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Transcript
Generalized Anxiety
Disorder
‫الهام الجماس‬.‫د‬.‫ا‬
Anxiety
Anxiety can be conceptualized as a 
normal and adaptive response to
threat that prepares the organism for
.flight or ϧfight
Generalized anxiety disorder
(GAD) is a chronic and highly comorbid
. illness characterized by pattern of frequent ,per
sistent , excessive and uncontrollable worry an
d feelings of apprehension (generalized free-flo
ating persistent anxiety). about everyday events
/problems, with symptoms of muscle and psychic
tension, causing significant distress /functional im
pairment.
Generalized anxiety disorder
It is marked by a later onset
than other anxiety disorders and
is associated with fluctuations i
n symptom severity and impairm
ent.
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.
Aetiology
Stressful events

Clinical observations indicate that generalized anxiety disorders 
often begin in relation to stressful events, and some become chronic
.when stressful problems persist
Aetiology
.)
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
Aetiology
.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) • 



Aetiology
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
Aetiology

Personality

.
Personality disorder srucco redrosid yteixna dezilareneG .
,sredrosid ytilanosrep tnadiova-suoixna htiw elpoep ni
.sredrosid ytilanosrep rehto htiw slaudividni ni osla tub

Aetiology
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 Ge
neralized Anxiety Disorder
A. Excessive anxiety and worry (apprehen
sive expectation), occurring more days t
han not for at least 6months, about a nu
mber of events or activities (such as wor
k or school performance).
B. The individual finds it difficult to contro
l the worry.
DSM-5 Diagnostic Criteria for Ge
neralized Anxiety Disorder
C. The anxiety and worry are associated w
ith three (or more) of the following six sy
mptoms (with at least some symptoms h
aving been present for more days than n
ot for the past 6 months):
Note: Only one item is required in childr
en.
DSM-5 Diagnostic Criteria for Ge
neralized 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 Ge
neralized Anxiety Disorder
D. The anxiety cause clinically significant distre
ss or impairment in social, occupational, or
other important areas of functioning.
E. The disturbance is not attributable to the physi
ological effects of a substance (e.g., a drug o
f abuse, a medication) or another medical c
ondition (e.g., hyperthyroidism).
DSM-5 Diagnostic Criteria for Ge
neralized Anxiety Disorder
F. The disturbance is not better explained by another menta
l 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 m
ore 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 

Treatment
Relaxation traimng 
lf practised regularly, relaxation appears to be able to reduce anxiety in less
...severe cases

Treatment
Cognitive- behaviour therapy 
This treatment combines relaxation with cognitive pro edures
.designed to help patients to control worrying thoughts

Pharmacotherapy

Among the first medications with demonstrated efficacy
were the -aminobutyric acid (GABA) agonist benzodiaze
pines, such as alprazolam, diazepam, and lorazepam,( m
ainly for Somatic symptoms).
Pharmacotherapy
Selective serotonin reuptake inhib
itors (SSRIs) have been considered firs
t-line pharmacological treatment.
Pharmacotherapy
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

Pharmacotherapy
The SNRIs venlafaxine XR and dulo
xetine were demonstrated efficacious,
Pharmacotherapy
Pregabalin, a GABA analogue that inhibits
the release of excitatory neurotransmitters, has
demonstrated efficacy for GAD in randomized
placebo-controlled trials.
Pharmacotherapy

Beta-adrenergic antagonists (atenolol) __ are
sometimes used to control anxiety associated
with cardiovascular symptoms, sympathetic
stimulation..
Physical
psychosurgery (very rare)__for
severe/intractable anxiety.
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
Management
Evaluate psychosocial maintaining factors
such as persistent social problems,
,relationship conflict

Management
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 longterm problem.