Generalized anxiety disorder GAD

The usually accepted prevalences for generalized anxiety disorder (GAD) are around 1.6% for current, 3.1% for 1 year and 5.1% lifetime (Roy-Byrne, 1996). The condition is twice as common in women as in men (Pigott, 1999). A small minority (10%) have GAD alone, and about the same proportion suffer from mixed anxiety and depression. Morbidity is high. About a half of those with uncomplicated GAD seek professional help, but two-thirds of those with comorbid GAD do so. Up to a half take medication at some point. The condition may coexist with other anxiety disorders such as phobias, with affective disorders, or with medical conditions such as unexplained chest pain and irritable bowel syndrome. 

With a lifetime prevalence of 28.8%, anxiety disorders collectively represent the most prevalent Diagnostic and Statistical Manual of Mental Disorders, 4th edition, Text Revision (DSM-IV-TR)2 class of disorders, with specific phobia (12.5%) and social anxiety disorder (12.1%) being the most common.3 Recent reports from the National Comorbidity Survey Revised (NCS-R) estimate the lifetime and 1-year prevalence of generalized anxiety disorder (GAD) for those 18 years of age and older to be 5.7% and 3.1%, respectively.3,4 Rates for panic disorder (PD) are slightly lower, with an estimated 12-month prevalence of 2.7% and lifetime prevalence of 4.7%. 

Freud coined the term anxiety neurosis approximately 100 years ago, and all forms of anxiety would be subsumed under that collective diagnostic entity for decades to come. In 1980, based on an emerging literature DSM-111 classified anxiety disorders into several discrete syndromes including panic disorder, obsessive-compulsive disorder (OCD), and generalized anxiety disorder (GAD). 

Finally, generalized anxiety disorder (GAD) is characterized by a chronic, unremitting yet uncontrollable worry that disturbs emotional well-being and interferes with social and occupational functioning. 

Generalized Anxiety Disorder (GAD). Theoretically, panic disorder and GAD should be fairly easy to distinguish. The symptoms of a panic attack are known for their intensity and their brevity, whereas the symptoms of GAD tend to be somewhat milder and considerably more persistent. Nevertheless, patients commonly confuse the two when describing their symptoms. It is not at all unusual for a patient to describe an anxiety attack or panic attack that comes on gradually and lasts several hours (or even days). This does not represent a true panic attack but a periodic fluctuation in the severity of their anxiety. 

Anxiety Treatment of generalized anxiety disorder (GAD) and social anxiety disorder (SAD) (extended-release [ER] only). 

Social anxiety disorder/generalized anxiety disorder (GAD) Paroxet ne (immediate-and controlled-release except Pexei/a), sertraline, escitalopram. 

There is also evidence for both the familial aggregation and heritability of generalized anxiety disorder (GAD) in a limited number of studies. There is a five-fold average increase in the rister of GAD among relatives of probands with GAD compared to that among relatives of controls 5 (Mendlewicz et al. 1993 Noyes et al. 1987) and the heritability of GAD among female twins is 0.32 (Kendler et al. 1992). 

Several SSRls have been PDA approved for one or more specific anxiety diagnoses [e.g., paroxetine for social anxiety, generalized anxiety disorder (GAD)... 

Depression, generalized anxiety disorder (GAD) PO 10 mg/day Uniabeied Uses Mixed anxiefy and depressive disorder Contraindications Usewifhin 14 days of MAOIs... 

The selective serotonin reuptake inhibitors (SSRI) have been used in adults for a wide variety of disorders, including major depression, social anxiety (social phobia), generalized anxiety disorder (GAD), eating disorders, premenstrual dysphoric disorder (PMDD), post-traumatic stress disorder (PTSD), panic, obsessive-compulsive disorder (OCD), trichotillomania, and migraine headaches. Some of the specific SSRI agents have an approved indication in adults for some of these disorders, as reviewed later in this chapter. The SSRIs have also been tried in children and in adults for symptomatic treatment of pain syndromes, aggressive or irritable ( short fuse ) behavior, and for self-injurious and repetitive behaviors. This chapter will review general aspects of the SSRIs and discuss their approved indications in children and adolescents. 

Buspirone has been shown to be very effective in treating generalized anxiety disorder (GAD). It is especially useful when combined with a benzodiazepine, probably because using these two drugs together causes the activation of two neurotransmitter systems (GABA and serotonin). 

