Generalized Anxiety Disorder

History

• Hallmark of generalized anxiety disorder is excessive worrying and apprehensive expectation of a wide range of normal events and activities, such as: ^r1c1
  • Work or school responsibilities and interactions
  • Family health and finances
  • In children, worry about competence or quality of their performance
• Common psychological symptoms related to generalized anxiety disorder include: ^r8
  • Being nervous and unable to relax, with poor or disturbed sleep ^{r1c2c3c4c5c6c7c8c9}
  • Worrying about trivial or minor matters, with no control over worrying
  • Extreme restlessness and inability to concentrate ^r1c10c11
  • Irritability ^c12c13
  • Fear of the worst happening and feeling scared in general
  • Feeling that objects are unreal (derealization) or that the self is “not really here” (depersonalization) ^r7c14c15
  • Sensation of losing control, “going crazy,” or passing out ^r7c16c17
  • Fear of death ^r7c18
• Muscle tension and fatigability are highly correlated with generalized anxiety disorder ^r1c19c20
• Common physical symptoms related to anxiety include the following, ranked in order of clinical significance: ^r9
  • Palpitations ^c21c22
  • Dyspepsia or abdominal discomfort ^c23c24
  • Dizziness ^c25c26
  • Unsteady gait ^c27c28
  • Dyspnea ^c29c30
  • Feeling hot and/or experiencing diaphoresis, regardless of ambient temperature ^c31c32
  • Feeling faint, hands trembling, and face flushing ^c33c34c35
  • Paresthesia marked by numbness and tingling ^c36c37c38
  • Choking sensation ^c39
• Other common physical symptoms include: ^r1
  • Nausea ^c40
  • Diarrhea ^c41
  • Cold extremities ^c42
  • Xerostomia ^c43
  • Bruxism ^c44
  • Headache ^c45
• Symptoms are typically more severe in younger adults ^r1

Physical examination

• Signs related to general emotional well-being include nervousness, irritability, and heightened vigilance ^r1c46c47c48
• Physical signs include: ^r1
  • Visible tremor ^c49
  • Cold hands ^c50
  • Tachycardia ^c51
  • Tachypnea ^c52

Causes

• Exact cause is unknown ^c53
  • Onset of pure generalized anxiety disorder is often associated with stress arising from emotional loss and dangerous situations ^r10c54
    • Includes loss of a close relative or long-term separation from a partner ^c55c56
  • Childhood adversity has a 32.4% association with anxiety disorders ^r11c57

Risk factors and/or associations

Primary diagnostic tools

• Diagnosis is based on patient history and physical examination findings; DSM-5-TR criteria must be met for a diagnosis of generalized anxiety disorder ^r1c74
  • Excessive use of alcohol, caffeine, or other stimulants must be ruled out as a cause of symptoms
• GAD-7 scale^r8 and Beck Anxiety Inventory^r9 are useful screening instruments that can aid clinicians in achieving a diagnosis
  • GAD-7 assesses symptoms over the past 2 weeks instead of 6 months (per DSM-5-TR^r1) using 7 criteria, operating on the assumption that severe symptoms are typically chronic ^r8
  • Beck Anxiety Inventory contains 21 items comprising somatic, affective, and cognitive symptoms related specifically to anxiety disorders ^r9

  • GAD-7 scale.

    Scoring: Sum each column. Then sum the column totals to achieve a grand score. The GAD-2 subscale is composed of the first 2 items of the GAD-7 scale.

    From Wild B et al: Assessing generalized anxiety disorder in elderly people using the GAD-7 and GAD-2 scales: results of a validation study. Am J Geriatr Psychiatry. 22(10):1029-38, Figure 1.

    Over the last 2 weeks, how often have you been bothered by the following problems?	Not at all	Several days	More than half the days	Nearly every day
    Feeling nervous, anxious, or on edge	0	1	2	3
    Not being able to stop or control worrying	0	1	2	3
    Worrying too much about different things	0	1	2	3
    Trouble relaxing	0	1	2	3
    Being so restless that it is hard to sit still	0	1	2	3
    Becoming easily annoyed or irritable	0	1	2	3
    Feeling afraid as if something awful might happen	0	1	2	3
    Total score

  • Beck anxiety inventory.

