Hello, I’m Dr. Carlo Carandang, and I’m a psychiatrist with AnxietyBoss.com. Today, I will talk about generalized anxiety disorder. Generalized anxiety disorder, also known as GAD, is an anxiety disorder where you have excessive worry about events and situations and it disrupts your life. So you as the audience will benefit from this presentation by learning more about GAD and how it can be treated.
I’m an expert in anxiety and depression and I’m a psychiatrist with over 15 years of experience treating patients with anxiety and depression. In addition, I’m the author of the self-help book Anxiety Protocol and founder of AnxietyBoss.com. Finally, I have many years of research and teaching experience on the topics of anxiety and depression.
So let’s look at some facts about GAD. The lifetime prevalence of GAD in the population is approximately 4.1%…so in other words, if you look at the lifespan of people in the population, you will see that at some point in people’s lives in the population, 4.1% of them will have developed GAD. So this is not a rare condition, and is actually fairly common. So also when you look at GAD, it is the most common anxiety disorder that presents to family doctors and primary care settings.
Those at increased risk for developing GAD include women, low-income earners, and those who are separated, divorced or widowed. So here are some of the groups that are at increased risk for developing GAD. GAD also tends to co-occur with other disorders such as substance abuse, other anxiety disorders, mood disorders, and personality disorders.
Generalized anxiety disorder is characterized by symptoms of excessive worry and rumination about everyday events and situations. So for instance, you might have extreme worries about your finances; you might have extreme worries about your children; you might have worries about your spouse, relationships, and job. So what happens in generalized anxiety disorder is that the worry about everyday events and situations are taken to another level, where not only do you worry about things that you would normally worry about but you take it to another level in which you worry about it almost all the time. And you worry about different things, not just one thing but different things, and it’s the intensity of the worry and ruminations that defines generalized anxiety disorder and what differentiates it from normal worry.
So with normal worry you might have a problem with your finances or you might have a problem with your boss at your job, and of course you would normally worry about those things. And when you have normal worry, the function of normal worry is to actually solve problems. However when you have generalized anxiety disorder, your worrying becomes a problem onto itself. So instead of having worry to solve problems, what happens is that the worrying becomes the problem, so that it paralyzes you where you can’t do anything about the problem besides worrying about it. Because if you have normal worry, what the worry does is it actually helps you to think and rethink about the problem. And eventually the normal worry helps you to solve the problem and take action, whereas with the pathological worry that you see with generalized anxiety disorder, what happens is that the worrying then becomes the problem and you don’t actually solve the problem that you’re worrying about the first place because now you have worrying as the biggest problem and it paralyzes you to take action to solve your problems. So that’s what differentiates generalized anxiety disorder worry from normal worry.
In Generalized Anxiety Disorder (GAD), these excessive worry and ruminations last most of the time and last for at least six months. In addition to the excessive worry and the ruminations, you can also get the physical symptoms of anxiety, which include restlessness, and you can have fatigue because all of this worrying actually expends a lot of energy. You also can become tired easily and quite irritable- so when you have generalized anxiety disorder, you’re at the end of your rope, because you spend all of your time and energy worrying constantly and ruminating that you become irritable. So any little thing will just trigger you, where even some little irritation or some little thing will just set you off. Other physical symptoms of GAD include muscle tension- so when you’re always worrying it just revs you up so that your muscles are always tense. You’re just so tense that you feel like you’re in need of massages all the time because you can’t relax. And because you’re on edge due to the worry, you can have poor concentration as the worrying distracts you from anything else. So again, the worrying becomes the problem and you become revved up and you’re not able to focus on the tasks at hand. And also when you’re worrying and have extreme anxiety from generalized anxiety disorder, it can affect your sleep so you’re not able to go to sleep or you might wake up a lot and you don’t feel rested.
How Do You Diagnose Generalized Anxiety Disorder?
As described in the previous slide, you have to have those symptoms of extreme worry and ruminations in combination with the physical symptoms of anxiety. So you have to have these constellation of symptoms as described in the previous slides, and it can’t be normal worry- it has to be pathological worrying. So in addition to the pathological worry, ruminations, and the physical symptoms, in order to make the diagnosis of GAD, it needs to interfere with your life and it needs to disrupt your functioning- GAD can actually paralyzed you to the point where you’re not able to do anything else and you’re not able to accomplish tasks. It can also negatively impact your relationships and your job performance. It affects your ability to care for yourself- so when the worry and anxiety disrupts your life to the point where you’re not able to take care yourself or it impacts your relationships or your job performance, then it could be generalized anxiety disorder. Also, before making the diagnosis of generalized anxiety disorder, these symptoms are not the result of a substance such as caffeine or amphetamines, as these substances can make you highly anxious and irritable and it can look like you might have generalized anxiety disorder.
