Generalized Anxiety Disorder
"I always thought I was just a worrier.
I'd feel keyed up and unable to relax. At
times it would come and go, and at times
it would be constant. It could go on for
days. I'd worry about what I was going to
fix for a dinner party, or what would be a
great present for somebody. I just
couldn't let something go.
"I'd have terrible sleeping problems.
There were times I'd wake up wired in the
middle of the night. I had trouble
concentrating, even reading the newspaper
or a novel. Sometimes I'd feel a little
lightheaded. My heart would race or pound.
And that would make me worry more. I was
always imagining things were worse than
they really were: when I got a
stomachache, I'd think it was an ulcer.
"When my problems were at their worst, I'd
miss work and feel just terrible about it.
Then I worried that I'd lose my job. My
life was miserable until I got
treatment."
Generalized anxiety disorder (GAD) is much
more than the normal anxiety people
experience day to day. It's chronic and
fills one's day with exaggerated worry and
tension, even though there is little or
nothing to provoke it. Having this
disorder means always anticipating
disaster, often worrying excessively about
health, money, family, or work. Sometimes,
though, the source of the worry is hard to
pinpoint. Simply the thought of getting
through the day provokes anxiety.
People with GAD can't seem to shake their
concerns, even though they usually realize
that their anxiety is more intense than
the situation warrants. Their worries are
accompanied by physical symptoms,
especially fatigue, headaches, muscle
tension, muscle aches, difficulty
swallowing, trembling, twitching,
irritability, sweating, and hot flashes.
People with GAD may feel lightheaded or
out of breath. They also may feel
nauseated or have to go to the bathroom
frequently.
Individuals with GAD seem unable to relax,
and they may startle more easily than
other people. They tend to have difficulty
concentrating, too. Often, they have
trouble falling or staying asleep.
Unlike people with several other anxiety
disorders, people with GAD don't
characteristically avoid certain
situations as a result of their disorder.
When impairment associated with GAD is
mild, people with the disorder may be able
to function in social settings or on the
job. If severe, however, GAD can be very
debilitating, making it difficult to carry
out even the most ordinary daily
activities.
GAD affects about 4 million adult
Americans1 and about twice as many women
as men.2 The disorder comes on gradually
and can begin across the life cycle,
though the risk is highest between
childhood and middle age.2 It is diagnosed
when someone spends at least 6 months
worrying excessively about a number of
everyday problems. There is evidence that
genes play a modest role in GAD.13
GAD is commonly treated with medications.
GAD rarely occurs alone, however; it is
usually accompanied by another anxiety
disorder, depression, or substance
abuse.2,4 These other conditions must be
treated along with GAD.
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Role of Research in Improving the
Understanding and Treatment of Anxiety
Disorders
NIMH supports research into the causes,
diagnosis, prevention, and treatment of
anxiety disorders and other mental
illnesses. Studies examine the genetic and
environmental risks for major anxiety
disorders, their course-both alone and
when they occur along with other diseases
such as depression-and their treatment.
The ultimate goal is to be able to cure,
and perhaps even to prevent, anxiety
disorders.
NIMH is harnessing the most sophisticated
scientific tools available to determine
the causes of anxiety disorders. Like
heart disease and diabetes, these brain
disorders are complex and probably result
from a combination of genetic, behavioral,
developmental, and other factors.
Several parts of the brain are key actors
in a highly dynamic interplay that gives
rise to fear and anxiety.14 Using brain
imaging technologies and neurochemical
techniques, scientists are finding that a
network of interacting structures is
responsible for these emotions. Much
research centers on the amygdala, an
almond-shaped structure deep within the
brain. The amygdala is believed to serve
as a communications hub between the parts
of the brain that process incoming sensory
signals and the parts that interpret them.
It can signal that a threat is present,
and trigger a fear response or anxiety. It
appears that emotional memories stored in
the central part of the amygdala may play
a role in disorders involving very
distinct fears, like phobias, while
different parts may be involved in other
forms of anxiety.
Other research focuses on the hippocampus,
another brain structure that is
responsible for processing threatening or
traumatic stimuli. The hippocampus plays a
key role in the brain by helping to encode
information into memories. Studies have
shown that the hippocampus appears to be
smaller in people who have undergone
severe stress because of child abuse or
military combat.15,16 This reduced size
could help explain why individuals with
PTSD have flashbacks, deficits in explicit
memory, and fragmented memory for details
of the traumatic event.
Also, research indicates that other brain
parts called the basal ganglia and
striatum are involved in
obsessive-compulsive disorder.17
By learning more about brain circuitry
involved in fear and anxiety, scientists
may be able to devise new and more
specific treatments for anxiety disorders.
