Generalized anxiety disorder is a mental disorder that is characterized by a state of persistent general anxiety that is not related to a specific situation or object.

Symptoms of generalized anxiety disorder include: constant nervousness, muscle tension, trembling, palpitations, sweating, dizziness, and discomfort in the solar plexus area. Patients often experience fear of an accident or illness in themselves or their loved ones, and other forebodings and worries.

The disorder is most common among women. The disease often begins in childhood or adolescence.

Medication and psychotherapy are used to treat this mental disorder.

Causes of generalized anxiety disorder

According to A. Beck's cognitive theory, individuals who are prone to anxious reactions exhibit a persistent distortion in the perception and processing of information. As a result, they begin to consider themselves incapable of overcoming various difficulties and controlling what is happening in the environment. Patients with anxiety focus their attention on possible danger. On the one hand, they are firmly convinced that anxiety helps them adapt to the situation, on the other hand, they consider it an uncontrollable and dangerous process.

There are also theories that suggest that panic disorders are hereditary.

In psychoanalysis, this type of mental disorder is considered as the result of an unsuccessful unconscious defense against anxiety-provoking destructive impulses.

Symptoms of generalized anxiety disorder

Generalized anxiety disorder is characterized by frequent fears and worries about actual circumstances and events that cause the person to become overly concerned about them. However, patients with this type of disorder may not realize that their fears are excessive, but severe anxiety makes them feel uncomfortable.

In order to diagnose this mental disorder, it is necessary that its symptoms persist for at least six months, the anxiety is uncontrollable, and at least three cognitive or somatic symptoms of generalized anxiety disorder are detected (at least one in children).

Clinical manifestations (symptoms) of generalized anxiety disorder in adults and children include:

excessive worry and anxiety that are associated with events or actions (study, work) that occur almost constantly;

difficulty controlling anxiety;

accompanied by restlessness and anxiety by at least 3 out of 6 symptoms:

feeling nervous, restless, on the verge of a breakdown;
impaired concentration;
fatigue;
irritability;
sleep disturbance;
muscle tension.

the focus of anxiety is not associated with only one specific phenomenon, for example, panic attacks, the possibility of being embarrassed in public, the possibility of infection, weight gain, the development of a dangerous disease, and others; the patient expresses anxiety about many reasons (money, professional obligations, safety, health, daily responsibilities);

disruption of the patient’s life in the social or professional sphere due to the presence of constant anxiety, somatic symptoms that lead to clinically significant discomfort;

the disorders are not caused by the direct action of exogenous substances or any disease and are not associated with developmental disorders.

Most patients with generalized anxiety disorder also have one or more other mental disorders, including specific phobia, major depressive episode, panic disorder, and social phobia.

Patients with this disorder turn to doctors for help even in cases where they do not have other somatic or mental illnesses.

Adults with anxiety symptoms are 6 times more likely to visit a cardiologist, 2 times more likely to see a neurologist, and 2.5 times more likely to see a rheumatologist, urologist, and otolaryngologist.

Treatment for generalized anxiety disorder

When treating generalized anxiety disorder in adults and children, adherence to a daily routine is of great importance.

Physical activity also plays an important role. Physical activity should be such that by the evening a person falls asleep from fatigue.

Drug treatment of generalized anxiety disorder involves the use of various groups of drugs:

sedative-type antidepressants. The most commonly used are amitriptyline, paxil, mirtazapine, and azaphen.
neuroleptics. Unlike anxiolytics, they have such a positive property as the absence of addiction to them. The most commonly used drugs are eglonil, thioridazine, and teraligen.

In some cases, low doses of seroquel, haloperidol, and rispolept are used; with pronounced demonstrative radical - low doses of chlorpromazine.

Additionally, vitamins, mood stabilizers, metabolic, and nootropic drugs can also be used.

But treatment is not limited to just medications and a proper lifestyle.

Another important method of treating generalized anxiety disorder is psychotherapy.

At the onset of the disease, with good sensitivity of patients, sessions of directive hypnosis (hypnosuggestive therapy) are recommended. When the patient is in a hypnotic trance, the psychotherapist instills in him the attitude of good susceptibility to drug treatment, recovery, solution of internal problems that are revealed during hypnoanalysis; stable instructions are given to relieve internal tension, normalize appetite, sleep, and improve mood.

At the beginning of treatment, about ten sessions of individual hypnosis are necessary, then sessions can be group and repeated about 1-2 times during the month.

The treatment also uses cognitive-behavioral group psychotherapy, which can be supportive and problem-oriented.

Biofeedback, relaxation techniques (applied relaxation, progressive muscle relaxation), and breathing exercises (eg, abdominal breathing) will be helpful to a certain extent.

Generalized anxiety disorder is a fairly common mental disorder with an undulating chronic course, causing a decrease in quality of life and ability to work, depression and aggravating the course of somatic diseases. Therefore, this disease requires prompt diagnosis and appropriate therapy.

Generalized anxiety disorder (GAD) is an anxiety disorder characterized by excessive, uncontrollable and often irrational worry and anxious anticipation of certain events or actions. Excessive worry interferes with daily activities because people with GAD tend to live in anticipation of unhappiness and are overly preoccupied with daily concerns about health, money, death, family problems, problems with friends, interpersonal problems, and difficulties at work. GAD often involves a variety of physical symptoms, such as fatigue, inability to concentrate, headaches, nausea, numbness in the arms and legs, muscle tension, muscle pain, difficulty swallowing, wheezing, difficulty concentrating, trembling, muscle twitching, irritability, anxious agitation, sweating, restlessness, insomnia, hot flashes, rash, inability to control anxiety (ICD-10). To be diagnosed with 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 with a family history of GAD. Once GAD occurs, it can become chronic, but it can be brought under control or completely eliminated with proper treatment. A standardized rating scale, such as the GAD-7, is used to assess the severity of generalized anxiety disorder. GAD is the most common cause of disability in the United States.

Reasons

Genetics

About a third of the abnormalities associated with generalized anxiety disorder are determined by genes. People with a genetic predisposition to GAD are more likely to develop GAD when exposed to stressors.

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. Long-term abstinence from drinking alcohol can lead to the disappearance of anxiety symptoms. A quarter of people receiving treatment for alcohol addiction took about two years for their anxiety levels to return to normal. In a study conducted in 1988-90, dependence on alcohol and benzodiazepines was associated with about half of the cases of anxiety disorders (such as panic disorder and social phobia) in people receiving mental health care in a British mental health clinic. After stopping alcohol or benzodiazepine use, they experienced a worsening of their anxiety disorders, but their anxiety symptoms resolved 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 use, 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 connectivity of the amygdala and the processing of fear and anxiety. Sensory input enters the amygdala through the basal-lateral complex (includes the lateral, basal, and accessory basal ganglia). The basal-lateral complex processes sensory memories associated with fear and transmits information about the importance of the threat to other parts of the brain (prefrontal cortex and postcentral gyrus) associated with memory and sensory information. Another part, namely the nearby central nucleus of the amygdala, is responsible for the response to species-specific fear, which is associated with the brain stem region, the hypothalamus and the cerebellum. In people with generalized anxiety disorder, these connections are functionally less pronounced, and the central nucleus contains more gray matter. There are other differences - the amygdala region has poorer connectivity with the insula and cingulate region, which is responsible for general salience, and better connectivity with the parietal cortex and the prefrontal cortex circuit, which is responsible for executive actions. The latter is likely a strategy needed to compensate for dysfunction of the amygdala, which is responsible for anxiety. This strategy confirms cognitive theories, according to which, by reducing emotions, the level of anxiety is reduced, which, in essence, is a compensatory cognitive strategy.

Diagnosis

DSM-5 criteria

The 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 as follows:

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

B. Anxiety is difficult to control.

B. Anxiety and agitation caused by three of the following six symptoms (predominant over 6 months):

Anxiety or a feeling of being on edge and on edge.

Fatigue.

Difficulty concentrating or feeling “blacked out.”

Irritability.

Muscle tension.

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

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

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

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

E. The anxiety cannot be explained by another mental disorder (for example, anxiety and worry associated with panic attacks, observed in panic disorder, fear of negative evaluative opinions in social anxiety disorder and social phobia, fear of dirt and other obsessions in, fear of separation in anxiety disorder, caused by separation, reminder of traumatic events in, fear of weight gain in, physical complaints in somatic symptom disorder, impaired body image in body dysmorphic disorder, feeling of serious illness in hypochondriacal disorder, delusional ideas in delusional disorder). Since the publication of the Diagnostic and Statistical Manual of Mental Disorders (2004), there have been no significant changes to the concept of generalized anxiety disorder (GAD), although minor changes include revisions to the diagnostic criteria.

ICD-10 criteria

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

A. A period of at least six months of marked tension, worry 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 points.

Symptoms of autonomic arousal:

(1) Palpitation, rapid heartbeat.

(2) Sweating.

(3) Trembling or shaking.

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

Symptoms related to the chest and abdomen:

(5) Difficulty breathing.

(6) Feeling of suffocation.

(7) Chest pain or discomfort.

(8) Nausea or abdominal distress (eg, rumbling stomach).

