What is generalized anxiety disorder? Is it an anxious temperament or is it a symptom of another mental illness such as depression? Or is it a valid disorder on its own caused by a buildup of sexual tension?  

Publishing On: 8/31/2023

Duration: 19 minutes, 23 seconds

Transcript:

Welcome to the Carlat Psychiatry podcast, keeping Psychiatry honest since 2003, and this is a Throwback Thursday episode where we're going to update this 2019 classic with new research and CME at the end. 

KELLIE NEWSOME: 25 different meds in 25,000 patients. That's the full stack of psychopharm research and generalized anxiety disorder. In this months issue, we cover a new meta analysis on all that data. Some of the meds rise to the top and some of them sink to the bottom. Before we get into treatment, just what is this generalized anxiety disorder and where did it come from? 

CHRIS AIKEN: Generalized anxiety disorder is one of those disorders that's hotly debated. It entered the DSM in 1980, and in every addition since then, people have tried to take it out of the diagnostic manual. And although people think that it's a manifestation of another disorder like depression or dysthymia or painic, it's actually been around for a long time. It was known to the ancient Greeks who called it vain fear. Aristotle wrote of it describing a man who by nature is apt to fear everything, even the squeak of a mouse. Fast forward to 1869 and physicians had a new word for this condition, pantophobia, meaning fear of everything. 

KELLIE NEWSOME: Who put the pan in pantophobia. Pan means all and pantophobia means fear of all things. Panic comes from a different pan. The great God of pan. 

CHRIS AIKEN: No, he's not the God of pan. He is Pan. 

KELLIE NEWSOME: Right Pan, the God of all things wild. Because in ancient times, people would panic when they heard wild animal sounds outside their village at night. 

CHRIS AIKEN: And in ancient times, that kind of anxiety would have been normal because it was a wise guide; protected people from real dangers in the wilderness. Now it might be that we have so many anxiety disorders today because we still have that biological guide, that instinct within us, but we don't have as many real dangers in the world to direct it toward. So we directed in random places at uncontrollable worries and random phobias. And even though we don't face as many attacks from wild animals in today's world, this ancient instinct can still be a wise guide in modern life, even on Wall Street. 

KELLIE NEWSOME: Stockbrokers are more successful when they are better able to feel the anxiety in their bodies. In 2016 researchers at the University of Cambridge measured how well stockbrokers could feel their own levels of anxiety, such as racing heart, stomach pain and muscle tension. They then followed them through a volatile period of intense rapid trading. And the ones who were more in touch with their gut feelings made more money. 

CHRIS AIKEN: Research like that tells us that we really don't want to kill anxiety or dampen it down to where we can't feel it at all. It can be a helpful guide. Anxiety disorders are not really so much about the presence of anxiety, but the presence of a phobic reaction either to something that the patient is afraid of outside like snakes or tunnels, or to their own thoughts, or their own experiences, as in PTSD or generalized anxiety disorder. So a patient with an anxiety disorder often has an urgent, desperate need to get rid of the anxiety entirely right now, and that's not what we want to do at all. We want to tell them what recovery looks like, that during recovery, they'll still have anxiety. They'll just be able to use it more as a helpful guide instead of circling around it in a phobic, anxious state. 

KELLIE NEWSOME: Back to our history. 

CHRIS AIKEN: Pantophobia the fear of everything soon got merged into a bigger condition called Neurasthenia. Neurasthenia laid the groundwork for a lot of modern psychiatry, but it wasn't very specific. In it were lumped hysteria or conversion disorder, OCD, anxiety disorders, fainting spells and chronic fatigue. The symptoms of neurasthenia were many, but the cause was thought to be one: exhaustion of the central nervous system. Neurasthenia was treated by a neurologist, and one neurologist who was drawn into its orbit was Sigmund Freud.  

In 1895, Freud became the first physician to parse out a particular diagnosis from this neurasthenia category, and in doing so, he set into motion what we now understand as generalized anxiety disorder. Freud called it anxiety neurosis. He thought that the key symptom of anxiety neurosis was anxious expectation. He described a woman who would anxiously expect and think about pneumonia and death and funerals every time she heard her husband cough. And when we read. Freud's description of anxiety neurosis, it sounds almost like the modern DSMs description of generalized anxiety disorder. In addition to the anxious expectation in their thoughts, these patients had general irritability, anxiety attacks. Freud threw a lot of physical symptoms in the mix, sweating, ravenous hunger, night terrors, vertigo, nausea, diarrhea, muscle tension. 

KELLIE NEWSOME: It sounds like the build up of sexual tension. 

