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anxiety:gad [on May 21, 2019]
anxiety:gad [on January 11, 2024] (current)
psychdb [Psychotherapy]
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 == Epidemiology == == Epidemiology ==
-The 12-month prevalence is up to 5%, and the lifetime prevalence is 6%. For youth (age 13-18), it is 3%GAD is more frequent in Caucasians compared to other groupsIt affects 2 females for every 1 maleThe usual age of onset varies ​and may be bimodal with the median age of onset being approximately ​31 years. GAD is associated with high rates of comorbid psychiatric conditions including other anxiety disorders ​and depression. +  * The lifetime prevalence ​for generalized anxiety disorder ​is between ​to 9%.[(American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). ArlingtonVA.)][([[https://​pubmed.ncbi.nlm.nih.gov/​25081580/​|Katzman,​ M. A., Bleau, P., Blier, P., Chokka, P., Kjernisted, K., & Van Ameringen, M. (2014). Canadian clinical practice guidelines for the management ​of anxiety, posttraumatic stress ​and obsessive-compulsive disorders. BMC psychiatry, 14(1), 1-83.]])] 
-===== Diagnostic Criteria =====+    * There is a bimodal ​distribution, ​with onset in late-teens to early twenties and again in the 30s and 40s. 
 +    * The median age of onset is 31 years of age, with a peak in middle age. 
 +  * Individuals from developed countries are more likely to experience ​GAD than non-developed countries. 
 +    * Similarly, individuals ​of European descent are more likely to experience GAD than non-Europeans,​ suggesting perhaps a role for social-economic factors in contributing to symptoms.[([[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC4609238/​|Prins,​ S. J., Bates, L. M., Keyes, K. M., & Muntaner, C. (2015). Anxious? Depressed? You might be suffering from capitalism: contradictory class locations ​and the prevalence of depression ​and anxiety in the USASociology of health & illness, 37(8), 1352-1372.]])] 
 +  * Women are 2 to 3 times more likely to have GAD than men.[([[https://​pubmed.ncbi.nlm.nih.gov/​25081580/​|Katzman,​ M. A., Bleau, P., Blier, P., Chokka, P., Kjernisted, K., & Van Ameringen, M. (2014). Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders. BMC psychiatry, 14(1), 1-83.]])]
  
-<WRAP group> +== Prognosis == 
-<WRAP half column>+  * Many individuals with GAD report a life-long history of anxiety and nervousness 
 +  * GAD tends to wax and wane over the course of of the lifespan, and rates of full remission are very low. 
 +    * This suggests the GAD may not be a "​mental disorder"​ //per se//, but rather a diagnostic construct that spans across different dimensions, including other mental disorders, personality disorders, and temperament.[([[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC5573555/​|Crocq,​ M. A. (2017). The history of generalized anxiety disorder as a diagnostic category. Dialogues in clinical neuroscience,​ 19(2), 107.]])] 
 +  * GAD accounts for over 110 million disability days per year in the United States.[(American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.)] 
 + 
 +== Comorbidity == 
 +  * Individuals with GAD are more likely to meet criteria for other anxiety disorders and depression. 
 +  * There is also an increased risk for medical disorders, including pain syndromes, hypertension,​ and cardiovascular and gastrointestinal disorders. 
 + 
 +== Risk Factors == 
 +  * Temperamental traits including behavioural inhibition, negative affectivity (neuroticism),​ and harm avoidance are risk factors for GAD.[(American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.)] 
 +  * Adverse childhood events and parental overprotection are associated with GAD.[(American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.)] 
 + 
 +== Cultural == 
 +  * There is significant variation in the expression of generalized anxiety disorder across the world. In some cultures, somatic symptoms may be the predominant presentation,​ whereas cognitive symptoms may predominate in others. 
 +===== DSM-5 Diagnostic Criteria =====
 == Criterion A == == Criterion A ==
 Excessive anxiety and worry (apprehensive expectation),​ occurring //more days than not// for at least ''​6''​ months, about a number of events or activities (such as work or school performance). Excessive anxiety and worry (apprehensive expectation),​ occurring //more days than not// for at least ''​6''​ months, about a number of events or activities (such as work or school performance).
