Generalized Anxiety Disorder: A
causes.
Mental Health Disorder
(Biochemical Aspect)
Heartche L. Selibio
Central Mindanao University
s.selibio.heartche@cmu.edu.ph
ABSTRACT
Generalized Anxiety Disorder is a mental health disorder
characterized by persistent and constant worrying or anxiety
which is multifocal. It is believed to develop and persist as a
result of biological and psychological causes. Interaction
between the nervous and endocrine systems or the
Neuroendocrinology is also said to play a part in the
development of the said mental disorder. This paper discussed
about different factors that results to development of GAD,
specifically in the Neurochemical/Biochemical aspect.
Discussion of development and progression of GAD provides
a thorough idea about the mental health disorder and its
biochemistry. In this review, a discussion of pathogenesis;
neuroendocrinology, role of genetics, epinephrine,
norepinephrine, 3-methoxy-4-hydroxyphenylglycol (MHPG),
apelin 36, oxidative Stress, serotonin and GABA were
presented. Furthermore, Diagnosis and treatments which
includes psychotherapy and pharmacotherapy were also
presented.
Keywords: Generalized anxiety disorder, epinephrine,
norepinephrine, 3-methoxy-4-hydroxyphenylglycol,
oxidative stress, apelin 36, serotonin, GABA
CONTENT
I. Introduction
II. Generalized Anxiety Disorder (GAD)
III. Diagnosis of Generalized Anxiety Disorder
IV. Generalized Anxiety Disorder Pathogenesis
Role of Genetics in GAD
Role of Epinephrine, Norepinephrine, and 3-
methoxy-4-hydroxyphenylglycol (MHPG) in GAD
Role of Apelin 36 and Oxidative Stress in GAD
Role of Serotonin and GABA in GAD
V. Neuroendocrinology/Immunology
VI. Treatment
Psychotherapy
Pharmacotherapy
VII. Conclusion
VIII. References
I. Introduction
Generalized anxiety disorder (GAD) is one of the most
prevalent anxiety disorders seen in both general
medical practice and the general population. GAD is
characterized by persistent and constant anxiety. This
excessive hard to manage anxiety about multiple
things is frequently accompanied by
nonspecific psychological and physical
symptoms. Patients with GAD are at increased risk for
suicide, other mental and physical health conditions,
such as chronic pain syndromes, asthma or chronic
obstructive pulmonary disease, and inflammatory bowel
disease. There are multiple factors that contributes to the
development of GAD, which believed to develop and
persist as a result of biological and psychological
Female sex, low socioeconomic position, and exposure
to childhood adversity (such as physical or sexual abuse,
neglected, and violence), alcoholism, and drug use are
all known risk factors for generalized anxiety
disorder. There are multiple factors that contributes to
the development of GAD.
II. Generalized Anxiety Disorder
Generalized anxiety disorder (GAD) is an ubiquitous
and impairing but frequently goes undiagnosed and
untreated illness. Patients with GAD are at increased
risk to commit suicide, experience cardiovascular-
related problems, and other psychological and physical
health conditions. Some symptoms of GAD are
chronic, persistent anxiety and worry, along with
vague physical and psychological symptoms (such as
restlessness, exhaustion, trouble focusing, irritability,
muscle tension, or sleep difficulties). Although
worrying is a common human experience, pathological
worry stands out more for its severity and negative
impact on functioning than for its content. Women are
twice as likely as males to experience GAD. With low
social standing, widowhood, separation, or divorce, or
middle age raises the likelihood of developing GAD.
Comorbid psychiatric diseases,
neurochemistry/biochemistry, a history of substance
misuse or trauma, and a family history of GAD are
additional risk factors. In older persons, persistent
medical conditions may coexist with new-onset GAD.
III. Diagnosis of Generalized Anxiety Disorder
The length of GAD screening tests varies, and many
include screening for additional disorders. The
single screening question: "Are you nervous? " has
100% sensitivity and 59% specificity among average
primary care patients. In the past two weeks, how
frequently did patients experience "feeling
apprehensive, anxious, or on edge" and "not being able
to stop or control worrying," was asked in 2-item
Generalized Anxiety Disorder (GAD-2) screening
tool. For a total score of 0 to 6, each question is given
a score of 0, 1, 2, or 3. For detecting GAD, a score of
3 or higher has a sensitivity of 86% and a specificity
of 83%. Combining the GAD-2 tool with the PHQ-2
(which has sensitivity), the 4-item Patient Health.
