Updated: 9/2/2020

Generalized Anxiety Disorder

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Snapshot
  • A 40-year-old man seeks help at an urgent care for palpitations and tremors. He is otherwise healthy. After an electrocardiogram rules out any cardiac issues, the physician performs a thorough history and exam, noting that he has tremors, cold and clammy hands, tachycardia, and overall restlessness. He reports these feelings come and ago, and he has felt this way for the past 3 years. On further investigation, he has a remote history of generalized anxiety disorder and had taken tricyclic antidepressants (TCAs). He is wary of medications given the side effects he had experienced on TCAs, and he hopes to find an alternative way to treat his anxiety.
Introduction
  • Overview
    • generalized anxiety disorder (GAD) is a type of anxiety disorder, which also includes panic disorder, phobia disorders, and obsessive-compulsive disorder
      • GAD is characterized by anxiety lasting > 6 months unrelated to any specific triggers or if identifiable stressor has ended
  • Epidemiology
    • incidence
      • very common
    • risk factors
      • genetic susceptibility
      • environmental instability
  • Pathogenesis
    • mechanism
      • unclear but mediators of anxiety in the brain appear to be norepinephrine, serotonin, dopamine, and GABA
      • some patients may also have genetic predisposition to anxiety
  • Associated conditions
    • other mood disorders
      • major depressive disorder
      • substance misuse disorders
Presentation
  • Symptoms
    • excessive anxiety and persistent worrying
    • at least 3 of the following
      • restlessness
      • fatigue
      • difficulty concentrating
      • irritability
      • muscle tension
      • sleep disturbance
  • Physical exam
    • excitation/hyperactivity
      • tremors
      • rapid heartbeat
      • sweating
      • restlessness
      • dry mouth
      • globus sensation
      • cold and clammy hands
      • shaking
Differential
  • Adjustment disorder
    • key distinguishing factors
      • anxiety or other mood changes with onset within 3 months of an identifiable stressor or trigger, lasting < 6 months once that stressor has ended
      • treatment also consists of cognitive behavioral therapy and selective serotonin reuptake inhibitors
Treatment
  • Lifestyle
    • cognitive behavioral therapy
      • indications
        • all patients
        • may often need pharmacotherapy as well
  • Medical
    • selective serotonin reuptake inhibitors (SSRIs)
      • indications
        • first-line
      • drugs
        • fluoxetine
        • paroxetine
        • sertraline
        • escitalopram
    • serotonin-norepinephrine reuptake inhibitors (SNRIs)
      • indications
        • first-line
      • drugs
        • venlafaxine
        • duloxetine
    • tricyclic antidepressants (TCA)
      • indications
        • second-line due to worse side effect profile
    • buspirone
      • indication
        • adjunct to SSRIs
    • benzodiazepines
      • indications
        • second-line due to potential for addiction and short-lived effects
    • herbal
      • indication
        • patients wary of medications
      • modalities
        • kava plant has been shown in verified studies to have a mild beneficial effect for patients with generalized anxiety disorder
        • kava toxicity manifests as liver failure, hepatitis, or cirrhosis
Complications
  • Complications
    • decreased quality of life
    • substance abuse

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(M3.PY.15.106) A 46-year-old woman presents to her family physician for a general wellness checkup with a chief complaint of high levels of anxiety over the past year. Her anxiety has started to affect her performance at work, making her even more anxious and concerned that she will lose her job. She started psychotherapy several months ago and has experienced minimal improvement in her symptoms from this treatment. The patient is vehemently opposed to beginning any pharmacologic treatment for anxiety; however, she is interested in potential herbal remedies and has started taking kava. She also takes vitamin D, a multivitamin, fish oil, protein powder, and drinks goat milk regularly. The patient works as a commercial sex worker and has a history of IV drug abuse and alcohol abuse which she states she has not used in over a year. She has chronic tension headaches for which she self-administers acetaminophen usually multiple times per day. Her last wellness appointment was unremarkable and these problems are new. Laboratory values are ordered as seen below.

Hemoglobin: 13 g/dL
Hematocrit: 38%
Leukocyte count: 6,870/mm^3 with normal differential
Platelet count: 227,000/mm^3

Serum:
Na+: 138 mEq/L
Cl-: 102 mEq/L
K+: 4.1 mEq/L
HCO3-: 25 mEq/L
BUN: 20 mg/dL
Glucose: 111 mg/dL
Creatinine: 1.0 mg/dL
Ca2+: 10.2 mg/dL
AST: 82 U/L
ALT: 90 U/L

Which of the following is the most likely cause of this patient's lab derangements?
Tested Concept

QID: 103596
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Acetaminophen

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Acute hepatitis B infection

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Alcoholic hepatitis

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Chronic hepatitis C infection

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Dietary supplement

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Select Answer to see Preferred Response

(M2.PY.15.108) A 43-year-old woman presents to a new primary care physician complaining of anxiety. She has been worrying non-stop recently about the possibility that her husband will lose his job as a teacher. Her husband, who is present, assures the physician that his job is entirely secure and states that she has "fretted" for their entire marriage, though the exact topic causing her anxiety varies over time. She also worries excessively about everyday tasks, such as whether she will catch the train on time and whether their house in Southern California is sufficiently earthquake-proof. She has no way to overcome these worries. She endorses other symptoms including poor sleep (associated with racing thoughts about her various worries), fatigue, and impaired concentration at work, all of which have been present for at least the past year. Her vital signs are within normal limits and there are no abnormalities on physical exam. What is the most likely diagnosis? Tested Concept

QID: 105778
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Acute stress disorder

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Social phobia

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Agoraphobia

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Posttraumatic stress disorder

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Generalized anxiety disorder

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(20/21)

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Evidence (3)
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EXPERT COMMENTS (4)
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