What is Generalized Anxiety Disorder?

Patients with generalized anxiety disorder (GAD) often have characteristic appearances, such as twisted facial muscles, locked eyebrows, tight postures, and restlessness, and even trembling, pale skin, sweaty hands, feet, and armpits. It is worth noting that although patients are prone to crying, they are a reflection of widespread anxiety and do not indicate depression.

Generalized anxiety disorder; generalized anxiety disorder; generalized anxiety disorder; generalized anxiety disorder

Generalized anxiety disorder is characterized by frequent or persistent, comprehensive, anxiety and excessive anxiety without clear targets or fixed content. This anxiety has nothing to do with any particular situation around it, but is usually caused by excessive worry. The typical manifestation is often too much worry or annoyance about some problems in real life, such as worrying about yourself or relatives getting sick or having an accident, abnormally worrying about economic conditions, and excessively worrying about work or social ability. This kind of nervousness, anxiety or worry is very out of step with the reality, which makes the patient feel unbearable, but unable to get rid of it; often accompanied by hyperautonomic nervous system, exercise tension and excessive vigilance. Generally speaking,

Susceptibility factors

In anxiety disorders, heredity is an important susceptibility factor. According to research, the incidence of all anxiety disorders in monozygotic twins (MZ) is higher than that of dizygotic twins (DZ). However, most studies have not found genetic differences in the incidence of various anxiety disorders, so the specific role of genetics in generalized anxiety is unclear.

It is generally considered to be one of the predisposing factors for generalized anxiety disorder, but there is no firm evidence. Anxiety is a common emotional disorder in children. However, most anxious children can grow into healthy people, and not all anxious adults come from anxious children.

Anxious personality is related to anxiety disorders, but other personality traits can also prevent it from responding effectively to stressful events.

Triggers

The occurrence of general anxiety is often related to life stress events, especially threatening events such as interpersonal problems, physical illnesses, and work problems.

Persistence factor

The persistence of life stress events can lead to chronicity of widespread anxiety. At the same time, thinking can also make symptoms stubborn, such as fear that others will notice their anxiety, or that anxiety will affect their performance. Similar fears can create a vicious circle, making symptoms severe and persistent.

Neurobiology research

Functional imaging studies of normal subjects suggest that anxiety is mainly an increase in cerebral blood flow and metabolism, but when excessive ventilation and increased vascular tone cause vasoconstriction, anxiety is induced by decreased cerebral blood flow. Therefore, the changes in cerebral blood flow under anxiety state are not straight but change in a "U" shape. Most EEG studies have found reduced alpha wave activity, increased alpha wave frequency, and increased beta wave activity in patients with normal anxiety and neurotic anxiety. In addition, slow-wave activity in the form of , , and slow was observed in the anxious state.

Studies that affect blood and EEG suggest that the cortex on the right side of the frontal lobe may play a more important role in the perception and response to negative emotions such as anxiety. The aversive response to classical conditioned reflexes subsides more quickly and is more effective against defensive reflex suppression. Carter found that the cognitive manifestation of anxiety-anxiety is associated with high activity throughout the cortex, especially in the left hemisphere. Anxiety is not only a manifestation of anxiety, but it can be alleviated through verbal and logical reasoning, which can explain the role of high activity in the left hemisphere.

High alertness plays an important role in anxiety and it can lead to wakefulness and insomnia. Moderate arousal can increase attention and therefore behavioral performance. High arousal enhances conditioned reflexes, causing complex learning and behavioral disturbances. Anxious people sleep lightly and less, and various sleep disorders can be found in anxious patients, but generally speaking, the main reasons are prolonged sleep latency (decreased sleep time), reduced slow-wave sleep, increased susceptibility to awakening, and increased number of wakes.

Awakening levels are largely controlled by the brainstem, which plays an important role in the biology of anxiety. These include norepinephrine adrenergic blue nucleus nucleus, 5-HT energy raphe nuclei and para giant cell nuclei. Early biological theories of anxiety suggested that the blue nucleus plays a central role in the development of anxiety. Yohimbine (-2 norepinephrine adrenergic receptor antagonist) can increase the activity of the blue nucleus and induce anxiety. Clonidine, an agonist of the alpha-receptor, reduces the activity of the blue nucleus and reduces anxiety. The anxiolytic effect of other drugs can also reduce the activity of the blue nucleus, such as benzodiazepines and opioids.

