case-Based review

Generalized Anxiety Disorder in Adults
Case Study and Commentary, Raushanah Hud-Aleem, DO, and Darnell Ladson, DO

CME jointly sponsored by
Wayne State University School of Medicine and JCOM

This article has a companion CME exam that follows the article. To earn credit, read the article and complete the CME evaluation on pages 362 and 363.
Estimated time to complete this activity is 1 hour.
Release date: 15 July 2008; valid for credit through
30 July 2009.
Program Audience
Primary care physicians.
Educational Needs Addressed
Generalized anxiety disorder (GAD) is a common psychiatric disorder associated with signficant impairment, including loss of productivity, high utilization of health care resources, and reduced quality of life. Patients typically present with vague somatic compliants rather than psychological symptoms, making diagnosis challenging. Optimal recognition and use of effective therapy are critical skills for the physician and should improve the patient’s prognosis for recovery and reduce unnecessary suffering.
Educational Objectives
After participating in this CME activity, primary care physicians should be able to
1. Describe the epidemiology of GAD
2. Know the diagnositic criteria for GAD
3. Describe key components of a historical and physical assessment in patients with anxiety
4. Identify effective treatments for GAD

G

eneralized anxiety disorder (GAD) is one of the most common psychiatric disorders encountered in the primary care setting. Lifetime prevalence of GAD is approximately 5% in the U.S. adult population [1,2]; prevalence in the primary care setting has been estimated at 8%
[3,4]. GAD usually has a chronic course that is associated with significant psychosocial impairment, disability, decreased quality of life, and increased use of health care resources
[5–8]. In spite of the high prevalence of GAD, it is frequently www.turner-white.com overlooked and undertreated. Only 30% of GAD patients who present to primary care are diagnosed [7]. Increasing the awareness of GAD among patients and physicians may lead to improved recognition and appropriate intervention, thereby reducing disability and improving quality of life.
CASE STUDY
Initial Presentation
A 26-year-old graduate student presents to her primary care physician complaining of difficulty with sleep, fatigue, and diarrhea with mucus. She is worried that she may have “colitis.”
History
The patient says that she has difficulty falling asleep. Her nights are not restful and she has fatigue throughout the day.
She has been experiencing the diarrhea off and on for the past year. She feels it might be related to “stress.” Associated abdominal discomfort is usually relieved with defecation.
Upon further questioning, the patient acknowledges that she is a “worry wort” and has been this way as long as she can remember. She often worries about her family, school, and finances and fears that one day she will get mugged or have a car wreck.
She complains that she is constantly on edge and has a very difficult time not worrying about things. She says she tends to worry about insignificant things and often tries to anticipate the outcome of events: “I can’t turn my mind off.
Even when there’s nothing to worry about, I’ll find something.” The worrying makes it difficult for her to focus on her school work. She says her mind frequently goes blank and she feels like she is not retaining her study materials.
She denies ever being attacked or involved in an auto accident. She does not drink or use illicit drugs. She takes no medications and has no known medical conditions. She denies fever, vomiting, weight loss, bloody stool, joint pain, and skin rash. There is no family history of Crohn’s disease or ulcerative colitis.
The patient denies suicidal ideation as well as panic attacks, depression, obsessive-compulsive disorder, social phobia, and eating disorder. There have not been any recent stressors.

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