Generalized Anxiety Disorder
Authors: Gayatri Patel, Tonya L. Fancher
Journal: Annals of Internal Medicine (2013)

In the ClinicDecember 3, 2013Generalized Anxiety DisorderGayatri Patel, MD, MPH, Tonya L. Fancher, MD, MPH, Deborah Cotton, MD, MPH, Darren Taichman, MD, PhD, and Sankey Williams, MDGayatri Patel, MD, MPH, Tonya L. Fancher, MD, MPH, Deborah Cotton, MD, MPH, Darren Taichman, MD, PhD, and Sankey Williams, MDAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-159-11-201312030-01006 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Anxiety can be an appropriate response to stressful situations but is considered a pathologic disorder when it is disabling and difficult to control. Generalized anxiety disorder (GAD) is the most common anxiety disorder seen in primary care, affecting approximately 3% of adults in the United States (1, 2). This disorder is characterized by at least 6 months of pervasive and excessive anxiety; recurring worry about common events; and physical symptoms, such as muscle tension, insomnia, and fatigue (3). The disorder is associated with reduced global life satisfaction, decreased work productivity, lower health-related quality of life (4), and greater health care ...References1. Ballenger JC, Davidson JR, Lecrubier Y, Nutt DJ, Borkovec TD, Rickels K, et al. Consensus statement on generalized anxiety disorder from the International Consensus Group on Depression and Anxiety. J Clin Psychiatry. 2001;62 Suppl 11:53-8. [PMID: 11414552] Google Scholar2. Kessler RC, Brandenburg N, Lane M, Roy-Byrne P, Stang PD, Stein DJ, et al. Rethinking the duration requirement for generalized anxiety disorder: evidence from the National Comorbidity Survey Replication. Psychol Med. 2005;35:1073-82. [PMID: 16045073] Google Scholar3. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition: DSM-V. 5th ed. Arlington, VA: American Psychiatric Publishing; 2013. Google Scholar4. Revicki DA, Travers K, Wyrwich KW, Svedsäter H, Locklear J, Mattera MS, et al. Humanistic and economic burden of generalized anxiety disorder in North America and Europe. J Affect Disord. 2012;140:103-12. [PMID: 22154706] Google Scholar5. Marciniak MD, Lage MJ, Dunayevich E, Russell JM, Bowman L, Landbloom RP, et al. The cost of treating anxiety: the medical and demographic correlates that impact total medical costs. Depress Anxiety. 2005;21:178-84. [PMID: 16075454] Google Scholar6. Gale C, Davidson O. Generalised anxiety disorder. BMJ. 2007;334:579-81. [PMID: 17363830] Google Scholar7. Brawman-Mintzer O, Lydiard RB, Emmanuel N, Payeur R, Johnson M, Roberts J, et al. Psychiatric comorbidity in patients with generalized anxiety disorder. Am J Psychiatry. 1993;150:1216-8. [PMID: 8328567] Google Scholar8. Wittchen HU, Zhao S, Kessler RC, Eaton WW. DSM-III-R generalized anxiety disorder in the National Comorbidity Survey. Arch Gen Psychiatry. 1994;51:355-64. [PMID: 8179459] Google Scholar9. Kasen S, Cohen P, Chen H, Must A. Obesity and psychopathology in women: a three decade prospective study. Int J Obes (Lond). 2008;32:558-66. [PMID: 17895885] Google Scholar10. Kessler RC, McGonagle KA, Zhao S, Nelson CB, Hughes M, Eshleman S, et al. Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States. Results from the National Comorbidity Survey. Arch Gen Psychiatry. 1994;51:8-19. [PMID: 8279933] Google Scholar11. Brown ES, Fulton MK, Wilkeson A, Petty F. The psychiatric sequelae of civilian trauma. Compr Psychiatry. 