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82 Gen eralized Anxiety Disordertreatments. The use of these antide press ants also has the benefit of treating comorbid depressionwhen it occurs.Other medications that are showing som e promise in treating social phobia include venlafax-ine (which inhibi ts the reuptake of both serotonin and norepinephrine) and gabapentin (whichworks at the GABA receptor co m ple x). Tricyclic antidepressants, however, have not been shownto be efficacious.9. Are there other types of treatment for social phobia?An im portant form of treatment for social phobia is cognitive behavioral therapy (CBT). Thistype of therapy involves cognitive restructuring by helping the individual with social phobia identifyhis or her cognitive distortions and challenge the accuracy of their perceptions. They also learn howto decrease their physiolog ic response of anxiety with various techn iques including deep-breathingand progressive muscle relaxation. Graded e xposure to the feared situation also is employed as theylearn to tolerate increasingly greater exposure to the feared situation. Eventually, the anxious re-sponse is extinguished.Group CBT also is helpful in the treatment of social phobia. This form of treatment includessocial skills training and role-playing, and allows individuals to get direct, immediate feedback ontheir perceptions of how othe rs view them.

BIBLIOGRAPHY1 American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th ed.Washington, DC, American Psychiatric Association, 1994.2. Goisman RM, Allsworth J Rog ers MP, et al: Simple phobia as a com orbid anxiety disorder. Depress Anxiety7(3):105-112, 1998.3. Heimberg RG, Juster HR: Treatment of social phobia in cognitive-behavioral groups. J Clin Psychiatry

S5(Suppl):3846, 1994.4 Jefferson JW: Socia l phob ia: pharm acolog ic treatment overview. J Clin Psychiatry 56(Suppl 5): 18-24,199s.5 . Keck PE , McElroy SL: New uses for antidepressants: Social phobia. J Clin Psychiatry 58(Suppl 14):32-38,1997.6. Kessler RC, M cGonagle KA, Zhoa S et al: Lifetime and 12-month prevalence of DSM-111-R psychiatric disor-ders in the U nited States: Results from the National Co morbidity Survey. Arch Gen Psychiatry51 :8-19, 1994.7. Schneier FR, Johnson J, Hornig CD , t al: Social phobia: Comorbidity and morbidity in an epidemiologicsample. Arch Gen Psychiatry 49:282-288, 1992.

16. GENERALIZED ANXIETY DISOR DERRobert D Davies, M . D . , and Leslie Winter, M . D

1. What is generalized anxiety disorder?Anxiety and worry are commo nly exp erienced responses to the stress of day-to-day life. We allworry at times about various aspects of our lives-particularly the unknown o r novel. Th is is ab-solutely normal. However, when worry and anxiety are the predominate approach to life, it is notnormal. People with generalized anxiety disorder (G AD ) experience excessive levels of anxietyand w orry most of the time and have great difficulty controlling their worry. Th e excessive level ofanxiety they experience causes significant distress and often impairs their ability to function in var-ious areas of their life (such as socially or occupationally). Many people with GA D become p reoc-cup ied with the physical sym ptom s associated with anxiety (such as gastrointestinal distress andfatigu e) and worry a bou t their health. Th is worry may lead them to repeatedly seek out medicalevaluations and reassurance. Thus, GA D typically is seen in primary care settings rather than i nmental health settings.

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GeneralizedAnxiety Disorder 832 List the physical symptoms of generalized anxiety disorder.Physical restlessness (feeling on edge)Fatigue M uscle tensionDifficulty concentrating or mind going blank

The d iagnosis of GA D is made only wh en at least three of these symptom s are present.

IrritabilitySleep disruption

3 What is the prevalence of GAD?Estimates from epidem iologic surveys estimate that the lifetime prevalence of GA D in the gen-eral population is 5.1 , with a higher prevalence in women (6.6 , versus 3.6 in m en). It is achronic condition that may d emonstrate periodic episodes of acute worsening throughout its course.GA D o ften begins in childhood and persists throughout life. For some individuals it may consist ofchronic, yet mild sym ptom s; for others it may cause significant levels of imp airment i n social set-tings, interpersonal relationships, and occupational functioning.GA D is seen most often in primary care rather than in psychiatric settings. This may be related,in part, to the myriad physical symptoms that ar e typically present in people with GA D. Chro nicmedical conditions such as irritable bowel syndrome and headaches often occur along with GA D.4. What other psychiatric illnesses are likely to occur with GAD?It has been estimated that 50-90 of people with GAD also have at least one other psychiatriccondition. This high degree of comorbidity has caused some researchers to call into question the va-lidity of the diagnosis of GAD as a distinct clinical entity. It is possible that w hat w e call GA D maybe a predisposing condition that leads to other anxiety and mood disorders. Major depression anddysthymia frequently are seen in individuals with GA D. Som e believe that this cluster of symptomsreflects a mixed anxiety-depressive state. Other anxiety disorders such as panic disorder, simplephobias, social phobia, and obsessive-compulsive disorder also can occu r in an individual with

