Mental Disorders >> Generalised Anxiety Disorder

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Anxiety Disorders
Generalised Anxiety Disorder
M. S. Ahluwalia

Psychopathology

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Psychopathology >> Clinical Features of Anxiety Disorders - Generalised Anxiety Disorder >> Contents
Contents
1. Introduction to Anxiety Disorders
2. Generalised Anxiety Disorder
3. Diagnosis
4. Case Study
5. Aetiology
6. Treatment
10

Psychopathology >> Clinical Features of Anxiety Disorders – Generalised Anxiety Disorder >> Introduction to Anxiety Disorders
1. Introduction to Anxiety Disorders (1/2)
11
Anxiety is normal…
• Anxiety is a common reaction to stress. It prevents
humans from being careless.
• Examples:
• Anxiety about your examination makes you study.
• Anxiety over her baby’s health makes a mother
care for her baby.
…however, in same situations anxiety can be abnormal
• If anxiety crosses a reasonable limit, it might become a disorder
• Examples:
• when one is so anxious that he/she has a breakdown in the
exam hall, forgetting everything
• when a mother is so anxious about her baby’s health, that she
spends day and night praying to God
Nature of Anxiety
Fear
• Fear is a basic emotion of human beings associated with
the perception of a real threatening situation and involves
the ‘fight or flight’ response activated by the sympathetic
nervous system.
• Example: If a street thug attacks you, you would feel intense
fear. Then, you would either run for dear life, or hit him back.
• Thus fear involves:
• cognition of the threatening object,
• subjective cognition of being in danger,
• physiological components like increased heart rate,
• behavioural components like running or hitting.
Anxiety
• Anxiety also involves subjective perception of threat,
physiological changes and some behavioural reaction.
• However, there is no immediate threat - you are
projecting the threatening situation in future and
reacting to it as if it is imminent. If you cannot go out of
your home because of apprehensions of an attack by a
hoodlum, it is anxiety.
• Anxiety serves an adaptive function - it prepares a person
for fight or flight if the danger really comes. But if the
person avoids the situation that in her perception may
cause the danger, and if such imagined situations are
unrealistic, then the effect becomes debilitating.

One may distinguish between adaptive
anxiety and pathological anxiety by
assessing the realistic probability of the
occurrence of the object of anxiety and
by assessing how dysfunctional it makes
the person.

Focus of this document
Psychopathology >> Clinical Features of Anxiety Disorders – Generalised Anxiety Disorder >> Introduction to Anxiety Disorders
1. Introduction to Anxiety Disorders (2/2)
13
Common Characteristics/Nature of Anxiety Disorders
• Cognition or subjective perception of danger – may be accompanied by
vivid, occasionally morbid, images of the difficulties encountered.
• Physiological Responses - through activation of sympathetic nervous
system. Usually includes dilated pupils, increased heart rate, trembling,
breathing discomfort, nausea etc.
• Behavioural Responses - usually a tendency to avoid the dreaded situation.
Except in OCD and sometimes PTSD, where repetitive behaviour is observed.
Anxiety
Disorder
Anxiety Disorder is a blanket term that covers a group of disorders characterized by
irrational fear of some thing or situation. The person is usually aware of the irrationality.
1
Panic Disorder
(with or without
agoraphobia)
2
Phobic Disorders
(specific or social)
3
Generalised
Anxiety Disorder
(GAD)
4
Obsessive
Compulsive
Disorder
(OCD)
5
Post Traumatic
Stress Disorder
(PTSD)
Types of Anxiety Disorders
(DSM IV TR)

