Question:
Generalized Anxiety Disorder - Definition ?
Answer:
I have a copy of Barlow's new, (1988), book, "Anxiety and it's
Disorders,". He has a whole chapter on GAD and the short version I got
from it is that GAD has in the past been defined under DSM-III. By that
definition, GAD has the status as a residual category; i.e., patients
could not be diagnosed as having GAD unless they did not meet the
criteria for any other anxiety or affective disorder. Diagnosis by
exclusion, as in this case, is fuzzy.
In ther past there was a disagreement as to whether GAD was severe
enough to by classified as a disorder, so a duration period of one month
for symptoms was established. However, many people had life experiences
like a close death, divorce, etc., which had symptoms lasting more than
a month but then disappearing, so that didn't really work.
Therefore, a new category, DSM-III-R was created which defines GAD as;
"Unrealistic or excessive anxiety and worry (apprehensive expectation)
about two or more life circumstances, e.g., worry about possible
misfortune to one's child (who is in no danger) and worry about finances
(for no good reason), for a period of six months or longer, during which
the person has been bothered more days than not by these concerns. In
children and adolescents, this may take the form of anxiety and worry
about academic, athletic, and social performance."
Also; "the focus of the anxiety and worry above is unrelated to Panic
Disorder, Social Phobia, OCD or Anorexia Nervosa." DSM-III only said,
"Not due to another mental disorder such as a Depressive Disorder or
Schizophrenia."
And; "At least 6 of the following 18 symptoms are often present when
anxious (do not include symptoms present only during panic attacks)."
He goes on to list many symptoms of PA's. DSM-III required the
candidate for diagnosis be at least 18 years of age. Not included in
DSM-III-R.
Barlow believes GAD and panic disorder should be considered as separate
problems for treatment purposes. A person may have both at the same
time.
On treatment for GAD, he is not fond of benzo's. He says, "In fact,
what clinical investigators have reported all along is that the
benzodiazepines have, at best, a limited therapeutic effect lasting no
more than several weeks." And, "this class of drugs is not a
comprehensive treatment for GAD." Barlow basically believes that
benzo's should only be used for short term relief from anxiety problems.
He does believe Buspar may be effective but needs more testing.
Barlow's recommended treatment is a package combining cognitive and
relaxation procedures, both used as copyin procedures.
In summary, Barlow believes GAD is a separate diagnosis and "All
treatments appear to be beneficial, but cognitive coping procedures seem
particularly powerful, producing the greatest percentage of change on
major measures of outcome."
The DSM-4 published by the APA (American Psychiatric Association) is a
way to classify mental syndromes (i.e. collections of symptoms) based
upon symptoms only. However, the etiology (or cause) of these symptoms
is not addressed (mainly
because so little is known about causes of emotional disorders).
However, there is much overlap in symptoms. I.E. a person with PD may
have features suggesting OCD or social phobia or GAD. There is
considerable overlap amoung all the anxiety syndromes. Likewise, there
is considerable overlap between the anxiety syndromes and the depressive
syndromes.
(Let's forget, for the moment, various overlaps with personality
disorders, bipolar states, etc, etc)
All this has suggested to some researchers that there may be one (or
more) underlying mental problems, each of which may manifest itself
with several different expressions.
For example, a peptic ulcer in the stomach is a disease process.
However, the symptom could be belly pain, or throwing up blood, or
feeling dizzy upon standing because of blood loss into the bowel, or,
any combination of these symptoms.
In the above example, using a classification based upon symptoms (as
occurs in the DSM-4) a person with a peptic ulcer might be diagnosed as
(1) belly pain, or (2) throwing up blood, or (3) dizziness, or (4)
mixtures of 1, 2, and 3.
While such a classification can place a patient in a category (i.e. 1,
2, 4, or 4), it completely ignores the cause of these symptoms: peptic
ulcer disease. And the primary treatment for all four catagories is the
same, i.e. heal the ulcer.
So, the question of whether GAD exists, or whether it is some form of
panic disorder (or vice versa) is really an inappropriate question. This
is because GAD is DEFINED to exclude PD, as well as other forms of
anxiety disorder.
Therefore, by DSM-4 definition, GAD is a separate from PD.
However, in reality, as in the case of the peptic ulcer (referred to
above), both GAD and PD may be syndomes caused by ONE underlying
disorder.
P.S. I'm still formulating my thoughts on this, and have some more
reading and thinking to do.
I look forward to further input from others on GAD, and it's relation to
PD (if any), and also the possibly of ONE anxiety disease, with multiple
expressions, i.e. PD, GAD, OCD, social phobia, separation anxiety,
hypochondriasis, depersonalization disorder, etc, etc.
Any thoughts on these observations, or on a possible underlying disorder
to explain all the anxiety syndromes?
Are "depresion" and "anxiety" forms of the same disorder?
