The document discusses anxiety disorders, specifically generalized anxiety disorder (GAD). It notes that primary care physicians treat 60% of patients with panic and anxiety disorders, but 90% of cases have been undiagnosed. GAD has a lifetime prevalence of 5% in American adults and involves excessive, uncontrollable worry about multiple events for at least 6 months. Treatment options for GAD include SSRIs, SNRIs, benzodiazepines, buspirone, cognitive behavioral therapy, and augmenting SSRIs with bupropion or pregabalin. The document also provides screening tools and discusses managing GAD with comorbid depression.

1. Anxiety Disorder
By: Shima Ghavimi, MD
PGY-1

2. According to ACP
Studies show that 60% of patients with panic
and anxiety disorders are treated by primary care
physicians. That means you have a tremendous
opportunity to help these patients and make a
major difference in their lives.
 90% of all cases have been undiagnosed.

3. Generalized Anxiety Disorder

4. Generalized Anxiety Disorder
Life time prevalence of GAD in American
adults is 5 %
Excessive worry and anxiety that is difficult to
control
Symptoms occurs more days than not for at
least 6 months and are bout a number of events
And activities

5. GAD
3 or more of the following symptoms:
Restlessness or feeling keyed up or on edge, easily
fatigued, difficulty concentrating, irritability, muscle
tension, sleep disturbance
Causes significant stress or impairment

6. Risk Factors
Female
Older age
Positive family history
Less strong risk factors:
Increase in stress, history of physical and
emotional trauma and smoking

7. The prevalence of chronic medical illness
including lung disease , DM , heart disease ,
HTN, arthritis is greater among those with
anxiety
Is A/W being divorced or separated
Blacks, Latino and Asian have decreased risk of
GAD.

8. GAD and depression
According to DMS-IV a patient with diagnosed
depression can only be diagnosed with anxiety
once depression has undergone remission
Therefore when managing a patient with
depression and anxiety we first treat the
depression as anxiety often improves with
treatment of depression.

9. Screening
Score: 5-9 = mild anxiety;
10-14 = moderate anxiety;
15-21 = severe anxiety.

13. GAD Treatment
Medications including buspirone,
benzodiazepines, antidepressants (SSRIs,
venlafaxine, imipramine)
Cognitive-behavioral therapy

14.  SSRIs: first-line treatment for chronic anxiety,
while benzodiazepines are used for acute
exacerbations. SNRIs are appropriate as an
alternative to SSRIs, while an emerging literature
indicates that pregabalin can be effective as an
augmentive agent. Buspirone and bupropion
are appropriate agents; sedative-hypnotics are
not typically appropriate in the treatment of
anxiety, except as symptomatic relief of
insomnia.

15. A patient comes to you for discussion of treatment for
GAD. She recently became dissatisfied with the care
provided by her psychiatrist and would like to change
her regimen under your care. She is on an SSRI, but
finds that her anxiety symptoms are not sufficiently
controlled. In addition, she has numerous episodes of
acute anxiety exacerbation. Which of the following
might be possible additions or alternations to her
regimen?

16. a) Augmenting SSRI with bupropion or
pregabalin
b) Adding a benzodiazepine
c) Switching from an SSRI to an SNRI
d) Increasing the dose of SSRI
e) All of the above

17. a) Augmenting SSRI with bupropion or
pregabalin
b) Adding a benzodiazepine
c) Switching from an SSRI to an SNRI
d) Increasing the dose of SSRI
e) All of the above

18. Refrences:
ACP Manual on Anxiety Disorder, 2015.
Anxiety Disorders Association of America. Anxiety
disorders. Retrieved on April 28, 2009 from
http://www.adaa.org/GettingHelp/Briefoverview.asp
National Institute of Mental Health. (2008). The
Numbers Count: Mental disorders in America.
Retrieved on September 1, 2008, from
http://www.nimh.nih.gov/health/publications/the-
numbers-count-mental-disorders-in-
america.shtml#Anxiety