Anxiety Disorder, Generalized

SOURCE

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.

DEFINITION

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

ETIOLOGY

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

PATHOPHYSIOLOGY

• 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.

EPIDEMIOLOGY

• 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.

RISK FACTORS

• 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)

CLINICAL PRESENTATION

SIGNS AND SYMPTOMS

• 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.

DIAGNOSIS

MEANS OF CONFIRMATION AND DIAGNOSIS

• 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.

DESIRED OUTCOMES

• 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.

TREATMENT: NONPHARMACOLOGIC THERAPY

• 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.

TREATMENT: PHARMACOLOGIC THERAPY

• Drug choices (Table 1):

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