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Updated: Jun 4 2024

Generalized Anxiety Disorder

  • Snapshot
    • A 40-year-old man seeks help at an urgent care for palpitations. He is otherwise healthy. After an electrocardiogram rules out any cardiac issues, the physician performs a thorough history and exam, noting that he has restlessness. He reports these feelings come and go, and he has felt this way for the past 3 years. He has anxiety surrounding multiple different unrelated aspects of his life including his health, his performance at work, his marriage, his parenting, and his financial stability among many other things that he finds troublesome.
  • 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
        • normal stress response 
        • major depressive disorder
        • substance misuse disorders
        • globus hystericus 
  • 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
    • Social anxiety disorder
      • Physiological distress, avoidance behaviors, fear of embarrassment, humiliation, and rejection in social situations
      • Distinguish from generalized anxiety disorder, as it only occurs in the setting of social situations
    • 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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