GENERALIZED ANXIETY DISORDER

Excessive anxiety 6 month period Worry is difficult to control somatic symptoms, such as muscle tension, irritability, difficulty sleeping, and restlessness subjectively distressing, and produces impairment in important areas of a person's life.

Epidemiology and Comorbidity Common condition F:M (2:1) onset in late adolescence or early adulthood Common: older adult probably the disorder that most often coexists with another mental disorder social phobia, specific phobia, panic disorder, or a depressive disorder Etiology not known heterogeneous group of persons certain degree of anxiety is normal and adaptive differentiating normal anxiety from pathological anxiety and differentiating biological causative factors from psychosocial factors are difficult Biological and psychological factors probably work together. Diagnosis DSM-IV-TR Differentiate anxiety d/o vs normal anxiety and other mental d/o Excessive and difficult to control DSM-IV-TR Diagnostic Criteria for Generalized Anxiety Disorder 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 person 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 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 focus of the anxiety and worry is not confined to features of an Axis I disorder, e.g., the anxiety or worry is not about having a panic attack (as in panic disorder), being embarrassed in public (as in social phobia), being contaminated (as in

obsessive-compulsive disorder), being away from home or close relatives (as in separation anxiety disorder), gaining weight (as in anorexia nervosa), having multiple physical complaints (as in somatization disorder), or having a serious illness (as in hypochondriasis), and the anxiety and worry do not occur exclusively during posttraumatic stress disorder. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hyperthyroidism) and does not occur exclusively during a mood disorder, a psychotic disorder, or a pervasive developmental disorder Clinical Features anxiety is excessive and interferes with other aspects of a person's life This pattern must occur more days than not for at least 6 months motor tension most commonly manifested as shakiness, restlessness, and headaches. autonomic hyperactivity commonly manifested by shortness of breath, excessive sweating, palpitations, and various gastrointestinal symptoms. cognitive vigilance evidenced by irritability and the ease with which patients are startled >>> seek out a general practitioner or internist for help with a somatic symptom >>>specialist for a specific symptom

Differential Diagnosis panic disorder, phobias, obsessive-compulsive disorder (OCD), and posttraumatic stress disorder (PTSD). To meet criteria for generalized anxiety disorder The key to making a correct diagnosis is documenting anxiety or worry that is unrelated to the depressive disorder. Treatment Psychotherapy Cognitive approaches address patients' hypothesized cognitive distortions directly Behavioral approaches address somatic symptoms directly major techniques used in behavioral approaches are relaxation and biofeedback. Supportive therapy offers patients reassurance and comfort, although its long-term efficacy is doubtful. Insight-oriented psychotherapy

focuses on uncovering unconscious conflicts and identifying ego strengths

Pharmacotherapy Three major drugs to be considered for the treatment of generalized anxiety disorder are benzodiazepines, the serotonin-specific reuptake inhibitors (SSRIs), buspirone (BuSpar), and venlafaxine (Effexor) Other drugs that may be useful are the tricyclic drugs, antihistamines, and the B-adrenergic antagonists (propranolol).

OTHER ANXIETY DISORDERS

Anxiety Disorder due to a General Medical Condition
panic attacks, generalized anxiety, obsessions and compulsions, and other signs of distress Epidemiology The occurrence of anxiety symptoms related to general medical conditions is common, although the incidence of the disorder varies for each specific general medical condition. Etiology Hyperthyroidism, hypothyroidism, hypoparathyroidism, and vitamin B12 deficiency Frequently associated with anxiety symptoms Pheochromocytoma produces epinephrine ->can cause paroxysmal episodes of anxiety symptoms Certain lesions of the brain and postencephalitic states reportedly produce symptoms identical to those seen in obsessive-compulsive disorder (OCD) Other medical conditions cardiac arrhythmia, can produce physiological symptoms of panic disorder Hypoglycemia can also mimic the symptoms of an anxiety disorder DSM-IV-TR Diagnostic Criteria for Anxiety Disorder Due to a General Medical Condition Prominent anxiety, panic attacks, or obsessions or compulsions predominate in the clinical picture. There is evidence from the history, physical examination, or laboratory findings that the disturbance is the direct physiological consequence of a general medical condition. The disturbance is not better accounted for by another mental disorder (e.g., adjustment disorder with anxiety in which the stressor is a serious general medical condition). The disturbance does not occur exclusively during the course of a delirium. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. Specify if: With generalized anxiety: if excessive anxiety or worry about a number of events or activities predominates in the clinical presentation

