Anxiety Disorders PDF

Anxiety Disorders Veronica Clarisse Mendoza, RPm, CHRA  Anxiety.... is a negative mood state characterized by bodily symptoms of physical tension and by apprehension about the future A subjective sense of unease, a set of behaviors (looking worried and anxi...

Anxiety Disorders Veronica Clarisse Mendoza, RPm, CHRA  Anxiety.... is a negative mood state characterized by bodily symptoms of physical tension and by apprehension about the future A subjective sense of unease, a set of behaviors (looking worried and anxious or fidgeting), or physiological responses such as elevated heart rate and muscle tension “We perform better when we are a little anxious.”  Anxiety as "the shadow of intelligence" The human ability to plan for the future was connected to that gnawing feeling that things could go wrong and we had better be prepared for them. Severe anxiety usually doesn’t go away—that is, even if we “know” there is nothing to be afraid of, we remain anxious.  Fear vs Anxiety Difference It is an immediate alarm reaction to It is a future-oriented mood state, danger. characterized by apprehension because we cannot predict or It is an immediate emotional reaction control upcoming events. to current danger characterized by strong escapist action tendencies It is more often associated with and a surge in the sympathetic muscle tension and vigilance in branch of the autonomic prep­aration for future danger and nervous system cautious or avoidant behaviors. General Information Many of the anxiety disorders develop in childhood and tend to persist if not treated. Most occur more frequently in females than in males (approximately 2:1 ratio) They differ from tran­sient fear or anxiety, often stress-induced, by being persistent (e.g., typically lasting 6 months or more) Highly comorbid with each other  Causes Biological Psychological Social Contributions Contributions Contributions Genetics A general “sense of Stressful life events Low levels of gamma- uncontrollability” may aminobutyric acid (GABA) develop early as a are associated with function of upbringing increased anxiety and other disruptive or Serotonergic and traumatic environmental noradrenergic factors neurotransmitter systems Parenting style are also associated Overly responsive limbic system  Generalized Biological Vulnerability 1 is the first vulnerability (or diathesis). We can see that Triple a tendency to be uptight or high-strung might be inherited. But a generalized biological vulnerability to Vulnerability develop anxiety is not sufficient to produce anxiety itself Theory Generalized Psychological Vulnerability is a theory of the development of 2 You might also grow up believing the world is anxiety and related disorders dangerous and out of control and you might not be able to cope when things go wrong based on your early experiences Specific Psychological Vulnerability 3 in which you learn from early experience, such as being taught by your parents, that some situations or objects are fraught with danger even if they really aren’t. ex: dogs/being evaluated by others Content Separation Anxiety Disorder Selective Mutism Phobia Social Anxiety Disorder Panic Disorder Agoraphobia Generalized Anxiety Disorder Separation Anxiety Disorder Fearful or anxious about separation from attachment figures to a degree that is developmentally inappro­priate. There is persistent fear or anxiety about harm coming to attachment figures and events that could lead to loss of or separation from attachment figures and reluctance to go away from attachment figures, as well as nightmares and physical symptoms of distress.  Separation Anxiety Disorder Diagnostic Criteria: A. At least 3 of the following recurrent or persistent: Excessive distress in anticipating or experiencing separation from home or from major attachment figures. Excessive worry about losing major attachment figures or about pos­sible harm Excessive worry about experiencing an untoward event (e.g., getting lost, being kidnapped, having an accident, becoming ill) that causes separation from a major attachment figure Reluctance or refusal to go out, away from home, to school, to work, or elsewhere Excessive fear of or reluctance about being alone or without major attachment figures at home or in other settings. Reluctance or refusal to sleep away from home or to go to sleep without being near a major attachment figure. Nightmares involving the theme of separation. Complaints of physical symptoms (e.g., headaches, stomachaches, nau­sea, vomiting) when separation from major attachment figures occurs or is antici­pated. B. Lasting at least 4 weeks in children and adolescents and typically 6 months or more in adults.  