Generalized Anxiety Disorder (GAD)

Generalized Anxiety Disorder (GAD), is characterized by persistent and excessive worry about a number of different things. Individuals with GAD find it difficult to control their worry. They may worry more than seems warranted about actual events or may expect the worst even when there is no apparent reason for concern.

It’s possible to develop generalized anxiety disorder as a child or an adult. Generalized

It’s no laughing matter!

anxiety disorder has symptoms that are similar to panic disorder, obsessive-compulsive disorder and other types of anxiety, but they’re all different conditions.

 

People with the disorder, experience excessive anxiety and worry, often expecting the worst even when there is no apparent reason for concern. They anticipate disaster and may be overly concerned about money, health, family, work, or other issues. GAD is diagnosed when a person finds it difficult to control worry on more days than not for at least six months and has three or more symptoms.

Symptoms of GAD include the following:

• Restlessness or feeling keyed up or on edge
• Persistent worrying or obsession about small or large concerns that’s out of proportion to the impact of the event
• Inability to set aside or let go of a worry
• Worrying about excessively worrying
• Distress about making decisions for fear of making the wrong decision
• Carrying every option in a situation all the way out to its possible negative conclusion
• Difficulty handling uncertainty or indecisiveness
• Difficulty concentrating or mind going blank
• Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep)
   

  Physical signs and symptoms may include:

  • Fatigue
  • Irritability
  • Muscle tension or muscle aches
  • Trembling, feeling twitchy
  • Being easily startled
  • Trouble sleeping
  • Sweating
  • Nausea, diarrhea or irritable bowel syndrome
  • Headaches

Sometimes just the thought of getting through the day produces anxiety. They don’t know how to stop the worry cycle and feel it is beyond their control, even though they usually realize that their anxiety is more intense than the situation warrants.

GAD affects 6.8 million adults, or 3.1% of the U.S. population, in any given year. Women are twice as likely to be affected.

The disorder comes on gradually and can begin across the life cycle, though the risk is highest between childhood and middle age. Although the exact cause of GAD is unknown, there is evidence that biological factors, family background, and life experiences, particularly stressful ones, play a role.

There may be times when their worries don’t completely consume them, but they still feel anxious even when there’s no apparent reason. For example, they may feel intense worry about their safety or that of their loved ones, or they may have a general sense that something bad is about to happen.

Their anxiety, worry or physical symptoms cause them significant distress in social, work or other areas of their life. Worries can shift from one concern to another and may change with time and age.

When their anxiety level is mild, people with GAD can function socially and be gainfully employed. Although they may avoid some situations because they have the disorder, some people can have difficulty carrying out the simplest daily activities when their anxiety is severe.

When I was diagnosed, I had no idea what GAD was, I thought it just meant that I generally was anxious. I held onto this  belief for a long time, then finally I asked my counselor what it meant and I got a long list of issues, like those listed in this post.

I had been through several surgeries very close together and was feeling exhausted from the trials of my physical being, and I started worrying about not waking up from the anesthesia. Worrying about my home life. Worrying about the constant pain I was experiencing and not knowing what to do about it. With five back to back surgeries, it was just too much for me, the first surgery should have taken care of the problem, but it did not and led to another surgery and so forth until the 5th surgery was complete.

But my anxiety stayed high as I was anticipating yet another surgery because the last 4 had not proven to be successful, why did the doctor think that number 5 was the final one. I had sunk into a deep depression and there was just too much living going on around me at the time, that I was not able to participate in the way I wanted to. I felt like an outcast and most often stayed hidden in my house.

I was restricted on my movement, and activities, so much so, I could not bend over to pick something up off the floor. It was devastating to say the least. I was not making it to my counseling sessions. My husband was doing grocery shopping. I was an invalid, in my mind set at the time.

It was a hard time, that thankfully it has past, but GAD still remains. I take medication for my treatment and I never miss a dose.

Symptoms in children and teenagers

In addition to the symptoms above, children and teenagers who have generalized anxiety disorder may have excessive worries about:

• Performance at school or sporting events
• Being on time (punctuality)
• Earthquakes, nuclear war or other catastrophic events

A child or teen with generalized anxiety disorder may also:

• Feel overly anxious to fit in
• Be a perfectionist
• Redo tasks because they aren’t perfect the first time
• Spend excessive time doing homework
• Lack confidence
• Strive for approval
• Require a lot of reassurance about performance

Causes

As with many mental health conditions, the exact cause of generalized anxiety disorder isn’t fully understood, but it may include genetics as well as other risk factors.