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 == Criterion C == == Criterion C ==
 +<WRAP group>
 +<WRAP half column>
 The anxiety and worry are associated with at least ''​3''​ of the 6 symptoms (with at least //some// symptoms present for more days than not for the past ''​6''​ months); The anxiety and worry are associated with at least ''​3''​ of the 6 symptoms (with at least //some// symptoms present for more days than not for the past ''​6''​ months);
-<callout type="​info"​ icon="​fa fa-child">​Only ''​1''​ item is required in children</​callout>​ +<callout type="​info"​ icon="​fa fa-child">​ 
 +Only ''​1''​ item is required in children 
 +</​callout>​
   - **Blanking out** or difficulty concentrating ​   - **Blanking out** or difficulty concentrating ​
   - Easily **fatigued**   - Easily **fatigued**
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   - **Irritability**   - **Irritability**
   - **Muscle tension**   - **Muscle tension**
 +</​WRAP>​
 +<WRAP half column>
 +<callout icon="​fa fa-lightbulb-o"​ type="​success"​ title="​Mnemonic">​
 +The mnemonic ''​**BESKIM**''​ can be used to remember the criteria for generalized anxiety disorder.
 +  * ''​**B**''​ - **Blank mind** ​
 +  * ''​**E**''​ - **Easily fatigued** ​
 + 
 +  * ''​**S**''​ - **Sleep disturbance**
 +  * ''​**K**''​ - **Keyed Up/​Restless/​On-edge**
 +  * ''​**I**''​ - **Irritability** ​
 +  * ''​**M**''​ - **Muscle tension** ​
 +</​callout>​
 +</​WRAP>​
 +</​WRAP>​
  
 == Criterion D == == Criterion D ==
 The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational,​ or other important areas of functioning. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational,​ or other important areas of functioning.
-</​WRAP>​ 
- 
-<WRAP half column> 
  
  
 == Criterion E == == Criterion E ==
-The disturbance is not attributable to the physiological effects of [[anxiety:​substance-anxiety|a substance (e.g. - a drug of abuse, a medication)]] or another medical condition (e.g. - hyperthyroidism).+The disturbance is not attributable to the physiological effects of [[anxiety:​substance-medication|a substance (e.g. - a drug of abuse, a medication)]] or another medical condition (e.g. - hyperthyroidism).
  
 == Criterion F == == Criterion F ==
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   * The content of delusional beliefs ([[psychosis:​schizophrenia-scz|schizophrenia]] or [[psychosis:​delusional-disorder|delusional disorder]])   * The content of delusional beliefs ([[psychosis:​schizophrenia-scz|schizophrenia]] or [[psychosis:​delusional-disorder|delusional disorder]])
  
 +==== Specifiers ====
 +<panel icon="​fa fa-search-plus fa-fw" size="​xs"​ title="​Panic Attack Specifier">​
 +<WRAP group>
 +<WRAP half column>
 +**Specify if**:
 +  * Recurrent //​unexpected//​ panic attacks. An abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and during which time at least ''​4''​ of the following symptoms occur (**Note:** The abrupt surge can occur from a calm state or an anxious state):
 +  - Sweating
 +  - Trembling or shaking
 +  - Unsteady, dizziness, light-headed,​ or faint
 +  - Derealization (feelings of unreality) or depersonalization (being detached from one self)
 +  - Excessive/​accelerated heart rate, palpitations,​ or pounding heart
 +  - Nausea or abdominal distress
 +  - Tingling, numbness, parathesesias
 +  - Shortness of breath
 +  - Fear of losing control or “going crazy”
 +  - Fear of dying
 +  - Choking feelings
 +  - Chest pain or discomfort
 +  - Chills or heat sensations
  
-<​callout ​icon="​fa fa-lightbulb-o"​ type="​success"​ title="​Mnemonic"​+</​WRAP>​ 
-The mnemonic ''​**BE SKIM**'' ​can be used to remember ​the criteria for generalized ​anxiety disorder.[(http://www.mdedge.com/​currentpsychiatry/​article/​63313/​mnemonics-mnutshell-32-aids-psychiatric-diagnosis)] +<WRAP half column>​ 
-<​HTML><​br><​br>​</HTML+<​callout>​ 
-  * ''​**B**''​ - **Blank mind**  +**Note**: ​The symptoms presented in this specifier are for the purpose of identifying a panic attack. However, panic attacks are **not** a mental disorder. Panic attacks ​can occur in the context of //any// [[anxiety:​home|anxiety disorder]] as well as other mental disorders ​(e.g. - [[mood:1-depression:​home|depressive disorders]],​ [[trauma-and-stressors:​ptsd|posttraumatic stress disorder]], [[addictions:​home|substance use disorders]]) and some medical conditions (e.g. cardiac, respiratory,​ vestibular, gastrointestinal). When the presence of a panic attack is identified, it should be noted as a specifier (e.g. - "​social anxiety disorder with panic attacks"​). For [[anxiety:​panic|panic disorder]], the presence of panic attack is contained within the criteria for the disorder and panic attack is not used as a specifier. 
