Generalized anxiety disorder recognized by DSM-IV, a chronic psychiatric
condition of excessive worry or fear, is distinct from anxiety related to
depression, medications, or other causes. Symptoms typically begin in the teens
or twenties and, while persisting, tend to fluctuate considerably over time. The
condition occurs in up to 5% to 15% of general medical outpatients, more
commonly in women. Significant adjustments can be noted in motor tension,
autonomic hyperactivity, and hypervigilance.
Anxiety may result from medications or drugs, medical conditions, or specific
life situations. Generalized anxiety not associated with any specific
physiological cause is poorly understood. Genetic or neurochemical factors may
play a role, possibly along with behavioral and developmental
- Traumatic early life experiences
- Anxious mother
- Stress, depression, other psychiatric conditions
- Life situations (social or financial
|Signs and Symptoms|
- Muscle tension
- Feelings of unreality
- Impaired concentration
- Excessive worry/sense of impending doom
- Sighing respiration
- Sleep disturbances
- Situation-related anxiety
- Adjustment disorder with anxiety
- Phobic anxiety
- Panic disorder
- Depression with anxiety
- Post--traumatic stress disorder
- Medical conditions that may cause or contribute to anxiety, including
angina pectoris, cardiac arrhythmias, asthma, congestive heart failure, limbic
lobe epilepsy, hyperthyroidism, hypoglycemia, valvular heart disease,
- Anxiety caused by medications, including psychostimulants,
sympathomimetic agents, theophylline, and indomethacin
- Caffeine, alcohol, or cocaine
The patient may appear nervous, irritable, or tense. With generalized anxiety
disorder, there will be no specific findings on physical
To rule out other conditions, test thyroid function and calcium levels. Use a
general laboratory screen if the patient has physical symptoms. Laboratory
findings are negative in cases of generalized anxiety
Conduct a detailed medical history, focusing on substance use, and life
stresses. The DSM-IV states six diagnostic criteria, which are listed
- Excessive anxiety and worry occurring more often than not for
- Patient cannot control the worry.
- Anxiety is associated with at least three of the following six
symptoms for 6 months: restlessness; fatigue; difficulty concentrating;
irritability; muscle tension; and sleep disturbance
- The focus of the anxiety is not confined to features of other Axis I
disorders (panic disorder, social phobia, separation anxiety disorder, anorexia
- The anxiety or symptoms cause significant distress or impairment in
social, occupational, or other functioning.
- The anxiety is not due to direct effects of a substance or a medical
condition and does not occur exclusively with a mood disorder, psychotic
disorder, or pervasive developmental disorder.
Having the patient hyperventilate may reproduce the symptoms and
differentiate the disorder from cardiac and neurologic
- Special tests: EEG for patients over 40 to rule out other conditions;
EEG for patients with prominent episodic neurological
If no specific known etiology, treatment focuses on eliminating or reducing
the symptoms. Except in severe cases, counseling and relaxation therapies may be
tried first, with pharmacologic therapy used as needed.
- Short-term counseling can assist the patient in restoring
self-esteem, problem solving, and coping with life stresses.
- Patients can be instructed in self-treating techniques to control
anxiety; many patients require no pharmacological treatment and succeed with
self-regulation techniques, including deep breathing.
- If symptoms of hypervigilance, autonomic hyperactivity, and muscle
tension persist, a short course of therapeutics may be
the patient undergoes counseling and learns self--control
Benzodiazepines depress subcortical levels of the CNS; side effects include
dizziness or drowsiness, constipation or nausea and vomiting, EEG changes, and
orthostatic hypotension; contraindicated with narrow-angle glaucoma, psychosis,
or pregnancy. Some benzodiazepines, which should be used for one to two months
as needed, are listed below.
