1. The Diagnosis and Treatment ofGeneralized Anxiety Disorder Everett Painter University of Tennessee - Knoxville Psychological DysfunctionMarch 15, 2010

2. Anxiety Defined 1 : painful or apprehensive uneasiness of mind usually over an impending or anticipated ill; fearful concern or interest. 2: an abnormal and overwhelming sense of apprehension and fear often marked by physiological signs (as sweating, tension, and increased pulse), by doubt concerning the reality and nature of the threat, and by self-doubt about one's capacity to cope with it.(Merriam-Webster)

3. Normal vs. Disordered Anxiety

4. The Experience ofGeneralized Anxiety Disorder “I worry about EVERYTHING even when there is nothing to worry about. I’m always restless, on edge, irritable, and waiting for the other shoe to drop.”

5. The Experience ofGeneralized Anxiety Disorder The intensity, duration, or frequency of anxiety and worry is out of proportion with reality. Worry is associated with everyday, routine issues and typically shifts from one concern to another. In children, this worry is associated with their competence and performance. Depressive symptoms. (APA, 2000)

6. The Experience ofGeneralized Anxiety Disorder Irritability. 6. Muscle aches and soreness. Somatic symptoms such as sweating and nausea. Clients often express that they have felt anxious and nervous all their lives. (Brown et al., 2001 & Rapee, 2001) 9. Chronic; symptoms fluctuate and are often worse during times of stress. (APA, 2000)

7. The Experience ofGeneralized Anxiety Disorder Video 1Video 2Video 3

8. The Impact ofGeneralized Anxiety Disorder Once thought to cause no more than mild impairment. Now recognized to cause significant life dissatisfaction and loss of functioning. Impairment includes: negative perceptions of health, reduced physical and social functioning, emotional issues, reduced role and occupational functioning. Implications: reduced health, relationship problems, work issues, and general interference in daily activities due to constant worry, significant use of health care system. (Henning et. al, 2007 and WFMH, 2008)

9. DSM-IV-TR Diagnostic Criteria:300.02 Generalized Anxiety Disorder 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 person finds it difficult to control the worry. (APA, 2000)

10. DSM-IV-TR Diagnostic Criteria:300.02 Generalized Anxiety Disorder The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some of the symptoms present for more days than not for the past 6 months). *Only one item is required in children. (APA, 2000)

11. DSM-IV-TR Diagnostic Criteria:300.02 Generalized Anxiety Disorder 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). (APA, 2000)

12. DSM-IV-TR Diagnostic Criteria:300.02 Generalized Anxiety Disorder The focus of the anxiety and worry is not confined to features of an Axis 1 disorder and the anxiety and worry do not occur exclusively during Posttraumatic Stress Disorder. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. (APA, 2000)

13. DSM-IV-TR Diagnostic Criteria:300.02 Generalized Anxiety Disorder The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hyperthyroidism) and does not occur exclusively during a Mood Disorder, a Psychotic Disorder, or a Pervasive Developmental Disorder. (APA, 2000)

14. Prevalence:300.02 Generalized Anxiety Disorder One year prevalence rate 3%, lifetime rate 5%. (APA, 2000) Recent survey of 15 countries found rate to be between 1-22%. (WFMH, 2008) Women are twice as likely to be affected. (WFMH, 2008) First degree relatives are more likely to also have the disorder. (Rapee, 2001)

15. Comorbidity:300.02 Generalized Anxiety Disorder Mood Disorders a) Nearly two-thirds of GAD clients also suffer from Major Depressive Disorder. (WFMH, 2008) b) Some believe that GAD should be characterized with MDD due to the strong relationship between the two. (Moffitt et al., 2007) 2.Other Anxiety Disorders Substance-Related Disorders a) Nearly one-third of GAD clients also suffer from alcohol abuse or dependence. (WFMH, 20008) 4. Other stress related conditions (i.e., headaches, irritable bowel syndrome, etc). * Some surveys indicate that 90% of those with GAD report a history of other mental disorders. (Brown et al., 2004)

16. Etiology:300.02 Generalized Anxiety Disorder 1. Biology a) Anxiety seems to have a familial association. (APA, 2000 and Rapee, 2001) b) Alterations in brain chemistry may increase risk. (WFMH, 2008) c) Amygdala and prefrontal cortex dysfunction have been implicated in persistent anxiety. (Monk et al., 2008) d) Other genetic factors are related to those for Major Depressive Disorder. (APA, 2000)

17. Etiology:300.02 Generalized Anxiety Disorder Social/Environmental a) Early/current traumatic events. b) Parenting style (overprotective). c) Family environment and culture. d) Use and withdrawal from addictive substances.e) Stress (also stress of a positive nature). f) Anxiety within peer relationships. (ADAA , 2010 , WFMH, 2008 and Rapee, 2001)

