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Generalized Anxiety Disorder: Practical Assessment and Management MICHAEL G

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Generalized Anxiety Disorder: Practical Assessment and Management MICHAEL G Generalized Anxiety Disorder: Practical Assessment and Management MICHAEL G. KAVAN, PhD; GARY N. ELSASSER, PharmD; and EUGENE J. BARONE, MD Creighton University School of Medicine, Omaha, Nebraska Generalized anxiety disorder is common among patients in primary care. Affected patients experience excessive chronic anxiety and worry about events and activities, such as their health, family, work, and finances. The anxiety and worry are difficult to control and often lead to physiologic symptoms, including fatigue, muscle tension, restless- ness, and other somatic complaints. Other psychiatric problems (e.g., depression) and nonpsychiatric factors (e.g., endocrine disorders, medication adverse effects, withdrawal) must be considered in patients with possible generalized anxiety disorder. Cognitive behavior therapy and the first-line pharmacologic agents, selective serotonin reuptake inhibitors, are effective treatments. However, evidence suggests that the effects of cognitive behavior therapy may be more durable. Although complementary and alternative medicine therapies have been used, their effectiveness has not been proven in generalized anxiety disorder. Selection of the most appropriate treatment should be based on patient preference, treatment success history, and other factors that could affect adherence and subsequent effective- ness. (Am Fam Physician. 2009;79(9):785-791. Copyright © 2009 American Academy of Family Physicians.) ▲ Patient information: nxiety disorders, such as generalized GAD is 3.1 percent in population-based sur- A handout on general- anxiety disorder (GAD), panic dis- veys,2 and between 5.3 and 7.6 percent among ized anxiety disorder, 3,9 written by the authors of order, posttraumatic stress disor- patients who visit primary care offices. The this article, is available der, and obsessive-compulsive highest rate of GAD (7.7 percent) occurs in at http://www.aafp.org/ Adisorder, are the most common mental health persons 45 to 49 years of age, and the lowest afp/20090501/ problems in the United States.1,2 As with rate (3.6 percent) occurs in persons 60 years 785-s1.html. other anxiety disorders, GAD is associated and older.1 Women are almost twice as likely This article exempli- with impairments in mental health, social/ as men to be diagnosed with GAD over their fies the AAFP 2009 Annual 10 Clinical Focus on manage- role functioning, general health, bodily pain, lifetime. Although the prevalence of GAD ment of chronic illness. physical functioning, and daily activities. It decreases with age in men, it increases in is also associated with an increase in physi- women.11 The online version 3 of this article con- cian visits. One third of patients with GAD tains supplemental have one or more additional anxiety disor- Diagnosis content at http://www. ders, often accompanied by a decline in func- The diagnostic criteria for GAD from the aafp.org/afp. tional status and an increased risk of other Diagnostic and Statistical Manual of Men- psychiatric problems or substance abuse.3,4 tal Disorders, 4th ed., text revision (DSM- GAD is linked to self-medication with alco- IV-TR) are shown in Table 1.12 Controversy hol or other drugs5 and to suicidal ideation.6 exists regarding the duration of symptoms Impairment associated with GAD is equal to necessary to make a diagnosis. Some authors that associated with major depression,7 and suggest using a one-month symptom dura- it is related to increased health care use and tion because the six-month requirement may economic costs.7,8 Despite the prevalence of unnecessarily exclude from treatment those GAD and its subsequent impact on health, patients whose symptoms fluctuate.13,14 functioning, and the economy, the condi- Patients with GAD may constantly worry tion is too often misdiagnosed and managed about their health, family, work, and finances. incorrectly.7 Worrying is difficult to control, often nega- tively affecting relationships and social and Epidemiology work activities.3 Patients with GAD com- GAD is the most common anxiety disorder monly present with nonspecific somatic in primary care. The 12-month prevalence of symptoms (e.g., insomnia, headaches, muscle Downloaded from the American Family Physician Web site at www.aafp.org/afp. Copyright © 2009 American Academy of Family Physicians. For the private, noncommercial use of one individual user of the Web site. All other rights reserved. Contact [email protected] for copyright questions and/or permission requests. Generalized Anxiety Disorder SORT: KEY RECOMMENDATIONS FOR PRACTICE Evidence Clinical recommendation rating