Separation Anxiety Disorder Diagnostic Features: May be un­able to stay or go in a room by themselves and may display "clinging" behavior Often have difficulty at bed­time and may insist that someone stay with them until they fall asleep They may make their way to their parents' bed during the night May be reluctant or refuse to attend camp, to sleep at friends' homes, or to go on errands. Adults may be uncomfortable when traveling independently Cardiovascular symptoms such as palpitations, dizziness, and feeling faint are rare in younger children but may occur in adolescents and adults.  Separation Anxiety Disorder Prevalence Development and Course The 12-month prevalence among adults Onset of separation anxiety disorder in the United States is 0.9%-1.9%. may be as early as preschool age and In children, 6- to 12-month prevalence may occur at any time during child­hood is estimated to be approximately 4%. and more rarely in adolescence. In adolescents in the United States, May persist through adulthood the 12-month prevalence is 1.6%. As children age, worries emerge; these Most prevalent anxiety disorder in are often worries about specific children younger than 12 years dangers Clinical samples, equal in males and Adults with the disorder are typically females overconcemed about their offspring Community samples, more prevalent in and spouses and experience marked males discomfort when separated from them. Risk and Prognostic Factors Environmental Often develops after life stress, especially a loss In young adults, other examples of life stress include leaving the parental home, entering into a romantic relationship, and be­coming a parent. Parental overprotection and intrusiveness may be associated with sepa­ration anxiety disorder. Genetic and physiological Heritability was estimated at 73% in a community sample of 6-year-old twins, with higher rates in girls Children with separation anxiety disorder display particularly enhanced sensitivity to respiratory stimulation using C02-enriched air  Culture-Related Diagnostic Issues 1 There are cultural variations in the degree to which it is considered desirable to tolerate separation, so that demands and opportunities for separation between parents and chil­dren are avoided in some cultures Gender-Related Diagnostic Issues 2 Girls manifest greater reluctance to attend or avoidance of school than boys Indirect ex­pression of fear of separation may be more common in males than in females Suicide Risk 3 Separation anxiety disorder in children may be associated with an increased risk for sui­cide. Selective Mutism Characterized by a consistent failure to speak in social situations in which there is an expectation to speak (e.g., school) even though the individual speaks in other situations.  Selective Mutism Diagnostic Criteria: A. Consistent failure to speak in specific social situations in which there is an expectation for speaking (e.g., at school) despite speaking in other situations. B. The disturbance interferes with educational or occupational achievement or with social communication. C. The duration of the disturbance is at least 1 month (not limited to the first month of school). D. The failure to speak is not attributable to a lack of knowledge of, or comfort with, the spoken language required in the social situation. E. The disturbance is not better explained by a communication disorder (e.g., childhood- onset fluency disorder) and does not occur exclusively during the course of autism spectrum disorder, schizophrenia, or another psychotic disorder.  Selective Mutism Diagnostic Features: Do not initiate speech or reciprocally respond when spoken to by others. Will speak in their home in the presence of immediate family members but often not even in front of close friends or second-degree relatives The disturbance is often marked by high social anxiety. The lack of speech may interfere with social communication, although children with this disorder sometimes use nonspoken or nonverbal means (e.g., grunting, pointing, writing) to communicate and may be willing or eager to perform or engage in social encounters when speech is not required (e.g., nonver­bal parts in school plays).  Selective Mutism Prevalence Development and Course Relatively rare disorder The onset of selective mutism is Ranges between 0.03% and 1% usually before age 5 years, but the depending on the set­ting and ages of disturbance may not come to clinical individuals in the sample attention until entry into school Does not seem to vary by sex or Although clinical reports suggest that race/ethnicity many individuals "'outgrow" selective More likely to manifest in young mutism, the longitudinal course of the children than in adolescents and adults disorder is unknown.  