Anxiety disorder with manifestations of generalized anxiety. Generalized anxiety disorder in adults. Clinical guidelines. course of generalized anxiety disorder

Generalized Anxiety Disorder (GAD) is an anxiety disorder characterized by excessive, uncontrollable and often irrational anxiety, a wary expectation of certain events or actions. Excessive anxiety interferes with daily activities, as people with GAD usually live in anticipation of unhappiness and are overly preoccupied with daily worries about health, money, death, family problems, friends problems, interpersonal problems, and difficulties at work. A variety of physical symptoms can often be observed in GAD, such as fatigue, inability to concentrate, headaches, nausea, numbness in the arms and legs, muscle tension, muscle pain, difficulty swallowing, fits of labored breathing, difficulty concentrating, tremors, muscle spasms, irritability, anxiety, sweating, restlessness, insomnia, hot flashes, rash, inability to control anxiety (ICD-10). For a diagnosis of GAD, these symptoms must be persistent and continuous for at least six months. Each year, GAD is diagnosed in approximately 6.8 million Americans and 2 percent of adults in Europe. GAD is 2 times more common in women than in men. The occurrence of this disorder is more likely in people who have experienced violence, as well as those who have a family history of GAD. GAD can become chronic once it occurs, but it can be controlled or completely eliminated with proper treatment. A standardized rating scale such as the GAD-7 is used to rate the severity of generalized anxiety disorder. GAD is the most common cause of disability in the US.

Causes

Genetics

About a third of the abnormalities associated with generalized anxiety disorder are due to genes. People with a genetic predisposition to GAD are more likely to develop GAD in the presence of stressful factors.

psychoactive substances

Long-term use of benzodiazepines can increase anxiety, and reducing the dosage leads to a decrease in anxiety symptoms. Long-term alcohol use is also associated with anxiety disorders. Prolonged abstinence from alcohol can lead to the disappearance of anxiety symptoms. It took about two years for a quarter of people in treatment for alcohol to have their anxiety levels return to normal. In a 1988-90 study, alcohol and benzodiazepine addiction linked about half of the cases of anxiety disorders (such as panic disorder and social phobia) in people receiving psychiatric care at a British psychiatric hospital. After stopping alcohol or benzodiazepines, their anxiety disorders worsened, but their anxiety symptoms improved with abstinence. Sometimes anxiety precedes the use of alcohol or benzodiazepines, but dependence on them only worsens the chronic course of anxiety disorders, contributing to their progression. Recovery from benzodiazepine use takes longer than recovery from alcohol, but it is possible. Tobacco smoking is a proven risk factor for the development of anxiety disorders. Use has also been linked to anxiety.

Mechanisms

Generalized anxiety disorder is associated with impaired functional communication between the amygdala and the processing of fear and anxiety. Sensory input enters the amygdala through the basolateral complex (which includes the lateral, basal, and adnexal basal ganglia). The basolateral complex processes sensory memories associated with fear and relays information about the importance of the threat to other parts of the brain (prefrontal cortex and postcentral gyrus) associated with memory and sensory information. The other part, namely the nearby central nucleus of the amygdala, is responsible for the response to species-specific fear, which is associated with the brainstem, hypothalamus and cerebellum. In people with generalized anxiety disorder, these connections are functionally less pronounced, and there is more gray matter in the central nucleus. There are other differences as well - the amygdala region has poorer connectivity to the insula and cingulate region responsible for general salience, and better connectivity to the parietal cortex and the prefrontal cortex circuit responsible for executive actions. The latter is probably the strategy needed to compensate for the dysfunction of the amygdala, which is responsible for feelings of anxiety. This strategy confirms cognitive theories, according to which anxiety levels are reduced by reducing emotions, which, in fact, is a compensatory cognitive strategy.

Diagnosis

DSM-5 Criteria

Diagnostic criteria for a diagnosis of generalized anxiety disorder (GAD), according to the Diagnostic and Statistical Manual of Mental Disorders DSM-5 (2013) published by the American Psychiatric Association, are:

A. Excessive anxiety and excitement (waiting with fear) prevailing for 6 months, the number of anxious days in most cases coincides with the number of events and activities (work or school activity).

B. Unrest is difficult to control.

B. Anxiety and agitation due to three of the following six symptoms (prevailing for 6 months):

Restlessness or feeling energized and on edge.

Fast fatiguability.

Difficulty concentrating or feeling "switched off".

Irritability.

Muscular tension.

Sleep disturbance (difficulty falling asleep, poor quality of sleep, insomnia).

It should be noted that the presence of one symptom is sufficient to determine GAD in children.

D. Anxiety, agitation, or physical symptoms resulting in clinically significant distress or impairment in social, occupational, or other important areas of life.

E. Anxiety is not related to the physiological effect of substances (eg, drugs that allow abuse) or other body disorders (eg, hyperthyroidism).

F. Anxiety cannot be explained by another psychiatric disorder (e.g. anxiety and anxiety associated with panic attacks seen in panic disorder, fear of negative appraisal in social anxiety disorder and social phobia, fear of dirt and other obsessions in anxiety disorder, fear of separation in anxiety disorder, caused by separation, a reminder of traumatic events in, fear of weight gain, complaints about the physical condition in somatic symptom disorder, impaired perception of one's body in body dysmorphic disorder, a feeling of serious illness in hypochondriacal disorder, delusions in and delusional disorder). Since the publication of the Diagnostic and Statistical Manual of Mental Disorders (2004), no notable changes have been made to the concept of generalized anxiety disorder (GAD), minor changes include revisions to the diagnostic criteria.

ICD-10 criteria

ICD-10 Generalized anxiety disorder "F41.1" Note: Alternate criteria apply for diagnosis in children (see F93.80).

A. A period of at least six months of marked tension, restlessness and anxiety, coinciding with the number of events and problems.

B. At least four of the following symptoms must be present, one of them must be from the first four items.

Symptoms of autonomic arousal:

(1) Palpitation, palpitations.

