Generalized anxiety disorder (GAD) is characterized by excessive, uncontrollable and often irrational worry, that is, apprehensive expectation about events or activities. This excessive worry often interferes with daily functioning, as individuals with GAD typically anticipate disaster, and are overly concerned about everyday matters such as health issues, money, death, family problems, friendship problems, interpersonal relationship problems, or work difficulties

The main diagnostic criteria of GAD are excessive anxiety and worry that is difficult to control, along with at least 3 from a list of 6 symptoms: restlessness, irritability, difficulty concentrating, muscle tension, sleep disturbances, and being easily fatigued and duration of the disorder for at least 6 months.  Symptoms must be distressing or impairing and not adequately explained by another related disorder.

Screening for GAD can potentially be helpful in improving detection rates in primary care, which can lead to more appropriate treatment and improved patient outcomes. GAD-7 was developed to facilitate the diagnosis. The scale has been shown to be an efficient tool that can screen for likely cases of GAD and can assess symptom severity and assist with the clinical assessment and treatment of GAD.  A link to the assessment tool is included.

The main treatment approaches for GAD include pharmacotherapy or psychotherapy or a combination of both. The often chronic and disabling nature of GAD means that some individuals may fail to respond fully to first-line treatment. Patients may therefore require a sequential trial of treatments.  Psychological therapies are an important first-line option in the management of GAD.

The treatment plan for GAD should account for (1) predominant symptoms, (2) severity of the condition, (3) presence of concomitant medical illness, (4) complications such as substance abuse or the risk of suicide, (5) outcomes of any previous treatments, (6) cost issues, (7) availability of treatment in a given area, and (8) patient preferences.

There are various options for medication management of GAD. Next week’s newsletter will focus on this topic.

GAD is frequently associated with other psychiatric conditions such as other mood or anxiety disorders, somatoform/pain disorders, medically unexplained symptoms, and substance use disorders.  It has also been linked with medical disorders such as heart disease, GI and chronic pain disorders.

Effective management of GAD has the potential to improve quality of life for patients and their families, as well as improve patient productivity and reduce the impact of the condition on health care resources.  The use of appropriate screening tools and providing information to patients with GAD on their condition and its treatment are an important starting point toward increasing recognition and appropriate treatment of GAD.

References:

http://www.integration.samhsa.gov/clinical-practice/GAD708.19.08Cartwright.pdf/

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2911006/

This case leads nicely into a discussion about how to approach the treatment of an anxiety disorder. The first step is to determine a specific diagnosis and determine the level of impairment of the symptoms. If the impairment is mild-moderate, one could start with a therapy approach and determine if medication treatment is needed in the future.

If the impairment is moderate-severe, the standard of care is to begin therapy and medication treatment concurrently. Medication treatment should minimally involve an approach to treat the underlying anxiety – first line would be an SSRI medication.

Other options, if that doesn’t work, could include: SNRIs, Remeron, and Buspar. For many patients, it is helpful to initially prescribe an adjunctive medication to provide some relief for their anxiety while the primary medication is “kicking in”. These include: Buspar (which can be useful for the underlying anxiety management as well as for acute anxiety management), Vistaril, Propranolol, and the benzodiazepines.

Some providers may consider low doses of the atypical antipsychotics, but the concern about that practice is that the patient is still exposed to the possible metabolic side effects of that class of medications even at low doses, as many of the metabolic side effects of antipsychotics are dose-independent. For patients for whom they are effective, these adjunctive medications yield benefits more quickly than the traditional anti-anxiety medications.

In many cases, these medications can be tapered off once the base medication has fully “kicked in”.  Buspar is typically dosed 7.5 mg bid and increased by 5 mg every 2-3 days as tolerated up to 30 mg bid. Onset of action may take 2 weeks. It is relatively well tolerated with less cognitive impairment than benzodiazepines. Major side effects include dizziness, fatigue, and nausea. Vistaril is typically dosed 25-50 mg bid-tid on a prn basis. It is less sedating than Benadryl, therefore is better tolerated during the daytime. Propranolol is typically dosed 20-40 mg if used on a prn basis and 20 mg bid-tid titrated up to 40 mg bid-tid as tolerated and needed if used on a standing basis.

We hope this extensive discussion about this case and the thinking process that occurred in the background was helpful for other similar cases you might encounter in your practice.