Generalised Anxiety Disorder: what it is and how to recognise it
Generalised Anxiety Disorder: in literature and in clinical practice there is a taxonomy (classification, nomenclature) of anxiety disorders that is sometimes careless because of possible co-morbidity with other disorders and because of the similarities of several symptoms in the different forms of the various anxiety disorders
This is the source of at least three risks:
- the first, more general, risk is that drugs are administered that are not specific to that ‘type’ of anxiety, but that a combination of antidepressant – generally of the SSRI (serotonin reuptake inhibitor) type – and anxiolytic is used, sometimes as needed
- the second risk is that little attention is paid to personality aspects and thus to the ‘type’ of person affected by a specific anxiety disorder
- the third is that Anxiety Disorders are not given the nosographic space (i.e. description of the illness) that they deserve.
This is a serious problem of iatrogenesis (i.e. an error, a neglect of prescription or diagnosis) that carries with it not indifferent social aspects (50 per cent of the world’s population has had at least one diagnosis of an anxiety disorder in the course of a lifetime).
From a functional point of view, it must be remembered that the alteration, the cerebral dysfunction concerned is that of the hypothalamus-pituitary-adrenal axis, i.e. – in short – the hormonal axis that connects the limbic structures, the hypothalamus and the pituitary gland with the adrenal gland for the release of cortisol that – if elevated – leads to anxiety-related behavioural expressions.
In fact, prolonged anxiogenic events lead to the same effects as depressive changes, i.e. reduction of neurotransmitters such as serotonin and noradrenaline, but also and above all hyperactivation of the aforementioned axis, with a significant increase, precisely, of the cortisol hormone in the blood, which is necessary to counteract or favour the response to the sudden change in situation.
This irrefutable fact should better guide the pharmacological prescription.
Moreover, it would be appropriate to take into account the ‘diathesis-stress’ paradigm, i.e. the interaction between the predisposition to the onset of a certain disorder (diathesis, which also involves personality aspects) and the existential conditions for it to manifest itself (which involves affective-emotional aspects).
As proof of the importance of the personality characteristics involved in Anxiety Disorders, the DSM 5 – in addition to the actual classification of Anxiety Disorders – provides the following separate categories
- Avoidant Personality Disorder (i.e. Phobic Personality Disorder)
- Obsessive-Compulsive Personality Disorder
- In good clinical practice, for a correct therapeutic indication it is necessary to adhere to at least these criteria
- investigate thoroughly the nature of the anxiety disorder, according to all indications obtainable from a careful anamnesis and careful listening to the description of symptoms
- draw as reliable a picture as possible of the patient’s personality
- understand the subjective sense of anxiety described by the patient
- observe the lifestyle and impairments, if any, of work and social relationships
- listen empathetically to the patient’s suffering and in close collaboration between psychiatrists and psychotherapists to verify the patient’s ability to tolerate psychotherapy, most often absolutely necessary in association with or in substitution for pharmacological therapy with remission of acute conditions (antidepressants and anxiolytics are the fourth most prescribed pharmacological category and in particular among anxiolytics delorazepam is the most widely sold in the world)
- do not underestimate the dynamics of anxiety disorders, superficially classifying them as the ‘evil of the century’.
In diagnostic practice using the DSM 5, the following two criteria must be followed for the two anxiety disorders considered in their own right and included in Personality Disorders, namely Avoidant Disorder and Obsessive Compulsive Disorder:
1) Criterion A: assessment of the level of impairment of the 4 ‘Elements of Personality Functioning, which are:
Self-domain: 1) Self-identity – 2) Self-determination
Interpersonal Domain: 3) Empathy – 4) Intimacy
2) Criterion B: at least two sub-domains or traits:
Negative Affectivity (emotional lability, anxiety)
Detachment (avoidance).
The following hierarchical structure must also be adhered to:
- Anxious-Evulsive Personality Disorder: Spectrum of Internalising Disorders (i.e. ‘withdrawal’ into oneself)
- Obsessive-compulsive disorder: Spectrum of Neurotic Disorders.
Regardless of the diagnostic modality, the necessity and usefulness of well differentiating the various types of anxiety disorders in order to administer and indicate the most suitable therapy is emphasised.
