Generalized Anxiety Disorder Background/Definition/Epidemiology

Humans have a natural response to survival, stress and fear. Such responses enable an individual to pursue pertinent objectives and respond accordingly to the presence of danger. The 'flight or fight' response in a healthy individual is provoked via a real challenge or threat and is utilized as a means of acting appropriately to the situation. However, when an anxiety disorder manifests in someone, then an inappropriate/excessive state of arousal develops. People then feel symptoms of fear, apprehension, or uncertainty. These feelings or reactions may surface even when no real threat exists.

Generalized Anxiety Disorder (GAD), is a common anxiety disorder that affects roughly 5% of the United States general population. "GAD is commonly associated with psychiatric and medical comorbidities and is often chronic. GAD is associated with extensive psychiatric and medical utilization and, if left untreated, can cause impairment as severe as major depressive disorder (MDD)" (Schlaepfer & Nemeroff, 2012, p. 343). The characteristics of GAD are: a near constant state of anxiety/worry disproportionate to the degree of stress/threat, feeling worried/anxious for the majority of days and such feelings persisting for over six months with a worsening of the condition with stress, lack of ability to control anxiety/worry, and feelings of uncertainty of themselves and displays of confirming and perfectionist attitudes.

For there to be confirmed diagnosis of GAD, patients must display three or more established symptoms for most of the time, during the 6 months or more. These symptoms are:

1. Difficulty with concentration

2. Being irritable

3. Experiencing disturbed sleep

4. Being on edge/restless

5. Feeling tired

6. Having muscle tension (Lader, 2015).

Other than these symptoms other symptoms associated with the heart can occur. "Patients have physical anxiety symptoms (such as tachycardia and tremor) and key psychological symptoms, including restlessness, fatigue, difficulty in concentrating, irritability, and disturbed sleep" (Lader, 2015, p. 1).

Pathophysiology

A defined pathophysiology of GAD or any anxiety disorders has not been established. Nevertheless, research suggests there are some mechanisms within the central nervous symptoms that become disrupted in people with anxiety disorders. One such example is the conditioned fear response evident in those with GAD. "Behavioral and psychophysiological findings demonstrated overgeneralization of conditioned fear among patients with GAD. Specifically, generalization gradients were abnormally shallow among GAD patients, reflecting less degradation of the conditioned fear response as the presented stimulus differentiated from the CS+" (Lissek et al., 2014, p. 909). Adding to the notion of conditioned fear response is disruption in the gamma-aminobutyric acid (GABA) system (Lissek et al., 2014). This is why benzodiazepines remain a somewhat effective treatment for those suffering from GAD and other related anxiety disorders. Other areas of interest in understanding GAD from this perspective is the activity in regions of the amygdala that can signal GAD in an individual.

A 2013 study examining the effects of GAD on the human amygdala noted GAD manifestation created changes in the circuits of that region involved with emotion processing. The researchers also found changes and disruptions when it came to coding of interceptive states as well as the processing of fear. "Adolescents with GAD exhibited disruptions in amygdala-based intrinsic functional connectivity networks that included regions in medial prefrontal cortex, insula, and cerebellum. Positive correlations between anxiety severity scores and amygdala functional connectivity with insula and superior temporal gyrus were observed" (Roy et al., 2013, p. 290).

It seems GAD appears to disrupt certain processes within key regions of the human brain. This then can lead to an altered fear/stress response. It can also generate the physical symptoms associated with GAD.

Natural History

GAD seems to be rare in terms of solely appearing in the case of those suffering from GAD. Comorbidity is far more common with GAD presenting itself alongside other psychiatric disorder and normal anxiety. Most with GAD suffer from alcohol abuse, other anxiety disorders, and/or comorbid depression. These disorders tend to occur over the course of a lifetime. While GAD rarely leads to suicide, because of the higher rate of comorbidities, it can attribute to a lower quality of life and thus a potentially...

