Description of the disorder GAD is characterised by an excessive uncontrollable and often irrational worry about events or activities It has an insidious onset and a stable usually chronic course which may or may not be punctuated by repeated panic attacks episodes of acute anxiety ID: 912297
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Slide1
Generalized Anxiety Disorder(GAD):
Slide2Description of the disorder:
GAD is
characterised
by an excessive, uncontrollable and often irrational worry about events or activities.
It has an insidious onset and a stable, usually chronic course which may or may not be punctuated by repeated panic attacks( episodes of acute anxiety).
GAD is defined as excessive anxiety and worry about several events and activities for most days during at least a 6-month period. (Kaplan, Textbook of Psychiatry,)
The worry or subjective distress is difficult to control and is associated with a variety of physical symptoms and autonomic nervous system reactions(
Fricchione
, 2004)such as muscle tension, irritability, difficulty sleeping and restlessness.
The anxiety is not focused on features of another disorder, is not caused by substance use or a general medical condition and does not occur only during a mood or psychiatric disorder.
The anxiety is difficult to control, is subjectively distressing and produces impairment in important areas of a person’s life.
Slide3Clinical Features of GAD:
Psychological Symptoms:
Sustained and excessive anxiety and worry.
Sufferers live in a relatively constant future-oriented mood state of anxious apprehension, chronic tension, worry and diffuse uneasiness. This apprehension is the essence of GAD.
They attempt to be constantly ready to deal with upcoming negative events and have a strong sense of lacking control over the worry process (Barlow, 2002).
The nearly constant worries of people with GAD leave them continually upset, uneasy and discouraged.
The anxiety is excessive and interferes with other aspects of a person’s life.
There is no appreciation of logic.
This pattern must occur for more days than not for at least 3 months.
Slide4Clinical Features of GAD:
Physical and Social Symptoms:
The excessive anxiety is accompanied by either motor tension or restlessness.
The motor tension is most commonly manifested as shakiness and headache or muscle stiffness.
The anxiety
, worry or physical symptoms cause
a person significant
distress in social,
occupational,
or other areas of
one’s life.
Worries can shift from one concern to another and may change with time and age.
Slide5Clinical Features of GAD:
Symptoms in children and
teenagers:
Children and teenagers may have similar worries to adults, but also may have excessive worries about:
Performance at school or sporting events
Family members' safety
Being on time (punctuality)
Earthquakes, nuclear war or other catastrophic events
Slide6Clinical Features of GAD:
A
child or teen with excessive worry may:
Feel overly anxious to fit in
Be a perfectionist
Redo tasks because they aren't perfect the first time
Spend excessive time doing homework
Lack confidence
Strive for approval
Require a lot of reassurance about performance
Have frequent stomachaches or other physical complaints
Avoid going to school or avoid social situations
Slide7Symptoms of GAD:
Generalized
anxiety disorder symptoms can vary. They may include
:
Psychological Symptoms:
Persistent worrying or anxiety about a number of areas that are out of proportion to the impact of the events
Overthinking plans and solutions to all possible worst-case outcomes
Perceiving situations and events as threatening, even when they aren't
Difficulty handling uncertainty
Indecisiveness and fear of making the wrong decision
Inability to set aside or let go of a worry
Inability to relax, feeling restless, and feeling keyed up or on edge
Difficulty concentrating, or the feeling that your mind "goes blank
"
Slide8Symptoms of GAD:
Physical signs and symptoms may include:
Fatigue
Trouble sleeping
Muscle tension or muscle aches
Trembling, feeling twitchy
Nervousness or being easily startled
Sweating
Nausea, diarrhea or irritable bowel syndrome
Irritability
Slide9Differential Diagnosis:
To diagnose GAD, patients must both exhibit the full syndrome and their symptoms also cannot be explained by the presence of a comorbid anxiety disorder.
Since GAD patients often develop major depressive disorders, this condition must also be
recognised
and distinguished.