-  * ''​**E**''​ - **Easily fatigued** ​ +</callout
-  + 
-  ''​**S**'' ​**Sleep disturbance** +<​callout>​ 
-  * ''​**K**''​ - **Keyed Up/​Restless/​On-edge** +**Note**: Culture-specific symptoms (e.g. tinnitus, neck soreness, headache, uncontrollable screaming or crying) may be seen. Such symptoms should not count as one of the four required symptoms.
-  * ''​**I**'' ​**Irritability**  +
-  * ''​**M**''​ - **Muscle tension** ​+
 </​callout>​ </​callout>​
 </​WRAP>​ </​WRAP>​
 </​WRAP>​ </​WRAP>​
-===== Scales =====+</​panel>​ 
 + 
 +==== Signs and Symptoms ​==== 
 +  * Individuals may report muscle tension, trembling, twitching, feeling shaky, muscle aches. 
 +  * Somatic symptoms such as sweating, nausea, diarrhea, and headaches may also occur. 
 +===== Screening and Rating ​Scales =====
 <panel title="​Generalized Anxiety Scales"​ no-body="​true">​ <panel title="​Generalized Anxiety Scales"​ no-body="​true">​
-!^Name                                               ^ Rater      ^ Description ​                                                                                                                                                                                  ^ Download ​ ^+<​mobiletable 1> 
 +^ Name                                               ^ Rater      ^ Description ​                                                                                                                                                                                  ^ Download ​ ^
 ^ Generalized Anxiety Disorder 7 (GAD-7) ​                   | Patient ​   | The GAD-7 is a 7-item self-reported questionnaire for screening and a severity measure of generalized anxiety disorder ​     | {{ :​anxiety:​gad-7.pdf |Download}} ​        | ^ Generalized Anxiety Disorder 7 (GAD-7) ​                   | Patient ​   | The GAD-7 is a 7-item self-reported questionnaire for screening and a severity measure of generalized anxiety disorder ​     | {{ :​anxiety:​gad-7.pdf |Download}} ​        |
 ^ Beck Anxiety Inventory (BAI)                    | Patient ​   | The BAI is a 21-question self-report inventory for screening and a severity measure of generalized anxiety disorder ​      | {{ :​anxiety:​beck-anxiety.pdf |Download}} ​        | ^ Beck Anxiety Inventory (BAI)                    | Patient ​   | The BAI is a 21-question self-report inventory for screening and a severity measure of generalized anxiety disorder ​      | {{ :​anxiety:​beck-anxiety.pdf |Download}} ​        |
 +</​mobiletable>​
 </​panel>​ </​panel>​
 ===== Pathophysiology ===== ===== Pathophysiology =====
-  ​* [[https://​www.nature.com/​articles/​nrn3945|Tovote,​ P., Fadok, J. P., & Lüthi, A. (2015). Neuronal circuits for fear and anxiety. Nature Reviews Neuroscience,​ 16(6), 317.]] +<alert type="​info"​ icon="​fa fa-book fa-lg fa-fw">​ 
-  * [[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC3684250/​|Martin,​ E. I., Ressler, K. J., Binder, E., & Nemeroff, C. B. (2009). The neurobiology of anxiety disorders: brain imaging, genetics, and psychoneuroendocrinology. Psychiatric Clinics, 32(3), 549-575.]]+See also: 
 +  * **[[https://​www.nature.com/​articles/​nrn3945|Tovote,​ P., Fadok, J. P., & Lüthi, A. (2015). Neuronal circuits for fear and anxiety. Nature Reviews Neuroscience,​ 16(6), 317.]]** 
 +  ​* **[[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC3684250/​|Martin,​ E. I., Ressler, K. J., Binder, E., & Nemeroff, C. B. (2009). The neurobiology of anxiety disorders: brain imaging, genetics, and psychoneuroendocrinology. Psychiatric Clinics, 32(3), 549-575.]]** 
 +</​alert>​ 
 + 
 +  * The pathophysiology of worry, fear, and anxiety in GAD and other anxiety disorders remains under investigation. 