- Alprazolam (Xanax), 0.25 to 1 mg
- Chlordiazepoxide (Librium), 5 to 25 mg
- Clonazepam (Klonopin), 3.75 to 22.5 mg
- Clorazepate dipotassium (Tranxene), 3.75 to 22.5 mg
- Diazepam (Valium), 2 to 15 mg
- Halazepam (Paxipam), 20 to 40 mg
- Lorazepam (Ativan), 0.5 to 2 mg
- Oxazepam (Serax), 10 to 30 mg
- Prazepam (Centrax), 5 to 10 mg
- Hydroxyzine (Vistaril, Atarax), 10 to 25 mg as needed, may be used
for a patient at risk of abusing a benzodiazepine; side effects include
dizziness or drowsiness, dry mouth; contraindicated in pregnancy.
- A tricyclic antidepressant may be used for a patient with persistent
cognitive symptoms of apprehension. It inhibits the action of serotonin. Side
effects include dizziness, headache, stimulation, insomnia, nervousness,
numbness, incoordination, tremors, nausea, diarrhea, constipation, tachycardia,
palpitations, sore throat, tinnitus, blurred vision, and muscle pain or
weakness. Some tricyclic antidepressants are listed below.
- Buspirone (Buspar), 5 to 10 mg
- Imipramine, 10 mg
- Nortriptyline, 10 mg
|Complementary and Alternative
Supporting the nervous system with mind-body techniques, nutrition, and herbs
may be an effective way to minimize and resolve anxiety. Progressive muscle
relaxation, diaphragmatic breathing, biofeedback, meditation, and self-hypnosis
can help induce the relaxation response and alleviate
Avoid caffeine, alcohol, sugar, refined foods, and all known food allergens.
Fresh vegetables, whole grains, and protein nourish the nervous system. Calcium
(1,000 mg/day), magnesium (400 to 600 mg/day), and B-complex (50 to 100 mg/day)
help support the nervous system and minimize the effects of
Herbs are generally a safe way to strengthen and tone the body's systems. As
with any therapy, it is important to ascertain a diagnosis before pursuing
treatment. Herbs may be used as dried extracts (capsules, powders, teas),
glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless
otherwise indicated, teas should be made with 1 tsp. herb per cup of hot water.
Steep covered 5 to 10 minutes for leaf or flowers, and 10 to 20 minutes for
roots. Drink 2 to 4 cups/day. Tinctures may be used singly or in combination as
noted. A tea (3 to 4 cups/day) or tincture (10 to 20 drops four to six
times/day) from the following herbs will help to reduce anxiety and strengthen
the nervous system.
- Kava kava (Piper methysticum) for mild to moderate
- St. John's wort (Hypericum perforatum) for anxiety associated
- Passionflower (Passiflora incarnata) for anxiety with
- Oatstraw (Avena sativa) nourishes the nervous
- Lemon balm (Melissa officinalis) for anxiety with depression
and heart palpitations.
- Lavender (Lavandula angustifolia) for nervous exhaustion and
restoring the nervous system.
- Skullcap (Scutellaria lateriflora) relaxes and revitalizes the
Kava kava (100 to 200 mg bid to qid) and St. John's wort (300 mg bid to tid)
may be taken as dried extracts to maximize effectiveness in moderate anxiety.
Essential oils of lemon balm, bergamot, and jasmine are calming and may be
used as aromatherapy. Place several drops in a warm bath, atomizer, or cotton
An experienced homeopath should assess individual constitutional types and
severity of disease to select the correct remedy and potency. For acute
prescribing use 3 to 5 pellets of a 12X to 30C remedy every one to four hours
until acute symptoms resolve.
- Aconite for anxiety with palpitations, shortness of breath, and
fear of death
- Arsenicum album for anxiety with restlessness, especially after
- Phosphorus for anxiety when alone and fear that something bad
Acupuncture can be very effective in reducing anxiety.
Therapeutic massage can be very effective in reducing anxiety and alleviating
Patients learning self-regulatory techniques generally require multiple
training sessions and periodic follow-up to ensure the technique is successful.