    Scoring: Sum each column. Then sum the column totals to achieve a grand score.

    From Zarate R: Clinical improvisation and its effect on anxiety: a multiple single subject design. The Arts in Psychotherapy.48:46-53, 2016, Figure A1.

    	Not at all	Mildly but it didn't bother me much	Moderately—it wasn't pleasant at times	Severely—it bothered me a lot
    Numbness or tingling	0	1	2	3
    Feeling hot	0	1	2	3
    Wobbliness in legs	0	1	2	3
    Unable to relax	0	1	2	3
    Fear of worst happening	0	1	2	3
    Dizzy or lightheaded	0	1	2	3
    Heart pounding/racing	0	1	2	3
    Unsteady	0	1	2	3
    Terrified or afraid	0	1	2	3
    Nervous	0	1	2	3
    Feeling of choking	0	1	2	3
    Hands trembling	0	1	2	3
    Shaky/unsteady	0	1	2	3
    Fear of losing control	0	1	2	3
    Difficulty in breathing	0	1	2	3
    Fear of dying	0	1	2	3
    Scared	0	1	2	3
    Indigestion	0	1	2	3
    Faint/lightheaded	0	1	2	3
    Face flushed	0	1	2	3
    Hot/cold sweats	0	1	2	3
    Column sum

• Comprehensive clinical interview is used to assess for the following DSM-5-TR criteria: ^r1
  • Excessive anxiety and worry (apprehensive expectation) about various events or activities (eg, work or school performance), occurring more days than not, lasting 6 months or longer
  • Patient has difficulty controlling this worry
  • Anxiety and worry occur in conjunction with at least 3 (only 1 required in children) of the following symptoms, with at least some symptoms having been present for more days than not for the past 6 months:
    • Restlessness
    • Fatigability
    • Compromised ability to concentrate
    • Crankiness/irritability
    • Increased muscle tension
    • Poor sleep quality, including trouble falling asleep, difficulty staying asleep, or restlessness
  • Patient's symptoms lead to clinical distress and engender negative effects on work, school, or everyday life
  • Another medical condition or substance use disorder is not the cause
  • Different mental disorder has not given rise to the patient's symptoms
• Maintain a high index of suspicion for medical conditions that could cause the symptoms; laboratory testing is generally deferred, but CBC, thyroid function tests, basic chemistry panel, urine drug screening, and ECG should be obtained as indicated by the clinical presentation and medical history ^r17

Functional testing

• GAD-7 ^r8c75
  • Consists of 7 criteria, namely:
    • Feeling nervous, anxious, or on edge
    • Not being able to stop or control worrying
    • Worrying too much about different things
    • Trouble relaxing
    • Being so restless that it is hard to sit still
    • Becoming easily annoyed or irritable
    • Feeling afraid as if something awful might happen
  • Subjects rate how often they have been bothered by each symptom in the last 2 weeks, with responses being 0 (not at all), 1 (several days), 2 (more than half the days), and 3 (nearly every day); total score ranges from 0 to 21
    • Threshold score of 8 maximizes sensitivity and 15 maximizes specificity ^r8
    • Threshold of 10 is optimal for high sensitivity and specificity ^r8
  • Interpretation ^r18
    • 10: moderate anxiety
    • 15: severe anxiety
• Beck Anxiety Inventory ^r9c76
  • Comprises 21 criteria, specifically:
    • Numbness or tingling
    • Feeling hot
    • Wobbliness in legs
    • Unable to relax
    • Fear of the worst happening
    • Dizzy or lightheaded
    • Heart pounding or racing
    • Unsteady
    • Terrified
    • Nervous
    • Feelings of choking
    • Hands trembling
    • Shaky
    • Fear of losing control
    • Difficulty breathing
    • Fear of dying
    • Scared
    • Indigestion or discomfort in abdomen
    • Faint
    • Face flushed
    • Sweating (not due to heat)
  • Subjects are asked to rate how much each symptom has affected them over the past week on a 4-point scale ranging from 0 (not at all) to 3 (severely—I could barely stand it); total score ranges from 0 to 63
  • Interpretation ^r19
    • 0 to 9: normal
    • 10 to 18: mild to moderate anxiety
    • 19 to 29: moderate to severe anxiety
    • 30 to 63: severe anxiety

