"Generalized Anxiety Disorder", A Universal Problem

Anxiety is a universal experience which has an important protective function in the face of danger. It is a normal response to threat or stressful events and is usually short-lived and controllable provided the symptoms do not persist long after a threatening situation is averted.

Aetiological Factors :

There is a small genetic contribution. Many patients have personality traits of high anxiety and poor tolerance of stress and is common in patients undergoing examination, investigation or treatment in medical settings. The most important factors are unexpected life events which the patient can not handle. Sometimes these are relatively minor events, within the range of everyday experience e.g. sons and daughters returning late from school or college, son or husband returning late from office or business centre, and a rise in price hike of essential commodities which do not keep pace with the income or earning of general people, especially the low earning group. A particular pattern of anxiety, known as post-traumatic stress disorder, follows the major traumatic events involved in sudden, unexpected disasters such as floods, accidents and terrorist activity.

Diagonostic Criteria :

Generalized anxiety disorder is common in psychiatric and general practice; the prevalence in the general population is estimated to be 3-6% and women being more susceptible than men. A distinction is made between the mental symptoms of anxiety and the various physical symptoms. Anxiety symptoms assume clinical significance when they :

are abnormally severe or prolonged,

occur in the absence of stressful circumstances,

impair physical, social or occupation functioning.

Anxiety symptoms are commonly mistaken for symptoms of physical disease in general medical settings and patients are mismanaged as a result. Current classification systems distinguish between 'generalized or free floating anxiety, which occurs in the absence of any specific triggering circumstances or events, and 'phobic' anxiety which is related to specific situations needs to be bring into account by the physicians.

Symptoms are often life-long, though they usually worsen during times of stress.

Symptoms of anxiety are :

A) Psychological

Fear and apprehension

Inner tension and restlessness

Irritability

Impaired concentration

Increased startle response

Increased sensitivity to physical sensations

Depersonalisation

Disturbed sleep

B) Physical

Increased muscle tension, leading to localized pain

Stiffness and tremor

Sweating

Palpitations

Chest tightness and discomfort

Shortness of breath

Headache

Dry mouth

Difficulty in swallowing

Diarrhoea

Frequency of micturition

Dizziness

Differential Diagnosis :

The most important differential diagnosis is with depressive illness. To establish if depression is present, the patient should be questioned carefully about symptoms. Anxiety may also be a feature of obsessive - Compulsive disorder; alcohol misuse, dependence and withdrawal and schizophrenia. So, it is important to look for features of these conditions before making a diagnosis of anxiety disorder. Several physical illness can present with anxiety, these are : Hyperthyroidism or thyrotoxicosis, phaeochromocytoma, Hypoglycaemia, Paroxysmal tachycardia and temporal lobe epilepsy. These need to be considered in the differential diagnosis but especial investigations are necessary according situation.

Management :

Explanation and reassurance are essential in the management of all forms of anxiety. Reassurance is also needed to allay fears of physical illness if this can be done after appropriate examination and investigation.

Any patient meeting criteria for both anxiety and depressive disorders should receive appropriate treatment for depression, in addition to any specific therapy for anxiety that may be indicated. Specific relaxation techniques should be taught to those who do not respond to reassurance.

Drugs :

Benzodiazepines are effective anxiolytics, but have considerable potential for dependence, and must therefore be used with care. They are given in short courses when the patient is particularly distressed, and at certain stages in a clear management plan. Antidepressant drugs, both older tricyclies and newer drugs (e.g. selective serotorin re-uptake inhibitors) are also effective in relieving symptoms of generalized anxiety, but do not have the same potential for dependence.

Other treatment :

More specialized forms of psychotherapy are required in patients with severe symptoms; these include applied relaxation, anxiety management training and cognitive behaviour therapy. Relaxation training is usually more effective if taught by a nurse or physiotherapist and must be practised regularly to be beneficial.

Submitted By:
DR. M. MAHBUBUL HOQUE

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