CHRIS AIKEN: That's exactly what Freud thought. And that's the part that got left out of the DSM. In Freud's view, all these tense physical symptoms were due to the buildup of libidinous sexual energy that wasn't satisfied. In other words, people were repressing their own sexual desires. Freud's idea about the cause of this sexual tension was immediately criticized by his peers. 

PAUL HARTENBURG: The ideas of Doctor Freud on the sexual origin of the anxiety neuroses are far from being accepted by the majority of doctors, especially in France. 

CHRIS AIKEN: Doctor Paul Hartenberg, anxiety neurosis, 1902. Despite this controversy over its sexual origins, Freud's term anxiety neurosis stayed with us for a long time, all the way up until 1980, when Robert Spitzer, the chair of DSM 3 was eager to rid the book of any notions of a sexual origin of mental disorders. Apparently, Robert Spitzer could find no evidence that general anxiety was due to a lack of sexual activity. 

KELLIE NEWSOME: But he did find evidence of something else: panic disorder. In the 1970s, a psychopharm pioneer, Daniel Kline, had discovered a type of anxiety neurosis that responded particularly well to the tricyclic antidepressant Imipramine. These were the kind of patients that were coming up to the nurses stations complaining of having panic attacks, and when they took Imipramine their complaints and anxious behavior went away. 

CHRIS AIKEN: Just as Freud plucked anxiety neurosis out of neurasthenia, Robert Spitzer pulled panic disorder out of Floyd's concept of anxiety neurosis. Before 1980, patients with panic attacks and panic disorder were lumped into the same broad category of general anxiety neurosis. 1980 was the first time where panic disorder stood on its own as a unique diagnosis. This gave Robert Spitzer an opportunity to rename the rest of the anxiety neurosis and call it generalized anxiety disorder, allowing it to stay in the DSM, which was important because in that day most outpatient psychiatrists were diagnosing most of their patients with anxiety neurosis and they didn't want to accept a DSM that excluded most of their patients from diagnostic reality.  

Now as time went on, we've come to realize that Dr. Klein's idea was not quite as sharp as he thought it was, because this response to Imipramine is certainly not unique to panic disorder. People with generalized anxiety disorder respond to antidepressants just as well and usually to the same ones that people with panic disorder respond to. At the time though that was not the thinking, and it was thought that generalized anxiety disorder was a mild form of chronic anxiety that was best treated with psychotherapy, while panic disorder was some kind of biological condition with lots of physical symptoms that could be induced by laboratory scenarios like changing the balance of carbon dioxide in the blood and that was uniquely responsive to medications. 

KELLIE NEWSOME: But even Freud had a hindered battle along. In his early paper, he viewed panic attack as a biological response was not necessarily related to sexual conflict. And Dr. Aiken, Freud did come up with empirical evidence to support his sexual theory on anxiety. 

CHRIS AIKEN: No, we're not going to get into that Kelly.  

KELLIE NEWSOME: No I want to read it. Anxiety might prove to be a legacy from the Ice Age, when early mankind, threatened by the Great Freeze, had converted libido into anxiety. The state of terror must have generated the thought that in such a chilling environment, biological reproduction is the enemy of self preservation and primitive efforts of birth control must in turn have produced intense anxiety. 

CHRIS AIKEN: Yeah, Freud's really digging for evidence there. He saying that long ago in the Ice Age it was too cold to have sex. I mean, too cold to raise children, so people had to resort to abstinence, which made our ancestors very anxious, and we somehow inherited that anxiety. It sounds farfetched, but it's actually pretty close to home. With anxiety about climate change rising, millennials are having less sex than generations before them and less children. The birth rate in the US has fallen this year to the lowest level in 32 years. 

KELLIE NEWSOME: But wait, I'm not sure if any of this actually proves Freud’s point. But let's cut to the chase, did his treatment work? 

CHRIS AIKEN: Yes. Psychodynamic psychotherapy does work in both panic disorder and generalized anxiety disorder. There's a handful of randomized controlled trials in these conditions, where it's compared favorably to cognitive behavior therapy. We don't often think of psychodynamic therapy as an effective treatment for these anxiety disorders, but it really can be. It just doesn't have as many studies as CBT does. Modern day psychoanalysts no longer see these anxiety disorders as due to direct sexual conflicts, but rather to conflicts in their interpersonal attachments. Of course, some of those attachments could be sexual in nature, so Freuds theory isn't entirely thrown in the wastebasket after all.  

