THE CASE
Sandra H,* a 24-year-old single woman with a history of asthma, presented to our family medicine clinic as a new patient. Ms. H said she lived at home with her mother. She completed high school but never attended college due to anxiety. She had held several jobs since high school and recently decided to apply to a local college, which prompted a desire to gain control over the anxiety that had been present since middle school. She reported feeling anxious, having difficulty breathing, shaking all over, having difficulty concentrating, and experiencing numbness and tingling in her fingers. She was often irritable at home, which she attributed partly to anxiety but mostly to disrupted sleep. We administered the 7-question Generalized Anxiety Disorder (GAD-7) questionnaire and she scored 15 (of a possible 21) points, indicative of severe anxiety.
● How would you proceed with this patient?
* The patient’s name has been changed to protect her identity.
Approximately 1 in 5 patients presenting to primary care clinics have at least 1 anxiety disorder and 7.6% have generalized anxiety disorder (GAD).1 Yet many go untreated. The lifetime prevalence of GAD is 3.7% worldwide and 7.8% in the United States.2 Only 5% of cases emerge by age 13,2 but incidence increases through adolescence and young adulthood, with a quarter of all cases occurring by age 25.2 GAD occurs about twice as often in women as it does in men. It is typically recurrent, and many patients require ongoing treatment.2
GAD diagnostic criteria and differential considerations
Diagnosis of GAD requires at least 6 months of excessive worry or anxiety about a variety of circumstances, occurring on most days and for more than half the day.3 The worry or anxiety in GAD is difficult to control, disrupts meaningful areas of life, and surrounds everyday concerns, such as finances, health, or family-related issues. Among adolescents with GAD, worries typically include school performance and may often present as perfectionism.4 At least 3 of the following 6 symptoms result from chronic anxiety: restlessness, fatigue, poor concentration, irritability, muscle tension, and sleep disturbance.2
Rule out other conditions. Make sure symptoms of GAD are not better explained by another medical problem, including other mental disorders or substance use disorders.3 Complaints of anxiety in the context of mania, hypomania, or withdrawal from alcohol or a sedative hypnotic suggest a different underlying cause, thereby requiring a complete history with symptom chronology and collateral information. The pattern of anxiety seen in GAD also differs from the focused sources of anxiety found in disorders such as social anxiety disorder (SAD) and post-traumatic stress disorder. For example, SAD might center on embarrassment in a social setting rather than reflect a pattern of general worry.5
Consider comorbidities. Further complicating diagnosis and treatment, GAD has been linked to higher rates of comorbidity and higher health care utilization. About 90% of GAD patients experience psychiatric comorbidity, with major depressive disorder co-occurring about 60% of the time.6 Substance use disorders co-occur with GAD more than 20% of the time.2 Despite comorbidities, it is the somatic complaints in GAD that often drive patient requests for medical care.7,8 GAD itself is an independent predictor of heart disease9 and is linked to increased risk of chronic or severe headaches10 and suicide.11,12
Continue to: Work with patients and family toward a diagnosis