(2) Sweating.

(3) Trembling or shaking.

(4) Dry mouth (not due to medication or thirst)

Symptoms relating to the chest and abdomen:

(5) Labored breathing.

(6) Feeling of suffocation.

(7) Chest pain or discomfort.

(8) Nausea or abdominal upset (eg, grumbling in the abdomen).

Symptoms relating to the brain and intellect:

(9) Dizziness, staggering feeling, fainting or delirium.

(11) Fear of losing control, going crazy or losing consciousness.

(12) Fear of death.

General symptoms:

(13) Sudden fever or chills.

(14) Numbness or tingling sensations.

Stress Symptoms:

(15) Muscle tension and pain.

(16) Restlessness and inability to relax.

(17) Feeling locked in, on edge, or mental stress.

(18) Sensation of "lump in throat", difficulty in swallowing.

Other non-specific symptoms:

(19) Exaggerated reaction to sudden situations, torpor.

(20) Difficulty concentrating, feeling "switched off" due to excitement and anxiety.

(21) Prolonged irritability.

(22) Difficulty falling asleep due to restlessness.

B. The disorder does not meet the criteria for panic disorder (F41.0), phobic anxiety disorder (F40.-) or hypochondriacal disorder (F45.2).

D. Most commonly used exclusion criteria: Not caused by a medical condition such as hyperthyroidism, an organic psychiatric disorder (F0), a substance use disorder (F1) such as amphetamine-like substance abuse or benzodiazepine withdrawal.

Prevention

Treatment

Cognitive behavioral therapy is more effective than drugs (such as SSRIs), while both drugs reduce anxiety levels, cognitive behavioral therapy is more effective in combating depression.

Therapy

Generalized Anxiety Disorder is based on psychological components including cognitive avoidance, belief in positive anxiety, ineffective problem solving and emotional processing, intergroup problems, past trauma, low resistance to insecurity, focusing on negative phenomena, ineffective coping mechanism, emotional overstimulation , poor understanding of emotions, deceptive emotion control and regulation, experiential avoidance, behavioral restrictions. In order to successfully deal with the above cognitive and emotional aspects of GAD, psychologists often use techniques aimed at psychological intervention: social self-monitoring, relaxation techniques, self-control of desensitization, gradual stimulus control, cognitive restructuring, monitoring the results of anxiety, focusing on the present moment, living without expectations, problem solving techniques, basic fear processing, socialization, discussing and rethinking belief in anxiety, teaching emotion control skills, experiential exposure, psychological self-help training, nonjudgmental awareness and acceptance exercises. There are also behavioral therapies, cognitive therapies, and combinations of both for the treatment of GAD that focus on the above key components. Within CBT, the key components are Cognitive and Behavioral Therapy and Acceptance and Responsibility Therapy. Uncertainty tolerance therapy and motivational counseling are two new techniques in the treatment of GAD, both as stand-alone treatments and as adjuncts to enhance cognitive therapy.

Cognitive Behavioral Therapy

Cognitive Behavioral Therapy (CBT) is a psychological treatment for GAD that involves the therapist working with the patient to understand how thoughts and feelings affect behavior. The goal of this therapy is to change the negative thought patterns that lead to anxiety to more realistic and positive ones. Therapy includes the study of strategies aimed at making the patient gradually learn to resist anxiety, and become increasingly comfortable in anxiety-producing situations, as well as the practice of these strategies. Cognitive behavioral therapy may be accompanied by medication. The components of CBT for GAD are: psychoeducation, self-management, stimulus control techniques, relaxation, desensitization self-management, cognitive restructuring, anxiety disclosure, anxiety behavior modification, and problem-solving skills. The first step in the treatment of GAD is psychoeducation, which involves providing information to the patient about their disorder and treatment. The meaning of psychoeducation is to comfort, destigmatize the disorder, improve motivation for healing by talking about the treatment process, increase confidence in the doctor due to realistic expectations from the course of treatment. Self-management includes daily monitoring of the time and level of anxiety, as well as events that provoke anxiety. The point of self-monitoring is to identify anxiety-provoking factors. The method of stimulus control refers to the reduction of the conditions under which anxiety occurs. Patients are encouraged to set aside anxiety for a specific time and place chosen for anxiety, in which everything will be directed towards anxiety and problem solving. Relaxation techniques are designed to reduce stress in patients and provide them with alternatives in fearful situations (other than being anxious). Deep breathing exercises, progressive muscle relaxation, and relaxing falls are among the relaxation techniques. Self-desensitization is the practice of treating situations that cause anxiety and agitation in a state of deep relaxation until the underlying causes of the anxiety are addressed. Patients visualize how they cope with situations and reduce their anxiety levels in responses. When the anxiety subsides, they enter a state of deep relaxation and "turn off" the situations they represent. The point of cognitive reconstruction is to change a disturbing perspective into a more functional and adaptive one, focusing on the future and on oneself. This practice includes Socratic questions that force patients to look past their anxieties and concerns to understand that there are more powerful feelings and ways of interpreting what happened. Behavioral experiments are also used, in which the effectiveness of negative and positive thoughts in life situations is tested. In cognitive-behavioral therapy used to treat GAD, patients engage in anxiety-sensing exercises in which they are asked to imagine the worst possible outcome of the situations that frighten them. And, according to the instructions, instead of running away from the presented situations, patients are looking for alternative outcomes of the presented situation. The aim of this anxiety-revealing therapy is habituation and reinterpretation of the meaning of frightening situations. Prevention of anxious behavior requires the patient to monitor their behavior in order to identify the causes of anxiety and subsequent non-involvement in these disorders. Instead of involvement, patients are encouraged to use other coping mechanisms learned in the treatment program. Problem solving is focused on the actual problems, and is broken down into several steps: (1) identifying the problem, (2) formulating goals, (3) thinking of various solutions to the problem, (4) making a decision, and (5) executing and rechecking the solution. The feasibility of using cognitive-behavioral therapy for GAD is almost undeniable. Despite this, this therapy can be improved, as only 50% of people who receive CBT have returned to a highly functional life and a full recovery. Therefore, there is a need to improve the components of cognitive behavioral therapy. Cognitive Behavioral Therapy (CBT) helps one third of patients to a great extent, while having no effect on another third.