Risk and Prognostic Factors Temperamental Environmental Social inhibition on the part of parents may serve as a Negative affectivity model for social reticence and selective mutism in children (neuroticism) or behavioral Parents of children with selective mutism have been inhibition may play a role, as described as overprotective or more controlling than may parental history of shyness, parents of chil­dren with other anxiety disorders or no social isolation, and social disorder. anxiety May have subtle receptive language difficulties compared Genetic and physiological with their peers, al­though receptive language is still within the normal range. Because of the significant overlap between selective mutism and social anxiety disorder, there may be shared genetic factors between these conditions. Specific Phobia Individuals with specific phobia are fearful or anxious about or avoidant of circum­scribed objects or situations. The fear, anxiety, or avoidance is almost always immediately induced by the phobic situation, to a degree that is persistent and out of proportion to the actual risk posed. There are various types of specific phobias: animal; natural envi­ ronment; blood-injection-injury; situational; and other situations.  Specific Phobia Diagnostic Criteria: A. Marked fear or anxiety about a specific object or situation (e.g., flying, heights, animals, receiving an injection, seeing blood) Note: In children, the fear or anxiety may be expressed by crying, tantrums, freezing, or clinging. B.The phobic object or situation almost always provokes immediate fear or anxiety. C. The phobic object or situation is actively avoided or endured with intense fear or anxiety. D. The fear or anxiety is out of proportion to the actual danger posed by the specific object or situation and to the sociocultural context. E. Typically lasting for 6 months or more. Specifiers: Animal Natural environment Blood-injection-injury Situational Others  Specific Phobia Diagnostic Features: It is common for individuals to have multiple specific phobias. Average - three objects or situations, and approximately 75% - more than one Phobic stimulus - particular object or situation causing the disturbance An individual who becomes anxious only occasionally upon being confronted with the situation or object would not be diagnosed Active avoidance means the individual intentionally behaves in ways that are designed to prevent or minimize contact with phobic objects or situations Most consistently associated with abnormal activity in the amygdala, anterior cingulate cortex, thalamus, and insula in response to the phobic object/situation.  Specific Phobia Prevalence Development and Course Sometimes develops following a traumatic event, In US, 12-month prevalence is observation of others going through traumatic event, approximately 7% - 9% an unexpected pa nick attack in the to be feared European countries about 6% situation, or informational transmission Asian, African, Latin American Many individuals are unable to recall the specific countries - 2% to 4% reason for the onset Children - 5% (range from 3% - Develops in early childhood, majority of cases 9%) developing prior to age 10 years Adolescents - 16% Median age at onset is 7-11 years. mean age at about Older individuals 3%-5% 10 years. More frequent in female than May wax and wane developed in childhood and male (2:1) adolescence Phobias that do persist into adulthood are unlikely to remit for the majority of individuals.  Risk and Prognostic Factors Negative affectivity (neuroticism) or behavioral Temperamental inhibition, are risk factors for other anxiety disorders as well. Parental overprotectiveness, parental loss and separation, and physical and sexual abuse, tend to predict other anxiety disorders as well. As noted Environmental earlier, negative or traumatic encounters with the feared object or situation sometimes (but not always) precede the development of specific phobia. Genetic and Twin studies have examined the heritability of individual subtypes of fears and phobias, suggesting that animal phobia physiological has approximately 32% heritability, blood-injury-injection phobia (from 5-TR) has 33%, and situational phobia has 25%.  