Generalized Anxiety Disorder: A Dissent

I've got an axe to grind

This article is to explain “how I think about” anxiety. I’m a dual-board certified child and adult psychiatrist. I also used to teach neuroanatomy lab! I suspect generalized anxiety disorder (GAD) is not a “valid diagnosis.” This is not to say people don’t experience anxiety. What follows is an argument:

Neurologists have an ax to grind about the term  "dizzy."  Dizzy can mean more than one thing.

Altered sense of balance and place, possibly described as lightheaded, feeling faint, or as if head is spinning.

When some people say dizzy, what they mean as they feel lightheaded:

Feeling dizzy or about to pass out.

About to pass out can mean syncope:

Fainting, or a sudden temporary loss of consciousness.

But when other people use the word dizzy, they are sometimes referring to vertigo:

A sudden internal or external spinning sensation, often triggered by moving your head too quickly.

This experience is usually with positional changes in one’s head because one’s inner ear is sending signals to the brain. These signals can confuse eye tracking. This, in turn, creates the experience of disorientation and sequenced visual “resets” from the eyes having flawed coordination of movement. The neural basis of this movement starts with motor control via cranial nerves III, IV, and VI. This synchronization is knocked out of whack.

Normally, this system works great. It relies on a variety of very complex interactions, which are dependent on the medial longitudinal fasciculus, a neural pathway through the deep parts of the brain:

The medial longitudinal fasciculus (MLF) is a paired, highly specialized, and heavily myelinated nerve bundle responsible for extraocular muscle movements, including the oculomotor reflex, saccadic eye movements an smooth pursuit, and the vestibular ocular reflex.¹

This is a different experience from  "lightheaded," often due to blood pressure variability—not having blood get to your brain! You feel like you're going to pass out. This is often a result of insufficient cardiac output, oxygenation, or insufficient regulation of blood flow.

Lightheaded is one term, dizzy another, syncope another— awful experiences. At it’s worst, you can feel like you are going to die—in the colloquial sense, of course.

Both of these experiences are bad. But they have “different pathogenesis.” Yes, doctor-speak: different underlying biology for similar experiences. One is about the coordination of eye movement and inner ear input, and the other is about blood flow.

As a specialist in the part of human experience that neurology didn’t nab, my ax to grind it with the term: "anxiety."   Anxiety is our dizziness.  Humans use the word all the time, and it is useful in some contexts, but it's not exactly a precise medical term.  It has been used as a medical term, with, essentially, "pseudo-precision"--we have a diagnosis called “generalized anxiety disorder!” The NIH provides this guidance:

Generalized anxiety disorder (GAD) usually involves a persistent feeling of anxiety or dread, which can interfere with daily life. It is not the same as occasionally worrying about things or experiencing anxiety due to stressful life events. People living with GAD experience frequent anxiety for months, if not years.

Symptoms of GAD include:

• Feeling restless, wound-up, or on-edge

• Being easily fatigued

• Having difficulty concentrating

• Being irritable

• Having headaches, muscle aches, stomachaches, or unexplained pains

• Difficulty controlling feelings of worry

• Having sleep problems, such as difficulty falling or staying asleep

As you can tell, those are dreadfully nonspecific.

This is an officially a disorder. “Dizzy” could be defined as a disorder.  You know what? I am just going do it now --to prove it to you, and yes, I just made this up.

Generalized Dizziness Disorder

This disorder requires meeting both A and 3/5 B criteria.

A. An uncomfortable sensation in your head that makes it hard to do stuff, focus, or feel like staying where you are.

B.   Five of Eleven subsequent criteria must also be met for the diagnosis in the past two weeks:

1. The sensation of the room is spinning is subjectively experienced

2. The sensation of being about to pass out is subjectively experienced

3. The behavior will feature regular complaints to friends about how dizzy you feel

4. Avoidance of behaviors that would be part of your everyday life, causing significant impairment in Work, Social, or occupational functioning.

5. Orthostatic hypotension may be present on vital signs examination, with greater than 10 points in systolic blood pressure drop between one and two minutes after changing position from supine to sitting or sitting to standing.

6. The sensations lead to difficulty in specific tasks related to concentration.

7. The presence of nausea and/or vomiting

8. Reduced appetite

9. Difficulty keeping or making plans related to what's happening later tonight.

10. The presentation may be either paroxysmal or persistent.

11. There may be a position component to the sensation.

C. The dysfunction is not better described by another medical condition of known etiology

D. The person question can't be some anxious attention seeker because that would be totally annoying and coded under section F800.X disorders of annoyance and irritation to onlookers, stigmatizing subtype.

Generalized anxiety disorder? Not much better. 

The questions we need to ask, which I hope are obvious now, have to do with: not stopping at "well, I have good news, you have anxiety" as a diagnosis.

We need to ask subsequent questions as health professionals to figure out what's in someone's mind. What is it that you're worried about?   What's making you feel so anxious?  Are there other signs or symptoms?  Have we figured out what those are related to?

All the things that are part of an actual medical history.

To be fair, this is how the DSM-5, a product of the American Psychiatric Association, is structured; every disorder has the caveat of not being better explained by something else.  I wish generalizing anxiety disorder just had one criterion:

Proposed Update to Generalized Anxiety Disorder (GAD):

A: Come on, complete a diagnostic evaluation to determine what the actual diagnosis/es are if criteria for GAD are met.   Keep asking questions until you actually understand what is beneath that anxiety!

Anxiety is often a rational response to difficult circumstances in your mind. The circumstances in the world don't necessarily need to line up with the circumstances in your mind. People worry for understandable reasons: if we didn't worry about things that threatened us, we would all be dead.  We learn to fear because our brain is good at it. There is a whole structure in the brain, called the amygdala, dedicated to fear.  It is efficient. It needs to be efficient. We need to learn fear-based lessons quickly.  It ensures our survival.   It also ensures our misery. We learn to avoid rather quickly things that will kill us.

Anxiety can be a lot of things underneath the GAD diagnosis— once you know what is in someone's brain, body, and mind. It's adaptive after a traumatic experience to feel worried, some of the time.  Are these adaptive responses in one context happening in another context? Anxiety disorders, in a nutshell.

Most of the underlying thoughts, feelings, and biology are context dependent.   Reliable and Valid are not the same:

Generalized Need To Ask More Questions Disorder, Elsewhere Classified. Keep Going!

When we stop asking questions before we have an appropriate understanding of what's going on in someone's body and mind? This is bad medicine. And that sort of pervasive pseudo-precise problem? It makes my head spin!

1. The above pathway is what were messing with when VR isn’t working just right!