Beyond Stress: Generalized Anxiety Disorder

J.Adderton, BSN, MSN

Do you think working in healthcare is an environmental factor contributing to the risk of GAD?

The ebb and flow of life bring moments of peace and contentment. Occasionally, stress and anxiety are a normal part of life, especially when faced with change, challenge and difficult decisions. Everyday events, children going to school, job promotions, illness, vacations and more, cause some level of anxiety. During these times, anxiety levels heighten temporarily but most people work through and shake off the worry. However, there are those who are weighed down with excessive worry and unable to work through the anxiety. Generalized anxiety disorder (GAD) characterizes a condition of extreme and excessive worry that is usually accompanied by physical symptoms. Symptoms may include trembling, muscle tension, twitching, irritability, sweating and feeling light-headed.

Diagnosing GAD

The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) characterizes GAD as having excessive worry more days than not for at least (6) six months. Excessive worry is worry or tension without a specific threat or that is out of proportion to the actual risk. The following table provides a comparison between “normal” or reasonable worry and excessive severe worry.

Everyone experiences stress and anxiety intertwined with relaxed and peaceful moments in life. But what happens when anxiety becomes a roadblock in your ability to function in day to day activities and relationships? This article explores what happens when excessive worry leaves you unable to work through stressful situations.

Reasonable/Normal Anxiety	Excessive/Severe Anxiety
Not in the way or interrupt your daily routine (job, school, social life etc) Able to control anxiety effectively Unpleasant, but does not cause emotional or physical distress Lasts for only a short period of time	Significantly disrupts routine life Unable to de-escalate or control Extremely upsetting/stressful Worry about things and feel like the worst is always around the corner Excessive anxiety experienced most days than not

Without panic attacks present, we may think we are "just worrying too much." Our struggles of constant worry may be minimized or dismissed and, in turn, not properly diagnosed.

Most of us feel worried at some point in our lives and experience situations that can cause us to feel anxious, so what are professionals looking for to help determine if someone struggles with GAD? An evaluation of symptom criteria, as outlined in The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (also known as the DSM-5), is the first step—and looks for factors like excessive, hindering worry paired with a variety of physical symptoms, then use of proven diagnostic assessments to make a diagnosis and rule out other possibilities.

Symptoms

The DSM-5 outlines specific criteria to help professionals diagnose generalized anxiety disorder. Having a standard set of symptoms to reference when assessing clients helps them to more accurately diagnose mental health concerns and, in turn, provide a better plan of care.

When assessing for GAD, clinical professionals are looking for the following:

The presence of excessive anxiety and worry about a variety of topics, events, or activities. Worry occurs more often than not for at least 6 months and is clearly excessive.
The worry is experienced as very challenging to control. The worry in both adults and children may easily shift from one topic to another.
The anxiety and worry are accompanied with physical or cognitive symptoms.

In addition to behavioral symptoms of GAD, the presence 3 common physical symptoms (In children, only one symptom is necessary) supports the diagnosis of GAD. Many of the symptoms are associated with the “fight or flight” response to anxiety. Supporting symptoms for diagnosis would not be attributed to any other physical problem or illness. Physical symptoms include:

Tensing of muscles and body aches
Headaches
Feeling tired, low energy
Shakiness or muscle “twitches”
Difficulty swallowing
Difficulty falling asleep or staying asleep
Difficulty concentrating- mind drifts off or goes blank
Irritability
Increased sweating
Increased pulse or palpitation
Nausea
Feeling dizzy
Tingling in arms or legs
Feeling out of breath or smothering sensation
Flushing
Increased trips to the bathroom
Other symptoms that are not related to any other cause

GAD is Treatable

GAD is typically treated with psychotherapy, medication or both. Psychotherapy helps to identify sources of anxiety and effective coping strategies for relieving excessive worry. Coping strategies may include meditation, imagery, relaxation techniques, restructuring negative thinking patterns and healthy lifestyle changes. Ultimately, the goal of psychotherapy is to change the way we react to stressful triggers or events.

Medications are sometimes used to help relieve symptoms but are not a cure for GAD. Antidepressants, specifically serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs and monoamine oxidase inhibitors are often used as first line medication treatment. Beta blockers, used to treat high blood pressure, may also be prescribed to help with the “fight or flight” symptoms of anxiety. Benzodiazepines are often used for acute and short term relieve of symptoms. There are drawbacks due to the risk of tolerance, dependence and abuse of benzodiazepines. Buspar is a non-benzodiazepine medication specifically for the treatment of chronic anxiety.

Risk Factors

We all experience stress and anxiety at one point of our lives. Researchers are finding both genetics and environment can contribute to the risk of anxiety disorders. Risk factors may include:

Traits of shyness and behavioral inhibition as a child
Exposure to stressful and/or negative life events in early childhood or adulthood
Family history of anxiety or mental disorders
Substance abuse or other health conditions (i.e. thyroid disorders, heart arrhythmias) can also produce or exaggerate symptoms of anxiety.

