Alice (not her real name) is my first cousin whom I have known since my childhood. She is forty-two-year-old African-American citizen who was brought up in Los Angeles, California. Alice is the first born in a family of five. She has two elder sisters and two younger sisters. Alice has been married for fifteen years to the same man, and currently has two children (boy aged 15 years and a girl aged 10 years) from this marriage. Alice grew up in a middle-class family. Both her mother and father worked with the federal government. Her mother, as a high school teacher, and her father as an accountant. Consequently, she had a comfortable childhood. She describes her childhood as generally full of happiness and joy although she was troubled by constant worry during her childhood. She has no history of either physical or sexual abuse.
Alice has had prolonged history anxiety. I remember her depiction of anxiety when I was young. She was an anxious girl and would opt to separate herself from others. She also battled with shyness, which was manifested in her primary and high schools. Growing up, from the age of 15, Alice was profoundly worried about the wellbeing of her parents. Her mother and father were diagnosed with terminal diseases. Her father, who was aged 45 at that time, had been diagnosed with leukemia while her mother had been diagnosed with diabetes and avoidan personality disorder, which she has lived with since her childhood. Even though her parents were not at advanced stages of their illnesses, she was deeply worried that her parents would die. Consequently, she was worried that her education and those of her siblings would be adversely affected by the demise of their parents. Even though she did not confess to any of her family members at that time, she has reported having sleepless nights at some period linked to her worry and deep thoughts regarding her parent's health. Additionally, although she was academically above average student, she was always anxious about her academic performance. This was manifested by sleepless nights on the eve of examinations and sweating and palpitations in examination rooms. Additionally, while growing, Alice remembers having a deep fear of darkness, thunder, lightning, and insects. Even though she outgrew these fears, she still fears insects, especially spiders.
Alice's anxiety worsened after she graduated from high school and joined the university. Her efforts to obtain treatment from the university's hospital did not alleviate her condition. She was prescribed diazepam that she used throughout her undergraduate studies. She was required to use the medication during the period of high anxiety, especially during examinations. Moreover, she occasionally sought help from a therapist at the university's counseling center. The visits to the therapist were done on an occasional basis. In the winter of her first semester sophomore year, Alice began experiencing her first major episode of depression following her break-up with her boyfriend.
She describes being excessively worried and depressed due to the breakup. According to Alice, the anxiety and depression that followed her breaking up with the boyfriend were due to her worry that she could not find a replacement for her boyfriend, whom she loved a lot. This problem negatively affected her academic performance as she could no longer concentrate in her lectures, she often found herself missing lectures. She also described having had sleepless nights following the dissolution of her intimate relationship. The whole of her sophomore year was marked by poor academic performance. She was forced to redo some of her major courses following failures.
Even though she continually sought medication from the university's health care services as well as the therapist, her worry never disappeared entirely. Occasionally, the worry would reappear. The prescription of imipramine did not help treat her condition. She took the drug for four months but later avoided due to the unbearable side effects. After six months, her sleep improved, but worry and anxiety never fully disappeared.
Alice's worry continued plaguing her. The worry is often accompanied by fatigue, general body weakness, irritability, and insomnia. Over the years, her relatives and friends have scolded her for "excessively worrying about every little issue." Noteworthy, the worry persisted throughout her undergraduate studies. After finishing her undergraduate studies, Alice secured a job in a bank. Because her job was well paid, she felt that it was the right time to move out of her family's home and rent her own house near her working place. The pressure to keep up with friends' social status made her go for a car loan. The car loan took a toll on her financial situation. She reported having difficulty controlling anxiety over her financial problems, job security, and her health even though some of these (such as job security and her health) were not problematic.
A year after being employed, Alice got into a new intimate relationship. Alice reported that she fell in love with her current husband due his calmness and her sense of stability. Even though she was apprehensive of this relationship, she vowed to make sure that the relationship works. Alice's new romantic relationship went on well and ended in a marriage, a year later. Her husband has reported having had difficult times while dating and even currently. He claims that he has found her sending anxiety and the constant need for reassurance strenuous and tiresome. Consequently, her husband has reported withdrawing himself from her, which has led to persistent tension between them. The husband further reported that even though her performance in the bank has been excellent over the years as manifested by her financial compensation annually, Alice continues to be worried about her performance. These worries have affected her upward mobility in her current job.
