generalized anxiety disorder
Introduction
Introduction to generalized anxiety disorder Generalized anxiety disorder (referred to as generalized anxiety disorder) is a chronic anxiety disorder characterized by persistently significant nervousness, accompanied by autonomic nervous function excitement and excessive alertness. Patients with generalized anxiety disorder (GAD) often have characteristic appearances, such as facial muscle distortion, brow lock, tight posture, and restlessness, even tremors, pale skin, palms, feet, and sweat in the armpits. It is worth noting that patients are easy to cry, but the reflection of a wide range of anxiety states does not suggest depression. basic knowledge The proportion of illness: 0.03% Susceptible people: no specific population Mode of infection: non-infectious Complications: obsessive-compulsive disorder
Cause
Causes of generalized anxiety disorder
(1) Causes of the disease
The study of this disease is far less intimate than the panic disorder, but it has also accumulated some information.
Genetic
Noyes et al (1987) reported that the risk of patients with this disease was 19.5% in the relatives of patients with extensive anxiety disorder, while the risk of extensive anxiety disorder in the normal control group was 3.5%. The twins in Torgersen (1983) failed. The MZ-DZ co-morbidity rate was found to be significantly different for a wide range of anxiety disorders. Kendler et al. (1992) reported a group of female twins with extensive anxiety disorder. The heritability of this disease is about 30%. Some studies have shown that the genetic predisposition of this disease Not as significant as panic disorder.
2. Biochemistry
The use of benzodiazepines is often used to treat a wide range of anxiety disorders, suggesting that abnormalities in the benzodiazepine receptor system in the brain may be the biological basis of anxiety. The concentration of benzodiazepine receptors is highest in the occipital lobe. It is suggested that there may be occipital dysfunction in a wide range of anxiety disorders. Some brain function imaging studies have found abnormalities in the occipital lobe of patients with this disease. Preclinical and clinical brain imaging indicates that various types of anxiety and stress reactions also involve marginal lobes and basal ganglia. And the prefrontal cortex, the non-benzodiazepine anti-anxiety agent buspirone is a 5-HT1A agonist, which is effective in treating a wide range of anxiety disorders, suggesting that the serotonin system plays an important role in the pathogenesis of a wide range of anxiety disorders.
Psychology
Freud believes that anxiety is a physiological state of tension, originating from unresolved unconscious conflicts, self can not use effective defense mechanisms, it will lead to pathological anxiety, and Aeron Beck's cognitive theory believes that anxiety is facing A dangerous reaction, persistent distortion of information processing leads to dangerous misunderstandings and anxiety experiences. Pathological anxiety is related to the processing of selective information on threats. Anxious patients also feel that he is unable to deal with threats. An important factor for persistence, David Barlow distinguishes anxiety from fear, arguing that a wide range of anxiety disorders are characterized by feelings of loss of control rather than fear of threats, Noyes et al. (1987) report that about one-third of patients with extensive anxiety disorders With personality disorder, the most common is dependent personality disorder.
(two) pathogenesis
Susceptibility factor
(1) Inheritance: In anxiety disorders, heredity is an important risk factor. According to the study, the incidence of all anxiety disorders in monozygotic twins (MZ) is higher than that of twins (DZ), but large. Most studies have found no difference in the onset of various anxiety disorders, so the specific role of inheritance in generalized anxiety disorder is not clear.
(2) Childhood experience: It is generally considered to be one of the predisposing factors of generalized anxiety disorder. However, there is no definite evidence. Anxiety is a common emotional disorder in children. However, most anxious children can grow into healthy people. Not all anxious adults come from anxious children.
(3) Personality: Anxiety personality is associated with anxiety disorder, but other personality traits can also hinder its effective response to stress events.
2. Promoting factors
The occurrence of generalized anxiety disorder is often associated with life stress events, especially threatening events such as interpersonal problems, physical illnesses, and work problems.
3. Sustained factors
The persistence of life stress events can lead to chronic anxiety disorder; at the same time, the way of thinking can also make symptoms recalcitrant, such as fear of others paying attention to their own anxiety, or worry that anxiety will affect their performance, similar concerns will arise A vicious circle makes the symptoms severe and stubborn.
