Anxiety Disorders


All of us worry about things in our day-to-day life but people with generalized anxiety disorder (GAD) are extremely worried about these and many other things, even when there is little or no reason to worry about them. They are very anxious about just getting through the day. They think things will always go badly. At times, worrying keeps people with GAD from doing everyday tasks. Researchers have found that several parts of the brain are involved in fear and anxiety. GAD sometimes runs in families, but no one knows for sure why some people have it while others don’t.

GAD sometimes runs in families, but no one knows for sure why some people have it while others don’t. Scientists believe that biological, psycho-social and environmental factors are involved in development of GAD. Alterations in the gabaergic and seratoninergic systems or anomalies in the limbic system are the most affected biological factors. Stressful situations, family environment, threatening life experiences, and excessive worry about common subjects are among the well known psychological risk factors of GAD. learning more about fear and anxiety in the brain, scientists may be able to create better treatments. Researchers are also looking for ways in which stress and environmental factors may play a role.

Who Is at risk?

  • Generalized anxiety disorders affect about 3.1% American adults age 18 years and older (about 18%) in a given year, causing them to be filled with fearfulness and uncertainty.
  • The average age of onset is 31 years old.
  • GAD affects about 6.8 million American adults, including 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.

Diagnosing anxiety disorders

  • GAD is diagnosed when a person worries excessively about a variety of everyday problems for at least 6 months.
  • People with GAD may visit a doctor many times before they find out they have this disorder. They ask their doctors to help them with headaches or trouble falling asleep, which can be symptoms of GAD but they don’t always get the help they need right away. It may take doctors some time to be sure that a person has GAD instead of something else.
  • First, talk to your doctor about your symptoms. Your doctor should do an exam to make sure that another physical problem isn’t causing the symptoms. The doctor may refer you to a mental health specialist.

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

Symptoms of anxiety disorders

Cognitive symptoms: 

  • Thoughts of imminent danger
  • Concerned over inability to cope

Behavioral symptoms: 

  • Avoidance behavior:
    • Leads to increased anxiety
  • Safety behavior:
    • Tries to eliminate the danger (unlike coping behavior)
    • May maintain or increase anxiety

Physical symptoms:

  • Shortness of breath
  • Rapid heartbeat
  • Dry mouth
  • Sweating
  • Muscle tension and muscle aches,
  • Shakiness
  • Dizziness
  • Nausea
  • Hot flashes or chills
  • Frequent urination
  • Restlessness
  • Difficulty swallowing
  • Difficulty concentrating.
  • Trouble falling asleep or staying asleep.
  • Fatigue
  • Headaches
  • Dry mouth
  • Paresthesia
  • Palpitations
  • Chest pain
  • Dyspnea
  • Diarrhea
  • Constipation
  • Aerophagia
  • Sexual problems


  • Nervousness
  • Panicky
  • On edge

History taking

Client reports anxiety and worry more days than not for the past 6 months. His/her anxiety is related to work, school, performance,…. He/she finds it difficult to control the worry. His/her anxiety and worry are associated with (3 or more of) the restlessness or feeling keyed up or on edge; being easily fatigued; difficulty concentrating or mind going blank; irritability; muscle tension; and sleep disturbance.

Client is/not worried about having panic attacks (Panic Disorders), being embarrassed in public (Social Phobia, being contaminated (OCD), being away from home or close relatives (Separation Anxiety Disorder, gaining weight (Anorexia Nervosa), having multiple physical complaints (Somatization Disorder) or having serious illness (Hypochondriasis).

According to client his/her anxiety and worry or the related physical symptoms cause clinically significant distress or impairment in social, occupational or other important areas of functioning.

At this time, I have no impression that his symptoms are direct effect of substance use or general medical condition (Hyperthyroid.



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

Avoidance behaviors

    1. Avoidance of activities
    2. Poor interpersonal relationships
    3. Non-assertive in new situations

Past Medical History:

  • Depression, anxiety, PTSD, or other psychiatric diagnosis
  • Cardiovascular disorders
  • Endocrine disorders

Social history:

  • Living conditions
  • Relationships
  • Employment
  • Financial status
  • Substance use
  • Hobbies

Physical exam

  1. General appearance
  2. Vital signs
    1. Pulse Rate
    2. Respiratory Rate
    3. Blood Pressure
  3. Mental Status Exam

Laboratory work up

  • CBC
  • Electrolytes
  • TSH
  • Urine Drug Screen

Management of anxiety disorders


  • A type of psychotherapy called cognitive behavior therapy is especially useful for treating GAD. It teaches a person different ways of thinking, behaving, and reacting to situations that help him or her feel less anxious and worried.
  • Avoiding stimulants such as cocaine, crack, crystal meth
  • Avoid drinking alcohol as a self-treatment for anxiety. It might work in low doses in short term but causes serious health problems such as depression, rebound anxiety …
  • Mindfulness:
  • Breathing:
  • Imagery: 
  • Progressive Muscle Relaxation: 
  • Anxiety Ladder:
    • Create a hierarchy of fearful events. Start with the least fearful at the bottom and the most fearful event on the top ladder.
  • Meditation: 
    • Stress management techniques and meditation can help people with anxiety disorders calm themselves and may enhance the effects of therapy.


