Kaplan and Sadock's Comprehensive Textbook of Psychiatry

1. Generalized Anxiety Disorder
• Anxiety can be conceptualized as a normal
and adaptive response to threat that prepares
the organism for flight or fight
• Persons who seem to be anxious about almost
everything, however, are likely to be classified
as having generalized
• anxiety disorder associated with somatic
symptoms, such as muscle tension, irritability,
difficulty sleeping, and restlessness

2. • The anxiety is not focused on features of
another Axis I disorder, is not caused by
substance use or a general medical
condition, and does not occur only during a
mood or psychiatric disorder.

3. Epidemiology
• Generalized anxiety disorder is a common
condition; reasonable estimates for its 1-year
prevalence range from 3 to 8 percent.
• The ratio of women to men with the disorder is
about 2 to 1, but the ratio of women to men who
are receiving inpatient treatment for the disorder
is about 1 to 1. A lifetime prevalence is close to 5
percent with the Epidemiological Catchment Area
(ECA) study suggesting a lifetime prevalence as
high as 8 percent.

4. • In anxiety disorder clinics about 25 percent of
patients have generalized anxiety disorder.
The disorder usually has its onset in late
adolescence or early adulthood, although
cases are commonly seen in older adults
• Also, some evidence suggests that the
prevalence of generalized anxiety disorder is
particularly high in primary care settings

5. Comorbidity
• Generalized anxiety disorder coexists with
another mental disorder, usually social
phobia, specific phobia, panic disorder, or a
depressive disorder
• As many as 25 percent of patients eventually
experience panic disorder. Generalized anxiety
disorder is differentiated from panic disorder
by the absence of spontaneous panic attacks.

6. Biological Factors
• benzodiazepines and the azaspirones (e.g.,
buspirone [BuSpar]) have focused biological
research efforts on the γ-aminobutyric acid
and serotonin neurotransmitter systems
• Benzodiazepines (which are benzodiazepine
receptor agonists) are known to reduce
anxiety

7. • Where as flumazenil (Romazicon) (a
benzodiazepine receptor antagonist) and the
β-carbolines (benzodiazepine receptor reverse
agonists) are known to induce anxiety.

11. Treatment
• The most effective treatment of generalized
anxiety disorder is probably one that
combines psychotherapeutic,
pharmacotherapeutic, and supportive
approaches.

12. Psychotherapy
• The major techniques used in behavioral approaches
are relaxation and biofeedback
• Insight-oriented psychotherapy focuses on uncovering
unconscious conflicts and identifying ego strengths
• Psychodynamic therapy proceeds with the assumption
that anxiety can increase with effective treatment. The
goal of the dynamic approach may be to increase the
patient's anxiety tolerance (a capacity to experience
anxiety without having to discharge it), rather than to
eliminate anxiety

13. Pharmacotherapy
I. Benzodiazepines
II. Buspirone
III. Venlafaxine
IV. Selective Serotonin Reuptake Inhibitors
V. Other drugs

14. Anxiety Disorder due to a General
Medical Condition

15. Etiology
• A wide range of medical conditions can cause
symptoms similar to those of anxiety disorders
(Table 16.7-1).
Hyperthyroidism, hypothyroidism, hypoparath
yroidism, and vitamin B12 deficiency are
frequently associated with anxiety symptoms
• A pheochromocytoma produces
epinephrine, which can cause paroxysmal
episodes of anxiety symptoms

18. Generalized Anxiety
• generalized anxiety disorder symptoms has
been reported in patients with sjogren’s
syndrome, and this rate may be related to the
effects of sjogren’s syndrome on cortical and
subcortical functions and thyroid function
• generalized anxiety disorder symptoms in a
medical disorder seems to be in Graves'
disease

19. Phobias
• 17 percent prevalence of symptoms of social
phobia in patients with Parkinson's disease
• patients complain of a fear of falling, which
may express itself by their being unwilling or
fearful of walking

20. Differential Diagnosis
• A mental status examination is necessary to
determine the presence of mood symptoms or
psychotic symptoms that may suggest another
psychiatric diagnosis
• For a clinician to conclude that a patient has an
anxiety disorder caused by a general medical
condition, the patient should clearly have anxiety
as the predominant symptom and should have a
specific causative nonpsychiatric medical disorder

21. Treatment
• the removal of the primary medical condition
does not reverse the anxiety disorder
symptoms, treatment of these symptoms
should follow the treatment guidelines for the
specific mental disorder
• In general, behavioral modification
techniques, anxiolytic agents, and
serotonergic antidepressants have been the
most effective treatment modalities

22. Substance-Induced Anxiety Disorder
• Substance-induced disorder is the direct result
of a toxic substance, including drugs of
abuse, medication, poison, and
alcohol, among others.

23. Etiology
• as amphetamine, cocaine, and caffeine, have
been most associated with the production of
anxiety disorder symptoms, many
serotonergic drugs (e.g., lysergic acid
diethylamide [LSD] and
methylenedioxymethamphetamine [MDMA])
can also cause both acute and chronic anxiety
syndromes in users
• wide range of prescription medications

26. Clinical Features
• Nevertheless, alcohol use disorders and other
substance-related disorders are commonly
associated with anxiety disorders.
• Alcohol use disorders are about four times more
common among patients with panic disorder
than among the general population, about three
and a half times more common among patients
with OCD, and about two and a half times more
common among patients with phobias

27. Course and Prognosis
• The course and prognosis generally depend on
removal of the causally involved substance and
the long-term ability of the affected person to
limit use of the substance.
• The anxiogenic effects of most drugs are
reversible.
• When the anxiety does not reverse with cessation
of the drug, clinicians should reconsider the
diagnosis of substance-induced anxiety disorder
or consider the possibility that the substance
caused irreversible brain damage.

28. Treatment
• anxiety disorder symptoms continue even
after stopping substance use, treatment of the
anxiety disorder symptoms with appropriate
psychotherapeutic or pharmacotherapeutic
modalities may be appropriate

29. Anxiety Disorder not Otherwise
Specified

30. Mixed Anxiety-Depressive Disorder
• Mixed anxiety-depressive disorder describes
patients with both anxiety and depressive
symptoms who do not meet the diagnostic
criteria for either an anxiety disorder or a mood
disorder.
• The combination of depressive and anxiety
symptoms results in significant functional
impairment for the affected person.
• The condition may be particularly prevalent in
primary care practices and outpatient mental
health clinics

31. Diagnosis
• anxiety and depression and the presence of
some autonomic symptoms, such as
tremor, palpitations, dry mouth, and the
sensation of a churning stomach.

32. Clinical Features
• anxiety disorders and some symptoms of
depressive disorders are common symptoms
of autonomic nervous system hyperactivity,
such as gastrointestinal complaints, are
common and contribute to the high frequency
with which the patients are seen in outpatient
medical clinics.

34. Treatment
• the anxiolytic drugs, some data indicate that
the use of triazolobenzodiazepines
(e.g., alprazolam [Xanax]) may be indicated
because of their effectiveness in treating
depression associated with anxiety