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Generalized anxiety disorder

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Generalized anxiety disorder
ICD-10 F41.1
ICD-9 300.02
OMIM {{{OMIM}}}
DiseasesDB {{{DiseasesDB}}}
MedlinePlus {{{MedlinePlus}}}
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MeSH {{{MeshNumber}}}

General anxiety disorder or generalized anxiety disorder (GAD) is an anxiety disorder that is characterized by excessive and uncontrollable worry about everyday things. The frequency, intensity, and duration of the worry are disproportionate to the actual source of worry, and such worry often interferes with daily functioning.

IntroductionEdit

GAD affects approximately 5% of the total population, yet is more prevalent in women and much more prevalent in youth, where 12% to 20% are affected (Achenbach, Howell, McConaughy & Stranger, 1995). People with GAD often have a variety of symptoms such as tension, skittishness, restlessness, hyperactivity, worrying, fear, and rumination. These symptoms must be consistent, persisting at least every other day and persist for at least 6 months (DSM-IV; American Psychiatric Association, 1994, as cited in Heimberg, 2004).

GAD sufferers often worry excessively over things such as their job, their finances, and the health of themselves and their family. However, GAD sufferers can also worry over more minor matters such as deadlines for appointments, keeping the house clean, and whether or not their workspace is properly organized.

Only about 30% of the causes of GAD are inherited, yet certain traits cause people to become more prone to obtaining it. People with general nervousness, depression, inability to tolerate frustration, and feelings of being inhibited are more likely to be shown in GAD patients. People with GAD tend to have more conflicts with others and are very hard on themselves, they also tend to avoid common situations for fear of worry and anxiety (Leahy, 2000 as cited in Hemiberg, 2004, pg 270). In youth GAD often leads to lower levels of social supports, academic underachievement, underemployment, substance use and high probability of obtaining other psychiatric disorders (Velting, Setzer, & Albano, 2004 as cited in Gosch, 2006, pg 247). GAD differs from other anxiety disorders in the sense that there is no clear stimulus that elicits anxiety or was associated with how it began. It also lacks the clear avoidance and escape behaviors of phobias and unlike panic attacks associated with most disorders, GAD stays fairly moderate in its anxiety levels (Deffenbacher and Suinn, 1987, pg 332).

DiagnosisEdit

According to the Diagnostic and Statistical Manual IV-Text Revision (DSM-IV-TR), the following criteria must be met for a person to be diagnosed with Generalized Anxiety Disorder.

  1. Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least six months, about a number of events or activities (such as work or school performance).
  2. The person finds it difficult to control the worry.
  3. The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms 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. irritability
    4. muscle tension
    5. sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep)
    6. difficulty concentrating or the mind going blank
  4. The focus of the anxiety and worry is not confined to features of an Axis I disorder, e.g., the anxiety or worry is not about having a panic attack (as in panic disorder), being embarrassed in public (as in social phobia), being contaminated (as in obsessive-compulsive disorder), being away from home or close relatives (as in Separation Anxiety Disorder), gaining weight (as in anorexia nervosa), having multiple physical complaints (as in somatization disorder), or having a serious illness (as in hypochondriasis), and the anxiety and worry do not occur exclusively during posttraumatic stress disorder.
  5. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
  6. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hyperthyroidism) and does not occur exclusively during a Mood Disorder, a Psychotic Disorder, or a Pervasive Developmental Disorder.

PrevalenceEdit

The World Health Organization's Global Burden of Disease project did not include generalized anxiety disorders.[1] In lieu of global statistics, here are some prevalence rates from around the world:

  • Australia: 3 percent of adults[1]
  • Canada: Between 3-5 percent of adults[2]
  • Italy: 2.9 percent[3]
  • Taiwan: 0.4 percent[4]
  • United States: Approximately 6.8 million American adults, or about 3.1 percent of people age 18 and over, in a given year[5]

Potential Causes of GADEdit

Some research suggests that GAD may run in families, and it may also grow worse during stress. GAD usually begins at an earlier age and symptoms may manifest themselves more slowly than in most other anxiety disorders. Some people with GAD report onset in early adulthood, usually in response to a life stressor. Once GAD develops, it is chronic.

TreatmentEdit

Treatments for GAD include medications and cognitive behavioral therapy. A combination of the two has proved the most effective in alleviating symptoms; medication alone may reduce some anxiety but will not eliminate it entirely.

