82

Generalized Anxiety Disorder

treatments. The use of these antidepressants also has the benefit of treating comorbid depression when it occurs. Other medications that are showing some promise in treating social phobia include venlafaxine (which inhibits the reuptake of both serotonin and norepinephrine) and gabapentin (which works at the GABA receptor complex). Tricyclic antidepressants, however, have not been shown to be efficacious.

9. Are there other types of treatment for social phobia? An important form of treatment for social phobia is cognitive behavioral therapy (CBT). This type of therapy involves cognitive restructuring by helping the individual with social phobia identify his or her cognitive distortions and challenge the accuracy of their perceptions. They also learn how to decrease their physiologic response of anxiety with various techniques including deep-breathing and progressive muscle relaxation. Graded exposure to the feared situation also is employed as they learn to tolerate increasingly greater exposure to the feared situation. Eventually, the anxious response is extinguished. Group CBT also is helpful in the treatment of social phobia. This form of treatment includes social skills training and role-playing, and allows individuals to get direct, immediate feedback on their perceptions of how others view them.
BIBLIOGRAPHY
1. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC, American Psychiatric Association, 1994. 2. Goisman RM, Allsworth J, Rogers MP, et al: Simple phobia as a comorbid anxiety disorder. Depress Anxiety 7(3):105-112, 1998. 3. Heimberg RG, Juster HR: Treatment of social phobia in cognitive-behavioral groups. J Clin Psychiatry S5(Suppl):3846, 1994. 4 . Jefferson JW: Social phobia: A pharmacologic treatment overview. J Clin Psychiatry 56(Suppl 5): 18-24, 199s. 5. Keck PE, McElroy SL: New uses for antidepressants: Social phobia. J Clin Psychiatry 58(Suppl 14):32-38, 1997. 6. Kessler RC, McGonagle KA, Zhoa S, et al: Lifetime and 12-month prevalence of DSM-111-R psychiatric disorders in the United States: Results from the National Comorbidity Survey.Arch Gen Psychiatry 51 :8-19, 1994. 7. Schneier FR, Johnson J, Hornig CD, et al: Social phobia: Comorbidity and morbidity in an epidemiologic sample. Arch Gen Psychiatry 49:282-288, 1992.

16. GENERALIZED ANXIETY DISORDER

Robert D.Davies, M.D., and Leslie Winter, M.D
1. What is generalized anxiety disorder? Anxiety and worry are commonly experienced responses to the stress of day-to-day life. We all worry at times about various aspects of our lives-particularly the unknown or novel. This is absolutely normal. However, when worry and anxiety are the predominate approach to life, it is not normal. People with generalized anxiety disorder (GAD) experience excessive levels of anxiety and worry most of the time and have great difficulty controlling their worry. The excessive level of anxiety they experience causes significant distress and often impairs their ability to function in various areas of their life (such as socially or occupationally). Many people with GAD become preoccupied with the physical symptoms associated with anxiety (such as gastrointestinal distress and fatigue) and worry about their health. This worry may lead them to repeatedly seek out medical evaluations and reassurance. Thus, GAD typically is seen in primary care settings rather than i n mental health settings.

Generalized Anxiety Disorder

83

2. List the physical symptoms of generalized anxiety disorder.

Physical restlessness (feeling on edge) Irritability Fatigue Muscle tension Difficulty concentrating or mind going blank Sleep disruption The diagnosis of GAD is made only when at least three of these symptoms are present.
9

3. What is the prevalence of GAD?

Estimates from epidemiologic surveys estimate that the lifetime prevalence of GAD in the general population is 5.1%, with a higher prevalence in women (6.6%, versus 3.6% in men). It is a chronic condition that may demonstrate periodic episodes of acute worsening throughout its course. GAD often begins in childhood and persists throughout life. For some individuals it may consist of chronic, yet mild symptoms; for others it may cause significant levels of impairment in social settings, interpersonal relationships, and occupational functioning. GAD is seen most often in primary care rather than in psychiatric settings. This may be related, in part, to the myriad physical symptoms that are typically present in people with GAD. Chronic medical conditions such as irritable bowel syndrome and headaches often occur along with GAD.

4. What other psychiatric illnesses are likely to occur with GAD? It has been estimated that 50-90% of people with GAD also have at least one other psychiatric condition. This high degree of comorbidity has caused some researchers to call into question the validity of the diagnosis of GAD as a distinct clinical entity. It is possible that what we call GAD may be a predisposing condition that leads to other anxiety and mood disorders. Major depression and dysthymia frequently are seen in individuals with GAD. Some believe that this cluster of symptoms reflects a mixed anxiety-depressive state. Other anxiety disorders such as panic disorder, simple phobias, social phobia, and obsessive-compulsive disorder also can occur in an individual with GAD. Substance abuse is likely-just as it is with all other anxiety disorders. Personality disorders also may be seen in these individuals, and it can be difficult to sort out the effects of chronic anxiety from those of maladaptive personality traits. 5. Which psychiatric conditions might be confused with GAD? The differential diagnosis of GAD is extensive because worry and anxiety are seen in so many conditions. Depression, particularly when there is a prominent degree of guilty rumination, may look like GAD. Conditions involving anxiety triggered by specific situations (such as specific phobias, social situations in social phobia, or exposure to trauma-related situations in post-traumatic stress disorder) may be confused with GAD. Panic disorder, particularly when there is a great deal of anticipatory anxiety, may be confused with GAD-as can the excessive worry about weight or body image seen in anorexia nervosa and bulimia. People with GAD may be mistakenly diagnosed as having somatization disorder due to their tendency to become focused on physical symptoms and preoccupied with their health. Personality disorders (particularly avoidant personality disorder) may look like GAD. Finally, substance use disorders (including nicotine and caffeine) and substance withdrawal also can elicit symptoms of excessive anxiety.
6. List the medical conditions that can cause anxiety. Hyperthyroidism or hypothyroidism Seizure disorders Hypoglycemia CNS tumors Diabetes mellitus Strokes Traumatic brain injuries Pheochromocytoma Chronic obstructive pulmonary disease Cardiac arrhythmias Mitral valve prolapse Asthma Substance intoxication andor withdrawal Pulmonary emboli
7. Can certain types of medicationscause anxiety symptoms? Yes. Many classes of drugs used for medical as well as psychiatric conditionscan cause symptoms of anxiety. Anxiety is a common side effect of some drugs (such as bronchodilators, psychostimulants,