Procedures ^c77c78

Most common

• Anxiety due to thyroid disorder ^c79c80c81
  • Characterized by unusually high^r20 or low^r21 levels of thyroxine due to dysfunction or removal of thyroid gland
  • Anxiety and/or depression symptoms (eg, being more irritable, sad, emotionally sensitive, or anxious) ^r22
  • Differentiating features are as follows: ^r23
    • Hypothyroidism can present with fatigue, dry skin, constipation, vocal changes, and prolonged ankle jerk reflex ^r23
    • Hyperthyroidism can present with hypertension, tachycardia, warm and moist skin, and brisk ankle jerk reflex ^r20
  • DSM-5-TR diagnostic criteria:
    • Evidence from history, physical examination, or laboratory findings that disturbance is not a direct pathophysiologic consequence of another medical condition
    • Disturbance is not better explained by another mental disorder
    • Disturbance does not occur exclusively during the course of a delirium
    • Disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning
  • Diagnosis can be confirmed by the following laboratory findings:
    • Hypothyroidism ^d1
      • TSH level is elevated to more than 10 mIU/L in primary hypothyroidism ^r21r24
      • Low serum levels of total or free thyroxine ^r22
    • Hyperthyroidism ^d2
      • TSH level is suppressed ^r20
      • High serum levels of total or free thyroxine
• Illness anxiety disorder ^r25r26c82d3
  • Preoccupation with the possibility of having or acquiring serious illness based on misinterpretations of benign or minor physical sensations; previously known as hypochondriasis
  • Some psychological and physical symptoms of anxiety are also present
  • Subject of anxiety differs, as the patient focuses mainly on their body and general health to the exclusion of work, finances, or family matters
  • Diagnosis can be confirmed by DSM-5-TR criteria:
    • Preoccupation with having or acquiring a serious illness for at least 6 months
    • Frequent visits to the clinic or maladaptive avoidance of medical attention
• Social anxiety disorder (social phobia) ^r27r28c83
  • Phobic anxiety disorder with concerns about social situations involving unfamiliar people or possible scrutiny
  • Psychological and physical symptoms of anxiety are present in certain social situations
  • Anxiety is specific to social situations
    • Characterized by early onset; typically appears by age 11 years in 50% of patients and age 20 years in 80% of patients ^r27
  • Diagnosis can be confirmed by DSM-5-TR criteria:
    • Extreme fear or anxiety related to meeting strangers, speaking in public, or being observed in social situations
    • Social phobia must last for at least 6 months and cause clinically significant impairment in social interactions
• Panic disorder ^r29c84
  • Marked by recurrent panic attacks or extreme but brief episodes of anxiety, at intervals ranging from 24 hours to several months; may coexist with generalized anxiety disorder
  • Physical signs and symptoms of anxiety (eg, sweating, palpitations, dizziness, tachycardia) are present during a panic attack
  • Intense fear or discomfort of an attack reaches its peak within minutes, unlike the constantly elevated anxiety of generalized anxiety disorder
    • History of childhood trauma or abuse is more likely in patients with panic disorder than in those with generalized anxiety disorder
  • Diagnosis can be confirmed by DSM-5-TR criteria:
    • Extreme panic or anxiety reaching its peak within minutes, manifesting more than 4 somatic symptoms of anxiety
    • At least 1 panic attack preceded by more than 1 month of apprehensive expectation of a similar episode
• Major depressive disorder ^r30r31c85d4
  • Sadness, lethargy, and apathy lasting at least 2 weeks, with reduced interest and pleasure in normal activities; may coexist with generalized anxiety disorder
  • Irritability, fatigue, poor sleep, and digestive symptoms are typically present, as with generalized anxiety disorder
