Too Much Worry Generalized Anxiety Disorder
Worrying Too Much, All the Time, About Everything
Generalized Anxiety Disorder [GAD]
From the series” I want you to know what I know.”
Mental Health Problems that Shouldn’t be Missed and their Medication Treatments
1. A Great Pretender: GAD presenting first as Over Anxious Disorder of Childhood, at a very young age, is A Great Pretender, disguising itself as a physical problem like headaches, gastrointestinal distress, or sleep difficulties. It may present with school difficulties with poor concentration to the primary care practitioner, and be misdiagnosed and mistreated as ADHD. Persistent physical complaints at any age caused by GAD are treated symptomatically, and don’t get better because the cause is not addressed. The worry and anxiety is often ignored or seen as normal.
2. Normal Worry vs. GAD: Anxiety in GAD is a. difficult to control, b. interferes significantly with functioning, c. more persistent, distressing, involving more things and often without a cause. It is d. present more days than not and lasts at least 6 months.
3. Physical and Other Symptoms: Three of the following are present, in children only one is needed, a. problems concentrating and mind goes blank, b. restless, keyed up, on edge, c. irritability, d. easily fatigued, e. muscle tension, f. sleep disturbance.
4. Other Anxiety Disorders to Rule Out: the anxiety in GAD is generalized, not focused as in a. Panic Disorder fear of Panic Attacks b. Social Phobia fear of being embarrassed in public, c. Obsessive Compulsive Disorder worried by specific ideas and not completing rituals d. Post Traumatic Stress Disorder fear around a specific life changing trauma, e. almost exclusive medical fears about weight gain, Anorexia, multiple physical complaints, Somatization, or having a serious illness, Hypochondriasis.
5. Other Mental Health Disorders to Rule Out: Unipolar Depressions where sadness, irritability, lack of pleasure and interest predominates, Bipolar Depression defined by severe mood swings, severe irritability, nastiness, anger, and rage, Psychotic Disorders with bizarre and illogical thinking and behavior, and loss of touch with reality having hallucinations, paranoia, delusions, Autistic Spectrum , lack of , delay in, or unusual language, with poor non verbal skills, lack of emotional give and take.
6. Rule Out General Medical Conditions, Medications, Drugs of Abuse as Causes: For example, Thyroid Illness, Seizures, etc, Medications e.g. stimulants, antidepressants, Over the counter preparations, Substances of abuse e.g. Caffeine, Nicotine, Alcohol, Marijuana etc,
7. Making the Diagnosis: A physical examination , lab tests, drug screen may be necessary to rule out medically based causes. Though there are screening tests to clarify the symptom picture, there is no definitive physical or paper test, lab test, imaging like MRI, to diagnosis GAD. The diagnosis is made clinically, that is by a. family and personal history, b. presenting symptoms and mental status exam and lastly and sometimes most revealing is c. the response to treatment . The individual's and family history of response to treatment from psychotropic medication helps develop a profile of what neurohormones may by causing the GAD and aids in choosing and adjusting the appropriate medication specific to an individual’s unique brain chemistry. This is discussed below under the appropriate heading.
8. History from Multiple Sources and the Nature of Anxiety Disorders: People with excessive anxiety, by their nature tend to over evaluate and over respond to anxiety driven symptoms, yet because of shame, embarrassment, guilt, fear, worry i.e. anticipatory apprehension, consciously and un consciously under reported and distort the symptoms, and are very fearful of treatment s especially medication. Because of this, history taken multiple times, and from multiple sources is needed to clarify the totality of the symptom picture, its intensity, duration, and the amount of distress and impairment it may be causing. There are always at least two sides to the history, what the person is subjectively experiencing and are aware of, and objectively what others are observing, both are needed to get the complete picture. GAD is an internalizing disorder its true nature and intensity many times only known to the sufferer, who wants help, but is simultaneously fearful of seeking out help and them may be more fearful of the treatment. The core symptoms directly interfere with uncovering the disorder , getting and following treatment.
9. Consequences of Untreated and Under Treated Anxiety: GAD does more damage to ones emotional, mental and physical functioning than is usually appreciated. It also leads to less than optimal functioning is all domains, work, school, family, peers, socially, including ones leisure and play life. The most common complications are developing major depression, drug and alcohol problems, and symptoms that can mimic almost any physical, other psychiatric and neurological disorders. This is all the more unfortunate because there are excellent and safe treatments both biological and psychosocial that are readily and easily available, but the diagnosis has to be made, and the treatment taken. Treatment biological or not will clarify the diagnosis, with biological treatment making the other more effective and vice versa. The ideal treatment should be bio educational, psychosocial, and cognitive behavioral, each facilitating the other.
