CHAPTER II

LITERATURE REVIEW
2.1 Definitions

Generalized anxiety disorders (Anxiety Disorder, GAD) is a condition of a disorder

characterized by excessive anxiety and worry and irrational sometimes unrealistic to events
of everyday life. This condition is experienced by almost all day, lasting for at least 6
months. Anxiety felt difficult to control and is associated with somatic symptoms such as
muscle tension, irritability, difficulty sleeping, and anxiety causing suffering clear and
significant disruption in social and occupational functioning. 1

2.2. Epidemiology
Studies lifetime prevalence of anxiety disorders in the general population overall is
estimated to range between 1.9% to 5.4%. The ratio between women and men about 2: 1, but
the ratio of inpatient hospital 1: 1. 3 According to a WHO study, 38% of individuals with
GAD had moderate to severe occupational role impairment, with a mean of 6.3 days per
month disability.Furthermore, GAD is also associated with both Increased health care
utilization and comorbid health problems. Disability is, Thus, a significant problem in GAD. 2

2.3. Comorbidity

Generalized anxiety disorder is a disorder that often occurs together with other mental
disorders, usually social phobia, specific phobia, panic disorder or depressive disorder. The
possibility of 50 to 90 percent of patients with anxiety disorders have a whole other mental
disorders. As many as 25 percent of patients eventually experience a panic disorder. 1

Generalized anxiety disorder with panic disorder is distinguished by the absence of

spontaneous panic attacks. Additional high percentage of GAD patients who are likely to
have major depressive disorder. Other common disorders associated with anxiety disorders
are disorders distimik generalized and substance-related disorders. 1

2.4. Etiology

Biological theory

Brain areas suspected to be involved in the onset of GAD is the occipital lobe which
has the highest benzodiazepine receptors in the brain. Basal ganglia, the limbic system and
frontal cortex is also hypothesized to be involved in the etiology of onset of GAD. In patients
with GAD also found abnormal serotonergic system. Neurotransmitters associated with GAD
is GABA, serotonin, norepinephrine, glutamate and cholecystokinin. PET (Positron Emission
Tomography) in patients with GAD found a decreased metabolism in the basal ganglia and
white matter of the brain. 1

Genetic theory

In one study it was found that there is a genetic relationship GAD patients and Major
Depression disorders in female patients. Approximately 25% of first-degree relatives of
patients GAD also suffer the same disorder. While research on twins obtains the figure of
50% in monozygotic twins and 15% in dizygotic twins. 1

Psychoanalytic theory

Psychoanalytic theory hypothesizes that anxiety is a symptom of unconscious

conflicts are not resolved. At the most primitive level of anxiety associated with a breakup
with a love object. In more mature level of anxiety associated with losing the love of the
objects are important. Castration anxiety associated with oedipal phase whereas the superego
anxiety is fear of a person's values and his own disappointing (the most mature anxiety). 1

Theory of Cognitive-Behavior

GAD sufferers respond incorrectly and not appropriate to the threat caused by
selective attention to negative things in the environment, their distortion in information
processing and a very negative view of the ability themselves to face the threat. 1

2.5. Clinical Features

The main symptoms of GAD is anxiety, motor tension, autonomic hyperactivity and
cognitive alertness. Anxiety is excessive and affect various aspects of life of the
patient. Manifests as a vibrating motor tension, fatigue and headache. Autonomic
hyperactivity arise in the form of short breathing, sweating, palpitations, and accompanied by
gastrointestinal symptoms. There is also a cognitive vigilance in the form of irritability. 1

GAD patients usually come to a general practitioner for somatic complaints, or come
to a specialist for specific symptoms such as chronic diarrhea. Patients usually exhibit
attention-seeking behavior (seeking behavior). Some patients received a diagnosis of GAD
and adequate therapy, and several others requested additional medical consultation for their
problems. 1

2.6. diagnosis

Generalized anxiety disorder characterized by patterns of worry and anxiety that often
and settle that exceeded the proportion of the impact of an event or circumstance that became
the center of anxiety. The difference between anxiety disorders and anxiety are normal
overall is suppression with the use of the word "excessive" to the criteria and to the
specifications of symptoms causing trouble or difficulty. 3

Diagnostic guidelines PPDGJ III Comprehensive Anxiety Disorders 4

Patients must show anxiety as the primary symptoms that take place almost every day
for several weeks to several months, which is not restricted or only me predominate
in certain circumstances a special situation (its "free floating" or "float")
These symptoms usually include the following elements:
a. Anxiety (worried about bad luck, feels like the tip of a horn, difficulty
concentrating, etc.);
b. Motor tension (restlessness, headache, shivering, unable to relax); and
c. Autonomic overactivity (lightheadedness, sweating, heart palpitations, shortness of
breath, stomach complaints, headache, dry mouth, etc.).
In children, often seen their excessive need to be soothed (reassurance) and recurrent
somatic complaints are prominent.
The presence of other symptoms are temporary (few days), in
particular depression, anxiety disorder is the primary diagnosis cancel the Whole, as
long as it does not meet the full criteria of a major depressive episode (F32.-), phobic
anxiety disorders (F40.-), panic disorder (F41.0), or obsessive compulsive disorder
(F42.-)
Anxiety Disorders Diagnostic Criteria for Comprehensive according to DSM IV-TR4

