Generalised Anxiety Disorder

Gastroenterology (12%) Core Clinical Conditions

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Definition Aetiology Pathophysiology Sign and Symptoms Investigations Management

Generalised Anxiety Disorder (GAD) is a prevalent mental health condition characterised by excessive and persistent worry and anxiety about various aspects of life. It goes beyond normal everyday concerns, causing significant distress and interfering with a person's daily functioning. Individuals with GAD often find it challenging to control their worries, leaving them in a continual state of apprehension. One of the key features of GAD is the excessive and pervasive nature of worrying. It extends across a wide array of situations, including health, relationships, work, and personal issues. These worries are often unfocused and disproportionate to the actual threat present. Individuals with GAD tend to anticipate worst-case scenarios, continually expecting catastrophic outcomes, even when faced with minor difficulties.
The chronic nature of GAD means that individuals experience anxiety and worry persistently, often throughout most of their day. They may find it challenging to relax, feeling constantly on edge or restless. Physical symptoms may accompany these feelings, such as muscle tension, irritability, sleep disturbances, and difficulty concentrating. The relentless worry experienced by those with GAD can be exhausting and affect their overall quality of life.
It's essential to note that GAD is different from temporary anxiety or stress. While it's normal to feel anxious before an upcoming event or during a challenging situation, individuals with GAD struggle to escape the grip of constant worry. They may become preoccupied with an array of concerns, even when there is no immediate threat or danger.

1. Biological Factors:
Biological factors play a fundamental role in the development of GAD. Studies have shown that individuals with a family history of anxiety disorders are more likely to develop GAD themselves, suggesting a possible genetic predisposition. Moreover, imbalances in neurotransmitters, such as serotonin, dopamine, and norepinephrine, have been implicated in the cause of GAD. These neurotransmitters are responsible for regulating mood, emotions, and the body's stress response, and any disruption in their functioning may contribute to the development of anxiety disorders.
2. Psychological Factors:
Psychological factors, such as personality traits and cognitive processes, also contribute to the aetiology of GAD. Individuals with a tendency towards perfectionism, high levels of neuroticism, or a history of experiencing traumatic events are more susceptible to developing GAD. Additionally, cognitive processes like excessive worry, catastrophizing, and negative thinking patterns contribute to the maintenance and exacerbation of GAD symptoms. These maladaptive thought patterns intensify anxiety and perpetuate the cycle of worry.
3. Environmental Factors:
Environmental factors can significantly impact the development of GAD, particularly when combined with biological and psychological factors. Stressful life events, such as loss, financial difficulties, work-related pressure, or relationship conflicts, can trigger the onset of GAD symptoms. Additionally, childhood adversity, including abuse, neglect, or chronic parental stress, increases the risk of developing anxiety disorders later in life. Environmental factors serve as triggers and contribute to the persistence of GAD symptoms by activating the stress response system.
4. Neurobiological Factors:
Neurobiological factors also play a crucial role in the aetiology of GAD. The amygdala, an area of the brain responsible for processing emotions and fear responses, appears to be hyperactive in individuals with GAD. This heightened activity leads to an exaggerated fear response and a reduced ability to regulate anxiety effectively. Furthermore, the prefrontal cortex, involved in executive functions such as decision-making and emotion regulation, shows reduced activity in those with GAD, impairing their ability to inhibit anxiety-provoking thoughts.

5. Behavioural Factors:

Behavioural factors contribute to the development and maintenance of GAD. Avoidance behaviours, such as avoiding situations or places that trigger anxiety, reinforce the fear response and prevent individuals from learning that their feared outcomes are unlikely to occur. This avoidance perpetuates the cycle of worry and anxiety, reinforcing the belief that they are unable to cope with these situations. Additionally, excessive reassurance seeking and safety behaviours reinforce the belief that anxiety is justified and even necessary, further contributing to the maintenance of GAD symptoms.