10. Biological, Genetic, Neurochemical Basis: The biologically based pleasure-pain / fight- flight responses are necessary for the survival of self and species. These are hard wired bio evolutionary adaptations modulated by many neurochemicals, including serotonin, dopamine, and neurepinephine, which also may be involved in the cause of anxiety disorders and some forms of depression. Worry or Apprehensive Expectation about avoiding pain, and seeking pleasure, and the generalized surveillance this requires if excessive may become GAD, and the psycho physiological symptoms associated with fight –flight response is very similar to panic. In these disorders there is an imbalance and over responsiveness of the neurohormones involved. The medications chosen should specifically address these neurochemical cause and not just treat and mask symptoms.
11. Medication and Neurochemistry ,(1) Antianxiety/Antidepressants: In most GAD the medications of choice belong to a class that selectively inhibits the re uptake of serotonin and neurepinephine, and are called SSRIs [Prozac, Zoloft, Paxil, Celexa, Luvox]or SSNRIs [Effexor, Cymbalta]or Selective Serotonin or Norepinephrine Reuptake Inhibitors, there is Strattera marketed for ADHD, but it is really an antidepressant/antianxiety like the others medication in this re uptake class, it only selectively works on Norepenephine, a SNRI. Another medication in class by itself is WelButrin, doesn’t work on serotonin directly but only on Norepinephrine and Dopamine, a SDNRI ,usually used as an anti depressant, but useful in certain GAD, e.g. associated with ADHD. All these medication statistically are equally effective but their positive and negative or side effects may vary vastly from person to person, even people in the same family ,even identical twins, that should be neurochemical clones. The twin response shows that genetics isn’t everything and that environment place a role in how the same genetics expresses itself in this case with medication responses.
12. Medication and Neurochemistry ,(2 ):Atypical neuroleptics: A misunderstood and underused class because their initial uses, were classified as antipsychotics, and latter found useful for mood stabilization. Medications in this class include Risperdal, Zyprexa, Seroquel, Geodon, and Abilify. In small doses the atypicals have profound effects on serotonin, and modulate in a more complex way other neurohormones such as dopamine, having an effect on helping anxiety from a different biochemical perspective. These may be considered the initial medications of choice if there is a. severe anxiety of long duration, b. causing severe emotional lability i.e. irritability, easy crying, low frustration tolerance, c. severe sleep disturbance d. mood instability i.e. mood swings, e. thinking problems like very poor concentration, thought blocking, derailment f. behavioral or thinking disorganization g. multiple and severe physical symptoms e.g. headaches, severe muscular tension and agitation h. known or suspected adverse reaction to SSRIs, including that they may make the anxiety worse or precipitate more serious symptoms The traditional antianxiety/antidepressant may in any presentation even a mild one worsen symptoms but especially with the presentations discussed above.
13. Medication and Symptom Relief, (3) Benzodiazepines: The medication classes so far discussed have specific biochemical effects, and tolerance to their effects don’t occur, and are not habit forming or addicting, which is not the case of the benzodiazepines that are widely used for anxiety and anxiety related problems. Medicines in this class include Valium, Avian, Xanax, Klonopin, Tranxene, to name a few. Though benzodiazepines are non specific, and de stabilizing in their effects they still have their usefulness if used properly and adjunctively, in small doses for a short period of time for sleep, muscular tension, tremor and for initial control of anxiety and panic. The destabilizing and disinhibiting effects of this class are similar to alcohol, in that it may paradoxically make some anxious people agitated, irritable, angry, explosive, sad, and lead to emotional lability and mood instability.
14. Medication Choice by Specific Neurochemical Profile and Treatment Trial: The only guidelines there are in choosing a class or an individual medication is family history or personal history of the patient, that is past medication responses, to the same or similar medications. Short of this one chooses an individual medication based on its specific neurochemical effects negative and positive, as it matches up to the individual persons symptom picture, choosing specific symptoms or clusters and matching it to an individual medication effects. In either case because of the extreme uniqueness of individual neurochemistry based on genetics and environmental expression of that genetics , there will be a unique response, and the only way to ensure logical scientific medication choices is through a medication trial. The response to a trial of a specific medication together with history, using specific target symptoms is often the only way to develop an individual’s unique neurochemical profile, and ensure adequate treatment.
