Generalized anxiety disorder

Definition

Unlike patients with panic disorders whose symptoms come on suddenly, patients with generalized anxiety disorder experience persistent diffuse anxiety, without the specific symptoms that characterize phobic disorders, panic disorders, or obsessive-compulsive disorders. Although the symptoms and signs of anxiety vary from individual to individual, common signs are motor tension, autonomic hyperactivity, apprehensive expectation, and vigilance. Patients with generalized anxiety disorder do not report acute fluctuations in anxiety level and autonomic arousal characteristic of panic disorder.

The anxious mood has been continuous for at least 1 month C Patient is at least 18 years of age data are lacking because of variations in definition and case acquisition. In patients who seek professional help for anxiety, women outnumber men by two to one. There is no evidence to support the popular belief that anxiety is related to the stresses of modern society. In contrast to panic disorder, studies showing a familial or genetic basis for generalized anxiety disorder are inconclusive.

Complications

In contrast to panic disorder, generalized anxiety disorder has a more chronic course and favorable outcome. However, the symptoms are persistent and can lead to secondary depression and alcohol and drug abuse, especially of benzodiazepines.

Differential diagnosis

Symptoms and signs resembling anxiety may occur with a number of medical disorders including coronary artery disease, thyroid disease, and drug intoxication or withdrawal. Anxiety may be present in other psychiatric disorders such as depression, schizophrenia, and organic mental states. Diagnosis of these conditions is essential, since the treatment of them is different from that of the anxiety disorders. Because patients with generalized anxiety may abuse alcohol or antianxiety medications to reduce or block anxiety, a careful history of drug use is important. Although the overall degree of psychosocial or occupational impairment is generally less than that noted for the other anxiety disorders, chronic anxiety is an uncomfortable emotion that can restrict a person’s ability to enjoy a normal life.

Etiology and pathophysiology

One approach to understanding the etiology of anxiety has been to delineate the mechanisms by which antianxiety drugs exert their therapeutic effects. High affinity, ste-reospecific receptors for benzodiazepines have been discovered which appear to be coupled to the receptor for the inhibitory neurotransmitter gamma-aminobutyric acid (GABA). Considerable evidence supports the hypothesis that the anxiolytic actions of the benzodiazepines are mediated through this receptor.

These findings have several implications. First, the characterization of a benzodiazepine receptor complex implies the existence of a natural (endogenous) ligand for the receptor. Conceivably, the levels of this substance might correlate with individual differences in anxiety or emotionality or tolerance to stress. Second, pharmacologic antagonists of this receptor block the effects of benzodiazepines and may induce anxiety, a finding which implicates these mechanisms in pathologic anxiety. Third, new anxiolytic compounds that influence benzodiazepine receptor binding are being discovered that have fewer and potentially less serious side effects. The possibility exists that anxiogenic substances may also be found in the brain. Though major questions remain to be answered, these advances have opened new avenues for understanding the origins and management of anxiety.

Treatment

Because feelings of anxiety are normal human emotions with adaptive value, a decision must be made before any treatment or medication is considered concerning whether or not the manifestations of anxiety are within the normal range. There is no justification for the use of anxiolytic drugs in anxiety if it is considered to be within the normal limits of human experience.

Once a decision is made to treat, consideration should be given first to modalities of nonpharmacologic intervention, including supportive or intensive psychotherapy. These approaches may modify maladaptive life-styles, cognition, and avoidance behaviors. Behavior therapy aims at teaching the patient practical means to reduce anxiety and includes techniques like relaxation training, biofeedback, and desensitization. These techniques are of at least temporary benefit for many people.

When generalized anxiety is severe enough to warrant treatment with drugs, benzodiazepines are the agents of choice. In many patients, short courses of anxiolytic drugs (5 to 7 days) are effective, following which the drug should be discontinued. Patients should be warned about the possibility of dependence with long-term use, and the physician should make regular assessments of the need for continuation of medications.