There are differences between fear and anxiety.  Fear is that which is tangible.  If there is imminent danger of harm then fear comes into play and causes the fight or flight queues in each and every one of us from our primal instincts. nbsp; Adrenaline kicks in and a person can find they are capable of unique and sometimes powerful responses to the danger.  Anxiety is a fear, however the feelings and reactions to the perceived danger is out of proportion to the actual danger at hand.  The mind misinterprets the severity of the stimulus in the individual who is experiencing it (Heller, 1999)

James is a 31 year old medical resident who has been diagnosed with GAD.  The fatigue and fast-paced emergency response required for his residency caused errors in patient care.  James was worried that, although he had not made any critical or fatal errors, there was a chance that he may make one in the future.  James was no longer able to function as a resident in the high-stress field of internal medicine which he had taken on.  He began to hesitate and question his diagnoses and was no longer confident in his competency.  He called in sick often and would avoid stressful situations.  Because of the absences James was being threatened by the lead resident.  He was failing in accomplishing his requirements and would be reported to the head of the program if he did not improve his attendance.  His continued inability to manage his stress caused James to resign from his position by the end of his first year.  During his initial residency, he applied to go into another field, hoping that this field would prove less fatiguing, and therefore less stressful.  Unfortunately, James found that after only a few brief months in the new department he began to feel the same anxiousness he had felt in his previous post at the hospital.  Even a research position he was able to obtain proved to be more stress than James was able to work with.  He was overwhelmed with the fear of making a life-threatening mistake and could not continue with his medical career.

Anxiety comes from the Latin word anxietas which means:  worried about the unknown.  It is also associated with the Greek word artare which can be translated into compress or strangle (Heller, 1999).  Both translations are used in defining the psychological conditions involving anxiety.  Generalized Anxiety Disorder (GAD) is defined by the National Institute of Mental Health as being “an anxiety disorder characterized by chronic anxiety, exaggerated worry and tension” (2006).  Those who suffer from Generalized Anxiety Disorder worry about trivial issues.  They worry so much they begin to suffer from physical symptoms like fatigue, headaches, muscle tension and aches, and difficulty swallowing.  They can also experience trembling, nervous ticks or twitches, irritability, hot flashes, and sweating (NIMH, 2006).  Those who suffer from GAD are aware of their irrational behavior, but have trouble combating it.

This disorder which is characterized by the above mentioned symptoms is usually triggered by something.  If it begins in a child it could have developed from how he was raised.  An over-zealous parent can bring on the onslaught of symptoms in their child.  He can begin to work so hard to obtain the goals set for him by others that he begins to feel stress.  This stress can culminate into anxious behavior.  Because the child determined to please, he will continue to persevere, without complaint, until the stress becomes more than he can handle, and he develops GAD.  Other environmental causes for anxiety disorders can be traumatic, as in sexual abuse, or physical harm which devastates a child.  When the child finds that they have troubles expressing their fears because of a traumatic experience they can begin to internalize the feelings, and later suffer from Generalized Anxiety Disorder.  Later in life also, in adulthood, there are ways that GAD can develop.  When responsibilities become more than can be taken care of by an individual, they begin to worry about things.  In a younger adult, it could be that they begin to worry about their future success.  In middle-age the stress and worry of paying the bills, making sure that they can keep their job or other personal responsibilities like children’s college, or insurance and retirement can motivate or distress an individual until they begin to experience GAD (Morrison, 2004).

GAD was not recognized as a specific disorder until 1980, with the publication of the DSM-III (Lederman, 2007).  The reason that Generalized Anxiety Disorder was not recognized on its own was that many of the symptoms mirrored those of other anxiety disorders, so it was just lumped in with the other disorders.  Another reason that Generalized Anxiety Disorder was not identified was because the physical symptoms that are experienced by those suffering from it are also symptoms which could be diagnosed as medical problems, and not a mental illness (Lederman, 2007).  A third stumbling block that had to be overcome; GAD is also suffered in conjunction with other anxiety disorders like depression, so the patient was treated for that and the symptoms of GAD were then masked by the medications being administered for dperession.

            The DSM-IV Classifies GAD as an anxiety disorder.  This is a vague classification though.  Those responsible for the information contained in DSM-IV, which was compiled in 1994, were hesitant to include Generalized Anxiety Disorder in it’s pages because the diagnostic status could be faulted (Tyrer& Baldwin, 2006).  GAD is specific because of the unwarranted worry associated with it.  The concerns that worry someone suffering from Generalized Anxiety Disorder seem to be inappropriately escalated to a severe degree (AllPsych.com (2004).  GAD develops over a period of time, and is many times not recognized until it has escalated to a point where the person is in need of medication, therapy, or both, in order to help him through the symptoms to a workable solution (AllPsych.com, 2004).  As the name suggests, GAD is all-encompassing anxiety, and not specific to a particular event, as in a phobia.

