Generalized Anxiety Disorder docx - د.الهام

Fifth stage

Psychiatry
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د. الهام

30/10/2016

Generalized Anxiety Disorder
Anxiety
Anxiety can be conceptualized as a normal and adaptive response to threat that prepares the organism for flight or fight.

Generalized anxiety disorder

(GAD) is a chronic and highly comorbid illness characterized by pattern of frequent, persistent , excessive and uncontrollable worry and feelings of apprehension (generalized free-floating persistent anxiety). about everyday events/problems, with symptoms of muscle and psychic tension, causing significant distress /functional impairment.
It is marked by a later onset than other anxiety disorders and is associated with fluctuations in symptom severity and impairment.

Epidemiology

Life time prevalence 5.7%.

Aetiology

In general terms, generalized anxiety disorder appears to be caused by stressors acting on a personality that is predisposed to anxiety by a combination of genetic factors and environmental influences in childhood. However,evidence for the nature and importance of these causes is incomplete.
Stressful events
Clinical observations indicate that generalized anxiety disorders often begin in relation to stressful events, and some become chronic when stressful problems persist.
Early experiences
Parenting styles characterized by overprotection and lack of emotional warmth may also be a risk factor for generalized anxiety disorder as well as for other anxiety and depressive disorders in offspring

Psychoanalytic theories
Psychoanalytical theory proposes that anxiety arises from intrapsychic conflict when the ego is overwhelmed by excitation from any of the following three sources: • the outside world (realistic anxiety) • the instinctual levels of the id, including love, anger, and sex (neurotic anxiety) • the superego (moral anxiety).

Cognitive-behavioural theories

Conditioning theories propose that generalized anxiety disorders arise when there is an inherited predisposition to excessive responsiveness of the autonomic nervous system, together with generalization of the responses through conditioning of anxiety to previously neutral stimuli.

Personality

Personality disorder. Generalized anxiety disorder occurs in people with anxious-avoidant personality disorders, but also in individuals with other personality disorders.

Neurobiological mechanisms

The mechanisms are complex, involving several brain systems and several neurotransmitters.
Studies in animals have indicated a key role for the amygdala, which receives sensory information both directly from the thalamus and from a longer pathway involving the somatosensory cortex and anterior cingulate cortex.

DSM-5 Diagnostic Criteria for Generalized Anxiety Disorder

A. Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6months, about a number of events or activities (such as work or school performance).
B. The individual finds it difficult to control the worry.
C. The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms having been present for more days than not for the past 6 months):
Note: Only one item is required in children.
1. Restlessness or feeling keyed up or on edge.
2. Being easily fatigued.
3. Difficulty concentrating or mind going blank.
4. Irritability.
5. Muscle tension.
6. Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep).
D. The anxiety cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
E. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism).
F. The disturbance is not better explained by another mental disorder

Comorbidity
Other anxiety disorders (simple phobias, social phobia, panic disorder).
Depression/dysthymia.
Alcohol and drug problems.
Other physical conditions (e.g. IBS, HVS, atypical chest pain).

Differential diagnosis

Normal worries ;
Depression;
Mixed anxiety/depression,
Other anxiety disorders (the anxiety is more focused);
Drug and alcohol problems;
Medical conditions;
Side-effects of prescribed medications.

Course

Chronic and disabling.
Prognosis generally poor.

Treatment

Self-help and psychoeducation guided self-help
Relaxation traimng lf practised regularly, relaxation appears to be able to reduce anxiety in less severe cases...
Cognitive- behaviour therapy this treatment combines relaxation with cognitive proedures designed to help patients to control worrying thoughts.
Psychosurgery (very rare) __for severe/intractable anxiety.

Pharmacotherapy
Among the first medications with demonstrated efficacy were the g-aminobutyric acid (GABA) agonist benzodiazepines, such as alprazolam, diazepam, and lorazepam, ( mainly for Somatic symptoms).
Selective serotonin reuptake inhibitors (SSRIs) have been considered first-line pharmacological treatment.
Buspirone - for Psychic symptoms (beneficial effects may take 2-4wks). is similarly effective for short-term management of generalized anxiety disorder and is less likely to cause dependency, but has a slower onset of action.
The SNRIs venlafaxine XR and duloxetine were demonstrated efficacious,
Pregabalin, a GABA analogue that inhibits the release of excitatory neurotransmitters, has demonstrated efficacy for GAD in randomized placebo-controlled trials.
Beta-adrenergic antagonists (atenolol) __ are sometimes used to control anxiety associated with cardiovascular symptoms, sympathetic stimulation..

Management

The steps in the management of such patients can be summarized as follows:
Check the diagnosis and comorbidity, especially depressive disorder, substance abuse, or a physical cause such as thyrotoxicosis. If any of these are present, treat them appropriately.
Evaluate psychosocial maintaining factors such as persistent social problems, relationship conflict,
Discuss the plan with the patient, the general practitioner, and the comummity team and allocate tasks and responsibility appropriately. Plans should recognize that generalized anxiety disorder is often a long-term problem.