Assessment and Differential Diagnosis
GAD patients frequently report that they have been anxious all their lives. Typically, they were moderately anxious during child-hood, later developing full-blown GAD when their stress levels increased through activities such as attending college or starting to work. Patients with early onset of symptoms report experienc-ing significant anxiety and fears, social isolation, obsessional-ity, more academic difficulties and disturbed home environment during their childhood. The social maladjustment and emotional overreactivity persist into adulthood. Epidemiological studies and clinical studies suggest that the onset of GAD typically be-gins between the late teens and late twenties. However, not all GAD patients have a lifelong history of excessive anxiety. Some patients develop their disorder at a later age, that is, in one’s thir-ties or later. These patients frequently report identifiable, precipi-tating stressful events, specifically unexpected, negative, impor-tant events in the year preceding development of GAD.
Patients with GAD experience chronic anxiety and ten-sion. They find the worry as being uncontrollable. However, some patients intentionally initiate and maintain worry with an almost superstitious assumption that, by doing so, they can avert a nega-tive event. Patients tend to worry predominantly about family, personal finances, work and illness. They are also likely to re-port worrying over minor matters, such as making a slight social faux pas. The majority report being anxious for at least 50% of the time during an average day. In children and adolescents, the worries often revolve around quality of performance in school/ competitive areas; catastrophic events; and physical/mental inad-equacies. They typically require excessive reassurance and often appear shy, overcompliant and perfectionistic. Frequent multiple physical complaints are common. They may have an unusually mature and serious manner and appear older than their actual age. These children are often the eldest in small, competitive, achievement-oriented families.
Individuals with GAD commonly complain of feeling tense, jumpy and irritable. They have difficulty falling or stay-ing asleep, and tire easily during the day. Particularly distressing to patients is the difficulty in concentrating and collecting their thoughts. Cognitions appear to play a central role in GAD, as well as other anxiety disorders. Patterns of cognitions, however, appear to be disorder-specific. Cognitions about interpersonal conflict or acceptance by others are quite common.
Patients may present complaining of muscular tension, especially in their neck and shoulders and headaches which fre-quently are described as frontal and occipital pressure or tension. Patients commonly experience sweaty palms, feel shaky and tremulous, complain of dryness of the mouth, and experience palpitations and difficulty breathing. They may also experience gastrointestinal symptoms such as heartburn and epigastric full-ness and approximately 30% of patients experience severe gas-trointestinal symptoms of irritable bowel syndrome. Physical complaints frequently lead patients to seek medical attention, and most will initially consult a primary care physician. Al-though chest pain is more frequently reported by patients with panic disorder, Carter and Maddock (1992) observed that 34% of patients with GAD without panic attacks experienced chest pain. They also found that these patients were predominantly males and many had undergone extensive cardiac evaluations that re-vealed no demonstrable cardiac pathology.