            Some genetic and environmental studies that have been performed in order to further understand GAD.  In one study, it was shown that a close family member who suffered from GAD would contribute to another family member developing the disorder.  In a similar study it was found that a close family member did not need to have suffered from GAD in order for another family member to experience it.  In twin studies which were conducted, it was found that a “37% rate of heritability” of GAD was evident (Morrison, 2004).  There are conclusions that determine a genetic predisposition to the disorder, however it appears that an environmental trigger is necessary in order for the person to become anxious, and begin to display the symptoms of GAD.  Tests have been conducted to look at the chemical makeup of the brain of suffers of GAD.  Some tests conclude that there is a neurotransmitter in the brain which can cause anxious symptoms, but in another study GAD patients who are at rest do not show any different neurotransmitter systems from others who do not suffer from GAD.  The conclusion from this test was that although there are no differences while at rest, the range of responsiveness of someone suffering from GAD is smaller than that of someone who does not exhibit symptoms of Generalized Anxiety Disorder (Morrison, 2004).

The patient, James, is suffering from Generalized Anxiety Disorder that appears to be environmental in cause.  He has lived his entire life excelling.  His father and a sister are both doctors and his other sister is also successful.  He did well in school, and was expected to be successful as an adult as well.  His belief in doing things the very best that he could caused him to begin to develop the symptoms associated with GAD when he began making small mistakes.  He began to worry that his mistakes would escalate into larger ones with critical or fatal results.  Without knowing it, James and his family unwittingly caused his anxiety disorder.

Environment plays a large part in the original feelings of fear and anxiety in humans.  In the times when man lived in caves there were many dangers and fears.  There was fear of losing ones’ life to dangerous animals or to lack of food.  There was fear of other tribesmen who wanted to be in power and fear of falling off a cliff in the dark.  These fears are the introduction to anxiety today.  Because people became conditioned to fear the dangers it became a part of what in inherent in a human being.  Natural selection created mental capacity to know when to run and when to stay and fight depending on the severity of a situation.  In today’s society men no longer must fear imminent danger of being eaten by a beast in western civilizations so their inherent instincts to fight or flee have found new conditions in which to be utilized (Heller, 1999).  Sigmund Freud stated that it is a free-floating anxiety, one that you cannot put your finger on, but exists instead in the mind of the one experiencing it (Heller, 1999).

Studies that have been conducted show there are connections between environmental factors and childhood GAD.  The factors include problems in prenatal development, difficulties in normal childhood development, family conflict and adversities in social situations (Manassis and Hood, 1998).  Studies involving adolescent Generalized Anxiety Disorder are done in classroom and other actual environments to determine how many are experiencing extreme anxious behavior above that of the typical student.  There have not been many extensive studies involving adult or adolescent Generalized Anxiety Disorder.  Many psychologists still believe this is not a true disorder, but is instead a vague description of a culmination of different, already identified, anxiety disorders. 

In James’s case, his environment has a lot to do with why he is experiencing such severe and debilitating GAD symptoms.  Because he came from a high-achieving family with his own abilities being exceptional throughout his lifetime, he finds that any failures or mistakes he makes become more severe than they actually are.  He considers any mistake devastating and in such cannot function if he believes that he does not employ the level of competence that he is used to performing with.  James lived his life in the glory of his exceptional talents.  When he found himself in a less than glorified position, working 36 straight hours causing severe fatigue, he was getting careless.  His work showed his fatigue and stress which caused him to become distressed.  After noticing that he and the other residents were making mistakes he internalized the mistakes and took the others’ mistakes personally as though he had made them as well.  James wanted so desperately to excel in his residency that he began to worry uncontrollably about his abilities to perform.  On top of this his personal life with his girlfriend began to suffer.  It could be that he was just so consumed with worry about his professional life becoming null and void that he began to take it out on his girlfriend, or he just became so conflicted that he believed that she would not want to stay with him because he had failed at becoming a physician.  His worry about everything became too much for his friend to endure and she discontinued the relationship.  There is no indication of anyone else in his family experiencing severe anxiety problems, and it appears that James’s symptoms are all coming from the environment he has created for himself. 

Because James was now unemployed he began to worry about even more insignificant issues and moved into his parents’ house to try to recuperate.  His personal self-worth has bottomed out and he no longer feels the ambition to excel, succeed, or even to try to perform in any capacity.  He finds himself overwhelmed by the slightest of tasks.  This would indicate more environmental causes for the GAD that James suffers from.

Psychologists do believe that there are environmental causes, probably beginning in mid-adolescence which can build up to adult GAD.  They consider genetic propensity to the disorder can lie dormant for the entire life of an individual unless there is an environmental catalyst which causes the original feelings of anxious behavior which can then develop into full-blown Generalized Anxiety Disorder.  Because of the all-encompassing feeling of worry and distress each stimulant that is experienced can exacerbate the condition.  They do believe that there have to be underlying chemical imbalances, typically inherited from a family member, in order for the disorder to develop.