  • Diagnosis can be confirmed by DSM-5-TR criteria:
    • Depressed mood for most days over 2 weeks along with at least 2 characteristic symptoms
      • Anhedonia
      • Change in weight or appetite
      • Insomnia or hypersomnia
      • Psychomotor agitation or retardation
      • Fatigue
      • Feelings of worthlessness or inappropriate guilt
      • Diminished ability to concentrate or indecisiveness
      • Suicidal ideation or attempt
• Obsessive-compulsive disorder ^r32c86
  • Characterized by continually recurring thoughts or images (obsessions) that increase anxiety and repetitive or ritualistic actions (compulsions) performed to alleviate that anxiety
  • Excessive worrying and some symptoms of anxiety can be present
  • Differentiated by repetitive rituals and behaviors (eg, hand-washing, mental acts of ordering or checking) performed to alleviate anxiety
    • Anxiety relates more to imagined or fantastic events
  • Diagnosis can be confirmed by DSM-5-TR criteria:
    • Obsessive thoughts and compulsive behaviors take up at least 1 hour of the day
    • Patient suffers from clinically significant impairment in an occupational or social setting
• Posttraumatic stress disorder ^r33c87d5
  • Psychological disturbance or anhedonic/dysphoric mental state caused by experiencing a serious traumatic event
  • Heightened anxiety is typically present, along with its mental and physical symptoms
  • Main distinguishing criterion is the association of anxiety with a specific event, not with normal daily functioning, and the presence of flashbacks, dreams, and dissociative states relating to that event
  • Diagnosis can be confirmed by DSM-5-TR criteria:
    • Adults and children older than 6 years
      • Traumatic experience (eg, grave injury, sexual violence, threat of death) or such an event affecting a close friend or relative
        • Repeated exposure to circumstances surrounding such events, as with first responders or emergency department personnel
      • Psychological disturbance lasting longer than 1 month, including invasive memories, dreams, flashbacks, avoidance of stimuli associated with such events, irritability, anxiety, and insomnia
      • Patient suffers from clinically significant impairment in an occupational or social setting
    • Children younger than 6 years, specific criteria include:
      • Witnessing traumatic events, especially those affecting a primary caregiver
      • Constriction of play, social withdrawal, and emphasis on expression of negative emotions (eg, fear, guilt, shame)
• Drug withdrawal ^r34c88d6
  • Withdrawal symptoms caused by cessation of sedative use (eg, alcohol, benzodiazepines) or opioid use ^d7
    • Initial symptoms and signs of withdrawal include heightened anxiety, as well as irritability, nausea, agitation, diaphoresis, and tachycardia from sedative or opioid use
  • Short-term episodic nature of anxiety symptoms, compared to the chronic nature of generalized anxiety disorder symptoms
    • In case of withdrawal from benzodiazepines, signs and symptoms begin 2 to 10 days after last use ^r34
    • Alcohol withdrawal may be accompanied by seizures and delirium; symptoms typically peak 72 hours after the last ingestion of alcohol (without medication) ^r34
    • Opioid withdrawal is associated with anxiety and panic symptoms, with onset typically 4 to 6 hours after last use of a shorter-acting opioid (eg, heroin, oxycodone) or 1 to 2 days after last use of an opioid with a longer half-life (eg, methadone, buprenorphine) ^r35
  • Diagnosis can be confirmed by patient history and observation
• Substance intoxication ^r1c89
  • Anxiety and panic may be present with intoxication from a variety of substances (eg, stimulants [including caffeine], alcohol, inhalants, cannabis, phencyclidine)
  • Typical history would relate anxiety to intoxication with these substances, which would typically be absent with abstinence
  • Diagnosis primarily made from patient history and clinical signs

