Generalized Anxiety Disorder

Background

• Generalized anxiety disorder (GAD) is characterized by chronic, unfocused, excessive worry and stress associated with clinically significant distress and functional impairment, often accompanied by insomnia, restlessness, muscle tension, and fatigue.
• The age of onset appears to be variable, some cases occurring between ages 10-14 years in children and adolescents and most cases occurring in early adulthood at median age 30 years in adults.
• Anxiety disorders are the most common mental health disorder among children and adolescents, with studies investigating GAD in children as young as 7 years old.
• GAD may result from abnormal serotonergic and noradrenergic neurotransmitter activity and cortisol systems. A combination of genetic and environmental factors may play a role in symptom manifestation.
• The clinical course is usually chronic, with lower likelihood of remission in those with comorbid psychological conditions and poor family support.
• GAD is associated with increased risk of suicidal behavior as well as all-cause and cardiovascular-related mortality.

Evaluation

• Suspect generalized anxiety disorder in patients with ongoing excessive worry for at least 6 months not related to a single stressor, especially if other stress-related symptoms are present.
• Diagnosis is generally clinical, with laboratory or other testing indicated only if it is needed to rule out other causes of anxiety-like manifestations, such as cardiopulmonary disorders, endocrine disease such as hyperthyroidism, medications, or substance abuse.
• Several tools are available for diagnosis and assessment of anxiety symptoms and generalized anxiety disorder.
  • The 7-item generalized anxiety disorder scale (GAD-7) may also be useful for diagnosis of generalized anxiety disorder in adults and adolescents.
  • The Hamilton Rating Scale for Anxiety (HAM-A) scores 14 features of anxiety from not present (0 points) to disabling (4 points), with total score range 0-56.
  • The Clinical Global Impressions (CGI) Scale quantifies clinician's experience-based assessment of the severity of a patient's mental condition (total score range 1-7) and/or assessment of the change in a patient's condition from 1 week before start of treatment (total score range 1-7) to the current state.
  • The Patient Health Questionnaire for Depression and Anxiety (PHQ-4) scores 2 items related to depression and 2 items related to anxiety, with total score range 0-12.
  • Screening tools useful for diagnosis of generalized anxiety disorder in children include SCARED score, YAM-5-I score, Severity measure for generalized anxiety disorder - child age 11-17, and Pediatric anxiety rating scale (PARS).

Management

• Psychological therapy (counseling) and medications may be individually effective for the treatment of generalized anxiety disorder, but a combination of both treatments may yield better results than either alone.
• Options for psychological therapy include cognitive behavioral therapy, psychodynamic psychotherapy, mindfulness meditation, relaxation therapy, and acceptance-based behavioral therapy.
• First-line medications for treatment of generalized anxiety disorder include:
  • selective serotonin reuptake inhibitors (SSRIs) (such as escitalopram, paroxetine, or sertraline) (Strong recommendation)
  • serotonin norepinephrine reuptake inhibitors (SNRIs) (such as duloxetine or venlafaxine extended release) (Strong recommendation)
  • consideration of antiseizure medications (such as pregabalin, especially for those intolerant of SSRIs/SNRIs)
• Second-line medications to consider for treatment of generalized anxiety disorder include:
  • other antidepressants such as imipramine, bupropion extended release, and vortioxetine (Weak recommendation)
  • benzodiazepines (such as alprazolam, bromazepam, diazepam, or lorazepam) (Weak recommendation)
  • atypical antipsychotics (such as quetiapine)
• Pregabalin or atypical antipsychotics may provide some benefit as adjunctive therapy to 1 of the first-line agents.
• Herbal therapies such as lavender oil gel caps, kava, and Galphimia glauca extract may have some efficacy for generalized anxiety disorder.
• Other therapies that may be effective in treatment include resistance training exercise, self-help interventions, therapeutic massage, and acupuncture.
• In patients treated with medication, follow-up monthly (more frequently in special populations) to assess progress, compliance, and adverse effects.