    • There is preliminary evidence that aerobic exercise may have a calming effect. Since caffeine, certain illicit drugs, and even some over-the-counter cold medications can aggravate the symptoms of anxiety disorders, they should be avoided.
  • CBT: 
    • Changing your thoughts of perception of danger
    • Increasing your confidence



  • The use of anti-depressants is recommended as one of the pharmacological treatments of choice for GAD.
  • When the response to the optimal dosage of one of the SSRIs is inadequate or if they are not well tolerated, the patient should switch to another SSRI. If there is no improvement after 8-12 weeks, consider using another drug with a different mechanism of action (SNSRI, TAD)

Ways to make treatment effective:

  • If you think you have an anxiety disorder, the first person you should see is your family doctor. A physician can determine whether the symptoms that alarm you are due to an anxiety disorder, another medical condition, or both.
  • If an anxiety disorder is diagnosed, the next step is usually seeing a mental health professional. The practitioners who are most helpful with anxiety disorders are those who have training in cognitive-behavioral therapy and/or behavioral therapy, and who are open to using medication if it is needed.
  • You should feel comfortable talking with the mental health professional you choose. If you do not, you should seek help elsewhere. Once you find a mental health professional with whom you are comfortable, the two of you should work as a team and make a plan to treat your anxiety disorder together.
  • Remember that once you start on medication, it is important not to stop taking it abruptly. Certain drugs must be tapered off under the supervision of a doctor or bad reactions can occur. Make sure you talk to the doctor who prescribed your medication before you stop taking it. If you are having trouble with side effects, it’s possible that they can be eliminated by adjusting how much medication you take and when you take it.
  • Most insurance plans, including health maintenance organizations (HMOs), will cover treatment for anxiety disorders. Check with your insurance company and find out. If you don’t have insurance, the Health and Human Services division of your county government may offer mental health care at a public mental health center that charges people according to how much they are able to pay. If you are on public assistance, you may be able to get care through your state Medicaid plan.
  • Many people with anxiety disorders benefit from joining a self-help or support group and sharing their problems and achievements with others.
  • Internet chat rooms can also be useful in this regard, but any advice received over the Internet should be used with caution, as Internet acquaintances have usually never seen each other and false identities are common.
  • Talking with a trusted friend or member of the clergy can also provide support, but it is not a substitute for care from a mental health professional.
  • The family is very important in the recovery of a person with an anxiety disorder. Ideally, the family should be supportive but not help perpetuate their loved one’s symptoms. Family members should not trivialize the disorder or demand improvement without treatment.


Treatment of GAD

Cognitive Therapy

  • Self-instruction
    • detect negative self-verbalization (“I won’t be able to…”) and replace them with positive self-instruction
  • Training in handling anxiety symptoms:
    • Relaxation
    • Recognize, Reexamine and Replace anxious thoughts
  • Cognitive distraction and thought stopping
    • focus attention on non-threatening stimuli such as counting trees… etc.
  • Problem resolution techniques:
    • Reduces the intensity of the apprehension and increases the feeling of control
  • Cognitive Restructuring:
    • replaces irrational or distorted thoughts with other more rational ones
    • The work is structured around a skill-training model


Behavioral Techniques:

  • Relaxation techniques:
    • Progressive relaxation
    • Breathing control
  • Exposure techniques:
    • Systematic desensitization
    • Gradual exposure
  • Self-control techniques:
    • Self-observation
    • Self-reinforcement/self-punishment
    • Control of stimuli
  • Training in social skills:
    • after analyzing the problem behavior and retraining it



  • Antidepressants
    • Paroxtetine
    • Velnlafaxine
    • Imipramine
    • Sertraline
    • Escitalopram
    • Duloxetine
  • 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
    • 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®)
    • Benzodiazepines (Long Acting) only for acute phase and for short term:
      • BDZs are not recommended currently because of risk of physical dependence, tolerance, memory problem, and withdrawal
      • Preferred only in Generalized Anxiety Disorder and for short period of time
      • Clonazepam (Klonopin®)
    • Benzodiazepines (Short-acting) only for acute phase and for short term:
      • Indicated in the elderly or with decreased clearance
      • Alprazolam (Xanax®)
      • Lorazepam (Ativan®)
      • Oxazepam (Serax®)

Adverse effects of medications

  • The adverse effects of anti-depressants described include sedation, dizziness, nausea, dry mouth, constipation, falls, and sexual dysfunction (with the exception of dizziness and sexual dysfunction) decrease after 6 months in patients who continue with the medication.
  • The prescription of venlafaxine is not recommended to patients at high risk of cardiac arrhythmia or recent myocardial infarct, and will only be used in patients with hypertension when the hypertension is controlled.
  • When the response to the optimal dosage of one of the SSRIs is inadequate or if they are not well tolerated, the patient should switch to another SSRI. If there is no improvement after 8-12 weeks, consider using another drug with a different mechanism of action (SNSRI, TAD).
  • During pregnancy, the choice of the treatment must consider whether the potential advantages for the mother of the prescribed SSRIs outweigh the possible risks to the embryo.
  • BDZs provide fast initial relief of anxiety symptoms, but the evidence suggests that their effects do not differ significantly from those obtained with a placebo after 4 to 6 weeks of treatment.
  • The use of BDZs is associated with higher risk of dependence, tolerance, sedation, traffic accidents, and withdrawal effects (rebound anxiety).


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