Some researchers overly equate anxiety with arousal, and describe all behaviors in terms of intensity and avoidance of conflict. Awakening should not be equated with anxiety, as an increase in arousal levels is accompanied by both positive and negative emotional responses. Anxiety is a rise in arousal levels, which is accompanied by negative emotional characteristics. However, relative to the brain stem nucleus, the generation of emotional characteristics is more likely to come from the limbic system and the frontal lobe.

The limbic system consists of the amygdala, hippocampus, septum, and hypothalamus, which may be the site of the main emotions. It also plays an important role in learning and memory. Gray has established a theory based on data from animal studies that believes that the hippocampus system has a central role in anxiety. That is, the system is important for the induction and regulation of anxiety, and it produces effects through the input of norepinephrine and 5-HT. Stimuli from the frontal and cortical cingulate regions provide information to the hippocampal system to produce predictions of desired events, which are then compared to real events. Aversive events or a mismatch between endogenous predictions and events can activate a hypothetical behavioral suppression system to respond to arousal, attention, and anxiety. But LeDoux found that the amygdala may be more involved in the fear response than the hippocampus, that is, the amygdala is related to the acquisition of emotional (including anxiety-related) memories. If research has found that patients who undergo surgical removal of the amygdala can confirm their faces, they cannot identify the emotions expressed.

The right anterior frontal cortex engages in more emotional responses than the left. The left anterior frontal cortex specializes in language and writing, processes information in order, and suppresses the role of the amygdala. EEG and imaging studies suggest that anxiety can activate the right frontal cortex at least when sensory components are present. Recent studies suggest that the cerebellum is involved in frontal lobe function and regulates anxiety responses. In animal experiments, the fear response disappeared and the aggression decreased after the middle cerebellum injury. In imaging studies, patients with anxiety and obsessive-compulsive disorder have increased metabolic activity in the cerebellar vermiform and para- vermiform.

At present, studies have found that there are various neurotransmitters in the nervous system, including benzodiazepine-GABAergic, norepinephrine and 5-HT neurotransmitter system and adrenocorticotropin-releasing hormone pathway and anxiety. Biology is directly related. These transmitters not only have important significance in the occurrence, maintenance and elimination of anxiety, but also can cause certain physiological changes through neuroendocrine reactions. These physiological changes have a certain effect on the mood of anxiety, thereby changing the impact of anxiety on individuals.

Extensive anxiety research is far less intensive than panic disorder, but some data have also been accumulated.

Patients with generalized anxiety disorder often have other anxiety or affective disorders at the same time. According to Sanderson and Barlow (1990) analysis of the symptoms of 22 patients with generalized anxiety that met the DSM-III diagnostic criteria, 20 (91%) could make at least two diagnoses at the same time. 13 (59%) also had social phobia; 6 (27%) were also diagnosed with panic disorder; another 6 were also diagnosed with poor mood (depressive neurosis); and some also suffered from simple fear Disease (23%), obsessive-compulsive disorder (9%), and major depression (14%), and 73% had panic attacks during the course of the disease. Wittchen et al. (1991) also observed that in patients with anxiety disorder, 69% of the epidemiologically investigated cases, and 95% of clinical cases have two or more anxiety or depressive diseases coexisting (Comorbidity).

The changes in cerebral blood flow under anxiety state are not straight but change in a "U" shape. Most EEG studies have found reduced alpha wave activity, increased alpha wave frequency, and increased beta wave activity in patients with normal anxiety and neurotic anxiety. In addition, slow-wave activity in the form of , , and slow was observed in the anxious state.

