The DSM-IV identifies the principle characteristic of generalized anxiety disorder as excessive anxiety and worry, usually, over a period of greater than 6 months. The concerns are considered to be far out of proportion to reality. The anxiety is accompanied by at least three of the following symptoms: restlessness, easy fatiguability, difficulty concentrating, muscle tension, irritability, and sleep disturbance. The symptoms are sufficiently severe to interfere with the person’s life style, and are not attributable to another mental disorder or drugs.
In primary care, patients with GAD often present to their physicians with a cluster of autonomic symptoms, such as:
Cardiac (chest pains, palpitations, tachycardia, tachypnea)
Pulmonary (hyperventilation, smothering sensations, dyspnea)
Gastrointestinal (globus hystericus, indigestion, abdominal pains, flatulance, diarrhea, constipation)
Genitourinary (frequency, menstrual irregularities, sexual dysfunction)
Dermatologic (paresthesias, sweating, hot flashes, chills, pruritis)
Treatment
As in most other forms of anxiety disease, the treatment of GAD requires pharmacotherapy, psychotherapy and patient education. In GAD more than any other, however, therapeutic success absolutely depends on effective patient education. It is much easier for people to recognize panic disorder as a disease, with its dramatic symptoms, or a obsessive compulsive disorder or phobias, with their obviously irrational components. In GAD, the symptoms are primarily those of other well known diseases: cardiac, pulmonary, gastrointestinal, genitourinary, and dermatologic. Indeed, they are most often comorbid. Patients are often convinced that their suffering is caused entirely by one of these diseases, and that their anxiety actually is their own fault.
The first step in treatment is the diagnostic process itself. The alert physician, after a thorough history and physical examination, but before ordering any studies, will share with the patient the real possibility that the basic problem may be an anxiety disease. When the studies prove negative, the physician can then use this information as a confirmation of the original impression. A diagnosis made totally by exclusion is not convincing to patients and adds immeasurably to the therapeutic difficulties.
Pharmacotherapy
There are three groups of medications that have proven effective in the management of GAD: BZDs, azipirones, and Antidepressants. On a short term basis, the BZDs, especially short-acting BZDs (alprazolam, loreazepam, and clonazepam) may be the drugs of choice. They work promptly and predictably and have a minimum of side-effects if started at a low dose.
The only available azipirone at this time, buspirone, is recommended in patients when there is a concern about mental alertness, possible addictive tendency, or combination use with alcohol, and where there is concern about physical dependence and withdrawal. Buspirone has been proven quite effective, but usually requires 2 to 4 weeks to exert its full effects (although some mild effects may be noticed after only 1 week.)
Antidepressants, especially imipramine, also have proven effective for some patients. These drugs are well suited for long term therapy.
Psychotherapy
CBT may also be effective for patients with GAD, and there is some evidence to indicate that positive results may be more enduring than with medication. The relatively high costs, the almost certain comorbidity, and the variable nature of GAD, however, may make this option less acceptable.
Even with all of the effective therapy that is available, GAD remains a difficult challenge for both patients and their physicians. Patients need to understand and believe the chronic or recurring and protean nature of this disease. They need to be able to put each new symptom in context, but they also need to realize that no persistent symptom should be ignored. Physicians need to recognize the chronicity and variability also, but always remember that these patients have the same risk of other physical diseases as other patents. One very successful management technique is to schedule these patients for regular visits every 1 to 2 months. Many patients who are undergoing multiple symptoms are able to feel comfortable with saving up their complaints for the next visit, rather than making frantic telephone calls or emergency visits.