Generalized Anxiety Disorder PDF

CHAPTER 5: ANXIETY DISORDERS 1. Generalized Anxiety Disorder CLINICAL DESCRIPTION - Characterized by excessive and persistent worry and find it difficult control the worry. During the course of disorder the focus of worry may shift from one concern to another. - People with GAD m...

CHAPTER 5: ANXIETY DISORDERS 1. Generalized Anxiety Disorder CLINICAL DESCRIPTION - Characterized by excessive and persistent worry and find it difficult control the worry. During the course of disorder the focus of worry may shift from one concern to another. - People with GAD mostly worry about minor, everyday life events, a characteristic that distinguishes GAD from other anxiety disorders. - characterized by muscle tension, mental agitation, susceptibility to fatigue, some irritability, and difficulty sleeping. Children with GAD most often worry about competence in academic, athletic, or social performance, as well as family issues. Older adults tend to focus, understandably, on health; they also have difficulty sleeping, which seems to make the anxiety worse. DIAGNOSTIC CRITERIA F41.1 A. Excessive Anxiety and Worry  Duration: Occurring more days than not for at least 6 months.  Focus: About various events or activities (e.g., work, school). B. Difficulty Controlling Worry  The individual finds it challenging to control the worry. C. Associated Symptoms The anxiety and worry are linked to three or more of the following symptoms (present for more days than not over the past 6 months). In children, only one symptom is required: 1. Restlessness or feeling keyed up/on edge. 2. Easily fatigued. 3. Difficulty concentrating or mind going blank. 4. Irritability. 5. Muscle tension. 6. Sleep disturbance (difficulty falling/staying asleep or unsatisfying sleep). D. Clinically Significant Distress or Impairment   The anxiety, worry, or physical symptoms cause notable distress or impairment in social, occupational, or other important areas of functioning. E. Exclusion of Substances or Medical Conditions  The disturbance is not due to the physiological effects of a substance (e.g., drug abuse, medication) or a medical condition (e.g., hyperthyroidism). F. Exclusion of Other Mental Disorders  The symptoms are not better explained by another mental disorder (e.g., panic disorder, social anxiety disorder, OCD, PTSD, etc.). DIAGNOSTIC FEATURES  The essential feature of generalized anxiety disorder is excessive anxiety and worry (apprehensive expectation) about a number of events or activities.  The individual finds it difficult to control the worry and to keep worrisome thoughts from interfering with attention to tasks at hand. Key points about GAD: 1. Adult vs. Children Worries: o Adults worry about job responsibilities, health, family, finances, etc. o Children focus on competence and performance quality. 2. Key Features of GAD: o Excessive worries interfere with daily life significantly. o Worries are pervasive, distressing, and longer-lasting. o Shifts in focus of worry are common during the disorder. 3. Distinguishing GAD from Normal Anxiety: o GAD worries are excessive and disruptive, unlike everyday worries. o Physical symptoms like restlessness and muscle tension are common in GAD. o GAD symptoms impact social, occupational, and important areas of functioning. ASSOCIATED FEATURES Physical Symptoms in Generalized Anxiety Disorder (GAD): 1. Muscle Tension Related Symptoms:  o Trembling, twitching, feeling shaky, muscle aches, soreness. 2. Somatic Symptoms: o Sweating, nausea, diarrhea, exaggerated startle response. 3. Comparison with Other Anxiety Disorders: o Less prominent autonomic hyperarousal symptoms (e.g., accelerated heart rate, shortness of breath, dizziness) compared to panic disorder. 4. Associated Conditions with GAD: o Stress-related conditions like irritable bowel syndrome, headaches are common in individuals with GAD. PREVALENCE  Prevalence Rates: o Adolescents: 0.9% o Adults: 2.9% in the US, global mean: 1.3%. o Lifetime risk in the US: 9.0%.  Gender and Age Differences: o Women and girls are twice as likely to have GAD. o Older adults (75+) have a 12-month prevalence of 2.8% to 3.1%.  Ethnicity and Income Disparities: o Europeans more affected than Asians/Africans. o High-income countries report more GAD symptoms. In essence, GAD rates vary by age, gender, ethnicity, and income levels, with higher prevalence among women, older adults, Europeans, and those in high-income countries. DEVELOPMENT AND COURSE 1. Onset and Age Factors: o Mean age of onset in North America: 35 years, rarely before adolescence. o Onset varies widely, typically older in lower-income countries. 2. Symptoms and Fluctuations: o Early symptoms manifest as anxious temperament. o Symptoms persist chronically, fluctuating between severe and milder forms. o More persistent in lower-income countries, with higher impairment in high-income countries. o Low rates of full remission.  3. Impact of Early Onset: o Early onset linked to more comorbidity and impairment. o Younger adults often experience more severe symptoms than older adults. 4. Clinical Expression Across Age Groups: o Symptoms remain consistent across lifespan, with age-appropriate worry content. 5. GAD in Children and Adolescents: o Worries about performance, punctuality, catastrophic events. o Perfectionistic tendencies, seek excessive reassurance. 6. GAD in the Elderly: o Concerns about chronic physical diseases triggering excessive worry. o Safety worries, especially about falling, may limit activities in frail elderly. RISK AND PROGNOSTIC FACTORS Behavioral and Personality Factors  Behavioral Inhibition: Tendency to be reserved or shy in new situations.  