According to ICD-10, the diagnosis of generalized anxiety must be anxiety symptoms for most of the period of at least several weeks, which usually lasts for more than 6 months. The anxiety symptoms include: Worry: If you are worried about the future, feel "anxious", pay attention Difficulty in concentration, often worrying too much, and having nervousness, irritability, etc .; Exercise stress, fatigue, poor sleep, restlessness, headache, tremor, unable to relax; Other high alert symptoms: such as sweating, increased heart rate , Dry mouth, stomach upset, dizziness, dizziness and other symptoms can diagnose the disease.

The main diagnostic point is that patients who meet the criteria for general anxiety always see themselves as annoying people. Seeking medical treatment is not so much to treat doubts, but rather to make them worry about things they worry about, such as children's Health, the significance of a symptom. Doctors should consider whether there are excessive concerns about patients who return to the hospital for these complaints or tension headaches or other manifestations of anxiety.

The above two types of anxiety disorders are primary and not secondary to organic diseases, schizophrenia, affective disorders and other types of neurological signs.

Characteristic enzyme

Serotonin, corticotropin, monoamine oxidase

General diagnosis is not difficult based on clinical manifestations and symptoms. In the diagnosis of panic disorder, attention should be paid to the exclusion of physical organic problems, such as frequent attacks and expected anxiety, which may be misdiagnosed as general anxiety disorder; certain physical diseases such as mitral valve prolapse may have similar panic attacks The symptoms should be identified. In the diagnosis of generalized anxiety, secondary anxiety caused by physical disorders such as hyperthyroidism, hypertension, coronary heart disease or withdrawal from addictive drugs should be excluded.

Distinguish from normal people's anxiety response during stress

Anxiety disorder has a strong emotional experience, with autonomic symptoms and motor restlessness. At the same time, the degree and duration of anxiety are extremely disproportionate to the actual "stimulation". The anxiety response of normal people does not fully have the above characteristics.

Specific physical illnesses can show similar symptoms

This possibility must be fully considered in any case, especially if there is no reasonable psychological explanation for its anxiety symptoms. Hyperthyroidism can cause irritability, restlessness, tremor, and tachycardia. At this time, physical examination can reveal goiter, slight tremor, and eyeball protrusion. If necessary, thyroid function tests can be performed. Pheochromocytoma and hypoglycemia can cause episodic anxiety.

Other physical diseases are more likely to cause anxiety through psychological mechanisms, such as patients fearing the fatal consequences of the disease. Such situations often occur when patients have special reasons to fear a serious consequence, such as the death of a patient's relatives due to similar clinical symptoms and progression of the disease. Therefore, it is necessary in clinical work to ask patients if they know other people with similar symptoms.

When general anxiety disorder is characterized by physical symptoms, it is easily misdiagnosed as other diseases. At this time, negative laboratory test results increased patient anxiety rather than relieved, because these results could not explain serious clinical symptoms. If clinicians consider the diversity of anxiety symptoms and recognize that palpitations, headaches, frequent urination, abdominal discomfort, and other symptoms listed in Table 2 may be clinical manifestations of widespread anxiety, similar misdiagnoses can be greatly reduced.

Schizophrenia

Patients with schizophrenia sometimes complain mainly of anxiety without obvious psychotic symptoms, and even deny it under direct inquiry. But careful questioning about the cause of the symptoms can reduce misdiagnosis, as patients will be exposed to strange ideas such as the perception of threatening effects around them. Anxiety symptoms can be seen in many mental illnesses, but they are not the main clinical phase of this kind of mental illness. The content of anxiety is not intrinsically related to the main symptoms of other mental illnesses. It should be noted that it is different from depression. Anxiety and depression can accompany it. In diagnosis, it is often determined by analysis of the sequence and severity of the two. Therefore, in the diagnosis of these two diseases, we must attach great importance to the collection of medical history and observation of their symptoms.

