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07-SEPTEMBER-2008 03:17:44 - Generalized anxiety disorder December 2006 Generalised anxiety disorder Classification and external resources ICD-10 F41.1 ICD-9 300.02 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.1 They often exhibit a variety of physical symptoms, including fatigue, headaches, nausea, muscle tension, muscle aches, difficulty swallowing, trembling, 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. 1 Approximately 6.8 million American adults experience GAD, which affects about twice as many women as men.2 Contents 1 Diagnosis 2 Prevalence 2.1 Epidemiology 3 Potential Causes of GAD 4 Self-help 5 Treatment 5.1 Cognitive behavioral therapy 5.2 SSRIs 5.3 Other Drugs 5.4 Benzodiazepines 5.5 Herbal 6 GAD and Comorbid Depression 7 See also 8 Notes 9 References 10 External links Diagnosis 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. 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. The person finds it difficult to control the worry. 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. restlessness or feeling keyed up or on edge being easily fatigued irritability muscle tension difficulty falling or staying asleep, or restless unsatisfying sleep difficulty concentrating or the mind going blank Symptoms can also include nausea, vomiting, and chronic stomach aches. 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. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. 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. Prevalence The World Health Organization's Global Burden of Disease project did not include generalised anxiety disorders.3 In lieu of global statistics, here are some prevalence rates from around the world: Australia: 3 percent of adults3 Canada: Between 3-5 percent of adults4 Italy: 2.9 percent5 Taiwan: 0.4 percent5 United States: approx. 3.1 percent of people age 18 and over in a given year 6.8 million2 Epidemiology 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 men6. Potential Causes of GAD Some research suggests that GAD may run in families7, 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 disorders8. Some people with GAD report onset in early adulthood, usually in response to a life stressor. Once GAD develops, it can be chronic, but can be managed, if not all-but-alleviated, with proper treatment.9 Self-help Common-sense action may be taken to reduce the general level of anxiety. The actions may be appropriate to a specific type of stress. For example, if there are frequent worries about financial difficulties, then financial planning may help. Other actions may improve general mental resilience. For example, exercise may help in releasing tension and, by improving fitness, enable the individual to manage tasks more easily and feel better about themselves.10 Treatment A meta-analysis of 35 studies11shows the psychological method of cognitive behavioral therapy to be more effective in the long term than pharmacologic treatment drugs such as SSRIs, and while both treatments reduce anxiety, CBT is more effective in reducing depression. Cognitive behavioral therapy Main article: Cognitive behavioral therapy Cognitive behavioral therapy is a psychological method of treatment for GAD is cognitive behavioral therapy CBT, which involves a therapist working with the patient to understand how thoughts and feelings influence behavior.12 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 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.13 CBT usually helps one third of the patients substantially, whilst another third does not respond at all to treatment. 14 SSRIs Main article: Selective serotonin reuptake inhibitor Pharmaceutical treatments for GAD include selective serotonin reuptake inhibitors SSRIs,13 which are antidepressants that influence brain chemistry to block the reabsorption of serotonin in the brain.15 SSRIs are mainly indicated for clinical depression, but are also effective in treating anxiety disorders.13 Common side effects include nausea, sexual dysfunction, headache, diarrhea, among others. Common SSRIs prescribed for GAD include: fluoxetine Prozac paroxetine Paxil escitalopram Lexapro;Cipralex Other Drugs imipramine Tofranil venlafaxine Effexor Buspirone BuSpar Pregabalin Lyrica 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 agonist belonging to the azaspirodecanedione class of compounds. Benzodiazepines Main article: Benzodiazepine Benzodiazepines or benzos are fast-acting sedatives that are also used to treat GAD and other anxiety disorders.13 These are often given in the short-term due to their nature to become habit-forming. Side effects include drowsiness, reduced motor coordination and problems with equilibrioception. Common benzodiazepines used to treat GAD include13: alprazolam Xanax chlordiazepoxide Librium clonazepam Klonopin diazepam Valium lorazepam Ativan Herbal Main article: Kava 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 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. GAD and Comorbid Depression In the National Comorbidity Survey 2005, 58% of patients diagnosed with 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. 