The key to correct diagnosis is documenting anxiety or worry that is unrelated to the depressive disorder.
Slide10Prevalence and age of onset:
Although quite common, most people with GAD manage to function in spite of their high levels of worry and low perceived well-being.
They are less likely to go to clinics seeking psychiatric treatment, but more likely to go with physical complaints, like fatigue and headache.
GAD is approximately twice as common in women as in men.
Age of onset is difficult to determine because 60 to 80 percent remember having being anxious almost all their lives and many others report a slow and insidious onset (Roemer et al, 2002).
Some data indicate that life events are associated with the onset of GAD. The
occurance
of several negative life events greatly increases the likelihood that the disorder will develop.
GAD often occurs in older adults where it is the most common anxiety disorder (Stein,2004).
Slide11Co-morbidity with other disorders:
GAD often co-occurs with other disorders, especially other anxiety and mood disorders, such as panic disorders, social phobia, specific phobia, PTSD, etc.
Many people with GAD may experience occasional panic attacks without qualifying for a diagnosis of panic disorder (Barlow,2002).
The high incidence of comorbid mental disorders in patients with GAD make the clinical course and prognosis of the disorder difficult to predict.
Slide12Etiology of GAD:
PSYCHOSOCIAL CAUSAL FACTORS:
Psychoanalytic Viewpoint:
Generalized or free-floating anxiety results from an unconscious conflict (of usually sexual or aggressive nature) between ego and id impulses that is not adequately dealt with because the person’s defense mechanisms have either broken down or have never developed.
In specific phobias, the defense mechanisms of repression and displacement actually work, whereas in free-floating anxiety, these defenses do not work, leaving the person anxious nearly all the time.
Role of unpredictable and uncontrollable events:
People with GAD may have a history of experiencing many important life events as unpredictable and/or uncontrollable. Which is stressful and anxiety
provoking(
Craske
and
Waters,2005
).
People with GAD may have a history of trauma in childhood (
Borkovec
et al,2004).
Moreover, they have a far less tolerance for uncertainty than
nonanxious
controls(
Dugas
et al, 2004), which suggests that they are especially disturbed by not being able to predict the future.
P
eople’s intolerance for uncertainty, tension and hypervigilance, stem from their lacking safety signals in the
environment, and from experiencing
unsignaled
stressors, which fail to give them
a sense of control
. This uncertainty may create chronic anxiety and they feel constantly tense and vigilant for possible threats.
Slide13PSYCHOSOCIAL FACTORS:
A sense of mastery: the possibility of
immunising
against anxiety:
Directly manipulating the controllability and predictability of our life experiences for prolonged periods of time, may
immunise
us against developing
generalised
anxiety :
Laboratory study
– a longitudinal experiment with
infant rhesus monkeys-
(Mineka et al, 1986).
‘
Master’ group
- with control over access to
reinforcers
;
‘
Yoked’ group
without control;
B
oth groups exposed to same level of
reinforcers
.
They differed in responses to fear and anxiety-provoking situations.
The experiment proved that early experiences with control and mastery can
immunise
the individual to some extent against the harmful effects of exposure to stressful situations.
In humans, the parent’s responsiveness to their children’s needs directly influence their children’s developing sense of mastery.
Slide14PSYCHOSOCIAL FACTORS:
The central role of worry and its positive functions:
The worry process is the central feature of GAD.
5 benefits of worry according to people with GAD(
Borkovec
et al, 2004):
1. superstitious avoidance of catastrophe
2. actual avoidance of catastrophe
3. avoidance of deeper emotional issues
4. coping and preparation
5. motivating device
While worrying, their emotional and physiological responses to aversive imagery are suppressed, which serve to reinforce the process of worry.
This suppression further insulates the person from fully processing worry
Full processing of worry is needed for extinction of the underlying anxiety
T
he threatening part of worry is therefore maintained.
The worry process is further reinforced superstitiously because most things people worry about never
happens (Craske,2003).