Depression

Compared with anxiety symptoms, the symptoms of depression are more serious. At the same time, the symptoms appear in different order. Anxiety symptoms first appear in general anxiety. Therefore, patients and their families should be asked at the same time as the medical history to confirm the diagnosis. Sometimes an agitated depressive episode is misdiagnosed as anxiety, but a careful inquiry into its symptoms can reduce misdiagnosis. Depression often has significant anxiety or agitation, and patients with generalized anxiety often have unpleasant lives due to long-term nervousness. The main point of identification is that patients with generalized anxiety disorder usually have anxiety symptoms first, and gradually feel like life after a long illness Unhappy; no diurnal mood changes; often difficult to fall asleep and sleep instability and rarely wake up early; autonomic symptoms are not as rich as depression; appetite is often not affected; more importantly, patients with this disease are not as depressed Disease like lack of interest or happiness. But the differential diagnosis of atypical depression may be more difficult. When the symptoms of depression and anxiety are obvious and meet the diagnostic criteria of the two diseases, two diagnoses are made at the same time. In addition, it is worth noting that the mental disorders identified with this disease include: somatization disorder, personality disintegration disorder, etc.

Among the symptoms of neurosis, mixed conditions are common. At this time, the type of symptoms should be identified, and the corresponding diagnosis can be made. However, it should be noted that the symptoms of depression are more dangerous and may lead to suicide. Therefore, we must master the principle of giving priority to the diagnosis of depression.

Alzheimer's and Alzheimer's

Sometimes Alzheimer's and Alzheimer's patients will complain mainly of anxiety, and clinicians often ignore their accompanying memory disorders or blame them for lack of concentration. Therefore, when elderly patients are accompanied by anxiety symptoms, their memory function should be carefully evaluated.

Withdrawal of psychoactive substances, alcohol or caffeine

Psychoactive substances, alcohol withdrawal, or caffeine abuse can all cause anxiety, which can often lead to misdiagnosis if patients hide their medical history. If the patient reports that anxiety is particularly severe in the early morning, it is suggestive of alcohol dependence (withdrawal response is often apparent at this time), but sometimes anxiety secondary to depressive disorder is also apparent in the early morning. ^[2]

Depressive disorders should be ruled out first, because patients with chronic illnesses are often accompanied by depressive disorders, and patients with depressive disorders can also show symptoms of anxiety. Including two parts of medication and psychotherapy.

medical treatement

Because general anxiety disorder recurs easily, various treatment periods should generally not be shorter than half a year; in some cases, medication needs to be maintained for 3 to 5 years to fully relieve it. The commonly used drugs are the following categories.

At present, benzodiazepines and buspirone are mainly used in clinical practice. The former should be used for panic attacks; one of them can be used for generalized anxiety disorder. Both drugs have anxiolytic effects. Common amount:

Benzodiazepines: such as

due to

The onset of panic attacks is sudden and intermittent. Onset of generalized anxiety is slow, and the course of the disease lasts for several years. Often there is no obvious incentive. Many patients often don't remember when they begin to show symptoms, thinking that this has been the case since childhood; they have never been anxious throughout their lives. The duration of panic disorder is longer and less spontaneous. The earlier the age of onset, the more severe the anxiety symptoms and the more impaired social functioning. The research conclusions on the prognosis are quite different, which may be due to different samples. Some people think that the recovery and improvement rate is 75%, and some people think that it is less than 50%. However, although the patient's symptoms persist, it will not lead to mental disability and social loss. It is worth noting that attention should be paid to suicide in anxiety disorder, and some scholars believe that suicide in anxiety disorder is not an isolated phenomenon.

Buspirone, norepinephrine, epinephrine, yohimbine, clonidine, alprazolam, laurazepam, clonazepam, nitrazepam, estazolam, diazepam, imipramine Triazine, venlafaxine, clomipramine, desipramine, fluoxetine, paroxetine, doxepin, trazodone, tianiptin, amitriptyline, oxygen, sodium valproate, carbon dioxide ^[5]

Generalized anxiety disorder is one of the most common anxiety disorders, accounting for 2% to 8% of the population. It is also one of the most common diagnoses in primary care. The age of onset of generalized anxiety varies greatly, ranging from 20 to 40 years. Both men and women develop generalized anxiety disorders, but there is no clear comparative study of the prevalence of men and women.

Blazer et. Wittchen et al. (1994) reported that the prevalence of this disease in the US population aged 15-45 years is 3.1% and the lifetime prevalence rate is 5.1%. About 90% of patients have other mental disorders during their lifetime.