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| __NOTOC__
| | #Redirect [[Generalized anxiety disorder]] |
| {{DiseaseDisorder infobox |
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| Name = Generalised anxiety disorder |
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| ICD10 = {{ICD10|F|41|1|f|40}} |
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| ICD9 = {{ICD9|300.02}} |
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| DSM-IV TR = {{DSM-IV TR|300.02}} |
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| }}
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| {{CMG}}; {{AE}} {{KS}}
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| ==Overview==
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| '''Generalized anxiety disorder''' ('''GAD''') is an [[anxiety disorder]] that is characterized by excessive, uncontrollable and often irrational worry about everyday things, which is disproportionate to the actual source of worry. This excessive worry often interferes with daily functioning, as individuals suffering GAD typically catastrophise, anticipate disaster, and are overly concerned about everyday matters such as [[health]] issues, [[money]], [[family]] problems, friend problems or work difficulties.<ref name="nimh">[http://www.nimh.nih.gov/publicat/anxiety.cfm#anx7 "Anxiety Disorders"], National Institute of Mental Health. Accessed [[28 May]] [[2008]].</ref> They often exhibit a variety of physical symptoms, including [[fatigue (medical)|fatigue]], [[headache]]s, muscle tension, [[Myalgia|muscle aches]], difficulty [[swallowing]], [[tremor|trembling]], [[Muscle contraction|twitching]], [[irritability]], [[sweating]], [[insomnia]], and [[hot flashes]]. These symptoms must be consistent and on-going, persisting at least 6 months, for a formal diagnosis of GAD to be introduced. <ref name="nimh" /> Approximately 6.8 million [[United States|American]] adults experience GAD, affecting about twice as many women as men.<ref name="numbers">[http://www.nimh.nih.gov/publicat/numbers.cfm "The Numbers Count"], National Institute of Mental Health. Accessed [[28 May]] [[2007]].</ref>
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| ==Differential Diagnosis==
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| ==Epidemiology and Demographics==
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| ===Prevalence===
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| Twelve month prevalence in overall population is:
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| *900 per 100,000 (0.9%) in adolescents.
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| *2,900 per 100,000 (2.9%) in adults.
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| ==Risk Factors==
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| ==Natural History,Complications,and Prognosis==
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| ==Diagnosis==
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| According to the ''Diagnostic and Statistical Manual'' IV-Text Revision ([[DSM-IV-TR]]), the following criteria must be met for a person to be diagnosed with Generalized Anxiety Disorder.
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| # Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least six months, about a number of events or activities (such as work or school performance).
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| # The person finds it difficult to control the worry.
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| # The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms present for more days than not for the past 6 months). Note: Only one item is required in children.
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| ## restlessness or feeling keyed up or on edge
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| ## being easily fatigued
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| ## irritability
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| ## muscle tension
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| ## difficulty falling or staying asleep, or restless unsatisfying sleep
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| ## difficulty concentrating or the mind going blank
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| Symptoms can also include nausea, vomiting, and chronic stomach aches.
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| # The focus of the anxiety and worry is not confined to features of an Axis I disorder, e.g., the anxiety or worry is not about having a [[panic attack]] (as in panic disorder), being embarrassed in public (as in [[social phobia]]), being away from home or close relatives (as in [[Separation Anxiety Disorder]]), gaining weight (as in [[anorexia nervosa]]), having multiple physical complaints (as in [[somatization disorder]]), or having a serious illness (as in [[hypochondriasis]]), and the anxiety and worry do not occur exclusively during [[post-traumatic stress disorder]].
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| # The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
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| # The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., [[hyperthyroidism]]) and does not occur exclusively during a Mood Disorder, a Psychotic Disorder, or a Pervasive Developmental Disorder.
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| ==Diagnostic Criteria==
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| ===DSM-V Diagnostic Criteria for Intellectual Disability<ref name=DSMV>{{cite book | title = Diagnostic and statistical manual of mental disorders : DSM-5 | publisher = American Psychiatric Association | location = Washington, D.C | year = 2013 | isbn = 0890425558 }}</ref>===
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| {{cquote|
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| *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
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| performance).
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| '''''AND'''''
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| *B. The individual finds it difficult to control the worry.
