GENERALIZED ANXIETY DISORDER - GUIDELINES FOR DIAGNOSIS AND TREATMENT

Generalised anxiety disorder (GAD) is the most common anxiety disorder . It is usually a chronic condition, but the severity of symptoms may depend greatly on the degree of stress the patient is under at any one time. According to DSM-IV, the symptoms of GAD consist of excessive a nxiety and worry, hyperarousal, increased muscular tension, difficulti es concentrating, irritability and sleep disturbances. While autonomic symptoms are not required for the diagnosis, subgroups of patients wi th GAD do manifest a considerable degree of cardiac or gastrointestina l symptoms. GAD is frequently associated with affective and other anxi ety disorders. The treatment of GAD includes psychological and pharmac ological interventions. Psychological interventions consist of explana tions, reassurance, support and, in more persistent conditions, cognit ive and behavioural therapy. In pharmacotherapy, benzodiazepines, anti depressants, antihistamines and, less frequently, antipsychotics and b eta-adrenergic blockers are used. The choice of medication depends on the severity of symptoms, the degree to which psychic and somatic symp toms contribute to the overall picture, and whether symptoms are episo dic or continual. Benzodiazepines have anxiolytic, sedating and muscle relaxing properties. Since their onset of effect is rapid, they are u seful whenever rapid anxiolysis is indicated. Benzodiazepines with a l ong elimination half-life are preferable if long term treatment is req uired, but may accumulate in elderly patients or in patients with live r disease. Benzodiazepines do not seem to lose their effectiveness dur ing long term treatment. However, because of their addictive potential , in most cases, benzodiazepines should only be given for a short time . Frequently, patients with GAD use benzodiazepines intermittently, i. e. only in situations that they perceive as stressful. Benzodiazepines should only be prescribed on a long term basis in severely anxious pa tients who have responded poorly to other treatments. In such patients , the improvement in functioning that can be induced by the drugs outw eighs the risk of addiction. Antidepressants, and particularly those w ith serotonin (5-hydroxytryptamine; 5-HT) reuptake inhibiting properti es, reduce worries and obsessions, and so are useful in patients in wh om excessive worrying predominates. However, they have to be taken on a long term basis to provide adequate control of symptoms and often ha ve unpleasant adverse effects. Anxiolytics that affect specific seroto nin receptors also have anxiolytic properties by lowering psychic anxi ety, but also have to be taken long term to be effective. Antihistamin es and antipsychotics have some anxiolytic effect and are not habit fo rming. They can be prescribed on an 'as needed' basis or as a regular prescription. Antihistamines should be given to patients in whom addic tion to benzodiazepines is a possibility. However, antipsychotics shou ld be avoided in all but the exceptional case because they may induce tardive dyskinesia. beta-Adrenergic blockers have no direct anxiolytic properties, but are useful as adjunctive therapy in patients with pro minent cardiac symptoms or tremor.