 +  * Excitation of the cortico-striatal-thalamic-cortical (CSTC) loop is thought to be responsible for worry and anxiety in anxiety disorders (and obsessions in [[ocd:​1-ocd|OCD]]). 
 + 
 ===== Differential Diagnosis ===== ===== Differential Diagnosis =====
-<WRAP group> +<callout type="​tip"​ title="​Anxiety is a Broad Term!" icon="​true">​ 
-<WRAP half column>​ +Anxiety is also such a broad term that you must explore it in more detail to determine the correct diagnosis when someone says they are "​anxious."​ If the anxiety is about:
-<callout type="​tip"​ title="​Anxiety is a broad term!" icon="​true">​ +
-Anxiety is also such a broad term that you must explore it in more detail to determine the correct diagnosis when someone says they are "​anxious." ​\\ \\ If the anxiety is about:+
   * A fear of panicking, dying, or losing control, think [[anxiety:​panic|panic disorder]]   * A fear of panicking, dying, or losing control, think [[anxiety:​panic|panic disorder]]
   * Being trapped or being unable to escape, think [[anxiety:​agoraphobia|agoraphobia]]   * Being trapped or being unable to escape, think [[anxiety:​agoraphobia|agoraphobia]]
   * Being embarrassed in front of, or judgment by others, think [[anxiety:​social-anxiety|social anxiety]]   * Being embarrassed in front of, or judgment by others, think [[anxiety:​social-anxiety|social anxiety]]
   * Constant, pervasive worries, and they can't stop worrying, think [[anxiety:​gad|generalized anxiety disorder]]   * Constant, pervasive worries, and they can't stop worrying, think [[anxiety:​gad|generalized anxiety disorder]]
-  * Thinking that something terrible will happen if certain rituals/complusions ​aren't performed, or they will never feel "​right,"​ think [[ocd:​1-ocd|obsessive-compulsive disorder]]+  * Thinking that something terrible will happen if certain rituals/compulsions ​aren't performed, or they will never feel "​right,"​ think [[ocd:​1-ocd|obsessive-compulsive disorder]] 
 +</​callout>​
  
 +<callout type="​danger"​ title="​Don'​t Forget About Medical Etiologies"​ icon="​true">​
 +Certain medical conditions can be misdiagnosed as generalized anxiety disorder, or vice versa. Refer to these two papers for an overview to avoid misdiagnosis! ​
 +  * [[http://​www.psychiatrictimes.com/​special-reports/​managing-anxiety-medically-ill|Dong,​ Yu, et al. Managing anxiety in the medically ill. Psychiatric Times 32.1 (2015): 33-33.]]
 +  * [[https://​www.karger.com/​Article/​FullText/​367913|Cosci,​ F., Fava, G. A., & Sonino, N. (2015). Mood and anxiety disorders as early manifestations of medical illness: a systematic review. Psychotherapy and psychosomatics,​ 84(1), 22-29.]] ​
 </​callout>​ </​callout>​
  
 +<WRAP group>
 +<WRAP half column>
 +  * **Anxiety disorder due to another medical condition**
 +    * The diagnosis of anxiety disorder associated with another medical condition should be assigned if the individual'​s anxiety and worry are judged, based on history, laboratory findings, or physical examination,​ to be a physiological effect of another specific medical condition (e.g. - pheochromocytoma,​ hyperthyroidism). A thorough work up should be considered if there are associated physical exam findings, or ongoing acute symptoms without improvement after treatment.
