Anxiety Disorders Overview

Generalized Anxiety Disorder (GAD)

• GAD is characterized by excessive worry about minor, everyday events, often shifting focus.
• GAD presents with symptoms like muscle tension, mental agitation, fatigue, irritability, and sleep difficulties.
• Children with GAD typically worry about academic, athletic, or social performance, as well as family issues.
• Older adults often worry about health and experience sleep problems, exacerbating anxiety.

Panic Disorder (PD)

• PD involves unexpected panic attacks that can feel life-threatening or like losing control.
• Panic attacks are distinguished by an abrupt surge of intense fear or discomfort, peaking within minutes.
• Common attack symptoms include: palpitations, sweating, trembling, shortness of breath, choking sensations, chest pain, nausea, dizziness, chills, tingling, derealization, fear of losing control, and fear of dying.
• Individuals with PD worry about future attacks and their consequences, interpreting attacks as signs of imminent death or incapacity.
• Nocturnal panic attacks, waking from sleep in panic, may indicate a more severe form of the disorder.
• Frequency and severity of panic attacks varies, from weekly to daily occurrences.
• Worry about the attacks often includes concerns about physical health, social judgments, and mental health, leading to behavioral changes to avoid panic.

Prevalence

• GAD:
• Adolescents: 0.9%
• Adults: 2.9% in the US, global mean: 1.3%.
• Lifetime risk in the US: 9.0%.
• Women and girls are twice as likely to have GAD.
• Older adults (75+) have a 12-month prevalence of 2.8% to 3.1%.
• Higher prevalence among Europeans than Asians/Africans.
• High-income countries report more GAD symptoms.
• PD:
• 12-month prevalence: 2%–3% among adults/adolescents in the US and Europe.
• Global lifetime prevalence: 1.7%.
• Lower among Latinx, African Americans, Caribbean Blacks, and Asian Americans compared to non-Latinx Whites.
• U.S. prevalence in American Indians: 2.6%–4.1%.
• Rates in Asian, African, and Latin American countries: 0.1%–0.8%.
• Women are affected about 2:1 compared to men.

Development and Course

• GAD:
• Mean age of onset: 35 years, rarely before adolescence in North America.
• Onset varies, typically older in lower-income countries.
• Early symptoms manifest as an anxious temperament.
• Symptoms often persist chronically, fluctuating between severe and milder forms.
• Lower remission rates.
• Early onset linked to more comorbidity and impairment.
• Younger adults experience more severe symptoms than older adults.
• Symptoms remain consistent across the lifespan, with age-appropriate worry content.
• Children and adolescents worry about performance, punctuality, and catastrophic events.
• Perfectionistic tendencies, seeking excessive reassurance.
• In the elderly, concerns about chronic physical diseases trigger excessive worry.
• Safety concerns, especially about falling, may limit activities in frail elderly.
• PD:
• Age of onset in early to mid-adulthood
• Can persist for years, with periods of remission and relapse
• Nocturnal panic attacks may worsen the disorder.
• Symptoms may differ across cultures and genders

Risk and Prognostic Factors

• GAD:

• Behavioral/Personality Factors:

• Behavioral Inhibition (reserved in new situations)

• Negative Affectivity (high neuroticism)

• Harm Avoidance (avoid potential dangers)

• Reward Dependence (seeking approval and reward)

• Attentional Bias to Threat (focusing on negative information)

• Environmental Factors:

• Childhood adverse experiences (abuse, neglect, trauma)

• Overprotective or controlling parenting styles

• Genetic Factors:

• One-third of risk for GAD is genetic, shared with negative affectivity and other anxiety/mood disorders.

• PD:

• Family history of panic disorder

• History of childhood trauma or abuse

• Certain personality traits, such as neuroticism and anxiety sensitivity

Treatment

• GAD:
• Medications:
• Benzodiazepines are often prescribed but only for short periods due to potential risks.
• Psychological therapy is generally more effective long-term.
• Cognitive Behavioral Therapy (CBT) helps identify and challenge negative thoughts and learn coping mechanisms.
• Exposure therapy gradually confronts feared situations to reduce anxiety.
• Mindfulness-based therapies promote present-moment awareness to manage anxiety.
• Relaxation techniques (yoga, meditation) can reduce muscle tension and stress.
• Lifestyle changes (exercise, healthy diet, adequate sleep) can improve overall well-being.
• Support groups offer a safe space for sharing experiences and encouragement.
• PD:
• Medications:
• Antidepressants (SSRIs, SNRIs) can reduce panic attacks and anxiety symptoms.
• Benzodiazepines can provide short-term relief from panic, but they are not a long-term solution.
• Beta-blockers can help manage physical symptoms like rapid heartbeat.
• Psychological therapy:
• CBT is effective for teaching coping skills and challenging negative thoughts.
• Exposure therapy helps individuals confront situations they normally avoid due to anxiety.
• Panic control therapy (PCT) involves learning about panic attacks, practicing relaxation techniques, and gradually exposing individuals to panic-provoking situations.
• Lifestyle changes (exercise, healthy diet, adequate sleep) are important for managing stress and supporting recovery.
• Support groups can create a safe and understanding community for people with panic disorder.

Differential Diagnosis

GAD

• Distinguishing GAD from Other Disorders:
• Social Anxiety Disorder: Anticipatory anxiety in social situations.
• Separation Anxiety Disorder: Excessive worry about separation from attachment figures.
• Specific Diagnoses:
• Panic Disorder: Includes unexpected panic attacks.
• Illness Anxiety Disorder: Fear focuses solely on personal health.
• Obsessive-Compulsive Disorder: Obsessional thoughts differ from GAD worry.
• Posttraumatic Stress Disorder: Anxiety linked to trauma.
• Differentiating Factors:
• GAD worry focuses on future events, while OCD involves intrusive thoughts.
• Anxiety in PTSD may mask GAD symptoms.
• Adjustment Disorder:
• Anxiety related to identifiable stressors within 3 months, lasting up to 6 months.
• Comorbidity with Other Disorders:
• GAD may coexist with depressive, bipolar, or psychotic disorders if anxiety is severe.

PD

• Distinguishing PD from Other Disorders:
• Agoraphobia: Fear of situations where escape might be difficult or help unavailable.
• Specific Phobias: Fear of specific objects or situations.
• Social Anxiety Disorder: Fear of social situations.
• Generalized Anxiety Disorder (GAD): Excessive worry about a range of issues, without panic attacks.
• Substance Use Disorder: Panic symptoms can occur due to substance withdrawal.
• Medical Conditions: Certain medical conditions can cause panic-like symptoms.

Comorbidity

• GAD:

• High: Anxiety and unipolar depression, linked to negative affectivity.

• Shared Risk: Genetic, environmental, and temperamental factors.

• Low: Substance use, conduct, psychotic, neurodevelopmental, and neurocognitive disorders.

• PD:

• Depression is a common comorbidity, and the two conditions often share underlying biological and psychological vulnerabilities.

• Other common comorbidities include:

• Agoraphobia

• Substance use disorders

• Other anxiety disorders

• Obsessive-compulsive disorder

• Posttraumatic stress disorder.