Generalized Anxiety Disorders (GAD)

Definition

  1. Excessive anxiety and worry that is difficult to control and at least three of the following symptoms for at least 6 months:
    1. Restlessness
    2. Fatigue
    3. Decreased concentration
    4. Irritability
    5. Muscle tension
    6. Sleep distribution
  2. Symptoms must cause impairment
  3. 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

  1. History of excessive worry about
    1. Academic performance
    2. Relationships
    3. Illness or injury
    4. Family safety
    5. Jobs security
    6. Financial status
    7. Health
    8. Accidents
    9. Avoidance behaviors
  2. Avoidance of activities
    1. Poor interpersonal relationships
    2. Non-assertive in new situations
  3. Substance use
    1. Alcohol
    2. Tobacco
    3. Illicit drugs
    4. Steroids

 

Physical examination

  1. General appearance
    1. Irritable, Calm, …
  2. Vital signs
    1. PR
    2. RR
    3. BP
  3. Skin scars (self mutilation…), sweaty,…
  4. Pupils size (for drugs…)
  5. 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)

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