Culture-Related Diagnostic Issues 1 In the United States, Asians and Latinos report significantly lower rates of specific phobia than non-Latino whites, African Americans, and Native Americans. some countries outside of the United States, par­ticularly Asian and African countries, show differing phobia content, age at onset, and gender ratios. Gender-Related Diagnostic Issues (from 5-TR) 2 Animal, natural environment, and situational specific phobias are predominantly experienced by women Blood-injection-injury phobia is experienced nearly equally among women and men. Suicide Risk 3 Individuals with specific phobia are up to 60% more likely to make a suicide attempt than are individuals without the diagnosis. It is likely that these elevated rates are primarily due to comorbidity with personality disorders and other anxiety disorders.  Treatment Specific Phobia and Selective Mutism Exposure Therapy Specific phobia require structured and consistent exposure-based exercises Most patients who expose themselves gradually to what they fear must be under therapeutic supervision These treatments “rewire” the brain Social Anxiety Disorder The individual is fearful or anxious about or avoidant of social interactions and situations that involve the possibility of being scrutinized. These include social interactions such as meeting unfamiliar people, situations in which the individual may be observed eating or drinking, and situations in which the in­ dividual performs in front of others. The cognitive ideation is of being negatively evalu­ated by others, by being embarrassed, humiliated, or rejected, or offending others.  Social Anxiety Disorder Diagnostic Criteria: A. Marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others. Note: In children, the anxiety must occur in peer settings and not just during interac­ttions with adults. B. The individual fears that he or she will act in a way or show anxiety symptoms that will be negatively evaluated (i.e., will be humiliating or embarrassing: will lead to rejection or offend others). C. The social situations almost always provoke fear or anxiety. Note: In children, the fear or anxiety may be expressed by crying, tantrums, freezing, clinging, shrinking, or failing to speak in social situations. D. The social situations are avoided or endured with intense fear or anxiety. E. The fear or anxiety is out of proportion to the actual threat posed by the social situation and to the sociocultural context. F. Typically lasting for 6 months or more Specifier: Performance only - If the fear is restricted to speaking or performing in public  Social Anxiety Disorder Diagnostic Features: The individual is concerned that he or she will be judged as anxious, weak, crazy, stupid, boring, intimidating, dirty, or unlikable. Fear of offending others may be the predominant fear in individuals from cultures with strong collectivistic orientations. An in­dividual who becomes anxious only occasionally in the social situation(s) would not be di­agnosed with social anxiety disorder  Social Anxiety Disorder Prevalence Development and Course Median age at onset in US is 13 years, and 75% of In US, 12-month prevalence is individuals have an age at onset between 8 and 15 years approximately 7% Onset of social anxiety disorder may follow a stress­ful or European countries about 2.3% humiliating experience (e.g., being bullied, vomiting Prevalence rates decrease with during a public speech), or it may be insidious, developing age slowly. 12-month prevalence for older First onset in adulthood is rare adults ranges from 2% - 5% Social anxiety disorder may diminish after an individual Higher rates are found in with fear of dating marries and may reemerge after females than in males in general divorce population Adolescents endorse a broader pattern of fear and Gender rates are equivalent or avoidance slightly higher for males in Remission - 30% within 1 year; 50% within a few years; clinical samples approx 60% without specific treatment may take several years or longer  Risk and Prognostic Factors Underlying traits include behavioral inhibition and Temperamental fear of negative evaluation. No causative role but childhood maltreatment and Environmental adversity are risk factors for social anxiety disorder. Traits predisposing individuals to social anxiety disorder, such as Genetic and behavioral inhibition, are strongly genetically influenced. physiological The genetic influence is subject to gene-environment interaction First-degree relatives have a two to six times greater chance  Culture-Related Diagnostic Issues 1 Syndrome of taijin kyofusho (in Japan and Korea) is often characterized by social-evaluative concerns that are associated with the fear that the individual makes other people uncomfortable. Gender-Related Diagnostic Issues (from 5-TR) 2 Females report a greater number of social fears and comorbid disorders Males are more likely to fear dating, have conduct disorder or use substance to relieve symptoms. Paruresis is more common in males as well. Functional Consequences 3 Associated with elevated rates of school dropout and impairment in functioning Also associated with being single, unmarried, or divorced and with not having children, particularly among men Not being employed is a strong predictor for ihe persistence of social aimety disorder.  