Scenario
Suzie, a 22-year-old university student, has spent the past two years feeling constantly worried and tense. She often fears that something bad might happen, especially to her parents, and frequently travels home to check on them. Sleep is difficult, and she experiences stomachaches and headaches, which worsen as her exams approach. She avoids tasks that make her anxious, relies heavily on reassurance, and sometimes misses deadlines due to procrastination. Although she works part-time and has friends, she feels uneasy in situations involving drinking and often uses cleaning or music to calm herself.
Client Behavior and Diagnosis
The client, Suzie, indicates that she has suffered from intractable nervousness and worry since joining the university. Suzie further reports that she is constantly afraid that something bad may happen. From the onset, it appears that Suzie may have a mental illness characterized by psychological disturbance and imbalance.
The American Psychiatric Association (2022) defines mental illness as a medical condition involving variations in a person’s behavior, thinking, emotions, or a combination. The key triggers for mental illness are desperation or challenges in work, societal, or family interactions. Indeed, Suzie’s behavior shows that she may be experiencing problems with family and friends as she has to seek reassurance from them.
The American Psychiatric Association (APA) indicates that mental illness entails any mental disorder or health condition that involves notable shifts in an individual’s emotions, behavior, or thoughts. Suzie’s mental state mainly involved behavioral change after joining the university. She has become highly temperamental and tense in the past two years, so she does not enjoy a good night’s sleep. She seems to have developed a deep attachment to her parents, whom she fears may not be safe or fall ill, to the extent that she must constantly drive home and check on them.
She also suffers financial distress as she is always concerned that she may not have enough money and may have to borrow. This occurs even as she has a part-time job at a local restaurant, manages to pay for all her monthly bills, and has no existing overdraft facility. Suzie also suffers from constant headaches and stomach upsets. Her condition seems escalating as she expects to sit for her upcoming examinations.
The World Health Organization (WHO) is a United Nations (UN) agency that handles global health concerns. It defines mental disorders as a powerful clinical aggravation of a person’s conduct, cognition, or emotional control caused by impaired functioning or distress (Charlson et al., 2019). The organization provides a broader term for mental health conditions that incorporates mental diseases, psychosocial disabilities, and other mental states connected to the danger of self-inflicted injuries, impaired functioning, or significant distress.
Statistics from the United States and globally indicate that mental illness is prevalent. According to Charlson et al. (2019), close to 19 percent or one in five U.S. adults are likely to experience some form of mental illness. The condition may reach serious levels in 4.1% or one in 24 U.S. adults. According to the WHO 2019 statistics, nearly 970 million people (1 in every eight people) worldwide have a mental disease (Charlson et al., 2019). There are many forms of mental illnesses, such that individuals and organizations have developed systems for classifying mental health conditions.
Classification of Mental Illness
Different frameworks have been developed to better describe and understand psychological distress. The classification of mental illness was motivated by botanical taxonomy, a system for classifying plants. Apter (2019) indicates that the first system to classify mental illness was developed in 1763 by François Boissier de Sauvages de Lacroix, a French doctor. His system classified mental conditions into four groups based on the symptoms.
In 1863, the Classification of Psychiatric Diseases and Mental Disturbances was published by Karl Kahlbaum in Germany (Apter, 2019). He also used signs in classifying mental diseases and developed some key terms that are used today, such as Paranoia, Cyclothymia, Dysthymia, and Hebephrenia. Later in the 19th and 20th centuries, his ideas were used by Emil Kraepelin to develop a better system of classification. He is credited with helping to differentiate affective disorders from psychotic disorders and with forming the foundation for bipolar disorder and schizophrenia.
At present, there are two popular systems for classifying psychiatric conditions: the International Classification of Diseases (ICD) and the Diagnostic and Statistical Manual of Mental Disorders (DSM) (Apter, 2019). The systems are mainly differentiated by the framework they use to classify and conceptualize mental illness. The DSM framework is commonly used in the United States, as it was developed by the globally leading scientific and professional association.