DSM-5 Diagnosis: Generalized Anxiety Disorder
According to the DSM-5 (APA, 2013), for a patient to be diagnosed with Generalized Anxiety Disorder, he or she must present with a minimum of three symptoms. First, there must be presence of existence of extreme anxiety and worry originating from different activities or topics. This worry could be beyond normal and experienced in more than 6 months. An individual might spend most the day time thinking about threats that might not be possible. Alice's condition is highly likely to be generalized anxiety disorder because of her prolonged worry about her parents' illness, her examinations, her financial situations, and her job performance.
Secondly, a patient must manifest a worry worry that is difficult to be contained and vary in topics. Alice met this second criteria. Her worries were many. They included worries about parents' illness, her examinations, her financial situations, and her job performance. The third criteria for generalized anxiety disorder is that a person should present worry and anxiety along with not less than three of the following cognitive or cognitive symptoms: insomnia, muscle aches, irritability, impaired concentration, fatigue, and restlessness. Alice manifested at least three of these symptoms. Specifically, Alice showed fatigue, insomnia linked to excessive worry about her parents' health, and impaired concentration in classroom or lectures which affected her academic performance.
Etiology of Generalized Anxiety Disorder
Generalized Anxiety Disorder has been linked to many factors. one of these factors is the brain basis of anxiety. Like other types of anxiety, generalized anxiety disorder has been associated with elevated activation of the brain mechanism linked to fear or flight response. When an individual is confronted with a dangerous situation, two brain circuits are activated. This is followed by a relay of sensory system information about a risky situation, such as the sight of an oncoming vehicle that is likely to cause a head-on collision, to different brain regions. One of the two circuits spreads towards the cerebral cortex, the outermost layer of the cerebrum comprised of foldings of the grey matter, which plays the vital role of consciousness, thinking as well as decision making. The second circuit is composed of the amygdala, the part of the brain involved in emotions, emotional processing, emotional behavior, and motivation. The amygdala is also involved in the monitoring of the body's reactions towards the environment, evaluation of the emotional significance of events, and organization of responses that an individual may be aware or not aware of (Harvard Medical School, 2011).
Even though many brain circuits undergo simultaneous activation, the amygdala is involved in the initiation of a rapid response to danger. Its major role is communication with the hypothalamus, a portion of the brain located at the base of the brain, stimulating the faster release of hormones that elevate the blood pressure as well as the heart rate. Additionally, the secreted hormones make the muscles to contract in preparation of the body for flight or fight. The amygdala system is the first to undergo activation, followed by the cerebral cortex. This is important in enhancing survival of an individual. For instance, a person will make a quick dash to avoid an oncoming vehicle before he or she is even consciously aware of the imminent danger or accident (Harvard Medical School, 2011).
The amygdala also works in conjunction with other parts of the brain to store memories associated with emotions, such as memories linked to frightening events. In individuals suffering from anxiety disorders, such as generalized anxiety disorder, storage, and processing of emotion-related memories are problematic. In this group of individuals, the amygdala is too sensitive to situations that are non-threatening and thus overreacts to such situations. Consequently, the brain circuits are inadvertently triggered thus provoking an emergency stress response. With time, the person associates anxiety to memories, thoughts, and situations that are not linked with the real danger sources. This means that the brain unintentionally generates its fears.It is unclear if Alice's anxiety is caused by impaired amygdala. To determine if her anxiety is linked to impaired or abnormally functioning amygdala, there is a need to carry out human imaging studies such as positron emission tomography (PET) or functional magnetic resonance imaging (fMRI) to determine the neural activity and neurobiological bases of anxiety respectively (Forster, Novick, Scholl, & Watt, 2012).
Generalized anxiety disorder has also been reported to be caused by certain genetic variations. One of the important genes in the development of generalized anxiety disorder is 5-HTT. In adults with anxiety, those depressed, and healthy ones, a linkage between amygdala activation and a functional polymorphism in the serotonin transporter gene exist. Lau et al. (2009) study aimed at investigating the associations between gene and brain in adolescents examined the predictive impacts of LA allele homozygotes versus S and LG allele carriers (serotonin transporter gene variants) on the responses of the amygdala to emotional faces. The researchers gathered data using functional magnetic resonance imaging. Healthy adolescent and those with anxiety or depression but not currently enrolled in any medication were exposed to different facial expressions (neutral, happy, angry, and fearful) under different attention states. Findings of this study showed that healthy people (those who do not have anxiety) a copy or copies of the S or LG allele manifested stronger amygdala responses to fearful faces than healthy individuals who lack these alleles. Additionally, the presence of two copies of LA a...
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