Generalized anxiety disorder

A generalized anxiety disorder is characterized by excessive, almost daily anxiety and anxiety for 6 months or more about a variety of events or activities. The causes are unknown, although generalized anxiety disorder is common in patients with alcohol dependence, severe depression or panic disorder. The diagnosis is based on anamnesis and physical examination. Treatment: psychotherapy, drug therapy or a combination thereof.

Epidemiology

Generalized anxiety disorder (GHR) is quite common, about 3% of the population fall ill during the year. Women get sick twice as often as men. GAD often begins in childhood or adolescence, but can also begin in other age periods.

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Symptoms of generalized anxiety disorder

The immediate cause for the development of anxiety is not defined as clearly as in other mental disorders (for example, waiting for a panic attack, worrying in public or fear of infection); the patient is worried for a variety of reasons, the anxiety changes over time. Most often there is concern about professional obligations, money, health, safety, car repair and everyday duties. To meet the criteria for the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV), the patient should have 3 or more symptoms of the following: anxiety, fatigue, difficulty concentrating, irritability, muscle tension, sleep disturbances. The course is usually fluctuating or chronic, with deterioration during periods of stress. Most patients with GAD also have one or more comorbid psychiatric disorders, including a major depressive episode, a specific phobia, a social phobia, a panic disorder.

Clinical manifestations and diagnosis of generalized anxiety disorder

A. Excessive anxiety or anxiety (anxiety expectations) associated with a series of events or actions (for example, work or study) and that are most of the time for at least six months.

B. Anxiety is difficult to control arbitrarily.

C. Anxiety and anxiety are accompanied by at least three of the following six symptoms (and at least some symptoms are present most of the time over the past six months).

1. Anxiety, a feeling of an upsurge, a state on the verge of collapse.
2. Fast fatiguability.
3. Violation of concentration of attention.
4. Irritability.
5. Muscle tension.
6. Sleep disorders (difficulty sleeping and maintaining sleep, restless sleep, dissatisfaction with the quality of sleep).

Note: children are allowed only one of the symptoms.

G. The direction of anxiety or anxiety is not limited to motives that are characteristic of other disorders. For example, anxiety or anxiety is not associated only with the presence of panic attacks (as in panic disorder), the possibility of getting into an awkward position in the public (as in social phobia), the possibility of infection (as in obsessive-compulsive disorder), staying away from home (as with separation anxiety disorder), weight gain (as in anorexia nervosa), the presence of numerous somatic complaints (as in somatisation disorder), the possibility of developing a dangerous disease (as in hypochondria), the circumstance psycho-traumatic events (as in post-traumatic stress disorder).

D. Anxiety, anxiety, somatic symptoms cause clinically significant discomfort or disrupt the life of the patient in social, occupational or other important areas.

E. Infringements are not caused by the direct physiological action of exogenous substances (including addictive substances or drugs) or general disease (eg, hypothyroidism), and are not observed only when affective disorders, psychotic disorders occur, and are not associated with a general disorder development.

The course of generalized anxiety disorder

Symptoms of generalized anxiety disorder are often observed in patients referring to general practitioners. Usually, such patients make unspecified somatic complaints: fatigue, muscle pain or tension, mild sleep disorders. The absence of these prospective epidemiological studies does not allow us to state with certainty the course of this condition. However, retrospective epidemiological studies indicate that generalized anxiety disorder is a chronic condition, since in most patients the symptoms were noted for many years before the diagnosis was established.

Differential diagnosis of generalized anxiety disorder

Like other anxiety disorders, generalized anxiety disorder should be differentiated with other mental, somatic, endocrinological, metabolic, neurological diseases. In addition, when establishing a diagnosis, one should keep in mind the possibility of combining with other anxiety disorders: panic disorder, phobias, obsessive-compulsive and post-traumatic stress disorders. The diagnosis of generalized anxiety disorder is made when a complete set of symptoms is detected in the absence of comorbid anxiety disorders. However, in order to diagnose a generalized anxiety disorder in the presence of other anxiety conditions, it is necessary to establish that anxiety and anxiety are not confined to only a range of circumstances and themes characteristic of other disorders. Thus, the correct diagnosis involves identifying the symptoms of a generalized anxiety disorder when excluded or in the presence of other anxiety conditions. Since patients with generalized anxiety disorder often develop a large depression, this condition must also be excluded and properly delineated with a generalized anxiety disorder. Unlike depression, with generalized anxiety disorder, anxiety and anxiety are not associated with affective disorders.