The APA represents all psychiatrists and psychologists in the United States. It is in over 100 countries and has a growing membership of about 39000 (Apter, 2019). The organization published the first DSM framework in 1917 called the ‘Statistical Manual for the Use of Institutions for the Insane’ (Apter, 2019).
At the time, it was called the Committee on Statistics of the American Medico-Psychological Association, and the first publication delineated signs of 21 mental disorders, most of which were psychotic. The initial border was later renamed into the American Psychological Association, and it developed the first DSM system in 1952 and expanded the number of conditions to 128 (Apter, 2019). It provided short descriptions of mental disorders. Individual practitioners were free to diagnose the needs and interpret the meaning of the disease based on the cause rather than the symptoms.
The APA has continually improved and expanded the DSM framework over the years. Apter (2019) indicates that DSM-2 was released in 1968, DSM-3 in 1980, DSM-4 in 1994, and the current version of DSM-5 in 2013. DSM-5 was developed based on the recommendations of expert study groups that analyzed large data sets. The key difference from DSM-4 was the dropping of the multi-axial system. In its place, axes I, II, and III were merged into one group of Psychiatric and Medical Diagnoses (Apter, 2019).
The new category incorporated psychosocial references in describing the disorders. The APA preferred to drop Axis V, which involved an examination of a patient’s general functioning, as it was found to lack conceptual clarity. DSM-5 also introduced changes in the diagnosis of autism spectrum disorder by including gender dysphoria and previously separated conditions.
The latest version further preferred to reflect aetiological similarity in categorizing mental disorders. It also uses a polythetic system to list and assign patients’ diagnostic labels if they manifest the specified symptoms. According to the American Psychiatric Association (2022), DSM-5 provides over 20 broad categories of mental disorders. They include depressive disorders, anxiety disorders, schizophrenia spectrum and other psychotic disorders, and personality disorders. The specific conditions are elaborately explained and contain a summary of diagnostic features, and the diagnostic criteria outline the particular symptoms. The framework has added information on the prevalence of the disorders by indicating the percentage of the population that may be afflicted and the associated risk factors.
DSM-5 is longer and more comprehensive than DSM-4 but contains fewer disorders. It has described 237 individual conditions, down from 297 previously listed in DSM-4 (Apter, 2019). The latest version further revises the arrangement and naming of classes and the diagnostic criteria for different disorders. It additionally emphasizes the need to consider cultural and gender differences in presenting diverse symptoms.
In 2022, a text revision of the framework (DSM-5-TR) was published (American Psychiatric Association, 2022). The organization endeavored to detach mental ailments into diagnostic categories based on what people say and do. Individual descriptions of symptoms help to reflect on how people think and feel, including the development of the illness. The revision helped bridge the differences between DSM and ICD by using similar diagnostic categories to adopt standardization and consistency worldwide.
Possible Diagnosis
There are many and varied mental disorders, with some sharing most symptoms. The key symptoms in the case of Suzie are worry and anxiety. In a broader sense, the DSM-5 classifies mental disorders characterized by worry and anxiety under anxiety disorders. According to First et al. (2022), anxiety disorders are mainly characterized by overblown fear, apprehension, and corresponding behavioral disruptions.
Anxiety describes an anticipation a person may have of a future threat. Suzie has different concerns about her financial situation and regarding the upcoming exams. Fear involves a passionate reaction to a threat that may be real or perceived. Suzie fears that something may happen to her parents back home and has to drive there to check on them constantly.
Anxiety disorder is different from the development of normal anxiety or fear. Its key feature is that it involves persistent or excessive anxiety or fear. It induces stressful moments and can last for six months or more. Suzie has had the condition for about two years since joining the university. There also exists the possibility of some people overrating the danger in circumstances they avoid or fear.
The WHO notes that anxiety and depressive disorders are the most prevalent forms of mental illness. The body indicates that the cases of anxiety and depressive disorders rose significantly in 2020 due to the coronavirus pandemic. Anxiety disorder symptoms can be severe and may lead to marked distress or cause considerable impairment in functioning. Suzie shows such indications as she feels tense and struggles to sleep.