4. Neurobiology research
(1) Cerebral blood flow, metabolism and hemispheric activity: Functional imaging studies of normal subjects suggest that anxiety is mainly an increase in cerebral blood flow and metabolism, but when hyperventilation and increased vascular tone lead to vasoconstriction, The decrease of cerebral blood flow induces anxiety. Therefore, the changes of cerebral blood flow under anxiety state are not linear but U-shaped curve changes. Most EEG findings are found in patients with normal anxiety and neurosis anxiety. The decrease in alpha wave activity, the increase in alpha wave frequency, and the increase in beta wave activity, in addition, the slow wave activity in the form of , , and slow is also observed in the anxiety state.
Influencing blood and EEG studies suggests that the cortex on the right side of the frontal lobe may play an important role in the perception and response to negative emotions such as anxiety. Davion found in the normal volunteers that the left anterior region of the frontal lobe is more than the right anterior region. Classical conditioned reflex abrupt response subsides faster and is more effective at defensive reflex inhibition. Carter finds that anxiety-anxiety is associated with high activity throughout the cortex, especially in the left hemisphere, fear is not just a manifestation of anxiety. It can also be mitigated by verbal and logical reasoning, which can explain the high activity of the left hemisphere.
(2) Neuroanatomical regions and their functions: High alertness plays an important role in anxiety, which can lead to wakefulness and insomnia, moderate arousal can improve attention, and thus improve behavior, while high arousal enhances conditioned reflexes. Caused by complex learning and behavioral disorders, anxious people sleep shallowly and rarely, all kinds of sleep disorders can be seen in anxiety patients, but in general, mainly for the prolongation of sleep latency (sleep time reduction), slow wave sleep reduction, Easy to wake up and wake up increased.
The level of arousal is largely controlled by the brainstem, which plays an important role in the biological aspects of anxiety, including the noradrenergic blue plaque, 5-HT can be the nucleus and the giant cell nucleus, anxious Early biological theory suggests that the locus nucleus plays a central role in the development of anxiety, and yohimbine (-2 norepinephrine autoreceptor antagonist) can increase the activity of the locus nucleus and induce anxiety, clonidine (- Receptor agonists) can reduce the activity of the locus nucleus and reduce anxiety. The anti-anxiety effects of other drugs can also reduce the activity of the locus nucleus, such as benzodiazepines and opioids.
Some researchers overly equate anxiety with awakening, and describe all behaviors from the perspective of intensity and avoidance conflicts. Arousal should not be equated with anxiety, because elevated levels of arousal are accompanied by positive and negative emotional reactions. Anxiety is an increase in arousal level, which is accompanied by negative emotional characteristics. However, relative to the brainstem nucleus, the generation of emotional characteristics is more likely to come from the limbic system and the frontal frontal.
The limbic system consists of amygdala, hippocampus, septal nucleus and hypothalamus. It may be the emotional site of the main division, and plays an important role in learning and memory. Gray has established a theory based on animal research data, and believes that the hippocampus The system has a central role in anxiety, that is, the system is important for the induction and regulation of anxiety. It produces effects through the input of norepinephrine and 5-HT, and stimulates the stimuli from the frontal lobes and cerebral cortex. The hippocampus system provides information to produce predictions of desired events, which are then compared to real events. Aversion to events or endogenous predictions and events can activate a hypothetical behavioral suppression system to awaken, pay attention and anxiety. The reaction, but LeDoux found that the amygdala may be more involved in the fear response than the hippocampus, that is, the amygdala is associated with the acquisition of emotional (including anxiety-related) memory. If studies have found that patients with surgical amygdala can confirm the face, But the emotions expressed are not recognized.
The anterior frontal cortex is more emotionally active than the left side. The left frontal anterior cortex specializes in language and text, processes information sequentially, and inhibits the role of the amygdala. EEG and imaging studies suggest At least when the sensory component is present, anxiety can activate the cortex in the anterior frontal lobe. Recent studies suggest that the cerebellum participates in the function of the frontal lobe and regulates the anxiety response. In animal experiments, the fear response disappears after the middle cerebellar injury is observed. Invasive behavior is reduced. In imaging studies, patients with anxiety and obsessive-compulsive disorder have increased metabolic activity in the cerebellum and paralysis.