Questionnaire (PHQ-4), which has sensitivity of 83%
and specificity of 90% for major depressive disorder,
offers a quick and accurate screening for both major
depressive disorder and GAD. Patients with a positive
result on any screening tool should be further
evaluated to assess whether they meet the diagnostic
criteria in the Diagnostic and Statistical Manual of
Mental Disorders, Fifth Edition (DSM-5).
Diagnostic Criteria for Generalized Anxiety Disorder
(1) Excessive anxiety and worry about various
events have occurred more days than not for at
least 6 months.
(2) The person finds it difficult to control the
worry.
(3) The anxiety and worry are associated with at
least three of the following six symptoms (only
one symptom is required in children):
restlessness or a feeling of being keyed up or
“on edge,” being easily fatigued, having
difficulty concentrating, irritability, muscle
tension, and sleep disturbance.
(4) The anxiety, worry, or associated physical
symptoms cause clinically significant distress
or impairment in important areas of
functioning.
(5) The disturbance is not due to the physiological
effects of a substance or medical condition.
(6) The disturbance is not better accounted for by
another mental disorder.
Patients must meet all 6 criteria for a diagnosis of
IV. Generalized Anxiety Disorder Pathogenesis
Generalized anxiety disorder is hypothesized to develop
and persist as a result of biological and psychological
causes. While the psychosocial component examines
intrapsychic, social, and learning theories of the
condition, the biological section includes contributions
from genetics, neurochemistry or biochemistry,
neurophysiology, and neuroendocrinology.
Role of Genetics in GAD
Clinical research has focused a lot on how general
factors contribute to morbid anxiety. Family studies data
suggest a four-to fivefold lifetime risk expansion in
fostering an anxiety disorder among first degree family
members, and recent twin studies looking at anxious
traits have observes heredity rates going from 0.32 to
0.42. Due to their association with impaired serotonin
reuptake, polymorphisms of 5-HTTLPR in the promoter
region of the serotonin transporter gene have been
identified as potential candidate genes for anxiety
disorders. These variants may sensitize corticolimbic
pathways to decreased stress resilience and increased
anxiety, and is more prevalent in GAD patients than in
non-patients. A significant single-nucleotide
polymorphism was found in twin subjects, and
additional studies have highlighted coding and
noncoding regions as potential areas for further
investigation into the etiology of generalized anxiety
disorder. In a study of over 12,000 Hispanic or Latino
patients, genome-wide association studies (GWAs)
identified the rs78602344 region on chromosome 6 as a
common finding in GAD patients. A collection of
GWAs was used to analyze the information from the
brainstorm consortium in order to find patterns of
heritability and genetic associations. Psychiatric
disorders like anxiety and MDD were less genetically
distinct and shared more variant alleles that represented
risk factors than neurological disorders like epilepsy and
Parkinson's disease.
Role of Epinephrine, Norepinephrine, and 3-
methoxy-4-hydroxyphenylglycol (MHPG) in GAD
The sympathetic adrenal medullary discharge of
catecholamines, which is the source of most peripheral
epinephrine, can produce many of the somatic
symptoms of anxiety. Some anxious patients, but not all,
have been found to have increased peripheral adrenergic
discharge, while increased epinephrine (E) but not
norepinephrine (NE) were found in non-patients. In both
normal and phobic-anxious patients, there is a strong
correlation between plasma MHPG levels and anxiety
ratings. Studies shows the relationship between the
major metabolite of NE, 3-methoxy-4-
hydroxyphenylglycol (MHPG), and the locus coeruleus
and central adrenergic system, which have also been
linked to anxiety states. Norepinephrine is a
catecholamine that causes a physiological stress
response by activating the sympathetic nervous system
(SNS) and acting as both a hormone and a
neurotransmitter. Patients with GAD typically present
with tachycardia and diaphoresis as somatic symptoms
of SNS activation. Anxiety and the functioning of the
norepinephrine system have been studied through
chronic stress exposure, accordingly, long-term stress
exposure raised plasma norepinephrine levels. There
was a correlation between higher levels and increased α 2
receptor binding sites, indicating that chronic anxiety
resulted in norepinephrine system upregulation.
Figure 1. Norepinephrine degradation. 3-Methoxy-4-hydroxyphenylglycol is
shown at right. Enzymes are shown in boxes.
