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LESSON
ABOUT
Generalized Anxiety Disorder
Description/Etiology
Anxiety is fear, apprehension, worry, and often physiological distress in response to
perceived threats, uncertainty, critical decisions, and major life events. Normative anxiety
allows individuals to be more alert and aware regarding their situation. However, for some
individuals, anxiety can become excessive and problematic. Even when the client realizes
that his or her anxiety has gone beyond a normal or typical reaction, the client may still
have trouble controlling the anxiety and as a result his or her day-to-day functioning may be
compromised.
All anxiety disorders have the common elements of disproportionate fear and behavioral
disturbances. Generalized anxiety disorder (GAD) is characterized by extreme anxiety
and worry about numerous events, situations, or activities. The duration, intensity, and/
or frequency are disproportionate to the probability of the event occurring and to the
actual negative impact of the event or activity (American Psychiatric Association [APA],
2013). According to theDiagnostic and Statistical Manual of Mental Disorders, fifth
edition(DSM-5), this extreme anxiety or worry happens more days than it does not, is
present for a minimum of 6 months, and is focused on a variety of events or activities (e.g.,
work, school, family relationships). The anxiety and worry present in GAD most often is
accompanied by physical and cognitive symptoms. DSM-5 diagnostic criteria for GAD are
trouble maintaining control over this anxiety or worry and at least three of the following
symptoms: restlessness or being “on edge”; being easily tired; trouble concentrating;
irritability; muscle tension; and sleep disturbances (e.g., trouble falling asleep, trouble
staying asleep, poor sleep quality). Clients may be worrying about their abilities at school or
work, finances, relationships, natural disasters, or the personal safety of themselves or loved
ones. To meet diagnostic criteria, the anxiety, worry, or symptoms must have a noticeable
impact on the client’s functioning socially and at work or school and be causing the client
distress. Anxiety disorders frequently co-occur with other mental health diagnoses, physical
health problems, and alcohol and substance abuse, so the clinician needs to be thorough
when assessing clients for an anxiety disorder; if anxiety is a secondary diagnosis, it must be
determined if the primary diagnosis needs to be addressed first (APA, 2013).
ICD-9
300.02
ICD-10
F41.1
Author
Jessica Therivel, LMSW-IPR
Cinahl Information Systems, Glendale, CA
Reviewer
Pedram Samghabadi
In addition to experiencing worry and anxiety that are difficult to control, clients in whom
GAD is diagnosed tend to be future oriented, worrying about what is to come rather than
focusing on the reality of the present. They tend to have a negative cognitive bias (i.e., an
automatic negative focus to their thoughts and feelings). They are vulnerable to somatic
arousal (e.g., “butterflies” in their stomachs, sweaty palms, increased heart rate, muscle
tension) occurring as a physical response to their mental worries and anxieties. Clients with
GAD often first seek medical treatment for somatic symptoms. Clients with GAD may also
have relationship stressors that contribute to their anxiety.
The etiology of GAD is not known, but is generally agreed to be a combination of
biological, psychological, and environmental factors. Treatment may include evaluation,
psychotherapy, anti-anxiety medications, relaxation therapy, and education on wellness and
stress management.
October 14, 2016
Published by Cinahl Information Systems, a division of EBSCO Information Services. Copyright©2016, Cinahl Information Systems. All rights
reserved. No part of this may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or by
any information storage and retrieval system, without permission in writing from the publisher. Cinahl Information Systems accepts no liability for advice
or information given herein or errors/omissions in the text. It is merely intended as a general informational overview of the subject for the healthcare
professional. Cinahl Information Systems, 1509 Wilson Terrace, Glendale, CA 91206
Facts and Figures
DSM-5 states that the 12-month prevalence rate of GAD among adults in the United States is 2.9% and among adolescents is
0.9%, with individuals of European descent reporting symptoms more frequently than individuals of non-Europeandescent.
DSM-5reports a 12-month prevalence rate outside the United States of between 0.4% and 3.6%, with individuals in developed
countries more likely to report GAD symptoms than individuals in less developed countries (APA, 2013).
The National Institute of Mental Health (NIMH), using data from the 2000–2004National Comorbidity Survey Replication,
reports 12-month prevalence of GAD at 3.1% in adults in the United States, of whom 32.3% (approximately 1% of all
adults) have GAD that is severe. Lifetime prevalence of GAD by age group is 4.1% among 16–29-year-olds; 6.8% among
30–44-year-olds; 7.7% among 45–59-year-olds; and 3.6% among those 60 years and older (NIMH, n.d.).
Risk Factors
Women are more likely than men to develop anxiety disorders. A family history of anxiety is an additional risk factor. Clients
with a history of physical or psychological trauma, current stressful life events, and/or poor coping strategies have an increased
risk for GAD. Environment can be a contributing factor for risk: certain life or work environments are inherently more
stressful. Nutritional deficiencies (e.g., niacin, thiamin, vitamin B12) may increase the risk for GAD. Use of alcohol and
substances can increase the likelihood of developing anxiety or may be a means of coping with anxiety that already exists.