(3) Neurotransmitters: The current study found that there are various neurotransmitters in the nervous system, including benzodiazepine-GABA, norepinephrine and 5-HT neurotransmitter systems and corticotropin releasing hormone pathway. It is directly related to the biology of anxiety. These transmitters are not only important in the occurrence, maintenance and elimination of anxiety, but also can cause certain physiological changes through neuroendocrine reactions. These physiological changes produce certain emotions for anxiety. Role, thereby changing the impact of anxiety on the individual.
Prevention
Generalized anxiety disorder prevention
Due to the late development of psychiatry in the whole medicine, and because of the complexity of the basic theory of the profession, there are quite a few common causes and pathogenesis of common mental illnesses have not yet been elucidated, coupled with the influence of old ideas, the cause of mental illness is long The period is considered to be mysterious and neglected, thus hindering the development of psychiatric prevention. At present, in some countries, psychiatric prevention is taking different measures in different organizations, combining different social systems and cultures. As well as the national characteristics, we are moving towards the goal of preventing mental illness.
Complication
Generalized anxiety disorder complications Complications obsessive-compulsive disorder
Patients with extensive anxiety disorder often have other anxiety or affective disorders. According to Sanderson and Barlow (1990), 20 patients (91%) with at least 21 patients (91%) who met the DSM-III diagnostic criteria were analyzed simultaneously. In the next two diagnoses, 13 (59%) had social phobia at the same time; 6 (27%) were diagnosed with panic disorder at the same time; 6 cases were diagnosed with mood disorder (depressive neurosis) at the same time; At the same time, suffering from simple phobia (23%), obsessive-compulsive disorder (9%) and severe depression (14%), 73% of those with panic attacks during the course of the disease, Wittchen et al (1991) also observed patients with anxiety disorders Among them, 69% of epidemiological investigation cases, and 95% of clinical cases have two or more coexbidity of anxiety or depressive disease.
Symptom
Symptoms of generalized anxiety disorder Common symptoms Anxiety inattention, fatigue, irritability, depression, diarrhea, urgency, exhalation, difficulty, dizziness, dizziness
Generalized anxiety disorder is characterized by frequent or persistent, comprehensive, unaffected or fixed-content nervousness and over-anxiety. This anxiety has nothing to do with any particular situation around it, but is generally caused by excessive anxiety. Typical performance is often a problem in real life, too much worry or worry, such as worrying about the illness or accident of oneself or relatives, worrying about the economic situation, excessive worry about work or social ability, this nervousness, worry Or troubles are not commensurate with reality, making patients feel unbearable, but can not get rid of; often accompanied by autonomic hyperactivity, exercise tension and excessive vigilance, in general, anxiety symptoms of GAD patients are variable, can appear A range of physical and psychological symptoms.
Anxiety and trouble
Expressed as a fear of a dangerous or unfortunate event that may occur in the future, unpredictable, fearful anticipation, irritability, sensitivity to noise, restlessness, decreased concentration, fear, if the patient is not clear To the object or content he is worried about, but a strong inner fearer who is fearful and fearful, called free-floating anxiety, but often worried about it, two unrealistic Threat, or unfortunate events in life that may occur to him or his relatives and friends, for example, worrying about a childs car accident, etc. This type of anxiety and annoyance is very disproportionate to the reality, called an apprehensive expectation. The core symptoms of extensive anxiety, such patients often have a premonition of panic, all day long upset, restless, worried, seemingly unfortunately coming to the head of their own or their loved ones, attention is difficult to concentrate, in their daily life Things lose interest, and learning and work are seriously affected.
Such anxiety and annoyance are different from the so-called "anticipatory anxiety", such as fear of recurrence of panic attacks in patients with panic disorder, social phobia patients are troubled by public statements, and patients with OCD who repeatedly wash their hands are contaminated. Fear, and anorexia nervosa patients are distressed by the sudden increase in weight.
It should be explained that the patient complains about memory loss due to lack of concentration, but there is no real memory damage in the anxiety disorder. If it is found, it must be carefully examined to exclude organic lesions, generalized anxiety disorder. Characteristic performance is repeated concerns, including concerns about the disease, concerns about the safety of others, and social anxiety.
