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Edwin R. Alexander, M.D.
ANXIETY [GENERALIZED ANXIETY DISORDER]
About Your Diagnosis Generalized anxiety disorder (GAD), one of many different anxiety disorders, is characterized by exces-sive anxiety and worry about a number of events and activities, such as work or school performance. InGAD, anxiety and worry occur on most days and have been present for at least 6 months. In additionto 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 feelingkeyed up, uptight, or on edge; being easily fatigued or feeling "drained"; having difficulty concentratingor 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 distur-bances, especially difficulty falling or staying asleep or having a very restless, unsatisfying sleep. ForGAD to be diagnosed, the intensity of anxiety has to cause some impairment in the individual's abilityto function either on the job or in social relationships. The anxiety may also cause physical symptomsincluding shortness of breath, chest tightness, rapid and pounding heartbeat, sweating, a sensation ofchoking, and abdominal distress.
Some forms of anxiety besides GAD include panic attacks, in which the physical symptoms just men-tioned occur "out of the blue" for no apparent reason, last for a very brief period, and then resolve. Theindividual with panic attacks may not, in fact, be anxious most of the day and may be relatively calmbetween the episodes of panic.
Agoraphobia, another form of anxiety, is a fear of being out in open spaces alone, where one mightfeel trapped and unable to get home. Agoraphobia often occurs in conjunction with panic and some-times 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 pho-bias 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, andacute stress disorder, as well as the anxiety caused by legal drugs such as caffeine, the anxiety causedby drugs of abuse such as amphetamines or cocaine, and the anxiety caused by medical conditionsand medications, such as those used to treat asthma (steroids, aminophylline). In general, anxiety is astate 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 ofdegree. 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 DiagnosisGeneralized anxiety disorder is fairly common, affecting up to 10% of individuals at any particularpoint in time. Its childhood equivalent, the so-called overanxious anxiety disorder of children is alsofairly common. Studies of families suggest that anxiety can be transmitted to children genetically, espe-cially in conditions such as panic disorder. The matters about which anxious patients can worry areendless. They are likely to report worry over minor matters, and they are often anxious for at least halfthe day during an average day. In children and adolescents, the worries will center around the qualityof their school performance or some aspect of their social functioning in school. They may also be con-cerned with their own physical or mental imperfections as they see them, and such anxious adoles-cents will require constant reassurance. There are some medical conditions that have a high correlationwith anxiety. These include such conditions as ulcerative colitis, Crohn's disease, asthma, hypertension,heart disease, ulcer disease, reflux esophagitis, and headaches. During evaluation, anxious patientsoften have rapid or pressured speech and often shift from one subject to another without any apparentconnection. These patients may be extremely restless, shifting about in their chair or tapping their fin-gers or toes, ringing their hands, putting their head in their hands, and often even getting up and walk-ing 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 substanceabuse is causing the anxiety. Common drugs that can produce anxiety include theophylline, any med-ications with caffeine, steroids, many antihypertensives including Aldomet, stimulating antidepressantssuch as Prozac, inhalers used for breathing problems such as Brethine and Vanceril, thyroid medica-tion, and diet pills. Many over-the-counter medications such as some antihistamines, some cough andcold preparations, and diet pills that contain caffeine can also cause anxiety, and dietary intake ofexcessive amounts of caffeine and sugar can make any anxiety syndrome worse. Once a medication ora medical condition has been eliminated as a cause of anxiety, then an adequate history should beobtained for substance abuse to eliminate the possibility that the individual may be using some kind ofpsychostimulant that might be producing anxiety. Attention should also be directed toward uncoveringany precipitants in the individual's home environment or any major stressors that might be contributingto the anxiety.
TreatmentThe treatment of anxiety involves both behavioral techniques and medication. One behavioral tech-nique used is biofeedback, wherein patients are hooked to a machine and learn to decrease their mus-
cle tone or control their brain waves by regulating their breathing. Other behavioral techniques includeprogressive muscle relaxation, which is often done to a prerecorded tape; imagery, where individualsimagine that they are in some pleasant setting; meditation; and hypnosis. Behavioral techniques havebeen very effective in treating anxiety and are the commonly used methods in those patients who pre-fer not to take medication.
If you have been prescribed a medication for anxiety, it is most likely one of the minor tranquilizers ofthe benzodiazepine class. This would include such drugs as alprazolam (Xanax), lorazepam (Ativan), ordiazepam (Valium). Although these drugs are effective for the rapid relief of anxiety, they do have sideeffects. They typically slow down breathing and therefore may not be the best drugs to use in someonewho has asthma, bronchitis, or emphysema. They also are broken down by the liver, so they may bebad choices in someone who has severe liver disease, such as cirrhosis or hepatitis. Finally, these drugscan be habit forming; that is, they cannot be discontinued without being tapered for fear of withdrawalsigns and symptoms. Those individuals who have a history of substance abuse, particularly abuse ofdepressant drugs, such as alcohol, barbiturates, or benzodiazepines should not be prescribed thesedrugs. Because the duration of action of some of the benzodiazepines, such as Xanax and Ativan, isfairly short, they may have to be given three or four times a day. Also, the benzodiazepines may pro-duce a significant degree of sedation, which can impair driving and the ability to operate certainmachinery.
Another group of drugs that are used to treat anxiety are the antidepressants. The tricyclic antidepres-sant drugs, such as imipramine, have been very effective for years in treating anxiety disorders. Themajor drawback of these medications is that they are not effective as quickly as the benzodiazepines. Itmay take 10 days to 2 weeks before the beneficial effects of imipramine and other tricyclic antidepres-sants are seen. They also may initially increase anxiety before relieving it, and they have side effectssuch as weight gain, sexual dysfunction, dry mouth, constipation, and blurry vision. The advantages ofthe tricyclic antidepressants are twofold: (1) they can be given once daily, and (2) they may be moreeffective 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). Inparticular, 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, constipa-tion, 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 usingPaxil 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 potential-ly physically addicting, so it is often substituted for the benzodiazepines. The advantages of usingBuSpar 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 anxietyand is particularly effective for treating the runaway heartbeat and sense of heart pounding that manyanxious patients feel. Because Inderal is also used to treat high blood pressure, individuals with lowblood pressure should not take it. It can also sometimes make individuals feel very tired, and shouldnot be used in patients who have severe lung disease.
Anxiety disorders can cause significant suffering and worry for patients. However, these are treatableconditions.
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 regu-lar exercise program; and to watch your diet. If you are taking antianxiety medications, you should bevery careful when driving or operating dangerous machinery.
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; thereforeyou should avoid drinking alcohol.
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 orthoughts.
For More InformationFor more information on anxiety, please contact your local mental health center or your local commu-nity hotline. There are various support groups in most communities for specific anxiety disorders suchas panic, obsessive-compulsive disorder, and posttraumatic stress disorder.
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