Which of the following medications has antianxiety effects with minimal unwanted sedation?
1. Buspirone
2. Chlordiazepoxide
3. Lorazepam
4. Fluoxetine
Teaching Points
Selective serotonin reuptake inhibitors (SSRIs) are anxiolytic and most are nonsedating.
Buspirone is an anti-anxiolytic but has sedative effects as well. About 10% of patients experience dizziness or fatigue.
Lorazepam and chlordiazepoxide are benzodiazepines.
Benzodiazepines are common sedative medications with anxiolytic properties.
Anxiety, Generalized Anxiety Disorder (GAD)
Article Author:
Sadaf Munir
Article Editor:
James Hughes
Editors In Chief:
Mitchell Farrell Brian Froelke
Managing Editors:
Frank Smeeks Scott Dulebohn Erin Hughes Pritesh Sheth Mark Pellegrini James Hughes Richard Ciresi Phillip Hynes
Updated:
10/27/2018 12:31:36 PM
Introduction
Generalized anxiety disorder is one of the most common mental disorders. Up to 20% of adults are affected by anxiety disorders each year. Generalized anxiety disorder produces fear, worry, and a constant feeling of being overwhelmed. Generalized anxiety disorder is characterized by persistent, excessive, and unrealistic worry about everyday things. This worry could be multifocal such as finance, family, health, and the future. It is excessive, difficult to control, and is often accompanied by many non-specific psychological and physical symptoms. The excessive worry is the central feature of generalized anxiety disorder.
Diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) include the following:
Excessive anxiety and worry for at least six months
Difficulty controlling the worrying.
Anxiety and worry associated with at least three of the following:
Restlessness or feeling keyed up or on edge
Being easily fatigued, difficulty in concentrating or mind going blank, irritability
Muscle tension
Sleep disturbance.
Etiology
The etiology may include:
Stress
Physical condition such as diabetes or other comorbidities such as depression
Genetic, first-degree relatives with generalized anxiety disorder (25%)
Environmental factors such as child abuse
Substance abuse.
Epidemiology
Childhood anxiety occurs in about one-in-four children at some time between the ages of 13 and 18 years. The median age at onset is 11 years. However, the lifetime prevalence of a severe anxiety disorder in children 13 to 18 is approximately 6%. General prevalence in children younger than 18 years is between 5.7% and 12.8%. The prevalence is approximately twice as high among women as among men.
The American Psychiatric Association first introduced the diagnosis of generalized anxiety disorder two decades ago in the DSM-III. Before that time, generalized anxiety disorder was conceptualized as one of the two core components of anxiety neurosis, the other being panic. A recognition that generalized anxiety disorder and panic, although often occurring together, are sufficiently distinct to be considered independent disorders led to their separation in the DSM-III.
The DSM-III definition of generalized anxiety disorder required uncontrollable and diffuse (i.e., not focused on a single major life problem) anxiety or worry that is excessive or unrealistic in relation to objective life circumstances and that persists for one month or longer. Several related psychophysiological symptoms also were required to occur with the anxiety or worry for a diagnosis of generalized anxiety disorder. Early clinical studies evaluating DSM-III according to this definition in clinical samples found that the disorder seldom occurred in the absence of some other comorbid anxiety or mood disorder. Comorbidity of generalized anxiety disorder and major depression was especially strong and led some commentators to suggest that generalized anxiety disorder might better be conceptualized as a prodrome, residual, or severity marker than as an independent disorder. The rate of comorbidity of generalized anxiety disorder with other disorders decreases as the duration of generalized anxiety disorder increases. Based on this finding, the DSM-III-R committee on generalized anxiety disorder recommended that the duration requirement for the disorder be increased to six months. This change was implemented in the final version of the DSM-III-R. Additional changes in the definition of excessive worry and the required number of associated psychophysiological symptoms were made in the DSM-IV.
These changes in diagnostic criteria led to delays in cumulating data on the epidemiology of generalized anxiety disorder. Nonetheless, such data became available over the past decade. As described in more detail later, these new data challenged the view that generalized anxiety disorder should be conceptualized as a prodrome, residual, or severity marker of other disorders. Instead, the data suggest that generalized anxiety disorder is a common disorder that, although often comorbid with other mental disorders, does not have a rate of comorbidity that is higher than those found in most other anxiety or mood disorders. The new data also challenge the validity of the threshold decisions embodied in the DSM-IV.
