Chapter 19. Generalized Anxiety Disorder

Generalized anxiety disorder (GAD) is a chronic and highly comorbid illness characterized by excessive and uncontrollable worry (Box 19- ). It is marked by a later onset than other anxiety disorders (Kessler et al. 2005) and is associated with fluctuations in symptom severity and impairment (e.g., Wittchen et al. 2000). It demonstrates both a low probability of recovery (32%–58%) and a high likelihood of recurrence (45%–52%) (Rodriguez et al. 2006) over a 2- to 12-year period. GAD is associated with significant disability and impairment comparable to pure major depressive disorder (Hoffman et al. 2008) and can be more debilitating than pure substance use disorders, some anxiety disorders, and personality disorders, even after controlling for sociodemographic variables and comorbid conditions (Grant et al. 2005). DSM-5 Diagnostic Criteria for Generalized Anxiety Disorder 300.02 F41.1 Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance). The individual finds it difficult to control the worry. The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms having been present for more days than not for the past 6 months): Note: Only one item is required in children. Restlessness or feeling keyed up or on edge. Being easily fatigued. Difficulty concentrating or mind going blank. Irritability. Muscle tension. Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep). The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism). The disturbance is not better explained by another mental disorder (e.g., anxiety or worry about having panic attacks in panic disorder, negative evaluation in social anxiety disorder [social phobia], contamination or other obsessions in obsessive-compulsive disorder, separation from attachment figures in separation anxiety disorder, reminders of traumatic events in posttraumatic stress disorder, gaining weight in anorexia nervosa, physical complaints in somatic symptom disorder, perceived appearance flaws in body dysmorphic disorder, having a serious illness in illness anxiety disorder, or the content of delusional beliefs in schizophrenia or delusional disorder). Individuals with GAD attempt to enhance their sense of control or preparedness through anticipation of negative outcomes or worst-case scenarios. They scan their environment for potential danger and negatively interpret neutral or ambiguous stimuli as threatening (Mathews and MacLeod 1994). Because of their lack of present moment focus, these individuals tend to ignore information in their immediate surroundings that could potentially challenge their distorted views (Borkovec and Newman 1998), which triggers emotional distress. This emotional distress is associated with many somatic features, including restlessness, fatigue, irritability, concentration difficulties, muscle tension, and sleep disturbance. Overall, GAD is a serious and costly mental illness with regard to degree of distress, disability and subsequent loss of work productivity, and quality of life (Newman 2000). Thus, targeted interventions are necessary to effectively address core symptoms and associated features. In this chapter we discuss several empirically established approaches to treatment for GAD, including conventional cognitive-behavioral therapy (CBT), pharmacotherapy, psychodynamic psychotherapy, and integrative psychotherapy.