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PTSD Questions & Answers
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Joyce Boaz & Dr. Frank Ochberg, M.D.

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Generalized Anxiety Disorder (GAD)

Q: Dear Frank, What is Generalized Anxiety Disorder (GAD)? And how is it different from PTSD? Is the treatment the same?

A: Dear Joyce, Franklin Roosevelt famously said, "The only thing we have to fear is fear itself." He was leading the nation out of the Great Depression in his first inaugural address. He announced specific cures for a national calamity and he spoke with confidence in the face of despair. His phrase, "fear itself," lives on. But what is "fear itself" and how do we cope with it? Fear usually follows a rational cause, a threat, a risk of losing life, possessions, or reputation. Anxiety, on the other hand, is fear without good reason for that fear. Anxiety is "fear itself." Anxiety often compounds the reasonable reaction to a stressful situation with excessive dread and embarrassment, taking different shapes in different people. Generalized Anxiety Disorder is a psychiatric diagnosis applied to individuals who are continuously worried and have a rather long list of ways in which their worries take shape.

The Mayo Clinic website gives a good description and I agree with almost all that is posted: http://www.mayoclinic.org/diseases-conditions/generalized-anxiety-disorder/basics/definition/con-20024562 (I'm not well acquainted with the herbal remedies they mention and leave those suggestions to others). When we first discussed and defined PTSD we wanted to distinguish between those who were very anxious to begin with, and those who had persistent anxiety long after a serious traumatic event. We realized, of course, that the two conditions, GAD and PTSD, could overlap. And the remedies for the two diagnoses could be similar. But there is a good rationale for having distinct diagnoses.

First, let me clarify what each diagnosis means. GAD - generalized anxiety disorder - means that the physical manifestations of fear - sweating, trembling, having palpitations, rapid pulse, altered breathing- are easily triggered and the mental or emotional manifestations of fear - dread, worry, obsession, pessimism - are experienced even in the absence of any threat. GAD, unlike panic disorder, is a long term continuous state of anxiety. Panic is a sudden explosion of anxiety. GAD, unlike simple phobia or social phobia, is present almost all the time and doesn't require a particular stimulus to be evoked. But people with GAD are also prone to panic and phobia. GAD is often a product of "nature" rather than "nurture."

Some of us are more sensitive than others from our earliest days. In essence, we are born sensitive. That is both a blessing and a curse. It means we feel more, we respond more, we smell the roses and we are moved by beauty in nature and we are touched deeply by those we love. But we are also more easily hurt, irritated, embarrassed and isolated. If we manage our extra sensitivity well we are fine. If we do not, we are candidates for the diagnosis, GAD. GAD may arise spontaneously later in life. Many emotional conditions, thought to be of genetic origin, have their onset in adolescence or early adulthood. This is true of depression and bipolar disorder. It also is true of anxiety disorders including GAD. GAD may follow injuries, be those injuries physical, emotional, moral, or symbolic. GAD after a traumatic episode is quite similar to PTSD.

PTSD, as visitors to this website know, is always due to a trauma and it includes three or four dimensions: (1) re-experiencing the trauma through flashbacks or nightmares or sensations that are intrusive and unwanted; (2) avoiding reminders; (3) being numb, pessimistic and negative; (4) being generally aroused, vigilant and anxious.

I have a very sensitive, intelligent patient in his mid-thirties with GAD. He recently discovered that he had surgery without anesthesia when he was a few days old. He wonders and I wonder if this caused his persistent anxious condition. He doesn't have flashbacks or nightmares related to that surgery. He has no memory of the surgery. But could his body remember? Of course it could. He isn't numb and avoidant, the way people with PTSD are. But he got in trouble years ago with alcohol and drugs, because without them, he was too nervous and inhibited to socialize. His general anxiety inhibited his social life, his school performance and his occupational potential. I believe that PTSD and GAD are equally reasonable diagnoses.

Treatment for GAD is usually a combination of medication to alleviate anxiety and counseling, including CBT (cognitive behavioral treatment), to change the way one thinks about himself or herself and to learn how to self-soothe and to improve self-esteem. Treatment for PTSD is similar, although post-traumatic therapy usually involves revisiting the trauma scene in a constructive way, with a therapist, using some way to modulate and master the memory. The Gift From Within website has many examples of this.

Do you or does someone you care deeply about have GAD or PTSD or a combination of both? These are treatable conditions with similarities and differences. PTSD always has a traumatic event as a cause. GAD may have a traumatic event in the background, but it needn't have one and it often does not. GAD is, in my opinion, a disorder much like
other psychiatric disorders. PTSD is, in my opinion, an injury to an otherwise healthy neuro-psychological system. Neither GAD nor PTSD should be stigmatized, but too often both are. Neither GAD nor PTSD should cause shame and self-blame, but too often, both do.

"We have nothing to fear but fear itself," according to FDR. I'd say we needn't fear "fear itself." It can be demystified and overcome - whether it takes the shape of GAD or PTSD.

Frank

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