Generalized Anxiety Disorder
In everyday life we listen the words like feeling anxious, I am feeling anxiety etc. unfortunately these terms are mostly misused and even many people do not know the actual idea that what does anxiety mean in psychology. DSM-5 have mentioned different types of anxiety disorders like separation anxiety disorder, selective mutism, specific phobia, social anxiety disorder, panic disorder, agoraphobia, generalized anxiety disorder etc. But here we will focus on generalized anxiety disorder which is commonly referred as anxiety disorder.
What is anxiety?
American Psychological Association defined anxiety as an emotion characterized by feelings of tension, worried thoughts and physical changes like increased blood pressure. The person with anxiety have fear and nervousness about the future which may be in different ways for example a student who is concerned about the uncertainty of job after the degree may experience anxiety.
What is the difference between anxiety and fear?
It is very important to distinguish between anxiety and fear. Fear is actually the reaction to an actual dangerous situation. This actual danger may be harmful or life threatening. For example when a person comes across a lion or snake then he will respond with fear. While in anxiety the person has an anticipated fear about any future event like a student feel anxious because of his most important paper going to be held after some days.
Symptoms of Generalized anxiety disorder (GAD):
DSM-5 have given the following criteria for the diagnosis of generalized anxiety disorder (GAD):
A. 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).
B. The individual finds it difficult to control the worry.
C. 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.
- Muscle tension.
- Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep).
D. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
E. 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).
F. 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 post-traumatic 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
How GAD is diagnosed?
There are many different scales which measure the level of anxiety. Adult Manifest Anxiety Scale (AMAS), Anxiety Sensitivity Index (ASI), Anxiety Sensitivity Index–Revised 36 (ASI-R-36), Beck Anxiety Inventory (BAI), Covi Anxiety Scale (COVI), and Zung Self-Rating Anxiety Scale (SAS) etc. But the most widely used scale to measure the level of anxiety is Beck Anxiety Inventory. It was developed by Aaron T. Beck and his associates. BAI consists of 21 items on Likert scale, each item has four options from 0 to 3 (not at all to severely).
The scoring of BAI is very simple, just sum up all the responses and the total score will indicate your level of anxiety. The total score of BAI is 63 and the scores are interpreted as:
0-21= Low Level of Anxiety
22-35= Moderate level of Anxiety
36-63= Severe level of Anxiety, which means the person needs to consult a psychologist for professional help
How common is GAD?
According to the report of National Institute of Mental Health, anxiety disorders are so common in United States that they affect about 40 million adults of age 18 and older in the country which is about 18% of the whole population. Among these disorders Generalized Anxiety Disorder affects about 6.8 million adults (3.1% of the whole population) in the country. Females have twice the risk as compared to males.
In Pakistan there is no national level study conducted on the prevalence of GAD but different studies have been conducted at a small level. According to a study conducted by Mirza and Jenkins (2004) on public samples found that the prevalence of depression and anxiety was 33.62% among which the prevalence among females was 45.5% and among males it was 21.7%. In another study published in Pakistan Journal of Medical Association, conducted by Khan et al. found that 50.2% respondents from Karachi were having high level of anxiety.
Which factors contribute in the development of Anxiety Disorders?
Researches show that there is also a great role of gender in the development of Psychological disorders. There is a lot of evidence which shows that women have twice the risk of developing anxiety disorders as compared to men (de Graaf, Bijl, Ravelli, et al., 2002). There may be different reasons for that, for example men usually have more control over situations and also that they face more pressure in daily life as compared to women, thus they become more used to the stressful situations. The other possible reason may be that women are more likely to be sexually harassed and assaulted as compared to the men. There is also a contribution of cultural influence over genders.
Cultural factors also contribute in the development of anxiety and other psychological disorders. The major cultural factors causing anxiety and other psychological disorders are poverty, family relationships and the attitude of different cultures towards mental illness.
The role of culture and environment is also vital because there are different disorders which are common only in some specific cultures. For example Taijin Kyofusho is a syndrome found in Japanese culture in which people are likely to be embarrassed by themselves and have fear of embarrassing others by their appearance, actions and even body odor (McNally, 1997). Kayak-angst is a common disorder found in the public of Western Greenland. For example the hunters in that culture get panic attack when they are alone in sea and they think that they will be drowned in water. Another syndrome reported in people from east and south Asia is koro, in which people have fear that their genitals will move away from their body.
Anxiety disorders are more likely to run in families and there is a greater role of inheritance and genes. An individual whose relatives have any form of anxiety disorders have greater chance of developing anxiety disorders as compared to the person who do not have any relative with anxiety disorders (Hanna, 2000). If the parents of a child have anxiety disorders then there is a greater chance for the child to develop the disorders (Lieb et al., 2000), however it is not 100% sure that this will happen but it increases the chance. Another important aspect is that if a family member is having any kind of anxiety disorders, for example phobia, then the other member will be at greater risk of developing not only phobia but also the other forms of anxiety disorders like social anxiety, agoraphobia, panic attack, and generalized anxiety disorder (Kendleret al., 2001). A study on twins found that identical twins are at twice risk of anxiety disorders as compared to the fraternal twins with the percentage of 34% versus 17% respectively (Andrews et al., 1990).
