Anxiety: Generalized Anxiety Disorder Management
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Chronic pain conditions can increase the risk of suicide in patients with co-occurring generalized anxiety disorder (GAD).undefined#ref15">15
Although benzodiazepines have demonstrated effectiveness in the treatment of GAD, they are not considered first-line treatment due to the risk of dependence.6
GAD is one of the most common anxiety disorders. The chief symptom is the experience of persistent and excessive worry about general events that are out of proportion to the reality of the patient’s situation. The worrying thoughts can lead to significant dysfunction. Presenting symptoms may also be physical, such as headaches or abdominal distress.14 According to the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5), the defining diagnostic criteria (300.02 [F41.1]) include:2
In addition, the signs and symptoms of GAD are not due to another condition or in response to medications or substance use.2 Conditions that may have some symptoms similar to GAD include hyperthyroidism and substance use or withdrawal.3
GAD is a chronic condition, in most cases affecting women, that can cause significant disability and higher use of emergency services.5 GAD affects physical, cognitive, emotional, and behavioral aspects of a patient’s life. Patients can experience physical symptoms such as headaches, abdominal distress, sleep disturbances, and muscle tension. In most cases, these are the primary presenting symptoms described by the patient.14 Cognitive aspects include difficulty concentrating or an inability to focus. Emotional and behavioral aspects may involve restlessness and avoidance.3
Treatment of GAD involves a variety of psychotherapeutic interventions as well as psychopharmacologic interventions. Many patients prefer psychotherapy to pharmacologic treatments.7 If patients do not respond to monotherapy (i.e., either psychotherapy or pharmacotherapy), a combination of the two modalities may be effective.4
Psychotherapeutic modalities used to treat GAD include cognitive behavioral therapy (CBT), which is considered a first-line treatment for patients with GAD. The focus of treatment involves assisting patients with understanding the negative consequences of their unrealistic fears. It aims to help patients realize their potential to cope with those fears and reframe the fears to more accurately reflect reality. It also involves helping patients develop relaxation and productive coping skills to manage their anxiety symptoms.7
Medications used to treat GAD include antidepressants, primarily selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs), anticonvulsants, and anxiolytics. Although benzodiazepines can be used in the treatment of anxiety disorders, they are not recommended due to the high risk of dependency and abuse associated with their use.4 Venlafaxine, an SNRI; pregabalin, an anticonvulsant; escitalopram, an SSRI; and duloxetine, an SNRI, are generally considered the drugs of choice for the treatment of GAD. Sertraline and fluoxetine, both SSRIs, and buspirone, a nonbenzodiazepine anxiolytic, may also be considered as first line treatment.14 Low doses of quetiapine, an antipsychotic medication, may be considered for the treatment of GAD; although, the drug should be used with caution due to adverse side effects.11
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Rationale: Patients with GAD and chronic pain conditions are at heightened risk for suicide.15
Rationale: GAD may interfere with a patient’s ability to understand information. It is important to ensure that the patient’s level of anxiety allows for the processing of information.3
Rationale: Patients’ experience of being coerced or forced can lead to feelings of humiliation and diminished self-confidence.13
Rationale: It is important to ensure that patients understand the impact lifestyle issues have on their experience of anxiety symptoms. Helping patients develop healthier lifestyles by reducing caffeine, alcohol, and tobacco use can also reduce anxiety symptoms.3
Rationale: CBT, relaxation, mindfulness, and acceptance therapies have demonstrated effectiveness in the treatment of GAD. The cognitive reframing and altering of distorted thinking taught in CBT can reduce cognitive symptoms. Use of relaxation techniques can help reduce some of the physical symptoms of anxiety. Mindfulness and acceptance therapy can help patients develop self-awareness and challenge their need to avoid situations.3
Rationale: For patients with major depressive disorder, co-occurring GAD can lead to greater severity of depressive symptoms and poorer outcomes.8
Rationale: Medications used to treat GAD may cause adverse side effects, leading to a patient’s lack of cooperation with treatment.3
*In these skills, a “classic” reference is a widely cited, standard work of established excellence that significantly affects current practice and may also represent the foundational research for practice.
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