Diagnosis and Management of Generalized Anxiety Disorder ...

1 Diagnosis and Management of Generalized Anxiety Disorder and Panic Disorder in Adults AMY B. LOCKE, MD, FAAFP; NELL KIRST, MD; and CAMERON G. SHULTZ, PhD, MSW, University of Michigan Medical School, Ann Arbor, Michigan Generalized Anxiety Disorder (GAD) and panic Disorder (PD) are among the most common mental disorders in the United States, and they can negatively impact a patient's quality of life and disrupt important activities of daily living. Evidence suggests that the rates of missed diagnoses and misdiagnosis of GAD and PD are high, with symptoms often ascribed to physical causes. Diagnosing GAD and PD requires a broad differential and caution to identify confound- ing variables and comorbid conditions. Screening and monitoring tools can be used to help make the Diagnosis and monitor response to therapy.

2 The GAD-7 and the Severity Measure for Panic Disorder are free diagnostic tools. Suc- cessful outcomes may require a combination of treatment modalities tailored to the individual patient. Treatment often includes medica- tions such as selective serotonin reuptake inhibitors and/or psycho- therapy, both of which are highly effective. Among psychotherapeutic treatments, cognitive behavior therapy has been studied widely and has an extensive evidence base. Benzodiazepines are effective in reducing Anxiety symptoms, but their use is limited by risk of abuse and adverse effect profiles. Physical activity can reduce symptoms of GAD and PD. A number of complementary and alternative treat- ILLUSTRATION BY JENNIFER FAIRMAN. ments are often used; however, evidence is limited for most. Several common botanicals and supplements can potentiate serotonin syn- drome when used in combination with antidepressants.

3 Medication should be continued for 12 months before tapering to prevent relapse. (Am Fam Physician. 2015;91(9):617-624. Copyright 2015 American Academy of Family Physicians.). G. CME This clinical content eneralized Anxiety Disorder Epidemiology, Etiology, conforms to AAFP criteria (GAD) and panic Disorder (PD) and Pathophysiology for continuing medical education (CME). See are among the most common The 12-month prevalence for GAD and PD. CME Quiz Questions on mental disorders in the United among adults 18 to 64 years of age is page 606. States and are often encountered by primary and , respectively. In this popu- Author disclosure: No rel- care physicians. The hallmark of GAD is lation, the lifetime prevalence is in evant financial affiliations. excessive, out-of-control worry, and PD is women and in men for GAD, and is Patient information: characterized by recurrent and unexpected in women and in men for.

4 Panic attacks. Both conditions can negatively The etiology of GAD is not well under- 2015/0501 impact a patient's quality of life and disrupt stood. There are several theoretical models, important activities of daily living. The rates each with varying degrees of empirical sup- of missed diagnoses and misdiagnosis of port. An underlying theme to several mod- GAD and PD are high, with symptoms often els is the dysregulation of worry. Emerging ascribed to physical causes. evidence suggests that patients with GAD. This article reviews the Diagnosis and may experience persistent activation of areas Management of GAD and PD in adults. of the brain associated with mental activity Diagnosis and care of children and adoles- and introspective thinking following worry- cents with these conditions require special inducing Twin studies suggest that considerations that are beyond the scope of environmental and genetic factors are likely this review.

5 May 1, 2015from Downloaded Volume 91, Number 9 the American Family Physician website at American Academy of Family Copyright 2015 American Family Physicians. For thePhysician 617. private, noncom- mercial use of one individual user of the website. All other rights reserved. Contact for copyright questions and/or permission requests. GAD and Panic Disorder SORT: KEY RECOMMENDATIONS FOR PRACTICE. Evidence Clinical recommendation rating References Physical activity is a cost-effective treatment for GAD and PD. B 16, 17. Selective serotonin reuptake inhibitors are considered first-line therapy for GAD and PD. B 19, 20, 22. To avoid relapse, medication should be continued for 12 months after symptoms improve before tapering. C 11. When used in combination with antidepressants, benzodiazepines may speed recovery from Anxiety -related B 11, 28-30.

6 Symptoms but do not improve longer-term outcomes. Because benzodiazepines are associated with tolerance, they should be used only short term during crises. Psychotherapy can be as effective as medication for GAD and PD. Cognitive behavior therapy has the best A 11, 37. level of evidence. Successful treatment requires tailoring options to individuals and may often include a combination of modalities. C 11, 37, 42. GAD = Generalized Anxiety Disorder ; PD = panic Disorder . A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to The etiology of PD is also not well under- Table 1.

7 Diagnostic Criteria for Generalized Anxiety Disorder stood. The neuroanatomical hypothesis sug- gests that a genetic-environment interaction A. E xcessive Anxiety and worry (apprehensive expectation), occurring more is likely responsible. Patients with PD may days than not for at least 6 months, about a number of events or activities exhibit irregularities in specific brain struc- (such as work or school performance). tures, altered neuronal processes, and dys- B. The individual finds it difficult to control the worry. functional corticolimbic interaction during C. 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 emotional days than not for the past 6 months): Note: Only one item is required in children .

8 Typical Presentation and Diagnostic 1. Restlessness or feeling keyed up or on edge. Criteria 2. Being easily fatigued. Generalized Anxiety Disorder . 3. Difficulty concentrating or mind going blank. Patients with GAD typically present with 4. Irritability. excessive Anxiety about ordinary, day-to- 5. Muscle tension. day situations. The Anxiety is intrusive, 6. S leep disturbance (difficulty falling or staying asleep, or restless, causes distress or functional impairment, unsatisfying sleep). and often encompasses multiple domains D. T he Anxiety , worry, or physical symptoms cause clinically significant distress or ( , finances, work, health). The Anxiety impairment in social, occupational, or other important areas of functioning. is often associated with physical symptoms, E. T he disturbance is not attributable to the physiological effects of a substance ( , a drug of abuse, a medication) or another medical condition ( , such as sleep disturbance, restlessness, mus- hyperthyroidism).

9 Cle tension, gastrointestinal symptoms, and F. T he disturbance is not better explained by another mental Disorder ( , chronic Diagnostic and Statistical Anxiety or worry about having panic attacks in panic Disorder , negative Manual of mental disorders , 5th ed, (DSM-5). evaluation in social Anxiety Disorder [social phobia], contamination or other diagnostic criteria for GAD are listed in obsessions in obsessive-compulsive Disorder , separation from attachment figures in separation Anxiety Disorder , reminders of traumatic events in Table Some factors associated with GAD. posttraumatic stress Disorder , gaining weight in anorexia nervosa, physical include female sex, unmarried status, lower complaints in somatic symptom Disorder , perceived appearance flaws in body education level, poor health, and presence dysmorphic Disorder , having a serious illness in illness Anxiety Disorder , or the of life The age of onset is variable, content of delusional beliefs in schizophrenia or delusional Disorder ).

10 With a median age of 30 Reprinted with permission from the American Psychiatric Association. Diagnostic and A number of scales are available to estab- Statistical Manual of mental disorders . 5th ed. Washington, DC: American Psychiatric lish Diagnosis and assess severity. The GAD-7. Association; 2013:222. (Table 27) has been validated as a diagnostic tool and a severity assessment scale, with a 618 American Family Physician Volume 91, Number 9 May 1, 2015. GAD and Panic Disorder score of 10 or more having good diagnostic sensitivity and Greater GAD-7 Table 2. GAD-7 Screening Tool scores correlate with more functional The scale was developed and Over the last 2 weeks, how More validated based on DSM-IV criteria, but it often have you been bothered Not at Several than half Nearly by the following problems?