Symptoms related to the brain and intellect:

(9) Dizziness, feeling of staggering, 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 sensation.

Symptoms of tension:

(15) Muscle tension and pain.

(16) Restlessness and inability to relax.

(17) Feeling trapped, on edge, or mental tension.

(18) Feeling of a “lump in the throat”, difficulty swallowing.

Other nonspecific symptoms:

(19) Exaggerated reaction to sudden situations, numbness.

(20) Difficulty concentrating, feeling “passed out” due to excitement and anxiety.

(21) Long-term irritability.

(22) Difficulty falling asleep due to anxiety.

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

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

Prevention

Treatment

Cognitive behavioral therapy is more effective than medications (such as SSRIs), while both reduce anxiety, 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 tolerance to uncertainty, focusing on negative events, ineffective stress coping mechanism, emotional overarousal , poor understanding of emotions, destructive emotion management and regulation, experiential avoidance, behavioral limitations. In order to successfully address the above cognitive and emotional aspects of GAD, psychologists often use techniques aimed at psychological intervention: social self-monitoring, relaxation techniques, self-monitoring of desensitization, gradual stimulus control, cognitive restructuring, tracking the results of anxiety, focusing on the present moment, living without expectations, problem-solving techniques, processing core fears, socialization, discussing and reframing anxiety beliefs, teaching emotional control skills, experiential exposure, psychological self-help training, non-judgmental awareness and acceptance exercises. There are also behavioral therapies, cognitive therapies, and combinations of both to treat GAD that focus on the key components listed above. Within cognitive behavioral therapy, key components include cognitive and behavioral therapy, as well as acceptance and commitment therapy. Uncertainty acceptance therapy and motivational counseling are two new techniques in the treatment of GAD, both as stand-alone treatments and as adjuncts to enhance the effects of cognitive therapy.

Cognitive behavioral therapy

Cognitive behavioral therapy is a psychological treatment for GAD that involves the therapist working with the patient to understand the influence of thoughts and feelings on behavior. The goal of this therapy is to change the negative thinking that leads to anxiety, replacing it with a more realistic and positive one. Therapy involves learning strategies to help the patient gradually learn to cope with anxiety and become increasingly comfortable in anxiety-provoking situations, as well as practicing these strategies. Cognitive behavioral therapy may be accompanied by medication. Components of cognitive behavioral therapy for GAD include: psychoeducation, self-monitoring, stimulus control techniques, relaxation, self-monitoring desensitization, cognitive restructuring, worry disclosure, worry behavior modification, and problem-solving skills. The first step in treating GAD is psychoeducation, which involves providing information to the patient about the disorder and treatment. The purpose of psychoeducation is to provide comfort, destigmatize the disorder, improve motivation to seek treatment by talking about the treatment process, and increase trust in the doctor due to realistic expectations from the course of treatment. Self-monitoring involves daily monitoring of the timing and level of anxiety, as well as events that trigger anxiety. The point of self-control is to identify factors that provoke anxiety. Stimulus control technique refers to reducing the conditions under which anxiety occurs. Patients are asked to postpone anxiety to a certain time and place specifically chosen for anxiety, in which everything will be aimed at anxiety and solving problems. Relaxation techniques are designed to reduce patients' stress and provide them with alternatives to fearful situations (other than feeling anxious). Deep breathing exercises, progressive muscle relaxation, and relaxation falls are among the relaxation techniques. Self-desensitization is the practice of viewing situations that cause anxiety and worry in a state of deep relaxation until the underlying causes of anxiety are addressed. Patients imagine in reality how they cope with situations and reduce their level of anxiety in their responses. When the anxiety disappears, they enter a state of deep relaxation and “turn off” the situations they imagine. The point of cognitive reconstruction is to replace an anxious perspective with a more functional and adaptive one, focusing on the future and oneself. This practice involves Socratic questioning, which forces patients to look past their worries and problems to understand that there are more powerful feelings and ways of processing what happened. Behavioral experiments are also used to test the effectiveness of negative and positive thoughts in life situations. In cognitive behavioral therapy used to treat GAD, patients engage in anxiety-identification exercises in which they are asked to imagine the worst possible outcome of situations that frighten them. And, according to the instructions, instead of running away from the presented situations, patients look for alternative outcomes of the presented situation. The goal in this anxiety therapy is to habituate and reinterpret 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 independent non-involvement in these disturbances. Instead of engaging, patients are encouraged to use other coping mechanisms learned in the treatment program. Problem solving focuses on actual problems and is broken down into several stages: (1) defining the problem, (2) formulating goals, (3) thinking through various solutions to the problem, (4) making a decision, and (5) executing and revising 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 treated with cognitive behavioral therapy returned to a highly functional life and full recovery. Therefore, there is a need to improve the components of cognitive behavioral therapy. Cognitive behavioral therapy significantly helps one third of patients, while having no effect on the other third.

Acceptance and Commitment Therapy

Acceptance and Commitment Therapy (ACT) is a part of cognitive behavioral therapy that is based on the acceptance model. TPE is designed with three therapeutic goals in mind: (1) reducing avoidance strategies for feelings, thoughts, memories, and sensations; (2) reducing one's literal response to one's thoughts (i.e., understanding that the thought “I am worthless” does not mean that one's 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 areas and goals that are meaningful to a particular person, as well as creating habits of adherence to behavior that will help the person achieve his goals. This psychological therapy teaches skills of self-awareness (focusing on meaning in the present moment without judgment) and acceptance (openness and willingness to connect) that apply to events that are beyond your control. This helps a person, during such events, to adhere to behavior that contributes to the formation and affirmation of his personal values. Like many other psychotherapies, TPE is most effective when combined with medications.

Therapy for intolerance to uncertainty

Therapy for intolerance of uncertainty is aimed at changing the constant negative reaction manifested in relation to uncertain events and events, regardless of the likelihood of their occurrence. This therapy is used as an independent therapy for GAD. It builds patients' tolerance, ability to cope and accept uncertainty in order to reduce anxiety. The basis of intolerance of uncertainty therapy is the psychological components of psychoeducation, knowledge about anxiety, problem-solving skills, revaluation of the benefits of anxiety, virtual openness, awareness of uncertainty, and behavioral openness. Studies have proven the effectiveness of this therapy in the treatment of GAD; during follow-up of patients who underwent this therapy, improvement in well-being progressed over time.

Motivational counseling

A promising innovative approach that can increase the percentage of people cured after GAD. It consists of a combination of cognitive behavioral therapy with motivational counseling. Motivational counseling is a strategy aimed at increasing motivation and reducing ambivalence towards changes resulting from treatment. Motivational counseling has four key elements; (1) expressing empathy, (2) identifying inconsistencies between unwanted behavior and values that are inconsistent with the behavior, (3) developing resilience rather than direct confrontation, and (4) promoting self-reliance. This therapy is based on asking open-ended questions, listening carefully and thoughtfully to the patient's responses, “talking to change,” and talking about the advantages and disadvantages of change. Combining cognitive behavioral therapy with motivational counseling has been shown to be more effective than cognitive behavioral therapy alone.

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 disorders such as nausea, sexual dysfunction, headaches, diarrhea, constipation, anxiety, increased risk of suicide, serotonin syndrome and others.

Benzodiazepines

Benzodiazepines are the most commonly prescribed medications for GAD. Studies have suggested that benzodiazepines provide short-term relief. Despite this, there are certain risks when taking them, mainly the deterioration of cognitive and motor function, as well as the development of psychological and physical dependence, which make it difficult to stop taking them. People taking benzodiazepines have been shown to have decreased 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 disadvantages, benzodiazepines are only justified for short-term relief of anxiety. Cognitive behavioral therapy and medication are about equally effective in the short term, but cognitive behavioral therapy is more effective than medication over 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 this 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 medications

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 inhibitors (MAOIs) include moclobemide (Marplan) and, rarely, 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.

Concomitant diseases

GAD and depression

The National Comorbidity Survey (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 high rates 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 are more severely ill and less likely to respond to treatment than patients 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 (ie, subsyndromal) 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 mixed anxiety-depressive disorder, with an increased risk of severe depression or 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) are at increased risk for other comorbid disorders. It found that among people suffering from a substance abuse disorder, just over half of the 18 people studied had GAD as their primary disorder.

Other co-occurring 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 a comorbid anxiety disorder, of which GAD is the most common. GAD was not included in the World Health Organization's Global Burden of Disease Project. Statistics on disease rates 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.

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

GAD typically manifests from early childhood to late adulthood, with the average age of presentation being 31 years (Kessler, Berguland, et al., 2005) and the average patient age being 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 age 8-9. Risk factors for developing GAD include low to moderate socioeconomic status, living apart from a spouse, divorce, and widowhood. Women are twice as likely to be diagnosed with GAD than men. This is because women are more likely than men to live in poverty, experience discrimination, and experience sexual and physical violence. GAD is most common among older people. Compared with the general population, patients with internalizing disorders such as depression, generalized anxiety disorder (GAD), and posttraumatic 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

A study that examined the comorbidity of GAD and other depressive disorders confirmed that the effectiveness of treatment does not depend on the comorbidity of the other 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 statistical 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, J.C.; Davidson, JR; Lecrubier, Y; Nutt, D.J.; Borkovec, T.D.; Rickels, K; Stein, D.J.; 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.

