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An Overview of Generalised Anxiety Disorder (GAD)

Generalised anxiety disorder (GAD) - despite its name - is a specific type of anxiety disorder. The hallmark feature of GAD is persistent, excessive, and intrusive worry.

Anxiety disorders are a class of mental disorders that distinguish themselves from other problems with two key features: fear and anxiety. Fear is an emotion experienced in response to an imminent threat (real or imagined). Anxiety, on the other hand, is an emotional state experienced in anticipation of a potential future threat.


Who Gets GAD?


Though the median age of onset is 30 years, later than that of other anxiety disorders, GAD can occur at any point in the life cycle.


Women are about twice as likely to develop GAD in their lifetime as men. Because women experience anxiety more frequently, experts recommend routine anxiety screenings for women and girls aged 13 and older. Anxiety can grow worse over time if left untreated, so early detection is important to protect well-being.


GAD is among the three most common psychiatric problems in children (alongside separation anxiety and social anxiety disorders). Early-onset anxiety disorders can put children and teens at greater risk for a range of other psychological issues in adulthood.


However, early detection and intervention can result in significant or full remission of symptoms and may protect against the development of other problems later in life.


GAD is also the most commonly occurring anxiety disorder in older adults. New-onset GAD in older adults is commonly related to co-occurring depression. In this age group, GAD has historically likely been under-diagnosed and under-treated for a number of reasons.


However, as the field of geriatric psychiatry grows, so too does research about GAD in older adults and its treatment (including ways to overcome typical barriers to mental health care).


Signs and Symptoms


To meet formalised diagnostic criteria for GAD, excessive anxiety and worry must be present most of the day more days than not for at least six months.


Features of excessive worry include:

  • Worry even when there is nothing wrong.

  • Worry about a perceived threat in a manner that is disproportionate to the actual risk.

  • Worrying about something for the majority of your waking hours.

  • Asking others for reassurance about your specific concern, but continuing to worry anyway.

  • Worry that shifts from one topic to another.

Worries may manifest differently in adults versus children, but in both cases, they tend to be about typical life circumstances or stressors (e.g., health issues, financial matters, starting a new school or job).


For people with GAD, the worry is very difficult to control and is associated with multiple physical or cognitive symptoms such as:

  • Fatigue

  • Impaired sleep

  • Irritability (sometimes observable to others)

  • Muscle tension or soreness

  • Poor concentration (sometimes with memory problems)

  • Restlessness or edginess

Many people with GAD also experience other uncomfortable markers of prolonged anxiety, including sweating, stomach upset, or migraine headaches.


Symptoms Throughout Life


People with GAD will often describe themselves as feeling anxious or on edge for most of their lives. The expression of symptoms appears consistent across age groups. However, the content of the worry does tend to change across the lifespan.


Younger individuals may worry more about school and performance, while older people focus more on physical health, finances, and family’s well-being.


For those meeting the threshold of the formal diagnosis, symptoms tend to be chronic but wax and wane between full- and sub-threshold forms of the disorder over time.


Though remission rates are low overall, GAD symptoms are known to improve substantially when treated with psychotherapy, medication, or both.


Treatment can provide the tools necessary to help people with GAD successfully navigate subsequent periods of high stress and transition.


Diagnosis


GAD can be challenging to accurately identify because anxiety is an emotional state that everyone experiences from time to time in response to the stresses of everyday life. In fact, moderate anxiety can be quite helpful in a range of ways. For example, it can provide the motivation to get things done or to respond to actual threats to our safety if they occur.


The diagnosis of GAD occurs, however, when anxiety crosses a threshold of excessiveness and stays there for extended periods of time. In these cases, the anxiety, worry, or other symptoms make it extremely challenging for the person to fulfill responsibilities on a daily basis. This can result in a strain in personal relationships or problems at work or school.


GAD is typically diagnosed by a mental health professional or a physician. During an evaluation, the clinician will ask you about your symptoms and may use clinical judgment or standardised assessment tools to make a diagnosis. You may be asked to undergo or provide records from a physical exam by a medical doctor to ensure that physical and cognitive symptoms are unrelated to other medical problems.


Speaking openly with your provider is critical - it’s simply the best and fastest way to arrive at an appropriate treatment plan and get some relief from your symptoms.