• Risk Factors
  These factors may increase the risk of developing generalized anxiety disorder:
  • Personality. A person whose temperament is timid or negative or who avoids anything dangerous may be more prone to generalized anxiety disorder than others are.
  • Genetics. Generalized anxiety disorder may run in families.
  • Being female. Women are diagnosed with generalized anxiety disorder somewhat more often than men are.

Complications

Having generalized anxiety disorder does more than just make you worry. It can:

• Impair your ability to perform tasks quickly and efficiently because you have trouble concentrating
• Take your time and focus from other activities
• Sap your energy
• Disturb your sleep

Generalized anxiety disorder can also lead to or worsen other mental and physical health conditions, such as:

• Depression (which often occurs with generalized anxiety disorder)
• Substance abuse
• Trouble sleeping (insomnia)
• Digestive or bowel problems
• Headaches
• Heart-health issues

Preparing for your appointment

You may start by seeing your family doctor. However, you may need to see a psychiatrist or psychologist if you have severe anxiety or if you also have another mental health condition, such as depression.

What you can do

To prepare for your appointment, make a list of:

• Your symptoms, including when they occur, what seems to make them better or worse, and how much they affect your day-to-day activities, such as work, school or relationships
• What’s causing you stress, including major life changes or stressful events you’ve dealt with recently and any traumatic experiences you’ve had in the past
• Health problems you have, both physical conditions and mental health issues
• All medications you’re taking, including any vitamins or other supplements, and the dosages
  • Questions to ask your doctor
    • Are there other possible situations, psychological issues or physical health problems that could be causing or worsening my anxiety?
    • Do I need any tests?
    • What treatment do you recommend?
    • Should I see a psychiatrist, psychologist or other mental health provider?
    • Would medication help? If so, is there a generic alternative to the medicine you’re prescribing?
    • Are there any brochures or other printed material that I can have? What websites do you recommend?

    What’s the most likely cause of my symptoms?

Don’t hesitate to ask questions at any time during your appointment.

What to expect from your doctor

Being ready to answer questions from your doctor may reserve time to go over any points you want to spend more time on. Some questions the doctor may ask include:

• What are your symptoms?
• Do your symptoms interfere with your daily activities?
• Have your feelings of anxiety been occasional or continuous?
• When did you first begin noticing your anxiety?
• Does anything in particular seem to trigger your anxiety or make it worse?
• What, if anything, seems to improve your feelings of anxiety?
• What, if any, physical or mental health conditions do you have?
• What traumatic experiences have you had recently or in the past?
• Do you regularly drink alcohol or use recreational drugs?
• Do you have any blood relatives with anxiety or other mental health conditions, such as depression?

Tests and diagnosis

To help diagnose generalized anxiety disorder, your health provider may:

• Do a physical exam to look for signs that your anxiety might be linked to an underlying medical condition
• Order blood or urine tests or other tests, if a medical condition is suspected
• Ask detailed questions about your symptoms and medical history
• Use psychological questionnaires to help determine a diagnosis

Many experts use the criteria listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association, to diagnose mental conditions. This manual is also used by insurance companies to reimburse for treatment.

DSM-5 criteria for generalized anxiety disorder include:

• Excessive anxiety and worry about several events or activities most days of the week for at least six months
• Difficulty controlling your feelings of worry
• At least three of the following symptoms in adults and one of the following in children: restlessness, fatigue, trouble concentrating, irritability, muscle tension or sleep problems
• Anxiety or worry that causes you significant distress or interferes with your daily life
• Anxiety that isn’t related to another mental health condition, such as panic attacks or post-traumatic stress disorder (PTSD), substance abuse, or a medical condition

Generalized anxiety disorder often occurs along with other mental health problems, which can make diagnosis and treatment more challenging. Some disorders that commonly occur with generalized anxiety disorder include:

• Phobias
• Panic disorder
• Depression
• Substance abuse
• PTSD

Treatment

Like other anxiety disorders, GAD is treatable. Cognitive-behavioral therapy is effective for many people, helping them to identify, understand, and modify faulty thinking and behavior patterns. This enables people with GAD learn to control their worry. Some people with GAD also take medication.