Acceptance and Commitment Therapy

Acceptance and Commitment Therapy (CBT) is a part of cognitive behavioral therapy based on the model of acceptance. TPE is designed with three therapeutic goals in mind: (1) reducing the number of strategies to avoid feelings, thoughts, memories and sensations; (2) reducing a person's literal response to their thoughts (i.e., understanding that the thought "I'm useless" does not mean that human life is actually meaningless) and (3) strengthening the ability to stick to a promise to change one's behavior. These goals are achieved by switching from trying to control events to working on changing one's behavior and focusing on directions and goals that are significant for a particular person, as well as forming the habit of maintaining behavior that will help a person achieve his goals. This psychological therapy teaches the skills of self-awareness (focusing attention on meaning in the present moment without judgment) and acceptance (openness and willingness to connect) that are applied in uncontrollable events. This helps a person during such events to adhere to behavior that promotes education and the assertion of his personal values. Like many other psychotherapies, TPO is most effective when combined with medication.

Uncertainty Tolerance Therapy

Uncertainty intolerance therapy is aimed at changing the constant negative reaction shown in relation to uncertainties and events, regardless of the likelihood of their occurrence. This therapy is used as an independent therapy for GAD. It builds tolerance in patients, the ability to cope and accept uncertainty in order to reduce anxiety levels. Uncertainty intolerance therapy is based on the psychological components of psychoeducation, knowledge about anxiety, problem-solving skills, reassessment of the benefits of anxiety, the presentation of virtual openness, awareness of uncertainty, and behavioral openness. In the conducted studies, the effectiveness of this therapy in the treatment of GAD was proved, in the period of follow-up of patients who underwent this therapy, the improvement in well-being progressed over time.

Motivational counseling

A promising innovative approach that can increase the percentage of patients cured after GAD. It consists of a combination of cognitive behavioral therapy with motivational counseling. Motivational counseling is a strategy to increase motivation and reduce ambivalence about the changes that result from treatment. Motivational counseling has four key elements; (1) expressing empathy, (2) identifying the mismatch between unwanted behavior and values ​​that are inconsistent with that behavior, (3) developing resilience instead of direct confrontation, and (4) encouraging self-confidence. This therapy is based on asking open-ended questions, listening carefully and thoughtfully to the patient's responses, "talking for change", and talking about the advantages and disadvantages of change. The combination of CBT with motivational counseling has been shown to be more effective than CBT on its own.

Drug therapy

SSRIs

Drug therapy prescribed for GAD includes selective serotonin reuptake inhibitors (SSRIs). They are first line therapy. The most common side effects of SSRIs are nausea, sexual dysfunction, headaches, diarrhea, constipation, anxiety, increased risk of suicide, serotonin syndrome, and others.

Benzodiazepines

Benzodiazepines are the most commonly prescribed drugs for GAD. Studies have suggested that benzodiazepines provide short-term relief of the disease. Despite this, there are certain risks when taking them, mainly a deterioration in the functioning of cognitive and motor functions, as well as the development of psychological and physical dependence, which complicates the withdrawal. People taking benzodiazepines have been shown to have reduced concentration at work and in school. In addition, non-diazepine drugs affect driving and increase the number of falls in older people, which leads to hip fractures. Given these shortcomings, the use of benzodiazepines is justified only as a short-term relief of anxiety. Cognitive behavioral therapy and medication are about the same effectiveness in the short term, but cognitive behavioral therapy is more effective than medication in the long term. Benzodiazepines (benzos) are fast-acting narcotic sedatives used to treat GAD and other anxiety disorders. Benzodiazepines are prescribed for the treatment of GAD and have a positive effect in the short term. The World Anxiety Council does not recommend long-term use of benzodiazepines, as it contributes to the development of resistance, psychomotor impairment, memory and cognitive impairment, physical dependence, and withdrawal symptoms. Side effects include: drowsiness, limited motor coordination, balance problems.

pregabalin and gabapentin

Psychiatric drugs

Selective serotonin-norepinephrine reuptake inhibitors (SNRIs) - (Effexor) and duloxetine (Cymbalta).

New, atypical serotonergic antidepressants - vilazodone (Viibrid), vortioxetine (Brintellix), (Valdoxan).

Tricyclic antidepressants - imipramine (Tofranil) and clomipramine (Anafranil).

Certain monoamine oxidase (MAO) inhibitors are moclobemide (Marplan) and, occasionally, phenelzine (Nardil).

Other medicines

Hydroxyzine (Atarax) is an antihistamine, a 5-HT2A receptor agonist.

Propranolol (Inderal) is a sympatholytic, beta-inhibitor.

Clonidine is a sympatholytic, α2-adrenergic receptor agonist.

Guanfacine is a sympatholytic, α2-adrenergic receptor agonist.

Prazosin is a sympatholytic, alpha-inhibitor.

Accompanying illnesses

GAD and depression

The National Study on Comorbid Pathology (2005) found that 58% of patients diagnosed with major depression also had an anxiety disorder. In these patients, the comorbidity rate was 17.2 percent for GAD, and 9.9 percent for panic disorder. Patients diagnosed with anxiety disorder had a high rate of comorbid depression, including 22.4 percent of patients with social phobia, 9.4 percent with agoraphobia, and 2.3 percent with panic disorder. According to a longitudinal cohort study, about 12% of subjects had GAD comorbid with MDD. These data suggest that patients with comorbid depression and anxiety have severe disease and less response to therapy than those with only one disorder. In addition, they have a lower standard of living and more problems in the social sphere. In many patients, the symptoms observed are not severe enough (i.e., subsyndromic) to warrant a primary diagnosis of major depressive disorder (MDD) or anxiety disorder. Despite this, dysthymia is the most common comorbid diagnosis in patients with GAD. They may also have a mixed anxiety-depressive disorder, with an increased risk of severe depression or an anxiety disorder.