Treatment Social Anxiety Disorder Medication Psychological Tricyclic antidepressants Intervention SSRI Cognitive-behavioral group therapy (CBGT) program in which D-cycloserine (DCS) - groups of patients rehearse or role-play their socially phobic known to facilitate the situations in front of one another extinction of anxiety Change in DSM 5 TR The parenthetical “(Social Phobia)” in social anxiety disorder was removed Panic Disorder The individual experiences recurrent unexpected panic attacks and is persistently concerned or worried about having more panic attacks or changes his or her behavior in maladaptive ways because of the panic attacks Panic attacks are abrupt surges of intense fear or intense discomfort that reach a peak within minutes, accompanied by physical and/or cognitive symptoms. Limited-symptom panic attacks include fewer than four symptoms.  Panic Disorder Diagnostic Criteria: A. Recurrent unexpected panic attacks during which time four (or more) of the following symptoms occur: Note: The abrupt surge can occur from a calm state or an anxious state. 1. Palpitations, pounding heart, or accelerated heart rate 2. Sweating 3. Trembling or shaking 4. Sensations of shortness of breath or smothering 5. Feelings of choking 6. Chest pain or discomfort 7. Nausea or abdominal distress 8. Feeling dizzy, unsteady, light-headed, or faint 9. Chills or heat sensations 10. Paresthesias (numbness or tingling sensations). 11. Derealization (feelings of unreality) or depersonalization (being detached from one­self). 12. Fear of losing control or “going crazy.” 13. Fear of dying.  Panic Disorder Diagnostic Criteria: B. At least one of the attacks has been followed by 1 month (or more) of one or both of the following: 1. Persistent concern or worry about additional panic attacks or their consequences (e.g., losing control, having a heart attack, “going crazy”). 2. A significant maladaptive change in behavior related to the attacks (e.g., behaviors designed to avoid having panic attacks, such as avoidance of exercise or unfamiliar situations).  Panic Disorder Diagnostic Features: Recurrent means more than one unexpected panic attack Unex­pected refers to a panic attack for which there is no obvious cue or trigger at the time of oc­ currence—that is, the attack appears to occur from out of the blue Nocturnal panic attack - a type of unexpected panic attack, waking from sleep in a state of panic, which differs from panicking after fully waking from sleep Expected panic attacks are attacks for which there is an obvious cue or trigger, such as a situation in which panic attacks typically occur The presence of expected panic attacks does not rule out the diagnosis of panic disorder  Panic Disorder To meet criteria for panic disorder, a person must experience an unexpected panic attack and develop substantial anxiety over the possibility of having another attack or about the implications of the attack or its consequences In other words, the person must think that each attack is a sign of impending death or incapacitation.  Panic Disorder Prevalence Development and Course In US and several European Median age at onset in US is 20-24 years countries, 12-month prevalence A small number of cases begin in childhood, and onset is about 2% - 3% in adults and after age 45 years is unusual but can occur adolescents Usual course of untreated disorder is chronic but waxing Lower estimates reported for and waning Asian, African, and Latin Episodic outbreaks with years or remission in between is American countries, ranging possible from 0.1% to 0.8% Only a minority of individuals have full remissions without Females are more affected (2:1) subsequent relapse within a few years Low prevalence before age 14 years Gradually increase during adolescents, particularly in women  Risk and Prognostic Factors Negative affectivity (neuroticism) and anxiety sensitivity are risk factors. Separation anxiety in Temperamental childhood especially when sever may precede the development of Panic Disorder. Reports of childhood experiences of sexual and physical abuse are more common than other anxiety disorders. Environmental Smoking Identifiable stressors in months before first panic attack Current neural systems models for panic disorder em­phasize the amygdala and related structures, much as in other anxiety disorders Genetic and Increased risk among offspring of parents with anxiety and mood physiological