Relaxation techniques, meditation, yoga, exercise, and other alternative treatments may also become part of a treatment plan.

Other anxiety disorders, depression, or substance abuse often accompany GAD, which rarely occurs alone; co-occurring conditions must also be treated with appropriate therapies.

Although treatment is individualized, several standard approaches have proved effective. Your health care professional will use one or a combination of these treatments:

• Therapy
• Learn More About Cognitive-Behavior Therapy (CBT)
• Medication
• Residential Treatment
• Complementary and Alternative Treatment
• Transcranial Magnetic Stimulation (TMS)

Therapy

Cognitive-Behavioral Therapy (CBT)

A well-established, highly effective, and lasting treatment is called cognitive-behavioral therapy, or CBT. It focuses on identifying, understanding, and changing thinking and behavior patterns. Benefits are usually seen in 12 to 16 weeks, depending on the individual.

In this type of therapy the patient is actively involved in his or her own recovery, has a sense of control, and learns skills that are useful throughout life. CBT typically involves reading about the problem, keeping records between appointments, and completing homework assignments in which the treatment procedures are practiced. Patients learn skills during therapy sessions, but they must practice repeatedly to see improvement.

Exposure Therapy

A form of CBT, exposure therapy is a process for reducing fear and anxiety responses. In therapy, a person is gradually exposed to a feared situation or object, learning to become less sensitive over time. This type of therapy has been found to be particularly effective for obsessive-compulsive disorder and phobias.

Acceptance and Commitment Therapy (ACT)

Also known as ACT, this type of therapy uses strategies of acceptance and mindfulness (living in the moment and experiencing things without judgment), along with commitment and behavior change, as a way to cope with unwanted thoughts, feelings, and sensations. ACT imparts skills to accept these experiences, place them in a different context, develop greater clarity about personal values, and commit to needed behavior change.

Dialectical Behavioral Therapy (DBT)

Integrating cognitive-behavioral techniques with concepts from Eastern meditation, dialectical behavioral therapy, or DBT, combines acceptance and change. DBT involves individual and group therapy to learn mindfulness, as well as skills for interpersonal effectiveness, tolerating distress, regulating emotions.

Interpersonal Therapy (IPT)

Often referred to as IPT, interpersonal therapy is a short-term supportive psychotherapy that addresses interpersonal issues in depression in adults, adolescents, and older adults. IPT usually involves 12 to 16 one-hour weekly sessions. The initial sessions are devoted to gathering information about the nature of a person’s depression and interpersonal experience.

Eye Movement Desensitization and Reprocessing (EMDR)

Under certain conditions eye movements appear to reduce the intensity of disturbing thoughts. A treatment known as eye movement desensitization and reprocessing, or EMDR, seems to have a direct effect on the way that the brain processes information. Basically, it helps a person see disturbing material in a less distressing way.

EMDR appears to be similar to what occurs naturally during dreaming or REM (rapid eye movement) sleep. Scientific research has established EMDR as effective for posttraumatic stress disorder. And clinicians also have reported success using it to treat panic attacks and phobias.

Medication

Medication treatment of anxiety is generally safe and effective and is often used in conjunction with therapy. Medication may be a short-term or long-term treatment option, depending on severity of symptoms, other medical conditions, and other individual circumstances. However, it often takes time and patience to find the drug that works best for you.

Medications are commonly prescribed by physicians (family practice, pediatricians, OB-GYNs, psychiatrists), as well as nurse practitioners in many states.

More than one in 10 Americans take antidepressants, the primary type of medication used by people ages 18 to 44.

Four major classes of medications are used in the treatment of anxiety disorders:

Selective Serotonin Reuptake Inhibitors (SSRIs)
SSRIs relieve symptoms by blocking the reabsorption, or reuptake, of serotonin by certain nerve cells in the brain. This leaves more serotonin available, which improves mood. SSRIs (citalopram, escitalopram, fluoxetine, paroxetine, and sertraline) generally produced fewer side effects when compared with tricyclic antidepressants.  However, common side effects include insomnia or sleepiness, sexual dysfunction, and weight gain. They are considered an effective treatment for all anxiety disorders, although the treatment of obsessive-compulsive disorder, or OCD, typically requires higher doses.

Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)
The serotonin-norepinephrine reuptake inhibitor, or SNRI, class (venlafaxine and duloxetine) is notable for a dual mechanism of action: increasing the levels of the neurotransmitters serotonin and norepinephrine by inhibiting their reabsorption into cells in the brain. As with other medications, side effects may occur, including stomach upset, insomnia, headache, sexual dysfunction, and minor increase in blood pressure. These medications are considered as effective as SSRIs, so they are also considered a first-line treatment, particularly for the treatment of generalized anxiety disorder.

Benzodiazepines
This class of drugs is frequently used for short-term management of anxiety. Benzodiazepines (alprazolam, clonazepam, diazepam, and lorazepam) are highly effective in promoting relaxation and reducing muscular tension and other physical symptoms of anxiety. Long-term use may require increased doses to achieve the same effect, which may lead to problems related to tolerance and dependence.

Tricyclic Antidepressants
Concerns about long-term use of the benzodiazepines led many doctors to favor tricyclic antidepressants (amitriptyline, imipramine, and nortriptyline). Although effective in the treatment of anxiety, they can cause significant side effects, including orthostatic hypotension (drop in blood pressure on standing), constipation, urinary retention, dry mouth, and blurry vision.

Contact your physician if you experience side effects, even if you are not sure a symptom is caused by a medication. Do not stop taking a medication without consulting with the prescribing physician; abrupt discontinuation may cause other health risks.

Medications will work only if they are taken according the explicit instructions of your physician, but they may not resolve all symptoms of an anxiety disorder.

Ketamine
Clinical trials have shown that ketamine can lift depression in hours, or even minutes, much faster than the most commonly used antidepressant medications available today; they often take weeks to take effect. Also, the antidepressant effects of a single dose of ketamine can last for a week or longer. But it also has properties that make it a potential drug of abuse, which limits its usefulness as a depression medication.

Discussing Medications: What You Need to Know

Use these guidelines to talk to your health care professional about medications:

• To avoid potentially dangerous drug interactions, let your mental health care provider know all medications you are taking, including prescriptions and over-the-counter drugs, herbal or dietary supplements, and vitamins. And make sure your family doctor knows you are taking medications for an anxiety disorder.
• Ask these questions about a new prescription: How will the medication help me? What side effects might occur? Should I avoid any foods or beverages? Are drug interactions with other prescriptions a possibility?
• Learn when to take a new medication and how, such as on any empty stomach or with food, in the morning or evening, and how frequently.
• Find out how long it should take for the medication to start working and what you should expect when this happens.
• Ask for the prescribing physician’s after-hours phone number in case you develop side effects.
• A good source of information about medications and over-the-counter products is your pharmacist, who should have information about all your prescriptions to advise you about possible drug interactions, side effects, and instructions for use.
• Ask how often you should see the doctor for a medication check-up.
  If your physician does not want to spend the time to answer your questions, you may need a referral to a different physician.

Residential Treatment

A residential treatment center (RTC), sometimes called a rehab, is a live-in health care facility providing therapy for substance abuse, mental illness, or other behavioral problems.

ADAA has compiled a Q&A flyer based on typical questions from the public that we receive via email or phone regarding the selection of in-patient residential treatment centers.

Please note that there are very few in-patient residential treatment centers that focus on anxiety and depression. Most centers focus on substance abuse.

ADAA also recommends reaching out to support groups, such as ADAA’s free online peer-to-peer support group and suggest that you engage your peers for recommendations about a specific facility. There are also therapy and medication options that might be appropriate for you/your family to explore prior to seeking out in-patient residential treatment centers.

What is residential treatment and how is it different from other levels of care?

Residential treatment provides 24-hour staffing, and it is for treatment. Typical lengths of stay are 60 days or more and it is appropriate for someone who is not at risk to him- or herself or others. It is also provided in a homelike environment, which makes residents more comfortable and allows for exposure-treatment opportunities.

And partial hospitalization, sometimes called day treatment, typically provides five to six hours of treatment a day, five days a week. Average lengths of stay may be three to four weeks. This level of care can be close to the dosage of treatment someone would get in residential, but it doesn’t provide the 24-hour support or treatment seven days a week.

