Dr. Pam’s Information on
Generalized Anxiety (GAD) Disorder in adults
Generalized anxiety disorder (GAD) is characterized by:
1. Excessive and persistent worrying that is hard to control
2. Anxiety that causes significant distress or impairment
3. Occurs on more days than not for at least six months.
6. Fatigue l
7. Muscular tension
Sometimes, patients may:
8. Constantly scan the environment for cues of threat
9. Develop worrying in an attempt to solve problems
10. Use worrying to avoid the fear response
11. Have intolerance of uncertainty
12. Worry about the uncontrollability and presumed dangerous consequences of worrying
The disorder is approximately twice as common in women as it is in men.
GAD is probably the most common anxiety disorder among the elderly population.
Generalized anxiety disorder (GAD) is considered to be a potentially chronic illness, fluctuating in symptom severity over time and can be as debilitating as chronic depression.
GAD may also be associated with:
- substance abuse
- post-traumatic stress disorder
- obsessive-compulsive disorder
Patients major depression and GAD tended to have a more severe and prolonged course of illness and greater functional impairment.
GAD is common among patients with “medically unexplained” chronic pain and with chronic physical illness.
Excessive and persistent worrying is widely regarded as the main feature of generalized anxiety disorder.
Patients do present with other symptoms:
2. Autonomic hyperactivity (sweating)
3. Muscle tension
4. Poor sleep
6. Difficulty relaxing
8. Pain in the neck, shoulders, and back
GAD can have an effect on your heart!
GAD is associated with poor heart health, coronary heart disease, and cardiovascular death.
● Excessive worry has been associated with diminished heart rate variability and elevated heart rate
● Worrying and GAD have been commonly associated with increased blood pressure, diagnosed hypertension, and antihypertensive use in both disease-free patients and those with coronary heart disease
● Greater severity of worry has been associated with higher rates of fatal and nonfatal coronary heart disease, independent of the presence or severity of depression
● No evidence has been found to support the contention that worry might be beneficial for health promoting behaviors
1. Complete blood count
2. Chemistry panel
3. Serum thyroid evaluation (TSH)
5. ECG or Electrocardiogram in patients over 40 with chest pain or palpitations
6. Urine or serum toxicology analysis for drugs or medications
1. Substance abuse history (alcohol, prescription drugs, caffeine, and nicotine)
2. Medical history
3. Medication side effects
4. Family psychiatric history
5. Social history (stressful life events and past sexual, physical and emotional abuse, or emotional neglect)
The diagnosis of generalized anxiety can be made if a patient has:
1. Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least six months, about a number of events or activities (such as work or school performance).
2. The individual finds it difficult to control the worry.
3. The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms having been present for more days than not for the past six months):
a. Restlessness or feeling keyed up or on edge
b. Being easily fatigued
c. Difficulty concentrating or mind going blank
e. Muscle tension
f. Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep)
4. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning
5. The disturbance is not attributable to the physiological effects of a substance (eg, a drug of abuse, a medication) or another medical condition (eg, hyperthyroidism).
6. Exclusion of the other anxiety disorders:
a. Panic disorder h. Having a serious illness
b. Social anxiety disorder i. Anorexia nervosa
c. Obsessive-compulsive disorder j. Delusional disorder
d. Separation anxiety disorder k. Schizophrenia
e. Post-traumatic stress disorder
f. Somatic symptom disorder
g. Body dysmorphic disorder
The diagnosis of GAD in elderly individuals can be challenging due to:
1. Long-term physical illnesses
2. Chronic insomnia
3. Cognitive impairment
4. Side-effects of prescribed medication
7. Panic disorder
8. Adjustment disorder
9. Obsessive compulsive disorder
10. Separation anxiety disorder
Selective-serotonin reuptake inhibitors (SSRIs)
Selective-Serotonin Re-uptake Inhibitors (SSRIs) and efficacious in the treatment of generalized anxiety disorder (GAD).
In cases of co-occurring GAD and depression, a common comorbidity, SSRIs can provide effective treatment for both GAD and major depression. Other medications efficacious for GAD, eg, benzodiazepines or pregabalin, are not effective treatments for depression.
Studies have generally shown that all SRIs studied have the same degree of effectiveness.
The selection among SSRIs or SNRIs can be customized to the patient based on:
1. the drug’s side effect profile
2. drug-drug interactions
3. patient treatment history or preference
SSRIs — Selective serotonin reuptake inhibitors (SSRIs):
1. Paxil or paroxetine
2. Zoloft or sertraline
3. Celexa or citalopram
4. Lexapro or escitalopram
5. Prozac or fluoxetine
6. Luvox or fluvoxamine
SSRIs common side effects include:
- sexual dysfunction (inability to have an orgasm, low libido)
- gastrointestinal abnormalities (nausea and diarrhea)
- withdrawal on discontinuation
- drug interactions
- weight gain
- agitation and/or hyper-activation
Serotonin-norepinephrine reuptake inhibitors (SNRIs)
Serotonin-Norepinephrine Re-uptake Inhibitors (SNRIs) are great for the treatment of generalized anxiety disorder (GAD).
Serotonin-norepinephrine re-uptake inhibitors (SNRIs) inhibit serotonin and norepinephrine re-uptake. Their efficacy and tolerability is comparable to SSRIs and the use follows the same general guidelines.
