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Source: Melton ST, Kirkwood CK. Anxiety Disorders I: 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. 8th ed. http://accesspharmacy.com/content.aspx?aid=7989670. Accessed May 25, 2012.

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

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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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  • One-year prevalence rate is 2.7%.
  • More common in women, persons with social issues, and those with a family history of anxiety and depression.

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  • Childhood trauma
  • Stressful lifestyle
  • Chronic medical illness
  • Physical disability
  • Other psychiatric disorders (schizophrenia, dementia)
  • Alcohol, nicotine, caffeine use
  • Medications (e.g., sympathomimetics, thyroid hormones, antidepressants, corticosteroids)

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Signs and Symptoms

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  • Psychologic 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
  • Impairment:
    • Social, occupational, or other important functional areas
    • Poor coping skills
  • 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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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 (e.g., 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 psychologic or physiologic symptoms.

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  • Reduce severity, duration, and frequency of symptoms and improve functioning.
  • Minimize symptoms or functional impairment and improve quality of life long term.

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  • Psychotherapy, short-term counseling, stress management, cognitive therapy, meditation, supportive therapy, exercise
  • Cognitive behavioral therapy (CBT) is most effective option, used alone or in combination with antianxiety drugs.
  • Educate patients to avoid caffeine, stimulants, excessive alcohol, and diet pills.

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  • Drug choices (Table 1):
    • First line: Duloxetine, escitalopram, paroxetine, sertraline, venlafaxine XR
    • Second line: Benzodiazepines, buspirone, imipramine
    • Alternatives: Hydroxyzine, pregabalin, quetiapine
  • Benzodiazepines
    • All equally effective; most of improvement occurs in first 2 weeks of therapy. More effective for somatic and autonomic symptoms; antidepressants more effective for psychic symptoms (apprehension, worry).
    • Start with low doses, adjusting weekly.
    • Treat acute anxiety for up to 4 weeks; manage persistent symptoms with antidepressants.
    • May dose long half-life drugs once daily at bedtime ...

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