GAD and substance abuse disorders

People with GAD also have long-term comorbid alcohol abuse (30%-35%) and alcohol dependence, as well as drug abuse and dependence (25%-30%). Those with both disorders (GAD and substance abuse disorder) have an increased risk of other comorbid disorders. It was found that in people suffering from a substance abuse disorder, slightly more than half of the 18 studied had GAD as the primary disorder.

Other comorbid disorders

In addition to comorbid depression, GAD has been shown to often correlate with stress-related conditions such as irritable bowel syndrome. Patients with GAD may experience symptoms such as insomnia, headaches, pain and cardiac events, and interpersonal problems. Another study suggests that 20 to 40 percent of people with attention deficit hyperactivity disorder also have comorbid anxiety disorders, of which GAD is the most common. GAD has not been included in the Global Burden of Disease project of the World Health Organization. Statistics on the level of the disease around the world are as follows:

Australia: 3 percent of adults.

Canada: about 3-5 percent of adults.

Italy: 2.9 percent.

Taiwan: 0.4 percent.

USA: about 3.1 percent of people over 18 in a given year (9.5 million).

Typically, GAD presents from early childhood to late adulthood, with a median age of onset of 31 years (Kessler, Berguland et al. 2005) and a median patient age of 32.7 years. According to most studies, GAD appears earlier than other anxiety disorders. The prevalence of GAD in children is about 3%, in adults - 10.8%. In children and adults diagnosed with GAD, the disorder begins at 8-9 years of age. Risk factors for the development of GAD are: low and medium socioeconomic status, living apart from a spouse, divorce, and widowhood. Women are twice as likely to be diagnosed with GAD than men. This is due to the fact that women are more likely than men to live in poverty, experience discrimination, and sexual and physical violence. GAD is most common among the elderly. Compared to the general population, patients with internalizing disorders such as depression, generalized anxiety disorder (GAD), and post-traumatic stress disorder (PTSD) have higher mortality rates but die from the same causes (cardiovascular disease, cerebrovascular disease, and cancer) as people their age.

Comorbidity and treatment

In a study that examined the comorbidity of GAD and other depressive disorders, it was confirmed that the effectiveness of treatment does not depend on the comorbidity of another disorder. The severity of symptoms does not affect the effectiveness of treatment in these cases.

:Tags

List of used literature:

Association, American Psychiatric (2013). Diagnostic and manual of mental disorders: DSM-5. (5th ed.). Washington, D.C.: American Psychiatric Association. p. 222. ISBN 978-0-89042-554-1.

Lieb, Roselind; Becker, Eni; Altamura, Carlo (2005). "The epidemiology of generalized anxiety disorder in Europe". European Neuropsychopharmacology 15(4): 445–52. doi:10.1016/j.euroneuro.2005.04.010. PMID 15951160.

Ballenger, JC; Davidson, JR; Lecrubier, Y; Nutt, DJ; Borkovec, T.D.; Rickels, K; Stein, DJ; Wittchen, H.U. (2001). "Consensus statement on generalized anxiety disorder from the International Consensus Group on Depression and Anxiety". The Journal of clinical psychiatry. 62 Suppl 11:53–8. PMID 11414552.

Generalized anxiety disorder is characterized by excessive, almost daily anxiety and restlessness 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. Diagnosis is based on history and physical examination. Treatment: psychotherapy, drug therapy, or a combination of both.

ICD-10 code

F41.1 Generalized anxiety disorder

Epidemiology

Generalized anxiety disorder (GAD) is quite common, with about 3% of the population getting sick during the year. Women get sick twice as often as men. GAD often begins in childhood or adolescence, but may begin at other ages.

Symptoms of Generalized Anxiety Disorder

The immediate cause for the development of anxiety is not as clearly defined as in other mental disorders (for example, the expectation of a panic attack, excitement in public, or fear of infection); the patient is anxious for many reasons, the anxiety varies over time. The most common concerns are professional commitments, money, health, safety, car repairs, and day-to-day responsibilities. To meet the criteria for the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV), the patient must have 3 or more of the following symptoms: restlessness, fatigue, difficulty concentrating, irritability, muscle tension, sleep disturbances. The course is usually fluctuating or chronic, worsening during periods of stress. Most patients with GAD also have one or more comorbid psychiatric disorders, including major depressive episode, specific phobia, social phobia, and panic disorder.

Clinical manifestations and diagnosis of generalized anxiety disorder

A. Excessive anxiety or worry (anxious anticipation) associated with a series of events or activities (such as work or school) that occurs most of the time for at least six months.

B. Anxiety is difficult to voluntarily control.

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

1. Anxiety, a feeling of agitation, a state on the verge of collapse.
2. Fast fatiguability.
3. Violation of concentration.
4. Irritability.
5. Muscular tension.
6. Sleep disorders (difficulty falling asleep and maintaining sleep, restless sleep, dissatisfaction with the quality of sleep).

Note: Children are only allowed to have one of the symptoms.

D. The direction of anxiety or anxiety is not limited to motives characteristic of other disorders. For example, anxiety or anxiety is not only related to having panic attacks (as in panic disorder), the possibility of being embarrassed in public (as in social phobia), the possibility of infection (as in obsessive-compulsive disorder), being away from home (as in separation anxiety disorder), weight gain (as in anorexia nervosa), the presence of numerous somatic complaints (as in somatization disorder), the possibility of developing a dangerous disease (as in hypochondria), the circumstances of a traumatic event (as in post-traumatic stress disorder).

E. Anxiety, restlessness, somatic symptoms cause clinically significant discomfort or disrupt the patient's life in social, professional or other important areas.

