Anxiety, Generalized Anxiety Disorder (GAD)

Sadaf Munir; Veronica Takov.

Last Update: February 4, 2019.

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Introduction
Generalized anxiety disorder is one of the most common mental disorders. Up to 20% of adults
are affected by anxiety disorders each year. Generalized anxiety disorder produces fear, worry,
and a constant feeling of being overwhelmed. Generalized anxiety disorder is characterized by
persistent, excessive, and unrealistic worry about everyday things. This worry could be
multifocal such as finance, family, health, and the future. It is excessive, difficult to control, and
is often accompanied by many non-specific psychological and physical symptoms. The excessive
worry is the central feature of generalized anxiety disorder.[1][2][3]
Diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition
(DSM-IV) include the following:
 Excessive anxiety and worry for at least six months
 Difficulty controlling the worrying.
Anxiety and worry associated with at least three of the following:
 Restlessness, feeling keyed up or on edge
 Being easily fatigued, difficulty in concentrating or mind going blank, irritability
 Muscle tension
 Sleep disturbance.
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Etiology
The etiology may include:
 Stress
 Physical condition such as diabetes or other comorbidities such as depression
 Genetic, first-degree relatives with generalized anxiety disorder (25%)
 Environmental factors, such as child abuse
 Substance abuse.
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Epidemiology
Childhood anxiety occurs in about 1 in 4 children at some time between the ages of 13 and 18
years. The median age at onset is 11 years. However, the lifetime prevalence of a severe anxiety
disorder in children ages 13 to 18 is approximately 6%. General prevalence in children younger
than 18 years is between 5.7% and 12.8%. The prevalence is approximately twice as high among
women as among men.[4][5][6]
The American Psychiatric Association first introduced the diagnosis of generalized anxiety
disorder two decades ago in the DSM-III. Before that time, generalized anxiety disorder was
conceptualized as one of the two core components of anxiety neurosis, the other being panic. A
recognition that generalized anxiety disorder and panic, although often occurring together, are
sufficiently distinct to be considered independent disorders led to their separation in the DSM-
III.
The DSM-III definition of generalized anxiety disorder required uncontrollable and diffuse (i.e.,
not focused on a single major life problem) anxiety or worry that is excessive or unrealistic in
relation to objective life circumstances, and that persists for one month or longer. Several related
psychophysiological symptoms were also required for a diagnosis of generalized anxiety
disorder. Early clinical studies evaluating DSM-III according to this definition found that the
disorder seldom occurred in the absence of another comorbid anxiety or mood disorder.
Comorbidity of generalized anxiety disorder and major depression was especially strong and led
some commentators to suggest that generalized anxiety disorder might better be conceptualized
as a prodrome, residual, or severity marker than as an independent disorder. The rate of
comorbidity of generalized anxiety disorder with other disorders decreases as the duration
of generalized anxiety disorder increases. Based on this finding, the DSM-III-R committee
on generalized anxiety disorder recommended that the duration requirement for the disorder be
increased to six months. This change was implemented in the final version of the DSM-III-R.
Additional changes in the definition of excessive worry and the required number of associated
psychophysiological symptoms were made in the DSM-IV.
These changes in diagnostic criteria led to delays in cumulating data on the epidemiology
of generalized anxiety disorder. Nonetheless, such data became available over the past decade.
As described in more detail later, this new data challenged the view that generalized anxiety
disorder should be conceptualized as a prodrome, residual, or severity marker of other disorders.
Instead, it suggest that generalized anxiety disorder is a common disorder that, although often
comorbid with other mental disorders, does not have a rate of comorbidity that is higher than
those found in most other anxiety or mood disorders. The new data also challenged the validity
of the threshold decisions embodied in the DSM-IV.
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Pathophysiology
The exact mechanism is not entirely known. Anxiety can be a normal phenomenon in children.
Stranger anxiety begins at seven to nine months of life. Noradrenergic, serotonergic, and other
neurotransmitter systems are believed to play a role in the body's response to stress. The
serotonin system and the noradrenergic systems are common pathways involved in anxiety.
Many believe that low serotonin system activity and elevated noradrenergic system activity are
responsible for its development. It is, therefore, selective serotonin reuptake inhibitors (SSRI)
and serotonin-norepinephrine reuptake inhibitors (SNRI) that are the first-line agent for its
treatment.
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History and Physical