For example, it someday may be possible to
increase the influence of the thinking
parts of the brain on the amygdala, thus
placing the fear and anxiety response
under conscious control. In addition, with
new findings about neurogenesis (birth of
new brain cells) throughout life,18
perhaps a method will be found to
stimulate growth of new neurons in the
hippocampus in people with PTSD.
NIMH-supported studies of twins and
families suggest that genes play a role in
the origin of anxiety disorders. But
heredity alone can't explain what goes
awry. Experience also plays a part. In
PTSD, for example, trauma triggers the
anxiety disorder; but genetic factors may
explain why only certain individuals
exposed to similar traumatic events
develop full-blown PTSD. Researchers are
attempting to learn how genetics and
experience interact in each of the anxiety
disorders-information they hope will yield
clues to prevention and treatment.
Scientists supported by NIMH are also
conducting clinical trials to find the
most effective ways of treating anxiety
disorders. For example, one trial is
examining how well medication and
behavioral therapies work together and
separately in the treatment of OCD.
Another trial is assessing the safety and
efficacy of medication treatments for
anxiety disorders in children and
adolescents with co-occurring attention
deficit hyperactivity disorder (ADHD). For
more information about these and other
clinical trials, visit the NIMH clinical
trials web page,
www.nimh.nih.gov/studies/i
ndex.cfm, or the National Library of
Medicine's clinical trials database,
www.clinicaltrials.gov.
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Treatment of Anxiety Disorders
Effective treatments for each of the
anxiety disorders have been developed
through research.19 In general, two types
of treatment are available for an anxiety
disorder-medication and specific types of
psychotherapy (sometimes called "talk
therapy"). Both approaches can be
effective for most disorders. The choice
of one or the other, or both, depends on
the patient's and the doctor's preference,
and also on the particular anxiety
disorder. For example, only psychotherapy
has been found effective for specific
phobias. When choosing a therapist, you
should find out whether medications will
be available if needed.
Before treatment can begin, the doctor
must conduct a careful diagnostic
evaluation to determine whether your
symptoms are due to an anxiety disorder,
which anxiety disorder(s) you may have,
and what coexisting conditions may be
present. Anxiety disorders are not all
treated the same, and it is important to
determine the specific problem before
embarking on a course of treatment.
Sometimes alcoholism or some other
coexisting condition will have such an
impact that it is necessary to treat it at
the same time or before treating the
anxiety disorder.
If you have been treated previously for an
anxiety disorder, be prepared to tell the
doctor what treatment you tried. If it was
a medication, what was the dosage, was it
gradually increased, and how long did you
take it? If you had psychotherapy, what
kind was it, and how often did you attend
sessions? It often happens that people
believe they have "failed" at treatment,
or that the treatment has failed them,
when in fact it was never given an
adequate trial.
When you undergo treatment for an anxiety
disorder, you and your doctor or therapist
will be working together as a team.
Together, you will attempt to find the
approach that is best for you. If one
treatment doesn't work, the odds are good
that another one will. And new treatments
are continually being developed through
research. So don't give up hope.
Medications
Psychiatrists or other physicians can
prescribe medications for anxiety
disorders. These doctors often work
closely with psychologists, social
workers, or counselors who provide
psychotherapy. Although medications won't
cure an anxiety disorder, they can keep
the symptoms under control and enable you
to lead a normal, fulfilling life.
The major classes of medications used for
various anxiety disorders are described
below.
Antidepressants
A number of medications that were
originally approved for treatment of
depression have been found to be effective
for anxiety disorders. If your doctor
prescribes an antidepressant, you will
need to take it for several weeks before
symptoms start to fade. So it is important
not to get discouraged and stop taking
these medications before they've had a
chance to work.
Some of the newest antidepressants are
called selective serotonin reuptake
inhibitors, or SSRIs. These medications
act in the brain on a chemical messenger
called serotonin. SSRIs tend to have fewer
side effects than older antidepressants.
People do sometimes report feeling
slightly nauseated or jittery when they
first start taking SSRIs, but that usually
disappears with time. Some people also
experience sexual dysfunction when taking
some of these medications. An adjustment
in dosage or a switch to another SSRI will
usually correct bothersome problems. It is
important to discuss side effects with
your doctor so that he or she will know
when there is a need for a change in
medication.
Fluoxetine, sertraline, fluvoxamine,
paroxetine, and citalopram are among the
SSRIs commonly prescribed for panic
disorder, OCD, PTSD, and social phobia.
SSRIs are often used to treat people who
have panic disorder in combination with
OCD, social phobia, or depression.