Pathophysiology
The exact mechanism is not entirely known. Noradrenergic, serotonergic, and other neurotransmitter systems are believed to play a role in the body's response to stress. The serotonin system and the noradrenergic systems are common pathways involved in anxiety. Many believe that low serotonin system activity and elevated noradrenergic system activity are responsible for its development. It is, therefore, selective serotonin reuptake inhibitors (SSRI) and serotonin-norepinephrine reuptake inhibitors (SNRI) that are the first-line agent for its treatment. Anxiety can be a normal phenomenon in children. Stranger anxiety begins at seven to nine months of life.
History and Physical
Patients with anxiety can pose a diagnostic challenge. Somatic symptoms are more common than psychologic symptoms. Most patients present with vague or nonspecific somatic complaints. Somatic symptoms include shortness of breath, palpitations, fatigability, headache, dizziness, and restlessness. Most patients present with vague or nonspecific somatic complaints. Psychologic symptoms such as excessive, nonspecific anxiety and worry, feeling on edge, difficulty concentrating irritability, and sleeping difficulty.
Evaluation
Assessment begins by initially addressing behavior or somatic symptoms. Evaluate for psychosocial stress, psychosocial difficulties, and developmental issues. Review past medical history such as trauma, psychiatric conditions, and substance abuse.
Generalized Anxiety Disorder 7-Item (GAD-7) Questionnaire. This tool can be used to screen as well as to monitor outcome in patients with generalized anxiety disorder.
The following evaluation may be obtained to exclude organic causes:
Thyroid function tests
Blood glucose level
Echocardiography
Toxicology screen
Multidimensional Anxiety Scale for Children
Child Anxiety Related Emotional Disorders (SCARED)
Treatment / Management
The two main treatments for generalized anxiety disorder are cognitive behavior therapy and medications. Patients may benefit most from a combination of the two. It may take some trial and error to discover which treatments work best.
Cognitive Behavioral Therapy
This includes psychoeducation, changing maladaptive thoughts patterns, and gradual exposure to anxiety-provoking situations.
Pharmacotherapy
Several types of medications are used to treat generalized anxiety disorder.
Antidepressants
Selective serotonin reuptake inhibitor (SSRI) and serotonin-norepinephrine reuptake inhibitor (SNRI) classes are the first-line agents with a response rate of 30% to 50%. This class of drugs includes escitalopram (Lexapro), duloxetine (Cymbalta), venlafaxine (Effexor XR) and paroxetine (Paxil, Pexeva). In a study, 81% of children with anxiety disorders who received a combined sertraline hydrochloride and CBT were responded to the treatment.
Benzodiazepines
Examples diazepam and clonazepam are long-acting agents. These agents are used when an immediate reduction of symptoms is desired, or a short-term treatment is needed. Generally, cooperative and compliant patients who are aware that their symptoms have a psychological basis are more likely to respond to benzodiazepines. Since there is a concern for misuse and dependence, patients with a history of alcoholism or drug abuse are not appropriate candidates for this treatment.
Buspirone (BuSpar)
Buspirone is a non-benzodiazepine which does not cause dependency. It is also less sedating than benzodiazepines, and tolerance does not occur at therapeutic doses. This agent has a therapeutic lag in the efficacy of two to three weeks which limits its use.
Pearls and Other Issues
Consider further evaluation for anxiety disorder if an adult is excessively anxious or an infant or child is excessively clingy and difficult to console during the pediatric visit. Many medical conditions may mimic anxiety disorders. One should distinguish between the anxiety and the illness and should evaluate for organic diseases before making this diagnosis.
See References
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Anxiety, Generalized Anxiety Disorder (GAD) - Questions
Take a quiz of the questions on this article.
Which of the following has not been approved by the Federal Drug Administration (FDA) for treating generalized anxiety disorder (GAD)?
Answers
Teaching Points
Click Your Answer Below
Paroxetine
Buspirone
Venlafaxine
Mirtazapine
Which of the following statements about co-existing anxiety disorders in women who have drug addiction is FALSE?
Answers
Teaching Points
Click Your Answer Below
Anxiety disorders constitute the most common psychiatric disorders in women
The total lifetime prevalence of anxiety in all women is 30.5%
Benzodiazepines should be the first line pharmacotherapy for anxiety in addicted women
The most important steps in relieving anxiety in addicted women are abstinence from substances, adherence to prescribed medication regimens, and participation in recovery efforts
What is the best intervention in a patient with generalized anxiety disorder?
Answers
Teaching Points
Click Your Answer Below
Deep breathing
Television
Video games
Sports
Which of the following medications is not approved for treating generalized anxiety disorder?
