Evidence-Based Reviews

Generalized anxiety disorder: Helping patients overcome worry

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Mrs. M, age 44, is a married mother of 2 who presents to the psychiatric clinic with increased anxiety that recently has become intolerable, stating “I can’t stop my head.” She has experienced anxiety for “as long as I can remember.” She was a shy, anxious child who worried about her parents’ health. Her anxiety worsened at college, where she first sought care. She was prescribed diazepam as needed. The next semester, she had a depressive episode, treated with imipramine, 75 mg/d, which she tolerated poorly.

Mrs. M has received episodic supportive therapy since college. She has been plagued by bouts of anxiety and worry, with insomnia, tension, and fatigue. She worries about financial, career, family, and safety issues and has a phobia of spiders. Her family and friends often comment about her excessive worry, and it has strained her marriage and career; she was passed over for a promotion in part because of her anxiousness. Mrs. M also has experienced several depressive episodes.

Mrs. M has sought medical care for various non-specific somatic complaints; all laboratory tests were normal. Approximately 10 years ago, Mrs. M’s primary care physician prescribed fluoxetine, 20 mg/d, but Mrs. M stopped taking it after a few days, stating she felt “more anxious and jittery.”

To meet DSM-IV-TR diagnostic criteria for generalized anxiety disorder (GAD), patients must experience anxiety and worry that they find difficult to control. The worry and anxiety occur more days than not for at least 6 months and cause clinically significant distress and impairment (Table 1).1 These diagnostic criteria are being reevaluated—the DSM-5 Anxiety Work Group has proposed renaming the condition generalized worry disorder, specifying that only 2 domains need to be impacted by worry, shortening the required time frame of impairment from 6 months to 3 months, and including at least 1 behavioral change spawned by excessive worry.2 Although provisional, these recommendations suggest DSM-5 will include changes to GAD when it is published in 2013.

Table 1

DSM-IV-TR diagnostic criteria for generalized anxiety disorder

  1. 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)
  2. The person finds it difficult to control the worry
  3. The anxiety and worry are associated with ≥3 of the following 6 symptoms (with at least some symptoms present for more days than not for the past 6 months):
    1. restlessness or feeling keyed up or on edge
    2. being easily fatigued
    3. difficulty concentrating or mind going blank
    4. irritability
    5. muscle tension
    6. sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep)
  4. The focus of the anxiety and worry is not confined to features of other axis I disorders (eg, social phobia, OCD, PTSD, etc.)
  5. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning
  6. The disturbance is not due to the direct physiological effects of a substance (eg, a drug of abuse, a medication) or a general medical condition (eg, hyperthyroidism), and does not occur exclusively during a mood disorder, a psychotic disorder, or a pervasive developmental disorder
OCD: obsessive-compulsive disorder; PTSD: posttraumatic stress disorder
Source: Reference 1

A common, chronic condition

In the United States, the lifetime prevalence of GAD is 5.7%.3 It is twice as common in women. Although GAD can occur at any age, 75% of patients develop it before age 47; the median age is 31.3,4 Patients who present with GAD later in life have a better prognosis.3,4

Approximately 90% of GAD patients will meet criteria for another axis I disorder.3 When GAD patients present for treatment, social phobia and panic disorder are the most common comorbid psychiatric disorders. The lifetime prevalence of a mood disorder among GAD patients is 62%, but as few as 6% of GAD patients will meet criteria for a mood disorder at presentation.3 The onset of GAD usually precedes depression.5,6

Patients with GAD often first seek treatment from their primary care provider.7 A useful screening tool is the GAD-7 (Table 2).8 This instrument has a specificity of 92% and sensitivity of 76% for GAD for patients who score ≥8.7 Although the GAD-7 cannot confirm a GAD diagnosis, it can prompt clinicians to conduct a more structured interview. Because higher scores correlate with more severe symptoms, the GAD-7 can be used to measure progress.

Table 2

Screening for generalized anxiety disorder: The GAD-7

Over the last 2 weeks, how often have you been bothered by any of the following problems?Not at allSeveral daysMore than half the daysNearly every day
1.Feeling nervous, anxious, or on edge0123
2.Not being able to stop or control worrying0123
3.Worrying too much about different things0123
4.Trouble relaxing0123
5.Being so restless that it is hard to sit still0123
6.Becoming easily annoyed or irritable0123
7.Feeling afraid as if something awful might happen0123
GAD: generalized anxiety disorder
Source: Reference 8


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