Excessive anxiety or concerns that arise almost every day, all day, going for at least
6 months, about a number of activities or events (such as work or school activities)
Patients find it difficult to control the worries
Anxiety and worries are accompanied by three or more of the following six symptoms
(with at least some symptoms are more prevalent than not occurred during the last 6
months). Note: only one number required in children.
1. Anxiety
2. Feeling easily tired
3. Difficulty concentrating or mind becomes blank
4. irritability
5. muscle tension
6. Sleep disturbance (difficulty falling asleep or staying asleep, or restless
sleep, and unsatisfactory)
The focus of the anxiety and worry is not limited to disorders axis I, for example,
anxiety or fear is not about to suffer a panic attack (as in panic disorder), embarrassed
at the general situation (as in social phobia), contaminated (such as obsessive
compulsive disorder) , feel far from home or close relatives (such as anxiety disorder
 separation), weight gain (as in anorexia nervosa), suffering from physical complaints
of multiple (as in somatization disorder), or a serious illness (as in hypochondriasis)
as well as the anxiety and worry did not happen solely for post traumatic stress
disorder
Anxiety, worry, or physical symptoms cause clinically significant suffering, or
interference with the function of social, occupational, or other important functions.
Disturbance is not due to the direct physiological effects of a substance (eg, substance
abuse, medication) or a general medical condition (eg, hyperthyroidism), and does not
occur exclusively during a mood disorder, a psychotic disorder, or pervasive
developmental disorder
Table 3. Scale Generalised Anxiety Disorder (GAD-7)

2.7. Diagnoses

Generalized anxiety disorders should be distinguished from anxiety due to a general

medical condition (neurology, endocrinology, metabolic) or disorders related to substance
use. Required medical examination including blood chemistry tests, electrocardiography, and
thyroid function tests. Clinicians need to get rid of their intoxication, caffeine, stimulant
abuse, the condition of withdrawal or drugs such as alcohol, hypnotic-sedative and
anxiolytic. 5

Another psychiatric disorder that is a diagnosis of GAD is panic disorder, phobias,

obsessive compulsive disorder, hipkondriasis, somatization disorder, adjustment disorder with
anxiety, and personality disorders. Distinguishing GAD with major depressive disorder and
distimik not easy, and these disorders often occur together GAD. 5
 To be able to find comprehensive criteria anxiety disorders, patients should present
the overall syndrome, and the symptoms can not be explained by the presence of comorbid
anxiety disorders. To diagnose anxiety disorders whole in the context of other anxiety
disorders, it is important to document the anxiety or worry related to the environment or an
unrelated topic, or just a little touch, with other disorders.1

2.8. prognosis

Age of onset usually occurs is difficult to be specified; most patients with anxiety
disorders have been reported since long. Patients usually get the attention of the clinician at
the age of 20, although his first visit to the doctor can be at any age. Only one in three
patients who have anxiety disorders generalized come seeking psychiatric therapy. Most will
come to a general practitioner, internist, cardiologist, pulmonary specialist or
gastroenterologist. 1

Generalized anxiety disorder is a chronic condition that may last a lifetime. As many
as 25% of patients eventually develop panic disorder may also experience major depressive
disorder. 1

2.9 Treatment

a. pharmacotherapy

benzodiazepines

Is the first choice drug. Giving benzodiazepines starting with the lowest dose and
increased until reaching the therapeutic response. The use of the preparation with a half
medium and divided doses can prevent unwanted effects. The average duration of treatment
is 2-6 weeks, followed by a period of tapering off over 1-2 weeks. 1

Buspirone

Buspirone is effective in 60-80% of patients with GAD. Buspirone is more effective

in improving cognitive symptoms compared with somatic symptoms in GAD. No cause
withdrawl. The drawback is that new clinical effects felt after 2-3 weeks.There is evidence
that patients with GAD who are already using benzodiazepines will not respond well to
Buspirone. To do the joint use of benzodiazepines with a benzodiazepine tapering Buspirone
then performed after 2-3 weeks, when the effect of Buspirone therapy has already reached the
maximum. 1
SSRIs (Selective Serotonin Re-uptake Inhibitors)

Sertraline and paroxetin is a better choice than fluoxetine. Giving fluoxetine can
increase anxiety moment. SSRI GAD effective, especially in patients with a history of
depression. 1

b. psychotherapy

Cognitive-behavioral therapy

The cognitive approach invites the patient immediately recognize the distortions of
cognitive and behavioral approaches, recognize the somatic symptoms directly. The main
technique used for the behavioral approach is relaxation and biofeedback. 1

Supportive therapy

Patients were given reassurance and comfort, explored the potentials that exist and
has not looked, supported his ego, to be more able to adapt optimally in social and work
function. 1

Insight-oriented psychotherapy

This therapy invites patients to achieve disclosure of unconscious conflicts,

given egostrength, object relations, as well as the integrity of the patient self. From an
understanding of these components, we as therapists can estimate the extent to which a
patient can be modified to become more mature; if not achieved, at least we facilitate that
patients can adapt to social and job functions. 1
 BIBLIOGRAPHY

1. Sadock B, Kaplan H, Sadock V. Kaplan & Sadock's synopsis of psychiatry. Philadelphia:

Wolter Kluwer / Lippincott Williams & Wilkins; 2015.
2. Hoge EA, et al. Mindfulness and Self-Compassion in Generalized Anxiety Disorder:
Examining Predictors of Disability.Hindawi; 2013
3. Redayani P. 2015. Comprehensive Anxiety Disorders, Textbook of Psychiatry University
of Indonesia, Jakarta.
4. American Psychiatric Association. DSM-5. 2013. Generalized anxiety disorder.
5. Maslim R, 2013. Handbook Diagnosis of Mental Disorders Brief Referral of PPDGJ III
and DSM-5, Moulds Second, Jakarta.