General Anxiety Disorder

Case 1- AH

 

            The  DSM-IV defines General Anxiety Disorder (GAD) as including “excessive anxiety and worry,” that is, worry that occurs “more days than not for at least 6 months”.  Some worry is adaptive to every day life, but in the case of GAD, the worry is intrusive to one’s life, making it difficult to complete even simple tasks.  “Normal” worry is what most people would label “concern”.  It is typical to be “concerned” about an upcoming test or another specific event. “Worry” constitutes an unjustifiable concern about aspects of one’s life that he or she has no control over.

            Barlow and Durand (2005) claim that “what distinguishes pathological worrying from the normal kind” is the level of difficulty in “turning off or controlling” the worry process.  The worry found in GAD consumes the thoughts of the sufferer.  The worry characteristic of GAD has other related effects as well.  Difficulty concentrating, muscle tension, and sleep disturbance are not usually characteristic of normal concern, or, if these symptoms are present, they do not last for any extended period of time.

            Worry can have some adaptive qualities.  If we did not “worry” to some extent about how people react to our behavior, we would lack many interpersonal relationships. “Worrying” about completing assignments on time keeps many people from procrastinating or putting responsibilities off until it is too late to complete them well.  “Worrying” about car crashes, home theft, or other safety hazards may cause us to pay more attention to our behavior and take preventative measures against the things we can control (wearing a seat belt, installing a modest security system, or being extra cautious when in dangerous situations).  Worry, therefore, can highten our awareness to aspects of our environment that may be detrimental to survival.

Again, one must refer back to the varying degrees of “worry” that can be experienced.  Worry can be a positive, adaptive state that enhances performance.  For example, one may have concern about doing his job well, so he checks back over his work in order to make sure he did not make any careless errors.  Worrying about a specific event or situation that could have negative consequences in our lives is not necessarily a hindrance.  AH’s behavior pattern of arriving at work early in order to play out her day is neither an unusual nor a harmful behavior. It may help her to be more focused on what she needs to do for the rest of the day.  However, the frequency and uncontrollability of her worry, along with the presence of other interruptive symptoms constitute a diagnosis of GAD.

Negative effects occur when an individual’s thoughts become preoccupied with worry.  If a person worries so much that he or she becomes anxious, the worry is no longer adaptive.  It is not difficult to let worry consume one’s life; there are many things that can and will “go wrong” in one’s life every day, but this is normal.  When worry becomes so prevalent that it affects other processes, such as concentration or interactions with other people, it is problematic.  AH experienced a lack of concentration, difficulty in relaxing, uncontrollable worrying, irregular sleep patterns, and frequent muscle tensions and tension headaches.  Normal amounts of worry could have enhanced AH’s job performance, but because her worry was excessive, she “would be less attentive to her work and thus was more apt to make mistakes”.  In abnormal amounts, worry definitely has negative affects.

GAD typically has an earlier onset than other anxiety disorders.  “Its age of onset is between the late teens and early twenties,” and usually takes a chronic course (Caycedo and Griez, 2001).  Stress also plays a significant role in the appearance of GAD (Barlow et al., 1986).  This is probably due to the compounding nature of stress and worry in general.  Stress has a tendency to build up, which can cause considerable worry, even if one does not have general anxiety disorder.  The buildup of stress then causes worry, which could lead to perpetual worry—GAD.  For example, one may start worrying about a paper that is due.  The stress builds when he finds out that there will be a test soon in another.  Before long, any assignment, no matter how trivial, seems overwhelming.  The same is true with worry and stress in other aspects of life as well. 

The tendency to worry excessively is probably more of an enduring personality characteristic than something that occurs only occasionally.  We all have some tendency to worry a great deal about specific events, but we can usually get “back on track” by putting things into perspective fairly easily.  Excessive worry, however, seems to be enduring, almost perpetual.  If someone suffering from stress has no way of overcoming it or putting things into perspective, worry can easily take over and become uncontrollable.  Though we all experience moments of worry or anxiety, those with GAD have an enduring personality characteristic that causes them to be more anxious more frequently than an average “stressed” person.  To “worry” or “stress out” about an upcoming test is much different than uncontrollable “worrying” about any and all aspects of life.

A popular treatment for GAD is benzodiazepines; however, in the case of AH, whose job requires her to be alert and aware, these may not be a good choice.  One of the fears that AH mentioned most was that she would make errors in her work. Because benzodiazepines may affect performance at work and school, they might cause AH to experience even more anxiety by worrying that, since she is on medication, she may make even more errors at work. 

Borkovec and Inz (1990) found that “people with GAD engage in frantic, intense though processes or worry without accompanying images”.  In other words, they attempt to avoid the negative thoughts instead of dealing with them in their entirety.  This, Berkovec says, may be the central problem in GAD.  Cognitive-behavioral treatment requires patients to “confront anxiety-provoking images and thoughts head-on” (Barlow and Durand, 2005).  The best way to handle stress in minor cases is to talk about what is causing the person anxiety, put things into perspective, and then develop a rational plan of action that will lessen the stress.  (For example, if a student is “stressed out” because she feels she has too much work to do, she can talk to a friend or advisor who can help to develop a “priority list” that will help her complete assignments accurately and on time.)  A plan of rationalization helps the anxious person to deal with stressors directly and completely.  CBT seems to work in a similar way.  A good form of treatment for AH would probably be to face “head-on” what is bothering her, and then attempt “to ‘process’ the images and negative affect associated with anxiety” (Craske and Barlow, 1988).