With panic attacks: if panic attacks predominate in the clinical presentation With obsessive-compulsive symptoms: if obsessions or compulsions predominate in the clinical presentation Coding note: Include the name of the general medical condition on Axis I, e.g., anxiety disorder due to pheochromocytoma, with generalized anxiety; also code the general medical condition on Axis III. Clinical Features The symptoms of anxiety disorder due to a general medical condition can be identical to those of the primary anxiety disorders. A syndrome similar to panic disorder is the most common clinical picture, and a syndrome similar to a phobia is the least common.

Substance-Induced Anxiety Disorder

direct result of a toxic substance, including drugs of abuse, medication, poison, and alcohol, among others. result of the ingestion of so-called recreational drugs and as the result of prescription drug use.

Etiology wide range of substances can cause symptoms of anxiety that can mimic any of the DSM-IV-TR anxiety disorders. amphetamine, cocaine, and caffeine (sympathomimetic) have been most associated with the production of anxiety disorder symptoms, many serotonergic drugs (e.g., lysergic acid diethylamide [LSD] and methylenedioxymethamphetamine [MDMA]) can also cause both acute and chronic anxiety syndromes in users. A wide range of prescription medications is also associated with the production of anxiety disorder symptoms in susceptible persons. DSM-IV-TR Diagnostic Criteria for Substance-Induced Anxiety Disorder Prominent anxiety, panic attacks, or obsessions or compulsions predominate in the clinical picture. There is evidence from the history, physical examination, or laboratory findings of either (1) or (2): the symptoms in Criterion A developed during, or within 1 month of, substance intoxication or withdrawal medication use is etiologically related to the disturbance The disturbance is not better accounted for by an anxiety disorder that is not substance induced. Evidence that the symptoms are better accounted for by an anxiety disorder that is not substance induced might include the following: the symptoms precede the onset of the substance use (or medication use); the symptoms persist for a substantial period of time (e.g., about a month) after the cessation of acute withdrawal or severe intoxication or are substantially in excess of what would be expected given the type or amount of the substance used or the duration of use; or there is other evidence suggesting the existence of an independent nonsubstance-induced anxiety disorder (e.g., a history of recurrent nonsubstance-related episodes). The disturbance does not occur exclusively during the course of a delirium.

The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. Note: This diagnosis should be made instead of a diagnosis of substance intoxication or substance withdrawal only when the anxiety symptoms are in excess of those usually associated with the intoxication or withdrawal syndrome and when the anxiety symptoms are sufficiently severe to warrant independent clinical attention. Code [Specific substance]-induced anxiety disorder Alcohol; amphetamine (or amphetaminelike substance); caffeine; cannabis; cocaine; hallucinogen; inhalant; phencyclidine (or phencyclidinelike substance); sedative, hypnotic, or anxiolytic; other [or unknown] substance Specify if: With generalized anxiety: if excessive anxiety or worry about a number of events or activities predominates in the clinical presentation With panic attacks: if panic attacks predominate in the clinical presentation With obsessive-compulsive symptoms: if obsessions or compulsions predominate in the clinical presentation With phobic symptoms: if phobic symptoms predominate in the clinical presentation Specify if: With onset during intoxication: if the criteria are met for intoxication with the substance and the symptoms develop during the intoxication syndrome With onset during withdrawal: if criteria are met for withdrawal from the substance and the symptoms develop during, or shortly after, a withdrawal syndrome

Clinical Features vary with the particular substance involved Cognitive impairments in comprehension, calculation, and memory can be associated with anxiety disorder symptoms. These cognitive deficits are usually reversible when the substance use is stopped Treatment removal of the causally involved substance. find an alternative treatment if the substance was a medically indicated drug limit patient's exposure if the substance was introduced through environmental exposure treat the underlying substance-related disorder symptoms continue even after stopping substance use treatment of the anxiety disorder symptoms with appropriate psychotherapeutic or pharmacotherapeutic modalities may be appropriate.