Venlafaxine, a drug closely related to the
SSRIs, is useful for treating GAD. Other
newer antidepressants are under study in
anxiety disorders, although one,
bupropion, does not appear effective for
these conditions. These medications are
started at a low dose and gradually
increased until they reach a therapeutic
level.
Similarly, antidepressant medications
called tricyclics are started at low doses
and gradually increased. Tricyclics have
been around longer than SSRIs and have
been more widely studied for treating
anxiety disorders. For anxiety disorders
other than OCD, they are as effective as
the SSRIs, but many physicians and
patients prefer the newer drugs because
the tricyclics sometimes cause dizziness,
drowsiness, dry mouth, and weight gain.
When these problems persist or are
bothersome, a change in dosage or a switch
in medications may be needed.
Tricyclics are useful in treating people
with co-occurring anxiety disorders and
depression. Clomipramine, the only
antidepressant in its class prescribed for
OCD, and imipramine, prescribed for panic
disorder and GAD, are examples of
tricyclics.
Monoamine oxidase inhibitors, or MAOIs,
are the oldest class of antidepressant
medications. The most commonly prescribed
MAOI is phenelzine, which is helpful for
people with panic disorder and social
phobia. Tranylcypromine and
isoprocarboxazid are also used to treat
anxiety disorders. People who take MAOIs
are put on a restrictive diet because
these medications can interact with some
foods and beverages, including cheese and
red wine, which contain a chemical called
tyramine. MAOIs also interact with some
other medications, including SSRIs.
Interactions between MAOIs and other
substances can cause dangerous elevations
in blood pressure or other potentially
life-threatening reactions.
Anti-Anxiety Medications
High-potency benzodiazepines relieve
symptoms quickly and have few side
effects, although drowsiness can be a
problem. Because people can develop a
tolerance to them-and would have to
continue increasing the dosage to get the
same effect-benzodiazepines are generally
prescribed for short periods of time. One
exception is panic disorder, for which
they may be used for 6 months to a year.
People who have had problems with drug or
alcohol abuse are not usually good
candidates for these medications because
they may become dependent on them.
Some people experience withdrawal symptoms
when they stop taking benzodiazepines,
although reducing the dosage gradu-ally
can diminish those symptoms. In certain
instances, the symptoms of anxiety can
rebound after these medications are
stopped. Potential problems with
benzodiazepines have led some physicians
to shy away from using them, or to use
them in inadequate doses, even when they
are of potential benefit to the patient.
Benzodiazepines include clonazepam, which
is used for social phobia and GAD;
alprazolam, which is helpful for panic
disorder and GAD; and lorazepam, which is
also useful for panic disorder.
Buspirone, a member of a class of drugs
called azipirones, is a newer anti-anxiety
medication that is used to treat GAD.
Possible side effects include dizziness,
headaches, and nausea. Unlike the
benzodiazepines, buspirone must be taken
consistently for at least two weeks to
achieve an anti-anxiety effect.
Other Medications
Beta-blockers, such as propanolol, are
often used to treat heart conditions but
have also been found to be helpful in
certain anxiety disorders, particularly in
social phobia. When a feared situation,
such as giving an oral presentation, can
be predicted in advance, your doctor may
prescribe a beta-blocker that can be taken
to keep your heart from pounding, your
hands from shaking, and other physical
symptoms from developing.
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Taking Medications
Before taking medication for an anxiety
disorder:
Ask your doctor to tell you about the
effects and side effects of the drug he or
she is prescribing.
Tell your doctor about any alternative
therapies or over-the-counter medications
you are using.
Ask your doctor when and how the
medication will be stopped. Some drugs
can't safely be stopped abruptly; they
have to be tapered slowly under a
physician's supervision.
Be aware that some medications are
effective in anxiety disorders only as
long as they are taken regularly, and
symptoms may occur again when the
medications are discontinued.
Work together with your doctor to
determine the right dosage of the right
medication to treat your anxiety disorder.
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Psychotherapy
Psychotherapy involves talking with a
trained mental health professional, such
as a psychiatrist, psychologist, social
worker, or counselor to learn how to deal
with problems like anxiety disorders.
Cognitive-Behavioral and Behavioral
Therapy
Research has shown that a form of
psychotherapy that is effective for
several anxiety disorders, particularly
panic disorder and social phobia, is
cognitive-behavioral therapy (CBT). It has
two components. The cognitive component
helps people change thinking patterns that
keep them from overcoming their fears. For
example, a person with panic disorder
might be helped to see that his or her
panic attacks are not really heart attacks
as previously feared; the tendency to put
the worst possible interpretation on
physical symptoms can be overcome.
