Since he was a toddler, JB had been labeled a “worrywart.” He’d be paralyzed by so many fears while the other kids were outside having fun at recess. Is he doing his homework correctly? Will the teacher notice that one of the crayons in the box is missing? What if she held him responsible? These fears worsened as he grew older, becoming not only more frequent but also more realistic. He’d get nervous when he realized he hadn’t locked the door when he left his house. Because he was constantly insecure about whether or not a relationship would work out, he went from one failed relationship to the next. However, things went from bad to worse during a fire drill. He was walking to his classroom, already on edge after staying up all night preparing for a major exam, when the alarm rang. He thought it was real, it didn’t register in his head that it was just a drill and as he was on the 10th floor of the building, his mind raced to how to get out of the building. His heart pounded loudly inside his chest and he was sweating profusely and he couldn’t move. Students later found him crouched in the corner and it was only when the alarm stopped ringing was he finally able to calm down. He was taken to the school clinic and after several session/s with a psychiatrist, he was diagnosed with Generalized Anxiety Disorder.
Worry is a common emotion. In a world where things are tend to go wrong before they go right, it is only human nature to be in constant anticipation of plans getting messed up and having to deal with the resulting problems and adversities. When we talk about anxiety or more specifically Generalized Anxiety Disorder (GAD), it is imperative to first understand worry as it is its defining characteristic. (Alcaine, Behar and Borkovec 2004). Additionally, The DSM -5 Criteria (APA 2013, 222-226) describes the worry in GAD as unique as it must not contain features from other disorders such as public humiliation in social phobia, fear of compromised hygiene in obsessive compulsive disorder, or the constant worry that one has multiple health issues in hypochondriasis.
GAD is described by the New England Journal of Medicine as a condition “characterized by persistent anxiety and uncontrollable worry that occurs consistently for at least 6 months.” (Sareen and Stein 2015). The worry is multifocal and causes an increased risk of other mental and physical functions with major depression commonly coexisting with GAD. Studies show that patients usually present with neuroimaging of increased activity of components of the limbic system (Robinson et al 2014) , reduced activity in the prefrontal cortex (Ball, Campbell-Sills, and Stein 2013), and a possible decrease in connectivity between both areas of the brain. (Hilbert and Beesdo-Baum 2014).
The worst anxiety attacks can occur for a short period of time or even over days and some patients find themselves unable to leave the house and do their normal day-to-day activities such as going to school or work and relating to people. As a result, jobs are lost and relationships are strained all while the patient is unable to identify the problem. It is sad that in this day and age, there is such a stigma surrounding mental health that most people have a serious life-threatening attack before they seek help. Only then do they learn that there was a solution all along.
One of the main reasons Generalized Anxiety Disorder often goes undiagnosed is due to the wide range of symptoms that often overlap with other psychological disorders and medical illnesses. When a patient is suspected of such, doctors extensively rule out possible causes of anxiety before ultimately referring them to a psychiatrist. Even then, making a clinical diagnosis of GAD is still difficult.
The primary intervention for GAD can be summarized into the 5A’s: Assess, Advise Agree, Assist, and Arrange. Assessing the frequency and duration of how much a person worries as well as do a functional assessment of. The AND I C REST mnemonic by Seitz can be used for to assess for DSM-IV symptoms. It stands for Anxious, No control over worry, Duration of 6 months, Irritability, Concentration impairment, Restlessness, Energy decreased, Sleep impairment, and tension in muscles. (Seitz 2005). Secondly, patients are advised according to the severity of their symptoms as some patients require anxiolytics and extensive therapy while some benefit greatly simply from lifestyle modifications. Third step would be to agree. Agreeing is very important in GAD patients because it effectively targets worrying by affirming their concerns and begins to relax them once they feel that they are finally understood. Fourth step is assisting them in dealing with their anxiety as it will occur often without a health care professional’s immediate assistance. The goal of assisting GAD patients is to improve their coping mechanisms so that they learn to deal and overcome their anxiety instead of trying to escape it. Lastly, it is important to arrange certain things for patients such as regular follow-up appointments so as to monitor their progress and programs that they can do on their own. These five steps provide the background for treatment of GAD patients.
Contrary to popular belief, there are numerous health care professionals that are involved in the therapy of patients with GAD. After the primary care physician examines the patient and eliminates different medical and environmental factors as the causes for the anxiety, the patient is referred to a psychiatrist for diagnosis. After which, the psychiatrist can perform psychotherapy and medication or refer him to a psychologist. Different types of therapy include cognitive behavioral therapy, psychodynamic therapies, mindfulness-based therapy and applied relaxation therapy. Medications include selective serotonin-reuptake inhibitors or SSRIs and serotonin-norepinephrine reuptake inhibitors. or SNRIs. (Stein and Sarin ) These are the three types of health care professionals that are heavily involved in the diagnosis and treatment of GAD. Patients with severe GAD or coexisting mental conditions also greatly benefit from the help of a psychiatric nurse practitioner who may be able to assist them on a more regular basis.
Of the many professionalism characteristics necessary when treating patients especially those with GAD, the three most important are: reliability, demeanor, and accountability. GAD patients require a lot of assurance and it is imperative that they feel that they are heard and understood. Providing reliability would assure the patient that the health care professional is effective and gives them one less thing to worry about. A good demeanor will put the patient at ease even at the peak of a terrible anxiety attack. Accountability will further anchor the health care professional’s reliability and obligation in putting the patient at ease. Patients rely on these professionalism traits in order to be open to the idea that they can overcome their disorder.
Everyone tends to worry. Nothing in life is certain. But there is a line between a normal human response and a clinical disorder. Society especially with the current millennial culture tends to belittle mental conditions and easily shrug of Generalized Anxiety Disorder as something everyone goes through without acknowledging it as a problem. This is why it is so important that treatment strategies are person-centered. Eliminating anxiety is difficulty but dealing with it is possible. Too many GAD patients go undiagnosed and find themselves “self-treating” their anxiety, often with the wrong things like sex, alcohol, and drugs. GAD patients need to acknowledge that they have power over their disorder and regain control of their lives. With the right therapy and necessary medications, there is no reason why they cannot live a normal life.
Ball TM, Ramsawh HJ, Campbell-Sills L, Paulus MP, Stein MB. Prefrontal dysfunction during emotion regulation in generalized anxiety and panic disorders. Psychol Med 2013;43:1475-1486
Borkovec, Thomas D., O. Alcaine, and Evelyn Behar. “Avoidance theory of worry and generalized anxiety disorder.” Generalized anxiety disorder: Advances in research and practice 2004 (2004)
Hilbert K, Lueken U, Beesdo-Baum K. Neural structures, functioning and connectivity in Generalized Anxiety Disorder and interaction with neuroendocrine systems: a systematic review. J Affect Disord 2014;158:114-126
Robinson OJ, Krimsky M, Lieberman L, Allen P, Vytal K, Grillon C. Towards a mechanistic understanding of pathological anxiety: the dorsal medial prefrontal-amygdala ‘aversive amplification’ circuit in unmedicated generalized and social anxiety disorders. Lancet Psychiatry 2014;1:294-302
Sareem, J.S. and Stein, M.B. 2015. Generalized Anxiety Disorder. The New England Journal of Medicine.
Tenorio-Martínez, Rosalía, María del Carmen Lara-Muñoz, and María Elena Medina-Mora. “Measurement of problems in activities and participation in patients with anxiety, depression and schizophrenia using the ICF checklist.” Social psychiatry and psychiatric epidemiology 44.5 (2009): 377.