Anxiety Disorder not Otherwise Specified

Some patients have symptoms of anxiety disorders that do not meet the criteria for any specific DSM-IV-TR anxiety disorder or adjustment disorder with anxiety or mixed anxiety and depressed mood.

DSM-IV-TR Diagnostic Criteria for Anxiety Disorder Not Otherwise Specified This category includes disorders with prominent anxiety or phobic avoidance that do not meet criteria for any specific anxiety disorder, adjustment disorder with anxiety, or adjustment disorder with mixed anxiety and depressed mood. Examples include: 1. Mixed anxiety-depressive disorder: clinically significant symptoms of anxiety and depression, but the criteria are not met for either a specific mood disorder or a specific anxiety disorder 2. Clinically significant social phobic symptoms that are related to the social impact of having a general medical condition or mental disorder (e.g., Parkinson's disease, dermatological conditions, stuttering, anorexia nervosa, body dysmorphic disorder) 3. Situations in which the disturbance is severe enough to warrant a diagnosis of an anxiety disorder but the individual fails to report enough symptoms for the full criteria for any specific anxiety disorder to have been met; for example, an individual who reports all of the features of panic disorder without agoraphobia except that the panic attacks are all limited-symptom attacks 4. Situations in which the clinician has concluded that an anxiety disorder is present but is unable to determine whether it is primary, due to a general medical condition, or substance induced

Mixed Anxiety-Depressive Disorder

patients with both anxiety and depressive symptoms who do not meet the diagnostic criteria for either an anxiety disorder or a mood disorder combination of depressive and anxiety symptoms results in significant functional impairment for the affected person. The condition may be particularly prevalent in primary care practices and outpatient mental health clinics

ETIOLOGY Four principal lines of evidence suggest that anxiety symptoms and depressive symptoms are causally linked in some affected patients. neuroendocrine findings in depressive disorders and anxiety disorders, particularly panic disorder, including blunted cortisol response to adrenocorticotropic hormone, blunted growth hormone response to clonidine (Catapres), and blunted thyroid-stimulating hormone and prolactin responses to thyrotropin-releasing hormone. hyperactivity of the noradrenergic system is causally relevant to some patients with depressive disorders and with panic disorder. Specifically, these studies have found elevated concentrations of the norepinephrine metabolite 3-methoxy-4-hydroxyphenyglycol (MHPG) in the urine, the plasma, or the cerebrospinal fluid (CSF) of depressed patients and patients with panic disorder who were actively experiencing a panic attack. As with other anxiety and depressive disorders, serotonin and Gamma-aminobutyric acid (GABA) may also be causally involved in mixed anxiety-depressive disorder.

many studies have found that serotonergic drugs, such as fluoxetine (Prozac) and clomipramine (Anafranil), are useful in treating both depressive and anxiety disorders. a number of family studies have reported data indicating that anxiety and depressive symptoms are genetically linked in at least some families.

DSM-IV-TR Research Criteria for Mixed Anxiety-Depressive Disorder Persistent or recurrent dysphoric mood lasting at least 1 month. The dysphoric mood is accompanied by at least 1 month of four (or more) of the following symptoms: difficulty concentrating or mind going blank sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep) fatigue or low energy irritability worry being easily moved to tears hypervigilance anticipating the worst hopelessness (pervasive pessimism about the future) low self-esteem or feelings of worthlessness The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition. All of the following: criteria have never been met for major depressive disorder, dysthymic disorder, panic disorder, or generalized anxiety disorder criteria are not currently met for any other anxiety or mood disorder (including an anxiety or mood disorder, in partial remission) the symptoms are not better accounted for by any other mental disorder Clinical Features combine symptoms of anxiety disorders and some symptoms of depressive disorders. In addition, symptoms of autonomic nervous system hyperactivity, such as gastrointestinal complaints, are common and contribute to the high frequency with which the patients are seen in outpatient medical clinics. Treatment based on the symptoms present, their severity, and the clinician's own level of experience with various treatment modalities Psychotherapeutic approach cognitive therapy or behavior modification, although some clinicians use a less-structured psychotherapeutic approach, such as insightoriented psychotherapy Pharmacotherapy antianxiety drugs, antidepressant drugs, or both