No More Anxiety

1. Generalized Anxiety Disorder (GAD)

Symptoms

Patients with this disorder appear chronically apprehensive and complain of prolonged worry about ordinary everyday circumstances. In the absence of serious, realistic reasons, they report feelings of apprehension about the health and physical safety of family members, financial situation, or ability to perform at work or school.

An example of this is the mother who fears for her son, temporarily absent, when she hears the siren of an ambulance or an unexpected telephone ring, even though she is aware that he is not in a situation of real danger at that moment. Therefore, a continuous state of alarm and hypervigilance is established due to the belief that negative events have the possibility to occur.

The associated somatic component is constituted by symptoms of the neurovegetative system, including shortness of breath, palpitation, sweating (particularly in the palm of the hand), dry mouth, feeling of "knot in the throat", "light and empty head", hot flashes. Frequent are the disorders of the gastroenteric series: meteorism, digestive disorders, nausea and diarrhea. Symptoms related to a strong muscular tension, particularly in the head, neck and back, are often responsible for widespread pain and headaches located in the occipital and frontal.

Sometimes the involvement of the muscular sphere involves instead tremor and/or contractions and stiffening of the upper limbs. The state of apprehension also causes symptoms of the cognitive sphere, such as reduced concentration, easy distractibility, memory deficits and reduced vigilance.

Sleep disorders manifest as initial, central insomnia or sleep interrupted by frequent awakenings; insomnia may be one of the symptoms that lead the patient to the family physician and may induce the complication of abuse of hypnotics or anxiolytics in general.

Symptoms of somatized anxiety motivate the request for medical intervention, especially that of the family doctor, and involve the performance of laboratory tests and radiological investigations, even complex, with repercussions on the social level and that of health care costs. The patient with generalized anxiety has the conviction of having a physical disease, as opposed to the psychic origin of his disorders, sometimes giving meaning of disease to elements of little clinical value (arterial hypotension, gastralgia, irritable bowel syndrome).

There are many patients who date back to childhood the first manifestations of anxiety, claiming to "be born anxious". Usually the age of onset of GAD is to be placed in youth, around 16-20 years: however, the mode of onset of anxiety symptoms, unlike what happens for panic attacks, appear blurred, poorly defined and poorly affecting the quality of life. Only if stimulated to a precise memory will the patient identify as the first signs of GAD the sleepless nights spent with the heartbeat on the eve of a school exam or a sports competition, however adequately addressed.

He will also tend to link the onset of his discomfort to psychosocial events that are distant in time (marriage, work, birth of children) or to experiences that he experiences as persistent sources of stress. These latter observations make us think of generalized anxiety as a condition of individual predisposition, whose manifestations occur when the individual is faced with situations of greater responsibility and intense emotional involvement.

The course and complications of GAD

GAD shows a protracted course over time, with an oscillating trend and alternating phases of exacerbation. It has been calculated, for the disorder, an average duration of 55% of the life span, with greater exposure to the possibility of complications.

For example, self-treatment with alcohol, anxiolytics, analgesics or central nervous system stimulants is frequently encountered, with a well-founded risk of dependence and/or abuse.

Alterations in eating behavior, in the bosom of an abnormal desire to eat food, may also find in GAD a predisposing terrain.

Major depression can overlap with GAD by modifying its symptoms and sometimes masking its main feature, represented by apprehensive anticipation.

As the depressive picture deepens, inhibition and emotional detachment may prevail over the anxious component. Thus, we observe patients whose melancholic withdrawal induces them to report phrases such as: "I'm too sick: before I used to worry about everything, now I don't care about anything, whatever happens, happens".

More frequently, GAD appears associated with those forms of depression with a chronic course corresponding to Dysthymic Disorder.

The presence of these complications and others of somatic order (hypertension, peptic ulcer, heart disease) determines the request for medical intervention that tends, however, to be made at an advanced stage of the disorder.

On the other hand, the tendency observed in these patients to procrastinate this type of counseling is motivated by the low severity of symptoms and the acceptable level of performance and interpersonal skills.

How to Recognize a GAD

Referring to the Diagnostic Statistical Manual of Mental Disorders (DSM IV), the presence of an anxious state requiring therapeutic treatment is recognized by the concomitant presence of the following symptoms:

- Excessive anxiety and worry (apprehensive anticipation) occurring most days for at least six months, related to a quantity of events or activities (such as work or school performance);

- Difficulty controlling worry;

- anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning;

- the alteration is not due to the direct physiological effects of a substance (e.g., drug abuse, medication) or a general medical condition (e.g., hyperthyroidism);

- anxiety and worry are associated with three (or more) of the following six symptoms (with some of them present most days in the past six months): restlessness, feeling tense or on edge, easy fatigability, difficulty concentrating, memory lapses, irritability, muscle tension;

- Sleep alterations (difficulty falling asleep or maintaining sleep or restless, unsatisfactory sleep).

The GAD and the DAP

Generalized Anxiety Disorder is distinguished from Panic Attack Disorder by the presence of persistent anxiety symptoms that lack the criticality and drama of panic attacks and do not result in the development of phobic avoidance behaviors.

Comparison of the two disorders shows that GAD has longer duration, higher incidence of secondary depression, and more frequent use of medication-based therapies.

Reassurance sensitivity is more developed in patients with panic attacks, whereas it is lower in those with GAD.

Another important difference is that the anticipatory anxiety of DAP and the generalized anxiety of GAD, although overlapping in some aspects (somatic and neurovegetative symptoms and response to benzodiazepines), differ essentially for the object of apprehension that is selective and predictable in DAP, while it is changeable and ill-defined in GAD.

With regard to symptoms, in GAD there is a prevalence of somatic symptoms in the muscular and gastrointestinal spheres, the absence of derealization and depersonalization and a reduced phobic component.

Generalized Anxiety Disorder and Depressive Disorder

GAD differs from Depressive Disorder in the absence of psychomotor slowing, self-injurious ideation, guilt themes, and diurnal alternation.

More difficulties arise in the differential diagnosis with dysthymia (chronic depression), with which it can sometimes be associated and with which it has in common the early onset, the chronic fluctuating course with acute phases, the tendency to self-treatment with risk of substance abuse.

Common to both disorders are obsessive and dependent personality traits, with a tendency toward introversion and low self-esteem, the latter being more pronounced in dysthymia.

What, however, differentiates them is the social adaptation: in the GAD, in fact, maintains an adequacy of performance and relational skills, represented by the continuity and efficiency of work, school or social commitment, even in the presence of manifestations of anxiety.

In dysthymia, however, is often present the difficulty in maintaining a suitable and constant performance in the professional field, sometimes associated with situations of relational difficulties.

Under the cognitive profile in GAD, as in other anxiety disorders, prevail issues related to the fear of the uncertain and new, while in the depressive forms are placed in the foreground feelings of loss, inadequacy and self-evaluation related to a reduced psychophysical efficiency and performance.

The therapy of GAD

The approach to the patient with generalized anxiety may consist primarily in psychotherapeutic support, even without the association of pharmacological therapies. In general, psychotherapeutic work is aimed at recognizing possible triggers, reassurance, conflict resolution, and implementation of coping strategies by the patient. Relaxation techniques have been used as part of behavioral therapy and hypnosis programs.

From a pharmacological point of view, benzodiazepines (BDZ), since their appearance in 1950, have been shown to have anxiolytic, hypnotic and muscle relaxant effects, associated with rapidity of action and safety of use. These characteristics have made these products easy to use by both the doctor and the patient, making them among the most widely...