Pathogenesis. Of all anxiety disorders, generalized anxiety disorder is the least studied. The lack of information is partly due to a fairly serious change in views on this state over the past 15 years. During this time, the boundaries of the generalized anxiety disorder gradually narrowed, while the borders of the panic disorder expanded. The lack of pathophysiological data is also due to the fact that patients rarely go to psychiatrists for the treatment of isolated generalized anxiety. In patients with generalized anxiety disorder, comorbid affective and anxiety disorders are usually found, and in epidemiological studies, patients with isolated generalized anxiety disorder are rarely detected. Therefore, many pathophysiological studies are rather aimed at obtaining data that allow to differentiate generalized anxiety disorder with comorbid affective and anxiety disorders, primarily with panic disorder and major depression for which there is especially high comorbidity with generalized anxiety disorder.

Genealogical research. A series of twin and genealogical studies made it possible to detect differences between generalized anxiety disorder, panic disorder and major depression. The findings suggest that panic disorder is transmitted to families in a different way than generalized anxiety disorder or depression; at the same time, the differences between the last two states are less distinct. Based on the data of the study of adult female twins, scientists suggested that generalized anxiety disorder and major depression have a common genetic basis, which is manifested by this or that disorder under the influence of external factors. Scientists have also identified a link between the vector polymorphism involved in the reuptake of serotonin and the level of neuroticism, which in turn is closely related to the symptoms of major depression and generalized anxiety disorder. The results of a long prospective study in children confirmed this point of view. It turned out that the links between generalized anxiety disorder in children and major depression in adults are no less severe than between depression in children and generalized anxiety disorder in adults, and between generalized anxiety disorder in children and adults and between major depression in children and adults.

Differences from panic disorder. A number of studies have compared neurobiological changes in panic and generalized anxiety disorders. Although there were a number of differences between these two conditions, they differed from the condition of mentally healthy individuals by the same indices. For example, a comparative study of an anxiogenic response to lactate administration or inhalation of carbon dioxide showed that with a generalized anxiety disorder this reaction is enhanced compared to healthy individuals, and panic disorder differs from generalized anxiety only by more pronounced dyspnoea. Thus, in patients with generalized anxiety disorder, the response was characterized by a high level of anxiety accompanied by somatic complaints, but not associated with respiratory dysfunction. In addition, in patients with generalized anxiety disorder, the growth hormone secretion curve was smoothed in response to clonidine administration - as in panic disorder or major depression, as well as changes in the variability of cardiointervals and serotonergic system activity.

Diagnostics

A generalized anxiety disorder is characterized by frequent or persistent fears and anxieties that arise about real events or circumstances of concern to a person, but are clearly excessive in relation to them. For example, students are often afraid of exams, but a student who is constantly concerned about the possibility of failure, despite good knowledge and consistently high marks, can be suspected of generalized anxiety disorder. Patients with generalized anxiety disorder may not realize the excess of their fears, but the expressed anxiety causes them discomfort. In order to diagnose a generalized anxiety disorder, it is necessary that these symptoms are noted often enough for at least six months, the anxiety is not controlled and, in addition, at least three of six somatic or cognitive symptoms are detected. Among such symptoms include: a feeling of anxiety, rapid fatigue, muscle tension, insomnia. It should be noted that anxiety concerns are a common manifestation of many anxiety disorders. Thus, patients with panic disorder experience fears of panic attacks, patients with a social phobia - about possible social contacts, patients with obsessive-compulsive disorder - about obsessive ideas or sensations. Anxiety in generalized anxiety disorder is more global than in other anxiety disorders. A generalized anxiety disorder is also observed in children. Diagnosis of this condition in children requires the presence of only one of six somatic or cognitive symptoms indicated in the diagnostic criteria.

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Treatment of generalized anxiety disorder

Antidepressants, including selective serotonin reuptake inhibitors (SSRIs) (eg paroxetine, starting dose of 20 mg once daily), serotonin reuptake inhibitors and norepinephrine (eg, venlafaxine, prolonged action, initial dose 37.5 mg once a day), tricyclic antidepressants (eg, imipramine, an initial dose of 10 mg once a day) are effective, but only after application for at least a few weeks. Benzodiazepines in small and medium doses are also often effective, although prolonged use usually leads to the development of physical dependence. One of the strategies of treatment consists in the combined appointment at the initial stage of therapy of benzodiazepine and antidepressant. When the effect of an antidepressant is manifested, benzodiazepine is gradually canceled.

Buspirone is also effective at an initial dose of 5 mg 2 or 3 times a day. However buspirone must be taken at least 2 weeks before it starts to have an effect.

Psychotherapy, often cognitive-behavioral, can be both supportive and problem-oriented. Relaxation and biofeedback may be useful to some extent, although the number of studies confirming their effectiveness is limited.