2000;41:19-23. [PMID: 10646614] Google Scholar12. Hawker DS, Boulton MJ. Twenty years' research on peer victimization and psychosocial maladjustment: a meta-analytic review of cross-sectional studies. J Child Psychol Psychiatry. 2000;41:441-55. [PMID: 10836674] Google Scholar13. Hettema JM, Neale MC, Kendler KS. A review and meta-analysis of the genetic epidemiology of anxiety disorders. Am J Psychiatry. 2001;158:1568-78. [PMID: 11578982] Google Scholar14. Dadds MR, Holland DE, Laurens KR, Mullins M, Barrett PM, Spence SH. Early intervention and prevention of anxiety disorders in children: results at 2-year follow-up. J Consult Clin Psychol. 1999;67:145-50. [PMID: 10028219] Google Scholar15. Rapee RM, Kennedy S, Ingram M, Edwards S, Sweeney L. Prevention and early intervention of anxiety disorders in inhibited preschool children. J Consult Clin Psychol. 2005;73:488-97. [PMID: 15982146] Google Scholar16. Wang PS, Lane M, Olfson M, Pincus HA, Wells KB, Kessler RC. Twelve-month use of mental health services in the United States: results from the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62:629-40. [PMID: 15939840] Google Scholar17. Kohn R, Saxena S, Levav I, Saraceno B. The treatment gap in mental health care. Bulletin of the World Health Organization. 2004;82:811-90. Google Scholar18. Katon W, Roy-Byrne P. Anxiety disorders: efficient screening is the first step in improving outcomes [Editorial]. Ann Intern Med. 2007;146:390-2. [PMID: 17339624] Google Scholar19. Kroenke K, Spitzer RL, Williams JB, Monahan PO, Löwe B. Anxiety disorders in primary care: prevalence, impairment, comorbidity, and detection. Ann Intern Med. 2007;146:317-25. [PMID: 17339617] Google Scholar20. Means-Christensen AJ, Sherbourne CD, Roy-Byrne PP, Craske MG, Stein MB. Using five questions to screen for five common mental disorders in primary care: diagnostic accuracy of the Anxiety and Depression Detector. Gen Hosp Psychiatry. 2006;28:108-18. [PMID: 16516060] Google Scholar21. Spitzer RL, Kroenke K, Williams JB, Löwe B. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med. 2006;166:1092-7. [PMID: 16717171] Google Scholar22. Rollman BL, Belnap BH, Mazumdar S, Zhu F, Kroenke K, Schulberg HC, et al. Symptomatic severity of PRIME-MD diagnosed episodes of panic and generalized anxiety disorder in primary care. J Gen Intern Med. 2005;20:623-8. [PMID: 16050857] Google Scholar23. Löwe B, Wahl I, Rose M, Spitzer C, Glaesmer H, Wingenfeld K, et al. A 4-item measure of depression and anxiety: validation and standardization of the Patient Health Questionnaire-4 (PHQ-4) in the general population. J Affect Disord. 2010;122:86-95. [PMID: 19616305] Google Scholar24. Work Group on Psychiatric Evaluation. Psychiatric evaluation of adults. Second edition. American Psychiatric Association. Am J Psychiatry. 2006;163:3-36. [PMID: 16866240] Google Scholar25. Leichsenring F, Salzer S, Jaeger U, Kächele H, Kreische R, Leweke F, et al. Short-term psychodynamic psychotherapy and cognitive-behavioral therapy in generalized anxiety disorder: a randomized, controlled trial. Am J Psychiatry. 2009;166:875-81. [PMID: 19570931] Google Scholar26. Stanley MA, Wilson NL, Novy DM, Rhoades HM, Wagener PD, Greisinger AJ, et al. Cognitive behavior therapy for generalized anxiety disorder among older adults in primary care: a randomized clinical trial. JAMA. 2009;301:1460-7. [PMID: 19351943] Google Scholar27. Deacon BJ, Abramowitz JS. Cognitive and behavioral treatments for anxiety disorders: a review of meta-analytic findings. J Clin Psychol. 