National Association for Health Professionals
Anxiety Medicinenet.com and The Cleveland Clinic Department of Psychiatry and Psychology assist us in ex-amining a common disorder. Generalized anxiety disorder or GAD is characterized by excessive, exaggerated anxiety and worry about everyday life events. People with symptoms of generalized anxiety disorder tend to always ex-pect disaster and can't stop worrying about health, money, family, work or school. In people with GAD, the worry often is unrealistic or out of proportion for the situation. Daily life becomes a constant state of worry, fear and dread. Eventually, the anxiety so dominates the person's thinking that it inter-feres with daily functioning, including work, school, social activities and relationships. GAD affects the way a person thinks, but the anxiety can lead to physical symptoms as well. Symp-toms of GAD include:
• Excessive, ongoing worry and tension
• Restlessness or a feeling of being "edgy"
• The need to go to the bathroom frequently
In addition, people with GAD often have other anxiety disorders (such as panic disorder, obsessive-compulsive disorder and phobias), suffer from depression, and/or abuse drugs or alcohol.
What Causes Generalized Anxiety Disorder?
The exact cause of GAD is not fully known, but a number of factors—including genetics, brain chem-istry and environmental stresses—appear to contribute to its development.
• Genetics: Some research suggests that family history plays a part in increasing the likelihood
that a person will develop GAD. This means that the tendency to develop GAD may be passed on in families.
• Brain chemistry: GAD has been associated with abnormal levels of certain neurotransmitters in
the brain. Neurotransmitters are special chemical messengers that help move information from nerve cell to nerve cell. If the neurotransmitters are out of balance, messages cannot get through the brain properly. This can alter the way the brain reacts in certain situations, leading to anxi-ety.
• Environmental factors: Trauma and stressful events, such as abuse, the death of a loved one,
divorce, changing jobs or schools, may lead to GAD. GAD also may become worse during peri-ods of stress. The use of and withdrawal from addictive substances, including alcohol, caffeine and nicotine, can also worsen anxiety.
How Common Is Generalized Anxiety Disorder?
About 4 million adult Americans suffer from GAD during the course of a year. It most often begins in childhood or adolescence but can begin in adulthood. It is more common in women than in men.
How Is Generalized Anxiety Disorder Diagnosed?
If symptoms are present, the doctor will begin an evaluation by asking questions about your medical history and performing a physical examination. Although there are no laboratory tests to specifically diagnose anxiety disorders, the doctor may use various tests to look for physical illness as the cause of the symptoms. The doctor bases his or her diagnosis of GAD on reports of the intensity and duration of symptoms—including any problems with functioning caused by the symptoms. The doctor then determines if the symptoms and degree of dysfunction indicate a specific anxiety disorder. GAD is diagnosed if symp-toms are present for more days than not during a period of at least six months. The symptoms also must interfere with daily living, such as causing you to miss work or school
How Is Generalized Anxiety Disorder Treated?
If no physical illness is found, you may be referred to a psychiatrist or psychologist ,(mental health pro-fessionals who are specially trained to diagnose and treat mental illnesses). Treatment for GAD most often includes a combination of medication and cognitive-behavioral therapy.
• Medication: Medicines are available to treat GAD and may be especially helpful for people
whose anxiety is interfering with daily functioning. The medications most often used to treat GAD are from a class of drugs called benzodiazepines. These medications are sometimes re-ferred to as "tranquilizers," because they leave you feeling calm and relaxed. They work by de-creasing the physical symptoms of GAD, such as muscle tension and restlessness. Common benzodiazepines include Xanax, Librium, Valium and Ativan. Another medicine, BuSpar, also may be used to treat chronic anxiety. BuSpar works by affecting the activity of certain neuro-transmitters, including serotonin. Unlike the benzodiazepines, BuSpar does not cause sedation (sleepiness) or lead to dependency. Antidepressants, such as Paxil and Effexor, are also being used to treat GAD
• Cognitive-behavioral therapy: People suffering from anxiety disorders often participate in this
type of therapy, in which you learn to recognize and change thought patterns and behaviors that lead to troublesome feelings. This type of therapy helps limit distorted thinking by looking at worries more realistically.
• In addition, relaxation techniques, such as deep breathing and biofeedback, may help to control
the muscle tension that often accompanies GAD.
Are There Complications of Treatment? Dependency on anti-anxiety medications (benzodiazepines) is a potential complication of treatment. Other side effects of medications include sleepiness and sexual problems.
