Beruflich Dokumente
Kultur Dokumente
Contents
Abstract
1. Co-Morbidity
2. Impact of Generalized Anxiety Disorder (GAD) on Patients
3. Symptoms of GAD
A. Diagnosis and Assessment of GAD
5, Phormacoiogicai and Genetic Basis of GAD
6, Treatment ot GAD
6.1 Treatment Guidelines
6.2 Seiective Serotonin Reuptoke tntiibitors
.3 Serotonin Noradrenaiine Reuptake Inhibitors
6.4 Pregabalin
6.5 Buspirone
6.6 imipramine
6.7 Benzodiazepines
6.8 Limitations of First-Line Treatment Options
7, Treatment Response and Remission
8, Use of Nonpharmacological Approaches for Patients with GAD
9, Atypicai Antipsychotics in GAD
10. Discussion
11, Conciusions
Abstract
103
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HI
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m
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112
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113
115
116
Kalzman
104
CNSDfugs2009;23C2)
105
Co-mofbidity
Prevalence {%)
60,9-82.4
Dysthymia
37.7-39.5
1. Co-Morbidity
GAD is often co-morbid with mood and anxiety disorders (table \)P-~^^ In the US community-based NCS conducted in 8098 persons (aged
15-54 years). 90.4% of respondents with lifetime
GAD reported having at least one other lifetime
mental health disorder.f^--''
More recently, a German community study
of 4181 adults (aged 18-65 years) estimated the
12-month prevalence of GAD according to
DSM-IVf"I criteria to be \.5%S~^i Of the
12-month GAD cases. 93% had another DSM-IV
disorder, 59% fulfilled the criteria for major depressive disorder (MOD) and 56% fulfilled the
criteria for any other anxiety disorder.'-^^ Specific
phobia (29%) and social phobia (29%) were the
anxiety disorders that were most frequently comorbid with GAD.f-^'l The proportion of patients
with 12-month GAD and any co-morbid DSMIV eating disorder, eo-morbid alcohol abuse/
dependence and drug abuse/dependence were
2.5%, 6.4% and 1.4%, respectively. Furthermore,
a prospective community-based study in young
adults found that GAD is negatively associated
with being overweight.'-*'
GAD may occur as the primary disorder (i.e.
pre-dating other disorders) or as a secondary
2009 Aclis Dcrta Intormation BV, AJI righte reserved.
33.6-35.1
34.0-34.4
Agoraphobia
207-25.7
21.8-23.5
7.9-10.5
33.1
37.6
27.6
Panic disorder
Mania
Substance abuse
Alcohol use ot dependence
Drug use or dependence
Kxilzmau
106
Co-morbid disorder
Pre-dates GAD
a Same year
n Post-dates GAD
Drug disorder
Alcohol disorder
Social phobia
Simple phobia
Agoraphobia
Panic disorder
Dysthymia
Major depressive disorder
0
20
40
60
80
100
Lifetime co-morbid DSM-ill-R cases {%)
Fig. 1. The relative onset of mood and anxiety disorders that occur
co-morbidly with generalized anxiety disorder (GAD) [reproduced
from Stein,'^^' wtth permission from Physicians Postgraduate Press.
Copyright 2001],
107
Katzman
108
Table III. Summary of the main disease severity scales that may be used to assess generalized anxiety disorder (GAD)
Advantages
Disadvantages
GAD-7"'
Self rated
of patients with GAD is remission, i.e. the complete resolution of both symptoms and functional
impairment. Recurrence prevention is another
long-term consideration. It is also important to
consider patient-specific goals, e.g. the improvement of troubling symptoms, including problems
with sleep or concentration, chronic agitation,
irritability, recurrent headaches or muscle pain.
Factors such as anticipated adverse effects, a
history of prior response in the patient or a family
member, patient preference and cost should
be considered when deciding which treatment to
initiate.
Globally, there are several guideline committees that have reported their recommendations
and treatment algorithms for patients with GAD,
including the World Federation of Societies of
Biological Psychiatry,'^' the British Association
for PsychopharmacologyJ^*'' the National In.stitute for Health and Clinical Excellence,''''^'^ and
the Canadian Psychiatric Association (CPA)
(table IV).l''^t
In general, the consensus across treatment
guidelines is that first-line pharmacotherapy for
patients with GAD should consist of an antidepressant, cither an SSRI, such as paroxetine
and escitalopram, or a selective serotonin noradrenaline inhibitor (SNRI), such as venlafaxine
109
Table IV. Major organizations that have published guidelines/recommendations for the treatment of generalized anxiety disorder (GAD)
Organization (year of guideiines)
Guideiine
SSRI: paroxetine
SNRI: veniafaxine
Acute treatment:
SSRfs: paroxetine, escitalopram, sertraline
SNRi: ventafaxine
Benzodiazepines: aiprazoiam, diazepam
TCA: imipramine
Buspirone
Aniihistamines: hydroxyzine
Longer-term treatment:
SSRIs: paroxetine. escitaiopram
SSRI: paroxetine
SNRI: veniafaxine
Benzodiazepines (not to be used t)eyond 2-4 wk)
Antihistamines: hydroxyzine
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