84

Generalized Anxiety Disorder

and corticosteroids); with other drugs (e.g., meperidine, antihistamines, and benzodiazepines), anxiety may represent an idiosyncratic response to the medication. Rapid discontinuation may precipitate anxiety in a patient as well (reported with corticosteroids, benzodiazepines, some SSRIs, and venlafaxine). Toxicity may result in symptoms of anxiety (seen with theophylline). Almost all classes of antidepressants cause anxiety in some patients, particularly during the initiation of treatment. Antipsychotics commonly cause akathisia-a markedly distressing level of internal agitation. When evaluating a patient with anxiety, care must be taken to review the types and dosages of all current or recently discontinued medications.

8. What are the pharmacologic treatments used in GAD? Benzodiazepines, which decrease the severity of anxiety symptoms, have long been the mainstay of treatment for GAD. However, when a chronic condition is treated with a medication that only suppresses symptoms, the medication itself becomes chronic. Although benzodiazepines offer the benefit of rapid symptom relief, their chronic use can lead to tolerance (the need for escalating dosages to maintain efficacy) and dependence. Buspirone, the 5HT,, agonist, is effective in treating GAD. Its biggest benefit over benzodiazepines is that no dependence develops with chronic administration. Likewise there is no risk of abuse, which makes it a good consideration for individuals with comorbid GAD and substance use disorders. A major drawback, however, is that the onset of symptom relief may be delayed for several weeks after initiating treatment. This delay can have an adverse effect on medication compliance in the anxious patient, who may quickly decide that the medication is not working. Tricyclic antidepressants (TCAs) are beneficial in some cases of GAD. Their side-effect profile and lethality in overdose, however, tend to limit their use. The use of selective serotonin reuptake inhibitors (SSRIs) in treating GAD is increasingly widespread. SSRIs offer a more agreeable sideeffect profile for most patients. Both SSRIs and TCAs have the added benefit of treating comorbid depression when it occurs. 9. What other treatments are used to treat GAD? Management of anxiety symptoms through relaxation training, exercise programs, and stress reduction are all important aspects of treatment. These interventions help people to feel more in control of the degree of their anxiety and worry. Cognitive behavioral therapy has been shown to decrease the physiologic aspects of GAD and alter the cognitive distortions that fuel the anxiety. As GAD tends to be a chronic condition, therapies that aid the patient in understanding the precipitants to their anxiety, the connection between physical symptoms and psychological worry, and the cognitive processes that keep them focused on worrying, as well as help affect lifestyle changes tend to have the most long-lasting benefit.
BIBLIOGRAPHY
1. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorder, 4th ed. Washington, DC, American Psychiatric Association, 1994. 2. Beck AT, Emery G, Greenberg RL: Anxiety Disorders and Phobias: A Cognitive Perspective. New York, Basic Books, Inc., 1985. 3. Brauman-Mintzer 0, et al: Psychiatric comorbidity in patients with generalized anxiety disorder. Am J Psychiatry 1SO: 12 1 6 - 1218, 1993. 4. Elliston JM: IntegrativeTreatment of Anxiety Disorders. Washington, DC, American Psychiatric Press, Inc., 1996. 5. Lader MH: The nature and duration of treatment for GAD. Acta Psychiatr &and 98(Suppl 393): 109-1 17, 1998. 6 . Harvey AG, Rapee RM: Cognitive-behavior therapy for generalized anxiety disorder. Psychiatr Clin North Am 18(4):859-870, 1995. 7. Kendler KS: Major depression and generalised anxiety disorder: Same genes, (partly) different environments-revisited. Brit J Psychiatry 168(Suppl 30):68-75, 1996. 8. Kessler RC, McGonagle KA, Zhao S, et al: Lifetime and 12-month prevalence of DSM-111-R psychiatric disorders in the United States: Results from the national comorbidity study. Arch Gen Psychiatry 58:8-19, 1994. 9. Maser JD: Generalized anxiety disorder and its comorbidities: Disputes at the boundaries. Acta Psychiatr Scand 98(Suppl393): 12-22, 1998. 10. Rickels K, Schweizer E: The treatment of generalized anxiety disorder in patients with depressive symptomatology. J Clin Psychiatry 54(Suppl):20-23, 1993.