What is the recommended management for generalized anxiety disorder (GAD) causing physical symptoms in a female patient?

Management of Generalized Anxiety Disorder Causing Physical Symptoms in Women

For women with generalized anxiety disorder (GAD) causing physical symptoms, first-line treatment should include cognitive behavioral therapy (CBT) and/or selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs). 1

Assessment and Screening

• GAD is characterized by excessive, uncontrollable worry and is highly prevalent in women, with a lifetime prevalence of approximately 40%, twice that of men 1
• Physical symptoms commonly include palpitations, shortness of breath, dizziness, muscle tension, fatigue, and gastrointestinal disturbances 2
• Screening can be done efficiently using validated instruments such as the Generalized Anxiety Disorder-7 (GAD-7) scale 1, 2
• GAD severity can be categorized based on GAD-7 scores:
  • Mild: 0-9
  • Moderate: 10-14
  • Moderate to severe/severe: 15-21 1

Treatment Approach Based on Severity

For Mild Symptoms (GAD-7 score 0-9):

• Education and active monitoring
• Self-help resources based on cognitive behavioral therapy principles
• Structured physical activity/exercise 1

For Moderate Symptoms (GAD-7 score 10-14):

• Offer referral to educational and support services
• Consider low-intensity psychological interventions 1

For Moderate to Severe/Severe Symptoms (GAD-7 score 15-21):

• High-intensity interventions including:
  • Cognitive behavioral therapy
  • Behavioral activation
  • Structured physical activity/exercise
  • Acceptance and commitment therapy
  • Pharmacotherapy 1

Psychological Treatments

• Cognitive Behavioral Therapy (CBT) is the psychological treatment with the strongest evidence of efficacy for anxiety disorders 2
• CBT should be delivered by licensed mental health professionals using treatment manuals that include:
  • Cognitive change techniques
  • Behavioral activation
  • Biobehavioral strategies
  • Education
  • Relaxation strategies 1
• CBT has shown improved symptoms and decreased relapse rates compared to waitlist controls, usual care, or psychological placebos 1
• Group psychosocial interventions led by licensed mental health professionals can address:
  • Stress reduction
  • Positive coping strategies
  • Enhancing social support
  • Managing physical symptoms 1

Pharmacological Treatment

• First-line pharmacological therapies for GAD in women are SSRIs and SNRIs 1, 2, 3
• These medications have demonstrated statistically significant improvement in anxiety based on clinician evaluations in placebo-controlled trials 1
• For GAD, recommended dosing for duloxetine (an SNRI):
  • Initial dose: 30 mg once daily for 1 week
  • Target dose: 60 mg once daily
  • Maximum dose studied: 120 mg per day (though no evidence that doses greater than 60 mg/day confer additional benefit) 4
• Common side effects of SSRIs and SNRIs include:
  • Diarrhea, dizziness, dry mouth, fatigue, headache, nausea, sexual dysfunction, sweating, tremor, and weight gain 1
• Antidepressants have a higher treatment response rate compared to placebo (RR 1.41) with a number needed to treat of 7 3
• If anxiety symptoms are under control and environmental sources of anxiety are no longer present, consider tapering medication 1

Treatment Duration and Follow-up

• For patients who respond to antidepressant therapy, treatment should be continued for at least 12 months 5
• Regular follow-up is essential as patients with anxiety may not follow through on referrals or treatment recommendations 1
• Monthly assessment is recommended until symptoms have subsided to:
  • Evaluate compliance with psychological/psychosocial referrals
  • Assess medication adherence and side effects
  • Monitor symptom relief 1

Special Considerations for Women

• Anxiety disorders can increase in both frequency and effects during pregnancy and the postpartum period 1
• While pregnant and postpartum women were not included in many clinical trials of anxiety medications, SSRIs and SNRIs are widely used in these patient groups 1
• For older women (≥65 years), consider starting at lower doses:
  • For duloxetine: Start at 30 mg once daily for 2 weeks before considering an increase to 60 mg/day 4
• Consider culturally sensitive assessments and treatments, particularly for women from diverse backgrounds 1

Common Pitfalls and Caveats

• Anxiety disorders frequently co-occur with depressive disorders (56% prevalence of anxiety in patients with major depression) 1
• Consider screening for both anxiety and depression simultaneously due to their frequent co-occurrence 1
• Only about 20% of people with anxiety disorders seek care for these conditions, highlighting the importance of proactive screening 1
• Cautiousness and avoidance are cardinal features of anxiety, which may lead to poor follow-through with treatment recommendations 1
• GAD is often chronic, requiring long-term management strategies rather than short-term interventions 6

By following this evidence-based approach to managing GAD in women with physical symptoms, clinicians can help improve symptoms, functioning, and quality of life for these patients.