[ Pobierz całość w formacie PDF ]
E. The anxiety or physical symptoms
cause significant distress or impairment
in functioning.
F. Symptoms are notcaused bysubstance
use or a medical condition,and symptoms
are not related to a mood or psychotic
disorder.
II. Clinical Features of Generalized Anxiety
Disorder
A. Other features often include insomnia,
irritability, trembling, muscle aches
and soreness, muscle twitches, clammy
hands, dry mouth, and a heightened
startle reflex. Patients may also report
palpitations,dizziness, difficultybreathing,
urinaryfrequency,dysphagia,light-headedness,
abdominal pain, and diarrhea.
B. Patients often complain that they
can't stop worrying, which mayrevolve
around valid concerns about money,
jobs, marriage, health, and the safety
of children.
C. Chronic worry is a prominent feature
of generalized anxiety disorder, unlike
the intermittent terror that characterizes
panic disorder.
D. Mood disorders,substance- and stress-related
disorders (headaches, dyspepsia)
commonly coexist with GAD. Up to
one-fourth of GAD patients develop
panic disorder. Excessive worry and
somatic symptoms, including autonomic
hyperactivity and hypervigilance,
occur most days.
E. About 30-50% of patients with anxiety
disorders will also meet criteria for
major depressive disorder. Drugs
and alcohol may cause anxiety or
may be an attempt at self-treatment.
Substance abuse maybe acomplication
of GAD.
III. Epidemiology
A. Lifetime prevalence is 5%.
B. The female-to-male sex ratio for GAD
is 2:1.
C. Most patients report excessive anxiety
during childhood or adolescence;
however, onset after age 20 may
sometimes occur.
IV.Differential Diagnosis of Generalized
Anxiety Disorder
A. Substance-Induced AnxietyDisorder.
Substances such as caffeine,amphetamines,
or cocaine can cause anxietysymptoms.
Alcohol or benzodiazepine withdrawal
can mimic symptoms of GAD. These
disorders should be excluded byhistory
and toxicology screen.
B. Panic Disorder,Obsessive-Compulsive
Disorder,SocialPhobia, Hypochondriasis
and Anorexia Nervosa
1. Many psychiatric disorders present
with marked anxiety,and the diagnosis
of GAD should be made only if
the anxiety is unrelated to the
other disorders.
2. For example, GAD should not
be diagnosed in panic disorder
if the patient has excessive anxiety
about having a panic attack, or
if an anorexic patient has anxiety
about weight gain.
C. Anxiety Disorder Due to a General
Medical Condition. Hyperthyroidism,
cardiac arrhythmias,pulmonaryembolism,
congestiveheartfailure, and hypoglycemia,
may produce significant anxiety and
should be ruled out as clinicallyindicated.
D. Mood and Psychotic Disorders
1. Excessive worryand anxietyoccurs
inmanymood and psychotic disorders.
2. If anxiety occurs only during the
course of the mood or psychotic
disorder, then GAD cannot be
diagnosed.
V. Laboratory Evaluation of Anxiety
A. Serum glucose, calcium and phosphate
levels, electrocardiogram, and thyroid
studies should be included in the
initial workup of all patients.
B. Other Studies. Urine drug screen
and urinary catecholamine levels
may be required to exclude specific
disorders.
VI.Treatment of Generalized Anxiety
Disorder
A. The combination of pharmacologic
therapy and psychotherapy is the
most successful form of treatment.
B. Pharmacotherapy of Generalized
Anxiety Disorder
1. Venlafaxine (Effexor and Effexor
XR)
a. Venlafaxine is a first-line treatment
for GAD. Effexor XR can be
started at75 mg perday;however,
patients with severe anxiety
or panic attacks should be
started at 37.5 mg per day.
The dose should then be titrated
up to a maximum dosage of
225 mg of Effexor XR per day.
b. Venlafaxine usually requires
several weeks to achieve efficacy
and an adequate trial should
last for 4-6 weeks.
c. The side effect profile for GAD
patients is similar to that seen
with depressive disorders.
2. Other Antidepressants
a. Selective-serotonin reuptake
inhibitors and tricyclic antidepressants
are widely used to treat anxiety
disorders. SSRIs appear to
have similar efficacytovenlafaxine
and should also be considered
as a first-line therapy. Their
onset of action is much slower
than thatofthe benzodiazepines,
buttheyhave no addictivepotential
and may be more effective.
An antidepressant is the agent
of choice when depression
coexists with anxiety.
b. Antidepressants are especially
useful in patients with mixed
symptoms ofanxietyand depression.
3. Buspirone (BuSpar)
a. Buspirone is a first-line treatment
of GAD. Buspirone usually
requires 3-6 weeks at a dosage
of 10-20 mg tid for efficacy.
It lacks sedativeeffects. Tolerance
tothe beneficial effects ofbuspirone
does not seem to develop.
There is no physiologic dependence
or withdrawal syndrome.
b. Combined benzodiazepine-buspirone
therapymaybeused for generalized
anxietydisorder,withsubsequent
tapering of the benzodiazepine
after 2-4 weeks.
c. Patients who have been previously
treated with benzodiazepines
or who have a historyofsubstance
abuse have a decreasedresponse
to buspirone.
d. Buspirone may have some
antidepressant effects.
4. Benzodiazepines
a. Benzodiazepines can almost
always relieve anxiety if given
in adequate doses, and they
have no delayed onset of action.
b. Long-term useofbenzodiazepines
should be reserved for patients
who have failed to respond
to venlafaxine (Effexor), SSRIs,
buspirone (BuSpar) and other
antidepressants, or who are
intolerant to their side effects.
c. Benzodiazepines are veryuseful
for treating anxiety during the
period in which ittakes buspirone
or antidepressants to exert
their effects. Benzodiazepines
should then be tapered after
several weeks.
d. Benzodiazepines have few
side effects other than sedation.
Tolerance to their sedative
effects develops, but not to
their antianxiety properties.
e. Since clonazepam (Klonopin)
and diazepam (Valium) have
long half-lives, they are less
likelyto result in interdose anxiety
and are easier to taper.
f. Drug dependency becomes
a clinicalissueifthebenzodiazepine
is used regularly for more than
2-3 weeks.Awithdrawal syndrome
occurs in 70%ofpatients,characterized
byintense anxiety,tremulousness
dysphoria, sleep and perceptual
disturbances and appetite suppression.
Slowtapering ofbenzodiazepines
is crucial (especially those with
short half-lives).
C. Non-Drug Approaches to Anxiety
1. Patients should stop drinking coffee
and other caffeinated beverages,
and avoid excessivealcoholconsumption.
2. Patients should get adequate sleep,
withthe use ofmedication ifnecessary.
[ Pobierz całość w formacie PDF ]