Similarly, a person with social phobia
might be helped to overcome the belief
that others are continually watching and
harshly judging him or her.
The behavioral component of CBT seeks to
change people's reactions to
anxiety-provoking situations. A key
element of this component is exposure, in
which people confront the things they
fear. An example would be a treatment
approach called exposure and response
prevention for people with OCD. If the
person has a fear of dirt and germs, the
therapist may encourage them to dirty
their hands, then go a certain period of
time without washing. The therapist helps
the patient to cope with the resultant
anxiety. Eventually, after this exercise
has been repeated a number of times,
anxiety will diminish. In another sort of
exposure exercise, a person with social
phobia may be encouraged to spend time in
feared social situations without giving in
to the temptation to flee. In some cases
the individual with social phobia will be
asked to deliberately make what appear to
be slight social blunders and observe
other people's reactions; if they are not
as harsh as expected, the person's social
anxiety may begin to fade. For a person
with PTSD, exposure might consist of
recalling the traumatic event in detail,
as if in slow motion, and in effect
re-experiencing it in a safe situation. If
this is done carefully, with support from
the therapist, it may be possible to
defuse the anxiety associated with the
memories. Another behavioral technique is
to teach the patient deep breathing as an
aid to relaxation and anxiety management.
Behavioral therapy alone, without a strong
cognitive compo-nent, has long been used
effectively to treat specific phobias.
Here also, therapy involves exposure. The
person is gradually exposed to the object
or situation that is feared. At first, the
exposure may be only through pictures or
audiotapes. Later, if possible, the person
actually confronts the feared object or
situation. Often the therapist will
accompany him or her to provide support
and guidance.
If you undergo CBT or behavioral therapy,
exposure will be carried out only when you
are ready; it will be done gradually and
only with your permission. You will work
with the therapist to determine how much
you can handle and at what pace you can
proceed.
A major aim of CBT and behavioral therapy
is to reduce anxiety by eliminating
beliefs or behaviors that help to maintain
the anxiety disorder. For example,
avoidance of a feared object or situation
prevents a person from learning that it is
harmless. Similarly, performance of
compulsive rituals in OCD gives some
relief from anxiety and prevents the
person from testing rational thoughts
about danger, contamination, etc.
To be effective, CBT or behavioral therapy
must be directed at the person's specific
anxieties. An approach that is effective
for a person with a specific phobia about
dogs is not going to help a person with
OCD who has intrusive thoughts of harming
loved ones. Even for a single disorder,
such as OCD, it is necessary to tailor the
therapy to the person's particular
concerns. CBT and behavioral therapy have
no adverse side effects other than the
temporary discomfort of increased anxiety,
but the therapist must be well trained in
the techniques of the treatment in order
for it to work as desired. During
treatment, the therapist probably will
assign "homework" -- specific problems
that the patient will need to work on
between sessions.
CBT or behavioral therapy generally lasts
about 12 weeks. It may be conducted in a
group, provided the people in the group
have sufficiently similar problems. Group
therapy is particularly effective for
people with social phobia. There is some
evidence that, after treatment is
terminated, the beneficial effects of CBT
last longer than those of medications for
people with panic disorder; the same may
be true for OCD, PTSD, and social phobia.
Medication may be combined with
psychotherapy, and for many people this is
the best approach to treatment. As stated
earlier, it is important to give any
treatment a fair trial. And if one
approach doesn't work, the odds are that
another one will, so don't give up.
If you have recovered from an anxiety
disorder, and at a later date it recurs,
don't consider yourself a "treatment
failure." Recurrences can be treated
effectively, just like an initial episode.
In fact, the skills you learned in dealing
with the initial episode can be helpful in
coping with a setback.
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Coexisting Conditions
It is common for an anxiety disorder to be
accompanied by another anxiety disorder or
another illness. 4,5,6 Often people who
have panic disorder or social phobia, for
example, also experience the intense
sadness and hopelessness associated with
depression. Other conditions that a person
can have along with an anxiety disorder
include an eating disorder or alcohol or
drug abuse. Any of these problems will
need to be treated as well, ideally at the
same time as the anxiety disorder.
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How to Get Help for Anxiety Disorders
If you, or someone you know, has symptoms
of anxiety, a visit to the family
physician is usually the best place to
start. A physician can help determine
whether the symptoms are due to an anxiety
disorder, some other medical condition, or
both. Frequently, the next step in getting
treatment for an anxiety disorder is
referral to a mental health professional.
