Generalized Anxiety Disorder By William A. Kehoe, Pharm.D., MA, FCCP, BCPS Reviewed by Sarah T. Melton, Pharm.D., BCPP, BCACP; and Clarissa J. Gregory, Pharm.D., BCACP, BCGP, CACP LEARNING OBJECTIVES 1. Distinguish between generalized anxiety disorder (GAD) and other psychiatric or medical disorders. 2. Using validated screening tools and procedures, develop a screening and diagnostic plan for the patient with possible GAD. 3. Develop a treatment and monitoring plan, including patient education on the goals, expected outcomes, and risks of treatment, for the patient with GAD. 4. Justify the use of second- and third-line agents in the treatment plan for a patient with GAD. 5. Design an appropriate treatment plan for GAD for patients requiring special considerations including children, the elderly, and patients who are pregnant. INTRODUCTION ABBREVIATIONS IN THIS CHAPTER CBT Cognitive behavioral therapy Overview of Anxiety Disorders CSTC Cortico-striato-thalamo-cortical Anxiety disorders are common among patients in primary care and circuitry share a common thread: focusing on future threats. Worry, avoidant DSM-5 Diagnostic and Statistical Manual behavior or behavioral adaptations, and autonomic and other somatic of Mental Disorders, Fifth Edition complaints are also common. The Diagnostic and Statistical Manual of GABA γ-Aminobutyric acid Mental Disorders, Fifth Edition (DSM-5) lists separation anxiety, selec- GAD Generalized anxiety disorder tive mutism, specific phobia, social anxiety disorder (also called GAD-7 Generalized Anxiety Disorder social phobia), panic disorder, agoraphobia, generalized anxiety, 7-Item Scale substance abuse/medication-induced anxiety, and anxiety disorder SGA Second-generation antipsychotic caused by another medical condition in its chapter on anxiety dis- SNRI Serotonin-norepinephrine reup- orders (APA 2013). Of note, in prior DSM editions, posttraumatic and take inhibitor obsessive-compulsive disorders were included in the chapter on anx- SSRI Selective serotonin reuptake iety disorders. The DSM-5 reclassified these into separate chapters. inhibitor Box 1-1 lists common disorders in primary care clinics and the char- TCA Tricyclic antidepressant acteristics that help differentiate them. Table of other common abbreviations. Anxiety disorders are problematic for both patients and providers. Although anxiety disorders are common, with a lifetime prevalence of up to 31%, they are often unrecognized and underdiagnosed (Katzman 2014). Patients may not disclose their symptoms, or they may focus on somatic complaints and not attribute them to anxiety. If the patient does not disclose any underlying anxiety, most clinicians initially focus on the physical problems and somatic complaints. The result is that less than one-third of patients receive therapy for the underlying anxiety disorder (Revicki 2012). Clinicians should be aware that these disorders are common and provide appropriate screening and diagnostic workups. This chapter focuses on general- ized anxiety disorder (GAD). ACSAP 2017 Book 2 • Neurologic/Psychiatric Care 7 Generalized Anxiety Disorder Definitions and Diagnostic Criteria for GAD The characteristics of GAD as described in the DSM-5 are Box 1-1. Characteristics of Selected shown in Table 1-1. The issues assessed on two common Anxiety Disorders in the DSM-5 screening instruments (i.e., the Generalized Anxiety Disorder Generalized Anxiety Disorder Psychological symptoms: Excessive anxiety, 7-Item scale (GAD-7) and the Penn State Worry Questionnaire) uncontrolled worry, feeling on edge, poor concentration, are shown beside these criteria for reference. A score greater restlessness, irritability, impaired social or occupational than 10 on the GAD-7 suggests a diagnosis of GAD. The score functioning on the Penn State Worry Questionnaire designates an acu- Physical symptoms: Fatigue, muscle tension, difficulty ity level of worry as low (16–39), moderate (40–59), or high sleeping (60–80). These screening tools are readily available and easy Panic Disorder to use in the ambulatory setting. Recurrent panic attacks manifested by these symptoms: For the main features of GAD, see Table 1-1. Anxiety and Psychological: Fear of losing control or dying, fear of inability worry occur as a normal part of life. What distinguishes patho- to escape from fearful situations logic anxiety from normal worry is the severity of anxiety, Physical symptoms: Chest pain or discomfort, dizziness, difficulty in controlling it, and significant social and functional shortness of breath, tachycardia, tremor, nausea, palpitations, impairment it causes. Anxiety and worry may focus on poten- sweating tial future events, but they are out of proportion to what might Agoraphobia really