SSRIs and SNRIs are commonly used to treat GAD. Examples include SSRIs such as fluvoxamine (Luvox, Faverin), sertraline (Zoloft), paroxetine (Paxil, Seroxat), citalopram (Celexa), escitalopram (Lexapro, Cipralex) and the SNRI venlafaxine (Efexor). The antiepileptic pregabalin (Lyrica) is also used. Benzodiazepenes such as diazepam and alprazolam are sometimes used in the short-term in order to alleviate extreme cases of anxiety, but they are not safe for continuous use because of the high risk of dependency. The anti-anxiety drug buspirone (BuSpar) is sometimes used in addition to or instead of SSRIs in the treatment of GAD.

SSRIs and SNRIs are generally considered the most effective treatment because both anxiety and depression are thought to be associated with the neurotransmitter serotonin; thus a great deal of people who experience depression also experience anxiety symptoms (there is, however, no scientific proof of this). When both disorders are diagnosed, this is called comorbidity. Other antidepressant drugs such as tricyclics and MAO inhibitors are not used in the treatment of GAD.


SSRIsEdit

Main article: Selective serotonin reuptake inhibitor

Pharmaceutical treatments for GAD, include selective serotonin reuptake inhibitors (SSRIs),[6] which are antidepressants that influence brain chemistry to block the reabsorption of serotonin in the brain.[7] SSRIs are mainly indicated for clinical depression, but are also effective in treating anxiety disorders.[6] Common side effects include nausea, sexual dysfunction, headache, diarrhea, among others. Common SSRIs perscribed for GAD include:

Other DrugsEdit

Venlafaxine (Effexor) is a serotonin-norepinephrine reuptake inhibitor (SNRI). SNRIs, a class of drugs related to the SSRIs, alter the chemistries of both norepinephrine and serotonin in the brain. Imipramine (Tofranil) is a tricyclic antidepressant (TCA). TCAs are thought to act on serotonin, norepinephrine, and dopamine in the brain. Buspirone is a serotonin receptor agonist belonging to the azaspirodecanedione class of compounds.

BenzodiazepinesEdit

Main article: Benzodiazepine

Benzodiazepines (or "benzos") are fast-acting sedatives that are also used to treat GAD and other anxiety disorders.[6] These are often given in the short-term due to their nature to become habit-forming. Side effects include drowsiness, reduced motor coordination and problems with equilibrioception. Common benzodiazepines used to treat GAD include[6]:

Cognitive behavioral therapyEdit

Main article: Cognitive behavioral therapy

A psychological method of treatment for GAD is cognitive behavioral therapy (CBT), which involves a therapist working with the patient to understand how thoughts and feelings influence behavior.[8] The goal of the therapy is to change negative thought patterns that lead to the patient's anxiety, replacing them with positive, more realistic ones. Elements of the therapy include exposure strategies to allow the patient to gradually confront their anxieties and feel more comfortable in anxiety-provoking situations, as well as to practice the skills they have learned. CBT can be used alone or in conjunction with medication.[6]

GAD and Comorbid DepressionEdit

In the National Comorbidity Survey (2005), 58% of patients diagnosed with major depression were found to have an anxiety disorder; among these patients, the rate of comorbidity with GAD was 17.2%, and with panic disorder, 9.9%. Patients with a diagnosed anxiety disorder also had high rates of comorbid depression, including 22.4% of patients with social phobia, 9.4% with agoraphobia, and 2.3% with panic disorder. For many, the symptoms of both depression and anxiety are not severe enough (i.e. are subsyndromal) to justify a primary diagnosis of either major depressive disorder (MDD) or an anxiety disorder.

Patients can also be categorized as having mixed anxiety-depressive disorder, and they are at significantly increased risk of developing full-blown depression or anxiety. Appropriate treatment is necessary to alleviate symptoms and prevent the emergence of more serious disease.

Accumulating evidence indicates that patients with comorbid depression and anxiety tend to have greater illness severity and a lower treatment response than those with either disorder alone.[How to reference and link to summary or text] In addition, social function and quality of life are more greatly impaired.

In addition to coexisting with depression, research shows that GAD often coexists with substance abuse or other conditions associated with stress, such as irritable bowel syndrome. Patients with physical symptoms such as insomnia or headaches should also tell their doctors about their feelings of worry and tension. This will help the patient's health care provider to recognize whether the person is suffering from GAD.