If you thought by the way, that Freud's musings on the Ice Age origins of anxiety were a little far fetched, you're not alone. Freud himself never published that manuscript, which was discovered in the 1980s while rummaging through a pile of manuscripts left by Freud's disciple, the psychoanalyst Sandor Ferenczi. 

I'll wrap up with a few more words on GAD, generalized anxiety disorder. Why is it that generalized anxiety disorder is the cause of so much controversy? In DSM 5, generalized anxiety disorder is kind of a waste basket diagnosis. It's what's left over after all other causes of that persistent worry have been ruled out. The problem with this is that about 90% of people with generalized anxiety disorder actually have other psychiatric disorders that could arguably be the cause of their anxiety and worry. Here I'm talking about disorders like depression or other anxiety disorders that can cause people to fret and worry about life too much in general. People with post traumatic stress disorder, social anxiety disorder is one in particular. I mean, so many aspects of life involve interactions with other people. That it can look like someone with social anxiety is just worrying about everyday things all across the board when their real fear is interacting with others. So when generalized anxiety disorder came out in 1980, the first additions pretty much required that you rule out all those other causes that couldn't exist with it. In 1994, DSM four, and now DSM five got a little more lenient with that. Nowadays generalized anxiety is allowed to be diagnosed even in people who have, let's say, post traumatic stress or major depression. You can diagnose both together as long as the generalized anxiety doesn't occur exclusively during depressed episodes, or if it's another anxiety disorder you're diagnosing as long as the anxious worries are not better explained by that other anxiety disorder, like worry about interacting with other people. The problem is that it's pretty hard to tease all this apart, and on a clinical level, it's not always clear what the extra diagnosis of generalized anxiety adds to the picture after you've already diagnosed recurrent depression or chronic social anxiety. The overlap of the various anxiety disorders is so great that in some ways it makes sense to go back to the old notion of pantophobia or fear of everything to just lump them all together.  

When you see someone with a lot of different anxiety disorders, probably what's going on is they have a general tendency towards anxiety that's come out at different phases of their life. So the typical life course would look like this. Early elementary school and childhood: separation anxiety. The child will worry about leaving home, going to school. They'll lie in bed at night when their parents go away worrying what might happen to them, thinking of the worst scenario. They also have a lot of somatic symptoms of anxiety, like headaches and nausea, trouble catching their breath. Middle school years, social anxiety tends to come on. Then high school aged 15 to 22, this is when panic disorder typically starts. Then comes the 20s and there's more worry about everyday things, bills, life decisions, relationships, health. It looks a bit more like generalized anxiety. Now think about how difficult life must be through the years with all of these inhibitions and avoidance patterns building up over time. After a while it gets pretty depressing and by about age 30 patients with this constellation typically fall into depression. But when they come out of depression, they're still very vulnerable to go back into it unless the underlying anxiety disorder is treated. So the clinical pearl is, when you see a patient with depression, look back to what was going on before the depression started. Was it a life long history of chronic anxiety that might influence your medication decision? Or it might lead you to recommend psychotherapy? One thing to look out for is neurotic personality style, because even though that's not in the DSM that often precedes depression, and that might have particular relevance to which antidepressant you choose. We're going to cover that in next week's podcast. 

CHRIS AIKEN: One update to that podcast is that we've had a new study of sexual activity in people under age 25, and it confirms what we were saying there, that sexual activity has been on the decline in the last 20 or so years. The decline actually started in 1990 and in people who are under 25. Today, the decline is across the board, not just in sexual intercourse and dating, but in masturbation as well. The changes have even inspired a popular summer movie starring Jennifer Lawrence, No Hard Feelings.  

Any other updates? Well, maybe we were a bit too enthusiastic in saying that Vortioxetine (Trintellix) does not have sexual side effects. That is true in the most conservative sense. There was no statistical difference in the studies, but there was a trend toward greater sexual dysfunction. As the dose went up, not enough to reach statistical significance, but certainly something to keep your eye on as you're working with patients. 

KELLIE NEWSOME: So go on and get your CME for this podcast through the link in the show notes, and here’s a preview of the question:

1. What happened to the Anxiety Neurosis category in DSM-III?

A. It was removed entirely

B. It was replaced with Generalized Anxiety Disorder and Panic Disorder

C. It was replaced with neurotic temperament

D. It was lumped into anxious depression

__________

The Carlat CME Institute is accredited by the ACCME to provide continuing medical education for physicians. Carlat CME Institute maintains responsibility for this program and its content. Carlat CME Institute designates this enduring material educational activity for a maximum of one quarter (.25) AMA PRA Category 1 Credits^TM. Physicians or psychologists should claim credit commensurate only with the extent of their participation in the activity.