2004;60:429-41. [PMID: 15022272] Google Scholar28. Norton PJ, Price EC. A meta-analytic review of adult cognitive-behavioral treatment outcome across the anxiety disorders. J Nerv Ment Dis. 2007;195:521-31. [PMID: 17568301] Google Scholar29. Ayers CR, Sorrell JT, Thorp SR, Wetherell JL. Evidence-based psychological treatments for late-life anxiety. Psychol Aging. 2007;22:8-17. [PMID: 17385978] Google Scholar30. Bartley CA, Hay M, Bloch MH. Meta-analysis: aerobic exercise for the treatment of anxiety disorders. Prog Neuropsychopharmacol Biol Psychiatry. 2013;45:34-9. [PMID: 23643675] Google Scholar31. Baldwin DS, Anderson IM, Nutt DJ, Bandelow B, Bond A, Davidson JR, et al; British Association for Psychopharmacology. Evidence-based guidelines for the pharmacological treatment of anxiety disorders: recommendations from the British Association for Psychopharmacology. J Psychopharmacol. 2005;19:567-96. [PMID: 16272179] Google Scholar32. Brawman-Mintzer O, Knapp RG, Rynn M, Carter RE, Rickels K. Sertraline treatment for generalized anxiety disorder: a randomized, double-blind, placebo-controlled study. J Clin Psychiatry. 2006;67:874-81. [PMID: 16848646] Google Scholar33. Baldwin DS, Huusom AK, Maehlum E. Escitalopram and paroxetine in the treatment of generalised anxiety disorder: randomised, placebo-controlled, double-blind study. Br J Psychiatry. 2006;189:264-72. [PMID: 16946363] Google Scholar34. Bose A, Korotzer A, Gommoll C, Li D. Randomized placebo-controlled trial of escitalopram and venlafaxine XR in the treatment of generalized anxiety disorder. Depress Anxiety. 2008;25:854-61. [PMID: 18050245] Google Scholar35. Ball SG, Kuhn A, Wall D, Shekhar A, Goddard AW. Selective serotonin reuptake inhibitor treatment for generalized anxiety disorder: a double-blind, prospective comparison between paroxetine and sertraline. J Clin Psychiatry. 2005;66:94-9. [PMID: 15669894] Google Scholar36. Lenze EJ, Rollman BL, Shear MK, Dew MA, Pollock BG, Ciliberti C, et al. Escitalopram for older adults with generalized anxiety disorder: a randomized controlled trial. JAMA. 2009;301:295-303. [PMID: 19155456] Google Scholar37. Rynn M, Russell J, Erickson J, Detke MJ, Ball S, Dinkel J, et al. Efficacy and safety of duloxetine in the treatment of generalized anxiety disorder: a flexible-dose, progressive-titration, placebo-controlled trial. Depress Anxiety. 2008;25:182-9. [PMID: 17311303] Google Scholar38. Hartford J, Kornstein S, Liebowitz M, Pigott T, Russell J, Detke M, et al. Duloxetine as an SNRI treatment for generalized anxiety disorder: results from a placebo and active-controlled trial. Int Clin Psychopharmacol. 2007;22:167-74. [PMID: 17414743] Google Scholar39. Nicolini H, Bakish D, Duenas H, Spann M, Erickson J, Hallberg C, et al. Improvement of psychic and somatic symptoms in adult patients with generalized anxiety disorder: examination from a duloxetine, venlafaxine extended-release and placebo-controlled trial. Psychol Med. 2009;39:267-76. [PMID: 18485261] Google Scholar40. Schuurmans J, Comijs H, Emmelkamp PM, Gundy CM, Weijnen I, van den Hout M, et al. A randomized, controlled trial of the effectiveness of cognitive-behavioral therapy and sertraline versus a waitlist control group for anxiety disorders in older adults. Am J Geriatr Psychiatry. 