GA D. Sub stance abuse is likely-just as it is with all other anxiety disorders. Personality disordersalso may be seen in these indiv iduals, and it can be d ifficult to sort out the effects of chronic anxietyfrom those of maladaptive personality traits.5. Which psychiatric conditions might be confused with GAD?The differential diagn osis of GA D is extensive because worry and anxiety are seen in so manyconditions. D epres sion, particularly when there is a prominent d egree of guilty rumina tion, maylook like GA D. Conditions involving anxiety triggered by specific situations (such as specific pho -bias, social situations in social phobia, or exposure to trauma-related situations in post-traumaticstress disorder) may be confused with GA D. Panic disorder, particularly w hen there is a great d eal ofanticipatory anxiety, may be confused with GAD-as can the excessive worry about weight or bodyimag e seen in anorexia nervosa and bulimia. People with GA D may be mistakenly diagn osed ashaving som atization disorder du e to their tendency to become focused on physical sym ptoms andpreoccupied with their health. Personality disorders (particularly avoidant personality disorder) maylook like GA D. Finally, substan ce use disorders (including nico tine and caffeine) a nd sub stancewithdrawal also can elicit symptoms of excessive anxiety.6. List the medical conditions that can cause anxiety.Hyperthyroidism o r hypothyroidismHypoglycemia CN S tumorsDiabetes mellitus Strokes

PheochromocytomaChronic o bstructive pulmonary diseaseAsthmaPulmonary emboli

Seizure d isorders

Traumatic brain injuriesCardiac arrhythmiasMitral valve prolapseSubstance intoxication a n d o r withdrawal7. Can certain types of medications cause anxiety symptoms?Yes. Many classes of drugs used for medical as well as psychiatric conditionscan cause sym ptoms ofanxiety. Anx iety is a comm on side effect of some drugs (such as bronchodilators, psychostimulants,

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84 Gen eralized Anxiety Disorderand corticosteroids); with other d rugs (e.g., meperidine, an tihistamines, and benzodiazepines), anx i-ety may represent an idiosyncratic response t o the medication. Rapid discontinuation m ay precipi-tate anxiety in a patient as well (reported with corticosteroids, benzodiazepines, some SSRIs, andvenlafaxine). T oxicity may resu lt in sym ptom s of anxiety (seen with theoph ylline). Almost allclasses of antidepressants cause anxiety in some patients, particularly during the initiation of treat-ment. Antipsychotics commo nly cause akathisia-a markedly distressing level of internal agitation.When evaluating a patient with anxiety, care must be taken to review the types and dosages of allcurrent or recently discontinued medications.8 What are the pharmacologic treatments used inGAD?Benzodiazepines, which decrease the severity of anxiety symptoms, have long been the main-stay of treatment for GA D. How ever, when a chronic condition is treated with a m edication that onlysuppresses symptoms, the medication itself becomes chronic. Although benzodiazepines offer thebenefit of rapid sym ptom relief, their chronic use can lead to tolerance (the need for escalatingdosages to maintain efficacy) and depen dence.

Buspirone, the 5HT agonist, is effective in treating GA D. Its biggest benefit over benzodi-azepines is that no dependence develops with chronic administration. Likewise there is no risk ofabuse, which makes it a good consideration for individuals with comorbid GAD and substance usedisorders. A major draw back, however, is that the onset of sympto m relief may be d elayed for sev-eral weeks after initiating treatment. This delay can have an adverse effect on medication compli-ance in the anxious patient, who may q uickly decide that the m edication is not working.Tricyclic antidepressants (TC As) are beneficial in som e cases of GA D. Their side-effect profileand lethality in overdose, how ever, tend to limit their use. The use of selective serotonin reup take in-hibitors (SSRIs) in treating GAD is increasingly widespread. SSRIs offer a more agreeable side-effect profile for m ost patients. Both SSR Is and TC As have the added benefit of treating comorbiddepression w hen it occurs.9 What other treatments are used to treatGAD?Managem ent of anxiety symptoms through relaxation training, exercise programs, and stress re-duction are all important aspects of treatment. These interventions help peop le to feel more in controlof the degree of their anxiety and w orry. Cognitive behavioral therapy has been show n to decrease thephysiologic aspects of G AD and alter the cognitive distortions that fuel the anxiety. As GA D tends tobe a chronic condition, therapies that aid the patient in unde rstanding the precipitants to their anxiety,the connection between phy sical sym ptoms an d psycho logical worry, and the cognitive processesthat keep them focused on worrying, as well as help affect lifestyle changes tend to have the mostlong-lasting benefit.

BIBLIOGRAPHY1. American Psychiatric Association: Diagno stic and S tatistical Manual of Mental Disorder, 4th ed.2. Beck AT, Emery G , Greenberg RL: Anxiety Disorders and P hobias: A Cognitive Perspective. New York3. Brauman-Mintzer 0 et al: Psychiatric comorbidity in patients with gene ralized anxiety disorder. Am J4. Elliston JM: IntegrativeTreatment ofAnxiety Disorders. Washington, DC, Am erican Psychiatric Press, Inc., 1996.5 . Lader MH: T he nature and duration of treatment for GA D. Acta Psychiatr and 98(Suppl 393): 109-1 17, 1998.6 Harvey AG, Rapee RM : Cognitive-behavior therapy for generalized anxiety disorder. Psy chiatr Clin North

Am 18(4):859-870, 1995.7. Kendler KS: M ajor depression and generalised anxiety disorder: Sam e genes, (partly) different environ-ments-revisited. Brit Psychiatry 168(Suppl 30):68-75, 1996.8. Kessler RC, McGonagle KA,Zhao S, et al: Lifetime and 12-month prevalence of DSM-111-R psych iatric disor-ders in the United States: Results from the national comorbidity study. Arch Gen Psychiatry 58:8-19, 1994.9. Maser JD : Generalized anxiety disorder and its comorbidities: Disputes at the boundaries. Acta PsychiatrScand 98(S uppl3 93): 12-22, 1998.10. Rickels K, Schweizer E: The treatment of gen eralized anxiety disorde r in patients w ith depressive sym pto-matology. J Clin Psychiatry 54(Suppl):20-23, 1993.

Washington, DC , American P sychiatric Association, 1994.Basic Books, Inc., 1985.Psychiatry 1SO: 12 16 - 1218, 1993.