Generalized Anxiety Disorder

Frequency:
Lifetime prevalence: 5%
12 month prevalence: 3%
Age: Onset in early 20s is not unusual
Sex: Male-Female ratio: 1:2

Genetic factors: Evidence indicates that genetic factors play a role in the anxiety disorders, although there are other factors which may also be important.
Neurochemistry: Abnormalities in a number of brain neurotransmitter systems (chemicals) have been implicated in the aetiology of GAD.
Psychological theories: Anxiety is experienced for the first time during the process of birth.
Learning theories: Anxiety is a fear response that has been attached to another stimulus by conditioning. Anxiety thus can be learned and unlearned through experience.
Psychosocial stressors are also very important in the causation of GAD

Let’s now look at some of the common symptoms, i.e. what do people experience when they are anxious:

The symptoms can be divided into three main categories:
• Physical or somatic symptoms
• Psychological symptoms and
• Behavioural symptoms

Heart racing or palpitations
Dry mouth and difficulty swallowing (like a lump in the throat)
Dizziness or light-headednessLegs feeling weak, “like jelly”
Stomach churning and feeling sick (like butterflies in the tummy) (In Hindi, Pet mein gud gud hota hai!)
Increased shakiness, especially of hands and arms
Tingling and numbing sensation
Feeling hot, sweaty and flushed (for example, when I first moved to UK and took a driving test for my licence, I started sweating in the cold winter!! The driving examiner sitting beside me in the car asked me, “It can’t be that hot, what’s the matter? Why are you sweating so much?” I replied, “That’s because I am anxious”!!!)
Wanting to go to toilet (luckily it didn’t happen to me at that time)
Muscle tension
Rapid breathing, tight band across chest (In Hindi, “Dum ghutne lagta hai”)

Feeling frightened and panicky
Thinking that you might be losing your mind
That you might be having a heart attack
Feeling that you are losing control
Worrying that you may faint or vomit
Worrying that there may be something wrong seriously wrong with your brain
Worrying that you might a fool of yourself in front of other people by saying or doing something silly
Wanting to escape and to get to a safe place (In Hindi, “Dil bhaagna chahta hai”)

These are behaviours we resort to, in order to cope with some of the above symptoms. For example,

Making excuses to avoid doing something (like postponing sitting exams
Only shopping when it’s quiet or in small shops to avoid crowds
Rushing out of places or situations when feeling anxious
Avoid going to parties or functions
Avoid speaking when with other people
Avoid going out alone, or insist on taking someone with you
Using other props, like taking alcohol or taking a tablet

I shall try to explain what happens to your body when you get anxious and why you experience all those physical symptoms that I mentioned above. Let’s take another common example. Imagine you are crossing a busy road, when suddenly you hear a very loud car horn go off a few feet away from you and also hear sound of screeching brakes. What almost everyone does in this situation is to immediately jump or run, even before one has had a chance to think about what is happening. Having got out of the way of the car, you will then be left feeling a bit shaky, with your heart beating faster as well as some of the other symptoms in the list of physical symptoms that I mentioned before.

What actually has happened is that a split second after you heard that horn and screeching brakes, what we call the anxiety response in your brain was switched on. What the anxiety response does is that it prepares your body for immediate action in the face of danger. In practice, this means the following:

Your heart rate shoots up: This is in order to pump extra blood to the muscles of your arms and legs much more quickly, because you will be using your arms and legs to get out of the danger.

To keep your heart beating at this fast rate, you need extra oxygen to give the heart energy – so you breathe much more quickly to get the extra oxygen.

Because of the extra energy being sent to your arms and legs, the muscles are tenser, and are ready to spring into action.

Because your arms and legs need this extra blood for the muscles, much of the blood that usually goes to the stomach area is redirected away from the stomach and is sent to the arms and legs. This leads to the churning feeling in your stomach.

For the above reason, blood is also directed away from your brain, hence you feel light-headed and dizzy.

As your heart is pumping blood more quickly around your body, especially to the muscles, your temperature increases to cool your body down, you perspire more. Hence you feel hot and sweaty.

Now we turn to look at what you think and feel when your body is producing the physical symptoms, i.e. your psychological responses to anxiety. You begin to feel that you are losing control. This happens because when you don’t know what the physical symptoms mean; you cannot understand what is happening to you and your body. This is where nearly everyone will tend to think the worse, “Oh God! I am having a heart attack” or “I am going crazy”. In turn these thoughts will make you more anxious and this leads to a vicious circle.

The various psychological therapies that are employed in the treatment of anxiety disorders differ from place to place and from person to person, depending on individual needs and more importantly resources and availability. Some of them are explained briefly here.

Counselling
Counselling may be defined as “talking therapy”, which aims to ease a person’s discomfort, pain, distress or impaired performance.

Behaviour therapy
The most common form of behaviour therapy is exposure to the anxiety-provoking stimulus. People are repeatedly exposed to the stimulus until anxiety or panic subsides.