Among the professionals who can help are
psychiatrists, psychologists, social
workers, and counselors. However, it's
best to look for a professional who has
specialized training in
cognitive-behavioral therapy and/or
behavioral therapy, as appropriate, and
who is open to the use of medications,
should they be needed.
As stated earlier, psychologists, social
workers, and counselors sometimes work
closely with a psychiatrist or other
physician, who will prescribe medications
when they are required. For some people,
group therapy is a helpful part of
treatment.
It's important that you feel comfortable
with the therapy that the mental health
professional suggests. If this is not the
case, seek help elsewhere. However, if
you've been taking medication, it's
important not to discontinue it abruptly,
as stated before. Certain drugs have to be
tapered off under the supervision of your
physician.
Remember, though, that when you find a
health care professional that you're
satisfied with, the two of you are working
together as a team. Together you will be
able to develop a plan to treat your
anxiety disorder that may involve
medications, cognitive-behavioral or other
talk therapy, or both, as appropriate.
You may be concerned about paying for
treatment for an anxiety disorder. If you
belong to a Health Maintenance
Organization (HMO) or have some other kind
of health insurance, the costs of your
treatment may be fully or partially
covered. There are also public mental
health centers that charge people
according to how much they are able to
pay. If you are on public assistance, you
may be able to get care through your state
Medicaid plan.
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Strategies to Make Treatment More
Effective
Many people with anxiety disorders benefit
from joining a self-help group and sharing
their problems and achievements with
others. Talking with trusted friends or a
trusted member of the clergy can also be
very helpful, although not a substitute
for mental health care. Participating in
an Internet chat room may also be of value
in sharing concerns and decreasing a sense
of isolation, but any advice received
should be viewed with caution.
The family is of great importance in the
recovery of a person with an anxiety
disorder. Ideally, the family should be
supportive without helping to perpetuate
the person's symptoms. If the family tends
to trivialize the disorder or demand
improvement without treatment, the
affected person will suffer. You may wish
to show this booklet to your family and
enlist their help as educated allies in
your fight against your anxiety disorder.
Stress management techniques and
meditation may help you to calm yourself
and enhance the effects of therapy,
although there is as yet no scientific
evidence to support the value of these
"wellness" approaches to recovery from
anxiety disorders. There is preliminary
evidence that aerobic exercise may be of
value, and it is known that caffeine,
illicit drugs, and even some
over-the-counter cold medications can
aggravate the symptoms of an anxiety
disorder. Check with your physician or
pharmacist before taking any additional
medicines.
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For More Information
National Institute of Mental Health
(NIMH)
Office of Communications
6001 Executive Boulevard, Room 8184, MSC
9663
Bethesda, MD 20892-9663
Phone: 301-443-4513 or 1-866-615-NIMH
(6464), toll-free
TTY: 301-443-8431; FAX: 301-443-4279
FAX 4U: 301-443-5158
E-mail:
nimhinfo@ni
h.gov
Web site:
http://www.nimh.nih.gov
Anxiety Disorders Association of America
8730 Georgia Ave., Suite 600
Silver Spring, MD 20910
(240) 485-1001
www.adaa.org
Freedom from Fear
308 Seaview Avenue
Staten Island, NY 10305
(718) 351-1717
www.freedomfromfear.com
Obsessive Compulsive (OC) Foundation
337 Notch Hill Road
North Branford, CT 06471
(203) 315-2190
www.ocfoundation.org
American Psychiatric Association
1400 K Street, NW
Washington, DC 20005
(888) 357-7924
www.psych.org/index.cfm
American Psychological Association
750 1st Street, NE
Washington, DC 20002-4242
Phone: 1-800-374-2721 or (202) 336-5510
www.apa.org
Association for Advancement of Behavior
Therapy
305 7th Avenue, 16th floor
New York, NY 10001-6008
(212) 647-1890
www.aabt.org
National Alliance for the Mentally Ill
(NAMI)
Colonial Place Three
2107 Wilson Blvd., Suite 300
Arlington, VA 22201
Phone: 1-800-950-NAMI (6264) or (703)
524-7600
Internet:
ht
tp://www.nami.org
National Mental Health Association (NMHA)
2001 N. Beauregard Street, 12th Floor
Alexandria, VA 22311
Phone: 1-800-969-6642 or (703) 684-7722
TTY-800-443-5959
Internet:
ht
tp://www.nmha.org
National Center for PTSD
U.S. Department of Veterans Affairs
116D VA Medical and Regional Office
Center
215 N. Main St.
White River Junction, VT 05009
(802) 296-6300
E-mail:
ncptsd@ncp
tsd.org
Web site:
www.ncptsd.org
