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.
- Anxiety, apprehension, or worry not linked to a specific
cause or situation. Symptoms severe enough to impair functioning.
- Combination of vulnerability (e.g., genetic predisposition,
childhood adversity) and stress (e.g., occupational, traumatic experience).
- Noradrenergic model: Autonomic nervous system hypersensitive
and overreacts to various stimuli. Chronic noradrenergic overactivity
- 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.
- 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.
- Childhood trauma
- Stressful lifestyle
- Chronic medical illness
- Physical disability
- Other psychiatric disorders (schizophrenia, dementia)
- Alcohol, nicotine, caffeine use
- Medications (e.g., sympathomimetics, thyroid hormones,
- Psychologic and cognitive symptoms:
- Worries difficult to control
- Feeling keyed up or on edge
- Poor concentration or mind going blank
- Physical symptoms:
- Muscle tension
- Sleep disturbance
- 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.
Means of Confirmation
- Perform complete physical and mental status examination;
appropriate laboratory tests; and medical, psychiatric, and drug
- Symptoms may be associated with medical illnesses or drug
- 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.
- Reduce severity, duration, and frequency of symptoms and
- Minimize symptoms or functional impairment and improve quality
of life long term.
- 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.
- Drug choices (Table 1):
- First line: Duloxetine,
escitalopram, paroxetine, sertraline, venlafaxine XR
- Second line: Benzodiazepines, buspirone, imipramine
- Alternatives: Hydroxyzine, pregabalin, quetiapine
- 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
- May dose long half-life drugs once daily ...