Generalized Anxiety Disorder

David S. Baldwin '

1Clinical Neuroscience Division, School of Medicine, University of Southampton, Southampton, Hampshire, UK

2University Department of Mental Health, RSH Hospital, Southampton, UK


Anxiety neurosis; Free-floating anxiety; GAD Definition

Generalized anxiety disorder (GAD) is characterized by an excessive and inappropriate worrying that is persistent and not restricted to particular circumstances. Patients have physical anxiety symptoms (such as tachycardia and tremor) and key psychological symptoms, including restlessness, fatigue, difficulty in concentrating, irritability, and disturbed sleep. The disorder is common and disabling: a recent review of epidemiological studies in Europe suggests a lifetime prevalence of approximately 5%, and the associated functional impairment is similar to that with major depression. However, many of those who might benefit from treatment are not recognized or treated, which is disappointing, as a range of evidence-based treatments are available.

Role of Pharmacotherapy Efficacy in Acute Treatment

Current ► Evidence-Based Guidelines for the pharmacological management of patients with GAD recommend initial treatment with either a ► selective serotonin reuptake inhibitor (SSRI) or a serotonin-norepinephrine reuptake inhibitor (► SNRI), on the basis of proven efficacy and reasonable tolerability in randomized placebo-controlled trials (Baldwin et al. 2005; Bandelow et al. 2008). Approximately, 40-60% of patients will "respond" to placebo and 60-75% to the SSRIs ► escitalopram,

► paroxetine, or ► sertraline, when using global measures of improvement, and similar findings are seen for the SNRIs

► duloxetine or ► venlafaxine and for the novel anxiolytic drug ► pregabalin (Baldwin and Ajel 2007). Symptom severity on the primary outcome measure, traditionally the ► Hamilton Rating Scale for Anxiety, HAMA, can be reduced markedly, but many patients remain troubled by distressing anxiety symptoms at study end-point, despite seemingly making a good overall "response" to treatment.

Benzodiazepines are also efficacious (and can provide a rapid reduction in symptoms) in many patients and have similar overall efficacy to the psychological treatment cognitive therapy. However, they are usually ineffective in relieving comorbid depressive symptoms, and unwanted effects include sedation, disturbance of memory, and psychomotor function; other potential problems include development of ► tolerance, abuse and dependence, and distressing withdrawal symptoms. Because of these, it is advisable to use benzodiazepines only for short-term treatment (up to 4 weeks) or in patients who have not

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