 +  * **[[anxiety:​substance-medication| Substance/​medication-induced anxiety disorder]]**
 +    * A substance/​medication-induced anxiety disorder is different GAD by the fact that a substance or medication (e.g. - a drug of abuse, exposure to a toxin) is temporally and etiologically related to the anxiety. For example, severe anxiety that occurs only in the context of heavy coffee use would be diagnosed as caffeine-induced anxiety disorder, rather than GAD.
 +  * **[[anxiety:​social-anxiety|Social anxiety disorder]]**
 +    * Individuals with social anxiety disorder often have anticipatory anxiety about upcoming social situations where they must perform or be evaluated by other. Contrast this with GAD, where individuals worry persistently (whether or not they are being evaluated).
 +  * **[[ocd:​1-ocd|Obsessive-compulsive disorder (OCD)]]**
 +    * Several features distinguish the excessive worry of GAD from the obsessional thoughts in OCD. In GAD, the focus of the worry is about upcoming problems. In OCD, the obsessions are intrusive and unwanted thoughts, urges, or images.
 </​WRAP>​ </​WRAP>​
 <WRAP half column> <WRAP half column>
-<callout type="​danger"​ icon="​true">​Medical conditions can be misdiagnosed as generalized anxiety disorder, or vice versa. Refer to these two papers for an overview to avoid misdiagnosis!  +  * **[[trauma-and-stressors:​ptsd|Posttraumatic stress disorder (PTSD)]]** and **[[trauma-and-stressors:​adjustment|adjustment disorders]]** 
-  ​* [[http://​www.psychiatrictimes.com/​special-reports/​managing-anxiety-medically-ill|DongYuet alManaging ​anxiety in the medically ill. Psychiatric Times 32.1 (2015)33-33.]] +    * Anxiety is naturally present in posttraumatic stress disorder. ThusGAD is not diagnosed if the anxiety and worry are better explained by a diagnosis of PTSD. Anxiety may also be present in adjustment disorderbut this residual category should be used only when the criteria are not met for any other disorder (including generalized anxiety disorder)Also note that in adjustment disorders, the anxiety ​occurs ​in response to an identifiable stressor within ''​3''​ months of the onset of the stressor and does not persist for more than ''​6''​ months after the termination of the stressor. 
-  * [[https://www.karger.com/​Article/​FullText/​367913|CosciF., FavaG. A.& SoninoN. (2015). Mood and anxiety disorders as early manifestations ​of medical illne +  * **[[mood:1-depression:home|Depressive]],​ [[bipolar:​bipolar-i|bipolar]], and [[psychosis:home|psychotic disorders]]** 
-ss: a systematic review. Psychotherapy and psychosomatics,​ 84(1), 22-29.]]  +    * Generalized anxiety/worry is a common associated feature of major depressive disorder, bipolar disorder, and psychotic disordersThusGAD should not be diagnosed if the excessive worry is occurring in the context of these other disorders. 
-</​callout>​+  * **Other disorders of childhood** 
 +    * According to DSM-5generalized anxiety disorder may be overdiagnosed in childrenand other mental disorders such as separation disordersocial anxiety disorderand OCD should be explored first.[(American Psychiatric Association. (2013). Diagnostic ​and Statistical Manual ​of Mental Disorders ​(5th ed.). ArlingtonVA.)]