Different types of anxiety disorders are mainly differentiated by circumstances or things that generate fear or anxiety. Mental illnesses are highly comorbid, increasing the difficulty in determining the conditions. According to the American Psychiatric Association (2022), the problem calls for a close examination of the situations the patient fears or avoids and the constitution of the thoughts or beliefs connected to the mental illness. An overview of the different forms of anxiety disorders is depicted in Table 1 below. The table briefly describes each type of anxiety disorder, which helps distinguish between the different types.
Table 1. Different Types of Anxiety Disorders
Source: American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR). Psychiatry.org; American Psychiatric Association.
A keen evaluation of the description and symptoms in Table 1 above indicates that Suzie is suffering from a generalized anxiety disorder. The diagnosis is based on the indication under DSM-5. The framework shows that diagnosis can be ascertained if a patient has anxiety and worry occasioned by three or more symptoms that exist for six months or more. Suzie manifests signs of excessive fear or anxiety about several activities or events.
For instance, she is concerned about the upcoming exams and her financial situation. She has tried to implement measures to control the worry, such as cleaning and listening to music, and avoiding anxious problems. However, she is not able to independently contain her concern. Generalized anxiety disorder is further marked by individual experiences and physical signs, including being restless, easily exhausted, feeling on edge or keyed up, irritability, difficulty concentrating, sleep disturbance, and muscle tension. Suzie has manifested some of these signs, indicating that she feels irritable and struggles to sleep.
Theories Explaining Generalized Anxiety Disorder (GAD)
Avoidance Model of Worry and Generalized Anxiety Disorder (AMW)
The AMW theory proposes that people with GAD engage in excessive worry as a defense against unpleasant sensations and unexpected situations. It describes worrying as a cognitive avoidance strategy that enables the individual to maintain control and avoid potentially adverse outcomes. According to Gustavsson et al. (2022), people with GAD have an elevated feeling of risk, which drives them to worry and foresee numerous possible outcomes.
This excessive worry serves as a cognitive avoidance, allowing individuals to feel in control of potential hazards and unexpected events. Suzie depicts such worry, especially regarding her concerns about her parents, and seeks to establish control by visiting them regularly at home. People with GAD attempt to mentally prepare for likely unfavorable outcomes by continually worrying, which reduces the likelihood of being caught off guard by unforeseen occurrences.
In addition, the theory suggests that worry provides a brief escape from negative sensations. People suffering from GAD may temporarily disconnect from unpleasant feelings, such as dread and anxiety, by focusing on potential threats. This adverse support strengthens the worry cycle, promoting its persistence and the development of GAD. The AMW stresses how metacognitive beliefs aid in the maintenance of GAD.
Plag and Strohle (2023) state that metacognitive beliefs are thoughts and opinions about one’s cognition. People with high levels of metacognitive beliefs often perceive worry as a beneficial coping tool and believe that worrying may prevent negative things from occurring. These concepts perpetuate the anxiety cycle by encouraging worrying as a coping technique. The AMW theory also posits that individuals with GAD engage in excessive worry to avoid unexpected scenarios. Although it gives people a feeling of control and momentary comfort, this cognitive avoidance technique feeds the worry cycle and aids in the onset and maintenance of GAD.
Intolerance of Uncertainty Model (IUM)
The IUM theory developed out of the understanding that people with GAD cannot deal with ambiguity. Based on this understanding, people with GAD struggle with ambiguity and uncertainty in their everyday lives and have a more vital need for predictability. According to Ouellet et al. (2019), IUM, persons with GAD are too concerned in an attempt to reduce ambiguity.
Worry is a cognitive method for increasing one’s sense of certainty and control over upcoming events. People who are too concerned tend to foresee and prepare for every possible event that may go wrong to avoid ambiguity and potential hazards. This is manifest as Suzie experiences increased worry and anxiety as the exams near, and she may be trying to be in a position where she avoids ambiguous results.
The IUM also claims that patients with GAD exhibit negative attitudes about uncertainty. Uncertainty makes them uncomfortable and unpleasant, so they become overly cautious and anxious about potential risks and adverse outcomes. This cognitive bias towards negative perceptions of ambiguity exacerbates GAD symptoms by feeding the worry cycle.