Research, although very limited, shows that there are definite neurotransmitters which do not spark properly when triggered.  The studies have shown a 37% potential for twins where one experienced GAD the other will contract some anxiety symptoms as well, although they may not actually experience the same anxiety disorder, there is a higher possibility that they will both experience some form of anxiety (Heller, 1999).

Benzodiazepine receptors are blamed for many of the troubles involving GAD.  Benzodiazepine is a chemical found in many popular tranquilizers, or depressant medications that are used in the treatment of anxiety disorders.  When there is a reduction in the number of receptors in the brain, then there is less chance that the depressant drugs, like Valium, to be able to function and do their job.  In addition to this, there are many neurotransmitters in the brain that can help cause the onset of Generalized Anxiety Disorder.  Some amino acids are also considered to be an integral potential cause of GAD.  Amino acids are important in the transfer of neurotransmitters.  Without the transmission of these neurotransmitters, the brain is unable to adequately ascertain the severity of certain stimulus that is experienced.  Glutamate is referred to as an excitatory amino acid, gama-aminobytyric acid is classified as an inhibitory amino acid, and both catecholamines and indoleamines are considered monoaminergic or  amino acids (Ninan, 1999).  The monoaminergic amino acids, when deficient, result in several mood disorders, including general anxiety disorder (ISCID, 2007).

There have been many depressant drugs prescribed since the 1960’s in the treatment of Generalized Anxiety Disorder.  In 1977, however, it was found that many of these medications which were originally determined to be harmless became troublesome in their own way.  Valium, as mentioned above, was generously prescribed for people who were suffering from any number of anxiety disorders.  The trouble was that when it inhibited the neurotransmitters responsible for anxiety, they also inhibited other necessary functions, like being aware, learning, and responding to danger adequately.  Valium and other benzodiazepine based medications were quickly removed from consistent use, only being prescribed for short periods of time and under doctor observation.  These drugs not only became addictive, but their absorption into the body caused a tolerance to the medication and the dosage would have to be increased in order for it to continue its original effectiveness (Bonn & Bonn, 1998).

Currently, medications that are used in the equalization of neurotransmitters in the brain to help with the symptoms that are experienced by those who suffer from Generalized Anxiety Disorder are antidepressants like Paxil, Prozac, and Lexapro.  The use of these drugs enables certain cerebral chemical activities and influences them to help nerve cells in your brain send and receive messages (Mayo Clinic, 2005).  The antidepressants are found to be more useful and less habit-forming than the depressants which were used in the previous treatments for anxiety disorders including GAD.

Research that has been conducted on the genetic aspects of GAD along with other anxiety disorders suggests that there can be some genetic indicators involved in the contraction of the disorder.  There have been tests done on adolescents, both single births and twins and there have been some conclusions that would point toward the probability that genetic factors come into play in the development of anxiety disorders.  Researchers have found that parents who suffer from an anxiety disorder are likely to have a child with the disorder.  This can be a genetic pointer, however if the child lives in the home with a parent who suffers from an anxiety disorder, it is possible that the characteristics and symptoms are learned and not inherited from the parent.  In twin studies there was approximately a one in three chance of the potential for both children to suffer from an anxiety disorder, and the same percentage, if one twin did not suffer, neither would the other (Heller, 1999).  Even though researchers all find that there is a strong potential of genetic ties to anxiety disorders, they also have concluded that many of these subjects may never experience any symptoms of anxiety unless a traumatic or environmental stimulus was introduced to the patient initiating the feelings of worry and stress.

There is evidence of brain abnormalities being a factor in the contraction of Generalized Anxiety Disorder.  Psychiatrists and psychologists have used MRI scanning to view the brain.  The scans detected some abnormalities in the amygdala.  This part of the brain is responsible for controlling fear, memory, and emotions.  The resources are coordinated with heart rate, blood pressure and other physical responses to stressors (Simon, 2007).  In addition, the neurotransmitters’ gamma-aminobutyric acid (GABA) and serotonin levels may be responsible for the susceptibility to GAD.  GABA controls the way nerve cells fire and serotonin is a brain chemical which helps with feelings of well-being (Simon, 2007).

In the case study involving James, there is no history of anxiety disorders in his family.  His sisters, mother and father all display stable and reasonable thought processes without excessive worry.  James’s parents are concerned that their son has not been able to resolve his issues with stress and anxiety which would indicate that they have no understanding of the disorder.  I believe that James is not suffering from genetic causes for his anxiety.  It all appears to be a part of his life of over-achievement and his inability to cope with failure.  His father and mother are not supporting him properly, as his father is showing disappointment with James in his inability to continue with his medical career, or to say, following in his father’s footsteps.  Watching his sisters excel at their own careers and family paths is an added blow to the feelings of incompetence that James is dealing with.

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