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| '''''AND'''''
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| 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
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| past 6 months);
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| <SMALL>''Note:Only one item is required in children.''</SMALL>
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| :*1. Restlessness or feeling keyed up or on edge.
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| :*2. Being easily fatigued.
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| :*3. Difficulty concentrating or mind going blank.
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| :*4. Irritability.
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| :*5. Muscle tension.
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| :*6. Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep).
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| '''''AND'''''
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| *D. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
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| '''''AND'''''
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| *E. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g.,[[hyperthyroidism]]).
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| '''''AND'''''
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| *F. The disturbance is not better explained by another mental disorder (e.g., anxiety or worry about having panic attacks in panic disorder, negative evaluation in social anxiety
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| disorder [[social phobia]], contamination or other obsessions in [[obsessive-compulsive disorder]], separation from attachment figures in [[separation anxiety disorder]],
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| reminders of traumatic events in [[post traumatic stress disorder]], gaining weight in [[anorexia nervosa]], physical complaints in somatic symptom disorder, perceived appearance flaws in body dysmorphic disorder, having a serious illness in illness anxiety disorder, or the content of delusional beliefs in [[schizophrenia]] or [[delusional disorder]]).
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| }}
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| ==Prevalence==
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| The [[World Health Organization]]'s [[Global Burden of Disease]] project did not include generalised anxiety disorders.<ref name="WHO">[http://www.who.int/bulletin/pdf/2000/issue4/bu00-0485.pdf "Relating the burden of anxiety and depression to effectiveness of treatment"], World Health Organization.</ref> In lieu of global statistics, here are some prevalence rates from around the world:
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| *Australia: 3 percent of adults<ref name=WHO>WHO</ref>
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| *Canada: Between 3-5 percent of adults<ref>[http://www.canmat.org/resources/depression/gad.html Canadian Network for Mood and Anxiety Treatment<!-- Bot generated title -->]</ref>
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| *Italy: 2.9 percent<ref name="emed">[http://www.emedicine.com/med/byname/anxiety-disorders.htm eMedicine - Anxiety Disorders : Article Excerpt by William R Yates<!-- Bot generated title -->]</ref>
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| *Taiwan: 0.4 percent<ref name="emed" />
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| *United States: approx. 3.1 percent of people age 18 and over in a given year (6.8 million)<ref name="numbers" />
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| ===Epidemiology===
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| The usual age of onset is variable - from childhood to late adulthood. Women are two to three times more likely to suffer from generalized anxiety disorder than men<ref>{{cite book |title=Crash Course Psychiatry |last=Cameron |first=Alasdair |year=2004 |publisher=Elsevier Ltd |isbn=0-7234-3340-8 }}</ref>.
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| ==Potential Causes of GAD==
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| Some research suggests that GAD may run in families<ref>Kendler KS, Neale MC, Kessler RC, et al. Generalized anxiety disorder in women. A population-based twin study. Archives of General Psychiatry, 1992; 49(4): 267-72.</ref>, and it may also grow worse during stress. GAD usually begins at an earlier age and symptoms may manifest themselves more slowly than in most other anxiety disorders<ref>Robins LN, Regier DA, eds. Psychiatric disorders in America: the Epidemiologic Catchment Area Study. New York: The Free Press, 1991.</ref>. Some people with GAD report onset in early adulthood, usually in response to a life [[stressor]]. Once GAD develops, it can be [[Chronic (medicine)|chronic]] but can be managed if not all but alleviated with proper treatment.<ref> {{cite journal|title=The Clinical Course and Long Term Management of Generalised Anxiety Disorder|journal=J Clinical Psychopharmocology|date=1990|first=K|last=Rickels|coauthors=E. Schweizer|volume=10|issue=|pages=|id= |url=|format=|accessdate=2007-05-16}}</ref>
