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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.