15. Example of a Neurochemical Profile Based on Treatment Response: Most people with mild GAD do well on one of the serotonin medications like Prozac , however some people it actually makes more worried and agitated, and trying in these people WelButrin which normally is activating and makes worry worse in most people, working on dopamine, actually helps. This neurochemical response tells us that for this person has not a serotonin but a dopamine mediated GAD. To further illustrate in this same person, the Welbutrin is working well for anxiety but now there is increased irritability, sadness and mild mood swings, surprising because WelButrin is an excellent antidepressant and should not do this. A small dose of Risperdal , is added and the mood symptoms get better and the anxiety further improves. This response tells us that the mood symptoms like the anxiety symptoms are also not mediated by serotonin alone, or a deficit of dopamine, but more of an imbalance of the of the neurohormones involve, which is helped by the mood stabilizing effects of the Atypical Neuroleptic Risperdal. Thus further illustrating the neurochemical profile in terms of causation based on treatment response. This profile is quite common and often missed found in GAD people who may also have ADHD brain chemistry.
16. Guidelines for a Medication Trial in GAD: a. The initial medication choice should be based on family and personal history and severity of symptoms. If very severe with thinking problems and emotional lability start with a low dose of an atypical neuroleptic, such as Risperdal, otherwise start with the lowest dose of an SSRI like Prozac. b. The choice of medication is less important in uncertain cases then the principal of starting as low as possible, and going as slow as possible , c. be very attentive to the initial treatment response both positive and negative, d. this initial response will determine, whether to increase the dose, how fast o increase it, or to stop the medication and try another medication, either in a similar or different class, e. availability by phone or in person of the prescriber is necessary to answer any questions, and deal with problems, and to direct the next steps in the medication trial, f. the appropriate medication is now increased on a schedule determined by the needs of the patient, further responses to treatment, balancing good vs. negative effects, g. until the optimal effect is achieved.
17. Creative Psychopharmacology , Using Multiple and Adjunctive Medications in GAD: To illustrate, Prozac may alleviate the anxiety, but the dose needed causes short term memory and concentration problems so Wellbutrin is added. Risperdal used initially because of the extreme anxiety of long duration, accompanied by labile emotional states, with thinking problems, but obsessional features, and motor tension with migraines are still present and Prozac in then added for that cluster of symptoms. Essential and other tremors, and cardiac awareness can be treated with adjunctive beta blocker Inderal . The examples are only limited by the variety of symptom presentations and medications available. This creative use of medications is necessary to ensure symptom relief, compliance and prevention of relapses and complications.
18. Adequate Treatment: Dosing and Duration. Treatment to be adequate should reasonably eliminate the symptoms causing distress , optimize impaired functioning, prevent relapses and complications. This can be done with the right medications, at the right doses, and with a minimum or no side effects. This can be done by micro diagnosis, i.e. clarifying the symptom picture with more and less obvious symptoms, and then fine tuning the medications or adding others to achieve maximum symptom relief. Common strategies tried a. Maximizing the dose b. trying a very small dose c. another medication from the same class with slightly different biochemical mechanism d. adding another class of medications to address symptoms that might have different causes e. fine tuning to optimize symptom control and to eliminate side effects, to help ensure compliance for treatment duration e. duration of treatment should be at least 9 months to one year f. then a careful slow taper to tell between medication rebound effects and return of symptoms.
19. Uncovering of Co morbid Disorders: As treatment progresses not only are new and less obvious symptoms found, but also other or co morbid disorders. Just as with new symptoms these must be adequately treated for symptom relief and prevention. Good examples are GAD occurring with Mood Disorders. If Bipolar is uncovered and is the primary disorder, then its biology would explain most if not all the symptoms, including the GAD, and a mood stabilizer alone may the only medication needed and the original GAD medication can be stopped. Another example is Obsessive Compulsive Disorder, where the GAD may be adequately addressed with smaller doses of the medication, but much higher doses are need for the OCD. If Schizophrenia is uncovered, and an antipsychotic is then used, often the anti anxiety medication is not needed. Rarely antianxiety medication may uncover a seizure disorder.
20. Non Medication Approaches: Anxiety is fear of the unknown, so the more the GAD person knows about their disorder and treatment the better, and the more likely they will comply and be helped, so much an thorough education about the disorder and medications is essential. Highly anxious people have problems with learning based on thinking problems, short term memory and concentration so more than usual amount of time may be needed to teach them what they need to know, and to re explain it, with much re assurances and support. Psychotherapy and counseling is invaluable for this reason and to further clarify the symptom picture, and clarify what coping strategies that are adding to the anxiety that can be modified and unlearned. Cognitive behavioral approaches work on specific behaviors like facing fearful situations and thoughts rather than avoiding them, helping with cognitive distortions like catastrophic thinking. These approaches require someone trained and talented in these approaches. A variation of MBSR, that is Mindfulness Based Stress Reduction, which is based on insight oriented or mindfulness meditation, once learned can be practiced by oneself anywhere and anytime, is quite useful in symptom relief. What is learned in these psychosocial therapies should compliment medication management, and be useful when it is appropriate to taper the medication and deal with residual symptoms without medication.