Slide15PSYCHOSOCIAL FACTORS:
The negative consequences of worry:
Worry may lead to a greater sense of danger and anxiety because of all the possible catastrophic outcomes the person envisions.
People who worry tend subsequently to have more negative intrusive thoughts than those who do not worry (Wells et al,1997).
Attempts to control thoughts and worry may paradoxically lead to increased experience of intrusive thoughts and enhanced perception of uncontrollability (Abramowitz et al,2001).
These intrusive thoughts further trigger more worrisome issues, further enhance perception of uncontrollability, which is associated with
increased
anxiety.
Thereby a vicious circle of anxiety, worry and intrusive thoughts may develop(Mineka,2004).
Cognitive biases for threatening information:
Research evidences indicate that anxiety is associated with an automatic attentional and interpretive bias toward threatening information.
Slide16BIOLOGICAL CAUSAL FACTORS OF GAD:
Genetic Factors:
There is evidence for a modest heritability for genetic factors in GAD, though less than the other anxiety disorders. (
Plomin
et al, 2001).
Part of the problem for research in this area has been the evolving nature of our understanding of GAD and what its diagnostic criteria are.
T
he most significant twin studies in this area estimate the heritability of GAD at about 15 to 20 percent (
Hettema
et al, 2001).
There is increasing evidence suggesting a genetic predisposition for GAD and major depression, that is
conceptualised
as a basic personality trait referred to as ‘neuroticism’- a proneness to experience negative mood states (
Hettema
et al,2004).
Slide17BIOLOGICAL CAUSAL FACTORS OF GAD:
A functional deficiency of GABA and other neurotransmitters:
Research evidences suggested that functional deficiency in GABA(gamma
antibutyric
acid) promotes the maintenance of anxiety.
The benzodiazepine drugs appear to reduce anxiety by increasing GABA activity in certain parts of the brain implicated in anxiety like the limbic system and also by suppressing the stress hormone cortisol.
The neurotransmitter serotonin is also involved in modulating generalized anxiety(Goodman, 2004).
N
orepinephrine is also believed to play a role in regulating anxiety, along with GABA and serotonin.
Slide18BIOLOGICAL CAUSAL FACTORS OF GAD:
The corticotrophin-releasing hormone(CRH) system and anxiety:
Anxiety-producing hormone CRH(secreted by the paraventricular nucleus or PVN of the hypothalamus in response to stress), has been strongly implicated as playing an important role in generalized anxiety (and depression).
When activated by stress or perceived threat, CRH stimulates the release of ACTH from pituitary, which in turn causes the release of stress hormone cortisol from the adrenal gland(Thompson,2000).
CRH has effects on the bed nucleus of the
stria
terminalis(an extension of amygdala)- an important brain area mediating generalized anxiety(
Ohman
et al,2000).
Slide19BIOLOGICAL CAUSAL FACTORS OF GAD:
Neurobiological differences between anxiety and panic:
There are several fundamental distinctions between fear or panic, and anxiety, including their neurobiological bases.
Fear or panic involve activation of the fight-or-flight response. It involves arousal of amygdala and neurotransmitters norepinephrine and serotonin.
Generalized anxiety or anxious apprehension is a more diffused emotional state involving arousal and a preparation for a possible impending threat. There is mainly arousal of the limbic system and neurotransmitters GABA and CRH(Lang et al, 2000).
Slide20Treatment of GAD:
Medication from the benzodiazepine category like Valium are used for tension relief, reduction of other somatic symptoms and relaxation.
A comparatively newer medication
Buspirone
is also effective and is neither sedating or addictive.
Several categories of antidepressant medications are also used, which are effective on the psychological symptoms(Goodman,2004).
CBT involving a combination of
behavioural
techniques like PMR; and cognitive restructuring techniques are also effective. They aim at reducing distorted cognitions and information-processing biases associated with GAD, as well as too much overreaction on minor events(Newman et al,2002).
GAD may be referred to as one of the most difficult anxiety disorders to treat.