LecturePatient will present as → a 21-year-old female complaining of poor school performance. She is concerned about her performance despite reassurance from her professors. She tells you that her symptoms occur daily consisting of sleep disturbances, difficulty concentrating, and irritability. She reports her symptoms started around age 16 but have worsened.
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Key Points:
- Generalized anxiety disorder (GAD) involves persistent and excessive worry pertaining to multiple events or domains that continues for > 6 months
- Anxiety is not related to a specific focus, but rather is generalized to most issues
- GAD is the most common psychiatric illness seen by primary care providers.
DSM-5 Diagnostic Criteria
- Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance).
- The individual finds it difficult to control the worry.
- The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms having been present for more days than not for the past 6 months): Note: Only one item is required in children.
- Restlessness or feeling keyed up or on edge.
- Being easily fatigued.
- Difficulty concentrating or mind going blank.
- Irritability.
- Muscle tension
- Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep).
- The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of
- The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism).
- The disturbance is not better explained by another mental disorder (e.g., anxiety or worry about having panic attacks in panic disorder, negative evaluation in social anxiety disorder [social phobia], contamination or other obsessions in obsessive-compulsive disorder, separation from attachment figures in separation anxiety disorder, reminders of traumatic events in posttraumatic stress disorder, gaining weight in anorexia nervosa, physical complaints in somatic symptom disorder, perceived appearance flaws in body dysmorphic disorder, having a serious illness in illness anxiety disorder, or the content of delusional beliefs in schizophrenia or delusional disorder).
To be considered generalized anxiety disorder symptoms must occur greater than 6 months
- Patients with GAD might show psychological signs, physical signs or somatic signs. At times, they might show similar symptoms of a myocardial infarction. A quick ECG along with Troponin levels and CKMB should rule out an MI.
- Rule out medical disorders such as substance abuse, thyroid dysfunction or ETOH withdrawal
Psychotherapy, usually cognitive-behavioral therapy, can be both supportive and problem-focused. Relaxation and biofeedback may be of some help, although few studies have documented their efficacy.
Pharmacologic
- SSRIs: Paroxetine and escitalopram
- Take several weeks to work
- Buspirone is also effective; the starting dose is 5 mg PO bid or tid. However, buspirone can take at least 2 wk before it begins to help.
- Can be used as an adjunct to SSRIs
- SNRIs: Venlafaxine extended-release, starting dose 37.5 mg po once/day
- Benzodiazepines
- Used in the interim until SSRI response is seen
- Not used for long-term management as a result of abuse potential
- Herbal
- Kava plant has been shown in verified studies to have mild beneficial effect for patients with generalized anxiety disorder
- Kava toxicity manifests as liver failure, hepatitis, or cirrhosis
- Kava plant has been shown in verified studies to have mild beneficial effect for patients with generalized anxiety disorder
Question 1 |
Of patients with generalized anxiety disorder, what percentage have at least one other similar psychiatric disorder at some time in their life?
10% | |
30% | |
50% | |
80% |
Question 1 Explanation:
At least 80% of patients with GAD have had at least one other anxiety disorder in their lifetime.
Question 2 |
Which of the following symptoms is generally not characteristic of GAD?
awakening with apprehension and unrealistic concern about future misfortune | |
worry out of proportion to the likelihood or impact of feared events | |
a 6-month or longer course of anxiety and associated symptoms | |
association of the anxiety with depression | |
anxiety exclusively focused on health concerns |
Question 2 Explanation:
GAD is characterized by awakening with apprehension and concern about future misfortune, worry out of proportion to the likelihood or impact of feared events, a duration of 6 months or more of anxiety or associated symptoms, and an association with depressed moods. GAD is usually not associated exclusively with health concerns. When health concerns become the focus of worry, a diagnosis of hypochondriasis or another somatoform disorder becomes more likely.
Question 3 |
What is the psychotherapy of choice for this GAD?
cognitive-behavioral therapy (CBT) | |
hypnosis | |
supportive psychotherapy | |
psychoanalytic psychotherapy | |
none of the above |
Question 3 Explanation:
CBT is often effective in the treatment of GAD. Cognitive therapy challenges the distortions in patients’ thinking that trigger and heighten their anxiety. This technique can be combined with relaxation training, including deep breathing and progressive muscle relaxation. Biofeedback and imagery are also useful to achieve systematic desensitization. Because relaxation and anxiety are mutually exclusive, these techniques help patients achieve relief from their symptoms. Although cognitive therapy alone may alleviate GAD symptoms, the combination of cognitive and other behavioral techniques is more effective than cognitive therapy alone.
Question 4 |
Which of the following pharmacologic agents is not recommended in the treatment of GAD?
venlafaxine Hint: Venlafaxine and duloxetine, mixed serotonin-norepinephrine reuptake inhibitors, can be used for short- and long-term treatment | |
buspirone Hint: Buspirone, a nonbenzodiazepine anxiolytic, and other agents such as tricyclic antidepressants are used as well | |
benzodiazepines Hint: Although benzodiazepines are commonly used, they have mostly short-term benefits. Longer acting agents are preferred to short-acting benzodiazepines, but their use should be limited, if possible, because of withdrawal symptoms, habituation, and impaired mental and physical performance | |
selective serotonin reuptake inhibitors (SSRIs) Hint: SSRIs are often used in the pharmacologic treatment of GAD | |
clozapine |
Question 4 Explanation:
SSRIs are often used in the pharmacologic treatment of GAD. Venlafaxine and duloxetine, mixed serotonin-norepinephrine reuptake inhibitors, can be used for short- and long-term treatment. Although benzodiazepines are commonly used, they have mostly short-term benefits. Longer acting agents are preferred to short-acting benzodiazepines, but their use should be limited, if possible, because of withdrawal symptoms, habituation, and impaired mental and physical performance. Buspirone, a nonbenzodiazepine anxiolytic, and other agents such as tricyclic antidepressants are used as well. Clozapine is an antipsychotic agent used in the treatment of patients with schizophrenia. It has no role in the treatment of GAD, and its use in the United States is restricted.
Question 5 |
GAD is more common in which of the following?
elderly white men | |
school-age children | |
married people | |
those of higher socioeconomic status | |
young to middle-aged women |
Question 5 Explanation:
GAD is slightly more common in young and middle-aged women, ethnic minorities, those not currently married, and those of lower socioeconomic status.
There are 5 questions to complete.
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