The IUM also emphasizes the role of cognitive avoidance in GAD. People with GAD often avoid uncertain situations or act cautiously to alleviate anxiety. Although they only give temporary relief, these avoidance behaviors reinforce the notion that uncertainty is detrimental and should be avoided at all costs. Consequently, this avoidance prevents individuals from recognizing that uncertainty can be managed and maintains their aversion to it.
Plag and Strohle (2023) indicate that GAD is characterized by people’s inability to accept ambiguity. Excessive worrying is a cognitive strategy used to gain control and reduce uncertainty. People with GAD use avoidance methods and have negative attitudes toward ambiguity to avoid situations that make them nervous. Consequently, GAD symptoms, as well as the anxiety cycle and intolerance of ambiguity, persist.
Proposed Interventions
People should not be ashamed of mental sickness, as it is a medical problem comparable to diabetes and heart disease, among others. The good news is that mental health conditions are treatable, and most of the victims can lead and function normally in their daily lives. Several treatment options have been developed to treat GAD. They include cognitive behavior therapy (CBT)
Cognitive Behavior Therapy (CBT)
CBT is one of the most effective methods of treating GAD. The approach principally involves identifying and altering the thought and behavioral patterns that fuel anxiety, and it contains several components. Psychoeducation seeks to provide information regarding GAD, including its signs, causes, and maintenance factors, in the early phases of treatment (Stefan et al., 2019). Understanding the causes of anxiety might help people better understand their feelings and lessen their powerlessness and bewilderment.
The identification of cognitive distortions helps people to overcome such distortions or erroneous thinking processes that contribute to anxiety. According to Stefan et al. (2019), the common distortions include catastrophizing, which is the assumption of the worst-case scenario, and overgeneralization, which involves drawing general negative implications from a particular experience. The other distortion involves mind-reading that assumes negative thoughts or judgments from others.
Another element of CBT is cognitive restructuring, which occurs after detecting cognitive distortions. The patient works with a therapist to reframe these ideas into more grounded and reasonable ones (Sneddon et al., 2020). The process entails weighing the evidence in favor of and against worried beliefs, developing other theories, and cultivating more flexible mental processes. CBT provides several ways to deal with anxiety to assist people in lowering their overall anxiety levels. This may include relaxation techniques that promote physical and mental tranquility, such as deep breathing and progressive muscle relaxation (Stefan et al., 2019).
Exposure exercises teach people to question avoidance patterns and progressively confront scary circumstances. CBT also aids people in acquiring efficient problem-solving techniques to deal with problems. People can be taught to identify manageable problems, develop potential solutions, weigh the benefits and drawbacks, and act to fix the issues. This helps reduce anxiety and enhance one’s control over life.
The other key goal of CBT is to provide patients with long-term coping mechanisms to help avoid relapse. Patients are encouraged to use their newly acquired capabilities daily and foresee and prepare for any difficulties or triggers (Stefan et al., 2019). They are also advised on moving forward in the face of obstacles or challenging times. According to Sneddon et al. (2020), CBT is typically carried out over several sessions, usually between 12 and 20.
However, the required number of sessions may vary based on the requirements of each person, as it may be given in individual or group settings. It may also be given in conjunction with medicine in more complex situations. Overall, CBT gives people functional skills to control their anxiety and gives them the confidence to question their negative thought patterns. CBT assists people in creating healthy coping mechanisms and obtaining long-lasting symptom alleviation by treating both the cognitive and behavioral elements of GAD.
Pharmacotherapy and Psychotropic Medications
Pharmacotherapy, or medication use, is another effective strategy for treating GAD. The symptoms are treated with medicines, such as selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), and benzodiazepines. SSRIs are a class of antidepressants that have been shown to raise serotonin levels in the brain (Costello et al., 2022).