For more information:

Newman, M. G., Zuellig, A. R., Kachin, K. E., Constantino, M. J., & Cashman, L. (2002). The reliability and validity of the GAD-Q-IV: a revised self-report diagnostic measure of generalized anxiety disorder. Behavior Therapy, 33, 215-233.

National Institute of Mental Health Fact Sheet

**VivaLasViejas, ASN, RN** · Apr 3, 2019

All of the women on my mother's side of the family developed anxiety in our 50s, although technically I don't have an official diagnosis because my anxiety has been labeled a component of my bipolar disorder. I've noticed that it occurs most often when I am in a depressive phase; I'll wake up anxious even if nothing is wrong. I mean, I don't even have my eyes open yet when the palpitations and choking sensation begin, and I tremble and feel like something awful is about to happen.

There is no basis in fact for any of this, and I usually have no idea what triggers it. But I start to imagine all sorts of horrible scenarios, mostly starring my kids, and I'll start hyperventilating and feel my heart pounding. I also get clammy and dizzy, and there is an unpleasant burning sensation in my throat. It's almost like having a heart attack, only without the chest pain. (Yes, I've had it checked out.) It usually goes away in a couple of hours and I can go about my day in a relatively normal fashion, but I don't suppose that early-morning anxiety does me any good. I was in a depressive episode recently and woke up every day feeling like the world was about to end. I have PRN Klonopin which I rarely use, but there are times when it's absolutely necessary.

This is a good article. Mental illness isn't so scary when we talk about it. Thank you.

KalipsoRed21, BSN, RN · Apr 4, 2019

I certainly think being in the medical profession puts those in it at greater risk for this disorder. One risk factor of GAD we have on an almost daily basis and the higher the acuity one works with the more risk of witnessing “stressful/negative life events”. In fact I would say I can count on my hands the number of emotionally satisfying patients I’ve seen in my career. Most are stories that I will never forget, but absolutely tragic. The 24 year old with 3 children under 5 who suddenly finds out she has wide spread ovarian cancer. The late 30’s mother who did many rounds of IVF to finally have her twins, but died 3 days later of a blood clot, the 38 year old father of 2 who was hit by a drunk driver, the 21 year old who was driving down the street working his job and got shot and is now paralyzed, the 2 year old who died because her step father kicked her in the chest, the 6 year old that drowned at the family reunion, the 31 year old with mental retardation who’s parent’s died suddenly making and now no one cares for him appropriately and he doesn’t understand why, the elderly couple who can’t take care of each other anymore, the kids near by are not stepping in to help out and because of that one is going to a local memory care unit and the other to assisted living...they can’t stay in the same facility because they have different level of care needs but they have been married 65 years. And so much more and that is just 10 years in this profession...how can someone have any hope doing nursing for a living? I mean aside from having a strong faith in a higher power I don’t really think one can. Really sucks to be an atheist nurse.

studentnurseASN · Apr 4, 2019

I had more anxiety when I was younger. It was due to dealing with unknown situations. I still feel this way about new situations, but I find myself learning to make steps to prepare myself. It helps me reduce anxiety.

Chris Harris · Apr 4, 2019

I’ve had anxiety for years. Mental health treatment and my renewed faith in Christ helped me to overcome and virtually eradicate generalized anxiety psychosis bipolar shyness

but with help I’m much better

first tip I have is to eliminate unnecessary stress,get help, pray, and forgive!

Many mental illnesses are associated with unforgiveness!

TriciaJ, RN · Apr 6, 2019

On 4/3/2019 at 8:58 PM, KalipsoRed21 said:
I certainly think being in the medical profession puts those in it at greater risk for this disorder. One risk factor of GAD we have on an almost daily basis and the higher the acuity one works with the more risk of witnessing “stressful/negative life events”. In fact I would say I can count on my hands the number of emotionally satisfying patients I’ve seen in my career. Most are stories that I will never forget, but absolutely tragic. The 24 year old with 3 children under 5 who suddenly finds out she has wide spread ovarian cancer. The late 30’s mother who did many rounds of IVF to finally have her twins, but died 3 days later of a blood clot, the 38 year old father of 2 who was hit by a drunk driver, the 21 year old who was driving down the street working his job and got shot and is now paralyzed, the 2 year old who died because her step father kicked her in the chest, the 6 year old that drowned at the family reunion, the 31 year old with mental retardation who’s parent’s died suddenly making and now no one cares for him appropriately and he doesn’t understand why, the elderly couple who can’t take care of each other anymore, the kids near by are not stepping in to help out and because of that one is going to a local memory care unit and the other to assisted living...they can’t stay in the same facility because they have different level of care needs but they have been married 65 years. And so much more and that is just 10 years in this profession...how can someone have any hope doing nursing for a living? I mean aside from having a strong faith in a higher power I don’t really think one can. Really sucks to be an atheist nurse.

I agree with you that working in healthcare is a risk factor. Here are some thoughts: 1. Find a higher power, even if it's Wilson the Volleyball. 2. Find a job where most people get well and go home. 3. Good luck.