Generalized Anxiety Disorder

Snapshot

• A 24-year-old medical student presents to her primary care physician for an annual routine visit. She reports that over the past year, she has had difficulty sleeping, increasing fatigability, and difficulty concentrating. Combined with the increasing responsibilities as a medical student, she reports feeling anxious. She denies any specific triggers or situations that causes these symptoms. Her physician suggests referral to psychiatry for likely combination of cognitive behavioral therapy and pharmacotherapy.

Introduction

• Overview 
  • generalized anxiety disorder (GAD) is a type of anxiety disorder, which also includes panic disorder, phobia disorders, and obsessive-compulsive disorder
    • GAD is characterized by anxiety lasting > 6 months unrelated to any specific triggers or if identifiable stressor has ended
• Epidemiology
  • incidence
    • very common
  • risk factors
    • genetic susceptibility
    • environmental instability
• Pathogenesis
  • mechanism
    • unclear but mediators of anxiety in the brain appear to be norepinephrine, serotonin, dopamine, and GABA
    • some patients may also have genetic predisposition to anxiety
• Associated conditions
  • other mood disorders
    • major depressive disorder
• substance abuse disorders

Presentation

• Symptoms
  • excessive anxiety and persistent worrying
  • at least 3 of the following
    • restlessness
    • fatigue
    • difficulty concentrating
    • irritability
    • muscle tension
    • sleep disturbance
• Physical exam
  • excitation/hyperactivity
    • tremors
    • rapid heartbeat
    • sweating
    • restlessness
    • dry mouth
    • cold and clammy hands
• shaking

Differential

• Adjustment disorder 
  • key distinguishing factors
    • anxiety or other mood changes with onset within 3 months of an identifiable stressor or trigger, lasting < 6 months once that stressor has ended 
• treatment also consists of cognitive behavioral therapy and selective serotonin reuptake inhibitors

Treatment

• Lifestyle
  • cognitive behavioral therapy
    • indications
      • all patients
      • may often need pharmacotherapy as well
• Medical  
  • selective serotonin reuptake inhibitors (SSRIs)
    • indications
      • first-line
    • drugs
      • fluoxetine
      • paroxetine
      • sertraline
      • escitalopram
  • serotonin-norepinephrine reuptake inhibitors (SNRIs)
    • indication
      • first-line
    • drugs
      • venlafaxine
      • duloxetine
  • tricyclic antidepressants (TCA)
    • indication
      • second-line due to worse adverse effect profile
  • benzodiazepines
    • indication
• second-line due to potential for addiction and short-lived effects

Complications

• Complications
  • decreased quality of life
  • substance abuse