Catad_tema Mental disorders - articles

Generalized anxiety disorder in adults. Clinical recommendations.

Generalized anxiety disorder in adults

ICD 10: F41.1

Year of approval (revision frequency): 2016 (reviewed every 3 years)

ID: KR457

Professional associations:

Russian Society of Psychiatrists

Approved

Approved by the Russian Association _____

Agreed

Scientific Council of the Ministry of Health of the Russian Federation__ __________201_

free-floating alarm

diffuse anxiety

anxiety states

differential diagnosis of generalized anxiety disorder

diagnostic algorithm

neurotic disorders

principles of treatment for generalized anxiety disorder

therapy algorithm

treatment of anxiety disorders

psychopharmacotherapy

psychotherapy for neurotic disorders.

List of abbreviations

BP - blood pressure

ALT – alanine aminotransferase

AST-aspartate aminotransferase

GAD – generalized anxiety disorder

ITT – integrative anxiety test

ICD – international classification of diseases

MRI – magnetic resonance imaging

RCTs – randomized clinical trials

SSRIs – selective serotonin reuptake inhibitors

SNRIs – selective serotonin and norepinephrine reuptake inhibitors

T3 – triiodothyronine

T4 - thyroxine

TSH - thyroid stimulating hormone

TCD – transcranial dopplerography

USK - a technique for determining the level of subjective control of an individual

BAI (The Beck Anxiety Inventory) - Beck Anxiety Inventory

COPE (Coping) - a technique of coping behavior

DSM - diagnostic and statistical manual of mental disorders - diagnostic manual of mental disorders

HARS (The Hamilton Anxiety Rating Scale)

IIP (Inventory of Interpersonal Problems) - Questionnaire for the study of interpersonal problems

ISTA (ch Struktur Test nach G. Ammon) - Methodology “I-structural test” by G. Ammon, I. Burbil

LSI (Life style index) - “Life Style Index” methodology

MDMQ (Melbourne decision making questionnaire) - Melbourne Decision Making Questionnaire

MMPI (Minnesota Multihasic Personality Inventory) - Standardized clinical personality questionnaire

MPS (Multidimensional perfectionism scale) - Multidimensional perfectionism scale

SCL-90-R ((Symptom Check List-90- Revised) - Questionnaire of the severity of psychopathological symptoms

ShARS (Sheehan Anxiety Scale) - Sheehan Anxiety Scale

STAI (State-Trait Anxiety Inventory) - Spielberger Anxiety Scale

** Vital and Essential Drugs – a drug included in the list of “Life-Saving and Essential Medicines”

# - the instructions for use do not indicate this disease or disorder

Terms and definitions

Anxiety- a negatively colored emotion that expresses a feeling of uncertainty, expectation of negative events, difficult to define premonitions. Unlike the causes of fear, the causes of anxiety are usually not conscious, but it prevents a person from engaging in potentially harmful behavior, or motivates him to take action to increase the likelihood of a favorable outcome of events.

Psychopharmacotherapy is the use of psychotropic drugs in the treatment of mental disorders.

Psychotherapy is a system of therapeutic effects on the human psyche, and through the psyche and through it on the entire human body.

1. Brief information

1.1 Definition

Generalized anxiety disorder(GAD) is widespread and persistent anxiety and tension, not limited or caused primarily by any special environmental circumstances (“free-floating anxiety”). The disease is characterized by a chronic or recurrent course and can lead to severe maladjustment and an increased risk of suicide.

1.2 Etiology and pathogenesis

Risk factors for the development of GAD include:

Personality characteristics - restrained behavior in an unfamiliar situation, negative affectivity and increased caution, avoidance of possible real or imagined harm are among the factors associated with GAD.

Social factors - although overprotective upbringing and psychotraumatic influences in childhood are more common among patients with GAD, to date no specific psychosocial factor has been identified that is associated with the manifestation of GAD.

Genetic and physiological factors - the role of genetic factors for GAD is about 30%, however, these same genetic factors determine negative affectivity and influence the manifestation of other affective disorders, especially depressive disorders. It is believed that the genetic risk of fucking women is twice as high as for men.

GAD remains the least studied of all anxiety disorders due to its high comorbidity with other mood disorders. Currently, data have been obtained on the role of excessive activity of the noradrenergic system and low density of benzodiazepine receptors in the pathogenesis of GAD. The involvement of the immune system is also being explored, with the idea that persistent anxious rumination may contribute to the release of cytokines and maintain “smoldering inflammatory responses” in the body.

Among the psychological theories of GAD, one of the most popular is the metacognitive theory according to which in patients with GAD, in metacognitive functioning associated with the observation and assessment of their own cognitive processes, the idea of the protective and reality-controlling functions of excessive anxiety and catastrophic scenarios prevails. The fact that most negative scenarios associated with the future are not realized in this case serves as positive reinforcement and contributes to adherence to an anxious metacognitive model.

The psychodynamic approach indicates that the experience of separation from a significant other, personifying security and the lack of a stable or predominant anxious model of attachment in early childhood, leads to a deficit in the personality structure that determines the predominance of free-floating, non-fabulable anxiety over situational anxiety, problems in the differentiation of mental and somatic sensations and regulation of affective tension, which creates a predisposition for the manifestation of GAD.

1.3 Epidemiology

The lifetime prevalence of GAD varies from 0.1 to 8.5% and averages about 5% of cases in the adult population. Among other anxiety disorders, it makes up a significant proportion - from 12 to 25%.

1.4 Coding according to ICD-10

F41.1 – Generalized anxiety disorder

1.5 Classification

Classification of GTR:

Chronic generalized disorder

Recurrent generalized disorder

1.6 Clinical picture

Generalized anxiety:

Lasts at least 6 months;

Captures various aspects of the patient's life, circumstances and activities;

Focused primarily on upcoming events;

Uncontrollable, impossible to suppress by willpower or rational beliefs;

Disproportionate to the patient’s current life situation;

Often accompanied by feelings of guilt.

The clinical picture is represented mainly by three characteristic groups of GAD symptoms:

Worries and apprehensions that are difficult for the patient to control and that last longer than usual. This worry is generalized and does not focus on specific problems, such as the possibility of having a panic attack (as in panic disorder), being stranded (as in social phobia), or being dirty (as in obsessive-compulsive disorder).

Other mental symptoms of GAD include irritability, poor concentration, and sensitivity to noise.

Motor tension, which can be expressed in muscle tension, tremors, inability to relax, headache (usually bilateral and often in the frontal and occipital areas), aching muscle pain, muscle stiffness, especially the muscles of the back and shoulder area.
Hyperactivity of the autonomic nervous system, which is expressed by increased sweating, tachycardia, dry mouth, epigastric discomfort and dizziness and other symptoms of autonomic arousal.

Table 1.

Characteristic manifestations of GAD

Psychopathological manifestations

primary anxiety, manifested as:

constant tension,

fears

alertness,

expecting "bad"

nervousness,

inappropriate anxiety

concerns for various reasons (for example, about possible delays, the quality of work performed, physical illness, fear of an accident or illness, the safety of children, financial problems, etc.)

feeling dizzy, unsteady, or faint

feeling that objects are not real (derealization) or that the self has become separate or “not really here”

fear of loss of control, madness, or impending death

fear of dying

increased manifestations in response to small surprises or fright

difficulty concentrating or a “blank” mind due to anxiety

constant irritability

Autonomic symptoms:

gastrointestinal

respiratory

cardiovascular

urogenital

nervous system

dry mouth, difficulty swallowing, epigastric discomfort, excessive gas formation, rumbling in the stomach, nausea

a feeling of constriction, pain and discomfort in the chest, difficulty in inhaling (as opposed to difficulty exhaling with asthma), a feeling of suffocation and the effects of hyperventilation

a feeling of discomfort in the heart area, palpitations, a feeling of absence of a heartbeat, pulsation of the cervical vessels

frequent urination, loss of erection, decreased libido, menstrual irregularities, temporary amenorrhea

feeling of unsteadiness, feeling of blurred vision, dizziness and paresthesia, sweating, tremors or shaking, hot flashes and chills, numbness or tingling sensation

Sleep disorders

difficulty falling asleep due to anxiety

feeling of restlessness when waking up.

interrupted or shallow sleep

sleep with unpleasant dreams.

sleep with nightmares, often awakening

waking up in alarm

no feeling of rest in the morning

Factors indicating a more favorable prognosis: late onset of the disorder; insignificant severity of social maladjustment; gender - women are more predisposed to remission.

Factors indicating an unfavorable prognosis: poor relationships with a spouse or relatives; presence of comorbid mental disorders; gender – men are less predisposed to remission

Comorbidity of GAD with other mental disorders:

Comorbidity is a characteristic feature of GAD. Over 90% of all patients with a primary diagnosis of generalized anxiety disorder will also have another mental disorder during their lifetime.

The most common comorbidities are with the following mental disorders:

endogenous depression, recurrent depressive disorder;

bipolar affective disorder;

dysthymia;

alcohol addiction;

simple phobias;

social phobia;

obsessive-compulsive disorder;

drug addiction;

psychopathologically undifferentiated chronic fatigue syndrome;

asthenic disorders.

