Client Populations Diagnostic Criteria

Reviewing Generalised Anxiety Disorder

Myriad therapies treat anxiety. In this article, the first of a 3-part series, we review generalised anxiety. The next two articles examine how to treat it with CBT and Motivational Interviewing.

By Mental Health Academy 2024-10-08 03:56:54

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Myriad therapies treat anxiety. In this article, we review generalised anxiety, then examine (next two articles) how to treat it with CBT and Motivational Interviewing.

Related articles: Assessing and Treating Anxiety, Treating Generalised Anxiety with Cognitive Behavioural Therapy, Treating Generalised Anxiety with Motivational Interviewing.

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Introduction

To some degree, everyone experiences the normal human emotion of worry, fear, or apprehension about what may happen in the future. Normally, we deal with the anxiety-provoking stressor (such as feeling nervous before giving a talk) and let go of the tension or worry in due course (say, as we get into the speech, or at least afterward). But for some people, anxiety persists for an extended period of time, making it difficult to function in various life domains. 17.6% of U.S. adults reported symptoms of anxiety disorder in the two weeks before being surveyed (Statista, 2024), while in Australia, 17.2% of adults reported having an anxiety disorder in the previous 12 months (Australian Bureau of Statistics, 2022). During the pandemic, at least, anxiety appears to have been on the rise. A survey from the U.S. CDC that ran through the pandemic found that in August 2023, almost 32% of women and 25% of men had symptoms of anxiety disorder. It is estimated that around 4% of the global population suffer from anxiety disorders, making anxiety one of the most common mental health disorders in the world (Statista, 2024).

Thus, we ask: how should anxiety be treated? In this three-part series, we tackle that all-important question. In this first article, we look at what anxiety is with a narrow focus on generalised anxiety disorder (GAD), as it has been called the “basic” anxiety (Brown et al, 2001). We explore the symptoms and factors involved in assessment, discuss the “slippery” nature of the disorder, and suggest screening instruments which may be helpful. In the second article, we will pose a case example and look at how it could be treated with Cognitive Behavioural Therapy (CBT), while the third article will suggest treatment considerations with the same case example from a Motivational Interviewing (MI) perspective.

GAD: Symptoms and diagnostic considerations

Generalised anxiety disorder is characterised by pervasive worry and chronic arousal. Individuals suffering from this disorder tend to have multiple spheres of worry; their worry is excessive and uncontrollable, even though there is little or nothing to provoke it (and even though the individuals themselves often realise this). Such people are overly concerned about health issues, money, family problems, and/or difficulties at work; they may have an impending sense of doom about the future. Sometimes the mere thought of getting through the day provokes anxiety. They will have some or all of the following symptoms:

  • Restless, keyed up, on edge; easily startled
  • Easily fatigued
  • Difficulty concentrating
  • Irritability
  • Muscle tension and headaches
  • Sleep disturbance (either falling asleep or staying asleep)
  • Difficulty swallowing
  • Trembling
  • Twitching
  • Nausea
  • Light-headedness
  • Frequent urination
  • Feeling out of breath
  • Hot flashes (APA, 2022).

The core patterns are those of uncontrollable worry, future orientation (because of ruminating on all that can go wrong in it), negative cognitive biases (the sense that, “If it can possibly go wrong, it undoubtedly will”; “Disaster is just around the corner”), somatic arousal (as above: the body is expressing the tension and worry), role and task inefficiency, and unbalanced relationships, in that individuals with GAD may avoid close interpersonal relating, finding it stressful. Six months is the requisite length of time that someone must be exhibiting some of these symptoms more days than not in order to diagnose it as GAD (APA, 2022).

When their anxiety level is mild, people with GAD can function socially and hold down a job. When the anxiety is severe, sufferers find it difficult to carry out simple daily activities. The disorder, which affects about twice as many women as men, can begin at any point in the life cycle, with the years of highest risk being between childhood and middle age. Genes may play a role in GAD. It rarely occurs alone, often being comorbid with other anxiety disorders, depression, or substance abuse (Anxiety Recovery Centre, 2024; NIMH, n.d.; Otto, n.d.; Otte, 2011).

Because there is not generally a big, red dividing line between normal (non-disordered) levels of worry and those of this “basic” anxiety disorder, accurate assessment of GAD (which can often remain undetected) is crucial. 