Role of Apelin 36 and Oxidative Stress in GAD
Apelin is an endogenous ligand for G protein bound APJ
receptors in the central nervous system, which prevents
the death of hippocampal neurons. While oxidative
stress was occurred by free radicals which caused
apoptosis in the hippocampus, hypothalamus and
amygdala of the central nervous system (CNS). One
study showed that serum apelin-36 levels were found
significantly lower in people with GAD than in the
control group. It has been shown that GAD is linked to a
pro-inflammatory response. Inflammatory cytokines like
IL-1, IL-6, and TNF- have been found in the
hippocampus and amygdala, suggesting that they may
be involved in etiopathogenesis. In the same brain
regions, it has been shown that Apelin prevents the
secretion of these cytokines and was shown to have a
neuroprotective effect by preventing neuronal apoptosis
in GAD patients, in addition to its anti-proinflammatory
cytokine effect in the brain. By inhibiting the release of
inflammatory and anxiolytic cytokines, Apelin prevents
neuronal cell apoptosis.
The accumulation of free radicals and/or the absence of
antioxidants compromise the integrity of the envelope
phospholipids of neurons in the cortical regions, such as
the amygdala and the hippocampus. These modifications
affect the density and functions of catecholamine
receptors like GABA and
serotonin/dopamine/noradrenaline which assume a part
in the pathophysiology of GAD. The structures that are
responsible for organizing the stress response, such as
the hypothalamus, hippocampus, and amygdala,
commonly contain Apelin and its receptors. By reducing
the release of cytokines such as IL-1, IL-6, and TNF- in
these brain regions, Apelin inhibits the inflammatory
response. The apelinergic system has been shown to
improve behavioral performance and protect neurons by
preventing apoptosis in some studies. In disrupting
synaptic plasticity, it promotes the release of
inflammatory cytokines, and triggering preapoptotic
signaling, free radicals trigger apoptosis in the CNS's
hypothalamus, hippocampus, and amygdala.
A condition known as oxidative stress alters the normal
intracellular balance of oxidant substances produced
during aerobic metabolism and antioxidant system
processes that neutralize free radicals, activating a
number of enzymatic and non-enzymatic protective
mechanisms. If free radicals overwhelm the body's
ability to regulate them, a condition known as oxidative
stress ensues. Due to the presence of free, unpaired
electrons, these chemical species are highly reactive.
Figure 2. The cells in our body develop free radicals when the metabolic
processes are driven in a normal manner, but these free radicals are
balanced out by the production of antioxidants. The imbalance between
the production of free radicals and antioxidants in the body (Oxidative
Stress)
The delicate homeostatic mechanisms that involve
neurotransmitters, hormones, oxidizing substances, and
numerous other mediators are compromised by an
increase in free radicals. Polyunsaturated fatty acids
(PUFAs) make cell membranes susceptible to damage
from free radicals, resulting in peroxidation, due to their
structure's abundance of double bonds. Cell instability
as a result of lipid peroxidation damage compromises
fluidity, permeability, signal transduction, and alters
receptor, mitochondrial DNA, and nuclear DNA.
Oxidizing stress from free radicals is one of the factors
that contributes to an increase in the speed of the cell
cycle and consequent premature cell death, resulting to
many degenerative diseases in the central nervous
system, as well as psychiatric disturbances.
The CNS shows increased susceptibility to oxidative
stress due to its high consumption rate (20% of the total
oxygen inhaled by the body) that accounts for the
increased generation of oxygen free radicals and
reactive oxygen substrates. Since all the cells and tissues
of our body are also equipped with antioxidative
enzymes such as super oxide dismutase (SOD),
glutathione peroxidase (GPX), glutathione reductase
(GRd) and substances like reduced glutathione (GSH),
they dispose the free radicals as and when they are
generated thereby protecting the cells and tissues from
the oxidative attack. Degenerative changes are the root
cause of numerous degenerative diseases when the
balance is skewed more toward the production of free
radicals. Brain has a low degree of antioxidative defense
system as the concentration of different antioxidative
enzymes like SOD, GPX, GRd and catalase is low in
brain. One study found that patients with generalized
anxiety disorder had higher levels of MDA and lower
levels of SOD, glutathione, Vitamin E, and Vitamin C
before therapy and showed reversal of values following
treatment over a period of three months thereby suggest
an association between increased oxidative stress and
the generalized anxiety disorders.