Association with somatic pathology.

There is a high prevalence of certain physical illnesses in patients with anxiety disorders:

cardiovascular diseases;

gastrointestinal diseases;

respiratory disorders;

allergic diseases;

metabolic pathology;

back pain.

2. Diagnostics

2.1 Complaints and anamnesis

Main complaints: constant, “free-floating” anxiety, somatovegetative disorders.

2.2 Physical examination

2.3 Laboratory diagnostics

It is recommended to conduct a general blood test with a study of the leukocyte formula, a biochemical blood test: total protein, albumin, urea, creatinine, alanine aminotransferase (ALT), aspartate aminotransferase (AST), bilirubin, a study of blood electrolytes (sodium, potassium, chlorine), a general urine test.

2.4 Instrumental diagnostics

2.5 Experimental psychological diagnostics

It is recommended to use symptomatic questionnaires (Symptom Check List-90-Revised - SCL-90-R); Beck Anxiety Inventory (BAI); The Hamilton Anxiety Rating Scale (HARS). ); Spielberger Anxiety Scale (State-Trait Anxiety Inventory - STAI); Integrative Anxiety Test (ITT); Sheehan Anxiety Scale (ShARS)), GAD screening scale).

It is recommended to use methods for the psychological structure of personality (Standardized Clinical Personality Questionnaire MMPI (adapted by I.N. Gilyasheva, L.N. Sobchik and T.L. Fedorova (1982) - full version of MMPI); Methodology “I-structural test" by G. Ammon (ISTA), I. Burbil (2003)).

It is recommended to use methods for studying individual individual psychological characteristics of a person (Methodology for determining the level of subjective control of a person (USC); Questionnaire for studying personal beliefs “Personal Beliefs Test” (Kassinove H., Berger A., 1984); Multidimensional perfectionism scale (Multidimensional perfectionism scale – MPS)).

It is recommended to use methods for psychological diagnosis of risk factors for mental maladaptation (Life style index Methodology; E. Heim’s Methodology (1988) for determining the nature of coping behavior; Methodology of coping behavior (COPE); Melbourne Decision Making Questionnaire (Melbourne decision making questionnaire, – MDMQ) .

It is recommended to use methods for psychological diagnosis of a system of significant relationships (Questionnaire for the study of interpersonal problems (Inventory of Interpersonal Problems (IIP); Methodology for studying the severity of intrapersonal conflicts, developed by S. Leder et al. (1973)).

2.6 Differential diagnosis

GAD must be differentiated from the following disorders:

Social phobia;

Specific phobia;

Obsessive-compulsive disorder;

Post-traumatic stress disorder;

Panic disorder;

Affective mood disorders (endogenous depression, recurrent depressive disorder, bipolar disorder, dysthymia);

Somatoform disorders;

Schizophrenia (paranoid, sluggish), schizotypal disorder;

Personality disorders (hysterical, anancastic, anxious, emotionally labile);

Residual organic diseases of the brain;

Organic diseases of the brain;

Hypothalamic disorder;

Pathology of the thyroid gland;

Pheochromocytoma;

Use of psychoactive substances (eg, amphetamines, cocaine, etc.);

Withdrawal of benzodiazepines.

3. Treatment

3.1 Conservative treatment

3.1.1 Psychopharmacotherapy

Selective serotonin reuptake inhibitors (SSRIs) (paroxetine**, escitalopram#, sertraline**#) and selective serotonin and norepinephrine reuptake inhibitors (SNRIs) (venlafaxine#, duloxetine#) are predominantly recommended as first-line drugs. The effects of tricyclic antidepressants (clomipramine**#) have been proven.

The anxiolytic effect of pregabalin**, its influence on the mental, somatic and autonomic components of anxiety, as well as good tolerability and a high level of safety have been confirmed. Its use is recommended for GAD.

Short-term use of benzodiazepines (diazepam**#, lorazepam**, phenazepam**#) is recommended. The duration of use is limited by significant undesirable effects - sedation, decreased concentration and memory, impaired psychomotor functions, the risk of dependence, severe withdrawal syndrome, manifested by deterioration of the condition and increased anxiety after stopping use and therefore should be limited to short courses (no more than 2-3 weeks) .

The recommended duration of treatment for generalized anxiety disorder is at least 6 months after the onset of the therapeutic effect of the therapy used, but in most cases a longer period of treatment is advisable.

Possible side effects of psychopharmacotherapy for generalized anxiety disorder. When using psychotropic drugs, it is recommended to take into account the following side effects: drowsiness, lethargy, urinary retention, constipation or diarrhea, nausea, headaches, dizziness. At the same time, adequate dosages and prescriptions of medications strictly according to indications significantly reduce the risk of side effects.

It is recommended to evaluate the effectiveness and tolerability of therapy, which is carried out on days 7-14-28 of psychopharmacotherapy and then once every 4 weeks until the end of the course of treatment. In case of intolerance or insufficient effectiveness, dosages are adjusted or the drug is changed.

3.1.2 Psychotherapy

Contraindications to psychotherapeutic treatment:

1) patients with fear of self-disclosure and strong reliance on “denial” as a form of psychological defense;

2) patients with insufficient motivation to change;

3) patients with low interpersonal sensitivity;

4) patients who will not be able to attend all classes;

5) patients who will not participate in the process of active verbalization and listening, which is an essential part of any group;

6) patients whose characterological characteristics will not allow them to work constructively in a group and benefit from this work (who constantly act out their emotions outwardly as a defensive reaction, rather than observing their psychological state; or patients with severe negativism or rigidity).

Family, socio-psychological, and professional are recommended as special types of rehabilitation.

Supportive psychotherapy is recommended as one of the important forms of rehabilitation measures, which can be carried out on an outpatient basis in the form of individual and group psychotherapy

5. Prevention and clinical observation

6. Additional information affecting the course and outcome of the disease

6.1 Factors (predictors) contributing to protracted course

Main predictors of protracted course of GAD

Predictors of the continuous course of protracted forms	premorbid minimal cerebral deficiency; right-sided type of functional interhemispheric asymmetry; emotional neglect on the part of significant persons in the parental family, which leads to a biopsychosocial constellation that prevents the resolution of conflicts associated with the unsuccessful experiences of early relationships, the integration of new experiences, the formation of stable self-esteem and determines a decrease in the adaptive potential of the individual
Predictors of wave-like flow of protracted forms	personal characteristics of an individual that determine his vulnerability to stress, affecting the most significant relationships of the individual and having a similar (stereotypical) character
Psychological predictors of protracted course	the use of psychological defense in the form of repression; internality in relation to the disease; deeper violations of narcissistic regulation, forming instability of self-esteem, high vulnerability to criticism, selective attention to bad experiences; difficulties in building interpersonal relationships, manifested either by avoidance of contacts or the search for paternalistic relationships that ensure the maintenance of positive self-esteem
Social predictors of protracted course	raised by a single mother, divorce/parental separation, disharmonious relationships in the parental family, which indicates the special importance of family relationships in the formation of problem-solving behavior skills in patients with chronic, protracted neurotic disorders

Criteria for assessing the quality of medical care

Quality criteria

Level of evidence

Stage of diagnosis

Examination by a psychiatrist

A risk assessment for suicidal behavior was performed

An experimental psychological examination was performed

A general therapeutic biochemical blood test was performed (total protein, albumin, urea, creatinine, alanine aminotransferase, aspartate aminotransferase, bilirubin, blood electrolytes (sodium, potassium, chlorine))

A general urine test was performed

The level of thyroid-stimulating hormone and triiodothyronine and thyroxine was determined

Electroencephalography performed

Transcranial Doppler ultrasound was performed

Electrocardiography performed

Treatment stage

Psychopharmacotherapy prescribed

Psychotherapy was carried out

The effectiveness and tolerability of the prescribed therapy was assessed (on days 7-14-28 and monthly thereafter)

A change in therapy was made in the absence of effectiveness or intolerance to therapy

Achieved a decrease in somatic anxiety scores on the Hamilton Anxiety Scale

Achieved a decrease in mental anxiety scores on the Hamilton scale

An improvement in the severity of psychopathological manifestations on the SCL-90 scale was achieved to no less than an average degree

References

Erichev A.N., Morgunova A.M. Modern stressful situations and the emergence of feelings of anxiety. How to learn to fight. / Practical guide. SPb.: Publishing house. house. St. Petersburg MAPO, 2009. – 30 p.

Zalutskaya N.M. Generalized anxiety disorder: modern theoretical models and approaches to diagnosis and treatment. Part 1. / Review of psychiatry and medical psychology. – 2014 – No. 3 – P.80-89.

Karavaeva T.A., Vasilyeva A.V., Poltorak S.V., Chekhlaty E.I., Lukoshkina E.P. Criteria and algorithm for diagnosing generalized anxiety disorder. / Review of Psychiatry and Medical Psychology named after. V.M. Bekhterev. – 2015. – No. 3. – P. 124-130.

Kotsyubinsky A.P., Sheinina N.S., Butoma B.G., Erichev A.N., Melnikova Yu.V., Savrasov R.G. Holistic diagnostic approach in psychiatry. Message 1. / Social and clinical psychiatry. – 2013 – T. 23. – No. 4 – P.45-50.

