GENERALISED ANXIETY DISORDER (GAD)

Definition:

- GAD, formerly known as free-floating anxiety, is a mental health disorder characterized

by chronic, excessive, and unreasonable worry and anxiety about various aspects of life,
including minor events.
-
Diagnostic Criteria (DSM-5):

- Worry must persist for at least 6 months, occurring on more days than not.
- Difficulty in controlling the worry.
- The worry must encompass multiple events or activities.
- The content of worry cannot be exclusively related to other concurrent disorders.
-
Additional Symptoms (At least three of the following for the past 6 months):

- Restlessness or feeling keyed up or on edge.

- Being easily fatigued.
- Difficulty concentrating or experiencing a blank mind.
- Irritability.
- Muscle tension.
- Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep).

Clinical Picture of Generalized Anxiety Disorder:

Constant Future-Oriented Mood State:

- Individuals with GAD often live in a perpetual state of anxious apprehension, chronic
tension, and diffuse uneasiness related to the future.

Vigilance for Signs of Threat:

- Those with GAD exhibit marked vigilance for potential signs of threat in their
environment, which contributes to their anxiety.

Subtle Avoidance Activities:

- GAD individuals engage in subtle avoidance behaviors like procrastination, checking, or
contacting loved ones frequently to ensure their safety.

Associated Symptoms:
- Muscle tension, restlessness, and difficulty concentrating are common symptoms.
- Excessive worry and hypervigilance for potential threats are also prominent features of
GAD.

Common Spheres of Worry:

 - In one study, common areas of worry in people with GAD included family, work, finances,
and personal illness.

Difficulty with Decision-Making:

- GAD sufferers find it challenging to make decisions and tend to worry endlessly even
after making a decision.
- They often fret over possible errors and unforeseen circumstances, even when the
outcome is beyond their control.
-
Inability to Live in the Present:
- GAD individuals have difficulty appreciating the logic of not tormenting themselves about
uncontrollable outcomes, preventing them from experiencing the present moment and
finding joy.
-
Personal and Economic Burden:
- A recent study highlights the personal and economic burden of GAD on individuals and
society, emphasizing the need for effective treatment and support for those affected.

Additional Diagnostic Criteria (DSM-5):

E. Clinical Distress or Impairment:

- The anxiety, worry, or associated physical symptoms must lead to clinically significant
distress or impairment in social, occupational, or other important areas of functioning.
F. Exclusion of Substance/Medical Causes:
- The disturbance should not be attributed to the physiological effects of a substance (e.g.,
drug or medication) or another medical condition (e.g., hyperthyroidism).
G. Rule Out Other Mental Disorders:
- The disturbance should not be better explained by another mental disorder, such as
panic disorder, social anxiety disorder, obsessive-compulsive disorder, separation
anxiety disorder, post-traumatic stress disorder, anorexia nervosa, somatic symptom
disorder, body dysmorphic disorder, illness anxiety disorder, schizophrenia, or delusional
disorder.

Case Example of Generalized Anxiety Disorder:

A Graduate Student with GAD

- John, a 26-year-old graduate student, experienced lifelong anxiety, which worsened
when he left home for an Ivy League college.
- His anxiety interfered with multiple aspects of his life, including health concerns for
himself and his parents.
- He worried about his future and struggled to complete his master's thesis on time.
- Excessive worry about getting a bad grade and concern about what others thought of
him in class were common.
 - He had never dated due to shyness about dating, and he worried about potential
relationships and being perceived as boring.
- Physical symptoms included muscle tension, fatigue, difficulty concentrating,
restlessness, and sleep disturbances.
-
Prevalence, Age of Onset, and Gender Differences:
- Approximately 3% of the population suffers from GAD in any 1-year period, and 5.7%
experience it at some point in their lives.
- GAD tends to be chronic, with a 42% non-remission rate after 12 years.
- After age 50, GAD tends to disappear for many people.
- GAD is about twice as common in women as in men.

Comorbidity with Other Disorders:

- GAD often co-occurs with other disorders, including panic disorder, social phobia,
specific phobia, PTSD, and major depressive disorder.
- Excessive use of tranquilizing drugs, sleeping pills, and alcohol can complicate the
clinical picture.