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| ==Treatment==
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| ===SSRIs===
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| {{main|Selective serotonin reuptake inhibitor}}
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| Pharmaceutical treatments for GAD include [[selective serotonin reuptake inhibitor]]s (SSRIs),<ref name="mayo">[http://www.mayoclinic.com/health/generalized-anxiety-disorder/DS00502/DSECTION=8 "Generalized anxiety disorder"], Mayo Clinic. Accessed [[29 May]] [[2007]].</ref> which are antidepressants that influence brain chemistry to block the reabsorption of [[serotonin]] in the [[brain]].<ref>[http://www.mayoclinic.com/health/ssris/MH00066 "SSRIs"], Mayo Clinic. Accessed [[29 May]] [[2007]].</ref> SSRIs are mainly indicated for [[clinical depression]], but are also effective in treating anxiety disorders.<ref name="mayo" /> Common side effects include [[nausea]], [[sexual dysfunction]], [[headache]], [[diarrhea]], [[Selective serotonin reuptake inhibitor#Adverse effects|among others]]. Common SSRIs prescribed for GAD include:
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| * [[fluoxetine]] (''Prozac'')
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| * [[paroxetine]] (''Paxil'')
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| * [[escitalopram]] (''Lexapro;Cipralex'')
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| ===Other Drugs===
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| * [[imipramine]] (''Tofranil'')
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| * [[venlafaxine]] (''Effexor'')
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| * [[Buspirone]] (''BuSpar'')
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| * [[Pregabalin]] (''Lyrica'')
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| Venlafaxine (Effexor) is a [[serotonin-norepinephrine reuptake inhibitor]] (SNRI). SNRIs, a class of drugs related to the SSRIs, alter the chemistries of both [[norepinephrine]] and serotonin in the brain. Imipramine (Tofranil) is a [[tricyclic antidepressant]] (TCA). TCAs are thought to act on serotonin, norepinephrine, and [[dopamine]] in the brain. Buspirone is a [[serotonin]] [[Receptor (biochemistry)|receptor]] [[agonist]] belonging to the [[azaspirodecanedione]] class of compounds.
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| ===Benzodiazepines===
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| {{main|Benzodiazepine}}
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| [[Benzodiazepines]] (or "benzos") are fast-acting [[sedatives]] that are also used to treat GAD and other [[anxiety disorders]].<ref name="mayo" /> These are often given in the short-term due to their nature to become [[addiction|habit-forming]]. Side effects include [[drowsiness]], reduced [[motor coordination]] and problems with [[equilibrioception]]. Common benzodiazepines used to treat GAD include<ref name="mayo" />:
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| * [[alprazolam]] (''Xanax'')
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| * [[chlordiazepoxide]] (''Librium'')
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| * [[clonazepam]] (''Klonopin'')
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| * [[diazepam]] (''Valium'')
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| * [[lorazepam]] (''Ativan'')
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| ===Herbal===
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| {{main|Kava}}
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| [[Kava]], a relaxant made from a root only of a relative of the [[black pepper]] plant, is effective at controlling anxiety - particularly when used as a short term fast acting drug in combination with CBT (see below). The recommended use is for a support person such as the GAD sufferer's partner or housemate to encourage a dose when anxiety strikes as the patient is often unwilling/unable to dose themselves. Kava is absorbed through most mucous membranes and takes effect in roughly the same time as alcohol. It is a symptomatic relief for anxiety and does not address the fundamental problem, but it does give the patient a reliable mental crutch to work through the core problems. It appears that the required dosage actually decreases with regular use, perhaps as a form of [[Operant conditioning|conditioning]]. Two major advantages of Kava supported therapy are the rapid response of the active ingredients (removing the need for [[titration]]) and the lack of withdrawal symptoms. There are no specific contraindications with other chemical treatments, but caution must be observed when the patient is already taking psychoactive drugs. Due to reports of serious liver damage related to the use of kava, many countries, particularly across Europe, have banned the sale of it. The risks and benefits of using kava, as with any drug, must be reviewed and proper caution must be exercised.