Churkin A.A. Results of an epidemiological study of the prevalence of GAD among the population of a large industrial city. Report at an experimental meeting on diagnostics and therapy of GAD 03/25/2010.

Andlin-Sobocki P., Wittchen H-U Cost of anxiety discords in Europe. - Eur.J.Neurol., 2005; 12:9-44.

Behar, E., Borkovec, T.D. (2005). The nature and treatment of generalized anxiety disorder. In: B.O. Rothbaum (Ed.), The nature and treatment of pathological anxiety: essays in honor of Edna B. Foa (pp. 181-196). New York: Guilford.

Borkovec, T. D., Inz, J. (1990). The nature of worry in generalized anxiety disorder/. Behavior Research and Therapy, 28, 153-158.

Bruce S.E., Yonkers K.A., Otto M.W. Influence of psychiatric comorbidity on recovery and recurrence in generalized anxiety disorder, social phobia and panic disorder: 12-year prospective study. Am.J.Psychiatry, 2005, 62, p.1179-1187.

Diefenbach, G. J., Stanley, M. A. Beck, J. G. (2001). Worry content reported by older adults with and without generalized anxiety disorder. Aging and Mental Health, 5, 269-274.

Eng, W., Heimberg, R. G. (2006). Interpersonal correlates of generalized anxiety disorder: self versus other perception. Anxiety Disorders, 20, 380-387.

Hoehn-Saric, M. D., McLeod, D. R., Funderburk, F. Kowalski, P. (2004). Somatic symptoms and physiological responses in generalized anxiety disorder and panic disorder. An ambulatory monitor study. Archives of General Psychiatry, 61, 913-921.

Holaway, R. M., Rodebaugh, T. L., Heimberg, R. G. (2006). The epidemiology of worry and generalized anxiety disorder. In G. C. L. Davey, A. Wells (Egs.), Worry and its psychological disorder: Theory, assessment and treatment (pp. 3-20). Chichester: Wiley.

Lieb R., Becker E., Almatura C. The epidemiology of generalized anxiety disorder in Europe. European Neuropsychopharmacology, (15) 2005, pp. 445-452.

Mennin, D. S., Heimberg, R. G., Turk, C. L., Fresco, D. M. (2005). Preliminary evidence for an emotion dysregulation model of generalized anxiety disorder. Behavior Research and Therapy, 43, 1281-1310.

Romera I, Furnandez-Purez S, Montego BL, Caballero L, Arbesu JB, Delgado-Cohen H. Generalized anxiety disorder, with or without co-morbid major depressive disorder, in primary care: prevalence of painful somatic symptoms, functioning and health status . J Affect Disord 2010;127:160e8.

Turk C. L., Heimberg R. G., Luterek J. A., Mennin D. S., Fresco, D. M. (2005). Emotion dysregulation in generalized anxiety disorder: a comparison with social anxiety disorder. Cognitive Therapy and Research, 29, 89-106.

Wittchen H-U., Kessler R.C., Beesdo K., Krause P., Hofler M., Hoyer J. Generalized anxiety disorder and depression in primary care: prevalence, recognition, and management. J. Clin. Psychiatry 2002, 63 (suppl.8), p. 24-34.

Wittchen H-U. Generalized anxiety disorder: prevalence, burden, and cost to society. - Depress.Anxiety, 2002; 16: 162-171.

Yonkers K. A., Dyck I. R., Warshaw M. G., Keller M. B. (2000). Factors predicting the clinical course of generalized anxiety disorder. British Journal of Psychiatry, 176, 544-549.

Appendix A1. Composition of the working group

Vasilyeva Anna Vladimirovna – Doctor of Medical Sciences, Associate Professor, Leading Researcher of the Department of Borderline Mental Disorders and Psychotherapy Federal State Budgetary Institution “St. Petersburg Research Psychoneurological Institute named after. V.M. Bekhterev" of the Ministry of Health of the Russian Federation.
Karavaeva Tatyana Arturovna – Doctor of Medical Sciences, Associate Professor, Chief Researcher, Head of the Department of Borderline Mental Disorders and Psychotherapy Federal State Budgetary Institution “St. Petersburg Research Psychoneurological Institute named after. V.M. Bekhterev" of the Ministry of Health of the Russian Federation.
Mizinova Elena Borisovna – Candidate of Psychological Sciences, senior researcher at the Department of Borderline Mental Disorders and Psychotherapy, Federal State Budgetary Institution “St. Petersburg Research Psychoneurological Institute named after. V.M. Bekhterev" of the Ministry of Health of the Russian Federation.
Poltorak Stanislav Valerievich – Candidate of Medical Sciences, leading researcher at the Department of Borderline Mental Disorders and Psychotherapy, Federal State Budgetary Institution “St. Petersburg Research Psychoneurological Institute named after. V.M. Bekhterev" of the Ministry of Health of the Russian Federation.
Bukreeva N.D., Doctor of Medical Sciences, Head of the Scientific and Organizational Department of the Federal State Budgetary Institution "Federal Medical Research Center named after. V.P.Serbsky";
Rakityanskaya E.A., Candidate of Medical Sciences, Senior Researcher of the Scientific and Organizational Department of the Federal State Budgetary Institution "Federal Medical Research Center named after. V.P.Serbsky";
Kutueva R.V., junior researcher of the Scientific and Organizational Department of the Federal State Budgetary Institution "Federal Medical Research Center named after. V.P.Serbsky."

Conflict of interest absent.

Psychiatrists
Psychotherapists
Clinical psychologists
General doctors

Table P1– Levels of evidence

Confidence level	Source of evidence
	Prospective randomized controlled trials (RCTs) Sufficient, adequately powered studies involving large numbers of patients and generating large amounts of data Large meta-analyses At least one well-designed RCT Representative sample of patients
	Prospective with or without randomization with limited data Several studies with small numbers of patients Well-designed prospective cohort study Meta-analyses are limited but well conducted Results are not representative of the target population Well-designed case-control studies
	Non-randomized controlled trials Insufficiently controlled studies RCTs with at least 1 major or at least 3 minor methodological errors Retrospective or observational studies Series of clinical observations Conflicting data that does not allow a final recommendation to be made
	Expert opinion/data from the expert commission report, experimentally confirmed and theoretically substantiated

Table P2– Recommendation strength levels

Level of persuasiveness	Description	Decoding
		First line method/therapy; or in combination with standard technique/therapy
		Method/therapy second line; or in case of refusal, contraindication, or ineffectiveness of standard methods/therapy. Monitoring for adverse events is recommended
	there is no convincing evidence of either benefit or risk)	There are no objections to this method/therapy or no objections to the continuation of this method/therapy
	Absence of convincing level I, II or III publications of evidence showing a significant superiority of benefit over risk, or convincing publications of I, II or III level of evidence showing a significant superiority of risk over benefit

Appendix A3. Related documents

Order No. 1225n “On approval of the standard of primary medical and social care for neurotic, stress-related and somatoform disorders, generalized anxiety disorder in an outpatient setting of a neuropsychiatric dispensary (dispensary, office)” dated December 20, 2012.

Order No. 1229n “On approval of the standard of specialized medical care for neurotic, stress-related and somatoform disorders, generalized anxiety disorder” dated December 20, 2012.

Appendix B. Patient management algorithms

Algorithm for the management of patients with generalized anxiety disorder

Appendix B: Patient Information

What are anxiety disorders?

Anxiety disorders are a group of diseases of the nervous system, the main manifestation of which is a persistent feeling of anxiety that occurs for unimportant reasons or in the absence of any reason.

What are the main symptoms of anxiety disorders?

Unreasonable feelings of anxiety, difficulty breathing, dizziness, fear of death or imminent disaster, chest or abdominal pain, a feeling of “lump in the throat,” etc.

Diagnosis of anxiety disorders.

Typically, the diagnosis of an anxiety disorder is made after excluding all diseases that may cause similar symptoms. Diagnosis and treatment of anxiety disorders and panic attacks is carried out by a psychotherapist and psychiatrist.

A preliminary diagnosis can be made by a general practitioner or neurologist.

Treatment of anxiety conditions.

Treatment for anxiety disorders includes psychotherapy and medications that reduce anxiety (anxiolytics).

Psychotherapy includes various techniques that help a patient with an anxiety disorder correctly assess the situation and achieve relaxation during an anxiety attack. Psychotherapy can be carried out individually or in small groups. Learning how to behave in different situations helps you feel confident in your ability to cope with stressful situations.

Drug treatment for anxiety disorders includes the use of various drugs that affect anxiety. Medicines that reduce anxiety are called anxiolytics (sedatives). Drug treatment - prescription, correction of therapy, withdrawal of drugs is carried out only by a specialist doctor.

Appendix D

Instructions. Below is a list of problems and complaints that people sometimes have. Please read each paragraph carefully. Circle the number of the answer that most accurately describes the degree of discomfort or anxiety you have felt about this or that issue over the past week, including today. Circle only one of the numbers in each item (so that the number inside each circle is visible), without skipping any items. If you wish to change your report, cross out your first mark.

