QUICK RECERTIFICATION SERIES
Generalized anxiety disorder
Amy M. Klingler, MS, PA-C
GENERAL FEATURES
• Generalized anxiety disorder is characterized by exces-
sive, uncontrollable worry that causes distress and inter-
feres with a patient’s ability to function normally.
• Generalized anxiety disorder is twice as common in
women as it is in men and affects nearly 7 million adults
in the United States.
• Comorbid illnesses often found with generalized anx-
iety disorder include major depressive disorder, panic
disorder, phobias, and other anxiety disorders such as
obsessive-compulsive disorder, social anxiety, and post-
traumatic stress disorder.
• Patients commonly present with physical complaints
related to a heightened state of arousal. These may include
insomnia; fatigue; headaches; and neck, shoulder, or
back pain.
CLINICAL ASSESSMENT
• The differential diagnosis for generalized anxiety disor-
der includes depression, hypochondriasis, panic disorder,
and adjustment disorder.
• A comprehensive history should include a past medical
history including illnesses, medications, and any adverse
drug reactions; personal and family psychiatric history;
social history including stressful life events, alcohol and
illicit drug use, abuse, and neglect.
• Tests that can be used to rule out other causes for anxi-
ety include a complete blood cell count, comprehensive
metabolic panel, thyroid-stimulating hormone, urinaly-
sis, ECG, and urine toxicology.
• The Generalized Anxiety Disorder 7 Item Scale (GAD-7)
can be used as a screening tool; the Hospital Anxiety
Depression Scale is used to assess the severity of a patient’s
generalized anxiety disorder.
DIAGNOSIS
• According to the Diagnostic and Statistical Manual of
Mental Disorders, 5th edition (DSM-5), the diagnosis of
generalized anxiety disorder requires the presence of:
Amy M. Klingler practices at the Salmon River Clinic in Stanley,
Idaho. The author has disclosed no potential conflicts of interest,
financial or otherwise.
Dawn Colomb-Lippa, MHS, PA-C department editor
DOI: 10.1097/01.JAA.0000451864.10330.b4
Copyright © 2014 American Academy of Physician Assistants
42 www.JAAPA.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
° Excessive anxiety and worry (apprehensive expecta-
tion), occurring more days than not for at least 6
months, about a number of events or activities (such
as work or school performance).
° Difficulty controlling the worry.
° Anxiety and worry associated with three (or more) of
the following six symptoms, with at least some symp-
toms having been present for more days than not for
the past 6 months:
1. Restlessness or feeling keyed up or on edge
2. Being easily fatigued
3. Difficulty concentrating or mind going blank
4. Irritability
5. Muscle tension
6. Sleep disturbance (difficulty falling or staying asleep,
or restless, unsatisfying sleep).
Note: Only one item is required in children.
° Anxiety, worry, or physical symptoms that cause
clinically significant distress or impairment in social,
occupational, or other important areas of functioning
° A disturbance not attributable to the physiological effects
of a substance (such as a drug of abuse or a medication)
or another medical condition such as hyperthyroidism.
QUESTIONS
1. A 28-year-old woman presents to your office with a
12-month history of excessive, uncontrollable worry
that is interfering with her relationships and work
performance. You diagnose her with generalized anxiety
disorder. Which medication is the preferred first-line
therapy?
a. quetiapine
b. diazepam
c. nortriptyline
d. sertraline
2. Cormorbid illnesses commonly found in patients with
generalized anxiety disorder include all of the following
except:
a. obsessive compulsive disorder
b. major depressive disorder
c. schizophrenia
d. post-traumatic stress disorder
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TREATMENT
• Generalized anxiety disorder can be treated with medication,
cognitive behavioral therapy, or a combination of both.
• First-line medications include selective serotonin reuptake
inhibitors (SSRIs) such as paroxetine, sertraline, escita-
lopram, citalopram, fluoxetine, and fluvoxamine or
selective norepinephrine reuptake inhibitors (SNRIs)
such as venlafaxine and duloxetine.
• Patients usually achieve the full clinical effect of SSRIs
and SNRIs after 4 to 6 weeks. If, after 4 weeks a patient
has had a partial response it is reasonable to slowly titrate
the dose up to a maximum dose. If there has been no
response after 6 to 8 weeks at a therapeutic dose, the
initial drug should be tapered off and another agent
should be prescribed. If an SSRI was the first drug pre-
scribed, another SSRI or an SNRI can be used.
• Options for second-line treatment of anxiety include
benzodiazepines, tricyclic antidepressants, and some
anticonvulsants.
• Benzodiazepines are most commonly prescribed in
combination with an SSRI or SNRI to treat acute
anxiety, or are used during the titration phase to a
therapeutic dose of an SSRI or SNRI. Use benzodiazepines
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Generalized anxiety disorder
with caution in patients who have a history of substance
abuse or comorbid depression.
• Tricyclic antidepressants have a poor tolerability profile
and can be cardiotoxic; however, they may effectively
augment a first-line medication.
• Duration of treatment for generalized anxiety disorder
should be at least 12 months.
patients with generalized anxiety disorder.
stress disorder are common comorbidities affecting
disorder, major depressive disorder, and post-traumatic
generalized anxiety disorder. Obsessive compulsive
2. C. Schizophrenia is not a common comorbidity of
line medication for generalized anxiety disorder.
tricyclic antidepressant that is recommended as a second-
but SSRIs and SNRIs are preferred. Nortriptyline is a
disorder. Diazepam can be used as a first-line medication,
augment first-line medications for generalized anxiety
antipsychotic medication that has been used off-label to
generalized anxiety disorder. Quetiapine is an
1. D. Sertraline is an SSRI used as a first-line treatment for
Answers
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