ControversyEdit

The loose diagnostic criteria advanced by the DSM-IV makes it very easy for practitioners diagnose a patient with GAD. Assessment of the incidence and prevalence of GAD is difficult, because a large proportion of people with GAD have a comorbid diagnosis, either physical or mental. The diagnosis of GAD can be challenging because the difference between normal anxiety and GAD is not always distinct.[9]Furthermore the diagnostic criteria - restlessness, fatigue, difficulty concentrating, irritability, muscle tension or sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep) - are common factors of human life, otherwise known as normal anxiety. Without the evidence of the patient showing increased motor tension, autonomic hyperactivity (shortness of breath, rapid heart rate, dry mouth, cold hands, and dizziness) but not panic attacks; and increased vigilance and scanning (feeling keyed up, increased startling, impaired concentration), anxiety is not necessarily indicative of an anxiety disorder.

The implementation of drugs over cognitive behavioral therapy (CBT) for GAD is a source of consternation in the medical community as well. While pharmacological treatments have been successfully used to treat GAD, cognitive behavioral therapy has been shown in many clinical trials to be just as efficient and effective without the side effects or risks involved in taking pharmacological enhancers. While CBT has been proven to be effective in treating GAD, pyschostimulants are still prescribed on the hypothesis that there is a neurotransmitter pathophysiology deficiency in the patient, which has yet to be unequivocally proven.

Relevent main articlesEdit

Main article: GAD - History of the disorder.
Main article: GAD - Theoretical approaches.
Main article: GAD - Epidemiology.
Main article: GAD - Risk factors.
Main article: GAD - Etiology.
Main article: GAD - Diagnosis & evaluation.
Main article: GAD - Comorbidity.
Main article: GAD - Treatment.
Main article: GAD - Prognosis.
Main article: GAD - Service user page.
Main article: GAD - Carer page.

CriticismsEdit

General Anxiety Disorder is frequently mentioned in association with criticisms that pharmaceutical companies are attempting to market ordinary life experiences as "diseases" requiring a "cure", with a profit motive. Since the US approval of Paroxetine, for the treatment of GAD in 2001, the disorder has been subjected to extensive marketing campaigns with the key focus on drugs to treat it. Major concerns of such campaigns are that they lead people to receive unnecessary treatment (which can do more harm than good), and that potential side effects of such marketed drugs are not properly mentioned. [2]



See alsoEdit

References & BibliographyEdit

  1. 1.0 1.1 http://www.who.int/bulletin/pdf/2000/issue4/bu00-0485.pdf WHO
  2. http://www.canmat.org/resources/depression/gad.html
  3. http://www.emedicine.com/med/byname/anxiety-disorders.htm
  4. http://www.emedicine.com/med/byname/anxiety-disorders.htm
  5. [1] NIMH: The Numbers Count
  6. 6.0 6.1 6.2 6.3 6.4 "Generalized anxiety disorder", Mayo Clinic. Accessed 29 May 2007.
  7. "SSRIs", Mayo Clinic. Accessed 29 May 2007.
  8. "A Guide to Understanding Cognitive and Behavioural Psychotherapies", British Association of Behavioural and Cognitive Psychotherapies. Accessed 29 May 2007.
  9. Hoehn-Saire R, McLeod DR. Clinical management of generalized anxiety disorder. In: the clinical management of anxiety disorders. Coryell W, Winokur G, eds. New York: Oxford University Press, 1991: 79-100.

Key Texts – BooksEdit

  • Butler G. and Hope T.(1995)Managing Your Mind: The Mental Fitness Game

Oxford University Press, New York, N.Y. ISBN 0195111257

  • Bourne E.J.(1995)The Anxiety and Phobia Workbook (3rd edition)

New Harbinger Publications, Oakland, CA ISBN 157224223X

  • Davis M, Eshelman ER, McKay M (1995)The Relaxation and Stress Reduction Workbook (5th edition)Oakland, CA: New Harbinger Publications ISBN 1572242140
  • Copland E.(1998) Worry Control Workbook. New Harbinger Publications, Oakland, CA.ISBN 1572241209


Additional material – BooksEdit

(1) Barlow, David H., and V. Durand. Abnormal Psychology (an Integrative Approach). 4th ed. Belmont: Vicki Knight, 2005. 127-131.

Key Texts – PapersEdit

  • Durham RC, Murphy T, Allan T, Richard K. (1994)

Cognitive therapy, analytic psychotherapy and anxiety management training for generalised anxiety disorder. Br J Psychiatry;165:315–23.

Additional material - PapersEdit

External linksEdit

National Institute of Mental Health

NoteEdit

(1) Barlow, D. H., & Durand, V. M. (2005). Abnormal psychology: An integrative approach. Australia; Belmont, CA: Wadsworth.


Instructions_for_archiving_academic_and_professional_materials

GAD - Academic support materials

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