Generalized Anxiety Disorder

Generalized AnxietyDisorder

Dr.Safeyya
Alchalabi

Anxiety

Anxiety can be conceptualized as a normal and adaptive response to threat that aprepares the organism for flight or ϧfight.

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.

Generalized anxiety disorder

It is marked by a later onset than other anxiety disorders and is associated withfluctuations in symptom severity and impairment.

Epidemiology

Life time prevalence 5.7%.

Aetiology (triple vulnerability model)

Generalized biological vulnerability
Generalized psychological vulnerability
Specific psychological vulnerability


Aetiology
Generalized biological vulnerability:
• Genetic—modest role, shared heritability with depression.
• Neurobiological 
the NA system
HPA axis
Septohippocampal (‘behavioural inhibition’) system
BDZ-GABA system
other neurotransmitter systems: dysregulation of 5-HT systems, cholecystokinin (CCK-4 and CCK-8S).

Aetiology

Generalized psychological vulnerability:
• Diminished sense of control—trauma or insecure attachment to primary caregivers, leading to intolerance of uncertainty.
• Parenting—overprotective or lacking warmth, leading to lowperceive d control over events.

Aetiology

Specific psychological vulnerability:
stressful life events—trauma (e.g. early parental death, rape, war) and dysfunctional marital/family relationships.

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.


DSM-5 Diagnostic Criteria for Generalized Anxiety Disorder
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.

DSM-5 Diagnostic Criteria for Generalized Anxiety Disorder

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).

DSM-5 Diagnostic Criteria for Generalized Anxiety Disorder

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).

DSM-5 Diagnostic Criteria for Generalized Anxiety Disorder

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.

Management

Psychological:
generally less effective than in the other anxiety
disorders (lack of situational triggers);
some evidence for CBT combining behavioural methods (treat avoidance by exposure, useof relaxation, and control of hyperventilation) cognitive methods (teaching about bodily responses related to anxiety/education about panic attacks, modification of thinking errors).

Management

Crisis management
Benzodiazepines Normally for short‐term use only: max. 2–4 weeks, for somatic symptoms; although some are of the opinion that risks are overstated


Management
First‐line drug treatment (in order of preference)
SSRIs (up to maximum licensed dose)
May initially exacerbate symptoms.
A lower starting dose is recommended.
Fluoxetine and sertraline are preferred options
SNRIs (up to maximum licensed dose)
May initially exacerbate symptoms.
A lower starting dose is recommended
Pregabalin 150–600 mg/day in divided doses
Response may be seen in the first week of treatment
alone or as an adjunct to SSRI/SNRI

Management

Second‐line drug treatment (less well tolerated or weak evidence base, no order of preference)
Agomelatine  10–50 mg/day
Agomelatine has been shown to prevent relapse over a 6‐month period
Beta blockers (Propranolol 40–120 mg/day in divided doses)
Initiate at 40 mg and titrate dose up to effect if needed.
Useful for somatic symptoms, particularly tachycardia


Management
Second‐line drug treatment (less well tolerated or weak evidence base, no order of preference)
Buspirone 15–60 mg/day in divided doses
Has a delayed onset of action, takes up to 6 weeks to show equal efficacy with benzodiazepines
For Psychic symptoms
Hydroxyzine 50–100 mg/day in divided doses
It is unclear whether hydroxyzine’s efficacy is due to an anxiolytic effect or a sedative effect
Quetiapine (MR, 50–300 mg)
Recommended as monotherapy.
Probably not effective as adjunctive therapy to SSRI/SNRI in treatment resistance
Trifluoperazine (2–6mg/day)

Management

Second‐line drug treatment (less well tolerated or weak evidence base, no order of preference)
Tricyclic antidepressants
Clomipramine50–250 mg/day
Initiate clomipramine at 10 mg/day and increase the dose gradually
Imipramine75–200 mg/day in divided doses
Initiate imipramine 25 mg every 4 days; when at 100 mg can increase in 50 mg increments

Management

Second‐line drug treatment (less well tolerated or weak evidence base, no order of preference)
MAOI
Phenelzine45–90 mg/day in divided doses
For mixed anxiety and depressive states.
Patients need to avoid food high in tyramine
Mirtazapine 15–30 mg nocte
Vortioxetine 2.5–10 mg51


Management
Experimental
Chamomile 220–1500 mg/day
Gingko biloba240–480 mg/day
Lavender oil preparation 80–160 mg/day
Riluzole 50–100 mg/day doses
Liver function monitoring required

Management

Physical  psychosurgery (very rare) for severe/intractable anxiety.

Medical conditions associated with anxiety-likesymptoms

• Cardiovascular system (CVS): arrhythmias, ischaemic heart disease (IHD), mitral valve disease, cardiac failure.
• Respiratory: asthma, COPD, HVS, PE, hypoxia.
• Neurological: TLE, vestibular nerve disease.
• Endocrine: hyperthyroidism, hypoparathyroidism,
hypoglycaemia, phaeochromocytoma.
Miscellaneous: anaemia, porphyria, SLE, carcinoid tumour,pellagra.