Assessment of Generalised Anxiety Disorder

Being able to formulate a treatment program with the potential to greatly reduce, if not eliminate, symptoms of anxiety begins with a thorough assessment at the stage of the initial clinical interview. It should incorporate consideration of predisposing, precipitating, perpetuating, and protective factors.

Predisposing factors

These are considered to be factors that did not directly cause the development of the disorder but have increased the risk or probability of the eventual development of an emotional disorder. Sometimes called “vulnerability factors”, the list of predisposing factors for GAD includes most historic or genetic elements contributing to the current problem, such as:

  • A person’s genetic make-up
  • The early environment and upbringing
  • Childhood learning
  • Childhood or early illnesses
  • Underlying assumptions, core beliefs, or schemas

These factors typically present a significant amount of time before the disorder develops (Boston Children’s Hospital, 2024; Gasper, n.d.).

Precipitating factors

Factors that bring on the disorder are called precipitating factors. When there are no predisposing factors, precipitating ones may be the complete cause of the disorder. Often they contribute to the development of the disorder in conjunction with the predisposing factors. These triggers can be events that are either internal or external to the person, for example:

  • Illness
  • Losing a job
  • Ending a relationship
  • Death of a loved one
  • Natural or other disasters
  • Being victimised by domestic violence or abuse
  • Terror or other events, such as being assaulted, raped, or kidnapped

In the Stress-Diathesis Model, diathesis, the weakness or predisposing factor that renders a person vulnerable to developing a disorder, occurs along with stress, a noxious stimulus or precipitating factor that causes the diathesis to manifest. In mathematical terms, the equation goes: Diathesis + Stress = Disorder (Meek, 2024; Gasper, n.d.)

Perpetuating factors

Once a precipitating event has occurred, perpetuating factors cause the disorder to continue to manifest, so these can also be called maintaining factors. They can be continuations of predisposing and/or precipitating factors; thus, they can be sufficient for the maintenance of a disorder by themselves or contributory. As with precipitating factors, they can be internal or external to the person. Examples include:

  • Continuation of an illness
  • Continuation of an unhealthy relationship
  • Maladaptive behaviour patterns, such as avoidance of feared situations or objects
  • Maladaptive ways of interpreting situations (Meek, 2024)

Protective factors

The disorder may have developed, the person may be suffering, but thorough evaluation may turn up factors which help keep the anxiety from being overwhelming. Protective factors are the strengths, social supports, and positive patterns of behaviour that may be manifesting alongside of the maladaptive ones. The wise clinician looks for ways to strengthen protective factors which already exist and develop those which may be undeveloped but available. Examples here include:

  • A strong faith or spiritual holding
  • A well-developed social support network and sense of inclusion, which may consist of family, friends, and fellow members of groups attended (e.g., fellow congregation members or cohorts in volunteer or leisure activity groups, such as fellow choir members, knitters, or rock hounds)
  • Strong cultural identity and pride
  • Well-developed and/or numerous coping strategies
  • A pervading sense of one’s own resilience, despite the perceived threats
  • Problem-solving skills
  • Past life experience at prevailing over adversity, giving rise to the confidence that one can prevail again
  • Physical health and healthy behaviours, such as engaging physical activity (Government of Western Australia, n.d.; Zimmerman et al, 2020)

Unfortunately for practitioners dealing with suspected GAD, it tends to be one of the most difficult anxiety orders to diagnose with a high degree of reliability (Brown, O’Leary, & Barlow, 2001).

Classification: The slippery eel of Generalised Anxiety Disorder

Brown et al (2001), writing specifically about GAD, note that there are many reasons for which GAD is challenging to get right, diagnostically speaking. For one, it is regarded as the “basic” anxiety order because its defining features reflect fundamental processes of anxiety. Thus, logically, the distinctness of the diagnosis is mitigated by the fact that its features are present to some degree in all of the anxiety and mood disorders. Moreover, GAD is defined solely by features involving internal processes (that is: excessive worry and persistent symptoms of tension and/or arousal); thus the lack of a standout “key feature” characterising the disorder may also contribute to lower diagnostic reliability. This contrasts with other anxiety disorders for which such features are necessary in order to make the diagnosis (for example: avoiding a particular feared item – say, snakes – in specific phobias).

The clinician also needs to make sure that, when there are overlapping or alternating  episodes of anxiety and depression (which is frequently comorbid with anxiety), a diagnosis of GAD is not assigned to symptoms which more properly belong with a mood, psychotic, or developmental disorder.