E. Disturbances are not caused by the direct physiological action of exogenous substances (including substances that cause dependence or drugs) or a general disease (for example, hypothyroidism), and also do not occur only with the onset of mood disorders, psychotic disorder, and are not associated with a general disorder development.

course of generalized anxiety disorder

Symptoms of generalized anxiety disorder are often observed in patients who visit general practitioners. Typically, such patients present vague somatic complaints: fatigue, muscle pain or tension, mild sleep disturbances. The lack of data from prospective epidemiological studies does not allow us to speak with confidence about the course of this condition. However, retrospective epidemiological studies suggest that generalized anxiety disorder is a chronic condition, as most patients had symptoms for many years prior to diagnosis.

Differential diagnosis of generalized anxiety disorder

Like other anxiety disorders, generalized anxiety disorder should be differentiated from other mental, somatic, endocrinological, metabolic, neurological diseases. In addition, when making a diagnosis, one should keep in mind the possibility of combination with other anxiety disorders: panic disorder, phobias, obsessive-compulsive and post-traumatic stress disorders. A diagnosis of generalized anxiety disorder is made when a full set of symptoms are present in the absence of comorbid anxiety disorders. However, in order to diagnose generalized anxiety disorder in the presence of other anxiety conditions, it is necessary to establish that anxiety and anxiety are not limited to the circumstances and themes characteristic of other disorders. Thus, a correct diagnosis involves identifying symptoms of generalized anxiety disorder in the absence or presence of other anxiety conditions. Since patients with generalized anxiety disorder often develop major depression, this condition also needs to be ruled out and correctly distinguished from generalized anxiety disorder. Unlike depression, in generalized anxiety disorder, anxiety and restlessness are not associated with affective disturbances.

Pathogenesis. Of all the anxiety disorders, generalized anxiety disorder is the least understood. The lack of information is partly due to the rather significant changes in views on this condition over the past 15 years. During this time, the boundaries of generalized anxiety disorder gradually narrowed, while the boundaries of panic disorder widened. The lack of pathophysiological data is also explained by the fact that patients are rarely referred to psychiatrists for the treatment of isolated generalized anxiety. Patients with generalized anxiety disorder usually have comorbid affective and anxiety disorders, and patients with isolated generalized anxiety disorder are rarely identified in epidemiological studies. Therefore, many pathophysiological studies are rather aimed at obtaining data to differentiate generalized anxiety disorder with comorbid affective and anxiety disorders, primarily with panic disorder and major depression, which are characterized by a particularly high comorbidity with generalized anxiety disorder.

Genealogical research. Conducting a series of twin and genealogical studies revealed differences between generalized anxiety disorder, panic disorder and major depression. The findings suggest that panic disorder runs in families differently than generalized anxiety disorder or depression; at the same time, the differences between the last two states are less distinct. Based on data from a study of adult female twins, scientists have suggested that generalized anxiety disorder and major depression have a common genetic basis, which is manifested by one or another disorder under the influence of external factors. The researchers also found an association between serotonin reuptake transporter polymorphisms and levels of neuroticism, which in turn is strongly associated with symptoms of major depression and generalized anxiety disorder. The results of a long-term prospective study in children supported this view. It turned out that the links between generalized anxiety disorder in children and major depression in adults are no less close than between depression in children and generalized anxiety disorder in adults, as well as 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 disorder and generalized anxiety disorder. Although a number of differences have been identified between the two conditions, both of them differ from the state of mentally healthy individuals in the same ways. For example, a comparative study of the anxiogenic reaction to the introduction of lactate or inhalation of carbon dioxide showed that in generalized anxiety disorder this reaction is increased compared to healthy individuals, and panic disorder differs from generalized anxiety disorder only in more pronounced shortness of breath. Thus, in patients with generalized anxiety disorder, the reaction 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, a flattening of the growth hormone secretion curve in response to the administration of clonidine was revealed - as in panic disorder or major depression, as well as a change in the variability of cardio intervals and indicators of the activity of the serotonergic system.

Diagnostics

Generalized Anxiety Disorder is characterized by frequent or persistent apprehensions and anxieties that arise from real events or circumstances that are of concern to the person, but are clearly excessive in relation to them. For example, students are often afraid of exams, but a student who is constantly worried about the possibility of failure, despite good knowledge and consistently high grades, may be suspected of generalized anxiety disorder. Patients with generalized anxiety disorder may not realize the excessiveness of their fears, but expressed anxiety causes them discomfort. To be diagnosed with generalized anxiety disorder, these symptoms must occur frequently for at least six months, the anxiety must be uncontrollable, and at least three of the six physical or cognitive symptoms must be present. These symptoms include: a feeling of anxiety, fatigue, muscle tension, insomnia. It should be noted that anxious fears are a common manifestation of many anxiety disorders. So, patients with panic disorder have fears about panic attacks, patients with social phobia - about possible social contacts, patients with obsessive-compulsive disorder - about obsessions or sensations. The anxiety in generalized anxiety disorder is more global than in other anxiety disorders. Generalized anxiety disorder is also seen in children. Diagnosis of this condition in children requires the presence of only one of the six somatic or cognitive symptoms specified in the diagnostic criteria.

The prevalence of generalized anxiety disorder (GAD) is 6%. The median age of onset was 31 years, and the median age of onset was 32.7 years. The prevalence in children is 3%, in adolescents - 10.8%. The age of onset in children and adolescents is between 10 and 14. There is evidence that women are 2-3 times more likely to develop GAD than men, and that GAD is more common in the elderly. This disorder often goes unrecognized and less than a third of patients receive adequate treatment. The situation is complicated by the fact that, perhaps, it is necessary to separate GAD in children and GAD in adults.

GAD is associated with functional impairment and deterioration in quality of life. At the initial visit to the doctor, 60-94% of patients with GAD complain of painful physical symptoms, and in 72% of cases this is the reason for seeking medical help.