Generalised Anxiety Disorder (GAD)
This is certainly the seemingly easiest anxiety disorder to diagnose.
But this is not the case, because the signs and symptoms lead one to think much more easily of a diagnosis of Reactive Depression and, therefore, it is sometimes so treated.
Generalised anxiety manifests itself for no apparent reason, even from one day to the next, but it does not pass in the time to come; on the contrary, it becomes a ‘frightened’ state of mind.
The person normally able to handle the common anxiety that life calls for is suddenly no longer able to and everything becomes a source of worry and paralysing suffocation.
The person ‘does not know why’: all he knows is that he cannot help but be ‘anxious’ about everything and any event, even a mild one, frightens him to the point of not being able to implement the slightest protective remedies.
The mood is sad because there is that frustrating feeling that takes away energy and because undifferentiated and unjustified worry and fright lead to ideational blocking; thus it is fear and not loss of interest (as in the case of depression) that mobilises all investment.
The person feels, at any time of the day or night, suddenly overwhelmed by thoughts that seem too big to deal with, because they are loaded with anxiety that has become unmanageable.
Even legitimate anxieties and worries become insurmountable and a source of immobility.
Everything seems gigantic, beyond one’s possibilities, and even suddenly in moments of calm comes a tightening in the throat that makes one vulnerable to everything.
The social and relational significance of such a situation is obvious and the cascade of behaviour is really to be borne in mind for anyone who is close to a person in such a condition.
If fear frightens but makes the whole brain alert, generalised anxiety freezes and petrifies so much that one cannot put anything into action at all.
The thread to be grasped is contained in the phrase ‘I don’t know why’ that is generally said: it is precisely because one does not know why that one needs help ‘to know’.
A general tranquilliser for the day and one of the milder hypnoinducers for the night may be more than sufficient, perhaps combined with some food supplements in the case of sensitive asthenia.
Obligatory, instead, is psychodynamic or behavioural psychotherapy.
Clinical vignette on Generalised Anxiety Disorder (GAD)
Carla is in her thirties; she is a very pretty, elegant and refined young woman and has an excellent job as a translator.
She describes herself as characteristically anxious because of the simultaneous nature of her work and is always a little afraid of not keeping up but, as she always manages, her anxiety is controlled, thanks also to experience.
She is preparing for her upcoming wedding; her fiancé is a German doctor, whom she met at a conference.
Suddenly, Carla ‘falls ill’ with anxiety and is unable to do anything any more, she feels as if paralysed and feels that all the tasks are suffocating her.
She decides to consult a psychoanalyst, because she cannot cope.
During the first cognitive interviews, Carla is so anxious that she adopts behaviour and attitudes that are already visibly not in keeping with the style of someone seeking help.
She is agitated, her posture is all tentative (upright torso, sitting on the tip of a chair, purse on her legs) as if she were to leave suddenly.
This is taken as a good predictor signal, because it can be seen as an unconscious attitude that there, in the setting of the sessions, she might find ‘something’ to make her run away and this frightens her.
In the continuation of the interviews, the anamnesis is collected, the motivation for understanding and change is checked, together with the capacity for commitment and tolerance of frustration, and a focal brief psychodynamic psychotherapy is proposed, i.e. with a fixed number of sessions and with the objective (focus) of shedding light on the nature of the anxiety.
Already from the first sessions it emerges that the anxiety is indeed generalised on all fronts, but the triggering factor is to be found in the decision to get married.
Short-term therapy relies heavily – precisely because it is limited in time – on the analyst’s highly stimulated emergence of unconscious emotions.
It did not take much to unleash very contorted violent emotions of a sexual kind and it emerged, with the analyst’s insistence to proceed on the road of the evocative staging of violence, to unleash the latent motive of her generalised anxiety: everything in her had become worrisome and unbearable to handle because of the memory of some repulsive-attractive scenes from the film “The Night Porter” (a very complex sadomasochistic story between a former German SS general and a former prisoner).
Attraction-repulsion that were well removed and buried in the unconscious, but having to print the participations in Italian and German lit the fuse of a bomb that is as dangerous as it is important to defuse.
At stake is the quality and choice of sexuality and the ability to separate facts and people.
This clinical vignette well demonstrates both the need to deal with the person and not only with the symptom and the difficulty in untangling the meanders of anxiety.
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