Brown and colleagues warn that great care must be taken to distinguish whether the worries identified by the client are independent of a co-existing condition or (where there is no co-existing condition) are more appropriately diagnosed as a disorder other than GAD. Some of the chief distinctions revolve around separating GAD worry from apprehension over future panic attacks or the feared consequences of panic, concern over negative social evaluation (social anxiety), or excessive worry about one’s health from hypochondriacal concerns. Similarly, some symptoms and behaviours may be better accounted for by a diagnosis of OCD. Thorough knowledge of the diagnostic criteria for each condition listed in the DSM is always helpful.

Finally, there is the question of whether the person is entertaining “normal” or “excessive”, “pathological” worry; where does one draw the line? The DSM-5-TR states that the worry must be ongoing for at least six months (APA, 2022), but what if the worry over the half-year is periodical, focused partly on health, and spiking when the client goes for many anxiety-provoking tests and procedures related to, say, their cancer?  

In the real world of pressured schedules and low levels of reimbursement from public and private health insurance schemes, thorough assessment may be challenging. This is particularly true in light of the facts that: (1) there is almost always a need to determine if the features are better accounted for as GAD or another disorder, and (2) clients rarely come in with GAD as their sole presenting issue, but the presence of comorbid conditions seems to exert a large influence on the client’s response to treatment (Brown et al, 2001).

Additionally, it should be suggested to clients that they get a medical examination – especially if they have not had a medical workup in the last two years – thus enabling a ruling-out of physical conditions that may masquerade as GAD. Finally in this vein, it is important to evaluate for excessive alcohol and drug use, given that excessive use or withdrawal may produce symptoms quite similar to those of GAD and other anxiety disorders, for example: general anxiety, trembling, nausea, and insomnia (DiLonardo, 2023; Chambless, Cherney, Caputo, & Rheinstein, 1987).

Screening tools for Generalised Anxiety Disorder

The GAD-7

The Generalized Anxiety Disorder 7-item (GAD-7) is designed specifically to screen for generalised anxiety disorder. It asks the person being screened whether, in the last two weeks, they have been bothered by a series of seven problems, such as feeling nervous or becoming irritable. The responses are on a continuum from “not at all” (zero points) to “nearly every day” (gaining three points). The points for the seven responses are added for a total score, with a score of 8 or greater representing a reasonable cut-point for identifying probable cases of generalised anxiety disorder; further diagnostic assessment is then warranted to determine the presence and type of anxiety disorder. Using a cut-off of 8, the GAD-7 has a sensitivity of 92% and specificity of 76% for diagnosis of generalised anxiety disorder (National HIV Curriculum, n.d.).       

The GAD Self-Test

The Anxiety Recovery Centre in Victoria has a similar tool, the GAD Self-Test. It encourages people who think they may have an anxiety disorder to complete the test (of one page) and bring it with them when they present to a health professional.

Conclusion

Despite being one of the most common mental health concerns, anxiety can still be difficult to diagnose; this is particularly true of generalised anxiety, which can masquerade as numerous other conditions. We have listed the symptoms and the predisposing, precipitating, perpetuating, and protective factors related to it. The GAD-7 and GAD Self-Test can help screen to see if further assessment is needed.

Key takeaways

  • Anxiety has affected over 17% of the adult population in both the United States and Australia, has risen during the pandemic, and affects about 4% of the global population.
  • GAD symptoms run from restlessness, difficulty concentrating, and irritability to physical aspects, such as trembling, nausea, and need to urinate frequently.
  • GAD has a wide set of factors related to it, including genetic predisposition and adverse childhood events; adverse precipitating events, such as job loss or natural disaster; factors which maintain it, such as maladaptive behaviours or interpretations; and protective factors, such as social support and physical activity.
  • GAD is difficult to diagnose, as it must be distinguished from mental health conditions which have anxiety as a symptom, and also from other anxiety disorders; the dividing line between “normal” and “excessive” worry is not always clear.
  • The GAD-7 and GAD Self-Test are screening instruments which can kick-start a more formal assessment of the disorder.

Anxiety courses and training

Numerous Mental Health Academy courses cover the topic of working clinically with anxiety and anxiety disorders. Click the following links to learn more about each course:

Note: MHA members can access 500+ CPD/OPD courses, including those listed above, for less than $1/day. If you are not currently a member, click here to learn more and join.

References

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