We present to your attention an overview translation of clinical guidelines for the treatment of generalized anxiety disorder, compiled by experts from the Canadian Association of Anxiety Disorders. The translation was prepared jointly by the scientific Internet portal "Psychiatry & Neuroscience" and the Clinic of Psychiatry "Doctor SAN" (St. Petersburg).

Comorbidity

GAD is associated with a high rate of comorbid psychiatric disorders, including anxiety disorders and major depressive disorder. There is also an increased risk of somatic diseases, including pain syndromes, hypertension, problems with the cardiovascular system and stomach. The presence of comorbid depression increases the severity of the disease.

Diagnosis

GAD is characterized by increased anxiety and excitement (most of the days in the last six months) about a variety of events and activities, such as school or work. In addition, GAD has been associated with restlessness, muscle tension, fatigue, concentration problems, irritability, and sleep disturbances.

DSM-5 Criteria for Diagnosis of GAD

• Excessive anxiety and excitement (anxious anticipation) about a variety of events and activities, such as school or work.
• The person has difficulty controlling anxiety
• Excessive anxiety and excitement is associated with at least three of the following symptoms that bother a person most days for at least six months:
  • Restlessness or feeling “on edge”, “on edge”, easy fatigue, difficulty concentrating, irritability, muscle tension or sleep disturbances
• Disorder causes clinically significant distress or functional impairment

Psychological help

Meta-analyses clearly show that CBT significantly improves the symptoms of GAD. A small number of studies have compared CBT and pharmacotherapy, which have shown approximately the same strength of effect. Individual and group psychotherapy are equally effective at reducing anxiety, but individual psychotherapy may reduce anxiety and depressive symptoms more quickly.

The intensity of psychotherapy was assessed in a meta-analysis of 25 studies. For reducing anxiety, a course of psychotherapy lasting less than eight sessions is as effective as a course lasting more than eight sessions. For reducing anxiety and depression, more intensive courses are more effective than courses with a small number of sessions. Several studies have shown the benefit of ICBT.

The meta-analysis found no significant difference between the effects of CBT and relaxation therapy. However, more recent research suggests limited effectiveness of relaxation therapy. A large RCT found that balneotherapy, a relaxation therapy with spa treatments, was better than SSRIs at reducing anxiety; however, there are doubts about the correctness of the study.

The effectiveness of behavioral psychotherapy based on acceptance, metacognitive psychotherapy, CBT, aimed at correcting the perception of uncertainty, based on awareness of cognitive therapy, has been proven.

Psychodynamic psychotherapy can also work, but there is currently no clear evidence of its effectiveness.

The addition of Interpersonal and Emotional Process Therapy to CBT does not provide significant benefits compared to CBT without additions. Pre-talk before starting a CBT course helps reduce resistance to therapy and improve compliance, a strategy that is especially helpful in severe cases.

Combination of psychotherapy and pharmacological treatment

Few data are available on the use of a combination of psychotherapy and pharmacological treatment. A meta-analysis has shown that the combination of pharmacological treatment with CBT is more effective than CBT alone when comparing the results immediately after the course of treatment, but not after six months. Data from studies comparing the combination of diazepam or buspirone plus CBT with CBT alone are available. The small number of studies comparing pharmacotherapy with pharmacotherapy to which psychotherapy has been added provide inconsistent results.

There is currently no rationale for combining CBT with pharmacotherapy. But, as with other anxiety disorders, if the patient does not improve after CBT, pharmacotherapy is recommended. Similarly, if pharmacotherapy does not improve, then CBT can be expected to work. Meta-analyses and several RCTs report retention of psychotherapy outcomes for 1-3 years after treatment.

Pharmacological treatment

In the treatment of GAD, the effectiveness of SSRIs, SNRIs, TCAs, benzodiazepines, pregabalin, quetiapine XR has been proven.

First line

Antidepressants (SSRIs and SNRIs): RCTs support the efficacy of escitalopram, sertraline, and paroxetine, as well as duloxetine and venlafaxine XR. The effectiveness of SSRIs and SNRIs is the same. There is evidence that escitalopram is less effective than venlafaxine XR or quetiapine XR.

Other antidepressants: There is evidence that agomelatine is as effective as escitalopram.

Pregabalin: Pregabalin is as effective as benzodiazepines (LE: 1).

Second line

Benzodiazepines: Alprazolam, bromazepam, diazepam and lorazepam have been shown to be effective (level of evidence 1). Although the level of evidence is high, these drugs are recommended as second-line treatment and usually for short-term use due to side effects, dependence, and withdrawal.

TCAs and other antidepressants: Imipramine is as effective as benzodiazepines in the treatment of GAD (LE: 1). But due to side effects and potentially toxic overdose, imipramine is recommended as a second-line agent. There is little data on bupropion XL, but there is a study in which it showed the same effectiveness as escitalopram (a first-line agent), so it can be used as a second-line agent.

Vortioxetine, the so-called serotonin modulator, acts on various serotonin receptors. The results of studies on the effectiveness of vortioxetine are conflicting, but there is evidence in favor of its use in GAD.

Quetiapine XR: The efficacy of Quetiapine XR has been proven and is equivalent to that of antidepressants. But quetiapine is associated with weight gain, sedation, and a higher dropout rate compared to antidepressants due to side effects. Because of the tolerability and safety concerns of atypical antipsychotics, this drug is recommended as a second-line treatment for patients who cannot take antidepressants or benzodiazepines.

Other drugs: Buspirone has been shown to be as effective as benzodiazepines in several RCTs. There are insufficient data to compare buspirone with antidepressants. Due to the lack of efficacy in clinical practice, buspirone should be classified as second-line drugs.

Hydroxyzine has shown efficacy close to that of benzodiazepines and buspirone, but clinical experience with this drug in GAD is lacking.

third line

Third-line drugs include drugs with poorly studied efficacy, side effects, and are rarely used as primary treatment for GAD.

Complementary drugs

The strategy of using additional drugs has been studied in patients who have not responded adequately to SSRI treatment and may be used in cases of resistant GAD.