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| ===Cognitive behavioral therapy===
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| {{main|Cognitive behavioral therapy}}
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| A [[psychological]] method of treatment for GAD is [[cognitive behavioral therapy]] (CBT), which involves a [[therapist]] working with the patient to understand how [[thought]]s and [[feeling]]s influence [[behavior]].<ref name="cbt">[http://www.babcp.com/babcp/what_is_CBT.htm "A Guide to Understanding Cognitive and Behavioural Psychotherapies"], British Association of Behavioural and Cognitive Psychotherapies. Accessed [[29 May]] [[2007]].</ref> The goal of the therapy is to change negative thought patterns that lead to the patient's anxiety, replacing them with positive, more realistic ones. Elements of the therapy include [[Exposure Therapy|exposure strategies]] to allow the patient to gradually confront their anxieties and feel more comfortable in anxiety-provoking situations, as well as to practice the skills they have learned. CBT can be used alone or in conjunction with [[medication]].<ref name="mayo" />
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| CBT usually helps one third of the patients substantially, whilst another third does not respond at all to treatment. <ref>'''Barlow, D. H.''': (2007) ''Clincical Handbook of Psychological Disorders'', 4th ed.</ref>
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| ==GAD and Comorbid Depression==
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| In the National Comorbidity Survey (2005), 58% of patients diagnosed with [[Clinical depression|major depression]] were found to have an anxiety disorder; among these patients, the rate of comorbidity with GAD was 17.2%, and with [[panic disorder]], 9.9%. Patients with a diagnosed anxiety disorder also had high rates of comorbid depression, including 22.4% of patients with [[social phobia]], 9.4% with [[agoraphobia]], and 2.3% with panic disorder. For many, the symptoms of both depression and anxiety are not severe enough (i.e. are subsyndromal) to justify a primary diagnosis of either major depressive disorder (MDD) or an anxiety disorder.
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| Patients can also be categorized as having [[mixed anxiety-depressive disorder]], and they are at significantly increased risk of developing full-blown depression or anxiety. Appropriate treatment is necessary to alleviate symptoms and prevent the emergence of more serious disease.{{Fact|date=February 2007}}
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| Accumulating evidence indicates that patients with comorbid depression and anxiety tend to have greater illness severity and a lower treatment response than those with either disorder alone.{{Fact|date=February 2007}} In addition, social function and quality of life are more greatly impaired.
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| In addition to coexisting with depression, research shows that GAD often coexists with [[substance abuse]] or other conditions associated with [[Stress (medicine)|stress]], such as [[irritable bowel syndrome]].{{Fact|date=May 2007}} Patients with physical symptoms such as [[insomnia]] or [[headache]]s should also tell their doctors about their feelings of worry and tension. This will help the patient's health care provider to recognize whether the person is suffering from GAD.
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| ==See also==
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| * [[Anxiety disorder]]
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| * [[Social anxiety disorder]]
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| * [[Clinical depression]]
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| * [[Cognitive behavioral therapy]]
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| * [[Anxiety Disorders Association of America]]
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| ==Notes==
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| {{reflist|2}}
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| ==References==
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| * Kessler RC, Chiu WT, Demler O, Walters EE. Prevalence, severity, and comorbidity of twelve-month DSM-IV disorders in the National Comorbidity Survey Replication (NCS-R). Archives of General Psychiatry, 2005 Jun;62(6):617-27.
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| * Brown, T.A., O'Leary, T.A., & Barlow, D.H. (2001). Generalised anxiety disorder. In D.H. Barlow (Ed.), Clinical handbook of psychological disorders: A step-by-step treatment manual (3rd ed.). New York: Guilford Press.
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| * Barlow, D. H., & Durand, V. M. (2005). Abnormal psychology: An integrative approach. Australia; Belmont, CA: Wadsworth.
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| {{reflist|2}}
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| ==External links==
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| * [http://www.nimh.nih.gov/healthinformation/gadmenu.cfm National Institute of Mental Health - NIMH] - Information on generalised anxiety disorder
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| * [http://www.mayoclinic.com/health/generalized-anxiety-disorder/DS00502 Mayo Clinic] - Information on diagnosis and treatment for GAD
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| * [http://www.webmd.com/anxiety-panic/guide/general-anxiety-disorder WebMD] Information on symptoms and causes of GAD
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| * [http://www.adaa.org Anxiety Disorders Association of America] - Information for families, clinicians and researchers
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| {{Mental and behavioural disorders}}
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| [[Category:Psychiatry]]
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| [[Category:Low priority]]
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| [[de:Generalisierte Angststörung]]
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| [[es:Trastorno de ansiedad generalizada]]
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| [[fr:Anxiété généralisée]]
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| [[he:הפרעת חרדה מוכללת]]
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| [[nl:Gegeneraliseerde angststoornis]]
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| [[no:Generalisert angstlidelse]]
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| [[pl:Zespół lęku uogólnionego]]
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| [[fi:Yleistynyt ahdistuneisuushäiriö]]
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| [[sv:Generaliserat ångestsyndrom]]
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