| |
| Generalized Anxiety Disorder (GAD) |
Diagnosis of Generalized Anxiety Disorder
According to the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), the main feature of GAD is excessive, uncontrollable worry and anxiety about a number of events or activities. DSM-IV also states that the worry and anxiety must be associated with at least three of the following six somatic symptoms: restlessness or feeling keyed up or on edge, being easily fatigued, difficulty concentrating or mind going blank, irritability, muscle tension, and sleep disturbance. Furthermore, the focus of the worry and anxiety must not be confined to features of another Axis I disorder. For example, a GAD diagnosis would not be assigned to someone who only worries about the possibility of having a panic attack (as in panic disorder) or about being embarrassed in public (as in social phobia). As is the case with other Axis I disorders, the symptoms must lead to clinically significant distress or impairment in important areas of functioning.
Although the DSM-IV nicely encapsulates the symptoms of GAD, it is sometimes difficult for therapists to identify GAD solely on the basis of DSM-IV diagnostic criteria. Additional information about the typical clinical presentation of GAD clients can be useful when making difficult diagnostic decisions. For example, do GAD clients typically consult for their worries, their anxiety, or their somatic symptoms? Although excessive and uncontrollable worry is the cardinal feature of GAD, GAD clients most often seek professional help for their feelings of anxiety and their somatic symptoms. They may believe that they are "born worriers", that worry represents an immutable personality trait, and that there is therefore no reason to discuss their worries with their therapist. Thus, GAD clients typically do not mention their worries unless their therapist asks about them. "Have you recently been worrying more than usual?" is a simple question that is often neglected by therapists when clients report symptoms such as anxiety, fatigue, muscle tension, and problems with sleep.
Information about the typical worry themes of GAD clients can also be useful when making complex diagnostic decisions. For the most part, the worry themes of GAD clients are similar to those of individuals from the general population. For example, GAD clients commonly worry about interpersonal relationships, family, home, finances, work, and illness. It does appear, however, that GAD clients tend to worry more about minor matters and about unlikely future events. Thus, although the worry themes of GAD clients are similar to those of nonclinical individuals, there seem to be subtle differences between the worries of these two populations. Excessive worries about everyday minor matters (e.g., "Will I get caught in traffic on my way to work?") and highly unlikely future events (e.g., "Will I someday go bankrupt?") may be relatively specific to GAD and may help therapists to recognize this anxiety disorder. This does not imply that all GAD clients worry about minor matters or improbable future events, but that very few individuals without GAD report these worries.
A final feature of the clinical presentation of GAD clients which will be discussed here is their tendency to "live in the future". Given that worry is mainly future oriented, this feature of the clinical presentation is not surprising. However, this tendency to "live in the future" tends to create subtle forms of distress and interference with daily living for clients with GAD. For example, individuals with GAD may have considerable difficulty unwinding over the weekend because they are worried about what will happen at work on Monday morning. At work, they may have difficulty concentrating on the task at hand because they are worried about what others will think of their performance. This difficulty "living in the present" thus represents another important feature of the clinical presentation of GAD clients.
Case Illustration
The client, who will be referred to as Anne, was a 22 year old undergraduate nursing student. She lived alone in a small apartment on campus and seemed to enjoy living on her own. Her parents, who lived in a small town 120 miles away, had helped Anne get started when she left to go to university by buying her the "essentials" for her apartment. Anne was involved in a steady relationship, and had been with her boyfriend for just over two years. Although their relationship had its ups and downs, Anne truly cared for her boyfriend and hoped they would someday be married. Anne also had many friends and was quite active socially. She often had friends over for dinner on the weekend and was generally well liked by other students.
Anne was the eldest of three children. During her childhood, Anne often had to "take care" of her brothers, who were two and three years younger than herself. When she was between the ages of five and ten, her father and mother had experienced some marital difficulties, and Anne’s mother often confided in her. Although Anne was only a child, she often felt that she needed to take care of her mother, who seemed to feel vulnerable in the midst of these marital problems. Anne reported that she not only felt that she had to watch over her younger brothers, but also, to some extent, over her mother. Although Anne believed that her parents had a sound relationship and she certainly felt loved by both of them, Anne also felt a large degree of responsibility for the happiness of her brothers and mother. She reported that she was often on the lookout for problems and always tried to detect the first signs of difficulties between her parents.
Anne had always done very well in school, and was a self-proclaimed perfectionist who always tried to obtain the top grade. In high school, she had managed to get straight A’s while being very active in extra-curricular activities. Anne was a member of the school’s student association, was president of her class in grades 11 and 12, and was on the school basketball team every year. High school had been a wonderful time for Anne and she had many fond memories of these years.
After finishing high school, Anne became unsure about pursuing a career in nursing, and decided to take a year off to work before pursuing her university education. During that year, Anne worked in a department store. Although Anne generally enjoyed her job, she continued to worry about her choice of career. At this point in time, Anne's worries were not excessive, but she felt it was important not to delay her university education for more than a year. Anne eventually chose to enter a nursing program at a large university two hours away from her parents’ home. During her first year in the nursing program, Anne was very successful. She enjoyed her courses, obtained grades that were comparable to those she obtained in high school, and felt she had made the right choice by entering the nursing program. However, Anne began to experience anxiety problems during her second year at the university, which quickly escalated and became difficult to control. By the time Anne was in her third year, she could no longer cope with her problems and decided to consult our clinic.
As is often the case with GAD clients, Anne’s chief presenting complaint was her somatic symptoms. Specifically, Anne was concerned that these symptoms were interfering with her schoolwork. For example, because of her difficulties concentrating, Anne had great difficulty understanding the required readings for her courses. Given her sleep difficulties, Anne often felt tired and this also interfered with her schoolwork. Furthermore, the constant tension in her muscles made attending class very unpleasant. By seeking help from a specialist, Anne hoped to rid herself of these symptoms and return to her previous level of academic success and enjoyment. Anne had not thought of mentioning her worries to the therapist because it did not seem to her that they were part of the problem, much less the key element of the problem.
When the therapist asked Anne if she had been particularly worried over the past few months, she burst into tears. Anne explained that over the past year, she was "always" worrying about her parents. Ever since her best friend’s mother had died of cancer the previous year, she had begun to worry that her own mother, who was in excellent health, would also develop breast cancer. She soon began to worry about her father’s health and wondered if he might not develop some form of cancer as well. These worries about her parents' health had steadily gotten worse over the past year and Anne now spent about 5 hours every day worrying that her parents would develop cancer. When the therapist asked Anne if she had any other worries, she responded by saying that she had begun to worry "about everything". For example, Anne worried about her schoolwork, her relationship with her boyfriend, and "all sorts of little things" like being late for class, or having enough time to get everything done each week. Clearly, although Anne’s initial presenting complaint was not excessive and uncontrollable worry, she suffered from GAD.
Excerpt from:
Dugas, M. J. (2002). Generalized anxiety disorder. In M. Hersen (Ed.), Clinical behavior therapy: Adults and children (pp. 125-143). New York: John Wiley & Sons.
|
|