What Is the Outlook for People With Generalized Anxiety Disorder?
Although many people with GAD cannot be cured, most people gain substantial relief from their symp-toms with treatment.
Can Generalized Anxiety Disorder Be Prevented?
Anxiety disorders cannot be prevented. However, there are some things that you can do to control or lessen symptoms, including: Stop or reduce your consumption of products that contain caffeine, such as coffee, tea, cola and choco-late.
• Ask your doctor or pharmacist before taking any over-the-counter medicines or herbal reme-
dies. Many contain chemicals that can increase anxiety symptoms.
• Exercise daily and eat a healthy, balanced diet.
• Seek counseling and support after a traumatic or disturbing experience.
(Reviewed by the doctors at The Cleveland Clinic Department of Psychiatry and Psychology.) Children and Anxiety: The Massachusetts General Hospital School Psychiatry and MADI Resource Center presents a specific focus on children and anxiety-
What Does Generalized Anxiety Disorder Look Like in Children and Adolescents?
Children with generalized anxiety disorder are often preoccupied with worries about their success in activities and their ability to obtain the approval of others. These children may have persistent thoughts of self-doubt that they are unable to control, and they constantly criticize themselves. Children may be preoccupied with being on time to events and insist on doing a task "perfectly." In contrast to the ordi-nary, occasional worries or fears experienced in childhood, generalized anxiety disorder persists for at least six months and affects children throughout the day (at home, at school, and with friends). Children may appear inflexible or excessively worried about conforming to rules, or they may not be able to enjoy hobbies or other recreational activities. Some children may appear shy when, in fact, they are preoccupied with significant worries. Even if children are aware that their worries are more intense than is warranted by a situation, they may not be able to stop the worry. A trained clinician (such as a child psychiatrist, child psychologist or pediatric neurologist) should integrate information from home, school, and the clinical visit to make a diagnosis. At home, children with generalized anxiety disorder may have a combination of the symptoms listed below.
• Excessive worry and anxiety about a variety of matters on most days for at least 6 months. Chil-
dren may worry about school tasks, interactions with peers, being on time, and following rules. Worry about receiving approval is common. Children may worry about future activities, new experiences, or many other matters.
• Frequent self-doubt and self-critical comments • Inability to stop the worry despite parental reassurance • Physical problems, including headaches, stomach ache, fatigue, and muscle tensions • Signs of persistent anxiety, including restlessness, feeling "on edge," difficulty concentrating or
• Irritability, which often increases with increased worry • Sleep problems, which may include waking up early, waking up feeling unrested, or trouble fal-
• Experimentation with alcohol or drugs as a way to reduce suffering. Drugs and alcohol can
• Depression or thoughts of not wanting to be alive in some situations if children believe there is
At school, a child with generalized anxiety disorder may have a combination of the symptoms listed below.
• Excessive worry and anxiety about a variety of matters • Repeated seeking of teacher approval
• An inability to explain worries. Children may not understand why they are so anxious. • Inability to stop the worry. Despite adult reassurance, the worries continue. • Difficulty transitioning from home to school. Children may develop difficulty entering school
in the morning if they associate more worries with school. This may lead to late arrival times, long and tearful morning drop-offs, or tearful episodes at school.
• Refusal or reluctance to attend school. Anxiety may lead a child to insist on staying at home. • Avoidance of academic and peer activities • Self-criticism and low self-esteem • Difficulty concentrating due to persistent worry, which may affect a variety of school activities,
from following directions and completing assignments to paying attention
• Other conditions, such as attention deficit hyperactivity disorder (ADHD), may also be present,
compounding learning difficulties. Having one mental health condition does not "inoculate" the child from having other conditions as well.
• Other anxiety disorders, such as social phobia, separation anxiety, or panic disorder. Anxiety
disorders may not be recognized both because children may try to hide symptoms and because their symptoms are experienced internally and may not be easily seen.
• Learning disorders may co-exist and should not be overlooked in this population. A child's dif-
ficulties in school should not be presumed to be due entirely to anxiety. If the child still has aca-demic difficulty after symptoms are treated, an educational evaluation for a learning disorder should be considered. A child's repeated reluctance to attend school may be an indicator of an undiagnosed learning disability.
