GeneralisedAnxiety Disorder

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Generalised Anxiety Disorder (GAD) is a specific form of anxiety disorder with persistent, overpowering worry and anxiety, lasting at least 6 months to several years. It is characterised by exaggerated worry and tension, even though there might not be any major triggers. The person tends to think the worst of situations and is unduly concerned about health issues, family, finances and work.

SymptomsThe person with GAD may have the following symptoms:

• exaggerated worry and tension out of proportion to the triggers

• trembling• difficulty swallowing• inability to relax• feeling breathless• restlessness• hot flushes• difficulty concentrating• headaches• startle easily• irritability• insomnia• twitching• fatigue• nausea• muscle aches• giddiness• going to bathroom frequently

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The symptoms may range from mild to severe. Those with severe GAD symptoms may not be able to work or carry out daily activities. This may result in secondary depression and there is also an increased risk of substance abuse in attempts to selfmedicate. Other anxiety disorders can also accompany GAD.

CausesThe exact causes are not fully known, but several factors play a part:

Genetic factorsResearch suggests that a family history of anxiety disorders increases the likelihood of someone developing GAD. However, not all will go on to have the illness. There are other factors contributing to the onset of the condition, such as:

Physiological chemical imbalanceNeurotransmitters are special chemicals that carry signals across the nerve endings. If the neurotransmitters are out of balance, signals cannot get through the brain properly. This can alter the way the brain reacts in certain situations, leading to anxiety. It has been found that GAD is associated with abnormal levels of certain neurotransmitters in the brain.

PersonalityPeople of certain personality types may be more prone to developing GAD. This is related to the way they perceive and handle stress in their lives.

External factorsStressful events (such as abuse, the death of a loved one, divorce, changing jobs or schools) may lead to GAD. Symptoms are also worsened during periods of stress. The use of and withdrawal from addictive substances, such as alcohol, caffeine and nicotine, can worsen anxiety.

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Medical conditionsSpecific medical conditions are associated with anxiety symptoms, such as an overactive thyroid. The symptoms from the illness mimic anxiety symptoms, and the stress of having the medical illness also contributes to increased anxiety. Other medical conditions like cardiac arrhythmias, seizures, diabetes and high blood pressure are also associated with increased anxiety.

TreatmentGeneralised anxiety disorder can be treated with medications, psychological interventions or a combination of both. Choice of treatment depends on the severity of symptoms, and the person’s preference.

MedicationsWhile medications do not cure GAD, they can keep the symptoms under control and allow the person to get back to functional state. The main types of medications used to treat GAD are antidepressants, anti-anxiety drugs and beta-blockers. These medications can help to control some physical symptoms and improve some aspects of brain functioning.

AntidepressantsAntidepressants are used to treat GAD, as well as any associated depressive symptoms. The commonly used antidepressants include selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants, monoamine oxidase inhibitors, and some new antidepressants, such as serotonin-norepinephrine reuptake inhibitor (SNRI). These must be taken regularly for two to four weeks for significant improvements to occur.

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Possible side-effects of antidepressantsAntidepressants may cause mild and, usually, temporary side-effects in some people. Not everyone will experience the side-effects. The most common ones and their remedies are:

• Dry mouth – Drink more water.

• Constipation – Eat bran cereals, prunes, fruits and vegetables.

• Dizziness – Get up slowly from your bed or chair. Walk slowly and hold on to something stable. If the dizziness continues, sit down or lie down immediately. Do speak to your doctor if the symptom does not go away and interfere with your daily activities.

• Drowsiness – This will pass soon. Do not drive or operate machinery if feeling drowsy or sedated.

• Headache – This is transient and will usually go away.

• Nausea and stomach discomfort – Even when it occurs, it is transient after each dose; take medicine with food.

• Nervousness and insomnia – These may occur in the initial period of starting medication. Dose reduction or time will usually resolve this.

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Antianxiety drugsThe most commonly used antianxiety drugs are the benzodiazepines. They are useful not only for daytime anxiety symptoms but also to aid sleep at night. Although effective, benzodiazepines may cause dependence after prolonged use, resulting in withdrawal symptoms if the drug is stopped or reduced in dosage. Hence, benzodiazepines should only be used for short-term management of anxiety symptoms, and not for long-term treatment.

Hydroxyzine is an alternative antianxiety drug. It is less addictive than benzodiazepines, and is also used in other clinical situations, such as itchiness. Possible side-effects with this drug are sleepiness, hangover the next day, dry mouth and constipation.

Propranolol is a type of beta-blocker used to treat heart conditions. Used in GAD, it can lessen the physical symptoms of anxiety, such as heartpounding. However, those with a history of asthma or low blood pressure should not be prescribed this medication, as it can worsen the underlying medical problems.

Be sure to discuss with your doctor and highlight any important medical history, so that medications can be tailored to your needs.

Psychological interventionsThe recommended psychological treatment for GAD is cognitive-behaviour therapy. This usually involves: relaxation to reduce chronic tension; techniques for managing unhelpful beliefs about worry; learning to challenge and to let go of worries; adopting more helpful coping and problem solving strategies; and learning to be less focused on uncertainty and more focused on the present. For some individuals, mindfulness training and meditation may also be helpful to decrease worry and increase ‘present-moment’ focus.