happen. Of interest, although excessive worry is a cen- Agoraphobia may result from repeated panic attacks tral feature of GAD, it appears to be a psychological defense Psychological symptoms: Fear, anxiety, and avoidance in two mechanism to allow some sense of control over what might or more of the following situations: public transportation, happen if the feared event occurs (Behar 2009). Excessive open spaces, enclosed places, standing in line or being in a worry can become a learned cycle of thinking that becomes a crowd, being away from home alone cognitive pattern, leading to impairment. Social Anxiety Disorder Psychological symptoms: Fear of being embarrassed, humiliated, or evaluated by others; fear of situations such as speaking, eating, or interacting in a group of people or with authority figures; public speaking; talking with strangers Physical symptoms: GI upset – diarrhea; sweating, flushing, BASELINE KNOWLEDGE STATEMENTS tachycardia, tremor Readers of this chapter are presumed to be familiar with the following: Information from the American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). • Clinical pharmacology of the antidepressants, anxiolytics, benzodiazepines, anticonvulsants, and second-generation antipsychotics discussed in this chapter • Recognition of signs and symptoms of anxiety Somatic features of GAD are common, which can be why • Basic patient educational points for the medica- patients seek medical care. Complaints such as muscle tions described in this chapter aches and tension, headaches, backaches, GI issues, prob- lems with sleep, and fatigue are common. Anxiety disorders Table of common laboratory reference values. are also associated with several medical illnesses such as thyroid disease and respiratory disease. This association ADDITIONAL READINGS leads to increased disability and decreased quality of life (Saren 2006). One study found that patients with anxiety The following free resources have additional back- disorders and depression had higher rates of somatic dis- ground information on this topic: ease such as asthma, heart disease, back problems, ulcer, National Institute for Health and Care Excellence • migraines, and eyesight problems (Niles 2015). In addition, (NICE). Clinical Guideline: Generalized Anxiety a 1-SD increase in the severity of the anxiety and depres- Disorder and Panic Disorder in Adults. sive symptoms was associated with a 15% increase in the • Canadian Medical Association. Clinical Practice Guidelines for the Management of Anxiety, number of medical conditions. To put this in perspective, Posttraumatic Stress, and Obsessive-Compulsive 1 SD in BMI is associated with a 12% increase in medical Disorders. conditions (Niles 2015). Thus, anxiety disorders are associ- • Harvard Medical School, Department of Psychiatry, ated with physical health risks similar to being overweight. South Shore Program. Psychopharmacology Therefore, patients with somatic complaints for which no Algorithm Project. organic causes can be identified should be assessed for an anxiety disorder. ACSAP 2017 Book 2 • Neurologic/Psychiatric Care 8 Generalized Anxiety Disorder Table 1-1. DSM-5 Criteria for GAD and Screening Questions Characteristics of GAD according Excessive worry and anxiety occur most of the time for at least 6 mo to the DSM-5 The worry is difficult to control The anxiety and worry are associated with at least three of the following core symptoms: • Feeling restless, keyed up, or on edge • Fatiguing easily • Difficulty concentrating or the mind going blank • Irritability • Increased muscle tension • Difficulty falling asleep, staying asleep, or restlessness The symptoms cause significant distress or impairment The problems are not attributable to a physical ailment The problems are not explained by other mental disorders Factors screened for by the GAD-7 Feeling nervous, anxious, or on edge Not being able to stop or control worrying Worrying too much about different things Trouble relaxing Being so restless it is hard to sit still Becoming easily annoyed or irritated Feeling as if something awful might happen Factors screened for by the Penn If I do not have enough time to do everything, I do not worry about it State Worry Questionnaire My worries overwhelm me I do not tend to worry about things Many situations make me worry I know I should not worry about things, but I just cannot help it When I am under pressure, I worry a lot I am always worrying about something I find it easy to dismiss worrisome thoughts As soon as I finish one task, I start to worry about everything else I have to do I never worry about anything When there is nothing more I can do about a concern, I do not worry about it anymore I have been a worrier all my life I notice