disorders Respiratory disturbance such as asthma is also associated  Culture-Related Diagnostic Issues 1 Culture may influences the rate of panic attacks and panic disorder, if it’s expected or unexpected. Trúng gió (Vietnam) Ataque de nervios (Latin America) / Khyâl (Cambodia) Gender-Related Diagnostic Issues 2 Do not appear to differ between males and females. There is some evidence for sexual dimorphism, with an association between panic disor­der and the catechol-O-methyltransferase (COMT) gene in females only. Suicide Risk 3 Higher suicide attempts. and suicidal ideation for the past 12 months if the individual experienced a panic attack and a diagnosis of the disorder during the past 12 months  Four (or more) of the following symptoms occur: Palpitations, pounding heart, or accelerated heart rate. Panic Sweating. Trembling or shaking. Sensations of shortness of breath or Attack smothering. Feelings of choking. Specifier Chest pain or discomfort. Nausea or abdominal distress. Feeling dizzy, unsteady, light-headed, or More common in females but no faint. difference in symptoms Chilis or heat sensations. Paresthesias Derealization or depersonalization Fear of losing control or “going crazy.” Fear of dying. Agoraphobia Individuals with agoraphobia are fearful and anxious about two or more of the follow­ing situations: using public transportation; being in open spaces; being in enclosed places; standing in line or being in a crowd; or being outside of the home alone in other situations. The individual fears these situations because of thoughts that escape might be difficult or help might not be available in the event of developing panic-like symptoms or other inca­pacitating or embarrassing symptoms. These situations almost always induce fear or anxiety and are often avoided and require the presence of a companion.  Agoraphobia Diagnostic Criteria: A. Marked fear or anxiety about two (or more) of the following five situations: 1. Using public transportation (e.g., automobiles, buses, trains, ships, planes). 2. Being in open spaces (e.g., parking lots, marketplaces, bridges). 3. Being in enclosed places (e.g., shops, theaters, cinemas). 4. Standing in line or being in a crowd. 5. Being outside of the home alone. B. The individual fears or avoids these situations because of thoughts that escape might be difficult or help might not be available in the event of developing panic-like symp­toms or other incapacitating or embarrassing symptoms C. Almost always provoke fear or anxiety D. Situations are actively avoided, require the presence of a companion, or are endured with intense fear or anxiety E. The fear or anxiety is out of proportion to the actual danger F. Typically lasting for 6 months or more  Agoraphobia Diagnostic Features: In its most severe forms, agoraphobia can cause individuals to become completely homebound, unable to leave their home and dependent on others for services or assistance to pro­vide even for basic needs. Demoralization and depressive symptoms, as well as abuse of alcohol and sedative medication as inappropriate self-medication strategies, are common  Agoraphobia Prevalence Development and Course 1.7% of adolescents and adults The percentage of individuals with agoraphobia reporting every year panic attacks or panic disorder preceding the onset of Females are twice as likely as agoraphobia ranges from 30% in community samples to males to experience agoraphobia more than 50% in clinic samples May occur in childhood but 2/3 of the cases, initial onset is before age 35 years. incidence peaks in late First onset in childhood is rare adolescence and early adulthood Mean age at onset os 17 years 12-month prevalence of 65 years Age at onset without preceding panic attacks or panic and older is 0.4% disorder is 25-29 years Rates do not appear to vary Course is typically persistent and chronic across cultural/racial groups Complete remission is rare (10%) unless treated With more sever cases, rates of full remission decrease and rates or relapse and chronicity increase  Risk and Prognostic Factors Behavioral inhibition and neurotic disposition are closely associated but relevant to most anxiety Temperamental disorders. Anxiety sensitivity is also a characteristic. Negative events in childhood and other stressful events are associated with the onset Environmental Individuals with agoraphobia describe the family climate and child- rearing behavior as being characterized by reduced warmth and increased overprotection. Heritability is 61% Genetic and Of the various phobias, agoraphobia has the strongest and most specific physiological association with the genetic factor that represents proneness to phobias.  