Generalized anxiety disorder (GAD) is an anxiety disorder that is characterized by excessive, uncontrollable and often irrational worry. For diagnosis of this disorder, symptoms must last at least six months.[1] This excessive worry often interferes with daily functioning, as individuals suffering GAD typically anticipate disaster, and are overly concerned about everyday matters such as health issues, money, death, familyproblems, friendship problems, interpersonal relationship problems, or work difficulties.[2] Individuals often exhibit a variety of physical symptoms, including fatigue, fidgeting, headaches, nausea, numbness in hands and feet, muscle tension, muscle aches, difficulty swallowing, bouts of difficulty breathing, difficulty concentrating, trembling, twitching, irritability, agitation, sweating, restlessness, insomnia, hot flashes, and rashesand inability to fully control the anxiety (ICD-10).[3] These symptoms must be consistent and ongoing, persisting at least six months, for a formal diagnosis of GAD to be introduced.[2]
In any given year, approximately 6.8 million American adults and two percent of European adults experience GAD.[4][5] GAD is seen in women twice as much as men. GAD is also commonly seen in individuals with a history of substance abuse and a family history of the disorder.[6] Once GAD develops, it may become chronic, but can be managed or eliminated with proper treatment.[7]
Standardized rating scales such as GAD-7 can be used to assess severity of generalized anxiety disorder symptoms.[8] GAD is the most common cause of disability in the workplace in the United States.[9]
Mechanisms
Generalized anxiety disorder has been linked to disrupted functional connectivity of the amygdala and its processing of fear and anxiety.[21] Sensory information enters the amygdala through the nuclei of the basolateral complex (consisting of lateral, basal and accessory basal nuclei). The basolateral complex processes the sensory-related fear memories and communicates their threat importance to memory andsensory processing elsewhere in the brain, such as the medial prefrontal cortex and sensory cortices.
Another area, the adjacent central nucleus of the amygdala, controls species-specific fear responses in its connections to the brainstem, hypothalamus and cerebellumareas. In those with generalized anxiety disorder these connections functionally seem to be less distinct, and there is greater gray matter in the central nucleus. Another difference is that the amygdala areas have decreased connectivity with the insulaand cingulate areas that control general stimulus salience, while having greater connectivity with the parietal cortex and prefrontal cortexcircuits that underlie executive functions.[21] The latter suggests a compensation strategy for dysfunctional amygdala processing of anxiety. This is consistent with cognitive theories that suggest the use in this disorder of attempts to reduce the involvement of emotions with compensatory cognitive strategies.[21]
Diagnosis
ICD-10 criteria[edit]
ICD-10 Generalized anxiety disorder "F41.1"
Note: For children different criteria may be applied (see F93.80).
Note: For children different criteria may be applied (see F93.80).
A. A period of at least six months with prominent tension, worry and feelings of apprehension, about everyday events and problems.
B. At least four symptoms out of the following list of items must be present, of which at least one from items (1) to (4).
B. At least four symptoms out of the following list of items must be present, of which at least one from items (1) to (4).
- Autonomic arousal symptoms
- (1) Palpitations or pounding heart, or accelerated heart rate.
- (2) Sweating.
- (3) Trembling or shaking.
- (4) Dry mouth (not due to medication or dehydration).
- Symptoms concerning chest and abdomen
- (5) Difficulty breathing.
- (6) Feeling of choking.
- (7) Chest pain or discomfort.
- (8) Nausea or abdominal distress (e.g. churning in stomach).
- Symptoms concerning brain and mind
- (9) Feeling dizzy, unsteady, faint or light-headed.
- (10) Feelings that objects are unreal (derealization), or that one's self is distant or "not really here" (depersonalization).
- (11) Fear of losing control, going crazy, or passing out.
- (12) Fear of dying.
- General symptoms
- (13) Hot flushes or cold chills.
- (14) Numbness or tingling sensations.
- Symptoms of tension
- (15) Muscle tension or aches and pains.
- (16) Restlessness and inability to relax.
- (17) Feeling keyed up, or on edge, or of mental tension.
- (18) A sensation of a lump in the throat, or difficulty with swallowing.
- Other non-specific symptoms
- (19) Exaggerated response to minor surprises or being startled.
- (20) Difficulty in concentrating, or mind going blank, because of worrying or anxiety.
- (21) Persistent irritability.
- (22) Difficulty getting to sleep because of worrying.
C. The disorder does not meet the criteria for panic disorder (F41.0), phobic anxiety disorders (F40.-), obsessive-compulsive disorder (F42.-) or hypochondriacal disorder (F45.2).
D. Most commonly used exclusion criteria: not sustained by a physical disorder, such as hyperthyroidism, an organic mental disorder (F0) or psychoactive substance-related disorder (F1), such as excess consumption of amphetamine-like substances, or withdrawal from benzodiazepines.[3]
D. Most commonly used exclusion criteria: not sustained by a physical disorder, such as hyperthyroidism, an organic mental disorder (F0) or psychoactive substance-related disorder (F1), such as excess consumption of amphetamine-like substances, or withdrawal from benzodiazepines.[3]
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