Inpatient care is for very acute situations where someone may be considered a risk to him- or herself or others, and the length of stay lasting four or five days is meant to stabilize a mental health crisis.

Complementary & Alternative Treatments

There is growing scientific evidence about complementary and alternative treatments.

Complementary medicine is used along with conventional medicine. An example is in-home treatment to help modify symptoms of panic attacks. Alternative medicine can include a special diet to treat cancer instead of undergoing surgery, radiation, or chemotherapy recommended by a medical doctor.

Treating Anxiety Disorders and Depression

The following complementary and alternative practices may be used to treat anxiety and depressive disorders. We advise that you speak with your primary physician and/or mental health provider before selecting any alternative/complimentary treatment:

• Stress and Relaxation Techniques
  Relaxation techniques may produce modest short-term reduction of anxiety in people with ongoing health problems. These techniques have also been shown to be useful for older adults with anxiety.
• Avoid alcohol and other sedatives. These substances can worsen anxiety.
• Quit smoking and cut back or quit drinking coffee. Both nicotine and caffeine can worsen anxiety.
• Meditation
  Moderate evidence suggests that meditation is useful for symptoms of anxiety and depression in adults.
• Yoga
  Yoga, which combines physical postures, breathing exercises, meditation, and a distinct philosophy, is one of the top ten practices of CAM (complementary and alternative medicine). It may also help alleviate anxiety and depression.
• Acupuncture
  Evidence for the use of acupuncture — the Chinese practice of inserting needles into the body at specific points to manipulates the body’s flow of energy — to treat anxiety disorders is becoming stronger.
• Make sleep a priority. Do what you can to make sure you’re getting enough sleep to feel rested. If you aren’t sleeping well, see your doctor.
• Eat healthy. Healthy eating — such as focusing on vegetables, fruits, whole grains and fish — may be linked to reduced anxiety, but more research is needed.

Some people are interested in trying alternative medicine (a non-conventional approach instead of conventional medicine) or complementary medicine (a non-conventional approach used along with conventional medicine).

Several herbal remedies have been studied as a treatment for anxiety, such as those listed below, but more research is needed to fully understand the risks and benefits. Here’s what researchers know — and don’t know:

• Kava. Kava appeared to be a promising treatment for anxiety, but reports of serious liver damage — even with short-term use — caused several European countries and Canada to pull it off the market. The Food and Drug Administration has issued warnings but not banned sales in the United States. Avoid using kava until more rigorous safety studies are done, especially if you have liver problems or take medications that affect your liver.
• Valerian. In some studies, people who used valerian reported less anxiety and stress, but in other studies, people reported no benefit. Discuss valerian with your doctor before trying it. While it’s generally well-tolerated, there are a few case reports of people developing liver problems when taking preparations containing valerian. If you’ve been using valerian for a long time and want to stop using it, many authorities recommend that its use be tapered down to prevent withdrawal symptoms.
• Passionflower. A few small clinical trials suggest that passionflower might help with anxiety. In many commercial products, passionflower is combined with other herbs, making it difficult to distinguish the unique qualities of each herb. Passionflower is generally considered safe when taken as directed, but some studies have found it can cause drowsiness, dizziness and confusion.
• Theanine. This amino acid is found in green tea and may be found in some supplements. Preliminary evidence shows that theanine may make some people feel calmer, but there is limited evidence that it helps treat anxiety.

Before taking herbal remedies or supplements, talk to your doctor to make sure they’re safe for you and won’t interact with any medications you take.

Transcranial Magnetic Stimulation (TMS)

Transcranial magnetic stimulation, known as TMS, may be a safe, effective, and noninvasive option for people who have depression that has not improved with medications. TMS creates a magnetic field to induce a small electric current in a specific part of the brain; the current comes from the magnetic field created by an electromagnetic coil that delivers pulses through the forehead.

• To find out if TMS is the right treatment for you, speak to your therapist, doctor, or other mental health treatment provider. Your insurance may provide reimbursement for this treatment.

This procedure does not require sedation, and it does not cause seizures or a loss of consciousness. Those receiving TMS usually are treated four or five times every week for four to six weeks. Research shows that TMS produces few side effects.