Gender-Related Diagnostic Issues 1 Females have different patterns of comorbid disorders than males Males have higher rates of comorbid substance use disorders. Functional Consequences 2 Associated with considerable impairment and disability in terms of role functioning, work productivity, and disability days More than one-third of individuals with agoraphobia are completely homebound and unable to work.  Treatment Panic Disorder and Agoraphobia Medication Psychological Combined Psychological Intervention and Drug Treatments Benzodiazepines*** SSRIS (!) Gradual Exposure Cognitive Behavioral SNRIS Panic Control Treatment Therapy and medicatipn Cognitive Therapy Generalized Anxiety Disorder Characterized. by persistent and excessive anxiety and worry about various domains, including work and school performance, that the indi­vidual finds difficult to control. In addition, the individual experiences physical symptoms, including restlessness or feeling keyed up or on edge; being easily fatigued; difficulty con­ centrating or mind going blank; irritability; muscle tension; and sleep disturbance.  Generalized Anxiety Disorder Diagnostic Criteria: A. Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance) B. The individual finds it difficult to control the worry. 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. 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).  Generalized Anxiety Disorder Diagnostic Features: The intensity, duration, or frequency of the anxiety and worry is out of proportion The worries associated with generalized anxiety disorder are excessive and typically in­terfere significantly with psychosocial functioning, whereas the worries of everyday life are not excessive and are perceived as more manageable The worries associated with generalized anxiety disorder are more pervasive, pronounced, and distressing; have longer duration; and frequently occur without precipitants. Everyday worries are much less likely to be accompanied by physical symptoms  Generalized Anxiety Disorder Prevalence Development and Course 12-month prevalence is 0.9% Median age at onset is 30 years but sge at onset is among adolescents and 2.9% spread over a very broad range among adults in US Onset of the disorder rarely occurs prior to adolescence. Other countries - ranges from Symptoms tend to be chronic and wax and wane across 0.4% to 3.6% the lifespan Lifetime morbid risk is 9.0% Rates of full remission are very low Females are twice as likely as The content of an individual's worry tends to be age males appropri­ate. More common in individuals of Younger adults experience greater severity of symptoms European descent and from than do older adults. developed countries Generalized anxiety disorder may be overdiagnosed in children.  Risk and Prognostic Factors Behavioral inhibition, negative affectivity (neuroticism), and harm Temperamental avoidance have been associated with generalized anxiety disorder. Childhood adversities and parental overprotection have been associated Environmental No environmental factors have been identi­fied as specific to generalized anxiety disorder or necessary or sufficient for making the di­agnosis. 1/3 of the risk of experiencing this disorder is genetic Genetic and Genetic factors overlap with the risk of neuroticism and are shared with physiological other anxiety and mood disorders, especially MDD  Culture-Related Diagnostic Issues In some cultures, somatic symptoms predominate in the expression of the disorder, 1 whereas in other cultures cognitive symptoms tend to predominate. There is no information as to whether the propensity for excessive worrying is related to culture, although the topic being worried about can be culture specific Gender-Related Diagnostic Issues 2 More frequent in females (55%-60%) Similar symptoms but different patterns of comorbidity Females - other anxiety disorders and unipolar depression Males - substance use disorders Functional Consequences 3 Generalized anxiety disorder is associated with significant disability and distress that is independent of comorbid disorders, and most non-institutionalized adults with the disorder are moderately to seriously disabled. Accounts for 110 mil­lion disability days per annum in the U.S. population.  Treatment General Anxiety Disorder Medication Psychological Benzodiazepines Intervention Anti-depressants Cognitive Behavioral Therapy - for GAD in which patients evoke the worry process during therapy sessions and confront anxiety- provoking images and thoughts head-on. The patient learns to use cognitive therapy and other coping techniques to counteract and control the worry process Any question? 10-item quiz on our next F2F meeting.