2006;14:255-63. [PMID: 16505130] Google Scholar41. Fricchione G. Clinical practice. Generalized anxiety disorder. N Engl J Med. 2004;351:675-82. [PMID: 15306669] Google Scholar42. Chessick CA, Allen MH, Thase M, Batista Miralha da Cunha AB, Kapczinski FF, de Lima MS, et al. Azapirones for generalized anxiety disorder. Cochrane Database Syst Rev. 2006:CD006115. [PMID: 16856115] Google Scholar43. Ipser JC, Carey P, Dhansay Y, Fakier N, Seedat S, Stein DJ. Pharmacotherapy augmentation strategies in treatment-resistant anxiety disorders. Cochrane Database Syst Rev. 2006:CD005473. [PMID: 17054260] Google Scholar44. Brawman-Mintzer O, Knapp RG, Nietert PJ. Adjunctive risperidone in generalized anxiety disorder: a double-blind, placebo-controlled study. J Clin Psychiatry. 2005;66:1321-5. [PMID: 16259547] Google Scholar45. Tassone DM, Boyce E, Guyer J, Nuzum D. Pregabalin: a novel gamma-aminobutyric acid analogue in the treatment of neuropathic pain, partial-onset seizures, and anxiety disorders. Clin Ther. 2007;29:26-48. [PMID: 17379045] Google Scholar46. Montgomery S, Chatamra K, Pauer L, Whalen E, Baldinetti F. Efficacy and safety of pregabalin in elderly people with generalised anxiety disorder. Br J Psychiatry. 2008;193:389-94. [PMID: 18978320] Google Scholar47. Pfizer. Patient Health Questionnaire Screeners. Accessed at www.phqscreeners.com on 18 June 2013. Google Scholar48. American Psychiatric Association. Severity Measures for Generalized Anxiety Disorder. Accessed at www.psychiatry.org/practice/dsm/dsm5/online-assessment-measures#Disorder on 16 August 2013. Google Scholar49. Canadian Psychiatric Association. Clinical practice guidelines. Management of anxiety disorders. Can J Psychiatry. 2006;51:9S-91S. [PMID: 16933543] Google Scholar50. Davidson JR, Wittchen HU, Llorca PM, Erickson J, Detke M, Ball SG, et al. Duloxetine treatment for relapse prevention in adults with generalized anxiety disorder: a double-blind placebo-controlled trial. Eur Neuropsychopharmacol. 2008;18:673-81. [PMID: 18559291] Google Scholar51. Khan A, Leventhal RM, Khan S, Brown WA. Suicide risk in patients with anxiety disorders: a meta-analysis of the FDA database. J Affect Disord. 2002;68:183-90. [PMID: 12063146] Google Scholar52. Phillips AC, Batty GD, Gale CR, Deary IJ, Osborn D, MacIntyre K, et al. Generalized anxiety disorder, major depressive disorder, and their comorbidity as predictors of all-cause and cardiovascular mortality: the Vietnam experience study. Psychosom Med. 2009;71:395-403. [PMID: 19321850] Google Scholar53. Stein MB, Sherbourne CD, Craske MG, Means-Christensen A, Bystritsky A, Katon W, et al. Quality of care for primary care patients with anxiety disorders. Am J Psychiatry. 2004;161:2230-7. [PMID: 15569894] Google Scholar54. National Collaborating Centre for Mental Health. NICE Clinical Guideline 113: Generalised Anxiety Disorder and Panic Disorder (With or Without Agoraphobia) in Adults. London: National Institute for Health and Care Excellence; 2011. Accessed at http://guidance.nice.org.uk/CG113 on 14 June 2013. Google Scholar Author, Article, and Disclosure InformationAffiliations: PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics December 3, 2013Volume 159, Issue 11Page: ITC6-1KeywordsAntidepressantsAnxietyAnxiety disordersDrug therapyDrugsEmotionsMedical conditionsMusclesNervesPanic disorderPatientsPhysiciansPosttraumatic stress disorderPsychiatry and mental healthPsychologyResearch laboratoriesSocial anxiety disorderSpecificitySuicide ePublished: 3 December 2013 Issue Published: December 3, 2013 CopyrightCopyright © 2013 by American College of Physicians. All Rights Reserved.PDF DownloadLoading ...