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A comprehensive search of the medical literature was performed from January 1999 to December 2005. The search, limited to human subjects and English language journals, included MEDLINE®, PubMed, and the Cochrane Database of Systematic Reviews.

Anxiety disorders are vastly prevalent and often coexist with depression. The lifetime prevalence of anxiety disorders is approximately 29%, affecting one in four adults.1 Symptoms of anxiety are more common in patients who are frequent users of healthcare resources. The diagnosis of an anxiety disorder requires significant impairment in daily functioning. Less than a third of patients diagnosed with anxiety disorders in primary care receive adequate counseling or drug therapy.2 Five anxiety disorders commonly encountered in practice will be discussed in this chapter: Generalized anxiety disorder, panic disorder, posttraumatic stress disorder, social anxiety disorder, and obsessive–compulsive disorder (OCD).

Anxiety disorders are diagnosed using specific criteria from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision.3 Medical and pharmacological etiologies for anxiety should be assessed before diagnosing an anxiety disorder. Common medical conditions associated with anxiety include coronary artery disease, angina, stroke, hyperthyroidism, and pheochromocytoma. Drug-induced causes include stimulants, corticosteroids, anticonvulsants, antidepressants, sympathomimetics, thyroid hormones, and alcohol or central nervous system depressant withdrawal. A thorough history, including alcohol and substance use, should be obtained.

Clinical Presentation

Generalized anxiety disorder is a chronic disorder characterized by persistent, uncontrollable worry and anxious feelings that are difficult to control. Life stressors can worsen symptoms, but treatment is necessary for remission to occur. The lifetime risk of generalized anxiety disorder is 5.7%.1

Diagnostic Evaluation

Anxiety symptoms must exist nearly every day for a minimum of 6 months for a diagnosis of generalized anxiety disorder. At least three of the following symptoms must be present: Fatigue, irritability, sleep disturbance, restlessness or feeling on edge, muscle tension, and poor concentration.1,4 Increased heart rate may be evident on physical examination.


The two modes of treatment for generalized anxiety disorder are drug therapy and psychotherapy. Psychotherapy should be considered for all patients with generalized anxiety disorder.4 Antidepressants (i.e., selective serotonin reuptake inhibitors [SSRIs], serotonin norepinephrine reuptake inhibitors [SNRIs], or tricyclic antidepressants [TCAs]) are first-line agents because of the high comorbidity of depression and the chronicity of generalized anxiety disorder.5 The SNRIs, venlafaxine and duloxetine, and the SSRIs, escitalopram and paroxetine, have less adverse effects than TCAs, and are first-line agents indicated for use in generalized anxiety disorder (Table 22-1). The onset of anxiolytic effects of antidepressants is 2 to 4 weeks and optimal response may take 6 to 8 weeks or longer, but both the psychic and somatic symptoms are relieved.4 Benzodiazepines reduce the somatic symptoms and can provide relief in acute situations.4 Long-term use of benzodiazepines is associated ...

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