References Patients experiencing anxiety should be evaluated for depression. C 3 Cognitive behavior therapy has been shown to be at least as effective as medication for GAD with less A 17, 19 attrition and more durable effects. Some SSRIs (escitalopram [Lexapro], paroxetine [Paxil], sertraline [Zoloft]); SNRIs (venlafaxine [Effexor], A 25-27, 30-35 duloxetine [Cymbalta]); and benzodiazepines are more effective than placebo in the treatment of GAD. SSRI or SNRI therapy is more beneficial for patients with GAD and comorbid depression than A 24-27, 40 benzodiazepine or buspirone (Buspar) therapy. Kava is effective in the treatment of GAD, but safety concerns limit its use. B 49-52 GAD = generalized anxiety disorder; SNRI = serotonin-norepinephrine reuptake inhibitor; SSRI = selective serotonin reuptake inhibitor. A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease- oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp. org/afpsort.xml. aches, fatigue, gastrointestinal symptoms).5 Because of Table 1. DSM-IV-TR Diagnostic Criteria for the high level of comorbidity with other mental health Generalized Anxiety Disorder and medical problems, physicians must rule out other psychiatric disorders (e.g., depression)3 and nonpsychi- A. Excessive anxiety and worry (apprehensive expectation), atric conditions (e.g., hypoglycemia, cardiomyopathy; occurring more days than not for at least six months, about Online Table A). Some medications and other sub- a number of events or activities (such as work or school performance). stances may also cause symptoms of anxiety (e.g., caf- B. The person finds it difficult to control the worry. feine, alcohol, amphetamines; Online Table B). C. The anxiety and worry are associated with three (or more) Several self-report questionnaires are available to of the following six symptoms (with at least some symptoms assist physicians in the diagnosis of anxiety disorders. present for more days than not for the past six months). The seven-item GAD scale (GAD-7; Figure 1)3,15 is a reli- NOTE: Only one item is required in children. (1) Restlessness or feeling keyed up or on edge able, valid, and easy-to-use self-report questionnaire for (2) Being easily fatigued evaluating the presence and severity of GAD. A cutoff (3) Difficulty concentrating or mind going blank score of 8 points demonstrates strong sensitivity (92 (4) Irritability percent) and specificity (76 percent) for the diagnosis of (5) Muscle tension GAD, and higher scores are related to worsening func- (6) Sleep disturbance (difficulty falling or staying asleep, or tional impairment. The GAD-7 detects only a probable restless unsatisfying sleep) diagnosis of GAD; positive scores should be followed by D. The focus of the anxiety and worry is not confined to features more extensive interviewing (e.g., using the DSM-IV-TR of an Axis I disorder (e.g., the anxiety or worry is not about having a panic attack [as in panic disorder], being embarrassed criteria) accompanied by appropriate management and in public [as in social phobia], being contaminated [as in referral. A simpler two-item scale, GAD-2, is also shown obsessive-compulsive disorder], being away from home or in Figure 1.3,15 Although it has nearly the same accuracy close relatives [as in separation anxiety disorder], gaining as GAD-7, the latter provides additional information weight [as in anorexia nervosa], having multiple physical complaints [as in somatization disorder], or having a serious that can guide management. illness [as in hypochondriasis]), and the anxiety and worry do not occur exclusively during posttraumatic stress disorder. Treatment E. The anxiety, worry, or physical symptoms cause clinically Psychological, pharmacologic, and complementary and significant distress or impairment in social, occupational, or other important areas of functioning. alternative medicine (CAM) interventions for GAD F. The disturbance is not due to the direct physiologic effects of should begin with supportive listening and education a substance (e.g., a drug of abuse, a medication) or a general about anxiety. Helping patients understand that anxiety medical condition (e.g., hyperthyroidism) and does not occur is a manageable medical condition is essential. Patient exclusively during a mood disorder, a psychotic disorder, or a pervasive developmental disorder. education should include discussing the role of thoughts and lifestyle on anxiety and how modification of these DSM-IV-TR = Diagnostic and Statistical Manual of Mental Disorders, can reduce symptoms.16,17 4th ed., text revision. Reprinted with permission from American Psy- chiatric Association. Diagnostic and Statistical Manual of Mental Dis- PSYCHOLOGICAL COUNSELING orders. 4th ed., text revision. Washington, DC: American Psychiatric Association;
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