 </​WRAP>​ </​WRAP>​
 </​WRAP>​ </​WRAP>​
 ===== Investigations ===== ===== Investigations =====
-Baseline ​investigations include: CBC, fasting glucose, fasting lipid profiles, electrolytes,​ liver enzymes, serum bilirubin, serum creatinine, urinalysis, urine toxicology for substance use, TSH. An ECG should be performed ​for age > 40 years of agebeta-HCG (if relevant), and prolactin levels.[(guidelines>​[[https://bmcpsychiatry.biomedcentral.com/​track/​pdf/​10.1186/​1471-244X-14-S1-S1?​site=bmcpsychiatry.biomedcentral.com|Katzman ​MA, Bleau P, Blier P, et al. Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders. BMC Psychiatry. 2014;14(Suppl 1):S1.]])] +  * Depending on the initial presenting symptoms (e.g. - dizziness, tachycardia),​ potential ​investigations ​can include: CBC, fasting glucose, fasting lipid profiles, electrolytes,​ liver enzymes, serum bilirubin, serum creatinine, urinalysis, ​[[meds:​urine-drug-screen|urine toxicology]] for substance use, thyroid stimulating hormone (TSH).[([[https://​pubmed.ncbi.nlm.nih.gov/​25081580/​|Katzman,​ M. A., Bleau, P., Blier, P., Chokka, P., Kjernisted, K., & Van Ameringen, M. (2014). Canadian clinical practice guidelines ​for the management ​of anxietyposttraumatic stress and obsessive-compulsive disorders. BMC psychiatry, 14(1), 1-83.]])][([[https://​pubmed.ncbi.nlm.nih.gov/​25081580/​|Katzman, M. A., BleauP., BlierP.Chokka, P., Kjernisted, K., & Van Ameringen, M. (2014). Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders. BMC psychiatry, ​14(1), 1-83.]])] 
 +  * An ECG and beta-HCG should be ordered if relevant.
 ===== Treatment ===== ===== Treatment =====
-The following treatment recommendations are based on the 2014 Canadian Clinical Practice Guidelines for anxiety, posttraumatic stress and obsessive-compulsive disorders:​[([[https://​bmcpsychiatry.biomedcentral.com/​track/​pdf/​10.1186/​1471-244X-14-S1-S1?​site=bmcpsychiatry.biomedcentral.com|Katzman MA, Bleau P, Blier P, et al. Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders. BMC Psychiatry. 2014;​14(Suppl 1):​S1.]])] +  * The following treatment recommendations are based on the 2014 Canadian Clinical Practice Guidelines for anxiety, posttraumatic stress and obsessive-compulsive disorders:​[([[https://​bmcpsychiatry.biomedcentral.com/​track/​pdf/​10.1186/​1471-244X-14-S1-S1?​site=bmcpsychiatry.biomedcentral.com|Katzman MA, Bleau P, Blier P, et al. Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders. BMC Psychiatry. 2014;​14(Suppl 1):​S1.]])] 
 +  * There is currently no evidence to support combining treatment of psychotherapy and medications. However, when patients do not benefit from one form of treatment, switching or adding a different treatment is recommended.[([[https://​pubmed.ncbi.nlm.nih.gov/​25081580/​|Katzman,​ M. A., Bleau, P., Blier, P., Chokka, P., Kjernisted, K., & Van Ameringen, M. (2014). Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders. BMC psychiatry, 14(1), 1-83.]])]
 ==== Psychotherapy ==== ==== Psychotherapy ====
-Cognitive ​Behavioural Therapy ​(CBT) is an effective first-line option for the treatment of GAD and is as effective as pharmacotherapy. Internet-based and computer-based CBT have also demonstrated efficacy. The evidence does not support the routine combination of CBT and pharmacotherapy,​ but when patients do not benefit from CBT, a trial of pharmacotherapy is advisable, and vice versa.+<WRAP group> 
 +<WRAP half column>​ 
 +  * [[psychotherapy:​cbt|Cognitive ​behavioural therapy ​(CBT)]] is an effective first-line option for the treatment of GAD and is as effective as pharmacotherapy. Internet-based and computer-based CBT have also demonstrated efficacy. 
 +  * The evidence does not support the routine combination of CBT and pharmacotherapy,​ but when patients do not benefit from CBT, a trial of pharmacotherapy is advisable, and vice versa. 