18. Etiology:300.02 Generalized Anxiety Disorder Psychological a) Research has shown that those with GAD generally have a greater intolerance for uncertainty. (WFMH, 2008) b) This intolerance interacts with the biological and environmental risk factors. (WFMN, 2008) c) Some evidence suggests that poor regulation of emotion may also be a factor. d) May also function as a means to avoid other, more uncomfortable (primary) issues. (Borkovec et al., 2004)

19. Culture, Age and Gender:300.02 Generalized Anxiety Disorder 1. More than 50% report onset of symptoms during childhood or adolescence, although onset in adulthood also occurs. (APA, 2000) 2. In most cultures, GAD is still viewed as a sign of personal weakness. (WFMH, 2008) Must understand and distinguish between common cultural expressions of anxiety. 4. More often seen in women.

20. Differential Diagnosis Anxiety Disorder Due to a General Medical Condition Substance-Induced Anxiety Disorder If another Axis 1 disorder is present, the additional diagnosis of GAD should only be made if the focus of worry is unrelated to the other disorder. (APA, 2000) The worry associated with GAD tends to me more broad and spans both physical and social circumstances as opposed to a more narrow focus – i.e., panic disorder or social phobia. (Rapee, 2001)

21. Additional Assessment Options Structured interviews yielding DSM-IV diagnoses: 1) Diagnostic Interview Schedule for Children (DISC) 2) Anxiety Disorders Interview Schedule for DSM- IV Child and Parent Versions (ADIS-C/P) Questionnaires: 1) Revised Children's Manifest Anxiety Scale (RCMAS) 2) Multidimensional Anxiety Scale for Children (MASC) 3) Screen for Child Anxiety Related Emotional Disorders (SCARED)

22. Generalized Anxiety Disorder:Treatment Options Cognitive-Behavioral Therapy (CBT) a) Common strategies include self-monitoring, relaxation training, de-catastrophizing, rehearsal of coping strategies. (Borkovec et al., 2004) b ) Focus on controlling worry. Worry, while also the primary feature, has been shown to play a major role in the maintenance of GAD. (Rapee, 2001)

23. Generalized Anxiety Disorder:Treatment Options 2. Medication a) Selective Serotonin Reuptake Inhibitors (SSRIs) b) Serotonin-NorepinephrineReuptake Inhibitors (SNRIs) c) Benzodiazepines Have been shown to work well. However in situations with cormorbid conditions, antidepressants tend to be more effective. (Davidson, 2004) d) Tricyclic Antidepressants

24. Generalized Anxiety Disorder:Treatment Options (Supplements) 3. Self-Management/Healthy Lifestyle a) Changes in diet and nutrition. b) Regular exercise. c) Relaxation strategies. d) Basic stress management strategies. e) Learning new problem solving strategies. (WFMH, 2008)

25. Generalized Anxiety Disorder:Treatment Options (Supplements) 4. Support Groups

26. Resources Anxiety Disorders Association of America www.adaa.org National Alliance on Mental Illness www.nami.org National Institute of Mental Health www.nimh.nih.gov Nemour’s Foundation http://kidshealth.org/parent/emotions/feelings/anxiety.html World Federation for Mental Health www.wfmh.org

27. References Allgulander, C. (2007). What our patients want and need to know about generalized anxiety disorder. Revista Brasileira de Psiquiatria, 29, 172-176. American Psychiatric Association. (2000). Anxiety Disorders. Diagnostic and statistical manual of mental disorders: DSM-IV-TR (4th ed., pp 85-93). Arlington: Author. Borkovec, T. D., Newman, M. G., & Castonguay, L. G. (2004). Cognitive-behavioral therapy for generalized anxiety disorder with integrations from interpersonal and experiential therapies. The journal of lifelong learning in psychiatry, 2, 392-401. Brown, T. A., O’Leary, T. A., & Barlow, D. H. (2001). Generalized Anxiety Disorder. In Barlow, D. H. (Ed.), Clinical handbook of psychological disorders (3rd. Ed, pp. 154-208).

28. References (cont.) Henning, E. R., Turk, C. L., Mennin, D. S., Fresco, D. M., & Heimberg, R. G. (2007). Impairment and quality of life in individuals with generalized anxiety disorder . Depression and Anxiety, 24, 342-349. Moffitt, T. E., Harrington, H. L., Caspi, A., Kim-Cohen, J., Goldberg, D., Gregory, A. M. & Poulton, R. (2007). Depression and Generalized Anxiety Disorder. Archives of General Psychiatry, 64, 651-660. Rapee, R. N. (2001). The Development of Generalized Anxiety. In M. W. Vasey & M. R. Dadds (Eds.), The developmental psychopathology of anxiety (1st ed.,pp. 481-503). New York, NY: Oxford University Press. World Federation for Mental Health. (2008). Understanding generalized anxiety disorder [International Mental Health Awareness Packet].