Role of Serotonin and GABA in GAD
Another monoamine neurotransmitter is serotonin (5-
HT), which can be found in the CNS, intestines, and
platelets in the blood. The brainstem raphe nuclei are
where the majority of the serotonin-producing neurons
are clustered in the CNS. Anxious-trait patients had
higher levels of serotonin neuronal activity, synthesis,
and transporter availability than healthy controls in
humans. Activity of serotonin receptors and the
serotonin transporter (5-HT) has been studied in GAD.
In mice, variations in stress resilience were caused by
early suppression and overexpression of serotonin
receptors. This suggests that early factors in receptor
modulation may be the cause of lifelong susceptibility to
exaggerated stress responses. In human studies,
polymorphisms in 5-HTT alleles have been associated
with trait anxiety. As a result, clinical drug development
continues to target the serotonin transporter, impairment
of reuptake, and subtypes of serotonin receptors.
The majority of brain regions contain amino acid
neurotransmitter GABA, the primary inhibitory CNS
neurotransmitter. Additionally, the benzodiazepine
anxiolytics are well-described full agonists at the
GABAA receptor complex, enhancing native GABA's
effectiveness at the receptor. Several potential candidate
genes have been localized following the identification of
GABA receptor genes that are associated with anxiety
disorders. Anxiety disorders in humans were linked to
SLC6A1 GABA transporter gene polymorphisms.
Homeostasis between GABA and glutamate
neurotransmission is thought to be responsible for
appropriate emotional regulation, and GABAergic
neurons exert inhibitory control over pathways linked to
the amygdala. Deficits in intercortical facilitation, a
neural communication process controlled by GABA A
and GABAA receptors, were found to be associated with
an abnormal rise in anxiety symptoms in GAD patients.
Another study of the central benzodiazepine receptors
found that benzodiazepine binding is significantly
reduced in the left temporal pole of patients with GAD.
The density distribution of these cerebral
benzodiazepine receptors is more homogenous than in
control subjects, providing evidence for deficits in
GABA function in GAD.
V. Neuroendocrinology/Immunology
Generalized anxiety may occur in the presence of
endocrine disorders and following exogenous hormone
administration. In addition, the HPA axis is a crucial
feedback circuit that triggers the release of multiple
hormones during stress, eventually leading to the
adrenal glands producing cortisol. Albeit the HPA is
enacted by stressors, aftereffects of studies examining
cortisol levels in GAD have been mixed: GAD patients
have been found to have baseline hypercortisolemia.
However, hair samples from GAD patients and control
subjects also showed signs of hypercortisolemia,
suggesting that cortisol is secreted less frequently in
times of chronically high stress. Some of the most
important stress hormones, such as adrenocorticotropin
and cortisol, have been studied as potential biomarkers
for stress and anxiety. Additionally, immune processes
are regulated by the HPA axis.
Abnormal levels of hormones, including cortisol, are
related with either pro-inflammatory or smothered
immunological reactions. C-reactive protein (CRP),
interleukin-6, and tumor necrosis factor alpha (TNF-α),
all statistically significant elevations in subjects with
increased cognitive and somatic symptoms of anxiety,
were found in the Netherlands study of Depression and
Anxiety, which examined data from more than 2,800
adult participants. In the future, promising
immunotherapy targets for anxiety may emerge from
further study of pro- and anti-inflammatory proteins.
The evaluation of cyclooxygenase (COX-2) inhibitors
Figure
for the treatment 3. SLC6A1
of mood mechanism
disorders has resulted from
the inhibition of the production of cytokines and other
inflammatory entities like prostaglandins. The
administration of COX-2 inhibitors and substrate-
selective COX-2 inhibitors decreased the onset of stress-
induced symptoms and fear behaviors in animal and
mouse models. Muller et al. (2006) also conducted a
placebo-controlled, randomized study found that the
combination of the antidepressant reboxetine and the
COX-2 inhibitor cele-coxib reduced depressive
symptoms. These findings have implications for future
GAD treatment strategies.
VI. Treatment
Psychotherapy
Psychotherapy aims to assists patients develop effective
strategies to cope with symptoms of anxiety. Addressing
this unrealistic outlook by cognitive therapy and
cognitive behavioral therapy (CBT) has therefore been
effective for GAD patients. Applied relaxation to target
the excessive worry and muscle tension of GAD is also
an effective treatment. A combination of psychotherapy
and pharmacotherapy is promising for the treatment of
depression, and so it is possible that a similar combined
approach may prove effectiveness in the treatment of
GAD.