Generalized anxiety disorder (GAD)—Psychological disorder marked by long-term worry. 

The nosology of anxiety disorders has changed considerably over the past 40 years (141). Such disorders were not mentioned in the original DSM. In DSM-II, problems with anxiety were considered a subset of behavioral disorders and were restricted to overanxious and withdrawing reactions. The DSM-III defined three types of anxiety disorders in children and adolescents overanxious, avoidant, and separation disorder. The DSM-III also acknowledged that children and adolescents could meet adult criteria for simple phobias, panic disorder, posttraumatic stress disorder, and obsessive-compulsive disorder (OCD). In DSM-IV ( 45), generalized anxiety disorder (GAD) and social phobia (or social anxiety disorder with childhood onset) replaced overanxious disorder and avoidant disorder, respectively. 

Some of the growth in antidepressant use may be related to the broad application of these agents for conditions other than major depression. For example, antidepressants have received FDA approvals for the treatment of panic disorder, generalized anxiety disorder (GAD), post-traumatic stress disorder (PTSD), and obsessive-compulsive disorder (OCD). In addition, antidepressants are commonly used to treat pain disorders such as neuropathic pain and the pain associated with fibromyalgia. Some antidepressants are used for treating premenstrual dysphoric disorder (PMDD), mitigating the vasomotor symptoms of menopause, and treating stress urinary incontinence. Thus, antidepressants have a broad... 

FIGURE 8-1. Anxiety and depression can be combined in a wide variety of syndromes. Generalized anxiety disorder (GAD) can overlap with major depressive disorder (MDD) to form mixed anxiety depression (MAD). Subsyndromal anxiety overlapping with subsyndromal depression to form subsyn-dromal mixed anxiety depression, sometimes also called anxious dysthymia. Major depressive disorder can also overlap with subsyndromal symptoms of anxiety to create anxious depression GAD can also overlap with symptoms of depression such as dysthymia to create GAD with depressive features. Thus, a spectrum of symptoms and disorders is possible, ranging from pure anxiety without depression, to various mixtures of each in varying intensities, to pure depression without anxiety. 

FIGURE 8—4. Subsyndromal anxiety can also be a harbinger of an episode of a full generalized anxiety disorder (GAD). Such patients may have an intermittent clinical course, which waxes and wanes over time between subsyndromal anxiety and GAD. Decompensating to full GAD with recovery only to a state of subsyndromal anxiety over time can also be called the double anxiety syndrome. 

FIGURE 8—5. Not only may subsyndromal anxiety be a harbinger for decompensation to generalized anxiety disorder (GAD), but GAD in turn may be a harbinger for decompensation to panic disorder in some patients. 

FIGURE 8—6. Subsyndromal mixed anxiety depression (MAD) may be an unstable psychological state, characterized by vulnerability under stress to decompensation to more severe psychiatric disorders, such as generalized anxiety disorder (GAD), full-syndrome MAD, or major depressive disorder (MDD). 

Generalized anxiety disorder (GAD) is distinct from major depressive disorder with anxiety in that it is unusual for a patient to have GAD at one point in time and major depressive disorder with anxiety at another time. 

Pathological inability to forget aversive events may be therefore explained by reduced NE transmission in the PFC (Mueller et al., 2008b). Therefore, the NE system might playan important role in the pathology of generalized anxiety disorder (GAD), panic disorder (PD) and post-traumatic stress disorder (PTSD). However, different NE pathways may be involved. 

Anxiety disorders include a range of diagnoses in which panic or disabling anxiety is a prominent feature. These include panic disorder with and without agoraphobia, specific phobias, PTSD, social phobia, OCD, and generalized anxiety disorder (GAD) (Table 4.1). 

Noradrenergic model. This model suggests that the autonomic nervous system of anxious patients is hypersensitive and overreacts to various stimuli. The locus ceruleus may have a role in regulating anxiety, as it activates norepinephrine release and stimulates the sympathetic and parasympathetic nervous systems. Chronic noradrenergic overactivity down regulates 02-adrenoreceptors in patients with generalized anxiety disorder (GAD) and posttraumatic stress disorder (PTSD). Patients with social anxiety disorder (SAD) appear to have a hyperresponsive adrenocortical response to psychological stress. 

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