2. Sports uneasiness
The performance is a slap in the face, walking back and forth, nervous, can not sit still, visible eyelids, facial muscles or finger tremors, or patients feel shudder, some patients with eyebrows lock, facial muscles and limb muscle tension, pain, or feeling Muscle twitching, often feeling tired and weak.
3. Physical performance
(1) Digestive system: dry mouth, difficulty in swallowing, infarction, foreign body sensation in the esophagus, excessive exhaustion, increased or decreased intestinal peristalsis, stomach discomfort, nausea, abdominal pain, diarrhea.
(2) Respiratory system: chest pressure, difficulty in inhalation, shortness of breath and suffocation, excessive breathing.
(3) Cardiovascular system: palpitations, discomfort in the anterior region, arrhythmia.
(4) genitourinary system: frequent urination, erectile dysfunction, dysmenorrhea, amenorrhea.
(5) Nervous system: tremor, tingling, tinnitus, dizziness, headache, muscle pain.
(6) sleep disorders: insomnia, night terrors.
(7) Other symptoms: depression, forced thinking, disintegration of personality.
(8) Autonomic nervous function excitement: hyperhidrosis, facial redness or paleness and other symptoms.
The physical symptoms of generalized anxiety disorder are caused by excessive activity of the sympathetic nervous system and increased tension of skeletal muscle. The specific symptoms are rich, and can be classified according to various systems, such as excessive ventilation from swallowing air; anxiety caused by anxiety It can be differentiated from the exhalation difficulty of asthma; a series of physical symptoms caused by excessive breathing, in the symptoms of the nervous system, vertigo is a kind of instability rather than whirl, and some patients have blurred vision, but physical examination revealed Normal vision, headache often shows pain or tightness, mostly bilateral, occipital and frontal lobes are more common, pain is more common, mostly in the shoulder and back.
It is worth noting that patients often complain of physical symptoms rather than anxiety, and these physical symptoms can also be caused by physical illness. Therefore, the above conditions must be fully considered in differential diagnosis.
4. Excessive alertness
It is fearful and frightening. It is prone to shocking reactions to external stimuli; attention is difficult to concentrate; sometimes it feels blank in the brain; it is difficult to fall asleep and wake up; and irritability.
Examine
Generalized anxiety disorder
There is currently no specific laboratory test for this disease.
The cerebral blood flow changes under anxiety are not linear, but a "U"-shaped curve change. Most EEG studies have found a decrease in alpha wave activity in patients with normal anxiety and neurosis anxiety, alpha wave frequency. The increase, as well as the increase in beta wave activity, in addition, slow wave activity in the form of , and slow was also observed in the anxiety state.
Diagnosis
Diagnosis and diagnosis of generalized anxiety disorder
Diagnostic criteria
According to ICD-10, the diagnosis of GAD must be anxious for most of the period of at least a few weeks, usually lasting more than 6 months. The symptoms of anxiety include: 1 worry: if you are worried about the future, feel nervous, concentration Difficulties, often too much worry, and nervous, irritating, etc.; 2 sports tension, fatigue, poor sleep, restlessness, headache, tremors, can not relax; 3 other high alert symptoms: such as sweating, heart rate, mouth Dry, stomach upset, dizziness, dizziness and other symptoms can diagnose the disease.
The main diagnostic point is that patients who meet the GAD criteria always see themselves as troublesome people. Seeking medical treatment is not just to treat doubts, but rather to make them distract from worrying things, such as the health of children. The significance of a symptom, the doctor should consider whether there are excessive concerns about patients who repeatedly go to the hospital for examination due to these complaints or tension headaches or other anxiety manifestations.
Both types of anxiety disorders are primary, not secondary to organic diseases, schizophrenia, affective disorders and other types of neurological signs.
Differential diagnosis
According to the clinical manifestations and symptom characteristics, general diagnosis is not difficult. In the diagnosis of panic disorder, attention should be paid to the exclusion of physical problems of the body, such as frequent episodes, plus expectant anxiety, which may be misdiagnosed as a wide range of anxiety disorders; Diseases such as mitral valve prolapse may have symptoms similar to panic attacks. It should be noted that in the diagnosis of generalized anxiety, withdrawal syndromes such as hyperthyroidism, hypertension, coronary heart disease and other physical diseases or addictive drugs should be excluded. Secondary anxiety caused.