Answers
Teaching Points
Click Your Answer Below
Buspirone
Duloxetine
Amitriptyline
Paroxetine
A 31 year old female presents with a long history of headaches occurring 1 or 2 times a week that are typical for tension-type headaches (TTH). The patient has seen several physicians and had a normal MRI last year. She asks many questions and is concerned that there may be a more serious cause. Preventive medication is offered but she is concerned about possible side effects. She leaves without a prescription but calls numerous times in the next couple of weeks. Which of the following medications would be most appropriate?
Answers
Teaching Points
Click Your Answer Below
Topiramate
Valproic acid
Alprazolam
Pregabalin
Which of the following is not true about generalized anxiety disorder (GAD)?
Answers
Teaching Points
Click Your Answer Below
It can be treated with buspirone, benzodiazepines, and selective serotonin reuptake inhbitors (SSRIs)
It is more common in men than in women
Insomnia and tension are seen with GAD
It must last at least six months
Which age group has the highest prevalence of generalized anxiety disorder?
Answers
Teaching Points
Click Your Answer Below
Before adolescence
Between 20 to 30 years of age
Between 40 to 50 years of age
Greater than 65 years of age
Which of the following drugs is least effective in the treatment of generalized anxiety disorder?
Answers
Teaching Points
Click Your Answer Below
Sertraline
Venlafaxine
Buspirone
Bupropion
What is not a diagnostic criterion for generalized anxiety disorder?
Answers
Teaching Points
Click Your Answer Below
Sweating
Palpitations
Duration of at least 3 months
Trembling or shaking
Which of the following is true regarding generalized anxiety disorder in adults? Select all that apply.
Answers
Teaching Points
Click Your Answer Below
Associated with depression
SSRIs are a first-line treatment
Affects 10% of adults in the United States annually
Associated with substance abuse
The nurse is monitoring the treatment of a client with a generalized anxiety disorder (GAD). Which of the following are first-line treatment options? Select all that apply.
Answers
Teaching Points
Click Your Answer Below
Cognitive behavioral therapy
Benzodiazepines
Buspirone
Lithium
Anxiety, Generalized Anxiety Disorder (GAD) - References
References
The network structure of major depressive disorder, generalized anxiety disorder and somatic symptomatology., Bekhuis E,Schoevers RA,van Borkulo CD,Rosmalen JG,Boschloo L,, Psychological medicine, 2016 Aug 15 [PubMed]
Error-related brain activity in youth and young adults before and after treatment for generalized or social anxiety disorder., Kujawa A,Weinberg A,Bunford N,Fitzgerald KD,Hanna GL,Monk CS,Kennedy AE,Klumpp H,Hajcak G,Phan KL,, Progress in neuro-psychopharmacology & biological psychiatry, 2016 Nov 3 [PubMed]
One session treatment for specific phobias in children: Comorbid anxiety disorders and treatment outcome., Ryan SM,Strege MV,Oar EL,Ollendick TH,, Journal of behavior therapy and experimental psychiatry, 2016 Jul 20 [PubMed]
Developmental risk factors in generalized anxiety disorder and panic disorder., Newman MG,Shin KE,Zuellig AR,, Journal of affective disorders, 2016 Jul 5 [PubMed]
Generalized Anxiety Disorder and Social Anxiety Disorder, but Not Panic Anxiety Disorder, Are Associated with Higher Sensitivity to Learning from Negative Feedback: Behavioral and Computational Investigation., Khdour HY,Abushalbaq OM,Mughrabi IT,Imam AF,Gluck MA,Herzallah MM,Moustafa AA,, Frontiers in integrative neuroscience, 2016 [PubMed]
Long-term disability in anxiety disorders., Hendriks SM,Spijker J,Licht CM,Hardeveld F,de Graaf R,Batelaan NM,Penninx BW,Beekman AT,, BMC psychiatry, 2016 Jul 19 [PubMed]
Cortical functional activity in patients with generalized anxiety disorder., Wang Y,Chai F,Zhang H,Liu X,Xie P,Zheng L,Yang L,Li L,Fang D,, BMC psychiatry, 2016 Jul 7 [PubMed]
The Psychopharmacology Algorithm Project at the Harvard South Shore Program: An Algorithm for Generalized Anxiety Disorder., Abejuela HR,Osser DN,, Harvard review of psychiatry, 2016 Jul-Aug [PubMed]
Diagnostic and symptom-based predictors of emotional processing in generalized anxiety disorder and major depressive disorder: An event-related potential study., MacNamara A,Kotov R,Hajcak G,, Cognitive therapy and research, 2016 Jun [PubMed]
Neurobiological substrates of cognitive rigidity and autonomic inflexibility in generalized anxiety disorder., Ottaviani C,Watson DR,Meeten F,Makovac E,Garfinkel SN,Critchley HD,, Biological psychology, 2016 Sep [PubMed]
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