Cognitive therapy
This involves identifying the causes of anxious thinking (i.e. illogical ideas or automatic false notions) and the adoption of more logical (correct or accurate) ways of thinking. It is very effective but because it can be offered only by trained specialists, it may not be readily available.
Cognitive-behavioural therapy or CBT is a combination of two kinds of therapy -cognitive and behavioural. In behavioural therapy, as the name suggests, people learn how to change behaviour. Behaviour therapy helps you weaken the connections between troublesome situations and your habitual reactions to them, reactions such as fear, depression or rage, and self-defeating or self-damaging behaviour. It also teaches you how to calm your mind and body, so you can feel better, think more clearly, and make better decisions. You may have already heard of the most common behavioural techniques used in the treatment of anxiety disorders: desensitization, relaxation and breathing exercises.
On the other hand, cognitive therapy focuses on thoughts, assumptions and beliefs. With cognitive therapy, people may learn to recognize and change faulty or maladaptive thinking patterns. Cognitive therapy is not about "positive thinking" in the sense that you must always think happy thoughts. It's a way to gain control over racing, repetitive thoughts which often feed or trigger anxiety.
The two therapies often are used together because they are beneficial to each other. For example, in the midst of extreme anxiety, it may feel impossible to gain control over your thoughts and apply cognitive therapy techniques. Therefore, a behavioural technique such as deep breathing may help you calm down and focus on your thinking.

Relaxation techniques
Relaxation is the voluntary letting go of tension. This tension can be physical tension in the muscles, or it can be mental or psychological tension. When we relax physically, certain impulses are sent to brain, which in turn bring about a general feeling of calm, both physically and mentally. The purpose of muscle tension is to increase your alertness and readiness to respond. However, constant tension makes people oversensitive and they begin to respond to even smaller events as though they were threatening. By learning to relax, you can gain control over those feelings of anxiety. The three main components of relaxation therapy are:
Learn to recognize tension
Learn to relax your body in a general, total sense
Learn to let tension go in specific muscle groups.

Deep Breathing is one of easiest stress management techniques to learn and the best thing about it is it can be done anywhere! When we become stressed, one of our body's automatic reactions is shallow, rapid breathing which can increase our stress response. Taking deep, slow breaths is an antidote to stress and is one way we can "turn-off" our stress reaction and "turn-on" the relaxation response. Deep breathing is the foundation of many other relaxation exercises.

Get into a comfortable position, either sitting or lying down.
Put one hand on your stomach, just below your rib cage.
Slowly breathe in through your nose. Your stomach should feel like rising and expanding outward.
Exhale slowly through your mouth, emptying your lungs completely and letting your stomach fall.
Repeat several times until you feel relaxed.
Practice several times a day.

Progressive Muscle Relaxation
Our muscles respond to thoughts of perceived threats with tension, which is one of the most common stress symptoms. Too much tension can cause stiffness and may result in headaches, stiff necks and backaches. One way to relieve this tension is through Progressive Muscle Relaxation (PMR). It involves tensing, then relaxing the body muscles from head to toe. Since PMR can increase blood pressure, people with hypertension should not use this technique.
Wear lose, comfortable clothing. Sit or lie down somewhere comfortable.
Begin with your facial muscles and frown hard for 5-10 seconds, then relax all your muscles.
Work other facial muscles by clenching your jaw, tightly closing your eyes, and raising your eyebrows for 5-10 seconds. Feel the tension in these muscles and then release.
Then move on to other muscle groups, raise your shoulders, tighten your arms, your chest, your back, legs, etc.-until you've tensed and relaxed your whole body.

Social skills training

Some people lack appropriate social skills that are required of them by the demands of the society. It is precisely the reason why some people become anxious among strangers or in strange situations. Social skills’ training helps you to develop ways of:
• Meeting new people and establishing relationships
• Speaking effectively in public, whether formally or informally
• Holding up your end of a personal or group discussion
• Getting actively involved in group and leadership activities
• Establishing new romantic relationships on a realistic and enduring basis
• Ending relationships that aren't working out in a civil and appropriate fashion

Treatment by medications:
The following are some of the groups of medication used in the treatment of generalized anxiety disorder:

Benzodiazepines
Most of them are effective in the short term. They are relatively fast acting drugs. But the main problem with this class of drugs is dependency (addiction). People taking such drugs may experience a return of their anxiety symptoms when they stop the medication. A gradual reduction of the dose with the help of your psychiatrists will prevent a relapse or withdrawal symptoms. Some of these are Diazepam (Calmpose), Alprazolam (Xanax), Temazepam etc.

Tricyclic antidepressants (TCAs)
These drugs are usually used in the treatment of depression. Some of them however are also used in the treatment of anxiety disorders. Examples are Imipramine, Amitriptyline etc.

Selective serotonin reuptake inhibitors (SSRIs)
These were also used first for the treatment of depression, but are now being used, at times with good results, for the treatment of anxiety disorders. Examples are Flouxetine (Prozac), Sertraline etc.

Beta blockers
Beta blockers are mainly used to reduce some of the physical symptoms of anxiety, like a pounding heartbeat, sweating and shaking, and to control anxiety in public situations. But these drugs also reduce blood pressure and slow the heartbeat. E.g. Propranolol

Buspirone
This has been shown to be useful in the treatment of GAD. It takes about 2-4 weeks to relieve symptoms of GAD. Importantly it is not habit forming (non-addictive), and does not have many side effects.

G Andrews et al., in the Treatment of Anxiety Disorders, UK: Cambridge University Press, 1994.
Companion to Psychiatric Studies, Eds. Johnstone, Freeman & Zealey. Edinburgh: Churchill Livingstone, 1998.