In addition, your doctor has to make sure that the anxiety symptoms are not the result of a medical illness such as hyperthyroidism. So when you have hyperthyroidism, the thyroid gland that sits on top of your vocal cords on your throat- that’s where your thyroid gland sits- so when you have hyperthyroidism your thyroid gland produces too much thyroid hormone. Too much thyroid hormone then circulates in your bloodstream and this can rev you up and make you highly anxious. So excessive thyroid hormone can actually look like look like anxiety- so your doctor needs to rule out medical illness before generalized anxiety disorder is diagnosed.
Clinical Course of Generalized Anxiety Disorder
GAD can start when you are a child, but it can also start in your teenage years or can start when you’re an adult. generalized anxiety disorder also has a chronic and fluctuating course. In other words, it can last for a long time and it can come and go. So you might have times where you have an exacerbation of generalized anxiety disorder and then you’ll have periods where it goes away and you can function normally again and have normal worry. However, periods of stress such as pressures on the job and relationship problems will usually trigger an episode of generalized anxiety disorder- so an important part of treatment for generalized anxiety disorder involves identifying your stressors that trigger your generalized anxiety. And so what happens is that treatment then becomes about anticipating your stressors so that you can minimize the impact of those stressors on your GAD.
How GAD Develops
So how does generalized anxiety disorder develop? Well if you’ve listened and watched my previous videos I talked about how events and triggers lead to the thoughts about these triggers and how these thoughts can lead to anxious feelings and how anxious feelings can lead to avoidant behaviour and how the use of avoidance behaviors can maintain the belief in your thoughts which then serve to maintain the negative cycle of anxiety.
So here I give an example of the negative cycle of GAD worry and uncertainty- let’s say you have a stressor and then you have thoughts that something bad is going to happen. You might think that you will not be able to cope; you might think you can’t stand uncertainty; you might think the future and risks are unknown and that you must be prepared to reduce the risk. So these thoughts then induce anxiety, so you’re worried and fearful. So in addition to the anxious feelings, you get the physical symptoms of anxiety which include nervousness, tenseness, and you’re not able to relax and you have disrupted sleep. So these anxiety symptoms are very uncomfortable, and the anxiety makes you want to overcompensate to decrease the anxiety over short-term, so what you do then as you can’t stand uncertainty, you try to increase the certainty by planning ahead, making lists, over preparing, and over educating yourself. So for instance, if you have some concern that you might have some physical illness, you might go on the internet and research all there is to know about the particular illness that you’re worried about, and you spend all your time educating yourself, and eventually you just avoid and then you put off things.
However, these behaviors maintain the intolerance of uncertainty because if you’re not able to stand uncertainty and you try to increase the certainty what happens is that the behaviors just maintain this intolerance of uncertainty and then it just perpetuates this negative cycle of GAD worry and uncertainty. So that’s how generalized anxiety disorder develops in which your thoughts lead to feelings, which leads to over compensating behaviour, which then served to maintain the intolerance of uncertainty and then eventually it maintains this negative vicious cycle of GAD.
So let’s talk now about the neurobiology and family history of generalized anxiety disorder. So in generalized anxiety disorders, there is increased activity in the amygdala. So the amygdala is a part of the brain which controls your anxiety feelings and symptoms. So in GAD there might be a disruption of brain circuits which connect the anterior cingulate cortex, also known as the ACC, to the amygdala and it also may disrupt the dorsomedial prefrontal cortex and the amygdala and these have been postulated to be involved in negative emotional regulation. So what happens is that in GAD the thinking part of your brain, the frontal cortex, which is right here, that’s the thinking part of your brain. It connects directly to the amygdala which is here so the amygdala is actually located on both sides of the hemispheres of your brain and it’s located in this area which is a region called the temporal lobe. So what happens is the frontal lobes then connects via neurons and circuits to the amygdala, and so this thinking part of the brain, the frontal cortex, connects with the amygdala which is the feeling, the emotion part of the brain. With this connection, there’s a disruption in this connection which is thought to be involved with the pathogenesis and neurobiology of generalized anxiety disorder. So the initial research suggests that there’s a disruption between the cortex and amygdala which leads to generalized anxiety disorder. Generalized anxiety disorder runs in families and it does have a significant genetic component.
