Understand the differences and relationship between pharmacotherapy and psychotherapy for the treatment of generalized anxiety disorder.
Develop strategies for combined or sequenced treatment approaches for generalized anxiety disorder.
Enhance skills to negotiate these treatment approaches with patients.
Mr. X
Mr. X is a 60-year-old, married man referred by his primary care physician (PCP). He has experienced a very difficult year with the loss of his job and his wife’s diagnosis of breast cancer. He describes feeling worried and anxious on most days for several months. He also reports feeling on edge and “physically tense.” His dentist has also noted that he is grinding his teeth at night. He describes himself as a worrier but recently it has become uncontrollable, even disrupting his sleep. His PCP has medically cleared him.
Stress, anxiety, and worry are normal experiences that incorporate qualities of fear and related emotions. Such feelings can ensure adaptation and survival, but when excessive, may impair one’s ability to function. The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) defines generalized anxiety disorder (GAD) as excessive anxiety or worry occurring more days than not for at least 6 months about a number of events or activities (e.g., work or school performance). In addition, the individual finds it difficult to control the worry. Three or more of the following symptoms should be present:
Restlessness
Fatigue
Poor concentration
Irritability
Muscle tension
Disturbed sleep
Approximately 50% of patients with a complaint of anxiety will meet criteria for GAD. Related symptoms increase overall medical expenses including unnecessary consultations. Further, antianxiety agents are the fourth most prescribed medications in all of medicine. Available evidence indicates that GAD may last for many years with waxing and waning symptoms, often complicated by other intercurrent physical or psychiatric disorders. Although a DSM-IV-TR-derived diagnosis requires a duration of at least 6 months, clinicians often encounter very symptomatic patients who do not meet this specific duration criterion. Therefore, in addition to formalized diagnostic criteria, clinical judgment and experience are critical in deciding when anxiety is a discrete disorder requiring primary treatment and when it is a manifestation of another disorder.
Mr. X describes feeling very fatigued; having trouble concentrating; and worrying about his wife, children, house, and work. Owing to his worry, he works longer hours, calls his children daily to check on them, and has started several home repair projects to cope. He denies other mood symptoms. Approximately 20 years ago his PCP recommended a selective serotonin reuptake inhibitor (SSRI) to better manage feeling anxious and overwhelmed. The patient could not recall the name of the medication, took it only briefly, and reports that it did not help.
Adjustment disorder with anxious mood (characterized by lack of full symptom criteria for GAD and the presence of a recognized psychosocial stressor)
Psychotic, eating or mood disorders in which anxiety is related to the underlying condition
In addition, numerous medical disorders (e.g., hyperthyroidism, cardiovascular disease) may be complicated by anxious features.
NEUROBIOLOGY OF GENERALIZED ANXIETY DISORDER
Several neurotransmitters, neuropeptides, neurohormones, and cellular mediators are implicated in the pathophysiology of anxiety disorders. In this context, agents that are effective for treating GAD include those working through:
In addition, behavioral models are critical in understanding anxiety disorders and their therapeutic modulation. For example, conflict procedures (i.e., subjects experience the opposing impulses of desire and fear) have helped to conceptualize these conditions and are the basis for certain psychotherapeutic strategies.
TREATMENT OF GENERALIZED ANXIETY DISORDER
Pharmacotherapy for Generalized Anxiety Disorder
Several psychotropics and antiepileptic drugs have demonstrated efficacy for GAD. Table 10-1 lists these agents and their usual daily dosing ranges.
TABLE 10-1Medications for Treatment of Generalized Anxiety Disorder
(Adapted from Janicak PG, Davis JM, Preskorn SH, et al. Principles and Practice of Psychopharmacotherapy, 4th ed. Philadelphia: Lippincott Williams & Wilkins; 2006.)
Benzodiazepines.
Although other drugs exert anxiolytic effects, the benzodiazepines (BZDs) are still commonly used to treat GAD. A meta-analysis of well-controlled studies found these agents superior to placebo and comparable to each other in the short-term management of GAD.1 Almost all studies indicated that BZDs quickly reduce symptoms in many patients, with most improvement occurring during the first week. Patientsmost likely to respond demonstrate:
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Mr. X describes feeling very fatigued; having trouble concentrating; and worrying about his wife, children, house, and work. Owing to his worry, he works longer hours, calls his children daily to check on them, and has started several home repair projects to cope. He denies other mood symptoms. Approximately 20 years ago his PCP recommended a selective serotonin reuptake inhibitor (SSRI) to better manage feeling anxious and overwhelmed. The patient could not recall the name of the medication, took it only briefly, and reports that it did not help.
