be provided in progressive muscle relaxation and other possible relaxation techniques will be discussed (e.g., distraction from worries by engaging in pleasant activities; regular exercise; meditation).
- The next session will start with a discussion of how Ben is progressing with his breathing and relaxation exercises. The importance of regular (daily) relaxation will be emphasised.
- Follow-up will be organised for one month and three months. On each occasion the HSC will be administered to measure progress. If Ben's anxiety has not improved he will be referred elsewhere for specialist consultation.
Pages 301-303 from the Management of Mental Disorders.
4.14.6 Recognising tension
For the week monitor the tension in your body. Use the following form to record the location of your tension and the degree of tension. Monitor your tension levels at about the same time every day. Before your evening meal is usually a good time for this exercise.
In each box place the number corresponding to your level of tension.
4.14.7 Learning to relax
Relaxation is useful for reducing physical and mental tension. Relaxation helps people to: reduce worry and anxiety, improve sleep, and relieve physical symptoms caused by stress (e.g., headaches, stomach pains, diarrhoea or constipation).
If you follow the steps below you will be well on your way to learning how to relax. This exercise should take about 15-20 minutes. However, if you only have 5 minutes to spare, 5 minutes is certainly better than nothing!
1. Find a quiet and relaxing place
Choose a comfortable chair in a place which is free from noise and interruptions (make sure you take the phone off the hook). You may need to explain to your family what you are doing so that they will not disturb you. Telling your family may also reduce any embarrassment you may feel.
2. Clear your mind
Try to clear your mind of all worries or disturbing thoughts. If these worries or thoughts drift back into your mind while you are relaxing, do not worry, just let them float gently out of your mind without reacting to them. Let your mind be clear and calm.
3. Practise the slow breathing method for one minute
Breathe in for 3 seconds and breathe out for 3 seconds, thinking the word relax every time you breathe out. Let your breathing flow smoothly. Imagine the tension flowing out of your body each time you breathe out.
4. Relax your muscles
For each of the muscle groups in your body, tense the muscles for 7-10 seconds, then relax for about 10 seconds. Only tense your muscles moderately (not to the point of inducing pain). Tense and relax your muscles in the following order:
- Hands - curl hands into fists, then relax.
- Lower arms - bend your hand down at the wrist, as though you were trying to touch the underside of your arm, then relax.
- Upper arms - tighten your biceps by bending your arm at the elbow, then relax.
- Shoulders - lift your shoulders up as if trying to touch your ears with them, then relax.
- Neck - stretch your neck gently to the left, then forward, then to the right, then to the back in a slow rolling motion, then relax.
- Forehead and scalp - raise your eyebrows, then relax.
- Eyes - screw up your eyes, then relax.
- Jaw - clench your teeth (just to tighten the muscles), then relax.
- Tongue - press your tongue against the roof of your mouth, then relax.
- Chest - breathe in deeply to inflate your lungs, then breath out and relax.
- Stomach - push your tummy out to tighten the muscle, then relax.
- Upper back - pull your shoulders forward with your arms at your side, then relax.
- Lower back - while sitting, lean your head and upper back forward, rolling your back into a smooth arc thus tensing the lower back, then relax.
5. Enjoy the feeling of relaxation
Sit still for a few minutes enjoying the feeling of relaxation.
Practise once or twice every day for at least 8 weeks.
During the day, try relaxing specific muscles whenever you notice that they are tense.
Edited by Gavin Andrews MD, UNSW, 2007
© 2007 CRUfAD
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