2. Clinical characteristics
Generalized anxiety disorder (GAD) is a psychiatric diagnosis in the
International Statistical Classification of Diseases and Related Health
Problems, 10th Revision and in the Diagnostic and Statistical Manual
for Mental Disorders, Fourth Edition. Individuals with GAD are
characterized by a pervasive and uncontrollable state of worry
(apprehensive expectation). Primarily, they seek treatment by
practitioners not for worry but for disruption of sleep, muscle
tension, dyspepsia, restlessness, fatigability, and irritability. This
primary cognitive dysfunction, paired with secondary somatic
anxiety manifestations, impair the capacity for work, for relations,
and for leisure activities. GAD also increases the risk for subsequent
depressive episodes, self-medicating with alcohol, and complications
in concurrent somatic diseases.
In their reality management, GAD patients display a basically
distorted view on risks and threats, particularly those that concern
the health, security, and welfare of the individual and his/her
immediate family members. This distortion of imagined future
events is different from the cognitive dysfunction in depressed
patients, who mainly recollect past failures and mistakes that cause
ruminations, guilt feelings, and feelings of worthlessness. The
cognitive distortion seen in GAD also differs from that in obsessivecompulsive
disorder that chiefly deals with symmetry, contamination,
and ambivalence in moral issues.
GAD patients worry prospectively about hazards: what if our
business goes bankrupt, what if our daughter is run over on her way
fromdaycare, what ifwe get robbed on our summer trip orwe have an
accident far away from home. Work mates and family members
testify that a personwith GAD exaggerates thematically concerns over
potential events in ordinary life, that the person is a “worrywart.”
Culturally, daily worries are dealt with by simple methods such
as manipulating rosaries in Islamic and Jewish tradition, or polished
stones, and in Guatemala by talking about worries with little dolls
that are put under the pillow at night.
Several thought leaders have made substantial contributions to
our understanding of GAD, to mention a few: Gavin Andrews, Jules
Angst, David Baldwin, Borwin Bandelow, Johan den Boer, Tom
Borkovec, Jonathan Davidson, Jack Gorman, Marty Keller, Kenneth
Kendler, Donald Klein, David Nutt, Stefano Pallanti, Mark Pollack,
Karl Rickels, David Sheehan, Dan Stein, and Hans-Ulrich Wittchen.
Imaging studies of the amygdala and associated neuronal
circuits show an enhanced base activity, as well as an increased
reactivity to stimuli, indicating that there are deficits in emotional
processing that the individual is not aware of.1e3 Medications have
been shown to normalize this state of alertness parallel to
a reduction of reported anxiety symptoms.1 Sympathetic activation
that is normally reduced at night remained high in a laboratory
study of GAD patients.4 Inhaling carbon dioxide resulted in anxiety
symptoms and vegetative activation in GAD patients.5,6
Several psychological theories have been proposed to explain
the cause of worry and how worry is maintained. Borkovec and
Roemer7 theorize that the function of worry is to avoid, causing anineffective problem solving. Worry about imagined events
suppresses negative thoughts and images and strengthens avoidance
behavior. Another theory stresses the importance of intolerance
of uncertainty.8Worry arises when not trusting information. A
third theory concerns so-called meta-cognition, by which the
patient believes in worry preventing catastrophes, with metaworry
(worry about worrying) as a consequence.9 Since worry
becomes such an important strategy, it gets a life of its own. Finally,
there is extensive research into how GAD patients manage information
by cognitive schemata and selective bias toward threats.10
Support for worry being a trait rather than state was found in
a recent study of Dutch adolescents who were followed over
a period of 5 years.11