Psychology

Generalised anxiety disorder (GAD) is defined separately by two diagnostic criteria ICD-10 and DSM-IV. In both criteria, GAD is defined by its main symptom being prominent tension, worry, and feelings of apprehension about everyday events and problems in the ICD-10 or excessive anxiety and worry about a number of events or activities that is difficult to control in the DSM-IV (Tyrer  Baldwin, 2006, p.2157).
To differentiate GAD from other anxiety-related diagnoses, additional criteria were added. GAD is now distinguished as chronic excessive anxiety of 6 months duration or longer that interfere with normal functioning in school, work or the family (Lucey, 2005). Specific symptoms involved general, physiological, mental and sleep-related states. Both criteria agree on restlessness, the inability to relax or muscle tension as characterizing general states. Additionally, the ICD-10 included other symptoms namely hot flushes or cold chills, numbness or tingling sensations, aches and pains and difficulty swallowing while the DSM-IV added easy fatigability and irritability (Tyrer  Baldwin, 2006).
Only the ICD-10 specified physiological symptoms that are classified into autonomic arousal manifested by palpitations, sweating, trembling and dryness in the mouth and chestabdomen manifested by difficulty of breathing, chest pain, feeling of choking and nausea (Lucey, 2005). In regard to mental states, the ICD-10 specified symptoms of dizziness, depression and the fears of losing control or dying while the DSM-IV specified difficulty concentrating and mind going blank. Only the DSM-IV has a criterion regarding sleep, this being difficulty falling or staying asleep or sleep that is restless and unsatisfying.  In making a diagnosis, ICD-10 requires a minimum of three specific symptoms that includes one autonomic arousal symptom while the DSM-IV requires three symptoms at the least (Tyrer  Baldwin, 2006). In children and adolescents, only one specific symptom is necessary when using DSM-IV (Willacy, 2008).
Finally exclusion criteria added reliability to diagnosis. GAD is inferred if client symptoms do not fit into panic disorder, phobic anxiety disorder, obsessive-compulsive disorder, hypochondriasis, separation anxiety disorder, anorexia nervosa, somatisation disorder or post-traumatic stress disorder (Tyrer  Baldwin, 2006). Further, anxiety symptoms should not be the effect of physiological or developmental disorders, brain damage, medications, substance abuse, psychotic states or mood disorders.
According to Emslie (2008), GAD is one of three common anxiety disorders that affect 6 to 20 of children and adolescents (n.p.). GAD that occurs in childhood and adolescence is most often undiagnosed and untreated because of the inability of children to verbalize their physiological and mental states and the notion that anxiety is normal in children. Childhood onset without treatment leads to a poor prognosis as extreme anxiety often results in avoidance as a way of coping as when children refuse to attend school (Vidair  Gunlicks-Stoessel, 2009). This does not resolve the problem so that it tends to be chronic and as children go through changes that involve uncertainty, loss or threat later in life, other anxiety disorders and major depression develop along with GAD which together result in worse prognosis (Lucey, 2005).
Later in life, normal social and cognitive development is hampered. Various physiological ailments also develop. Social disability is one outcome of recurrent GAD. Among adults with a single diagnosis of GAD, 27 develop mild to moderate social disability while in those who also suffer co-morbid depression, this rate profoundly increases to 59 (Ma, et.al., 2009). Somatic pain from chronic tension is another effect of GAD. In adults, anxiety increases the likelihood of experiencing chronic body pains that make daily functioning more difficult and decreases response to treatments (Teh, et. al., 2009). Diabetes, peptic ulcers, irritable bowel disease and symptoms involving the heart are also common health outcomes of untreated GAD (Hoffman, Dukes  Wittchen, 2008).        
GAD is addressed through pharmacologic therapy and psychotherapy with cognitive behavioral therapy (CBT) as the current treatment of choice in both adults and children (Kehle, 2008). However, numerous placebo-controlled studies involving adult participants highlight the greater effectiveness of combining CBT with drug therapy especially in the long-term and in preventing recurrence as opposed to using either CBT or drugs (Tyrer  Baldwin, 2006). Pure drug therapy using selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants (TCAs) and benzodiazepines among others is primarily recommended only for acute GAD episodes.

A large-sample study, lauded as the first randomized clinical trial focusing on pediatric anxiety, confirmed the effectiveness of combination therapy in children. Using CBT and an SSRI, there was an 81 improvement in anxiety among those who received both CBT and SSRI compared to 60 in those who obtained CBT only and 55 in those who relied solely on SSRI (Vidair  Gunlicks-Stoessel, 2009). Those under placebo treatment had only 24 improvement.
In responding to GAD and depressive disorder co-morbidities in children and adolescents, a pilot study proved the effectiveness of CBT that addressed both anxiety and depression in 60 children (Vidair  Gunlicks-Stoessel, 2009). The treatment consisted of 8 sessions spread over a 3-month period in a primary care setting. Results were compared to a control group given outside referral and showed that among those who underwent CBT, there was a significantly greater reduction in anxiety and depression symptoms . 
Although combination therapy for GAD has been proven in clinical trial settings, research is needed to determine effectiveness in actual situations especially primary health care settings. This will take into account health care provider training and available resources that establish the capacity to provide care for GAD patients. Additionally, the effectiveness of other therapies should also be considered for study.