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How to help yourself1. Calming Technique

When you are anxious, you are more likely to hyperventilate. While this is not dangerous, you are left feeling exhausted or ‘on edge’, which makes you more likely to respond to stressful situations with intense anxiety and panic.

Use the calming technique set out in the following steps and you’ll be on your way to developing a better breathing habit.

Step 1. Sit on a comfortable chair or lie on a bed.

Step 2. Breathe in through the nose for 4 seconds (you can start with 3 seconds).

Step 3. Hold your breath for 2 seconds.

Step 4. Release your breath for over 6 seconds (through the mouth if possible), then pause slightly before breathing in again.

Step 5. Practise, practise, practise.

2. Learn to relaxLearning a relaxation technique can help you to unwind and bring tensions and anxiety under control. One of the body’s reactions to fear and anxiety is muscle tension.

One helpful method of reducing muscle tension is through a technique called Progressive Muscle Relaxation (PMR). In PMR, you tense up particular muscles and relax them and practise this technique consistently. You can read more about PMR in the last section.

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3. Postpone your worryWorry can occur at any time or place, often without you being aware of its exact triggers. As such, worry can interfere with your daily life. A strategy to deal with this problem is to postpone your worry to a particular worry period.

To begin, choose a particular time, place and length of time for worrying. This time, place and duration should be the same each day (e.g. 6 pm @ Study Room for 20 minutes). Try and select a convenient time, for regularity, that is not too close to bed time.

The second step is to postpone a worry as soon as you become aware of it. Note your worry briefly down on paper and remind yourself that you will have time to think about it later. Turn your focus to the present and the activities of the day to help let go of the worry until the worry period has arrived.

When your worry period comes around, use the time to reflect on the worries you have written down from that day. Only worry about the things you have noted down. It may, also, be helpful to write your thoughts down on paper rather than worrying in your head. By learning to postpone your worry, it will be less intrusive in your life and you will be managing your worry effectively, giving you a greater sense of control.

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4. Challenge your negative predictionsWorrying involves a type of thought process where you engage in negative and catastrophic thinking about things you predict could happen.

When such negative thinking style constantly hassles you, emotions (e.g. anxiety) may result, and you may experience unpleasant physical sensations (e.g. nausea, breathlessness, your heart beating fast, tensed muscles and giddiness) and avoid doing certain things. One way to lift those negative emotions and unpleasant bodily sensations is to challenge those bothersome thoughts.

First, write down what is worrying you and what you predict is going to happen. Next, you can challenge your worries by asking yourself:

• What is the evidence for my prediction?

• What is the evidence against my prediction?

• How likely is it that what I am predicting will actually happen (Rate 0 – 100%)?

• What is the worst that could happen?

• What is the best that could happen?

• What is the most likely think that will happen?

• How helpful is it for me to worry about this?

• How else could I view the situation?

5. Challenge your worrying thoughtsAsk yourself this question: If you believed your worrying has many benefits, how willing would you be to give it up? A way to challenge your worrying thoughts is to come up with a list of ‘Evidence For’ and ‘Evidence Against’ the idea that worrying is beneficial.

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6. Engage in time management and problem solvingTime ManagementAs a result of GAD (e.g. anxious apprehension), you are more likely to feel overwhelmed by obligations and deadlines, in addition to everyday hassles and stressors. Practice time management strategies, such as delegating responsibility, being assertive (e.g. saying “no”), and sticking to your daily agenda of tasks to be done based on their priorities.

Problem SolvingEngaging in problem solving may also help you to think differently and more realistically about the ‘worrying’ situations. There are some questions you need to ask yourself before launching into problem solving:

• Is it a real and likely problem that I am worried about?

• Is the problem happening now?

• Is the problem something I have some control over?

If the problem you are worried about is an unrealistic and unlikely prediction of the future, of which you have little control over, then, although the problem might appear real, it is not an actual problem that requires a solution. In these situations, you might find that challenging your worrying thoughts (Point 5) and letting go (Point 7) might be the most useful.

However, if it is a real problem in the here-and-now, it would be better to use problem-solving strategies.

Problem solving involves the following:Step 1. Identify and try to state the problem as clearly as possible. Write it down.

Step 2. Work out what possible options are available to deal with the problem and write them down.

Step 3. List the main advantages and disadvantages of each option, taking into account what resources are available to you.

Step 4. Identify the best option(s) to deal with the problem.

Step 5. List the steps required for this option to be carried out.

Step 6. Carry out the best option and evaluate the outcome.

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7. Acceptance and ‘Letting Go’To let go of your worries means you are doing the opposite of what you would normally do with your worries: engage with them, chase them, react to them, try to control them, and try to reason with them. There are a number of things you can do to let go of your worries:

Step 1. Be Aware and acknowledge the presence of worries. You could say to yourself: “Here comes a worry” or “I notice I’m worrying”.