1. Different from the anxiety reaction of normal people in stress, anxiety has a strong emotional experience, autonomic symptoms and motor anxiety, and its anxiety level and duration are not commensurate with the actual stimulus. Normal The anxiety response of a person does not fully possess the above characteristics.
2. Specific physical illnesses may manifest as similar symptoms. In any case, this possibility must be fully considered, especially when there is no reasonable psychological explanation for their anxiety symptoms, hyperthyroidism can lead to irritability, restlessness, and tremors. And tachycardia, at this time, physical examination can be found thyroid enlargement, fine tremor and eyeball protrusion, thyroid function test if necessary, pheochromocytoma and hypoglycemia can cause episode anxiety.
Other physical illnesses are more likely to cause anxiety through psychological mechanisms. For example, patients are afraid of the fatal consequences of the disease. This is often the case when patients have special reasons to fear certain serious consequences, such as patients with similar clinical symptoms and disease progression. And death, therefore, it is necessary to ask patients in clinical work whether they know other people with similar symptoms.
When generalized anxiety disorder is characterized by physical symptoms, it is easily misdiagnosed as other diseases. At this time, negative laboratory tests aggravate the patient's anxiety rather than alleviation because these results cannot explain serious clinical symptoms. Clinicians consider the diversity of anxiety symptoms, recognizing that palpitations, headaches, frequent urination, abdominal discomfort, and other symptoms listed in Table 2 may be clinical manifestations of generalized anxiety disorder, which can significantly reduce similar misdiagnosis.
3. Schizophrenia
Patients sometimes complain with anxiety and no obvious psychotic symptoms, even if they are directly questioned, but carefully ask the cause of the symptoms to reduce misdiagnosis, because the patient will expose some strange ideas, such as threats around Sexual effects, anxiety symptoms can be seen in a variety of mental illnesses, but not the main clinical phase of such mental illnesses. Their anxiety content is not intrinsically linked to the main symptoms of other mental illnesses. It is important to distinguish between depression and anxiety. And depression can be accompanied by the diagnosis, often relying on the analysis of the sequence of the two in the occurrence of the sequence and the severity of the comparison to determine, so in the diagnosis of these two diseases must pay great attention to the collection of medical history and observation of its symptoms .
4. Depressive disorder
Compared with anxiety symptoms, the symptoms of depression are more serious, and the order of symptoms appears differently. In general anxiety disorder, anxiety symptoms first appear. Therefore, when asking for medical history, patients and their families should be asked to confirm the diagnosis. Deafness episodes with agitation may be misdiagnosed as anxiety, but careful questioning of depressive symptoms can reduce misdiagnosis. Depression often has obvious anxiety or anxiety, while patients with generalized anxiety are often unhappy because of long-term nervousness. The main point is that patients with extensive anxiety disorders usually have symptoms of anxiety first. After a long time, they gradually feel that life is not happy. There is no change in mood changes; it is often difficult to fall asleep and sleep is unstable and wake up early; autonomic symptoms are not as good. Depressive is rich; appetite is often unaffected; more importantly, patients with this disease are not as interested or unhappy as things like depression, but the differential diagnosis of atypical depression may be more difficult, when depression and anxiety symptoms It is obvious that when the diagnostic criteria for the two diseases are met, the next two diagnoses are also worthwhile. Italy and mental disorders identification of the disease are: somatization disorder, such as the disintegration of personality disorders.
In the symptoms of neurosis, the mixing situation is very common. In this case, it should be identified which type of symptoms are the main symptoms, and the corresponding diagnosis can be made. However, it should be noted that the depressive symptoms are more dangerous and lead to suicide. Therefore, it is necessary to prioritize the diagnosis of depression. in principle.
5. Alzheimer's disease and Alzheimer's disease
Sometimes such patients complain of anxiety, and clinicians often ignore their accompanying memory impairment or blame it for inattention.
6. Psychoactive substances, withdrawal of alcohol or abuse of caffeine can lead to anxiety. If the patient conceals a history, it can often lead to misdiagnosis. If the patient reports that the anxiety is particularly serious in the morning, it indicates alcohol dependence (the withdrawal reaction is often here) It is obvious, but sometimes the anxiety secondary to depression is also evident in the morning.