 +</​WRAP>​ 
 +<WRAP half column>​ 
 +<​HTML>​ 
 +<div id="​amazon">​ 
 +<div class="​ribbon"><​i class="​fa fa-star"></​i>​ Recommended Reading</​div>​ 
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 +</​WRAP>​ 
 +</​WRAP>​
  
-==== Medications ​==== + 
-<panel type="​info"​ title="​Pharmacotherapy for generalized anxiety disorder"​ no-body="​true"​ footer="​CR = controlled release; XL = extended release; XR = extended release. *Note: Each of these 2nd-line treatments have distinct mechanisms, efficacy and safety profiles. ​Benzodiazepines ​would be considered first in most cases, except where there is a risk of substance abuse. Bupropion XL should be reserved for later. Quetiapine XR remains a good choice in terms of efficacy, but given the metabolic concerns associated with atypical antipsychotic,​ it should be reserved for patients who cannot be provided antidepressants or benzodiazepines.">​ +==== Pharmacotherapy ​==== 
-^ 1st line            | Agomelatine, [[meds:​antidepressants:​snri:​duloxetine|duloxetine]],​ [[meds:​antidepressants:​ssri:​escitalopram|escitalopram]],​ [[meds:​antidepressants:​ssri:​paroxetine|paroxetine]],​ [[meds:​antidepressants:​ssri:​paroxetine|paroxetine CR]], [[meds:​mood-stabilizers-anticonvulsants:​pregabalin|pregabalin]],​ [[meds:​antidepressants:​ssri:​sertraline|sertraline]],​ [[meds:​antidepressants:​snri:​venlafaxine|venlafaxine XR]]                                            +<panel type="​info"​ title="​Pharmacotherapy for generalized anxiety disorder" subtitle="​Katzman,​ M. A. et al. (2014). Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders. BMC psychiatry, 14(1), 1-83." no-body="​true"​ footer="​CR = controlled release; XL = extended release; XR = extended release. *Note: Each of these 2nd-line treatments have distinct mechanisms, efficacy and safety profiles. ​Within these second-line agents, benzodiazepines ​would be considered first in most cases, except where there is a risk of substance abuse. Bupropion XL should be reserved for later. Quetiapine XR remains a good choice in terms of efficacy, but given the metabolic concerns associated with atypical antipsychotic,​ it should be reserved for patients who cannot be provided antidepressants or benzodiazepines.">​ 
-^ 2nd line            | Alprazolam*, bromazepam*,​ bupropion XL*, buspirone, diazepam*, [[meds:​non-benzo-anxiolytics:​hydroxyzine|hydroxyzine]],​ imipramine, lorazepam*, quetiapine XR*, vortioxetine ​                   +^ 1st line            | **Monotherapy**: ​ agomelatine, [[meds:​antidepressants:​snri:​duloxetine|duloxetine]],​ [[meds:​antidepressants:​ssri:​escitalopram|escitalopram]],​ [[meds:​antidepressants:​ssri:​paroxetine|paroxetine]],​ [[meds:​antidepressants:​ssri:​paroxetine|paroxetine CR]], [[meds:​mood-stabilizers-anticonvulsants:​pregabalin|pregabalin]],​ [[meds:​antidepressants:​ssri:​sertraline|sertraline]],​ [[meds:​antidepressants:​snri:​venlafaxine|venlafaxine XR]]  
-^ 3rd line            | Citalopram, divalproex chrono, fluoxetine, mirtazapine,​ trazodone ​                                                                                  ​+^ 2nd line            | **Monotherapy**: ​ alprazolam*, bromazepam*,​ bupropion XL*, buspirone, diazepam*, [[meds:​non-benzo-anxiolytics:​hydroxyzine|hydroxyzine]],​ imipramine, lorazepam*, quetiapine XR*, vortioxetine ​                                                                                                                                                                                                                                            ​
-^ Adjunctive therapy ​ | __Second-line__: pregabalin\\ ​__Third-line__: aripiprazole,​ olanzapine, quetiapine, quetiapine XR, risperidone \\ __Not recommended__: ziprasidone ​ +^ 3rd line            | **Monotherapy**:​ citalopram, divalproex chrono, fluoxetine, mirtazapine,​ trazodone ​                                                                                                                                                                                                                                                                                                                                                       
-^ Not recommended ​    | Beta blockers (propranolol),​ pexacerfont,​ tiagabine ​                                                                                                ​|+^ Adjunctive therapy ​ | **Second-line**: pregabalin\\ ​**Third-line**: aripiprazole,​ olanzapine, quetiapine, quetiapine XR, risperidone \\ **Not recommended**: ziprasidone ​                                                                                                                                                                                                                                                                                       