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.citation needed 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.citation needed In addition, social function and quality of life are more greatly impaired. In addition to coexisting with depression, research shows that GAD often coexists with substance abuse or other conditions associated with stress, such as irritable bowel syndrome.citation needed Patients with physical symptoms such as insomnia or headaches 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. See also Anxiety disorder Social anxiety disorder Clinical depression Cognitive behavioral therapy Anxiety Disorders Association of America Notes ^ a b Anxiety Disorders, National Institute of Mental Health. Accessed 28 May 2008. ^ a b The Numbers Count, National Institute of Mental Health. Accessed 28 May 2007. ^ a b Relating the burden of anxiety and depression to effectiveness of treatment, World Health Organization. ^ Canadian Network for Mood and Anxiety Treatment ^ a b eMedicine - Anxiety Disorders : Article Excerpt by William R Yates ^ Cameron, Alasdair 2004. Crash Course Psychiatry. Elsevier Ltd. ISBN 0-7234-3340-8. ^ Kendler KS, Neale MC, Kessler RC, et al. Generalized anxiety disorder in women. A population-based twin study. Archives of General Psychiatry, 1992; 494: 267-72. ^ Robins LN, Regier DA, eds. Psychiatric disorders in America: the Epidemiologic Catchment Area Study. New York: The Free Press, 1991. ^ Rickels, K; E. Schweizer 1990. The Clinical Course and Long Term Management of Generalised Anxiety Disorder. J Clinical Psychopharmocology 10. Retrieved on 2007-05-16. ^ Mayo Clinic September 27, 2005, Generalized anxiety disorder, CNN, http://ion.cnn.com/HEALTH/library/DS/00502.html ^ http://dx.doi.org/10.1016/S0005-78949780048-2 ^ A Guide to Understanding Cognitive and Behavioural Psychotherapies, British Association of Behavioural and Cognitive Psychotherapies. Accessed 29 May 2007. ^ a b c d e Generalized anxiety disorder, Mayo Clinic. Accessed 29 May 2007. ^ Barlow, D. H.: 2007 Clincical Handbook of Psychological Disorders, 4th ed. ^ SSRIs, Mayo Clinic. Accessed 29 May 2007. References 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;626:617-27. 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. Barlow, D. H., Durand, V. M. 2005. Abnormal psychology: An integrative approach. Australia; Belmont, CA: Wadsworth. External links National Institute of Mental Health - NIMH - Information on generalised anxiety disorder Mayo Clinic - Information on diagnosis and treatment for GAD WebMD Information on symptoms and causes of GAD Anxiety Disorders Association of America - Information for families, clinicians and researchers Support Group v d e WHO ICD-10 mental and behavioral disorders F · 290-319 Neurological/symptomatic Dementia Alzheimer's disease, multi-infarct dementia, Pick's disease, Creutzfeldt-Jakob disease, Huntington's disease, Parkinson's disease, AIDS dementia complex, Frontotemporal dementia, Elopement, Sundowning, Wandering · Delirium · Post-concussion syndrome · Organic brain syndrome Psychoactive substance alcohol drunkenness, alcohol dependence, alcoholic hallucinosis, Alcohol withdrawal, delirium tremens, Korsakoff's syndrome, alcohol abuse · opioids opioid dependency · sedative/hypnotic benzodiazepine withdrawal · cocaine cocaine dependence · general Intoxication, Drug abuse, Physical dependence, Withdrawal Psychotic disorder Schizophrenia disorganized schizophrenia · Schizophreniform disorder · Schizotypal personality disorder · Delusional disorder · Folie à deux · Schizoaffective disorder Mood affective Mania · Bipolar disorder · Clinical depression · Cyclothymia · Dysthymia Neurotic, stress-related and somatoform Anxiety disorder Agoraphobia, Panic disorder, Panic attack, Generalized anxiety disorder, Social anxiety, Social phobia · OCD · Acute stress reaction · PTSD · Adjustment disorder · Conversion disorder Ganser syndrome · Somatoform disorder Somatization disorder, Body dysmorphic disorder, Hypochondriasis, Nosophobia, Da Costa's syndrome, Psychalgia · Neurasthenia Physiological/physical behavioral Eating disorder: Anorexia nervosa · Bulimia nervosa Sleep disorder: Dyssomnia Hypersomnia, Insomnia · Parasomnia REM behavior disorder, Night terror · Nightmare Sexual dysfunction: Erectile dysfunction · Premature ejaculation · Vaginismus · Dyspareunia · Hypersexuality · Female sexual arousal disorder Postpartum depression · Postnatal psychosis Adult personality and behavior Personality disorder · Passive-aggressive behavior · Kleptomania · Trichotillomania · Voyeurism · Factitious disorder · Munchausen syndrome · Ego-dystonic sexual orientation · Fetishism Mental retardation Mental retardation Psychological development developmental disorder Specific: speech and language expressive language disorder, aphasia, expressive aphasia, receptive aphasia, Landau-Kleffner syndrome, lisp · Scholastic skills dyslexia, dysgraphia, Gerstmann syndrome · Motor function developmental dyspraxia Pervasive: Autism · Rett syndrome · Asperger syndrome Behavioral and emotional, childhood and adolescence onset ADHD · Conduct disorder · Oppositional defiant disorder · Separation anxiety disorder · Selective mutism · Reactive attachment disorder · Tic disorder · Tourette syndrome · Speech stuttering · cluttering Retrieved from http://en..org/wiki/Generalized_anxiety_disorder Categories: Anxiety disordersHidden categories: Articles needing additional references from December 2006 | All articles with statements | Articles with statements since February 2007 | Articles with statements since May 2007 Views Article Discussion this page History Personal tools Log in / create account Navigation Main page Contents Featured content Current events Random article Search Go Search Interaction Community portal Recent changes Contact Donate to Help Toolbox What links here Related changes Upload file Special pages Printable version Permanent link Cite this page Languages Deutsch Español Français עברית Nederlands Norsk bokmål Polski Suomi Svenska This page was last modified on 22 August 2008, at 14:4
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