Amygdala is the part of brain which controls emotions and its high activity is recorded among the people with anxiety disorders. Moreover there are different neurotransmitters which are responsible for anxiety disorders when their level is disturbed in the brain. These neurotransmitters include:
- Gamma-aminobutyric acid (GABA)
There are some specific personality traits which increase the chances of anxiety disorders. A trait which is shown by infants and other children till the age of 4 years is known as behavioral inhibition which means that infant and child becomes irritated and starts crying which he faces new people, and toys etc. This behavioral pattern also increases the chances of anxiety disorders in later life (Kagan & Snidman, 1999).
Another personality trait which is responsible for anxiety disorders is the neuroticism. The person with high level of this trait react to the events with greater negativity than the average. Research found that the increased level of neuroticism leads towards anxiety disorders and depression (de Graaf et al., 2002). The individuals with high level of neuroticism is twice as likely to develop anxiety disorders (Brown, 2007).
There are different cognitive factors which are responsible for the development of anxiety disorders. People who have more negative beliefs about future are more vulnerable to develop anxiety disorders (Clark, Salkovskis, Hackmann, et al., 1999). The other factors which increase the chances of anxiety disorders include childhood traumatic experiences (Hofmann, Levitt, Hoffman, et al., 2001), abuse (Chaffin, Silovsky, & Vaughn, 2005), and restrictive parenting styles (Chorpita, Brown, & Barlow, 1998).
Andrews, G., Stewart, G., Allen, R., & Henderson, A. S. (1990). The genetics of six anxiety disorders: A twin study. Journal of Affective Disorders, 19, 23–29.
American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (DSM-5®). American Psychiatric Pub.
Beidel, D. C., Bulik, C. M., Stanley, M. A., & Watters, E. (2012). Abnormal psychology. Pearson.
Brown, T. A. (2007). Temporal course and structural relationships among dimensions of temperament and DSM-IV anxiety and mood disorder constructs. Journal of Abnormal Psychology, 116(2), 313–328. doi:10.1037/0021-843X.116.2.313
Chaffin, M., Silovsky, J. F., & Vaughn, C. (2005). Temporal concordance of anxiety disorders and child sexual abuse: Implications for direct versus artifactual effects of sexual
abuse. Journal of Clinical Child and Adolescent Psychology, 34, 210–222.
Chorpita, B. F., Brown, T. A., & Barlow, D. H. (1998). Perceived control as a mediator of family environment in etiological models of childhood anxiety. Behavior Therapy, 29, 457–476.
Clark, D. M., Salkovskis, P. M., Hackmann, A., Wells, A., Ludgate, J., & Gelder, M. (1999). Brief cognitive therapy for panic disorder: A randomized controlled trial. Journal
of Consulting and Clinical Psychology, 67, 583–589.
de Graaf, R., Bijl, R. V., Ravelli, A., Smit, F., & Vollenbergh, W. A. M. (2002). Predictors of first incidence of DSMIII-R psychiatric disorders in the general population: Findings from the Netherlands Mental Health Survey and Incidence Study. Acta Psychiatrica Scandinavica, 106, 303–313.
Hanna, G. H. (2000). Clinical and family-genetic studies of childhood obsessivecompulsive disorder. In W. K. Goodman, M. V. Rudofer, and J. D. Maser
(Eds.), Obsessive-compulsive disorder: Contemporary issues in treatment (pp.
87–103). Mahwah, NJ: Lawrence Erlbaum Associates.
Hanna, G. H. (2000). Clinical and family-genetic studies of childhood obsessive compulsive disorder. In W. K. Goodman, M. V. Rudofer, and J. D. Maser (Eds.), Obsessive-compulsive disorder: Contemporary issues in treatment (pp. 87–103). Mahwah, NJ: Lawrence Erlbaum Associates.
Kagan, J., & Snidman, N. (1999). Early childhood predictors of adult anxiety disorders. Biological Psychiatry, 46, 1536–1541.
Kendler, K. S., Myers, J., Prescott, C. A., & Neale, M. C. (2001). The genetic epidemiology of irrational fears and phobias in men. Archives of General Psychiatry, 58, 257–265.
Khan, M. S., Ahmed, U., Adnan, M., Khan, M. A., & Bawany, F. I. (2013). Frequency of generalised anxiety disorder and associated factors in an urban settlement of Karachi. JPMA. The Journal of the Pakistan Medical Association,63(11), 1451-1455.
Kring, A. M., Davison, G. C., Neale, J. M., & Johnson, S. (2005). Abnormal psychology. Wiley.
Lieb, R., Isensee, B., Sydow, K. von & Wittchen, H.-U. (2000). The Early Developmental Stages of Psychopathology Study (EDSP): a methodological update. European Addiction Research 6, 170–182.
Lieb, R., Wittchen, H., Höfler, M., Fuetsch, M., Stein, M., & Merikangas, K. (2000). Parental psychopathology, parenting styles, and the risk of social phobia in offspring: A prospective-longitudinal community study. Archives of General Psychiatry, 57, 859–866.
McNally, R. J. (1997). Atypical phobias. In G. C. L. Davey (Ed.), Phobias: A handbook of theory, research and treatment (pp. 183–199). Chichester, England: Wiley.
Mirza I, Jenkins R. Risk factors, prevalence, and treatment of anxiety and depressive disorders in Pakistan: systematic review. BMJ 2004; 328: 794.