Generalized Anxiety Disorder

When I was just starting out as a therapist, it seemed that I was seeing a lot of anxiety disorder patients.  This was because my psychiatrist colleague was well-known as being the sine con ultra in treating them, therefore we drew patients from the three bordering states.

Anxiety disorders are varied from generalized anxiety disorder or GAD, to the panic disorders, agoraphobia, social anxiety,  phobias, PTSD, and the Obsessive Compulsive Disorders.  Huge subjects worthy of detailed posts in the future.

GAD or generalized anxiety disorder can be thought of as a garden variety anxiety disorder because although it has its own distinct symptomatology and criteria, it can be often overlooked.

In the past these type of folks were said to be “high-strung” or “nervous nellies” and they suffered in silence.  The symptoms however troublesome are not of the severity, nor as crippling as a Panic Disorder, OCD with Panic, nor PTSD.  GAD can often be associated with the depression too and patients will present with mixed sequencing of symptoms.

It is very important to obtain a correct diagnoses in GAD patients, as they often do present with accompanying depressive symptoms.  If just the depressive symptoms are addressed, and not the anxiety disorder ones, then the patient will be only partially helped or not at all.

GAD patients can be seen as the worry warts of the world.  The diagnosis can not be applied unless one has had anxiety symptoms for over 6 months. The key component is unrelentless and uncontrolled  anxiety and worry about things; big ,small and in between.

This anxiety is seen as excessive  and exaggerated around  every day concerns that most of us have in our lives.  They have a tendency to ruminate constantly about various concerns non stop.

It is normal to have anxiety about uncertainly or changes in our lives, or in performing in front of other people, but GAD patients worry about things most others wouldn’t.  This pervasive anxiety is experienced even upon awakening and sometimes during the night.

The prospect of the day and associated activities is fraught with anxiety and fear and is repetitive each new day.  We call this anticipatory anxiety and can be paralyzing in some.

This makes it very difficult for these patients to even get up and start their day and can entail avoidance behavior, especially in panic disorder.

Patients suffering from GAD are usually the restless types, easily overwhelmed, and have much difficulty concentrating.  They have a hard time relaxing even in calm environments.  They usually present with sleep problems, fatigue and a lot of muscle tension.

Anxiety can manifest as physical symptoms of increased heart rate, palpitations, tingling or numbness, tightness in the chest as if having difficulty taking deep breaths, or feeling of not being able to swallow as before.

One might feel hot and cold chills or sweats. I have seen a fair amount of irritable bowel and GI symptoms that can not be attributed to physical causes. In addition,  I have likewise seen anxiety masked as vertigo, inner ear problems, and or ringing in the ears.                                                                                                                    As anxiety increases to panic level, the person will feel dizzy or light-headed and have fears of passing out.  There is trembling in hands or legs we call “jelly” legs.  At panic level there are fears of impending doom and dying, passing out, or feelings of “going crazy”.

Patients who have these extremely intense anxiety waves are then diagnosed as having a Panic Disorder, which is much more crippling and will be dealt with in a future post.

We know that anxiety is associated with the amygdala, which is a part of the limbic system of the brain.  The amygdala is involved with processing and memory of emotional reactions, including the fear response.

The disease is more common in women, which probably implicates female hormonal changes.  I have often seen exacerbation of anxiety premenstrually and decreased anxiety during pregnancy, which is  probably due to the high levels of progesterone, the “calming” hormone.

Anxiety disorders tend to  run in families, therefore there must be a genetic component, which probably involves dysfunction in neuronal structure and functioning.

There are those who believe that the tendency toward anxiety can even be seen in young children who demonstrate more than usual amount of separation anxiety, and who are more reactive emotionally to changes in their world.

As adolescents, they tend to be more worrisome or fearful than their peers.  My personal opinion is that this is true,  based on the histories of the majority of anxiety patients I have seen treated.

Two most implicated areas of neuronal dysfunction involves the serotonin reuptake activity  and the GABA system which regulates neuronal excitability.  We know that some SSRI’s or selective serotonin reuptake inhibitors can reduce anxiety , as well as using benzodiazepines, which acts on the GABA , or gamma aminobutyric acid system.

Is it then a serotonin or GABA problem, or both?  Alcohol and nicotine also work on the GABA system, which is why they are often used in self medication of anxiety.

Treatments options are dependant on the severity of symptoms.  Cognitive behavior techniques and relaxation exercise can be sufficient for mild anxiety.

I have had patients who experience some calming with passion-flower, hops, skullcap  and valerian root teas.  When the anxiety is more severe and or accompanied by depression, which happens often, medication is in order.

Paroxetine, marketed as Paxil in the U.S. and Deroxat here in France,  and Lexapro (escitalopram), sold as Seroplex in France, works great in reducing anxiety and in treating overlapping depression,  as well.

In some patients an anxiolytic, preferably clonazepam, or Klonopin,is needed and can be tapered down and off when the paroxetine kicks it, which usually takes a month for the fullest of anti anxiety benefits.

One of my patients swore that taking GABA supplements, bought over the counter helped.

All anxiety patients can benefit from any form of meditation, if they are able to do this,  however difficult it is for the majority of them.    A brain imaging study of Buddhists monks  during compassion meditation showed modulation in their amygdala, so meditation does work!

French physicians prefer to medicate with Lexomil or bromazepam,  which I have not seen as effective in reducing anxiety, but they seem to dole it out like M&M’s.

Unfortunately for  all of the anxiety and panic patients here in France, clonazepam was taken away from being prescribed by psychiatrists and relegated to just neurologist and pediatricians for treatment of epileptics.

As usual, most people will just put up with anxiety, and self medicate rather than seek professional help.  When it crosses over to panic though, it can be very crippling until treated.

If you or someone you know has these symptoms, encourage them to get some help.  Life is stressful enough,  without having to live with underlying fear and intense anxiety all the time.