Admission criteria

• Admit patients reporting acute suicidal ideation or intent
• Consider admission in patients with comorbid conditions (eg, significant substance use disorder with toxicity or withdrawal of sedative-hypnotics [including alcohol])

Recommendations for specialist referral

• Refer patients to a psychiatrist, psychologist, or appropriately trained mental health therapist for psychotherapy
• Psychiatric referral is necessary for patients with suicidal ideation or complex coexisting illnesses
• Psychiatric evaluation, if not already accomplished, is recommended after 2 failed medication trials (ie, 2 different drugs with no response despite reaching target dose) ^r12

Drug therapy

• Selective serotonin reuptake inhibitors ^c90
  • Escitalopram ^r7c91
    • Escitalopram Oral solution; Children and Adolescents 7 to 17 years: 10 mg PO once daily, initially. May increase the dose to 20 mg/day as needed and tolerated after 2 weeks or more.
    • Escitalopram Oral tablet; Adults: 10 mg PO once daily, initially. May increase the dose to 20 mg/day as needed and tolerated after 1 week or more.
    • Escitalopram Oral tablet; Older Adults: 10 mg PO once daily.
  • Paroxetine ^c92
    • Paroxetine Hydrochloride Oral tablet; Adults: 20 mg PO once daily, initially. May increase the dose by 10 mg/day at weekly intervals as needed and tolerated. Usual Max: 20 mg/day. Max: 50 mg/day.
    • Paroxetine Hydrochloride Oral tablet; Older Adults: 10 mg PO once daily, initially. May increase the dose by 10 mg/day at weekly intervals as needed and tolerated. Usual Max: 20 mg/day. Max: 40 mg/day.
  • Sertraline ^c93
    • Sertraline Hydrochloride Oral solution; Children and Adolescents 7 to 17 years: 25 mg PO once daily, initially. May increase the dose gradually as needed. Max: 200 mg/day.
    • Sertraline Hydrochloride Oral tablet; Adults: 25 mg PO once daily for 1 week, then 50 mg PO once daily for 1 week, and then may increase the dose by 50 mg/day at weekly intervals as needed. Max: 200 mg/day.
• Serotonin-norepinephrine reuptake inhibitors ^c94
  • Duloxetine ^c95
    • Duloxetine Oral capsule, gastro-resistant pellets; Children and Adolescents 7 to 17 years: 30 mg PO once daily for 2 weeks, initially. May increase the dose by 30 mg/day as needed. Usual dose: 30 to 60 mg/day. Max: 120 mg/day.
    • Duloxetine Oral capsule, gastro-resistant pellets; Adults: 60 mg PO once daily, or alternatively, 30 mg PO once daily for 1 week, then 60 mg PO once daily, initially. May increase the dose by 30 mg/day as needed. Usual dose: 60 mg/day. Max: 120 mg/day.
    • Duloxetine Oral capsule, gastro-resistant pellets; Older Adults: 30 mg PO once daily for 2 weeks, initially. May increase the dose by 30 mg/day as needed. Usual dose: 60 mg/day. Max: 120 mg/day.
  • Venlafaxine ^r7c96
    • Venlafaxine Hydrochloride Oral tablet, extended-release; Children† and Adolescents† 6 to 17 years weighing 25 to 39 kg: 37.5 mg PO once daily for 1 week, then 37.5 or 75 mg PO once daily for 1 week, and then may increase the dose by 37.5 mg/day every 2 weeks as needed. Max: 112.5 mg/day.
    • Venlafaxine Hydrochloride Oral tablet, extended-release; Children† and Adolescents† 6 to 17 years weighing 40 to 49 kg: 37.5 mg PO once daily for 1 week, then 75 mg PO once daily for 1 week, and then may increase the dose by 37.5 mg/day every 2 weeks as needed. Max: 150 mg/day.
