Definition
- Excessive anxiety and worry that is difficult to control and at least three of the following symptoms for at least 6 months:
- Restlessness
- Fatigue
- Decreased concentration
- Irritability
- Muscle tension
- Sleep distribution
- Symptoms must cause impairment
- The disturbance is not due to direct physiological effects of a condition
Epidemiology
- Generalized anxiety disorders affect about 3.1% American adults age 18 years and older (about 18%) in a given year
- The average age of onset is 31 years old
- GAD affects twice as many women as men
- The disorder develops gradually and can begin at any point in the life cycle, although the years of highest risk are between childhood and middle age.
Symptoms
- Restless
- Irritable
- Easily distorted
- Muscle tension
- Fatigue
- Palpitations
- Shortness of breath
- Chest tightness
- Nausea
- Numbness
Differential Diagnosis
- Major Depression
- Anxiety Adjustment Disorder
- Personality Disorder
- Panic disorders
- Social phobia
- OCD
- Anorexia nervosa
- Separation anxiety disorders
- PTSD
- Adjustment disorder
- Mood Disorder
- Psychotic disorder
- Substance use disorders
- Stimulant use
- Secondary to Medications or Drug use
- Cocaine Abuse
- Amphetamine
- Marijuana
- Lysergic Acid (LSD)
- Ephedrine and other Decongestants
- Digoxin Toxicity
- Theophylline toxicity
- Methylphenidate
- Anticholinergics
- Caffeine
- Secondary to withdrawal of:
- Smoking cessation
- Benzodiazepines
- Beta-Blocker
- Alcohol
- Narcotic
- Anticholinergic
- Caffeine
- Cardiopulmonary disease
- Atrial flutter
- Paroxysmal Supraventricular Tachycardia
- Hypertension
- Asthma
- Pulmonary Embolus
- Endocrine disease
- Hyperthyroidism
- Hypoparathyroidism
- Cushing’s Disease
- Carcinoid Syndrome
- Pheochromocytoma
- Hypoglycemia
- Menopause
Co-morbid medical conditions
- Major Depression
- Agoraphobia
- Simple phobia
- Social anxiety disorder
- Panic disorder
- Mania
- Dysthymia
- IBS
- Migraine
- musculoskeletal pains
History taking
- History of excessive worry about
- Academic performance
- Relationships
- Illness or injury
- Family safety
- Jobs security
- Financial status
- Health
- Accidents
- Avoidance behaviors
- Avoidance of activities
- Poor interpersonal relationships
- Non-assertive in new situations
- Substance use
- Alcohol
- Tobacco
- Illicit drugs
- Steroids
Physical examination
- General appearance
- Irritable, Calm, …
- Vital signs
- PR
- RR
- BP
- Skin scars (self mutilation…), sweaty,…
- Pupils size (for drugs…)
- MSE
Laboratory work ups
- TSH, T4
- CBC: to rule out anemia
- Urine drug screen
- Electrolytes
- Other tests as indicated
Treatment
- Behavioral Therapy
- Progressive muscle relaxation
- Relaxation training
- Biofeedback
- Breathing retraining (arousal reduction)
- Cognitive Therapy
- Systematic desensitization
- Recognize, Reexamine and replace anxious thoughts
- Antidepressants
- Paroxtetine (first line FDA approved option)
- Velnlafaxine XR (first line FDA approved option)
- Imipramine
- BDZs are not recommended currently because of risk of physical dependence, tolerance, memory problem, and withdrawal
- Encourage healthy lifestyle as an adjunct to treatment
- Physical activity
- Avoid drugs and alcohol
- Medications:
- Buspirone (Buspar)
- Non-addictive anxiolytics
- Less adverse effects compared with Benzodiazepines
- Benzodiazepines (Long Acting)
- Preferred in Generalized Anxiety Disorder
- Clonazepam (Klonopin)
- Benzodiazepines (Short-acting)
- Indicated in the elderly or with decreased clearance
- Alprazolam (Xanax)
- Lorazepam (Ativan)
- Oxazepam (Serax)
- SSRI:
- Indicated for concurrent depression
- Paroxetine (Paxil)
- Venlafaxine (Effexor)
- Nefazodone (Serzone)
- TCAs:
- Imipramine (Tofranil)
- Desipramine (Norpramin)
- MAOi:
- Indicated for concurrent phobia
- Phenelzine (Nardil)
- Tranylcypromine (Parnate)
- Beta Blockers
- Indicated for excessive autonomic symptoms
- Propranolol (Inderal)
- Atenolol (Tenormin)
- Buspirone (Buspar)