So how do you treat generalized anxiety disorder? Well the first line treatment for generalized anxiety disorder is psychotherapy. So if you have generalized anxiety disorder, the first thing you should do is to receive psychotherapy. Effective psychotherapy for GAD include cognitive behavioral therapy, also known as CBT, and short-term psychodynamic psychotherapy. Both are effective for GAD, so if you have GAD, you want to go to a therapist that has specialized skills and experience with anxiety disorders, and also with CBT or short-term psychodynamic psychotherapy. So these are the things to look for in a therapist when you’re wanting help with GAD.
So what about prescription medication treatment for generalized anxiety disorder? Well, prescription drug treatment for generalized anxiety disorder is a last resort treatment, so drugs are not first line for generalized anxiety disorder. Prescription drug treatment is only for cases where psychotherapy is not effective, or for severe cases. So when you have generalized anxiety disorder, the first thing you want to do is to actually seek psychotherapy, so participate in CBT. There’s a problem right now where people are actually going to their doctors and their doctors are automatically prescribing medications for anxiety disorders such as GAD, without even starting psychotherapy. But this is a mistake because medications were not meant to be given as first-line for anxiety disorders such as generalized anxiety disorder. Prescription medication treatment was meant to be a last resort if first-line treatment didn’t work. So for instance, if you had CBT (cognitive behavioral therapy) for generalized anxiety disorder and it ended up not working, then that would be a scenario where you would consider prescription medication treatment to treat your anxiety symptoms. The other scenario where you might consider prescription medication treatment for your GAD is if you have such severe symptoms that it is severely impacting your functioning, where you’re not able to perform your job and you’re not able to care for yourself and your relationships are in shambles. So those are examples where multiple domains of your life are in shambles because of your anxiety disorder, then that would be a case where for severe cases where you would consider prescription medication drug treatment. So to repeat, prescription medication treatment for generalized anxiety disorder is a last resort treatment. You need to try other other primary modalities such as cognitive behavioral therapy before even considering prescription medication treatment. I think in this society that we have currently, we are quick to to request a prescription to take care of all our problems, that we want the magic silver bullet to take care of our problems, including our anxiety problems. However that’s not the way to go about treating your generalized anxiety disorder. The first line is cognitive behavioral therapy, not medication treatment.
However, if you do need medications for generalized anxiety disorder, there are effective options, which include selective serotonin reuptake inhibitors also known as SSRIs, and serotonin norepinephrine reuptake inhibitors also called SNRIs. These can be effective for GAD. You also have benzodiazepines, buspirone, and pregabalin. So these are the lists of prescription medications that are effective for GAD, so you might ask what about treatments with benzodiazepines? This is a common question because benzodiazepines are overprescribed for all anxiety disorders. It’s given out like aspirin…doctors prescribed this like water. Basically it’s ridiculous the amount of benzodiazepines that are prescribed…let me repeat- benzodiazepines are overprescribed, so for generalized anxiety disorder, benzodiazepines are generally not indicated for GAD, given that GAD is a chronic illness, and for a chronic illness, you can’t prescribe benzodiazepines on a long-term basis because the longer you’re on benzodiazepines, the more risks are involved with taking it. Benzodiazepines are highly addictive and it’s best not to start on the benzodiazepine if you have generalized anxiety disorder, just because generalized anxiety disorder can last a long time. Although benzodiazepines are effective over the short term, they have long-term risks because you can get addicted to it. So then you have another problem if you start to become addicted to benzodiazepines, then you would need to be referred to a rehab program to address your drug addictions to benzodiazepines. So let me repeat- benzodiazepines are over prescribed for anxiety disorders and should really not be prescribed for anxiety. There are better treatment options with regards to anxiety. However if you have severe anxiety then that might be a case where benzodiazepines can be prescribed on a short-term basis. Only if you have severe anxiety symptoms then maybe your doctor can prescribe you a benzodiazepine on a short-term basis.
