Generalized anxiety disorder (GAD) is characterized by excessive or unrealistic anxiety and worries about life circumstances. In the general population, the prevalence of GAD is 2% to 5%. It is the most frequent anxiety disorder seen in primary care, where 22% of patients complain of anxiety problems.1DSM-IV lists 6 somatic symptoms associated with GAD: restlessness, increased fatigability, difficulty in concentrating, irritability, muscle tension, and sleep disturbance. These symptoms may present with hyperarousal, hypervigilance, and heightened muscle tension; autonomic symptoms are milder than in other anxiety disorders and can be absent.2
Patients with GAD do not form a homogeneous group. Cardiovascular or GI symptoms predominate in some patients. In one study, more than half of a surveyed population complained of palpitations and had had, at least once, a consultation with a cardiologist.3 In another study, results showed that patients with GAD who expressed high levels of cardiac complaints had higher levels of skin conductance, which measures sweat gland activity. They had greater cardiac variability during stress and required higher levels of benzodiazepines during treatment.4 In a study by Ballenger and colleagues,5 more than 50% of patients with irritable bowel syndrome (IBS) also had GAD. In addition, GAD was found to have high comorbidity with other anxiety disorders and depression.2 In the presence of medical comorbidity, anxiety may crystallize around the physical state.
Treatment of GAD and its somatic symptoms
Since excessive and often unrealistic worries are central to GAD, cognitive-behavioral therapy (CBT) is the preferred mode of psychological treatment. CBT teaches self-monitoring: patients learn to observe their anxious experiences and to correct faulty response patterns. In addition, various relaxation techniques help reduce the physiological expressions of hyperarousal and muscle tension.
Medications to control symptoms in GAD include benzodiazepines, SSRIs, serotonin-norepinephrine reuptake inhibitors (SNRIs), antipsychotics, and ß-blockers. The Table presents an overview of the most frequent pharmacotherapies for treating GAD.
Treatment of GAD depends on the severity of the problem and the preferences of the individual patient and can consist of psychotherapy, pharmacotherapy, or both. Because each patient is unique, treatment plans have to be tailored to meet specific needs. The quality and severity of psychic symptoms need to be examined; the fears and worries, the level of arousal, the presenting somatic symptoms, and their behavioral consequences all need to be taken into account. This article will briefly review the various treatments available for GAD and its symptoms.
Perception of physical symptoms
Many patients with GAD, particularly those with a family history, are concerned about having an illness and become preoccupied with their bodily state. Others experience cardiac or GI changes that may be harmless or may need medical attention. Patients worried about their physical state should undergo a thorough physical examination, and the results should be discussed with them to clarify which symptoms are due to anxiety and which symptoms to a potential physical illness.
One problem in assessing somatic symptoms is that patients show considerable discrepancies between perception of bodily states and actual changes of physiological states; they generally misperceive their bodily states.6 During acute stress, patients are fairly accurate in perceiving the direction of, but not the magnitude of, bodily changes. The relationship between bodily states and their perception is even more complex when changes are compared over longer periods.
References:
1. Wittchen HU. Generalized anxiety disorder: prevalence, burden and cost to society. Depression Anxiety. 2001; 16:162-172.
2. Noyes R Jr, Hoehn-Saric R. The Anxiety Disorders. Cambridge UK: Cambridge University Press; 1998:37-85.
3. Logue MB, Thomas AM, Barbee JG, et al. Generalized anxiety disorder patients seek evaluation for cardiological symptoms at the same frequency as patients with panic disorder. J Psychiatr Res. 1993;27:55-59.
4. Hoehn-Saric R, McLeod DR, Zimmerli WD. Symptoms and treatment responses of generalized anxiety disorder patients with high versus low levels of cardiovascular complaints. Am J Psychiatry. 1989;146:854-859.
5. Ballenger JC, Davidson JRT, Lecrubier Y, et al. Consensus statement on generalized anxiety disorder from the international consensus group on depression and anxiety. J Clin Psychiatry. 2001;62(suppl 11):53-58.
6. McLeod DR, Hoehn-Saric R. Perception of physiological changes in normal and pathological anxiety. In: Hoehn-Saric R, McLeod DR, eds. Biology of Anxiety Disorders. Washington, DC: American Psychiatric Press; 1993:223-243.
7. Hoehn-Saric R, Borkovec TD, Nemiah JC. Generalized anxiety disorder. In: Gabbard GO, ed. Treatments of Psychiatric Disorders. 2nd ed. Washington, DC: American Psychiatric Press; 1995:1691-1722.
8. Roth T, Walsh JK, Krystal A, et al. An evaluation of the efficacy and safety of eszopiclone over 12 months in patients with chronic primary insomnia. Sleep Med. 2005; 6:487-495.
9. Hoehn-Saric R, McLeod DR. Somatic manifestations of normal and pathological anxiety. In: Hoehn-Saric R, McLeod DR, eds. Biology of Anxiety Disorders. Washington, DC: American Psychiatric Press; 1993:77-222.