As first-line treatment for GAD, SSRIs, which include fluoxetine, paroxetine, escitalopram, or sertraline, are often suggested. The drugs function by boosting the accessibility of serotonin in the brain, a neurotransmitter critical for mood modulation. SNRIs also increase the level of serotonin and norepinephrine in the brain. They are effective in treating GAD and help reduce the symptoms of depression that occur concurrently (Harrison et al., 2019). Serotonin and norepinephrine, two neurotransmitters linked to anxiety, are increased by SNRIs, which contain venlafaxine and duloxetine.
Benzodiazepines, including alprazolam, diazepam, and lorazepam, are sedative medications that provide rapid relief from anxiety symptoms. They enhance the activity of a neurotransmitter called gamma-aminobutyric acid (GABA) in the brain (Klau et al., 2022). The neurotransmitter helps reduce relaxation and anxiety as it has a calming effect. The drugs are usually prescribed for short periods and at lower doses due to their potency and potential for dependence and tolerance.
It is crucial to note that GAD medication should be prescribed to each patient while considering factors like the intensity of symptoms, medical history, and potential drug interactions. The duration of medication may vary, and taking the medication long enough to gain the merits is frequently recommended (Marlene & Christos, 2023). While pharmacotherapy may not be sufficient to manage GAD in the long term, it is mainly used with psychotherapy, such as CBT, to treat underlying issues and give patients practical coping methods. Regular monitoring, follow-up appointments, and open discussion with a healthcare professional are essential for maximizing treatment results and altering pharmaceutical regimens.
Psychotropic medicines are also used to treat GAD since the drugs target the brain chemicals necessary for controlling anxiety and mood. According to De Filippis et al. (2023), psychotropic medicines most likely lower stress, alleviate physical pain, and enhance performance. The most common psychotropic medications include buspirone and pregabalin.
Harrison et al. (2019) state that buspirone is a non-benzodiazepine medication specifically approved for treating GAD since it affects serotonin receptors in the brain and has a gradual onset of action. It is considered a non-addictive alternative to benzodiazepines and can be used for long-term management of GAD. According to De Filippis et al. (2023), pregabalin (brand name Lyrica) was initially developed to treat seizures and neuropathic pain. The drug is more effective in reducing anxiety symptoms in GAD since it modulates the release of certain neurotransmitters, such as glutamate, and it has anxiolytic properties.
It is essential to note that a qualified healthcare professional should determine the choice of medication and dosage based on the individual’s specific symptoms, medical history, and preferences. Medication management for GAD often involves finding the correct balance between symptom relief and minimizing side effects. In addition, therapy, for instance, CBT, is usually recommended as a first-line treatment for GAD (Costello et al., 2022). Therapy can help individuals develop coping strategies, challenge negative thought patterns, and learn relaxation techniques to manage anxiety more effectively.
Combining medication with therapy can provide a comprehensive approach to treating generalized anxiety disorder. Therefore, regular follow-up with a healthcare professional is crucial when monitoring the effectiveness of the medication and making any necessary adjustments.
Conclusion
Suzie showed symptoms characterized by unending worry and anxiety that developed after joining the university. The signs showed that she could have a mental illness. Mental health conditions are classified into many broad categories and sub-categories. The DSM is one of the most common systems used to classify mental disorders and is mainly applied in the United States, as the APA developed it.
The latest version provides detailed information on many mental health conditions. Based on the information provided by the framework, Suzie was diagnosed with an anxiety disorder that is characterized by fear and anxiety. In particular, she suffered from GAD due to the high levels of worry and anxiety that persisted for over two years.
Several theories have been developed to help explain the existence of GAD. These theories include the AMW model, which views excessive worrying as a defense mechanism against distressing emotions and unpredictable circumstances, and the IUM theory, which explains that GAD arises from difficulty tolerating uncertainty.
Potential treatments include therapy—especially CBT—which focuses on recognizing and changing the thought and behavior patterns that sustain anxiety. Pharmacotherapy involves the use of first-line medication, which includes SSRIs, SNRIs, and benzodiazepines. Psychotropic medications can be used as an alternative and include buspirone and pregabalin. Different approaches can be combined to enhance the efficacy of the intervention.
References
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