Psychological Causal Factors:

Uncontrollability and Unpredictability:
- GAD is associated with a low tolerance for uncertainty and a history of experiencing
unpredictable or uncontrollable events.

Lack of Safety Signals:

- People with GAD may lack safety signals in their environment, leading to chronic tension
and hypervigilance for potential threats.

Sense of Mastery and Control:

- A history of control over one's environment can immunize against anxiety, but parents of
anxious children often have an overcontrolling parenting style.

The Role of Worry and Its Functions:

Central Role of Worry:
- Worry is considered the central feature of GAD and has both positive and negative
effects.
-
Positive Functions of Worry:
- People with GAD believe that worry helps avoid catastrophe, distract from emotional
topics, and prepare for negative events.
- Worry suppresses aversive emotional and physiological responses and insulates
individuals from processing the topic they are worrying about, thereby maintaining the
threat.
-
Negative Consequences of Worry:
 - Worry can increase anxiety and lead to more intrusive thoughts.
- Attempts to control thoughts and worry may paradoxically result in more intrusive
thoughts and a sense of uncontrollability, creating a vicious circle of anxiety and worry.

Biological Causal Factors: Genetic Factors

Modest Heritability:
- There is evidence of genetic factors contributing to Generalized Anxiety Disorder (GAD),
though the heritability is modest.

Comparison to Other Anxiety Disorders:

- Heritability in GAD is smaller compared to most other anxiety disorders, except phobias.

Challenges in Estimating Heritability:

- The evolving nature of diagnostic criteria for GAD has made it challenging to study its
genetic factors.
- Twin studies have shown variations in heritability estimates based on different definitions
of GAD.

Recent Twin Studies:

- Using DSM-IV-TR diagnostic criteria, recent twin studies estimate that 15 to 20 percent
of the variance in liability to GAD is due to genetic factors.

Common Genetic Predisposition:

- GAD and major depressive disorder appear to share an underlying genetic
predisposition.
- The development of GAD or major depression in individuals with a genetic risk is
influenced by specific environmental experiences, particularly nonshared environment.
- This common genetic predisposition is often associated with the personality trait of
neuroticism.

Neurotransmitter and Neurohormonal Abnormalities:

Functional Deficiency in GABA:
- Benzodiazepine medications, discovered in the 1950s to reduce anxiety, are believed to
exert their effects by stimulating the action of GABA (gamma-aminobutyric acid).
- Highly anxious individuals may have a functional deficiency in GABA, which normally
plays a role in inhibiting anxiety during stressful situations.
- Benzodiazepines reduce anxiety by increasing GABA activity in parts of the brain
associated with anxiety, like the limbic system, and by suppressing the stress hormone
cortisol.
- It's unclear whether the deficiency in GABA causes anxiety or is a consequence of it, but
it appears to contribute to the maintenance of anxiety.

Involvement of Serotonin:
 - More recently, research has suggested that serotonin, along with GABA, plays a role in
modulating generalized anxiety.
- The interactions and mechanisms involving GABA, serotonin, and possibly
norepinephrine in anxiety are not fully understood.

The Corticotropin-Releasing Hormone System:

- Corticotropin-releasing hormone (CRH) is an anxiety-producing hormone implicated in
generalized anxiety and depression.
- When activated by stress or perceived threat, CRH stimulates the release of
adrenocorticotropic hormone (ACTH) from the pituitary gland, leading to the release of
the stress hormone cortisol from the adrenal gland.
- CRH may play a significant role in generalized anxiety through its effects on the bed
nucleus of the stria terminalis, an extension of the amygdala, which is considered an
important brain area mediating generalized anxiety

Neurobiological Differences Between Anxiety and Panic:

Fear and Panic:
- Fear and panic involve the activation of the fight-or-flight response.
- Key brain areas involved include the amygdala and the locus coeruleus.
- The neurotransmitters norepinephrine and serotonin play a significant role in these
emotional responses.