Full name_________________________________ Date ____________________

How much did you worry?:	At all	A little	Moderately	Strongly	Very strongly
1.Headaches
2. Nervousness or internal trembling
3.Repetitive, persistent, unpleasant thoughts
4.Weakness or dizziness
5.Loss of sexual desire or pleasure
6.Feeling dissatisfied with others
7. The feeling that someone else can control your thoughts
8. The feeling that almost all your troubles are to blame for others
9.Memory problems
10.Your carelessness or sloppiness
11.Easy frustration or irritation
12.Pain in the heart or chest
13. Feeling of fear in open places or on the street
14. Loss of strength or lethargy
15.Thoughts about committing suicide


18.Feeling that most people can't be trusted
19.Poor appetite
20.Tearfulness
21. Shyness or constraint in communicating with people of the opposite sex
22. Feeling trapped or caught
23. Unexpected or unreasonable fear
24. Outbursts of anger that you could not control
25. Fear of leaving the house alone
26. Feeling that you yourself are largely to blame
27.Lower back pain
28. The feeling that something is stopping you from doing something
29.Feeling lonely
30. Depressed mood, blues
31. Excessive worry about various reasons
32. Lack of interest in anything
33. Feeling of fear
34. That your feelings are easily hurt
35.Feeling like others are getting into your thoughts
36. Feeling that others do not understand or sympathize with you
37. Feeling that people are unfriendly or don't like you
38. The need to do everything very slowly to avoid mistakes
39.Severe or rapid heartbeat
40.Nausea or upset stomach
41. Feeling that you are worse than others
42.Muscle pain
43. Feeling that others are watching you or talking about you
44.The fact that you have difficulty falling asleep
45. The need to check or double-check what you do
46.Difficulty in making decisions
47. Fear of riding on buses
48. Difficulty breathing
49. Attacks of fever or chills
50. Having to avoid certain places or activities because they scare you
51.The fact that you easily lose your thoughts
52. Numbness or tingling in various parts of the body
53.Lump in throat
54. Feeling that the future is hopeless
55.The fact that you find it difficult to concentrate
56.Feeling of weakness in various parts of the body
57.Feeling tense or on edge
58. Heaviness in the limbs
59.Thoughts about death
60.Overeating
61.Feeling awkward when people watch you
62. The fact that you have other people’s thoughts in your head
63.Impulses to cause bodily harm or harm to someone
64. Insomnia in the morning
65. The need to repeat actions: touch, wash, count
66. Restless and anxious sleep
67.Impulses to break or destroy something
68. Having ideas or beliefs that others do not share
69.Excessive shyness when communicating with others
70. Feeling awkward in crowded places (shops, cinemas)
71. Feeling that everything you do requires a lot of effort
72. Attacks of terror or panic
73. Feeling awkward when you eat or drink in public
74.The fact that you often get into arguments
75. Nervousness when you are alone
76. The fact that others underestimate your achievements
77.Feeling lonely even when you're with other people
78.Worrying so much that you couldn’t sit still
79.Feeling of worthlessness
80.Feeling that something bad is going to happen to you
81. The fact that you scream or throw things
82. Fear that you will faint in public
83. Feeling that people will abuse your trust if you let them
84. Sexual thoughts that make you nervous
85.The thought that you must be punished for your sins
86. Nightmarish thoughts or visions
87. Thoughts that something is wrong with your body
88. That you don't feel close to anyone
89.Feeling guilty
90. Thoughts that something is wrong with your mind

Key to the technique

Somatization SOM (12 items) – 1 4 12 27 40 42 48 49 52 53 56 58

Obsessive-compulsive O-C (10 items) - 3 9 10 28 38 45 46 51 55 65

Interpersonal anxiety INT (9 items) - 6 21 34 36 37 41 61 69 73

Depression DEP (13 points) - 14 15 20 22 26 29 30 31 32 54 56 71 79

Anxiety ANX (10 items) - 2 17 23 33 39 57 72 78 80 86

HOS Hostility (6 items) - 11 24 63 67 74 81

Phobias PHOB (7 points) - 13 25 47 50 70 75 82

Paranoia PAR (6 items) - 8 18 43 68 76 83

Psychoticism PSY (10 points) - 7 16 35 62 77 84 85 87 88 90

Additional points Dopoln (7 points) - 19 44 59 60 64 66 89

Processing of received data

Points for each scale - 9 indicators. The sum of points for each scale is divided by the number of points in this scale. For example, the sum of points on the 1st scale is divided by 12, on the 2nd - by 10, etc.
The overall score is the GSI (General Symptomatic Index). Divide the total sum of all points by 90 (number of points in the questionnaire).
Symptomatic index PSI (Positive Symptomatic Index). The number of points that are scored from 1 to 4 is counted.
PDSI (Positive Distress Symptomatical Index) index. Multiply the GSI index by 90 and divide by the PSI index.

Description of scales

Somatization. Items included in this scale reflect distress arising from awareness of impaired body function. The parameter includes complaints about the cardiovascular, gastrointestinal, respiratory and other systems. If the organic basis of complaints is excluded, a variety of somatoform disorders and anxiety equivalents are registered.
Obsessive-Compulsive. The core of this scale is the clinical syndrome of the same name. Includes items indicating the recurrence and undesirability of certain phenomena, as well as the presence of more general cognitive difficulties.
Interpersonal Sensitivity. The symptoms that form the basis of this scale reflect feelings of personal inadequacy and inferiority in social contacts. The scale includes items reflecting self-judgment, feelings of awkwardness, and severe discomfort in interpersonal interactions. Reflects a tendency to reflect and low self-esteem.
Depression. Items related to the depression scale reflect a wide range of circumstances associated with clinical depressive syndrome. Complaints of loss of interest in activities, lack of motivation, and loss of vitality were included. The scale also includes items related to ideation of suicide, feelings of hopelessness, worthlessness, and other somatic and cognitive characteristics of depression.
Anxiety. This scale refers to a group of symptoms and reactions that are usually clinically associated with obvious (overt) anxiety, reflecting a feeling of oppressive, unreasonable internal restlessness. The basis of this scale is complaints about a feeling of nervousness, impatience and internal tension in combination with somatic, motor manifestations.
Hostility (Anger-Hostility). This parameter is formed from three categories of hostile behavior: thoughts, feelings and actions.
Phobias (Phobic Anxiety). Complaints included in this scale reflect fears related to travel, open spaces, public places, transport, and phobic reactions of a social nature.
Paranoid Ideation. When creating this L.R. scale. Derogatis et al. took the position that paranoid phenomena are better understood when they are perceived as a way of thinking. Traits of paranoid thinking that were of primary importance, within the constraints of the questionnaire, were included in the scale. This is, first of all, projective thinking, hostility, suspicion, ideas of relationship.
Psychoticism. The basis of this scale is the following symptoms: auditory hallucinations, transmission of thoughts over a distance, external control of thoughts and intrusion of thoughts from outside. Along with these items, the questionnaire also presents other indirect signs of psychotic behavior, as well as symptoms indicating a schizoid lifestyle.

Appendix G2. Hamilton Anxiety Scale

Instructions and text

The examination takes 20 - 30 minutes, during which the experimenter listens to the subject's answer on the topic of the question and evaluates it on a five-point scale.

Anxious mood (concern, expectation of the worst, anxious fears, irritability).
Absent.
To a weak extent.
To a moderate extent.
To a severe extent.
To a very severe extent.

Tension (feeling tense, wincing, easily tearful, trembling, restless, unable to relax).
Absent.
To a weak extent.
To a moderate extent.
To a severe extent.
To a very severe extent.

Fears (fear of the dark, strangers, animals, transport, crowds, fear of being alone).
Absent.
To a weak extent.
To a moderate extent.
To a severe extent.
To a very severe extent.

Insomnia (difficulty falling asleep, interrupted sleep, restless sleep with a feeling of weakness and weakness upon awakening, nightmares).
Absent.
To a weak extent.
To a moderate extent.
To a severe extent.
To a very severe extent.

Intellectual impairment (difficulty concentrating, memory impairment).
Absent.
To a weak extent.
To a moderate extent.
To a severe extent.
To a very severe extent.

Depressive mood (loss of usual interests, loss of pleasure from hobbies, depression, early awakenings, diurnal fluctuations in state).
Absent.
To a weak extent.
To a moderate extent.
To a severe extent.
To a very severe extent.

Somatic symptoms (pain, muscle twitching, tension, myoclonic spasms, teeth grinding, broken voice, increased muscle tone).
Absent.
To a weak extent.
To a moderate extent.
To a severe extent.
To a very severe extent.

Somatic symptoms (sensory - ringing in the ears, blurred vision, hot or cold flashes, feeling of weakness, tingling sensation).
Absent.
To a weak extent.
To a moderate extent.
To a severe extent.
To a very severe extent.
Cardiovascular symptoms (tachycardia, palpitations, chest pain, pulsation in blood vessels, feeling of weakness, frequent sighs, dyspnea).
Absent.
To a weak extent.
To a moderate extent.
To a severe extent.
To a very severe extent.

Respiratory symptoms (feeling of pressure or compression of the chest, feeling of suffocation, frequent sighs, dyspnea).
Absent.
To a weak extent.
To a moderate extent.
To a severe extent.
To a very severe extent.

