ANXIETY [GENERALIZED ANXIETY DISORDER]

About Your Diagnosis
Generalized anxiety disorder (GAD), one of many different anxiety disorders, is characterized by excessive anxiety and worry about a number of events and activities, such as work or school performance. In GAD, anxiety and worry occur on most days and have been present for at least 6 months. In addition to the anxiety, individuals find it very difficult to control their worrying even when reassured by others. In GAD, anxiety and worry are associated with specific symptoms, including restlessness or feeling keyed up, uptight, or on edge; being easily fatigued or feeling "drained"; having difficulty concentrating or feeling that one's mind has gone blank; irritability out of proportion to whatever may have caused it; and feeling angry for no apparent reason. Muscle tension or tightness occurs, as well as sleep disturbances, especially difficulty falling or staying asleep or having a very restless, unsatisfying sleep. For GAD to be diagnosed, the intensity of anxiety has to cause some impairment in the individual's ability to function either on the job or in social relationships. The anxiety may also cause physical symptoms including shortness of breath, chest tightness, rapid and pounding heartbeat, sweating, a sensation of choking, and abdominal distress.
Some forms of anxiety besides GAD include panic attacks, in which the physical symptoms just mentioned occur "out of the blue" for no apparent reason, last for a very brief period, and then resolve. The individual with panic attacks may not, in fact, be anxious most of the day and may be relatively calm between the episodes of panic.
Agoraphobia, another form of anxiety, is a fear of being out in open spaces alone, where one might feel trapped and unable to get home. Agoraphobia often occurs in conjunction with panic and sometimes leads individuals to become virtual prisoners in their own homes.
Phobias are a type of anxiety involving fears of specific objects, places, or behaviors. Examples of phobias include fear of urinating in public restrooms, fear of using public transportation, fear of heights (acrophobia), fear of foreigners (xenophobia), and fear of closed-in places (claustrophobia).
Other forms of anxiety include the obsessive-compulsive disorder, posttraumatic stress disorder, and acute stress disorder, as well as the anxiety caused by legal drugs such as caffeine, the anxiety caused by drugs of abuse such as amphetamines or cocaine, and the anxiety caused by medical conditions and medications, such as those used to treat asthma (steroids, aminophylline). In general, anxiety is a state of fear or worry that (1) may or may not have a cause, (2) the individual cannot control, and (3) that significantly compromises the individual's ability to function normally.
It should be pointed out that worry and anxiety are normal feelings; however, it is all a matter of degree. Sometimes anxiety can allow us to make plans and provisions for the future and can, in fact, be beneficial. Such beneficial anxiety is called anticipation.

Living With Your Diagnosis
Generalized anxiety disorder is fairly common, affecting up to 10% of individuals at any particular point in time. Its childhood equivalent, the so-called overanxious anxiety disorder of children is also fairly common. Studies of families suggest that anxiety can be transmitted to children genetically, especially in conditions such as panic disorder. The matters about which anxious patients can worry are endless. They are likely to report worry over minor matters, and they are often anxious for at least half the day during an average day. In children and adolescents, the worries will center around the quality of their school performance or some aspect of their social functioning in school. They may also be concerned with their own physical or mental imperfections as they see them, and such anxious adolescents will require constant reassurance. There are some medical conditions that have a high correlation with anxiety. These include such conditions as ulcerative colitis, Crohn's disease, asthma, hypertension, heart disease, ulcer disease, reflux esophagitis, and headaches. During evaluation, anxious patients often have rapid or pressured speech and often shift from one subject to another without any apparent connection. These patients may be extremely restless, shifting about in their chair or tapping their fingers or toes, ringing their hands, putting their head in their hands, and often even getting up and walking across the room. Patients will use such phrases as "I feel like I'm going to jump out of my skin," "My whole body's on fire," "I think I'm going to have a heart attack," or similar comments.
In the treatment of anxiety, it is important to determine whether some medical condition or substance abuse is causing the anxiety. Common drugs that can produce anxiety include theophylline, any medications with caffeine, steroids, many antihypertensives including Aldomet, stimulating antidepressants such as Prozac, inhalers used for breathing problems such as Brethine and Vanceril, thyroid medication, and diet pills. Many over-the-counter medications such as some antihistamines, some cough and cold preparations, and diet pills that contain caffeine can also cause anxiety, and dietary intake of excessive amounts of caffeine and sugar can make any anxiety syndrome worse. Once a medication or a medical condition has been eliminated as a cause of anxiety, then an adequate history should be obtained for substance abuse to eliminate the possibility that the individual may be using some kind of psychostimulant that might be producing anxiety. Attention should also be directed toward uncovering any precipitants in the individual's home environment or any major stressors that might be contributing to the anxiety.

