1. Generalized Anxiety Disorder
ا.د.الهام الجماس

2. Anxiety
Anxiety can be conceptualized as a normal and adaptive response to threat that prepares the organism for flight or ϧfight.

3. Generalized anxiety disorder
(GAD) is a chronic and highly comorbid
. illness characterized by pattern of frequent ,persistent , excessive and uncontrollable worry and feelings of apprehension (generalized free-floating persistent anxiety). about everyday events/problems, with symptoms of muscle and psychic tension, causing significant distress /functional impairment.

4. Generalized anxiety disorder
It is marked by a later onset than other anxiety disorders and is associated with fluctuations in symptom severity and impairment.

5. Epidemiology
Life time prevalence 5.7%.

6. Aetiology
In general terms, generalized anxiety disorder appears to be caused by stressors acting on a personality that is predisposed to anxiety by a combination of genetic factors and environmental influences in childhood. However,evidence for the nature and importance of these causes is incomplete.

7. Aetiology Stressful events
Clinical observations indicate that generalized anxiety disorders often begin in relation to stressful events, and some become chronic when stressful problems persist.

8. Aetiology Early experiences ).
Parenting styles characterized by overprotection and lack of emotional warmth may also be a risk factor for generalized anxiety disorder as well as for other anxiety and depressive disorders in offspring

9. Aetiology
Psychoanalytic theories.
• the superego (moral anxiety).

10. Aetiology Cognitive-behavioural theories
Conditioning theories propose that generalized anxiety disorders arise when there is an inherited predisposition to excessive responsiveness of the autonomic nervous system, together with generalization of the responses through conditioning of anxiety to previously neutral stimuli.

11. Aetiology Personality .
Personality disorder. Generalized anxiety disorder occurs in people with anxious-avoidant personality disorders, but also in individuals with other personality disorders.

12. Aetiology Neurobiological mechanisms
The mechanisms are complex, involving several brain systems and several neurotransmitters.
Studies in animals have indicated a key role for the amygdala, which receives sensory information both directly from the thalamus and from a longer pathway involving the somatosensory cortex and anterior cingulate cortex.

13. DSM-5 Diagnostic Criteria for Generalized Anxiety Disorder
A. Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6months, about a number of events or activities (such as work or school performance).
B. The individual finds it difficult to control the worry.

14. DSM-5 Diagnostic Criteria for Generalized Anxiety Disorder
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 past 6 months):
Note: Only one item is required in children.

15. DSM-5 Diagnostic Criteria for Generalized Anxiety Disorder
1. Restlessness or feeling keyed up or on edge.
2. Being easily fatigued.
3. Difficulty concentrating or mind going blank.
4. Irritability.
5. Muscle tension.
6. Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep).

16. DSM-5 Diagnostic Criteria for Generalized Anxiety Disorder
D. The anxiety cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
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).

17. DSM-5 Diagnostic Criteria for Generalized Anxiety Disorder
F. The disturbance is not better explained by another mental disorder

18. Comorbidity
Other anxiety disorders (simple phobias, social phobia, panic disorder).
Depression/dysthymia.
Alcohol and drug problems.
Other physical conditions (e.g. IBS, HVS, atypical chest pain).

19. Differential diagnosis
Normal worries ;
Depression;
Mixed anxiety/depression,
Other anxiety disorders (the anxiety is more focused);
Drug and alcohol problems;
Medical conditions;
Side-effects of prescribed medications.

20. Course
Chronic and disabling.
Prognosis generally poor.

21. Treatment
Self-help and psychoeducation.
guided self-help

22. Treatment
lf practised regularly, relaxation appears to be able to reduce anxiety in less severe cases...

23. Treatment Cognitive- behaviour therapy
This treatment combines relaxation with cognitive pro edures designed to help patients to control worrying thoughts.

24. Pharmacotherapy
Among the first medications with demonstrated efficacy were the -aminobutyric acid (GABA) agonist benzodiazepines, such as alprazolam, diazepam, and lorazepam,( mainly for Somatic symptoms).

25. Pharmacotherapy
Selective serotonin reuptake inhibitors (SSRIs) have been considered first-line pharmacological treatment.

26. Pharmacotherapy
Buspirone - for Psychic symptoms (beneficial effects may take 2-4wks).
is similarly effective for short-term management of generalized anxiety disorder and is less likely to cause dependency, but has a slower onset of action.

27. Pharmacotherapy
The SNRIs venlafaxine XR and duloxetine were demonstrated efficacious,

28. Pharmacotherapy
Pregabalin, a GABA analogue that inhibits the release of excitatory neurotransmitters, has demonstrated efficacy for GAD in randomized placebo-controlled trials.

29. Pharmacotherapy
Beta-adrenergic antagonists (atenolol) __ are sometimes used to control anxiety associated with cardiovascular symptoms, sympathetic stimulation..

30. Physical
psychosurgery (very rare)__for severe/intractable anxiety.

31. Management
The steps in the management of such patients can be summarized as follows:
Check the diagnosis and comorbidity, especially depressive disorder, substance abuse, or a physical cause such as thyrotoxicosis. If any of these are present, treat them appropriately.

32. Management
Evaluate psychosocial maintaining factors such as persistent social problems, relationship conflict,

33. Management
Discuss the plan with the patient, the general practitioner, and the comummity team and allocate tasks and responsibility appropriately. Plans should recognize that generalized anxiety disorder is often a long-term problem.