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SOURCE

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Source: Melton ST, Kirkwood CK. Anxiety disorders: generalized anxiety, panic, and social anxiety disorders. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM, eds. Pharmacotherapy: A Pathophysiologic Approach. 10th ed. New York, NY: McGraw-Hill; 2017. http://accesspharmacy.mhmedical.com/content.aspx?bookid=1861&sectionid=146065193. Accessed January 17, 2017.

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DEFINITION

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  • Anxiety, apprehension, or worry not linked to a specific cause or situation. Symptoms severe enough to impair functioning.

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ETIOLOGY

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  • Combination of vulnerability (eg, genetic predisposition, childhood adversity) and stress (eg, occupational, traumatic experience).

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PATHOPHYSIOLOGY

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  • Noradrenergic model: autonomic nervous system hypersensitive and overreacts to various stimuli. Chronic noradrenergic overactivity downregulates α2-adrenoreceptors.

  • γ-Aminobutyric acid (GABA) receptor model: underactivity of GABA systems or downregulated central benzodiazepine receptors. Reduced benzodiazepine binding in the left temporal lobe.

  • 5-HT model: excessive 5-HT transmission or overactivity of stimulatory 5-HT pathways.

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EPIDEMIOLOGY

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  • One-year prevalence rate is 2.9%

  • More common in women, persons with social issues, and those with a family history of anxiety and depression.

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RISK FACTORS

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  • Childhood trauma.

  • Stressful lifestyle.

  • Chronic medical illness.

  • Physical disability.

  • Other psychiatric disorders (schizophrenia, dementia)

  • Alcohol, nicotine, caffeine use.

  • Medications (eg, sympathomimetics, thyroid hormones, antidepressants, corticosteroids)

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CLINICAL PRESENTATION

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SIGNS AND SYMPTOMS
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  • Psychological and cognitive symptoms:

    • Excessive anxiety.

    • Worries difficult to control.

    • Feeling keyed up or on edge.

    • Poor concentration or mind going blank.

  • Physical symptoms:

    • Restlessness.

    • Fatigue.

    • Muscle tension.

    • Sleep disturbance.

    • Irritability.

  • Gradual onset at mean age of 21 years.

  • Course is chronic with multiple spontaneous exacerbations and remissions. High relapse percentage and low recovery rate.

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DIAGNOSIS

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MEANS OF CONFIRMATION AND DIAGNOSIS
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  • Perform complete physical and mental status examination; appropriate laboratory tests; and medical, psychiatric, and drug history.

  • Symptoms may be associated with medical illnesses or drug therapy.

  • Anxiety may occur in psychiatric illnesses (eg, mood disorders, schizophrenia, substance withdrawal).

  • Diagnostic criteria require persistent symptoms most days for at least 6 months; anxiety or worry must be about multiple matters and accompanied by at least three psychological or physiologic symptoms.

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DESIRED OUTCOMES

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  • Reduce severity and duration of symptoms and improve functioning.

  • Remission with minimal or no anxiety symptoms, no functional impairment and improve quality of life long term.

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TREATMENT: NONPHARMACOLOGIC THERAPY

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  • Psychoeducation, psychotherapy, short-term counseling, stress management, cognitive therapy, meditation, exercise.

  • Cognitive behavioral therapy (CBT) is most effective psychological therapy, used alone or in combination with antianxiety drugs.

  • Educate patients to avoid caffeine, stimulants, excessive alcohol, and diet pills.

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TREATMENT: PHARMACOLOGIC THERAPY

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  • Drug choices (Table 1):

    • First line: duloxetine, escitalopram, paroxetine, sertraline, venlafaxine XR.

    • Second line: benzodiazepines, buspirone, imipramine, pregabalin.

    • Alternatives: hydroxyzine, quetiapine.

  • Benzodiazepines.

    • All equally ...

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