Gastrointestinal symptoms (difficulty swallowing, flatulence, abdominal pain, heartburn, feeling of fullness, nausea, vomiting, rumbling in the abdomen, diarrhea, weight loss, constipation).
Absent.
To a weak extent.
To a moderate extent.
To a severe extent.
To a very severe extent.

Genitourinary symptoms (frequent urination, strong urge to urinate, amenorrhea, menorrhagia, frigidity, premature ejaculation, loss of libido, impotence).
Absent.
To a weak extent.
To a moderate extent.
To a severe extent.
To a very severe extent.

Autonomic symptoms (dry mouth, redness of the skin, pale skin, increased sweating, headaches with a feeling of tension).
Absent.
To a weak extent.
To a moderate extent.
To a severe extent.
To a very severe extent.

Behavior during examination (fidgeting in place, restless gestures or gait, hand tremors, frowning eyebrows, tense facial expression, sighs or rapid breathing, pale face, frequent swallowing of saliva, etc.).
Absent.
To a weak extent.
To a moderate extent.
To a severe extent.
To a very severe extent.

Anxious mood - Concern, expectation of the worst, anxious fears, irritability.

Voltage - Feeling of tension, shuddering, easy tearfulness, trembling, anxiety, inability to relax.

Fears - Fear of the dark, strangers, animals, transport, crowds, fear of being alone.

Insomnia - Difficulty falling asleep, interrupted sleep, restless sleep with a feeling of weakness and weakness upon awakening, nightmares .

Intellectual impairment - Difficulty concentrating, memory impairment.

Depressed mood - Loss of usual interests, loss of pleasure from hobbies, depression, early awakenings, daily fluctuations in state.

Somatic symptoms (muscular) - Pain, muscle twitching, tension, myoclonic spasms, teeth grinding, broken voice, increased muscle tone.

Somatic symptoms (sensory) - Ringing in the ears, blurred vision, hot or cold flashes, feeling weak, tingling sensation.

Cardiovascular symptoms - Tachycardia, palpitations, chest pain, pulsation in blood vessels, feeling of weakness, frequent sighs, dyspnea.

Respiratory symptoms - Feeling of pressure or compression of the chest, feeling of suffocation, frequent sighs, dyspnea.

Gastrointestinal symptoms - Difficulty swallowing, flatulence, abdominal pain, feeling of fullness, nausea, vomiting, rumbling in the abdomen, diarrhea, weight loss, constipation.

Genitourinary symptoms - Frequent urination, strong urge to urinate, amenorrhea, menorrhagia, frigidity, premature ejaculation, loss of libido, impotence.

Vegetative symptoms - Dry mouth, redness of the skin, pale skin, increased sweating, headaches with a feeling of tension.

Behavior during examination - Fidgeting in place, restless gestures or gait, hand tremors, frowning eyebrows, tense facial expression, sighs or rapid breathing, pale face, frequent swallowing of saliva, etc.

Processing of received data

The questionnaire is structured in such a way that seven points measure so-called “somatic anxiety”, and the other seven measure “mental anxiety”.

Interpretation

0-7 - absence of anxiety;

8-19 - symptoms of anxiety;

20 and above - an anxious state;

25-27 - panic disorder.

Thus, the sum of the scores resulting from the assessment of persons without anxiety is close to zero. The maximum possible total score is 56, which reflects the extreme severity of the anxiety state.

Appendix G3. Recommended drug doses, level of evidence, and strength of recommendations for the treatment of GAD

	Level of evidence

Paroxetine**
Escitalopram#
Sertraline**##
Fluoxetine**#
Citalopram#

Venlafaxine#
Duloxetine#
Other groups of antidepressants
Clomipramine**#
Amitriptyline**#
Clomipramil
Mirtazapine#
Trazadone#
Benzodiazepines
Diazepam**#
Lorazepam**
Bromodihydrochlorophenylbenzodiazepine**#
Nitrazepam**
Alprazolam
Non-benzodiazepine drugs
Hydroxyzine**
Zopiclone**#
Buspirone
Etifoxine
Neuroleptics
Quetiapine#
Chloroprotexene
Clozapine#
Thioridazine**
Sulpiride**#
Antiepileptic drugs
Pregabalin**

Generalized anxiety disorder is a mental disorder that involves anxiety. It lasts for a long time and is not associated with any specific reasons in the form of situations or objects. Patients experience physical discomfort and mental suffering. The course is wavy: in some periods anxiety intensifies, and in others it becomes a general emotional background.

Generalized anxiety disorder - a mental disorder associated with anxiety

In itself, this condition is more often considered as not posing any serious threat. Quite often it is associated with patients’ fears that they have certain physical problems and attempts to find diseases of the cardiovascular system, gastrointestinal tract and others. This primarily manifests itself in the form of physical sensations that accompany waves of anxiety. In some cases, conversations with doctors are enough to convince patients that there are no serious problems with their body. But this doesn’t always happen.

In practice, generalized anxiety disorder is a condition that is most often combined with something else. In the emotional sphere - chronic mood disorders, depression or cyclothymia. It is also possible to manifest a phobic disorder or obsessive-compulsive disorder. Therefore, you should not think that this is a small trifle that arose out of excitement.

It is known that generalized anxiety disorder is more common in women, and patients are under chronic environmental stress. It is quite possible that the doctor will quite easily be able to convince someone that her tachycardia is associated with a mental state. But it is unlikely that her agreement with this should be equated with a complete solution to the problem.

Generalized Anxiety Disorder: Symptoms

Signs of anxiety should be observed for a long time, most often - several months. Moreover, patients experience anxiety more often than not during this period.

Fears, anticipation of trouble. It may be related to something specific, or it may be inexplicable. Feeling nervous and having difficulty concentrating.
Motor voltage. I can’t relax, my muscles cramp. Tremors and headaches may occur.
Signs of autonomic dysfunction. Sweating, most often expressed as cold sweat. Tachycardia, irritation of the stomach or rectum, signs of hyperventilation, dizziness.

A person with generalized disorder constantly expects trouble.

Before making a diagnosis, neurasthenia must be excluded. Many generalized anxiety disorders do not cancel, in particular depression. Attention should also be paid to possible amatic diseases.

For example, thyrotoxicosis or coronary heart disease, which is sometimes accompanied by similar symptoms. It’s also a good idea to inquire about what medications he is taking and whether there was any sudden withdrawal from any of them.

Generalized anxiety disorder: treatment

According to the methods themselves, it is divided into general psychotherapy and drug therapy, and according to its focus on eliminating the feeling of anxiety itself and the somatic symptoms that accompany it. Let's start with medications. In reference books and feature articles you can see a huge list of their different types and types. Let's list the main points of this splendor and point out why we don't like it.

Tranquilizers. It is widely prescribed in our time, although the reason is 90% in the inertia of thinking of the doctors who do it. They do not provide any therapeutic effect. Many people have reduced ability to concentrate, which creates a high risk of accidents during outpatient treatment. The body gets used to the fact that anxiety is repressed only under their influence, so the dose needs to be increased. Withdrawal from tranquilizers is associated with great risk. They are addictive. Treating any anxiety-related disorder is a bad way to go.
Typical antipsychotics. You can say the same thing as about tranquilizers. It’s not for nothing that they were once called “big” tranquilizers, and benzodiazepines “small”. Some extrapyramidal and neuroendocrine side effects are inevitable even at the smallest doses. There is a very serious suspicion that all cases of prescribing antipsychotics are associated with situations where, behind generalized anxiety, signs of something else and something completely bad are visible.
β-blocker drugs. This is only the case if there is tremors and rapid heartbeat that does not go away from taking other medications.
Atarax (hydroxyzine). Efficiency has been proven, but at the same time, short-term effects have been noted. It doesn’t change anything overall, only for a certain number of hours.
Afobazole (fabomotizole). There is a lot of talk, but not a single trial has proven its effectiveness.

This list could be expanded, but we don’t see much sense in that. From our point of view, treatment should be based on antidepressants and complex psychotherapy. At the same time, despite all the variety of types of drugs, the choice of antidepressants will have to be made between paroxetine, known under the brand names Paxil, Paroxin, and sertraline.

As for general therapy, this question is both simple and complex. We can say with absolute confidence that all signs of the disorder can be easily relieved with simple relaxation exercises and breathing exercises. However, our civilization has produced an amazing type of people. The psychotherapist suggests a simple exercise. You need to lie on the floor and consistently relax individual areas of the body. Okay, nice, well, completely safe from all points of view. True, he forgot himself and uttered the word “Shavasana”. This is the name in yoga for a relaxation pose lying on your back. He immediately sees these eyes and hears the indignant “What are you offering me here?”

The reaction is quite typical. People on the go can come up with any ways to avoid doing what could help them. Usually the client expects the therapist to listen to him. The verbal expression of generalized anxiety disorder largely depends on the personality type. Some talk dramatically about their imaginary illnesses, others talk more about depression, not about the feeling of anxiety specifically. Let's assume that the therapist has a dozen techniques in his arsenal that have been proven effective hundreds of times.