Step 2. Don’t Respond. Don’t judge or react to your worries. Just observe your worries with curiosity. Describe to yourself the thoughts, feelings and sensations you are experiencing right at that moment. Just allow the worries to be, without responding to them or trying to change them in any way.

Step 3. Let Go. Only after fully acknowledging, observing, and describing the worries you have in your mind, can you make the decision to let the worries go. Think of letting the worries just pass by like clouds moving slowly across the sky or leaves floating down a stream. Release the worries and you might say to yourself: “My worries are not facts, realities, or truths, they are just thoughts.They aren’t helpful to me. I’ll just let them go.”

Step 4. Be Present-Focused. Once you have told yourself to let the worries go, it is important to focus your attention on the present moment. When you worry, you are focused on the future and bad things that could happen. If you focus on the simple things happening in the present, you will be less likely to worry.

Step 5. Deal With A Wandering Mind. Whilst trying to remain focused on the present, you might get frustrated if you find your mind wandering back to worrying thoughts. This is natural and normal. The important thing to do is to recognise that your mind has wandered and to return your attention to the present and what it was that you were focusing on. Do this as many times as you need to.

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8. Have a balanced diet and adequate restWhile seemingly simple, taking basic care of the body cannot be overemphasized. People with high anxiety are also advised to cut down, or omit, caffeine in their daily diet. This is because caffeine can worsen the anxiety symptoms. Caffeine is found in coffee, tea, some soft drinks, and chocolate. Avoid alcohol, as it can cause more psychological and physical problems with prolonged use, as well as interfere with medications.

9. Talk to someoneSharing your problem with someone may be helpful. Others may give you a different perspective to the problem.

How can relatives and friends help?Relatives and friends can help by offering a supportive attitude towards the person. A person with anxiety experiences their symptoms as acutely as someone with physical pain or discomfort. Do not dismiss their symptoms as trivial. Listen to them patiently and try putting yourself in their shoes. You can respond by saying, “That must be difficult for you.” An anxious person may, also, be repetitive about their worries. Try not to express your frustration at the person.

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You can also help the person realise that they have a medical condition and that anxiety is not a weakness or character flaw. Encourage them to seek help for their symptoms and inform them that skills can be learnt to lessen the effects of stress and anxiety.

Seeking professional helpCGH’s Division of Psychological Medicine offers comprehensive psychiatric services. If you wish to book an appointment for psychiatric consultation, please contact our Appointment Centre at Tel: 6850 3333.

Progressive Muscle RelaxationWhen preparing to begin this exercise, make yourself comfortable by wearing loose clothing and taking off your shoes. Minimise the distraction to your five senses, such as turning off the TV and radio, and use soft lighting. Choose a comfortable place to sit while doing this exercise.

General Procedure1. Once you’ve set aside the time and

place for relaxation, slow down your breathing and give yourself permission to relax.

2. When you are ready to begin, tense the muscle group described. Make sure you can feel the tension, but not so much that you feel a great deal of pain. Keep the muscle tensed for approximately 5 seconds.

3. Relax the muscles and keep it relaxed for approximately 10 seconds. It may be helpful to say something like “Relax” as you relax the muscle.

4. When you have finished the relaxation procedure, remain seated for a few moments allowing yourself to become alert.

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Relaxation Sequence1. Right hand and forearm Make a fist with your right hand.

2. Right upper arm Bring your right forearm up to your

shoulder to ‘make a muscle’ like a body-builder.

3. Left hand and forearm Make a fist with your left hand.

4. Left upper arm Same as for your right upper arm.

5. Forehead Raise your eyebrows as high as they

will go, as though you were surprised by something.

6. Eyes and cheeks Squeeze your eyes tight shut.

7. Mouth and jaw Open your mouth as wide as you

can, as if you’re yawning.

8. Neck Be careful as you tense these

muscles. Face forward and then pull your head back slowly, as though you are looking up to the ceiling.

9. Shoulders Tense the muscles in your shoulders

as you bring your shoulders up towards your ears.

10. Shoulder blades / back Push your shoulder blades backwards, trying to almost touch them together, so

that your chest is pushed forward.

11. Chest and stomach Breathe in deeply, filling your lungs and chest with air.

12. Hips and buttocks Squeeze your buttock muscles.

13. Right upper leg Tighten your right thigh by lifting

your thigh and bending your knee as much as you can. You can also use both hands to pull your knee towards your body.

14. Right lower leg Do this slowly and carefully to avoid

cramps. Pull your toes towards you to stretch the calf muscle.

15. Right foot Curl your toes downwards.

16. Left upper leg Same as for the right upper leg.

17. Left lower leg Same as for the right lower leg.

18. Left foot Same as for the right foot.

Practice means progress. Only through practice can you become more aware of your muscles, how they respond to tension, and how you can relax them. Training your body to respond differently to stress is like any training – consistent practice is the key. Once you have mastered the principles of progressive muscle relaxation, you can also do this exercise while lying down.

Allinformationisvalidatthetimeofprinting(April2014) and subject to revision without prior notice.

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