 +^ Not recommended ​    | Beta blockers (propranolol),​ pexacerfont,​ tiagabine ​                                                                                                                                                                                                                                                                                                                                                                                      ​|
 </​panel>​ </​panel>​
  
-==== Combination Therapy ​==== +==== Child and Adolescent Considerations ​==== 
-There is no current evidence ​to support ​the routine combination ​of CBT and pharmacotherapyHowever, as in other anxiety and related disorders, ​when patients do not benefit from CBT or have a limited responsea trial of pharmacotherapy is advisable+  * For children and adolescents,​ psychological treatments are generally preferred over pharmacotherapy,​ or if warranted combination therapy may be an option. RCTs comparing combined pharmacological and psychological treatments in younger patients with anxiety have demonstrated efficacy equal or superior ​to either treatment alone.[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​24565357|Piacentini,​ J., Bennett, S., Compton, S. N., Kendall, P. C., Birmaher, B., Albano, A. M., ... & Rynn, M. (2014). 24-and 36-week outcomes for the Child/​Adolescent Anxiety Multimodal Study (CAMS). Journal ​of the American Academy of Child & Adolescent Psychiatry, 53(3), 297-310.]])] 
 +  * Psychological therapies for children often need to be adapted to suit the chronological ​and developmental ages of young patients and to include parental involvementMeta-analyses support the efficacy of CBT for the treatment of anxiety and related disorders ​in children and adolescents.[([[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC4791100/​|GarlandE. J.Kutcher, S., Virani, A., & Elbe, D. (2016). Update on the use of SSRIs and SNRIs with children and adolescents in clinical practice. Journal of the Canadian Academy of Child and Adolescent Psychiatry, 25(1), 4.]])] 
 +  * When pharmacotherapy is warranted, SSRIs are generally preferred, but all antidepressants should be used with caution in due to the risk for increased suicidal ideation and behaviours associated with antidepressant use in youth. 
 +===== Guidelines ===== 
 +{{page>​teaching:​clinical-practice-guidelines-cpg#​generalized-anxiety-disorder&​nouser&​noheader&​nodate&​nofooter}}
  
-== Pediatric Considerations == 
-Psychological therapies for children often need to be adapted to suit the chronological and developmental ages of young patients and to include parental involvement. Meta-analyses support the efficacy of CBT for the treatment of anxiety and related disorders in children and adolescents.[([[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC4791100/​|Garland,​ E. J., Kutcher, S., Virani, A., & Elbe, D. (2016). Update on the use of SSRIs and SNRIs with children and adolescents in clinical practice. Journal of the Canadian Academy of Child and Adolescent Psychiatry, 25(1), 4.]])] When pharmacotherapy is warranted, SSRIs are generally preferred, but all antidepressants should be used with caution in pediatric patients. 
- 
-For children and adolescents,​ psychological treatments are generally preferred over pharmacotherapy,​ or if warranted combination therapy may be an option. RCTs comparing combined pharmacological and psychological treatments in younger patients with anxiety have demonstrated efficacy equal or superior to either treatment alone.[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​24565357|Piacentini,​ J., Bennett, S., Compton, S. N., Kendall, P. C., Birmaher, B., Albano, A. M., ... & Rynn, M. (2014). 24-and 36-week outcomes for the Child/​Adolescent Anxiety Multimodal Study (CAMS). Journal of the American Academy of Child & Adolescent Psychiatry, 53(3), 297-310.]])] 
- 
-<panel type="​info"​ title="​Pharmacotherapy for generalized anxiety disorder in pediatric populations"​ no-body="​true">​ 
-^ Antidepressants ​        | Fluoxetine, fluvoxamine,​ sertraline ​ | 
-^ Benzodiazepines ​        | Alprazolam ​ | 
-</​panel>​ 
 ===== Resources ===== ===== Resources =====
 <WRAP group> <WRAP group>