As part of a thorough evaluation, your clinician will ask a range of questions about symptoms or behaviours that may or may not apply to you. This might include questions about your mood, eating behaviour, substance use, or history of trauma.


Your answers will help your healthcare provider to rule out other psychiatric problems or decide that your symptoms are better explained by a different diagnosis.


Newly Diagnosed


Receiving a diagnosis of GAD - or any psychiatric disorder - is an important step towards feeling better because diagnoses are used to guide treatment recommendations. Participate actively in a discussion with the diagnosing clinician to understand your treatment options and evaluate the best place to start.


If you are considering psychotherapy as a first-line treatment, educate yourself about evidence-based approaches such as cognitive behavioural therapy and acceptance and commitment therapy. Learn about what you can (and cannot) expect from the talk therapy process overall.


Differential Diagnosis


It is not uncommon for people with GAD to meet the criteria for another psychiatric diagnosis in the course of their lifetime. If multiple disorders occur simultaneously they are referred to as comorbid conditions.


The most commonly co-occurring disorder with GAD is depression.


However, a substantial subset of people struggles with co-occurring GAD and other anxiety disorders. Your psychiatrist will be able to accurately differentiate between the conditions and treat each appropriately.


Causes and Risk Factors


Like many other psychiatric disorders, GAD is thought to emerge in the context of particular biological and environmental factors.


A key biological factor is a genetic vulnerability. It is estimated that one-third of the risk of experiencing GAD is genetic, but genetic factors may overlap with other anxiety and mood disorders (particularly major depression).


Temperament is another associated factor with GAD. Temperament refers to personality traits that are often regarded as innate (and therefore might be biologically mediated).


Temperamental characteristics known to be associated with GAD include harm avoidance, neuroticism (or the tendency to be in a negative emotional state), and behavioural inhibition.

No specific environmental factors have been identified as specific or necessary to cause GAD, but environmental features associated with GAD include (but are not limited to):

  • Exposure to an unsafe setting (including trauma).

  • Modelling of dealing with stress in an anxious manner.

  • Observation of constant worrying by family members.

  • Overprotective parents.

  • Periods of prolonged stress.

Again, no one factor - biological or environmental - is understood to cause GAD. Rather, the disorder is thought to result from a "perfect storm" of environmental stressors that occur in an individual with a genetic predisposition for anxiety.


Treatment


Treatment for GAD typically falls into one of three categories: medication, psychotherapy, or self-help. The goals of any treatment are to help people with the disorder feel better physically and mentally and to make it more possible to fully engage in relationships, at work or school, or in other situations for which the worry previously seemed paralysing.


Treatment research is ongoing and encouraging, particularly with regards to the helpfulness of approaches like yoga and mindfulness. Because anxiety is a natural part of the human experience and treatments for GAD appear to offer far-reaching benefits on day-to-day functioning, even people with low-grade anxiety may benefit from treatment.


Coping


People with GAD have to cope with a variety of physical, behavioural, and emotional symptoms on a day-to-day basis. There are proven strategies to target each.


Social coping strategies, for example, involve talking to someone and recruiting support, while emotional coping strategies like mindfulness and learning triggers can help quell intrusive thoughts and overwhelm.


Every person has a unique situation, and not every strategy will work for everyone. Part of coping involves determining which strategy works best and optimising it to get the most from it.


In Children


While there is no specific known cause, kids in challenging life situations from an early age are at higher risk of developing GAD, and factors like puberty exacerbate the situation.


Up to 10% of children cope with anxiety disorders like GAD.


A proper diagnosis can lead to proper treatment and strategies that'll help the child cope with the disorder throughout their entire life. Parents and caregivers also play a vital role in being able to recognise symptoms and seek help when needed.


For Loved Ones


Caring for someone living with anxiety has its challenges, but there are several ways that you can help including learning about the problem, discouraging avoidance, limiting reassurance-seeking behaviour, and championing successes large and small. If you have an anxious child or teen, review some of the unique aspects of helping youngsters with GAD.


There will, of course, be limits to the ways in which you can be helpful to your loved one with GAD. This is when it is especially useful for your loved one to use the treatment resources (i.e., clinicians) available to them.


If your loved one is reluctant to seek treatment for anxiety, or is unaware of the severity of the problem, look for a quiet moment to have a non-judgmental conversation about how treatment might be a way to feel better, faster.


By Deborah R. Glasofer, PhD from Very Well Mind in July 2020


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