Treatment
The treatment of anxiety involves both behavioral techniques and medication. One behavioral technique used is biofeedback, wherein patients are hooked to a machine and learn to decrease their muscle tone or control their brain waves by regulating their breathing. Other behavioral techniques include progressive muscle relaxation, which is often done to a prerecorded tape; imagery, where individuals imagine that they are in some pleasant setting; meditation; and hypnosis. Behavioral techniques have been very effective in treating anxiety and are the commonly used methods in those patients who prefer not to take medication.

If you have been prescribed a medication for anxiety, it is most likely one of the minor tranquilizers of the benzodiazepine class. This would include such drugs as alprazolam (Xanax), lorazepam (Ativan), or diazepam (Valium). Although these drugs are effective for the rapid relief of anxiety, they do have side effects. They typically slow down breathing and therefore may not be the best drugs to use in someone who has asthma, bronchitis, or emphysema. They also are broken down by the liver, so they may be bad choices in someone who has severe liver disease, such as cirrhosis or hepatitis. Finally, these drugs can be habit forming; that is, they cannot be discontinued without being tapered for fear of withdrawal signs and symptoms. Those individuals who have a history of substance abuse, particularly abuse of depressant drugs, such as alcohol, barbiturates, or benzodiazepines should not be prescribed these drugs. Because the duration of action of some of the benzodiazepines, such as Xanax and Ativan, is fairly short, they may have to be given three or four times a day. Also, the benzodiazepines may produce a significant degree of sedation, which can impair driving and the ability to operate certain machinery.

Another group of drugs that are used to treat anxiety are the antidepressants. The tricyclic antidepressant drugs, such as imipramine, have been very effective for years in treating anxiety disorders. The major drawback of these medications is that they are not effective as quickly as the benzodiazepines. It may take 10 days to 2 weeks before the beneficial effects of imipramine and other tricyclic antidepressants are seen. They also may initially increase anxiety before relieving it, and they have side effects such as weight gain, sexual dysfunction, dry mouth, constipation, and blurry vision. The advantages of the tricyclic antidepressants are twofold: (1) they can be given once daily, and (2) they may be more effective than the benzodiazepines when depression is associated with the anxiety, as it often is.

Other antidepressants used to treat anxiety are the selective serotonin reuptake inhibitors (SSRIs). In particular, paroxetine (Paxil) seems to have significant antianxiety effects. It can be given once daily, usually in the evening, and may improve sleep. It has few side effects, except for diarrhea, constipation, and some sexual side effects. Paxil is similar to imipramine in that its therapeutic onset is delayed; it may take 2 to 3 weeks before he beneficial effects are seen. In addition, you may have to avoid using Paxil if you are taking certain other medications because of its interaction with them.
Buspirone (BuSpar) is also used for anxiety. It is the only drug approved for anxiety that is not potentially physically addicting, so it is often substituted for the benzodiazepines. The advantages of using BuSpar are that it is less likely to cause sedation and that there is no withdrawal on discontinuing it. Side effects of BuSpar may include gastrointestinal distress and headaches.
Finally, the beta-blocker, propranolol (Inderal) is often used for treating some of the effects of anxiety and is particularly effective for treating the runaway heartbeat and sense of heart pounding that many anxious patients feel. Because Inderal is also used to treat high blood pressure, individuals with low blood pressure should not take it. It can also sometimes make individuals feel very tired, and should not be used in patients who have severe lung disease.
Anxiety disorders can cause significant suffering and worry for patients. However, these are treatable conditions.

The DOs
* If you have an anxiety disorder diagnosed, it is very important to minimize your level of stress; to have some activity that you enjoy doing such as reading, writing, or knitting; to participate in a regular exercise program; and to watch your diet. If you are taking antianxiety medications, you should be very careful when driving or operating dangerous machinery.

The DON'Ts
* Do not use products containing caffeine, and decrease your sugar intake as much as possible. In addition, remember that most prescribed medications for anxiety have some sedating effects; therefore you should avoid drinking alcohol.

When to Call Your Doctor
* You should call your doctor if the nature of your anxiety changes, if you notice any side effects from your medications, or if your anxieties are accompanied by depression and suicidal ideation or thoughts.
For More Information
For more information on anxiety, please contact your local mental health center or your local community hotline. There are various support groups in most communities for specific anxiety disorders such as panic, obsessive-compulsive disorder, and posttraumatic stress disorder.