    • Venlafaxine Hydrochloride Oral tablet, extended-release; Children† and Adolescents† 6 to 17 years weighing 50 kg or more: 37.5 mg PO once daily for 1 week, then 75 mg PO once daily for 1 week, and then may increase the dose by 75 mg/day every 2 weeks as needed. Max: 225 mg/day.
    • Venlafaxine Hydrochloride Oral tablet, extended-release; Adults: 75 mg PO once daily, or alternatively, 37.5 mg PO once daily for 4 to 7 days, then 75 mg PO once daily, and then may increase the dose by 75 mg/day every 4 days or more as needed. Max: 225 mg/day.
• Benzodiazepines ^r7c97
  • Alprazolam ^c98
    • Alprazolam Oral tablet; Adults: 0.25 to 0.5 mg PO 3 times daily, initially. May increase the dose every 3 to 4 days as needed. Max: 4 mg/day. Use the lowest possible effective dose.
    • Alprazolam Oral tablet; Older Adults: 0.25 mg PO 2 or 3 times daily, initially. May increase the dose gradually every 3 to 4 days as needed. Max: 4 mg/day. Use the lowest possible effective dose.
  • Diazepam ^c99
    • Diazepam Oral solution; Infants, Children, and Adolescents 6 months to 17 years: 1 to 2.5 mg PO 3 to 4 times daily, initially. May increase the dose gradually as needed and tolerated. Adult Max: 40 mg/day.
    • Diazepam Oral tablet; Adults: 2 to 10 mg PO 2 to 4 times daily.
    • Diazepam Oral tablet; Older Adults: 2 to 2.5 mg PO 1 or 2 times daily, initially. May increase the dose gradually as needed and tolerated. Max: 40 mg/day.
  • Lorazepam ^c100
    • Lorazepam Oral solution; Children† 1 to 11 years: 0.025 to 0.05 mg/kg/dose PO up to every 4 hours as needed for anxiety. In older pediatric patients, the daily dosage for anxiety disorders is typically divided into 2 to 3 doses with a maximum of 10 mg/day.
    • Lorazepam Oral tablet; Children and Adolescents 12 to 17 years: 2 to 3 mg/day PO in 2 to 3 divided doses, initially. May increase the dose gradually as needed. Usual dose: 2 to 6 mg/day. Max: 10 mg/day.
    • Lorazepam Oral tablet; Adults: 2 to 3 mg/day PO in 2 to 3 divided doses, initially. May increase the dose gradually as needed. Usual dose: 2 to 6 mg/day. Max: 10 mg/day.
    • Lorazepam Oral tablet; Older Adults: 1 to 2 mg/day PO in 2 to 3 divided doses, initially. May increase the dose gradually as needed. Usual dose: 2 to 6 mg/day. Max: 10 mg/day.
• Azapirones ^c101
  • Buspirone ^r47c102
    • Buspirone Hydrochloride Oral tablet; Children† 6 to 12 years: 2.5 to 5 mg PO twice daily, initially. May increase the dose by 5 mg/day every 3 to 7 days as needed. Usual dose: 10 to 15 mg/day. Max: 60 mg/day. Coadministration of certain drugs may need to be avoided or dosage adjustments may be necessary; review drug interactions.
    • Buspirone Hydrochloride Oral tablet; Adolescents†: 2.5 to 5 mg PO twice daily, initially. May increase the dose by 5 mg/day every 3 to 7 days as needed. Usual dose: 10 to 60 mg/day. Max: 60 mg/day. Coadministration of certain drugs may need to be avoided or dosage adjustments may be necessary; review drug interactions.
    • Buspirone Hydrochloride Oral tablet; Adults: 7.5 mg PO twice daily, initially. May increase the dose by 5 mg/day every 2 to 3 days as needed. Usual dose: 20 to 30 mg/day. Max: 60 mg/day. Coadministration of certain drugs may need to be avoided or dosage adjustments may be necessary; review drug interactions.

