I. Overview: Generalized anxiety disorder (GAD) is a syndrome of persistent worry and anxiety about daily life events or thoughts that the patient often recognizes as excessive and inappropriate, but cannot control. It is a chronic disorder and is the most common type of anxiety disorder. The prevalence of this disorder is about 5% in the general population and up to 10% in the elderly, with women suffering twice as much as men.
Foreign data show that it is not uncommon for people to have a 10-year history of the disorder before a definitive diagnosis is made. The disease can be self-remitting, but less than 40% of those with a history of more than 5 years are in self-remission. A 40-year study showed that lack of adherence to treatment, being female, and having onset before age 25 were factors associated with poor outcome. The disease has a slow onset and is often associated with a number of psychosocial factors, with recurrent exacerbations. Patients not only suffer from their own pain and that of their families, but long-term recurrent exacerbations can also result in personality changes, decreased cognitive function of the brain, and severely impaired social functioning.
Second, clinical manifestations: the severity, duration and frequency of anxiety and worry in patients with generalized anxiety disorder exceed the impact of social events themselves. In addition to uncontrollable, excessive and unrealistic worry as well as autonomic symptoms, muscle tension and motor restlessness, patients are often accompanied by fatigue, irritability and sleep disturbances. Patients often visit general hospitals for excessive testing and treatment for autonomic symptoms. The following are specific manifestations of the disease.
(1) Worry: Patients are often in a state of distraction, worry and apprehension that something bad is going to happen. This worry can involve all aspects of life, such as the health and safety of family members, interpersonal relationships, the career future of family members, and the economic situation, etc. The degree is more pronounced than the usual worry (worrying about idle worries) and lasts longer. Some patients seem to have some cause, but their degree of worry is not proportional to the reality of the situation.
(2) Somatic symptoms: pain and fatigue are more prominent, and symptoms can accumulate in various systems such as respiratory, cardiovascular, digestive, urinary, and neurological, etc. It is common to have panic attacks, chest tightness, shortness of breath, dizziness, dullness, excessive sweating, dry mouth, bitter mouth, foreign body sensation in the throat, stomach discomfort, nausea, abdominal pain, bloating, constipation, frequent urination, neck, shoulder, back and waist pain, muscle tension, numbness of the trunk, wandering sensation, burning sensation, etc. Some patients may experience impotence Some patients may experience impotence, premature ejaculation, menstrual disorders, etc. The above physical symptoms cannot be proved by various clinical examinations with obvious organic diseases.
(3) Motor restlessness: Patients show rubbing their hands and feet, constantly walking back and forth, many small movements, sighing, trembling of limbs or lips, and even difficulty walking.
(4) Increased sensitivity: easily lose temper over trivial matters (knowing that it is unnecessary), complaining, inattentiveness, and often feeling memory loss. Sleep disorders are more prominent, often manifested as difficulty in falling asleep, dreamy, easy to wake up, difficult to go back to sleep after waking up, panic and nervousness after waking up, shouting in dreams, etc.
(5) Depression: About 2/3 of patients have combined depression, leading to a significantly higher risk of suicide.
(6) Other: Generalized anxiety disorder has a high co-morbidity rate with other disorders. About 1/4 of patients have panic disorder, and some also have fear and obsessive-compulsive symptoms, and patients also often have comorbid alcohol and substance dependence. There are also patients with comorbid physical disorders such as peptic ulcers, hypertension, and diabetes. Patients with co-morbidities often have more impaired social functioning, need to seek more medical help, and are less responsive to treatment, making them a high consumer of medical resources.
III. Treatment.
(1) Treatment goals: alleviate or eliminate patients’ anxiety and concomitant symptoms, minimize disability and suicide rate; restore social function and improve survival quality; prevent relapse.
(2) Treatment principles: comprehensive treatment (assessment-based pharmacotherapy, psychosocial family intervention, physiotherapy, etc.), long-term standardized treatment (acute phase, consolidation phase, maintenance phase), and individualized treatment.
(3) Treatment strategy: Generalized anxiety disorder is a chronic and highly recurrent disorder, with at least 50% of patients experiencing a second episode or significant exacerbation after the first episode, thus advocating pharmacological treatment throughout. The acute phase treatment is mainly to control symptoms and achieve clinical cure as much as possible (e.g. HAMAQ7), and medications usually start to work in 1-2 weeks, and the average treatment time for 50% improvement of anxiety symptoms is 2-4 weeks.
The consolidation phase treatment is at least 4-6 months, usually at the maximum effective therapeutic dose, during which the patient is unstable and at higher risk of relapse. Maintenance treatment should last at least 12 months to prevent relapse. Patients with recurrent exacerbations, recurrent negative life events, persistent sleep disturbances, and anxious personality traits should have their maintenance treatment duration increased accordingly.
IV. Precautions.
(1) Although generalized anxiety disorder is currently not a serious mental illness and the standardized comprehensive treatment is more effective, patients generally have poor treatment compliance, sensitivity to adverse reactions, long-term recurrent episodes resulting in abnormal brain function and brain structure, severely impaired social life, repeated medical visits consuming a large amount of medical resources and increasing family economic burden.
Therefore, patients and their families need to pay special attention to: take medication on time every day; some drugs may take several weeks to take effect (non-benzodiazepines); continue to take medication after symptoms improve; do not reduce and stop medication on your own; seek timely medical guidance on how to deal with adverse reactions and other related problems; make timely and reasonable arrangements for daily activities or sports you like; live, study and work as normally as possible, etc.
(2) Prohibit or cautiously use alcohol and weight-loss drugs, other psychoactive substances, and reduce smoking during medication administration.
(3) If there are co-morbidities that require the combination of multiple drugs, please be sure to use them under medical supervision.
(4) Benzodiazepines (Valium) have a faster onset of action than antidepressants (which have anxiolytic effects), and their early application can help patients improve sleep and reduce intolerance in the early stages of antidepressant use. However, long-term use of this class of drugs is not recommended.
(5) Generalized anxiety disorder is associated with psychosocial factors, abnormal brain structure and function, genetics, growth environment, repeated experience of negative life events and catastrophic cognition, etc. Therefore, comprehensive treatment is needed, such as assessment-based medication, psychotherapy, physical therapy, family and social interventions, and cultural and physical activities, etc. Many patients cannot be “eradicated” by medication alone. “Many patients cannot be treated with medication alone.