Negative Affectivity: High levels of neuroticism or emotional instability.  Harm Avoidance: Preference to avoid potentially dangerous situations.  Reward Dependence: Tendency to seek out approval and reward.  Attentional Bias to Threat: Focus on negative or threatening information. Environmental: Childhood adversities, overprotective/controlling parenting. Genetic: One-third of risk, shared with negative affectivity and other anxiety/mood disorders (e.g., depression) TREATMENT Drugs – Benzodiazepines are must prescribed give short time effect and carry some risk. Can be prescribed but for no more than a week or two. Psychological – more effective in the long term. DIFFERENTIAL DIAGNOSIS  Distinguishing GAD from Other Disorders:  o Social Anxiety Disorder: Anticipatory anxiety in social situations. o Separation Anxiety Disorder: Excessive worry about separation from attachment figures.  Specific Diagnoses: o Panic Disorder: Includes unexpected panic attacks. o Illness Anxiety Disorder: Fear focused solely on personal health. o Obsessive-Compulsive Disorder: Obsessional thoughts differ from GAD worry. o Posttraumatic Stress Disorder: Anxiety linked to trauma.  Differentiating Factors: o GAD worry focuses on future events, while OCD involves intrusive thoughts. o Anxiety in PTSD may mask GAD symptoms.  Adjustment Disorder: o Anxiety related to identifiable stressors within 3 months, lasting up to 6 months.  Comorbidity with Other Disorders: o GAD may coexist with depressive, bipolar, or psychotic disorders if anxiety is severe. COMORBIDITY  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. 2. Panic Disorder CLINICAL DESCRIPTION Understanding Panic Disorder (PD)  Severe Panic Attacks: Individuals experience unexpected panic attacks that can make them feel as if they are dying or losing control.  Combination of Anxiety and Panic: Panic disorder involves both anxiety and panic symptoms. To be diagnosed with panic disorder, an individual must: 1. Experience Unexpected Panic Attacks: At least one unexpected panic attack must occur.  2. Develop Anxiety About Future Attacks: The individual must have significant anxiety concerning: o The possibility of having another panic attack. o The implications or consequences of the attack. Implications of Attacks  Individuals may interpret each attack as a sign of imminent death or incapacitation. Panic Disorder: Diagnostic Criteria A. Recurrent Unexpected Panic Attacks  Definition: Abrupt surge of intense fear or discomfort, reaching a peak within minutes.  Symptoms: Four (or more) of the following must occur during the attack: i. Palpitations or accelerated heart rate. ii. Sweating. iii. Trembling or shaking. iv. Shortness of breath or smothering sensations. v. Feelings of choking. vi. Chest pain or discomfort. vii. Nausea or abdominal distress. viii. Dizziness, unsteadiness, or faintness. ix. Chills or heat sensations. x. Numbness or tingling sensations. xi. Derealization (unreality) or depersonalization (detachment from oneself). xii. Fear of losing control or "going crazy." xiii. Fear of dying.  Note: Culture-specific symptoms (e.g., tinnitus, neck soreness) do not count as one of the four symptoms. B. Aftermath of Panic Attacks  At least one panic attack must be followed by 1 month or more of one or both: i. Persistent Concern: Worry about additional panic attacks or consequences (e.g., losing control).  ii. Behavioral Changes: Significant changes to avoid panic attacks (e.g., avoiding exercise or unfamiliar situations). C. Exclusion of Substance or Medical Conditions  The panic attacks are not attributable to the physiological effects of a substance (e.g., drugs) or another medical condition (e.g., hyperthyroidism). D. Exclusion of Other Mental Disorders  The panic attacks are not better explained by another mental disorder (e.g., social anxiety disorder, specific phobia, OCD, PTSD). Diagnostic Features  Recurrent Attacks: More than one unexpected panic attack is necessary for diagnosis.  Unexpected Panic Attacks: Attacks occur without clear triggers, even during calm states.  Nocturnal Panic Attacks: Waking from sleep in panic; these may indicate more severe disorder.  Frequency and Severity: o Frequency can vary widely (e.g., weekly, daily). o Severity can include full-symptom attacks (four or more symptoms) or limited- symptom attacks (fewer than four). Worries and Behavioral Changes  Common concerns include: o Physical health fears (heart problems, seizures). o Social fears (embarrassment or being judged). o Mental health fears (losing control or "going crazy").  Maladaptive Changes: Attempts to avoid panic attacks often lead to lifestyle changes (e.g., avoiding exercise or public places). Associated Features  Anxiety: Persistent worry about health and panic attacks.  Catastrophic Thinking: Fear of severe health issues from mild symptoms.  Medication Intolerance: Low tolerance for side effects.   Daily Functioning: Concerns about completing tasks and managing stress.  Substance Use: Excessive use of drugs/alcohol to manage symptoms.  Control Behaviors: Extreme dietary restrictions to prevent attacks. Prevalence  General Estimates: o 12-month prevalence: 2%–3% among adults/adolescents in the U.S. and Europe. o Global lifetime prevalence: 1.7%.  Subgroup Variations: o Lower among Latinx, African Americans, Caribbean Blacks, and Asian Americans compared to non-Latinx Whites. o U.S. prevalence in American Indians: 2.6%–4.1%. o Rates in Asian, African, and Latin American countries: 0.1%–0.8%.  Gender: Women are affected about 2:1 compared to men.  Age Trends: o Rare in children (