Generalized Anxiety (Anxious Apprehension):

- Generalized anxiety is a more diffuse emotional state characterized by arousal and
preparation for possible impending threat.
- Brain areas, neurotransmitters, and hormones implicated include the limbic system
(especially the bed nucleus of the stria terminalis), GABA, and corticotropin-releasing
hormone (CRH).
- Serotonin may also play a role in both anxiety and panic, although likely in somewhat
different ways.
- People with generalized anxiety disorder (GAD) have been found to have a smaller left
hippocampal region, which may represent a common risk factor for GAD and major
depression.

Treatments: Medications:
Benzodiazepines:
- Medications from the benzodiazepine category like Xanax or Klonopin are commonly
used for tension relief and somatic symptom reduction.
- Their effects on psychological symptoms, including worry, are not as significant.
- Benzodiazepines can lead to physiological and psychological dependence and
withdrawal, making them challenging to taper.

Buspirone:
 - A newer medication, buspirone, is effective in treating GAD.
- It is not sedating and does not lead to physiological dependence.
- Buspirone has a greater impact on psychic anxiety compared to benzodiazepines, but it
may take 2 to 4 weeks to show results.

Antidepressant Medications:
- Several categories of antidepressant medications, similar to those used for panic
disorder, are useful in treating GAD.
- They tend to have a greater effect on the psychological symptoms of GAD compared to
benzodiazepines.
- These medications may take several weeks before their effects become apparent.

Cognitive-Behavioral Treatment:
- Cognitive-behavioral therapy (CBT) for generalized anxiety disorder (GAD) has evolved
and proven increasingly effective.
- CBT typically combines behavioral techniques with cognitive restructuring techniques.
- Behavioral techniques often include training in applied muscle relaxation.
- Cognitive restructuring aims to reduce distorted cognitions, information-processing
biases, and catastrophizing about minor events associated with GAD.

While GAD was initially challenging to treat, CBT approaches have improved over time.
Effectiveness of CBT:
- A quantitative review of controlled studies showed that CBT resulted in significant
changes across various GAD symptoms.
- The magnitude of symptom changes with cognitive-behavioral treatment is at least as
substantial as those achieved with benzodiazepines.
- CBT is associated with fewer dropouts compared to benzodiazepines.
- CBT can also help individuals who have been using benzodiazepines for an extended
period successfully taper their medications.

CBT for John's GAD:

- John, the graduate student with GAD, found success with cognitive-behavioral therapy.
- Prior to CBT, he had limited success with traditional talk therapy at a student counseling
center.
- During approximately 6 months of CBT, John benefited from muscle relaxation training to
reduce overall tension.
- Cognitive restructuring helped diminish his excessive worry across different life domains.
- While he still struggled with procrastination, it was improving.
- He started socializing more and ventured into dating as therapy progressed, with a more
positive perspective on dating outcomes.
- CBT contributed to John's improved overall well-being and functionality.
 Obsessive-Compulsive Disorder (OCD)

Definition: Characterized by unwanted, intrusive obsessive thoughts and accompanying

compulsive behaviors aimed at reducing distress or preventing feared outcomes.

- According to DSM-5, obsessions are persistent, disturbing, uncontrollable thoughts, and

compulsions involve repetitive behaviors or mental rituals.
- OCD can severely impact a person's quality of life and daily functioning.

Diagnostic Criteria for OCD

- A person must experience obsessions, compulsions, or both.
- Obsessions involve intrusive, distressing thoughts or images that cause anxiety.
- Compulsions are repetitive behaviors or mental acts aimed at reducing distress or
preventing dreaded events.
- The symptoms are time-consuming and cause significant distress or impairment.
- Symptoms must not be due to substance use or other mental disorders.

Insight in OCD:
- People with OCD must recognize that their obsessions are generated from their own
minds, not imposed externally.
- There's a continuum of insight among individuals with OCD, with some having no insight
into the senselessness of their obsessions.

Common Obsessive Themes:

- Many OCD obsessions revolve around contamination fears, harming oneself or others,
pathological doubt, symmetry concerns, sexual obsessions, and religious or aggressive
themes.