Contents
3. Diagnosis
4. Case Study
5. Aetiology
6. Treatment
14

Psychopathology >> Clinical Features of Anxiety Disorders – Generalised Anxiety Disorder
15
Epidemiology
• The prevalence rate of
GAD is quite high,
estimated to be about 3%
to 5% of the general
population.
• It usually begins in the
teens and is more
common in women.
Co-morbidity
• GAD often has other
anxiety disorders and
mood disorders as co-
morbid conditions.
Generalised
Anxiety
Disorder
Persistent excessive and irrational anxiety and worry generalized over a number of
things, which the person finds difficult to control.
Prognosis
• Many persons with GAD lead their life more or less normally without
consulting any doctor.
• They have some functional impairment and difficulties within the family; but
the problems may be somewhat manageable with some support from the
close ones.
• For one third cases, spontaneous recovery takes place at some point in life.
• For others the problem is severe enough to seek medical consultation. But,
the chief complaint is often presented as somatic problems or insomnia.
Free Floating Anxiety
• GAD is known as free floating anxiety in psychodynamic terms, because the
anxiety does not seem to be bound to one or few specific issues.
• The person typically is terrified of different possible mishaps. If you convince
the person of the irrationality of one issue, or if, in the course of natural
affairs, one issue is resolved, the person takes up a second and a third
issue and focuses on them.

Contents
3. Diagnosis
4. Case Study
5. Aetiology
6. Treatment
16

Psychopathology >> Clinical Features of Anxiety Disorders – Generalised Anxiety Disorder >> Diagnosis and Epidemiology
3. GAD Diagnosis
17
• As per, DSM IV–TR GAD is characterized by persistent excessive anxiety and
worries which the person finds difficult to control. There are 6 specific symptoms
among which at least 3 must be present to be diagnosed as GAD. These are:
1. Restlessness or feeling keyed up
2. Being easily fatigued
3. Difficulty in concentrating
4. Irritability
5. Muscle tension
6. Sleep disturbance
• Concentration to anything for a given period of time becomes extremely
difficult, as some or other point of anxiety always comes up.
• Somatic complaints like sweating, flushing, palpitation, upset stomach, lump in
throat, frequent urination, rapid breathing, twitches and tics are common.
• The person becomes fidgety, irritable and easily fatigued.
• Often vivid imageries of the disaster accompany the restlessness.
• Impatience, anger outbursts and insomnia are common.

Contents
3. Diagnosis
4. Case Study
5. Aetiology
6. Treatment
18

Psychopathology >> Clinical Features of Anxiety Disorders – Generalised Anxiety Disorder >> Case Study
4. GAD Case Study
• Since her childhood, Noor has always been nervous. During school days, she was anxious for her studies
and exams. She became extremely upset if her friends talked ill about her or the teachers scolded her. At
home, she became worried if her father came home later than usual. She apprehended some accident.
• She was admitted to college, but did not finish her graduation.
• Noor married at the age of 22, and became a housewife. Her husband had a small business in the town.
From the very beginning she was apprehensive about possible failure of her husband’s business and
worried over any temporary loss that occurred. Initially her husband was glad to see her worried, as he
interpreted it as her love for him. However, However, gradually he became irritated with the constant
worry and negative predictions she had. He tried to convince her that every business has its own ups
and downs, and there is nothing to be worried about. But, it had little effect.
• At the age of 26, Noor gave birth to a girl, and after four years to a boy. During pregnancy she was
scared that something would go wrong and her unborn child might be harmed. Her family consulted a
‘baba’ who gave her holy water and assured that everything would be alright. She was consoled a bit.
• Noor, is now 35yo. Her daughter is in puberty. Noor is extremely worried that her daughter might be
harmed, and remains anxious till she comes back from school. Noor fears that she might be assaulted on
her way back home. Her son is growing up - she is worried that he might get hurt during play. She
reports bad dreams and worries that these might come true. She restricts her son’s movement causing
lots of argument and dissatisfaction within the family. She becomes anxious and starts crying instead
of rationally justifying her stand. Her husband and children ultimately compromise with her demands.
• She has remained happy and relaxed for a negligible period of her life, always apprehending that some
danger might befall her and her loved ones. She is a frequent visitor to the ‘baba’, and remains
temporarily calm after he blesses her for a safe life.
19