Nondrug and supportive care

• Direct all patients and their families to self-help internet sites for education on generalized anxiety disorder (eg, Anxiety and Depression Association of America^r49) ^r48c103
  • Educate patients on lifestyle changes that may help reduce symptoms
    • Improving quality and quantity of sleep ^c104
    • Regular exercise ^c105
      • Exercise has been shown to have significant ability to reduce anxiety symptoms and is encouraged ^r50r51
    • Minimizing caffeine and alcohol intake ^c106c107
    • Avoiding nicotine and other drugs ^c108c109
• Psychotherapy
  • Cognitive behavioral therapy ^c110
    • Multiple types of psychotherapy have been applied to the treatment of generalized anxiety disorder, with evidence strongest for the efficacy of cognitive behavioral therapy ^r4
    • Recommended for all patients, although use may be guided by resource availability, patient finances, or patient preference
    • Teaches patients to substitute positive thoughts for anxiety-provoking ones ^r7
    • Brief description: ^r52
      • Present a cognitive model of anxiety to the patient and train in self-monitoring and identification of cues that contribute to interpretations of threat
      • Inform patients that therapy focuses on learning different, less anxiety-provoking ways of viewing the self, the world, and the future
      • Use standard cognitive therapy procedures (eg, outlining cognitive predictions, interpretations, beliefs, and assumptions that lead to threatening perceptions); emphasize Socratic method (ie, stimulate critical thinking by asking and answering questions)
      • Focus discussions on multiple alternative perspectives for any given situation of daily living; homework emphasizes frequent applications of alternative perspectives and behavioral tasks
    • Reduction in intolerance of uncertainty is an important predictor of outcome
    • Therapy can be delivered in 6 to 12 sessions at weekly intervals ^r52

Comorbidities

• Major depressive disorder is the most common coexisting psychiatric illness in patients with generalized anxiety disorder, coexisting in nearly two-thirds of cases ^r12c111c112
  • Occurs more often in female individuals than in male individuals ^r1
  • Combination of these disorders is termed cothymia^r7
  • Antidepressants are the preferred drug treatment, in combination with cognitive behavioral therapy
• Panic disorder ^r7c113
  • Occurs in 25% to 50% of patients with generalized anxiety disorder ^r5r12
  • Combination of buspirone with cognitive behavioral therapy is more effective than psychotherapy alone
• Separation anxiety disorder is often comorbid with generalized anxiety disorder in children ^r53

Special populations

• Children
  • Preferably, treat with cognitive behavioral therapy; medications such as antidepressants are often avoided over concern for adverse effects ^r7
    • However, the combination of cognitive behavioral therapy and sertraline has demonstrated efficacy in children between the ages of 7 and 17 years ^r54
• Pregnant patients
  • In the perinatal period, generalized anxiety may be exacerbated, requiring pharmacotherapy in addition to psychotherapy ^r12
    • Prescribe half the usual drug dose (typically buspirone) for pregnant patients. ^r12
    • 1 of the goals of therapy in these patients is to prevent premature birth or miscarriage due to anxiety

Screening tests

• Women's Preventive Services Initiative guidelines recommend screening for anxiety in adult and adolescent female patients aged 13 years or older, including pregnant and postpartum patients ^r57r58
  • Use clinical judgment to determine frequency of screening
• Appropriate screening instruments include: ^r58r59
  • Beck Anxiety Inventory ^c120
  • GAD-7 (Generalized Anxiety Disorder Scale) ^c121
  • K-10 (Kessler Psychological Distress Scale) ^c122
  • PHQ-9 (Patient Health Questionnaire) ^c123
  • GAD-2, PHQ-2, K-6 (abbreviated versions of the above scales)
  • SCARES (Screen for Child Anxiety Related Emotional disorders Scale) ^c124
  • HADS (Hospital Anxiety and Depression Scale) ^c125
  • Edinburgh Postnatal Depression Scale ^c126
  • Bright Futures Pediatric Symptom Checklist–Youth Report in adolescent and young adult female patients ^c127