Obsessive-Compulsive Behaviors:
- OCD compulsions can range from overt repetitive actions like handwashing and
checking to covert mental rituals such as counting or praying.
- Compulsions aim to alleviate anxiety and are often performed according to strict rules.
- People with OCD often feel driven to perform these behaviors.

Prevalence, Age of Onset, and Gender Differences:

- OCD is more prevalent than previously thought, with a 1-year prevalence rate of about
1.2% and a lifetime prevalence of 2.3%.
- The disorder often begins in late adolescence or early adulthood but can also occur in
children.
- Comorbidity with other mental disorders, especially depression, is common.
- Gender differences in prevalence vary, with some studies indicating a higher rate in
women.

Psychological Causal Factors:

 - OCD is linked to thought suppression, where attempting to suppress unwanted thoughts
can paradoxically increase their frequency.
- An inflated sense of responsibility and thought-action fusion contribute to the distress
caused by obsessions.

Cognitive Causal Factors

- People with OCD exhibit cognitive biases and difficulties in blocking out negative,
irrelevant information.
- Low confidence in memory and difficulties in inhibiting motor responses are also
associated with OCD symptoms.

Biological Causal Factors

- Genetic factors play a significant role in OCD, as evidenced by twin and family studies.
- Some forms of OCD are linked to Tourette's syndrome, a disorder with a substantial
genetic basis.
- Brain imaging studies have identified abnormalities in the orbital frontal cortex, cingulate
cortex/gyrus, and basal ganglia.
- Dysfunction in the cortico-basal-ganglionic-thalamic circuit is central to the brain
abnormalities seen in OCD, contributing to behaviors like checking and cleaning.
- These brain dysfunctions can be partially normalized with effective treatment.

Neurotransmitter Abnormalities
- The tricyclic drug Anafranil (clomipramine) has been found effective in treating OCD,
primarily due to its impact on the neurotransmitter serotonin.
- Serotonin plays a significant role in OCD, and several selective serotonin reuptake
inhibitors (SSRIs), like fluoxetine (Prozac), are also effective in treating OCD.
- While the exact nature of serotonin dysfunction in OCD is not fully understood, increased
serotonin activity and sensitivity to serotonin in certain brain structures are implicated in
OCD symptoms.
- Long-term use of clomipramine or fluoxetine results in down-regulation of serotonin
receptors, leading to a functional decrease in serotonin availability.
- Dysfunctions in other neurotransmitter systems, including dopaminergic, GABA, and
glutamatergic systems, also appear to be involved in OCD, though their roles are not
well understood.

Treatments
Behavioral and Cognitive-Behavioral Treatments
- Exposure and response prevention therapy, which involves exposing individuals to
distressing stimuli and preventing them from engaging in rituals, is an effective approach
for OCD treatment.
- OCD clients create a hierarchy of upsetting stimuli and rate them, then expose
themselves to these stimuli without engaging in rituals.
- Exposure is conducted in therapy sessions and through homework assignments.
 - This approach helps the majority of clients who stick with the treatment, leading to a
50-70% reduction in symptoms and improved quality of life.
- Exposure and response prevention therapy is considered superior to medication for
OCD treatment.

Medications
- Medications primarily targeting the serotonin neurotransmitter system, such as
clomipramine and fluoxetine, have mild to moderate effects in treating OCD.
- Approximately 40-60% of OCD clients experience a 25-35% reduction in symptoms with
these medications.
- Relapse rates are high when medication is discontinued (50-90%).
- Small doses of certain antipsychotic medications may benefit those who do not respond
to serotonergic drugs.
- Combining medication with exposure and response prevention therapy does not
consistently enhance treatment outcomes.

Neurosurgery
- For severe, intractable OCD cases unresponsive to other treatments, neurosurgery may
be considered.
- Candidates for neurosurgery must have had severe OCD for at least 5 years and no
response to other treatments.
- Neurosurgery, which destroys brain tissue in specific areas implicated in OCD, can lead
to at least a one-third reduction in symptoms in approximately 35-45% of cases.
- The effectiveness of these treatments varies, and research is ongoing to enhance the
understanding and treatment of OCD.