Physical health problems, whether caused by a chronic illness or a recent diagnosis of illness, can trigger GAD. Epidemiology
surveys have shown that GAD is more commonly found in unmarried adults versus married adults, members of racial and
ethnic minorities, and individuals of lower socioeconomic status.
Signs and Symptoms/Clinical Presentation
› Psychological: difficulty concentrating, excessive worry or fear, panic, irritability, impatience, negative cognitions
› Behavioral: restlessness, sleep and appetite disturbances
› Physical: sweating, muscle tension, shaking, shortness of breath, tightness in chest, gastrointestinal distress, rapid heartbeat
› Social: withdrawal, isolation, problems with academic, occupational, or social functioning, lost work time
Social Work Assessment
› Client History
• Assess client by taking a complete biopsychosocialspiritual history in order to explore all potential symptoms and causes of
anxiety
• Explore and assess social and family functioning for negative and positive aspects and measure available social supports
• Assess for risk of suicide or self-harm
› Relevant Diagnostic Assessments and Screening Tools
• Beck Anxiety Inventory to assess the severity of client’s self-reported anxiety
• Generalized Anxiety Disorder 7-Item Scale (GAD-7)
• The Short Anxiety Screening Test (SAST), a 10-item scale that may be clinician-scored or self-report
• The Geriatric Anxiety Inventory (for older adult clients), a 20-itemself-report
• The Hamilton Anxiety Rating Scale, a 14-item, clinician-scoredscale
• The Spence Children’s Anxiety Scale (SCAS) Child and Parent Version
• The Multidimensional Anxiety Scale for Children (MASC) is a 39-itemself report for children and adolescents ages 8 to 19
• The Revised Children’s Manifest Anxiety Scale (RCMAS) is a 37-itemself-report measure that uses true-false questions to
measure anxiety
› Laboratory and Diagnostic Tests of Interest to the Social Worker
• The social worker will want to be aware of any tests that reveal alcohol or substance use
Social Work Treatment Summary
Some clients may benefit from pharmacotherapy alone but the majority will benefit from a combination of psychotherapy
that involves behavioral, psychological, and lifestyle changes and/or psychoeducational interventions and medication
if it is indicated. Cognitive-behavioral therapy (CBT) and psychodynamic therapy are the most common psychological
interventions for clients with GAD. CBT teaches clients how to identify and change the thoughts and behaviors that trigger
or exacerbate their anxiety. CBT can also incorporate imaginal exposure and work to improve the client’s problem-solving
skills. Psychodynamic therapy helps clients uncover, explore, and work through unresolved emotional conflicts or traumas
that may be contributing to their anxiety. Clients may also benefit from stress-management programs that reduce overall stress
while promoting a healthier lifestyle. Examples include yoga; exercise programs; healthy, non-extreme diet changes; relaxation
training (e.g., progressive muscle relaxation); and meditation. For clients for whom pharmacotherapy is indicated, the most
common medications prescribed are antidepressants (e.g., tricyclic antidepressants, SSRIs), which although developed for
depression have shown effectiveness in treating anxiety symptoms. Benzodiazepines are anti-anxietymedications that act
immediately and can be potent, and usually are prescribed only for short periods to reduce the risk of dependency.
CBT is most effective as a face-to-face intervention. For individuals who are not able, or willing, to participate in face-to-face
therapy, CBT may take the form of self-help, in which the client uses audio- or videotapes, computer programs, written
exercises, or group meetings to self-administer the therapeutic intervention. Guided self-help interventions, which include
minimal contact with a professional, also are available.
National guidelines recommend a stepped-care model to organize services for the client with GAD. Stepped care aims to have
the right person providing the right care at the right time, “stepping up” services as required by the client’s needs. The stepped
care model for GAD consists of four steps.
› Step 1 is to identify if there is a need to screen for anxiety disorders. Once the screening is completed, if anxiety is identified
the social worker will assess the client
› Step 2 is to provide treatment and referral for symptoms that are sub-threshold or meet criteria for mild or moderate anxiety.
These interventions are considered low intensity and may be a computerized CBT program, structured group physical
exercise, or group-based peer support
› Step 3 takes place if there has been an inadequate response to step 2 or if the symptoms are moderate to severe instead
of mild to moderate. This step includes possible medications or a more intensive therapeutic intervention (e.g., CBT,
interpersonal therapy). This step also involves developing local care pathways (e.g., mental health, primary care doctor,
specialist) and treatment planning to prevent relapse or reduce the risk of relapse
› Step 4 is to assess and treat complicated, treatment-resistant GAD, for clients with extreme functional impairment or
for clients who are at a high risk for self-harm. At this step, social workers should be offering clients any interventions
involved in the previous steps that have not yet been tried. This may be the time to combine drug treatment with therapeutic
interventions
Social workers should be aware of their own cultural values, beliefs, and biases and develop specialized knowledge about
the histories, traditions, and values of their clients. Social workers should adopt treatment methodologies that reflect their
knowledge of the cultural diversity of the communities in which they practice.
.