Contents
3. Diagnosis
4. Case Study
5. Aetiology
6. Treatment
20

Psychopathology >> Clinical Features of Anxiety Disorders – Generalised Anxiety Disorder >> Aetiology
5. GAD Aetiology
21
Causes of GAD
1
Biological Factors
1.1
Genetic Factors
1.2
Brain and Biochemical
Abnormalities
2
Psychological Factors
2.1
Psychoanalytical Approach
2.2
Cognitive Behavioural
Approach

5.1. Biological Factors
22
1. Genetic Factors
• Research indicates a moderate
role of genetic factors.
• The research in this area has been
confounded by the different
expressions of anxiety.
• There is also some indication that
GAD and major depressive
disorder may share a common
underlying genetic predisposition.
2. Brain and Biochemical
Abnormalities
• The Gamma aminobutyric acid
(GABA) neurotransmitter plays a
role in GAD.
• Deficiency in GABA seems to
predispose one toward anxiety.
• Since cortisol level goes up under
stress, the corticotrophine
releasing hormone (CRH) may be
playing a significant role in GAD.
• Serotonin and norepinephrine
may also have some role in
producing GAD.

5.2.1. Psychoanalytical Approach
• The psychoanalytical approach traces the free
floating anxiety in GAD to the unconscious
conflict between the ego and id impulses,
usually sexual and aggressive in nature.
• It states that we often have socially
unaccepted desires, and these desires do not
come out in the consciousness because of the
repression of the ego.
• These desires are continuously seeking
expression, but are repeatedly thwarted and
hence the anxiety.
• The source of the anxiety is in the
unconscious, and therefore, not known.
• It seeks to be attached to one object or
another, with little success.
23
Psychoanalytical Explanation of GAD
Repressing force
of the ego
Unconscious
sexual/aggressive
desire seeking
expression
Anxiety due to
repressed impulse
Anxiety makes multiple
attempts to attach itself,
but does not succeed

5.2.2. Cognitive Behavioural Approach
• In this approach, the role of worry and sense of
mastery over it has been emphasised.
• Worry impairs the ability to stay happy, reduces sense
of well being and increases vulnerability to
uncontrolled or intrusive thoughts.
• Occurrence of uncontrollable negative events in life
has a role to play in GAD. The events are usually not as
traumatic as in PTSD. But, often, a series of small
events generates a perception of lack of control on the
things around.
• The person’s early environment may have been such
that she was never felt safe and relaxed.
• A relative lack of safety signals characterises the
person with GAD.
• If you try to stop being anxious, it often has a
rebound effect to encourage more intrusive
thoughts, starting a vicious cycle.
• Information processing of a person with GAD is
biased. She detects the threatening events more
quickly in comparison to the non-threatening ones.
Also, the imagery associated with negative events
seems to linger longer and prominently in them.
24
Cognitive Explanation of GAD
Automatic
thoughts about
uncontrollability of
events
Loss of Sense of
Mastery
General Ambience
of Anxiety and
consequent
inability to finish
work calmly
Series of small
uncontrollable
negative events

Contents
3. Diagnosis
4. Case Study
5. Aetiology
6. Treatment
25

Psychopathology >> Clinical Features of Anxiety Disorders – Generalised Anxiety Disorder >> Treatment
6. GAD Treatment
26
Treatment of GAD
1
Pharmocology
2
Psychological
Approaches
• Different drugs from the Benzodiazepine
category have been used extensively. While
this drug relieves anxiety immediately, it
may be habit forming.
• Another drug called Buspirone is prescribed
for GAD; however it takes a few weeks to
work.
• Different antidepressants may also be used.
• To deal with the psychological factors, you may
use a combination of cognitive and behavioural
techniques.
• GAD remains one of the relatively difficult
anxiety problems to treat, because the direct
effort to stop negative thoughts usually results
in a renewed invasion of such thoughts.
• Muscular relaxation may be combined with
cognitive restructuring.
• You may also point out the biased nature of
information processing and train your client
to avoid catastrophizing tendencies.
In real life the therapist might go for
a combination of therapies based
on the specific need of the client.

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