Generalized anxiety disorder: Differential diagnosis and treatment

Abstract

What is generalized anxiety disorder?GAD is characterized by excessive worry and symptoms of physiological arousal such as restlessness, insomnia, and muscle tension (box). To meet Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) criteria for the disorder, the patient must have excessive and difficult to control anxiety about several different events or activities.2 For example, anxiety confined to concern about personal safety would not qualify (but should elicit inquiries about symptoms of post-traumatic stress disorder or agoraphobia, for example). In addition to worry, patients must have at least three of the six physiological arousal symptoms listed in the box. These symptoms must not be caused by another psychiatric or medical disorder, or by the use of drugs, and they must cause serious distress or impairment for the clinical diagnosis to be made. The diagnostic criteria will probably be modified in the new DSM-V (for more information, see www.dsm5.org).DSM-IV diagnostic criteria for generalized anxiety disorder Excessive anxiety and worry occurring more days than not for at least six months Worry that is difficult to control The anxiety or worry is associated with three or more of the following: Restlessness or feeling “keyed up” or on edge Being easily fatigued Difficulty concentrating or mind going blank Irritability Muscle tension Sleep disturbance The focus of the anxiety is not part of another disorder (such as fears of embarrassment in public in social anxiety disorder) The ICD-10 (international classification of diseases, 10th revision) description of GAD contains slightly different description of symptoms. It focuses on physiological arousal such as trembling, sweating, palpitations, and dizziness and does not require symptoms to be present for six months. It is defined as: “Anxiety that is generalized and persistent but not restricted to, or even strongly predominating in, any particular environmental circumstances (it is “free-floating”). The dominant symptoms are variable but include complaints of persistent nervousness, trembling, muscular tensions, sweating, lightheadedness, palpitations, dizziness, and epigastric discomfort. Fears that the patient or a relative will shortly become ill or have an accident are often expressed.” Because most clinical trials use DSM-IV criteria, we will focus on GAD as defined by the DSM-IV classification so that the reader can best evaluate the treatment trial data.