The discovered the effects of GAD on cardiovascular health seem to form a negative correlation in women. "Current GAD predicted greater cardiovascular mortality (HR-values range from 1.86 to 1.99; p-values ≤ 0.025) independently from MetS and cardiovascular risk factors. In men, the MetS and MDE/GAD were not associated with mortality" (Butnoriene et al., 2015, p. 360). This could be for several reasons. The first is GAD can lead to depression and depression is often associated with lack of activity and poor lifestyle habits (Butnoriene et al., 2015).
Those living with GAD sufferers may see lack of energy, lack of interest, and constant worry. GAD sufferers may pose a problem for those taking care of them or living with them. GAD may also pose a problem health wise if the worry and fear prevents people with GAD from doing the necessary, everyday tasks of life needed to function normally. Because GAD can be chronic and can lead to the complication of MDD, it may lead to lifestyle choices that may be isolative in nature and promote unhealthy coping mechanisms such as alcohol abuse or disordered eating (Butnoriene et al., 2015).

Subjective Data

Clinical Presentation of GAD can appear through discovery of specific habits or symptoms in the patient. For example, worry and anxiety must be associated with 50% of the 6 symptoms listed in the first section. If a patient goes in to discuss his or her history with GAD the patient typically would state he or she has sleep disturbances, may be irritable, restless, and/or easily fatigued. Some questions related to flight or fight response may reveal the patient feels afraid in seemingly normal situations like entering a train, or ruminating over past actions. Because GAD frequently exists as a comorbidity, some questions should lean towards asking if the person has a history or social anxiety, depression, or suffered from any traumatic event in the past.

Sufferers of GAD often note experiencing behavior where they may eavesdrop on conversations or feel they need to know as many details as possible of whatever piqued their interest. They may exhibit low-risk taking behavior, avoidance behaviors, and fear mistakes or criticism. Questions may center on whether the person feels over-responsibility over the situations of others, or hearing negative news. Since perfectionism plays a key role in GAD, some events in a patient's history may reveal unrealistic and unfavorable assessment of their efforts and so forth.

In terms of family medical history, while there is no defined connection of GAD as a potentially inherited, those with GAD tend to have family members suffer from anxiety disorders (Lader, 2015). They also tend to display similar coping mechanisms that their family members have when dealing with anxiety. This leads into social history. Those with anxiety disorders may avoid social situations, especially when the disorder is severe. Avoidant behaviors, negative coping mechanisms like drinking may present in patients with GAD.

Objective Data

In a 2014 study, the researchers examined the clinical presentation of GAD within the human brain. "Generalized social anxiety disorder (GSAD) is characterized by aberrant patterns of amygdala-frontal connectivity to social signals of threat and at rest. The neuropeptide oxytocin (OXT) modulates anxiety, stress, and social behaviors" (Dodhia et al., 2014, p. 2061). They discovered oxytocin played a role in regulating anxiety in patients with GAD.

Higher social anxiety severity in GSAD subjects correlated with lower amygdala-ACC/mPFC connectivity on PBO and higher social anxiety also correlated with greater enhancement in amygdala-frontal connectivity induced by OXT. These findings show that OXT modulates a neural circuit known for social threat processing and emotion regulation, suggesting a neural mechanism by which OXT may have a role in the pathophysiology and treatment of social anxiety disorder (Dodhia et al., 2014, p. 2061).

Oxytocin appears to be an important marker for potential treatment ideas in those suffering from GAD.

Aside from oxytocin, a nurse performing an examination may find other physical positive symptoms may occur like constant worry and worrying to worry. Negative symptoms may be chronic fatigue, a person that easily fatigues, and sleep disturbances. Sleep disturbances are very common among those with anxiety disorders, especially those with GAD. The worrying is a signature aspect of GAD and should be assessed to understand the degree of GAD within the patient.

Since GAD has comorbidity with other disorders, one of which is alcohol abuse, physical symptoms of alcohol abuse may be determined from the examination if it exists in the patient as a comorbidity. Depression and other anxiety disorders like social anxiety disorder may present. This may mean the patient may show positive symptoms like withdrawal or negative symptoms like increased heartrate and sweating.

Assessment and Diagnosis

The five-differential diagnosis…