Additional second-line drugs: Pregabalin as an adjunct to the main drug has been shown to be effective in the treatment of patients who have not responded to previous treatment (Evidence level 2).

Complementary third-line drugs: The meta-analysis showed no improvement with the use of atypical antipsychotics as add-on medications, but did show an increase in discontinuation rates. Conflicting results show studies on the effectiveness of risperidone and quetiapine as additional drugs.

Due to weak evidence of efficacy, risk of weight gain, and metabolic side effects, atypical antipsychotics should be reserved for resistant cases of GAD and, with the exception of quetiapine XR, should only be used as an adjunct to the main drug.

Supportive pharmacological therapy

A meta-analysis showed that long-term use of SSRIs (6-12 months) was effective in preventing relapse (odds ratio of relapse = 0.20).

Relapse after 6-18 months of taking duloxetine, escitalopram, paroxetine and venlaaxin XR was observed in 10-20% of cases, compared with 40-56% in the control group. Continuing pregabalin and quetiapine XR also prevents relapse after 6-12 months.

Long-term RCTs have shown that escitalopram, paroxetine and venlafaxine XR help maintain a positive result for six months.

Biological and alternative therapies

In general, these treatments may be beneficial for some patients, but data are scarce.

Biological Therapy: One small study found rTMS to be effective as monotherapy and as an adjunct to SSRIs (Evidence level 3).

Alternative therapy: Lavender oil (Evidence level 1) and Galphemia glauca extract (Evidence level 2) have shown efficacy comparable to that of lorazepam. A Cochrane meta-analysis reports two studies showing passionflower as effective as benzodiazepines (Evidence Level 2) and one study showing no effect of valerian. Unfortunately, herbal preparations are not well standardized and vary greatly in the proportion of the active substance, so they cannot be recommended.

An RCT of strength training or aerobic exercise as an adjunct to mainstream treatment showed significant improvement in symptoms (LE: 2). A review of studies on the effectiveness of acupuncture showed that all studies show a positive effect, but due to the methodological features of the studies, the effectiveness of this type of treatment cannot be considered proven. There are studies suggesting that meditation and yoga may be helpful in the treatment of GAD (Evidence level 3).

Generalized Anxiety Disorder is a mental disorder in which a person develops general, persistent anxiety that is not associated with specific objects or situations. This disease is quite common, according to statistics, every year about 3% of the world's population reveal signs of a generalized anxiety disorder: constant nervousness, trembling throughout the body, muscle tension, sweating, tachycardia, dizziness, discomfort and discomfort in the solar plexus. A person lives with a constant feeling of anxiety, anxiety, fear for himself and for the health of his loved ones, a premonition of trouble, illness, death.

This mental disorder is most common in women and is usually associated with severe traumatic situations or is a consequence of chronic stress. Generalized anxiety disorder has an undulating course and most often becomes chronic.

Causes

There are several reasons for the development of generalized anxiety disorder: chronic alcohol dependence, chronic stress, the presence of panic attacks in patients. It can also be one of the symptoms of depression.

The development of constant anxiety in humans has a neurophysiological mechanism.

A. Beck developed a cognitive theory of the occurrence of generalized anxiety disorders. He believes that anxiety is a person's response to perceived danger. People who constantly suffer from anxious thoughts have a distorted reaction to the perception and processing of information, as a result of which they consider themselves powerless in the face of the prevailing life problems. The attention of patients with constant anxiety is selectively directed precisely at the probable danger. On the one hand, this mechanism allows a person to adapt to external circumstances, and on the other hand, anxiety occurs constantly and is not controlled by a person. Such reactions and manifestations create a "pathological circle" of the disease.

The patient, as a rule, does not realize the excessiveness of his fears, but they cause discomfort to a person, poison his life. A person with generalized anxiety disorder may skip college or stop going to work. This disease is manifested not only in adults, symptoms can occur in children and adolescents. Generalized anxiety disorder in a child may occur due to separation from the mother, unexpected or frightening circumstances, or because adults deliberately bully children "for the purpose of education." Often there is a fear in children before attending a kindergarten or school, after a situation that frightens them or a conflict with peers or teachers has arisen there.

Risk factors

Clinical manifestations

For a diagnosis of generalized anxiety disorder, a patient must have symptoms of anxiety for several weeks to several months.

Patients with symptoms of this disease look pale, tired, their torso is tense, their eyebrows are furrowed and drawn together, their hands and head are trembling. When talking, they show vegetative reactions: diffuse red spots on the chest, vascular white spots on the upper and lower extremities, sweating of the palms, feet, and armpits. The patient is tearful and depressed.

Usually a person cannot articulate exactly what scares him. There is no such area of ​​his life that would not bother him. Students may have a fear of passing exams or an important test, although there are no objective reasons for such a pronounced concern (the student prepared, taught, and he always has good grades).

A woman with generalized anxiety disorder constantly worries about the life and health of her children, if she returns home and sees an ambulance near the entrance, then she has only one thought that a terrible thing happened to her child. The consciousness of a woman paints a picture of a terrible illness or even death. Arriving home, and making sure that all her close and dear people are alive and well, and an ambulance has arrived at an unfamiliar neighbor, a woman can throw out all her emotions and feelings on unsuspecting children. In family life, such people bring discord and constant nervous tension with their violent reactions, anxieties and experiences.

People with generalized anxiety disorder show insufficient emotional participation in interpersonal contacts and in the social aspects of life.

A distinctive feature of patients with symptoms of this disease is that for them a painful state of uncertainty.

Most often, patients do not assess their increased anxiety as a mental disorder and turn to doctors with complaints of digestive, respiratory, cardiovascular problems, and insomnia.