SNRIs – Serotonin-norepinephrine Reuptake Inhibitors:
1. Cymbalta or duloxetine
2. Effexor or Venlafaxine
3. Pristiq or Desvenlafaxine
4. Fetzima or Levomilnacipran
5. Sevella or Milnacipran
Common side effects of SNRIs:
- Venlafaxine may increase blood pressure
Time to onset of clinically meaningful action: about 4 weeks (give it time to work!)
The initial therapeutic dose should be continued for four to six weeks. If the patient does not show a robust response, the SRI should be increased in one- to two-week increments until sufficient improvement is seen or the maximum recommended or highest tolerated dose is reached.
Buspirone has been shown in clinical trials to reduce symptoms of anxiety in patients with generalized anxiety disorder (GAD), offering similar effectiveness to benzodiazepines without the risk of dependence.
The medication should be given a trial of four to six weeks at the maximally tolerated dose before concluding it is ineffective. It also works well in addition to SSRIs or SNRIs listed above.
Buspirone’s time to onset is longer than benzodiazepines’ and similar to the antidepressants’ average of four weeks.
Typical side effects of Buspar can include:
Pregabalin has shown efficacy for generalized anxiety disorder (GAD).
It was approved in 2006 for the treatment of anxiety in Europe.
Pregabalin is NOT approved for treating GAD by the US Food and Drug Administration.
The doses for pregabalin range from 50 to 300 mg, though many patients may need a total daily dose of greater than 150 mg. Tolerance, withdrawal, and dependence are possible, but pregabalin is generally better tolerated than benzodiazepines.
Side effects of Pregabalin include:
Benzodiazepines have been found to be efficacious in the treatment of generalized anxiety disorder (GAD), generally leading to a reduction of emotional and somatic symptoms within minutes to hours, depending on the specific medication.
However, concerns about risks of dependence and tolerance have contributed to a decline in their use.
While benzodiazepines should be used with caution and avoided in patients with a history of a substance use disorder, their use need not be entirely avoided.
They may be used for acute, maintenance, or long-term treatment of GAD, either as monotherapy or, more commonly, as an adjunct to antidepressant treatment.
Benzodiazepines are most commonly used for acute management of anxiety and worry during the period before selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors take effect.
They can counteract the initial agitation often caused by the SSRI.
Once the patient responds to the SSRI, the benzodiazepine can be tapered off gradually.
Antidepressants are preferred over benzodiazepines when depression is also present, because antidepressants are effective treatments for both conditions.
Patients with chronic GAD, minimal current depressive symptoms, and no history of a substance use disorder are candidates for long-term, low-dose benzodiazepine treatment if antidepressants are ineffective or poorly tolerated.
1. Xanax or Alprazolam
3. Librium or Chlordiazepoxide
4. Klonopin or Clonazepam
5. Tranxene or Clorazepate
6. Valium or Diazepam
7. Ativan or Lorazepam
Side effects of benzodiazepines include:
- impairment of psychomotor performance - amnesia
- withdrawal symptoms after long-term treatment - dependence
- rebound anxiety after short-term treatment
Signs of withdrawal from benzodiazepines include:
- perceptual disturbances
Imipramine or Tofranil, is a tricyclic antidepressant (TCA), has been shown to be efficacious in treatment of patients with generalized anxiety disorder, including those without co-morbid depression or panic disorder.
Selective serotonin re-uptake inhibitors (SSRIs) and serotonin-norepinephrine re-uptake inhibitors (SNRIs) are generally preferred over TCAs because the latter have an increased risk of cardiotoxicity in overdose and less acceptable tolerability profiles.
Vilazodone or Viibryd, is a selective serotonin re-uptake inhibitor and a 5-HT1A receptor partial agonist, to be as efficacious as other SRIs in GAD
Quetiapine or Seroquel,
Quetiapine is an antipsychotic medication has been used for GAD but has not been approved for the disorder by the US Food and Drug Administration.
Adverse side effects associated with antipsychotics include:
- extrapyramidal symptoms
- tardive dyskinesia
- weight gain
- elevation of glucose and lipid levels
Hydroxyzine, Atarax, or Vistaril
Hydroxyzine was found to be more sedating than benzodiazepines and buspirone and thus potentially useful for treating insomnia associated with GAD.
DURATION OF MEDICATION USE
If effective, antidepressant treatment for generalized anxiety disorder (GAD) should be continued for at least 12 months rather than the 6 months supported by previous research.
If the patient experiences a relapse following termination of an effective medication, the length of treatment can be extended. After two relapses when tapering off the medication, ongoing maintenance treatment should be considered.
COGNITIVE BEHAVIORAL THERAPY
Cognitive behavioral therapy (CBT) is a short-term, goal-oriented psychotherapy treatment that takes a hands-on, practical approach to problem-solving. Its goal is to change patterns of thinking or behavior that are behind people's difficulties, and so change the way they feel.
Choosing between medication and cognitive behavioral therapy (CBT)
For most patients with a new diagnosis of GAD who need treatment, we recommend a serotonergic antidepressant (SSRI or SNRI), cognitive-behavioral therapy (CBT), or both, rather than other interventions. Serotonergic antidepressants and CBT are the most widely studied and best treatments for GAD.
Along with its use as mono-therapy, clinical trials support the use of cognitive-behavioral therapy (CBT) in combination with medication in patients who have experienced a partial drug response.
Combined therapy with medication and CBT should be administered with caution to avoid counterproductive interactions. Principles that should guide the practice include:
● Patients should be on a stable, tolerable medication dose prior to starting CBT.
● Avoid “as needed” and large doses of benzodiazepines.
● Avoid medications with sedative effects, including benzodiazepines and atypical antipsychotics.