• Side effects from medications. Medications may have cognitive or behavioral effects or physi-
cally uncomfortable side effects that interfere with school performance. After a child begins receiving medical treatment for symptoms, any mood changes or new behaviors should be dis-cussed with parents, as they can reflect medication side effects.
A child's symptoms of generalized anxiety may be evident during an office visit when a child is reluc-tant to meet the clinician. This feature alone does not indicate a child has anxiety, since children rou-tinely are nervous during office visits. Clinicians may benefit from talking with parents, school staff, and other important caregivers to evalu-ate a child's functioning in each area to determine the underlying cause of the child's symptoms. Clini-cians may encounter some of the following challenges in diagnosing and treating a child or adolescent with generalized anxiety.
• Symptoms vary over time and their appearance changes as a child grows. A clinician may need
to see a child over time to determine the appropriate diagnosis.
• Other anxiety disorders may look like generalized anxiety disorder • Symptoms of mood disorders, such as depression and bipolar disorder, and behavior disorders,
such as attention deficit hyperactivity disorder, can resemble the symptoms of anxiety . Depres-sion is often identified in these children.
• Certain medical conditions can cause anxiety . These conditions include hyperthyroidism, hy-
perparathyroidism, hypoglycemia, cardiac disorders, seizure disorders, gastrointestinal prob-lems, and vestibular or inner-ear disorders. Relevant laboratory tests and physical examinations may be helpful when a child has anxiety.
• Caffeine and other substances, such as stimulants, can produce anxiety . Consequently, evalua-
tion for caffeine use and other substance use, especially with adolescents, is important.
• Physical complaints such as stomach aches, headaches, and dizziness often occur in children
with anxiety. The clinician must determine whether these complaints warrant further medical investigation.
• Children may have difficulty talking about their worries . Phrasing questions with particular
sensitivity and compassion may allow a more complete picture of symptoms to emerge.
• Children may be unaware, or unwilling to admit , that their feelings or behavior may indicate
• Families may need to be coached about what they can reasonably expect from their child. Chil-
dren who suffer from any anxiety disorder will benefit if their family understands that therapy and medicines may reduce, but may not cure, symptoms.
Let’s look at some other anxiety disorders with assistance from the National Institute of Mental Health: Panic Disorder- Panic disorder is a real illness that can be successfully treated. It is characterized by sudden attacks of terror, usually accompanied by a pounding heart, sweatiness, weakness, faintness, or dizziness. During these attacks, people with panic disorder may flush or feel chilled; their hands may tingle or feel numb; and they may experience nausea, chest pain, or smothering sensations. Panic attacks usually produce a sense of unreality, a fear of impending doom, or a fear of losing control. A fear of one’s own unexplained physical symptoms is also a symptom of panic disorder. People hav-ing panic attacks sometimes believe they are having heart attacks, losing their minds, or on the verge of death. They can’t predict when or where an attack will occur, and between episodes many worry in-tensely and dread the next attack. Panic attacks can occur at any time, even during sleep. An attack usually peaks within 10 minutes, but some symptoms may last much longer. Panic disorder affects about 6 million American adults and is twice as common in women as men. Panic attacks often begin in late adolescence or early adulthood, but not everyone who experiences panic attacks will develop panic disorder. Many people have just one attack and never have another. The tendency to develop panic attacks appears to be inherited. People who have full-blown, repeated panic attacks can become very disabled by their condition and should seek treatment before they start to avoid places or situations where panic attacks have occurred. For example, if a panic attack happened in an elevator, someone with panic disorder may develop a fear of elevators that could affect the choice of a job or an apartment, and restrict where that person can seek medical attention or enjoy entertainment. Some people’s lives become so restricted that they avoid normal activities, such as grocery shopping or driving. About one-third become housebound or are able to confront a feared situation only when ac-companied by a spouse or other trusted person. When the condition progresses this far, it is called ago-raphobia, or fear of open spaces. Early treatment can often prevent agoraphobia, but people with panic disorder may sometimes go from
