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depression meet criteria for GAD.
II.Clinical manifestations and diagnosis
A.The diagnostic criteria for GAD suggest that patients
experience excessive anxiety and worry about a number
of events or activities, occurring more days than not for at
least six months, that are out of proportion to the likelihood
or impact of feared events. Affected patients also present
with somatic symptoms, including fatigue, muscle tension,
memory loss, and insomnia, and other psychiatric disor-
ders.
DSM-IV-PC Diagnostic Criteria for Generalized
Anxiety Disorder
1. Excessive anxiety and worry about a number of events or
activities, occurring more days than not for at least six
months, that are out of proportion to the likelihood or
impact of feared events.
2. The worry is pervasive and difficult to control.
3. The anxiety and worry are associated with three (or
more) of the following six symptoms (with at least some
symptoms present for more days than not for the past six
months):
Restlessness or feeling keyed up or on edge
Being easily fatigued
Difficulty concentrating or mind going blank
Irritability
Muscle tension
Sleep disturbance (difficulty falling or staying asleep, or
restless unsatisfying sleep)
4. The anxiety, worry, or physical symptoms cause clinically
significant distress or impairment in social, occupational,
or other important areas of functioning.
B.Comorbid psychiatric disorders and an organic
etiology for anxiety must be excluded by careful history
taking, a complete physical examination, and appropriate
laboratory studies. The medical history should focus upon
current medical disorders, medication side effects, or
substance abuse to anxiety (or panic) symptoms.
C.Psychosocial history should screen for major depres-
sion and agoraphobia, stressful life events, family psychiat-
ric history, current social history, substance abuse history
(including caffeine, nicotine, and alcohol), and past sexual,
physical and emotional abuse, or emotional neglect.
D.Laboratory studies include a complete blood count,
chemistry panel, serum thyrotropin (TSH) and urinalysis.
Urine or serum toxicology measurements or drug levels
can be obtained for drugs or medications suspected in the
etiology of anxiety.
Physical Causes of Anxiety-Like Symptoms
Cardiovascular
Angina pectoris, arrhythmias, congestive heart failure, hyper-
tension, hypovolemia, myocardial infarction, syncope (multi-
ple causes), valvular disease, vascular collapse (shock)
Dietary
Caffeine, monosodium glutamate (Chinese restaurant syn-
drome), vitamin-deficiency diseases
Drug-related
Akathisia (secondary to antipsychotic drugs), anticholinergic
toxicity, digitalis toxicity, hallucinogens, hypotensive agents,
stimulants (amphetamines, cocaine, related drugs), with-
drawal syndromes (alcohol, sedative-hypnotics), bronchodila-
tors (theophylline, sympathomimetics)
Hematologic
Anemias
Immunologic
Anaphylaxis, systemic lupus erythematosus
Metabolic
HyperadrenaIism (Cushing's disease), hyperkalemia,
hyperthermia, hyperthyroidism, hypocalcemia, hypoglycemia,
hyponatremia, hypothyroidism, menopause, porphyria (acute
intermittent)
Neurologic
Encephalopathies (infectious, metabolic, toxic), essential
tremor, intracranial mass lesions, postconcussive syndrome,
seizure disorders (especially of the temporal lobe), vertigo
Respiratory
Asthma, chronic obstructive pulmonary disease, pneumonia,
pneumothorax, pulmonary edema, pulmonary embolism
Secreting tumors
Carcinoid, insulinoma, pheochromocytoma
III.Treatment
A.Drug therapy. While benzodiazepines have been the
most traditionally used drug treatments for GAD, selective
serotonin reuptake inhibitors (SSRIs), selective serotonin
and norepinephrine reuptake inhibitors (SNRIs, eg
venlafaxine), and buspirone are also effective, and
because of their lower side effect profiles and lower risk
for tolerance are becoming first-line treatment.
B.Antidepressants
1.Venlafaxine SR (Effexor) may be a particularly good
choice for patients with coexisting psychiatric illness,
such as panic disorder, major depression, or social
phobia, or when it is not clear if the patient has GAD,
depression, or both. Venlafaxine can be started as
venlafaxine XR 37.5 mg daily, with dose increases in
increments of 37.5 mg every one to two weeks until a
dose of 150 mg to 300 mg is attained.
C.Tricyclic antidepressants, SSRIs, or SNRIs may be
associated with side effects such as restlessness and
insomnia. These adverse effects can be minimized by
starting at lower doses and gradually titrating to full doses
as tolerated.
1.Selective serotonin reuptake inhibitors
a.Paroxetine (Paxil) 5 to 10 mg qd, increasing to 20
to 40 mg.
b.Sertraline (Zoloft) 12.5 to 25 mg qd, increasing to
50 to 200 mg.
c.Fluvoxamine (Luvox) 25 mg qd, increasing to 100
to 300 mg.
d.Fluoxetine (Prozac) 5 mg qd, increasing to 20 to
40 mg.
e.Citalopram (Celexa) 10 mg qd, increasing to 20 to
40 mg.
f.Side effects of SSRIs include agitation, headache,
gastrointestinal symptoms (diarrhea and nausea),
and insomnia. About 20 to 35 percent of patients
develop sexual side effects after several weeks or
months of SSRI therapy, especially a decreased
ability to have an orgasm. Addition of bupropion (75
to 150 mg/day in divided doses) or buspirone (10 to
20 mg twice daily) may alleviate decreased libido,
diminished sexual arousal, or impaired orgasm.
2.Imipramine (Tofranil), a starting dose of 10 to 20 mg
po at night can be gradually titrated up to 75 to 300 mg
each night. Imipramine has anticholinergic and
antiadrenergic side effects. Desipramine (Norpramin),
25-200 mg qhs, and nortriptyline (Pamelor), 25 mg tid-
qid, can be used as alternatives.
3.Trazodone (Desyrel) is a serotonergic agent, but
because of its side effects (sedation and priapism), it
is not an ideal first-line agent. Daily dosages of 200 to
400 mg are helpful in patients who have not responded
to other agents.
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