Diagnostics

The psychiatrist examines the patient, collects an anamnesis, finds out hereditary predisposition to mental illness, bad habits (chronic nicotine intoxication, alcohol, drugs, caffeinated drinks, drug addiction). In a patient with generalized anxiety disorder, it is necessary to exclude somatic pathology, including thyrotoxicosis. It is also necessary to conduct a differential diagnosis with panic attacks and psychopathy, social phobias, hypochondria, obsessive-compulsive disorder, and depression.

Increased anxiety requires timely diagnosis and treatment, as it affects the course and prognosis of concomitant somatic pathology.

Therapy

The main goal of treating generalized anxiety disorders is to relieve the main symptoms of the disease - the patient's chronic anxiety, reduce muscle tension, autonomic manifestations and normalize sleep. The main methods of therapy for this disease are psychotherapy and drug treatment. It is necessary to exclude the patient from chronic caffeine intoxication, alcohol consumption, smoking, drug dependence.

The main drugs for the treatment of generalized anxiety disorders are anxiolytics and antidepressants. To eliminate unpleasant symptoms from the cardiovascular system, beta-blockers are prescribed. Drug treatment is prescribed to the patient in the case when the symptoms of increased anxiety do not allow a person to live, study, work.

Anxiolytics and antidepressants must be prescribed under the supervision of a doctor, the dosage should be effective, but safe.

Of the antidepressants, drugs from the group of selective serotonin reuptake inhibitors (paroxetine), tricyclic antidepressants (imipramine) are mainly prescribed. Very often, drugs from the group of benzodiazepines (clonazepam, phenazepam, diazepam, alprozalam) are used in the treatment of generalized anxiety disorders. With prolonged use of these drugs, dependence is formed, the sensitivity of receptors to them decreases (to achieve a therapeutic effect, an increase in the dose of the drug is required), and side effects appear.

Some patients with symptoms of constant anxiety begin to independently use Corvalol and Valocardin in the treatment, these drugs contain phenobarbital, they can be purchased at a pharmacy without a doctor's prescription. But some time after the use of these drugs, barbituric dependence (one of the most severe forms of drug dependence) occurs.

If a person has an excessive daily feeling of restlessness and anxiety for six months, we can talk about generalized anxiety disorder (GAD).

Causes of Generalized Anxiety Disorder

The exact causes of the development of the disease are unknown. Often it can be found in patients suffering from alcohol dependence, as well as from panic attacks and severe depression.

This disease is quite common. According to statistics, about 3% of the world's population falls ill every year. Moreover, women get sick twice as often as men. You can often meet the disease in children and adolescents, but generalized anxiety disorder also occurs in adults.

The disease is characterized by constant anxiety and fear arising from various circumstances or events that clearly do not require such unrest. Students, for example, may have an excessive fear of exams, even if they have good knowledge and high marks. Patients with GAD often do not realize the excessiveness of their fears, but the constant anxiety causes them discomfort.

For GAD to be diagnosed with certainty, its symptoms must have been present for at least six months, and the anxiety must be uncontrolled.

Symptoms of Generalized Anxiety Disorder

In GAD, the immediate cause for anxiety is not as clear-cut as in various panic attacks. The patient may be worried for a variety of reasons. The most common concerns are professional commitments, constant lack of money, safety, health, car repairs, or other day-to-day responsibilities.

The characteristic symptoms of generalized anxiety disorder are: increased fatigue, anxiety, irritability, impaired concentration, sleep disturbance, muscle tension. It should be noted that most patients with GAD already have one or more psychiatric disorders, including panic disorder, depressive or social phobia, etc.

Clinically, GAD manifests itself as follows: the patient feels constant anxiety and tension caused by a series of events or actions for six or more months. He cannot control this anxiety state, and it is accompanied by the above symptoms.

For the diagnosis of GAD in children, the presence of at least one of the six symptoms is sufficient. A diagnosis of generalized anxiety disorder in adults requires at least three symptoms.

In GAD, the focus of worry and anxiety is not limited to the motives that are characteristic of other anxiety disorders. So, anxiety and anxiety are not associated solely with the fear of panic attacks (panic disorder), fear of large crowds (social phobia), weight gain (anorexia nervosa), fear of separation in childhood (separation anxiety disorder), the possibility of getting a dangerous disease (hypochondria). ) and others. Anxiety causes discomfort in the patient and prevents him from leading a full life.

Typically, the symptoms of generalized anxiety disorder are caused by a number of physical disorders (such as hypothyroidism) and medications or drugs.

Risk factors

The chances of getting GAD increase when the following factors are present:

• female;
• low self-esteem;
• susceptibility to stress;
• smoking, drinking alcohol, drugs or addictive drugs;
• prolonged exposure to one or more negative factors (poverty, violence, etc.);
• family members with anxiety disorders.

Diagnosis of Generalized Anxiety Disorder

At the consultation, the doctor performs a physical examination of the patient, asks him about the history and symptoms of the disease. Diagnosis of the disease involves testing to look for other diseases that may have caused GAD (eg, thyroid disease).

The doctor asks the patient what medications they are taking, as some of them can cause serious side effects similar to the symptoms of GAD. Also, the doctor will definitely ask if the patient is addicted to tobacco, alcohol or drugs.

An accurate diagnosis of GAD is made when the following factors are present:

• symptoms of GAD continue for six months or more;
• they cause significant discomfort to the patient and prevent him from leading a full life (for example, the patient is forced to skip school or work);
• GAD symptoms are persistent and uncontrolled.

Treatment for Generalized Anxiety Disorder

Typically, treatment for generalized anxiety disorder consists of the following:

Medicines to treat generalized anxiety disorder include:

• Benzodiazepines, which help relax muscles and prevent them from tightening up in response to anxious thoughts. These medicines are taken under the strict supervision of a doctor, as they can be addictive.
• Anxiety medications such as Buspirone, Alprazolam;
• Antidepressants (mainly serotonin reuptake inhibitors).
• Beta-blockers to relieve the physical symptoms of GAD.

For the most successful treatment of GAD, it is important to identify the disease as early as possible, as this reduces the risk of severe psychological complications.

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