doctor to doctor for years and visit the emergency room repeatedly before someone correctly diagnoses their condition. This is unfortunate, because panic disorder is one of the most treatable of all the anxi-ety disorders, responding in most cases to certain kinds of medication or certain kinds of cognitive psy-chotherapy, which help change thinking patterns that lead to fear and anxiety. Panic disorder is often accompanied by other serious problems, such as depression, drug abuse, or alco-holism. These conditions need to be treated separately. Symptoms of depression include feelings of sadness or hopelessness, changes in appetite or sleep patterns, low energy, and difficulty concentrating. Most people with depression can be effectively treated with antidepressant medications, certain types of psychotherapy, or a combination of the two. OCD- People with obsessive-compulsive disorder (OCD) have persistent, upsetting thoughts (obsessions) and use rituals (compulsions) to control the anxiety these thoughts produce. Most of the time, the rituals end up controlling the person. For example, if people are obsessed with germs or dirt, they may develop a compulsion to wash their hands over and over again. If they develop an obsession with intruders, they may lock and relock their doors many times before going to bed. Being afraid of social embarrassment may prompt people with OCD to comb their hair compulsively in front of a mirror-sometimes they get “caught” in the mirror and can’t move away from it. Performing such rituals is not pleasurable. At best, it produces temporary relief from the anxiety cre-ated by obsessive thoughts. Other common rituals are a need to repeatedly check things, touch things (especially in a particular se-quence), or count things. Some common obsessions include having frequent thoughts of violence and harming loved ones, persistently thinking about performing sexual acts the person dislikes, or having thoughts that are prohibited by religious beliefs. People with OCD may also be preoccupied with order and symmetry, have difficulty throwing things out and hoard unneeded items. Healthy people also have rituals, such as checking to see if the stove is off several times before leaving the house. The difference is that people with OCD perform their rituals even though doing so interferes with daily life and they find the repetition distressing. Although most adults with OCD recognize that what they are doing is senseless, some adults and most children may not realize that their behavior is out of the ordinary. OCD affects about 2.2 million American adults, and the problem can be accompanied by eating disor-ders, other anxiety disorders, or depression. It strikes men and women in roughly equal numbers and usually appears in childhood, adolescence, or early adulthood. One-third of adults with OCD develop symptoms as children, and research indicates that OCD might run in families. The course of the disease is quite varied. Symptoms may come and go, ease over time, or get worse. If OCD becomes severe, it can keep a person from working or carrying out normal responsibilities at home. People with OCD may try to help themselves by avoiding situations that trigger their obsessions, or they may use alcohol or drugs to calm themselves.
OCD usually responds well to treatment with certain medications and/or exposure-based psychother-apy, in which people face situations that cause fear or anxiety and become less sensitive (desensitized) to them. NIMH is supporting research into new treatment approaches for people whose OCD does not respond well to the usual therapies. These approaches include combination and augmentation (add-on) treatments, as well as modern techniques such as deep brain stimulation. PTSD- Post-traumatic stress disorder (PTSD) develops after a terrifying ordeal that involved physical harm or the threat of physical harm. The person who develops PTSD may have been the one who was harmed, the harm may have happened to a loved one, or the person may have witnessed a harmful event that happened to loved ones or strangers. PTSD was first brought to public attention in relation to war veterans, but it can result from a variety of traumatic incidents, such as mugging, rape, torture, being kidnapped or held captive, child abuse, car accidents, train wrecks, plane crashes, bombings, or natural disasters such as floods or earthquakes. People with PTSD may startle easily, become emotionally numb (especially in relation to people with whom they used to be close), lose interest in things they used to enjoy, have trouble feeling affection-ate, be irritable, become more aggressive, or even become violent. They avoid situations that remind them of the original incident, and anniversaries of the incident are often very difficult. PTSD symptoms seem to be worse if the event that triggered them was deliberately initiated by another person, as in a mugging or a kidnapping. Most people with PTSD repeatedly relive the trauma in their thoughts during the day and in nightmares when they sleep. These are called flashbacks. Flashbacks may consist of im-ages, sounds, smells, or feelings, and are often triggered by ordinary occurrences, such as a door slam-ming or a car backfiring on the street. A person having a flashback may lose touch with reality and be-lieve that the traumatic incident is happening all over again. Not every traumatized person develops full-blown or even minor PTSD. Symptoms usually begin within 3 months of the incident but occasionally emerge years afterward. They must last more than a month to be considered PTSD. The course of the illness varies. Some people recover within 6 months, while others have symptoms that last much longer. In some people, the condition becomes chronic. PTSD affects about 7.7 million American adults, but it can occur at any age, including childhood. Women are more likely to develop PTSD than men, and there is some evidence that susceptibility to the disorder may run in families. PTSD is often accompanied by depression, substance abuse, or one or more of the other anxiety disorders. Certain kinds of medication and certain kinds of psychotherapy usually treat the symptoms of PTSD very effectively. Social Phobia- Social phobia, also called social anxiety disorder, is diagnosed when people become overwhelmingly anxious and excessively self-conscious in everyday social situations. People with social phobia have an intense, persistent, and chronic fear of being watched and judged by others and of doing things that will embarrass them. They can worry for days or weeks before a dreaded situation. This fear may become
