GAD & SAD Key Concepts (Exam Prep)

Generalized Anxiety Disorder (GAD)

• Definition: Excessive, uncontrollable worry about multiple domains (e.g., work, health, finances) with distress or impairment; worry is intrusive and chronic.
• Core symptoms: Intrusive worry, sleep disturbance, restlessness, muscle tension, gastrointestinal issues, chronic headaches.
• Prevalence: $2.9\%$ of U.S. adults (18–64) in a given year; lifetime prevalence: $7.7\%$ in women and $4.6\%$ in men.
• Global impact: Cross-country data show higher impairment in some high‑income countries; considerable comorbidity and functional impairment (Ruscio et al., 2017).
• Onset/demographics: Can begin in childhood/adolescence; not limited to a single age group.
• Theoretical factors
  • Emotional and cognitive factors: heightened negative emotions; belief that emotions are uncontrollable; maladaptive assumptions like "It's always best to expect the worst" and "I must anticipate danger".
  • Cognitive processing: automatic threat monitoring (e.g., Stroop findings show slower naming for threat-related words).
  • Cognitive Avoidance Model (Borkovec, Alcaine, & Behar; Newman & Llera): worrying maintains a constant, milder distress by avoiding awareness of threats; preferred to sudden spikes in negative emotion; reinforces chronic hypervigilance.
  • Interpersonal effects: worry and hypervigilance can yield maladaptive interpersonal behaviors (cold, intrusive, or hostile), worsening symptoms.
• Biological factors
  • Neural: greater amygdala reactivity and heightened sympathetic nervous system activity.
  • GABA system: possible deficiency in GABA or GABA receptors, contributing to excessive neuronal firing and diffuse anxiety.
  • Connectivity: reduced amygdala–prefrontal cortex (PFC) connectivity observed across adolescence and adulthood.
  • Heritability: modest heritability for GAD; broader trait anxiety more heritable.
• Treatments
  • Cognitive-Behavioral Therapy (CBT): effective for GAD; comparable to benzodiazepines in the short term; superior to placebo/non-directive therapy; effects can persist at follow-up (≈ $2\text{ years}$); also reduces co-morbid depressive symptoms.
  • Emotion Regulation Therapy (ERT): targets emotional awareness and regulation; efficacious for GAD with/without comorbid depression.
  • Biological treatments
  • Benzodiazepines: short-term relief; risk of dependence; not suitable for long-term use; symptoms often return after discontinuation.
  • Antidepressants: SSRIs/SNRIs effective (examples: $escitalopram\, (Lexapro)$, $duloxetine\, (Cymbalta)$, $venlafaxine\, (Effexor\ XR)$, $paroxetine\, (Paxil, Pexeva)$); meta-analyses support use; may improve quality of life; sometimes combined with CBT for greater benefit.
• Social Anxiety Disorder (SAD)
  • Overview: Excessive fear of social situations due to threat of scrutiny, rejection, or humiliation; impairment in social/occupational functioning; risk for comorbidity (e.g., depression).
  • Prevalence and impact: SAD is highly prevalent and socially impairing; close social support correlates with better prognosis.
• Key cross-cultural and developmental notes
  • Social support buffers risk; prognosis improves with perceived support (Hur et al., 2020).
  • SAD can emerge in adolescence and persist into adulthood; untreated cases lead to significant impairment.

DSM-5-TR Criteria for Social Anxiety Disorder (summary)

• A. Marked fear or anxiety in one or more social situations with possible scrutiny by others.
• B. Fear that one will act in a way or show anxiety symptoms that will be negatively evaluated.
• C. Social situations almost always provoke fear or anxiety.
• D. Social situations are avoided or endured with intense fear.
• E. Fear/anxiety is out of proportion to actual threat and context.
• F. Fear/anxiety/avoidance persists for at least $6\text{ months}$.
• G. Causes clinically significant distress or impairment.
• H. Not attributable to a substance or another medical condition.
• I. Not better explained by another mental disorder.
• J. If another medical condition is present, the fear is clearly excessive.
• Specifier: Performance only when fear is restricted to speaking or performing in public.

Case Study: Malcolm (Social Anxiety Disorder)

• Profile: Computer professional who fears elevators when others are present; believes others are judging him; avoids social interactions and places with potential social exposure (e.g., grocery stores, restaurants).
• Behavior patterns: Prefers isolation; avoids group presentations at work; uses online services to avoid phone calls or in-person interactions.
• Diagnostic pattern: Demonstrates core SAD features (fear of negative evaluation, avoidance of social situations, impairment in functioning).
• Treatment implications: CBT with exposure to social and performance situations; possible integration of social skills training and gradual in-vivo exposure; consider alternative work arrangements if feasible.

Quick reference notes

• GAD is characterized by excessive worry across domains with somatic symptoms and impairment.
• Worry serves as a cognitive avoidance strategy, maintaining chronic but tolerable distress.
• CBT and ERT are key, evidence-based treatments; benzodiazepines are short-term and carry dependence risk; SSRIs/SNRIs are effective pharmacological options.
• SAD involves marked fear of social scrutiny with significant impairment; DSM-5-TR criteria (A–J) guide diagnosis; performance-only specifier may apply.
• Case examples illustrate how avoidance and universal social fear manifest in real-life functioning and work impairment.