Problem
Goal
Intervention
Client has signs and
symptoms of GAD
Client will have improved
functioning, a reduction in
anxiety and worry, and a
reduction in any negative
physical or cognitive
symptoms related to GAD
Provide CBT or
psychodynamic therapy
dependent on client’s needs
or refer if unable to provide
services. Encourage client
to maintain a present focus
for his or her thoughts, not
a future focus. Determine
if client’s anxieties are
related to situations that
could be addressed by
step-by-step problemsolving skills training
or if they are anxieties
regarding hypothetical
situations, which are harder
to change with problem
solving. Utilize cognitive
restructuring to logically
analyze client’s anxieties
and change automatic
thoughts or negative
cognitions. Help client
improve self-monitoring
and self-awareness. Provide
relaxation training. Have
client utilize image rehearsal
of new coping strategies.
Utilize imaginal exposure if
appropriate. Address areas
of psychosocial functioning
that are causing anxiety
for client and help client
consider lifestyle changes
where possible. Work with
client on stress-management
techniques. Encourage
mindfulness to help enhance
self-awareness. Address
somatic complaints and refer
to primary care physician if
indicated
.
Applicable Laws and Regulations
› There are international guidelines set by the UN regarding involuntary psychiatric holds when self-harm or harm to others is
a risk. In the United States each state has its own legislation regarding involuntary holds. The social worker is responsible for
understanding the rules of his or her jurisdiction
› Since social workers are mandated reporters for child abuse and maltreatment, the social worker needs to be aware of
reporting guidelines for his or her state, region, or nation and recognize and report any suspicions of abuse, which may be
triggering the client’s anxiety symptoms, to the appropriate authorities
› Each country has its own standards for cultural competence and diversity in social work practice. Social workers must be
aware of the standards of practice set forth by their own governing body (e.g., National Association of Social Workers in the
United States, British Association of Social Workers in England) and practice accordingly
› Social workers should practice with awareness of, and adherence to, the social work principles of respect for human dignity,
social justice, and professional conduct as described by the International Federation of Social Workers (IFSW) Statement of
Ethical Principles
Available Services and Resources
› The Anxiety and Depression Association of America, https://www.adaa.org/, offers support and resources for clients and
professionals
› The National Alliance on Mental Illness (NAMI) has online community support groups for anxiety,
https://www.nami.org/Learn-More/Mental-Health-Conditions/Anxiety-Disorders
Food for Thought
› Brain research is implicating the amygdala and hippocampus as having a role in anxiety disorders. These two centers of the
brain influence how the brain creates anxiety and fear
› The Patient Health Questionnaire, which is a common screening tool in primary care settings, has been found to
underdiagnose anxiety disorders. Physicians may need education regarding alternative tools
› Spirituality can have a beneficial impact on GAD for some clients. Investigators in Pakistan found that when study
participants with GAD had a strong sense of spiritual well-being their GAD symptoms were less intense than those of
participants without a strong sense of spiritual well-being(Amjad & Bokharey, 2015)
› Older adults with anxiety reported that CBT was more acceptable as a treatment than pharmacotherapy (Gaudreau et al.,
2015)
› Older adults with GAD were found to use alcohol at a higher rate than older adults without GAD. Those whose alcohol use
was considered mild or moderate were less likely to experience sleep difficulties (Ivan et al., 2014)
Red Flags
› Clients who wish to pursue lifestyle changes for improved stress management (e.g., yoga, diet changes, beginning to
exercise) should get medical clearance from their physician
› Certain SSRIs (e.g., Paxil) have been found to be an inappropriate choice for adolescents because of a possible increased risk
for suicide. Any pharmacotherapy with children or adolescents should be accompanied by therapy to monitor for any signs
or symptoms of suicide risk
› Adolescents in whom GAD is diagnosed should be screened for alcohol and substance use, since in this age group the two
often co-occur
› Pregnant women should be screened for anxiety disorders. Researchers found that 24.1% of pregnant women studied
reported an anxiety disorder and 8.5% of those met criteria for GAD. The GAD-7 was found to be appropriate for screening
this population as there was satisfactory validity. Heightened anxiety during pregnancy can result in negative long-term
effects for the fetus (Simpson et al., 2014)
› Adolescents who use two or three illicit substances simultaneously for long periods have an increased risk for GAD in
adulthood. Both the functional impairment (e.g., cognitive impairments) and interpersonal relationship problems (e.g.,
trouble getting along at work, partner conflict) that may result from substance use may contribute to GAD (Brook et al.,
2014)
Discharge Planning
› Provide client with instructions to follow up with primary care physician to address somatic complaints and any other health
issues that are exacerbating the anxiety or may be causing the anxiety
› Locate community resources to support client and potentially reduce stress (e.g., group exercise, yoga classes, support
groups)
› Educate family members on GAD and teach them how they can support client and reduce stress and anxiety
› If client is a child or adolescent, work with the school if desired by the client and parents to minimize potential sources of
stress there (e.g., test anxiety, bullying)
› Educate client about potential negative effects of alcohol and substance use on anxiety symptoms
› Discourage client from engaging in avoidance behaviors related to school, work, friends, and family
› Social workers should continually educate themselves on empirically supported treatments that may be available for their
clients
References
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