so severe that it interferes with work, school, and other ordinary activities, and can make it hard to make and keep friends. While many people with social phobia realize that their fears about being with people are excessive or unreasonable, they are unable to overcome them. Even if they manage to con-front their fears and be around others, they are usually very anxious beforehand, are intensely uncom-fortable throughout the encounter, and worry about how they were judged for hours afterward. Social phobia can be limited to one situation (such as talking to people, eating or drinking, or writing on a blackboard in front of others) or may be so broad (such as in generalized social phobia) that the person experiences anxiety around almost anyone other than the family. Physical symptoms that often accompany social phobia include blushing, profuse sweating, trembling, nausea, and difficulty talking. When these symptoms occur, people with a social phobia feel as though all eyes are focused on them. Social phobia affects about 15 million American adults. Women and men are equally likely to develop the disorder, which usually begins in childhood or early adolescence.2 There is some evidence that ge-netic factors are involved. Social phobia is often accompanied by other anxiety disorders or depression, and substance abuse may develop if people try to self-medicate their anxiety. Social phobia can be successfully treated with certain kinds of psychotherapy or medications. Specific Phobia- Specific phobia is an intense fear of something that poses little or no actual danger. Some of the more common specific phobias are centered around closed-in places, heights, escalators, tunnels, highway driving, water, flying, dogs, and injuries involving blood. Such phobias aren’t just extreme fear; they are irrational fear of a particular thing. You may be able to ski the world’s tallest mountains with ease but be unable to go above the 5th floor of an office building. While adults with phobias realize that these fears are irrational, they often find that facing, or even thinking about facing, the feared object or situation brings on a panic attack or severe anxiety. Specific phobias affect an estimated 19.2 million adult Americans and are twice as common in women as men. They usually appear in childhood or adolescence and tend to persist into adulthood. The causes of specific phobias are not well understood, but there is some evidence that the tendency to develop them may run in families. If the feared situation or feared object is easy to avoid, people with specific phobias may not seek help; but if avoidance interferes with their careers or their personal lives, it can become disabling and treat-ment is usually pursued. Specific phobias respond very well to carefully targeted psychotherapy.
Complete the questions below to receive 10.5 continuing education credits. All questions must be answered
1. What is GAD characterized by? __________________________________________
2. Describe a physical symptom of GAD. ____________________________________
3. What other anxiety disorders may a person with GAD suffer from? ______________ 4. Name one factor that may cause GAD. ____________________________________ 5. Define “neurotransmitter.” _______________________________________________ 6. Name an environmental factor that may lead to GAD. _________________________ 7. How many adult Americans suffer from GAD?_______________________________ 8. On what does the doctor base the GAD diagnosis ?____________________________ 9. What type of medication is used to treat GAD? ______________________________ 10. How does a tranquilizer work? ___________________________________________ 11. Which drug does not cause sedation? ______________________________________ 12. Describe cognitive-behavioral therapy. _____________________________________ 13. Name one thing that can control GAD symptoms. ____________________________ 14. What are children with GAD preoccupied with? ______________________________ 15. List one symptom that a GAD child may have while at home. ___________________ 16. Describe a symptom of a GAD child while in school. _________________________ 17. Name one medical condition which can cause anxiety. ________________________ 18. Describe a symptom of a panic disorder. ____________________________________
19. What are rituals used for in OCD? ___________________________________________ 20. When does PTSD develop? _______________________________________________ 21. What is a social phobia? ___________________________________________________ 22. Name one specific phobia. _________________________________________________ 23. Who should the clinician talk with concerning evaluating a child? __________________ 24. What can caffeine cause? __________________________________________________
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OHSU Hospital and Clinics Department of Pharmacy Services Pharmacy and Therapeutics Committee October 2011 ANTICOAGULANTS: THE GUIDE TO REVERSAL Definition of Bleeding: Minor bleeding – Any clinically overt sign of hemorrhage (including imaging) that is associated with a <5 g/dl decrease in the hemoglobin concentration or < 15% decrease in the hematocrit felt by the cli