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generalized anxiety disorder (GAD)

Etiology: - commonly associated with - comorbid psychiatric disorder - depression - substance abuse, alcoholism - health problems Epidemiology: 1) 5% lifetime prevalence 2) more common in women than men 3) less common in the elderly 4) most common anxiety disorder in the elderly [3] 5) risk-factors for late-onset generalized anxiety disorder [7] - female sex (RR=3.43) - major depression (RR=60) - respiratory disorders, such as dyspnea, asthma, or bronchitis (RR=2.95) - current phobia (RR=2.55) [7] - other independent risk factor - cardiac disease - recent & childhood adverse events - cognitive impairment [7] Clinical manifestations: 1) pervasive & disabling worry about numerous life circumstances 2) anxiety out of proportion to likelihood or impact of feared events 3) worry is difficult to control 4) symptoms present for at least 6 months [8] 5) autonomic dysfunction 6) arousal symptoms a) restlessness, feeling keyed up or on edge b) easily fatigued c) difficulty concentrating or mind going blank - often perceived as a memory problem [3] d) irritability e) muscle tension f) sleep disturbance 1] difficulty falling asleep 2] difficulty staying asleep, or 3] restless or unsatifying sleep [2] 7) significant distress or impairment [3] - impairment generally due to avoidance behavior 8) elderly frequently focus on somatic manifestations, &/or downplay the underlying anxiety, thus the diagnosis easily missed [3] 9) common presenting symptms - headaches, muscle tension, gastrointestinal symptoms, back pain, insomnia [8] Special laboratory: - Generalized Anxiety Disorder 7 (GAD-7) scale Complications: - greater use of healthcare resources - diminished quality of life Differential diagnosis: - frequently comorbid with - mood disorders - personality disorders [6] - somatic symptom disorder - characterized by a symptom-specific complaint, such as pain or dysphagia - may be multiple complaints - patient does not ruminate about somatic concern(s) - panic disorder - anxiety disorder characterized by discrete intense periods of fear & associated symptoms, worry about additional attacks, change in behavior - >= one month (or less) duration - functional neurologic disorder/conversion disorder - physical symptoms (paralysis, abnormal movement, dysphagia, speech disorder, seizures, sensory impairment) Management: see anxiety disorder 1) cognitive behavioral therapy (CBT) is effective [1]; first line [14] - relaxation therapy alone (generally a component of CBT) is effective [3] - durability of effects > 12 months small to medium [13] 2) Kundalini yoga is effective [14] 3) pharmaceutical agents a) SSRI [5], SNRI [8] b) buspirone (BuSpar) or pregabalin 2nd line agents c) benzodiazepines may be use in selected patients [8] - avoid in patients with history of substance use disorder (MKSAP19) [1] d) hydroxyzine is not recommended [4] 4) less responsive to pharmacotherapy than panic disorder 5) combination of cognitive behavioral therapy with SSRI or SNRI [8]

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anxiety disorder

References

  1. Medical Knowledge Self Assessment Program (MKSAP) 11, 16, 17, 18, 19. American College of Physicians, Philadelphia 1998, 2012, 2015, 2018, 2021. - Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022
  2. Geriatrics at your Fingertips, 13th edition, 2011 Reuben DB et al (eds) American Geriatric Society
  3. Geriatric Review Syllabus, 8th edition (GRS8) Durso SC and Sullivan GN (eds) American Geriatrics Society, 2013
  4. Guaiana G, Barbui C, Cipriani A. Hydroxyzine for generalised anxiety disorder. Cochrane Database Syst Rev. 2010 Dec 8;(12):CD006815. Review. PMID: 21154375
  5. Lenze EJ, Rollman BL, Shear MK Escitalopram for older adults with generalized anxiety disorder: a randomized controlled trial. JAMA. 2009 Jan 21;301(3):295-303. PMID: 19155456
  6. Mackenzie CS, Reynolds K, Chou KL, Pagura J, Sareen J. Prevalence and correlates of generalized anxiety disorder in a national sample of older adults. Am J Geriatr Psychiatry. 2011 Apr;19(4):305-15. PMID: 21427639
  7. Zhang X et al. Risk factors for late-onset generalized anxiety disorder: Results from a 12-year prospective cohort (The ESPRIT study). Transl Psychiatry 2015 Mar 31; 5:e536 PMID: 2582611
  8. Stein MB, Sareen J Generalized Anxiety Disorder N Engl J Med 2015; 373:2059-2068. November 19, 2015 PMID: 26580998 http://www.nejm.org/doi/full/10.1056/NEJMcp1502514
  9. Wetherell JL, Petkus AJ, White KS, et al. Antidepressant medication augmented with cognitive-behavioral therapy for generalized anxiety disorder in older adults. Am J Psychiatry. 2013 Jul 1;170(7):782-789 PMID: 23680817
  10. Medscape: escitalopram (Rx)Lexapro http://reference.medscape.com/drug/lexapro-escitalopram-342961
  11. Patel G, Fancher TL. In the clinic. Generalized anxiety disorder. Ann Intern Med. 2013 Dec 3;159(11):ITC6-1, ITC6-2, ITC6-3, ITC6-4, ITC6-5, ITC6-6, ITC6-7, ITC6-8, ITC6-9, ITC6-10, ITC6-11; quiz ITC6-12. Review. PMID: 24297210
  12. Flint AJ. Generalised anxiety disorder in elderly patients: epidemiology, diagnosis and treatment options. Drugs Aging 2005; 22:101 PMID: 15733018
  13. van Dis EAM, van Veen SC, Hagenaars MA et al Long-term Outcomes of Cognitive Behavioral Therapy for Anxiety-Related Disorders. A Systematic Review and Meta-analysis. JAMA Psychiatry. Published online November 23, 2019 PMID: 31758858 https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2756136
  14. Simon NM, Hofmann SG, Rosenfield D et al Efficacy of Yoga vs Cognitive Behavioral Therapy vs Stress Education for the Treatment of Generalized Anxiety Disorder. A Randomized Clinical Trial. JAMA Psychiatry. 2021;78(1):13-20. Aug 12, 2020 PMID: 32805013 https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2769486
  15. DeMartini J, Patel G, Fancher TL. Generalized anxiety disorder. Ann Intern Med. 2019;170:ITC49-ITC64. PMID: 30934083