Patients with anxiety can pose a diagnostic challenge, as somatic symptoms are more common
than psychologic symptoms. Most patients present with vague or nonspecific somatic
complaints, including, but not limited to, shortness of breath, palpitations, fatigability, headache,
dizziness, and restlessness. Patients may also describe psychologic symptoms such as excessive,
nonspecific anxiety and worry, emotional lability, difficulty concentrating, and insomnia.
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Evaluation
Initial assessment begins by addressing behavior or somatic symptoms. Evaluate for
psychosocial stress, psychosocial difficulties, and developmental issues. Review past medical
history, including trauma, psychiatric conditions, and substance abuse.[7]
The following evaluation may be obtained to exclude organic causes:
 Thyroid function tests
 Blood glucose level
 Echocardiography
 Toxicology screen
The Generalized Anxiety Disorder 7-Item (GAD-7) Questionnaire is a screening tool that can
also be used to monitor patients with generalized anxiety disorder.
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Treatment / Management
The two main treatments for generalized anxiety disorder are cognitive behavior therapy and
medications. Patients may benefit most from a combination of the two. It may take some trial
and error to discover which treatments work best.[8][9][10]
Cognitive Behavioral Therapy
This includes psychoeducation, changing maladaptive thoughts patterns, and gradual exposure to
anxiety-provoking situations.
Pharmacotherapy
Several types of medications are used to treat generalized anxiety disorder.
Antidepressants
Selective serotonin reuptake inhibitor (SSRI) and serotonin-norepinephrine reuptake inhibitor
(SNRI) classes are the first-line agents with a response rate of 30% to 50%. This class of drugs
includes escitalopram (Lexapro), duloxetine (Cymbalta), venlafaxine (Effexor XR) and
paroxetine (Paxil, Pexeva). In a study, 81% of children with anxiety disorders who received a
combined sertraline hydrochloride and CBT were responded to the treatment.
Benzodiazepines
Examples diazepam and clonazepam are long-acting agents. These agents are used when an
immediate reduction of symptoms is desired, or a short-term treatment is needed. Generally,
cooperative and compliant patients who are aware that their symptoms have a psychological
basis are more likely to respond to benzodiazepines. Since there is a concern for misuse and
dependence, patients with a history of alcoholism or drug abuse are not appropriate candidates
for this treatment.
Buspirone (BuSpar)
Buspirone is a non-benzodiazepine which does not cause dependency. It is also less sedating
than benzodiazepines, and tolerance does not occur at therapeutic doses. This agent has a
therapeutic lag in the efficacy of two to three weeks which limits its use.
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Pearls and Other Issues

Consider further evaluation for anxiety disorder if an adult is excessively anxious or an infant or
child is excessively clingy and difficult to console during the pediatric visit. Many medical
conditions may mimic anxiety disorders. One should distinguish between the anxiety and the
illness and should evaluate for organic diseases before making this diagnosis.
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Enhancing Healthcare Team Outcomes

Anxiety disorders are very common and can have diverse presentation of signs and symptoms.
The condition has a very high morbidity and mortality and thus is best managed by a
multidisciplinary team that includes a mental health nurse, pharmacist, psychologist, a
psychiatrist and the primary care provider. Overall, anxiety disorders are underdiagnosed and
undertreated. When left untreated, anxiety disorders often lead to severe depression and abuse of
drugs and alcohol. In addition, there is a high rate of suicide among these patients. Many patients
with chronic anxiety have a poor quality of life. The education of both the patient and family is
important to reduce the high morbidity. Family members should help ensure medication
compliance and provide a supportive environment. Unfortunately, despite optimal treatment,
relapse rates are high. [11][12][13](Level V)
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Questions
To access free multiple choice questions on this topic, click here.
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References
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Sumber : https://www.ncbi.nlm.nih.gov/books/NBK441870/