In the meantime, if they’re prescribing the benzodiazepine, then there has to be other primary treatments that are prescribed at the same time, so that when it comes time for the primary treatments to become effective weeks later, the benzodiazepine can be discontinued. Primary treatment with SSRIs or SNRIs can take up to eight weeks for it to have full effect for your anxiety disorder. So while you’re waiting for the SSRI or the SNRI to take effect weeks later, then the benzodiazepine can be concurrently prescribed, but only for a few weeks. Then once the SSRI or SNRI becomes effective then the benzodiazepine can be slowly tapered and eventually discontinued. In addition, the SSRI and SNRI may initially cause increased anxiety and agitation. Your doctor should talk to you about this side effect before they prescribe medication for anxiety. These prescription medications have significant side effects, so your doctor needs to monitor these medications due to the risk for significant side effects. The problem with SSRIs and SNRIs is that they may initially cause increased anxiety and agitation during the first couple of weeks of taking it. So if this happens then your doctor might consider a benzodiazepine to address this side effect on a short-term basis until the SSRI or SNRI becomes effective for anxiety.
So for your anxiety, sometimes this is one of the problems of actually prescribing SSRIs and SNRIs for anxiety is that it may might actually increase your anxiety in the first couple weeks. So if you already have severe anxiety symptoms and then the SSRI or SNRI actually increases anxiety, then you gotta ask yourself if it is really worth taking these medications in the first place. So if you’re having problems with your prescription medications, you should always go to your doctor to discuss these side effects. But the purpose of talks like this is to give you education regarding when is the appropriate time to take these medications and it is my opinion that these prescription medications are over-prescribed and that other treatment modalities should be considered first before taking these prescription medications. These medications have significant side effects, such as the benzodiazepines which are highly addictive and the SSRIs and SSRIs which have significant side effects such as increased anxiety and increased agitation. I wonder why would somebody with anxiety would want to subject themselves to the side effects. I don’t know, but personally, if I have anxiety and I go to my doctor, I want to be treated with something that’s actually going to be helpful over the short term and the long term. So I do not necessarily want to get the quick fix, as I want my anxiety to be treated effectively for the long term. The problem is is that if you go for the quick fix, then there are other problems that may arise, so if you decide to go for prescription drug treatment for anxiety, then you subject yourself to the significant side effects that can occur with these prescription medications.
So let’s talk now about other treatments for GAD. Natural supplements have multiple studies that show several different natural supplements are effective and safe for generalized anxiety disorder. Natural supplements effective for GAD include lavender, passionflower, galphimia glauca, ginkgo biloba and chamomile. So natural supplements which include herbal and nutritional supplements generally have fewer side effects and are generally less expensive than prescription medications for anxiety. Fortunately, there are natural supplements that are out there that can help for anxiety. So there is this supplement that I created- it’s called KalmPro, which is a natural supplement that has the research studies showing its ingredients are both effective and safe for generalized anxiety disorder. So the good news about generalized anxiety disorder is that you don’t necessarily have to resort to prescription medication treatment, despite what the drug companies advertise and market to you directly. Prescription medications are not the the first and it’s not the primary solution for GAD, as there are other treatments out there, such as CBT (cognitive behavioral therapy), and then there’s alternative treatments like natural supplements such as KalmPro. Additional alternative treatments for generalized anxiety disorder include self-help- so research has shown that self-help interventions are effective for generalized anxiety disorder. Self-help interventions are convenient and can be done on your own time, do not require a doctor visit, do not require a therapist visit, and are relatively inexpensive. So fortunately, there are self-help books out there that can help for generalized anxiety disorder. I wrote this book called Anxiety Protocol, which is a self-help book which uses evidence-based techniques to help you treat your generalized anxiety disorder.
To summarize this talk on generalized anxiety disorder, let’s go through the main points here. So GAD is characterized by excessive worrying about events and situations. GAD has effective treatments which include psychotherapy as first-line treatment and pharmacotherapy as last resort treatment. There are also alternative treatments which include natural supplement treatment, such as with KalmPro, and also self-help interventions, such as with the book Anxiety Protocol, and other alternative treatments such as meditation and exercise which have preliminary evidence that they are both effective and safe for anxiety disorders such as generalized anxiety disorder.
This concludes my talk, I’m Dr. Carlo Carandang, thank you for listening.