Generalized Anxiety Disorder

The DSM-V criteria for Generalized Anxiety Disorder (F41.1) includes excessive anxiety and worry for at least 6 months. The subject of “apprehensive expectation” is about a number of events or activities (not just one thing). It is difficult to control the worry and includes at least three of these: restlessness, easy fatigability, difficulty concentrating or mind going blank, irritability, muscle tension, and sleep disturbance.

Like with most DSM diagnoses, the anxiety has to cause “clinically significant distress or impairment.” You have to rule out any substances of abuse (meth, cocaine, even marijuana significantly contributes to anxiety, and you need to rule out medical problems that would explain your symptoms like hyperthyroid, tachycardia, or pheochromocytoma). To make a diagnosis of GAD, it is important to rule out other mental disorders such as OCD, PTSD, etc.

Here are a variety of screening tools for yourself or for use in your clinic.

The World Federation of Societies of Biological Psychiatry has issued guidelines for the treatment of GAD. The first-line treatments for GAD are selective serotonin reuptake inhibitors (SSRIs), selective serotonin-and-norepinephrine reuptake inhibitors (SNRIs) and pregabalin. Pregabalin (Lyrica) is similar to gabapentin and is used for pain, peripheral neuropathy, fibromyalgia, and as an anti-epilepsy adjunct. In this study, efficacy and tolerability of pregabalin were high. “Compared to sertraline, pregabalin showed more rapid onset of action and equal efficacy”. Adverse reactions are dose dependent. I always start Lyrica really slow, just one a day. When I worked in neurology, patients never seemed to tolerate two or three-times-a-day dosing right off the bat, so I always have them take 75mg or less just once a day at bedtime for a week to start out. The initial side-effects of Lyrica at higher doses are dizziness, sea-sick feeling, world-spinning, and can lead to falls (Cvjetkovic-Bosnjak, Soldatovic-Stajic, Babovic, Boskovic, & Jovicevic, 2015).

Here is a study that attempted to prospectively describe metabolic syndrome abnormalities in patients with GAD who were treated for the first time with SSRIs (paroxetine, citalopram, escitalopram, sertraline, and fluoxetine)(Beyazyuz, Albayrak, Egilmez, Albayrak, & Beyazyuz, 2013).

“In the paroxetine group, there was a significant increase in the parameters of weight, BMI, waist circumference, fasting glucose, total cholesterol, LDL and triglyceride after 16 weeks of treatment.”

Triglycerides went up significantly in the citalopram and escitalopram groups.

Total cholesterol went up in the sertraline group.

“In the fluoxetine group, there were significant reductions in the parameters of weight, total cholesterol, and triglyceride.”

Of course, larger and longer controlled trials are needed to figure out if SSRIs contribute to metabolic syndrome. Remember, the best thing to do is to eat healthy.

 

A few sources:

Beyazyuz, M., Albayrak, Y., Egilmez, O. B., Albayrak, N., & Beyazyuz, E. (2013). Relationship between SSRIs and Metabolic Syndrome Abnormalities in Patients with Generalized Anxiety Disorder: A Prospective Study. Psychiatry Investig, 10(2), 148-154. doi:10.4306/pi.2013.10.2.148

Cvjetkovic-Bosnjak, M., Soldatovic-Stajic, B., Babovic, S. S., Boskovic, K., & Jovicevic, M. (2015). Pregabalin versus sertraline in generalized anxiety disorder. An open label study. Eur Rev Med Pharmacol Sci, 19(11), 2120-2124.

 

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