About one in 20 patients listens with interest and begins to practice. Even then he comes to clarify whether he is doing everything correctly. Well, great, what can I say? One moment we have depression and anxiety, and now we are practicing pranayama, doing yoga, and meditating. Does it help? Yes, it seems that such disorders exist in order to remind a person that he is not a piece of living meat, but a person, that he has not only a psyche, but also a soul.

Tranquilizers may be prescribed to treat anxiety disorders

The other 19 look with some incredible skepticism. First, they expect all relationships to be exclusively market ones. They feel like customers or the same clients as in a hairdresser. Secondly, they consider their own actions unacceptable. There is no need to think that the Eastern terms themselves or the word “meditation” cause fear. Actions are considered unacceptable. And this is not out of fear of self-medication. These same people can easily find an advertisement for some dubious drug and “prescribe” it for themselves.

Anxiety disorder and panic attacks

Generalized anxiety disorder is represented as a separate entity in ICD-10 with code F41.1. Above it is episodic paroxysmal anxiety, which in everyday life is more often called anxiety panic disorder. However, this does not mean that complex options are impossible, when a person experiences anxiety almost constantly, but sometimes also attacks of panic attacks. All this “beauty” easily turns into agoraphobia with panic disorder. The idea of her as a person with a tin foil hat on her head is not entirely correct. With hats, everything is somewhat more complicated and is extremely rare.

But this type of agoraphobia is much more common. What's happening? Patients are not afraid of open space. But they experience panic attacks on the street or on public transport. This all happens against a background of depression or anxiety. The result is a very unpleasant situation. They hear from family and friends that they have let something in on themselves. They don’t argue, even if they let them in, but how can they get out?

First of all, without sharing the depth of your experience with anyone close to you, because they still won’t understand. You need to ask your loved ones for help in order to get to a psychotherapist. Personally, the author of these lines thinks that we really need that same Paxil. The only exceptions can be cases of individual intolerance.

Paxil improves mental health in anxiety disorders

Generalized Anxiety Disorder: Treatment with Mantras

Next, you need to find methods of working with the body and consciousness at the same time. We have so much written and said about how to work and what to do. Many techniques can be found in the articles on this site. However, the author of this does not know anything better than the “So-Ham” mantra. Simple, great and incredibly effective. You can work with the mantra at least 24 hours a day and 7 days a week. Helps in the most severe cases. The essence of the practice can be explained as follows.

You need to associate inhalation with the sound “So”, and exhalation with the sound “Ham”, try to hear these sounds in the vibration of your own breath. You don't need to do anything else. As such, in the context of yogic practice, this mantra becomes a way to “merge” inhalation and exhalation into one process. Details can be found on relevant yoga and meditation websites. For us, since we are talking about panic attacks, the usual, initial level of practice is enough.

What happens as a result. Consciousness is distracted from somatic signs, and breathing is balanced, and even becomes conscious. Just five minutes and you will see for yourself that generalized anxiety disorder with panic attacks is not as scary as you might think.

The advantage is that you can work at any time. For example, 20 minutes statically, sitting on a chair with a straight back. At the same time, you can try to ensure that inhalations and exhalations are connected with the anteromedial canal. Those interested will find out the details themselves, and we will describe it in general terms. Imagine that a transparent tube runs from the larynx area to the navel area. When you inhale, a certain substance rises along it, and when you exhale, it descends. This is also accompanied by the sensation of the sound “So” when inhaling, and the sound “Ham” when exhaling. Breathing is calm, natural, there is no need to artificially manipulate it.

Regular practice will help not only get rid of anxiety, but also get through a panic attack.

In fact, there are many more methods. Qigong practice, meditation and various yoga exercises bring excellent results. All this is very rarely described in the medical literature. And if it is described, then in some completely adapted version. The reason is that the materialistic foundations of science do not allow us to recognize the possibility of the existence of bioenergy and a fairly large number of things that belong to the world of phenomenological reality. Here we have one advantage. We can act without waiting for anyone's confession. If psychology waited for confessions, then there would be no possibility of doing psychoanalysis at all.

Reciting mantras helps cope with anxiety disorder

This is the type of disorder when everyone can be their own psychotherapist. As mentioned above, most do not want this and prefer to rely on motherwort or something similar. Not bad either, but just don’t get carried away with herbal medicine. Let us remind you once again that natural does not mean safety. Fly agarics and toadstools, henbane - these are all also natural, but this does not make them any less dangerous.

Send specific messages to the heart, lungs, muscles and other organs through nerves throughout the body. Hormonal alarm signals come through the blood - for example, adrenaline is released. Taken together, these “messages” lead to the body speeding up and intensifying its work. The heart beats faster than usual. Nausea occurs. The body is covered with trembling (tremor). Sweat increases. It is impossible to avoid dry mouth, even if a person drinks a lot of liquid. Chest and headache hurt. Sucks in the pit of the stomach. Shortness of breath appears.

The excitement of a healthy body must be distinguished from painful, pathological anxiety. Normal anxiety is useful and necessary when experiencing stress. It warns of danger or a situation of possible confrontation. The individual then decides whether he should "take the fight" (for example, take a difficult exam). If too high, the subject understands that he needs to get away from such an event as quickly as possible (for example, when attacked by a wild animal).

But there is a special type of anxiety in which a person’s condition becomes painful, and manifestations of anxiety prevent him from carrying out normal life activities.

With GAD, a person is afraid for a long time. Often extreme confusion is unmotivated, i.e. the reason for it cannot be understood.

Symptoms of pathological anxiety may, at first glance, be similar to manifestations of a normal, healthy anxiety state, especially when we are talking about the so-called “anxious individuals.” For them, anxiety is an everyday norm of well-being, and not a disease. To distinguish generalized anxiety disorder from the norm, you need to find at least three of the following symptoms in a person:

anxiety, nervous excitement, impatience appear much more often than in usual living conditions;
fatigue sets in faster than usual;
it is difficult to gather attention, it often fails - as if it is turned off;
the patient is more irritable than usual;
muscles are tense and cannot be relaxed;
sleep disturbances appeared that were not there before.

Anxiety that occurs for only one of these reasons is not a sign of GAD. Most likely, obsessive anxiety for any single reason means a phobia - a completely different disease.

Generalized anxiety disorder occurs between the ages of 20 and 30. Women get sick more often than men. The causes of this disorder are unknown, so it often seems that they do not exist at all. However, a number of indirect factors can influence the development of such a condition. This

heredity: there are many anxious individuals in the family; had relatives who suffered from GAD;
during childhood, the patient suffered psychological trauma: he was poorly communicated with in the family, one of the parents or both died, a syndrome was identified, etc.;
after suffering major stress (for example, a family crisis), generalized anxiety disorder developed. The crisis is over, the provoking factors have been exhausted, but the signs of GAD remain. From now on, any minor stress, which has always been easy to cope with, maintains the symptoms of the disease.

GAD in some cases develops as a secondary, concomitant disease in those suffering from depression and schizophrenia.

The diagnosis of GAD is made if its symptoms have developed and persisted for 6 months.

Is it possible to overcome generalized anxiety disorder? The treatment of this disease has been studied quite well. The manifestation of the disease may not be severe, but in the worst cases it can make the patient unable to work. In the sudden mode, difficult and lighter periods change; under stress (for example, the patient has lost his job or separated from a loved one), spontaneous exacerbations are possible.

Patients with GAD tend to smoke incredibly heavily, drink alcohol, and use drugs. This way they distract themselves from the disturbing symptoms, and for a while it really helps. But it is quite obvious that by “supporting” themselves in this way, they can completely lose their health.

Treatment for GAD cannot be quick and, unfortunately, does not provide complete recovery. At the same time, the treatment process, if carried out in courses over many years, will provide significant relief of symptoms and a qualitative improvement in life.

Its task at the first stage is to show the patient what changes need to be made in the ideas and thoughts that provoke anxiety. Then the patient is taught to build his thinking without harmful, useless and false premises - so that it works realistically and productively.

Individual consultations are conducted, during which the person practices problem-solving techniques.

Where technical and financial conditions allow, there are group courses to combat anxiety symptoms. They teach relaxation and attach great importance to strategies for overcoming difficulties.

For self-help, psychological support centers (if they exist) can provide literature and videos teaching relaxation and how to overcome stress. Special techniques for relieving anxiety are described.

Drug therapy is based on the use of two types of drugs: buspirone and antidepressants.

Buspirone is considered the best medicine for this. Its action has not been fully studied. It is only known that it affects the production of a special substance in the brain - serotonin, which is presumably responsible for the biochemistry of anxiety symptoms.

Antidepressants, although not a direct target of anxiety, can be effective in treating it.

Currently, benzodiazepine drugs (for example, diazepam) are increasingly prescribed for the treatment of GAD. Despite their apparent ability to relieve anxiety, benzodiazepines are addictive, causing them to stop working. Moreover, additional treatment has to be carried out against addiction. In severe cases of GAD, diazepam is prescribed for a period of no more than 3 weeks.

Antidepressants and buspirone are not addictive.

To achieve the greatest effect, cognitive therapy and buspirone treatment are combined.

Advances in modern pharmacology allow us to expect new medications in the coming years that will help completely cure generalized anxiety disorder.