The More the Unmerrier: Birds of a Feather Mock Together
GAD stands for generalized anxiety disorder, an exaggerated state of persistent worrying that is uncontrollable and impairing, occurring more than 50% of the time over at least 6 months. It arises from genetic, neuropsychological, and developmental/personality factors.
Unfortunately, the majority of people (two-thirds) with GAD also have major depression or other anxiety disorders, such as social anxiety disorder (SAD), specific phobia, or panic disorder. It can also be seen with substance abuse, PTSD, and obsessive-compulsive disorder.1 Like the flock of birds alighting on the jungle gym in the Alfred Hitchcock thriller, the more there are, the more vicious the attack.
Comorbidities often seen with GAD3
Social anxiety disorder (SAD)
Also known as social phobia, SAD is an extreme fear of situations subject to scrutiny by others. A person with SAD fears embarrassment or humiliation, so endures these situations with difficulty or avoids them altogether.2 It can manifest as behavioral inhibition (withdrawal from new situations or people), shyness (feelings of awkwardness with others), and performance anxiety (fears of negative evaluation from others).
A specific phobia is an unreasonable fear of a particular object or situation that alters behavior for the purpose of avoiding the thing feared. It can be heights, insects, enclosed spaces, getting injections, flying, etc.
Panic disorder differs from panic attacks in that the panic can occur unexpectedly or result in avoidance behavior.
Treatment for GAD when there are other comorbidities
Luckily, there is tremendous overlap in the specific therapeutic strategies for both GAD and its assortment of likely comorbidities, making the attack on such a cluster nearly the same. This is probably because there is also tremendous overlap in the brain chemistry and circuitry that causes GAD and the comorbidities in general.
Especially cognitive behavior therapy (CBT) helps with GAD and all of the other psychiatric comorbidities. Cognitive and behavioral therapies are educational interventions that teach relaxation, coping skills, stress management, and assertiveness training.4 These skills are practiced during repeated exposure to stressors and stimuli, and repeated resolutions reinforce its success.
CBT is also helpful in depression, PTSD, panic disorder, OCD, and even medical conditions (smoking, over-eating, etc.), so it is doubly useful when someone suffering from GAD has one of these as a co-morbidity.
(SRIs, SNRIs) share therapeutic benefit for both GAD, major depression, SAD, and panic disorder.
- These include fluoxetine (Prozac), citalopram (Celexa), escitalopram (Lexapro, Cipralex), paroxetine (Paxil), sertraline (Zoloft)—the SRIs; and
- venlafaxine (Effexor), duloxetine (Cymbalta), and desvenlafaxine (Pristiq, Khedezla)—the SNRIs.
- Mirtazapine (Remeron), a different type of antidepressant, is also helpful for these.
- Additionally, depression, phobias, and panic disorder can benefit from the use of tricyclic antidepressants clomipramine and imipramine, as well as monoamine oxidase inhibitors (MAOIs).
Although not helpful with depression, will help with the social and other phobias, as will the other type of anti-anxiety medication, buspirone.
The benzodiazepines include Alprazolam (Xanax), clonazepam (Klonopin), clorazepate (Tranxene), chlordiazepoxide (Librium), diazepam (Valium), lorazepam (Ativan), oxazepam (Serax), temazepam (Restoril), and triazolam (Halcion).
Pregabalin (Lyrica) and gabapentin (Neurontin), although not a choice of interest with major depression, are included in treatment strategies for the phobias and panic disorders.
As with SAD and panic disorders, other comorbidities that are seen with GAD which benefit from the vast overlap of effective treatment strategies include:
- PTSD—intrusive thoughts from traumatic memories.
- Adjustment disorder—different from GAD due to different criteria that involve identifiable stimuli.
- Separation anxiety—as opposed to GAD, separation anxiety is usually only about one person or thing. (GAD is more encompassing.)
- Hypochondriasis—worry about one thing at a time, while those with GAD tackle many things at once, none of them successfully.
- Obsessive-compulsive disorder—a fixation on primal fears—germs or physical dangers, whereas GAD is more related to day-to-day worries (finance, family squabbles, etc.)
- Substance abuse and addiction
- Unexplained chronic pain
Recent studies have championed a combined approach of cognitive behavioral therapy along with medication.5 This is called an “augmentation of CBT” for GAD, especially when there are associated comorbidities that can benefit. Normally having multiple medical conditions is very difficult to treat, because of the conflicting pharmacology of the different therapeutic directions, but with comorbidities complicating GAD, it is different. Their arising from a commonality in the brain’s biochemistry can be used to advantage to shoo away many birds with the fewest stones.
Learn more about Anxiety
- Wittchen HU, Zhao S, Kessler RC, Eaton WW. DSM-III-R generalized anxiety disorder in the National Comorbidity Survey. Arch Gen Psychiatry 1994; 51:355.
- Dugas MJ, Marchand A, Ladouceur R. Further validation of a cognitive-behavioral model of generalized anxiety disorder: diagnostic and symptom specificity. J Anxiety Disord 2005; 19:329.
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