Pharmacotherapy
Benzodiazepines. Benzodiazepines became widely
available in the 1960s and all have anxiolytic, hypnotic,
anticonvulsant, and muscle relaxant properties. They are
produced by potentiating the effects of gamma-
aminobutyric acid (GABA) at GABAA
receptors/chloride ion channel complexes. This
interaction leads to hyperpolarization and reduced
neural transmission throughout the central nervous
system. Benzodiazepines are anxiolytic in patients with
GAD and have a rapid onset of action. However, their
efficacy in long-term treatment may not be as robust as
assumed.
Figure 4. GABA is mediator of Benzodiazepine- induced drug effects
Azapirones. The azapirone group of compounds-
buspirone, ipsapirone, and gepirone, is structurally and
pharmacologically unrelated to benzodiazepines, but
also has anxiolytic properties. The mechanism of the
anxiolytic action of buspirone and other azapirones is
not fully understood, but has been speculated to involve
reduced firing of serotonergic nerve fibers through the
partial agonist effect of these compounds at presynaptic
serotonin-1A (5-HT1A) autoreceptors on serotonergic
nerve cell bodies. Patients with GAD respond to
buspirone in a manner that is comparable to that of
benzodiazepines in terms of anxiety reduction, albeit at
a slower rate and lasting at least two weeks. Although
buspirone is the only agent currently available from this
group, ipsapirone and gepirone both have similar effects VIII. References
on GAD.
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DeMartini, J. MD, et al. (2019). Generalized Anxiety Disorder. Annals of

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Figure 5. 5-HT1A partial agonist (buspirone) mechanism of action. https://www.psychiatrist.com/wp-content/uploads/2021/02/18372_treatm
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Additional treatments (pharmacotherapy) for GAD
Munjack, D.J., et al. (1997). Generalized Anxiety Disorder: Some Biochemical
includes the intake of tricyclic anti-depressants, Aspects. Psychiatry Research, Volume 32, Issue 1.
selective serotonin reuptake inhibitors (SSRIs), and https://doi.org/10.1016/0165-1781(90)90133-P
serotonin- norepinephrine reuptake inhibitor-
venlafaxine. Ranjana, K.S., et al. (2012). Markers of Oxidative Stress in Generalized
Anxiety Psychiatric Disorder: Therapeutic Implications. Journal of Stress
VII. Conclusions Physiology & Biochemistry. https://cyberleninka.ru/article/n/markers-of-
oxidative-stress-in-generalized-anxiety-psychiatric-disorder-therapeutic-
implications
Generalized Anxiety Disorder is a common and
impairing illness. Symptoms includes chronic,
Spitzer, R. MD, et al. (2010) A Brief Measure for Assessing Generalized
persistent anxiety and worry, along with vague Anxiety Disorder: The GAD-7. Arch Intern Med.
physical and psychological symptoms (such as https://doi.org/10.1001/archinte.166.10.1092
restlessness, exhaustion, trouble focusing, irritability,
muscle tension, or sleep difficulties). The length of Stein, M.B., MD, MPH and Sareen, J., MD. (2015). Generalized Anxiety
its screening tests varies, and many include screening Disorder. The New England Journal of Medicine.
https://www.nejm.org/doi/full/10.1056/nejmcp1502514
for additional disorders. Patients with a positive
result on any screening tool will be further evaluated
to assess whether they meet the diagnostic criteria in
the Diagnostic and Statistical Manual of Mental
Disorders, Fifth Edition (DSM-5). Generalized
Anxiety Disorder’s pathogenesis includes the role of
Genetics, Epinephrine, Norepinephrine, and 3-
methoxy-4-hydroxyphenylglycol (MHPG). Apelin 36,
Oxidative Stress, Serotonin and GABA also plays a
part in the development of GAD. The interaction
between the nervous and endocrine systems or the
Neuroendocrinology have also been linked to the
pathogenesis of GAD. Treatment for GAD involves
psychotherapy (cognitive therapy and cognitive
behavioral therapy) and pharmacotherapy (intake of
Benzodiazepines, Azapirones, Tricyclic anti-
depressants, selective serotonin reuptake inhibitors
(SSRIs), and serotonin- norepinephrine reuptake
inhibitor- venlafaxine.