Types of TMS

Repetitive Transcranial Magnetic Stimulation (rTMS)

Repetitive transcranial magnetic stimulation, or rTMS, uses a magnet to activate the brain. It has been used as a treatment for depression, anxiety, and other disorders to target a specific location in the brain, which scientists believe reduces the chance for side effects.

• Each rTMS session usually lasts 30 to 60 minutes and does not require sedation or anesthesia. An electromagnetic coil held against the forehead is placed near an area of the brain that is thought to be involved in mood regulation; short electromagnetic pulses are administered through the coil. The magnetic pulses cause small electrical currents that stimulate nerve cells in the targeted region of the brain; they are about the same strength as a magnetic resonance imaging (MRI) scan.
• Scientists do not yet know if rTMS works best as a single treatment or combined with medication, psychotherapy, or both. More research continues to determine its safest and most effective uses.

The procedure is relatively new, so long-term side effects are not known. Studies on the safety of rTMS found that most side effects, such as headaches or scalp discomfort, were mild or moderate, and no one experienced a seizure.

Deep Transcranial Magnetic Stimulation (dTMS)

Deep transcranial magnetic stimulation (dTMS) is a relatively new method of stimulating larger, deeper brain regions.

• The procedure uses specialized coils that reach about 4 centimeters beneath the surface of the skull. Called H coils, these are designed to target different brain areas; for example, dTMS using the H1 coil has been approved by the FDA for depression that has not improved with any other type of treatment.
• During a dTMS session, a person wears a cushioned helmet, which generates brief magnetic fields, similar to those in MRI scans. This is an outpatient procedure that has few side effects, and it does not require anesthesia or result in memory loss. Each daily session of 20 minutes takes place over four to six weeks. People who have this procedure can resume their normal activities immediately afterward.

Coping and support

To cope with generalized anxiety disorder, here’s what you can do:

• Stick to your treatment plan. Take medications as directed. Keep therapy appointments. Consistency can make a big difference, especially when it comes to taking your medication.
• Join an anxiety support group. Here, you can find compassion, understanding and shared experiences. You may find support groups in your community or on the Internet.
• Take action. Work with your mental health provider to figure out what’s making you anxious and address it.
• Let it go. Don’t dwell on past concerns. Change what you can and let the rest take its course.
• Break the cycle. When you feel anxious, take a brisk walk or delve into a hobby to refocus your mind away from your worries.
• Socialize. Don’t let worries isolate you from loved ones or enjoyable activities. Social interaction and caring relationships can lessen your worries.

Prevention

There’s no way to predict for certain what will cause someone to develop generalized anxiety disorder, but you can take steps to reduce the impact of symptoms if you experience anxiety:

• Get help early. Anxiety, like many other mental health conditions, can be harder to treat if you wait.
• Keep a journal. Keeping track of your personal life can help you and your mental health provider identify what’s causing you stress and what seems to help you feel better.
• Prioritize issues in your life. You can reduce anxiety by carefully managing your time and energy.
• Avoid unhealthy substance use. Alcohol and drug use and even caffeine or nicotine use can cause or worsen anxiety. If you’re addicted to any of these substances, quitting can make you anxious. If you can’t quit on your own, see your doctor or find a treatment program or support group to help you.

Find a Therapist Near You

Search the adaa.org directory of licensed mental health providers who specialize in anxiety disorders, depression, OCD, PTSD, and related disorders.

Patient-Assistance Programs for Prescription Drugs

Most pharmaceutical companies offer patient-assistance programs for uninsured patients. These programs provide prescribed medication at little to no cost. Eligibility varies; see the Partnership for Prescription Assistance website for more information, or contact companies directly about their patient assistance programs.

• Community Assistance Program (CAP) provides free downloadable prescription cards accepted at over 56,000 pharmacies. Cardholders receive the lowest price available for any particular drug at their chosen pharmacy.
• NeedyMeds is a 501(c)(3) national non-profit information resource dedicated to helping people locate assistance programs to help them afford their medications and other healthcare costs.  ADAA is partnering with NeedyMeds to provide information resource pages about various anxiety and depression related disorders.

https://www.adaa.org/understanding-anxiety/generalized-anxiety-disorder-gad
http://www.mayoclinic.org/diseases-conditions/generalized-anxiety-disorder/basics/definition/con-20024562