Genetic and Environmental Factors:
Genetics also influence the development of GAD. Research suggests that individuals with a family history of anxiety disorders are more likely to develop GAD themselves. Specific gene variants related to neurotransmitter regulation and stress response have been identified as potential genetic risk factors for GAD.
Moreover, environmental factors, such as childhood experiences and traumatic events, can contribute to the development of GAD. Chronic exposure to stressors or adverse life events can alter the brain's stress response system, making individuals more susceptible to anxiety disorders.
Cognitive and Behavioral Factors:
Cognitive and behavioural factors also play a significant role in the pathophysiology of GAD. Individuals with GAD tend to have distorted thought patterns and cognitive biases, such as catastrophizing, overestimating threats, and excessive worry about future events. These maladaptive thought patterns contribute to the perpetuation of anxiety symptoms and the development of chronic anxiety.
Additionally, avoidance behaviours are commonly observed in GAD. As a result, individuals may limit their engagement in various activities or situations due to fear and excessive worry. This avoidance behaviour reinforces the anxiety response, contributing to the maintenance of GAD.
Neuroanatomical Abnormalities:
Neuroanatomical studies have reported abnormalities in brain areas implicated in anxiety regulation in individuals with GAD. The amygdala, which plays a critical role in fear and anxiety responses, tends to be hyperactive in individuals with GAD. This heightened activity can lead to increased anxiety symptoms.
Furthermore, the prefrontal cortex, responsible for regulating emotions and cognitive processes, shows abnormalities in individuals with GAD. Hypoactivity in this brain region may contribute to difficulties in emotion regulation and impair the ability to control anxiety.

1. Excessive Worry: People with GAD experience persistent and excessive worry about a wide range of everyday concerns such as work, health, finances, relationships, and more. These worries are often unrealistic and disproportionate to the situation.
2. Restlessness and Irritability: Individuals with GAD may find it difficult to relax and often feel restless. They may also become easily irritable or have a heightened sense of edginess.
3. Difficulty Concentrating: GAD can make it challenging to concentrate or focus on tasks at hand. Your mind may be preoccupied with worries, making it hard to stay present or complete daily activities.
4. Physical Symptoms: GAD often manifests physical symptoms that can include muscle tension, headaches, fatigue, and frequent gastrointestinal issues, such as stomachaches or nausea.
5. Sleep Problems: Sleep disturbances are common in individuals with GAD. They may have trouble falling asleep, staying asleep, or experience restless and unrefreshing sleep.
6. Excessive Self-Consciousness: People with GAD may feel excessively self-conscious and worry excessively about being judged or criticised by others. This can impact social interactions and make them avoid certain situations.
7. Avoidance Behaviours: Due to their anxiety, individuals with GAD may start avoiding situations or activities that trigger their worries. This avoidance can limit their engagement in daily life and restrict their opportunities for personal growth.
8. Intrusive Thoughts: GAD can be accompanied by intrusive and repetitive thoughts about potential negative outcomes or catastrophic events. These thoughts can be distressing and contribute to persistent worry.
9. Procrastination: Chronic worry can lead to procrastination as individuals with GAD often struggle with making decisions or initiating tasks due to fear of negative outcomes or uncertainty.

1. Clinical Assessment:
A detailed clinical assessment forms the foundation of diagnosing GAD. During this step, healthcare professionals gather information through a thorough interview with the individual experiencing symptoms. Typically, the clinician will ask about the nature, intensity, duration, and triggers of anxiety, as well as their impact on daily life. They may also explore past medical history, family history of anxiety or other mental health conditions, and any substance use that could contribute to anxiety symptoms.
2. Diagnostic Criteria:
The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) is the primary reference used by healthcare professionals to diagnose mental disorders. GAD diagnosis requires meeting specific criteria, which include excessive anxiety and worry occurring more days than not for at least six months. The anxiety must be associated with various physical and psychological symptoms such as restlessness, fatigue, difficulty concentrating, irritability, muscle tension, and sleep disturbances.
3. Psychological Assessments:
Healthcare professionals may employ psychological assessment tools to supplement the clinical evaluation process. These assessments help in quantifying the severity of anxiety symptoms and monitoring progress over time. One such commonly used tool is the Generalised Anxiety Disorder-7 (GAD-7) questionnaire, which involves seven questions assessing the frequency and intensity of anxiety symptoms.

1. Psychotherapy

Cognitive Behavioral Therapy (CBT): CBT is a widely used psychotherapeutic approach for treating GAD. It focuses on identifying and challenging negative thought patterns and beliefs that contribute to anxiety. CBT helps individuals develop healthier coping mechanisms and modify their behaviours to reduce anxiety.

2. Medication

Selective Serotonin Reuptake Inhibitors (SSRIs): These antidepressant medications, such as sertraline or escitalopram, are commonly prescribed for GAD. SSRIs help regulate serotonin levels in the brain, leading to a reduction in anxiety symptoms. However, medication should be prescribed and monitored by a qualified healthcare professional.

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