Patients using benzodiazepines are not likely to experience tolerance, but
physical and psychological dependence may occur with higher doses used
frequently. Monitor the patient for signs of dependence or abuse;
discontinuation requires tapering to prevent withdrawal
Hormonal balancing for cyclic anxiety
- Caffeine can produce or aggravate symptoms
- Avoid stimulants
- Avoid refined sugar--containing foods
- Daily exercise helps prevent or reduce anxiety
The condition of the patient with anxiety is often complicated with other
psychiatric or behavioral problems. The treatment of underlying or associated
conditions is necessary along with symptomatic relief of anxiety. Anxiety in
many patients may be complicated by substance abuse or
Variable prognosis: milder disorders may resolve with self-regulation
treatment; more severe conditions may continue and become chronic or become a
relapsing-remitting pattern. Psychotherapy may be necessary if other techniques
fail or as an adjunct to other therapies for symptom relief. For patients on
drug therapy, attempt gradual withdrawal every three to six months; in some
cases a chronic maintenance dose may be required.
Care should be taken in prescribing certain drugs, listed below, for the
- Benzodiazepines contraindicated (U.S. FDA safety category
- Hydroxyzine contraindicated (U.S. FDA safety category C)
- Buspirone with precaution (U.S. FDA safety category B)
- Imipramine and nortriptyline with precaution (U.S. FDA safety
While the herbal tea earlier described is safe in pregnancy, the dried
extracts of kava kava and St. John's wort should be
American Council on Collaborative Medicine. Dr. Victor Bagnall's
Nutritional Therapy. Accessed at: www.nutrimed.com/anxiety.htm on December
American Psychiatric Association. Diagnostic and Statistical Manual of
Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association;
Andreoli TE, Bennett JC, Carpenter CCJ. Cecil Essentials of Medicine.
3rd ed. Philadelphia, Pa: WB Saunders; 1993.
Barker LR, Burton JR, Zieve PD, eds. Principles of Ambulatory Medicine.
4th ed. Baltimore, Md: Williams & Wilkins; 1995:139-154.
Blumenthal M, ed. The Complete German Commission E Monographs: Therapeutic
Guide to Herbal Medicines. Boston, Mass: Integrative Medicine
Communications; 1998:422, 463-464.
Dr. Bower's Complementary and Alternative Medicine Home Page. Available at:
Goldberg RJ. Anxiety reduction by self-regulation: theory, practice, and
evaluation. Ann Intern Med. 1982;96:483.
Health and Healing News. Accessed at: www.hhnews.com/kava_update.htm on
December 2, 1998.
Herbal Alternatives. Accessed at: www.herbalalternatives.com/kava.htm on
December 2, 1998.
Jussofie A, Schmiz A, Hiernke C. Kavapyrone enriched extract from Piper
methysticum as modulator of the GABA binding site in different regions of
the rat brain. Psychopharmacology. 1994;116:469-474.
Kinzler E, Kromer J, Lehmann E. Effect of a special kava extract in patients
with anxiety-, tension-, and excitation states of non-psychotic genesis. Double
blind study with placebos over four weeks [in German]. Arzneimforsch.
Lehmann E, et al. Efficacy of special kava extract (Piper methysticum)
in patients with states of anxiety, tension and excitedness of non-mental
origin: a double blind placebo controlled study of four weeks treatment.
Lindenberg Von D, Pitule-Schodel H. D, L-Kavain in comparison with oxazepam
in anxiety states. Double-blind clinical trial. Forschr Med.
Morrison R. Desktop Guide to Keynotes and Confirmatory Symptoms.
Albany, Calif: Hahnemann Clinic Publishing; 1993:4, 40, 293.
Stein JH, ed. Internal Medicine. 4th ed. St. Louis, Mo: Mosby-Year
Volz HP, Kieser M. Kava kava extract WS 1490 versus placebo in anxiety
disorders—a randomized placebo controlled 25 week
outpatient trial. Pharmacopsychiatry.
Copyright © 2000 Integrative Medicine
CommunicationsThis publication contains
information relating to general principles
of medical care that should not in any event be construed as specific
instructions for individual patients. The publisher does not accept any
responsibility for the accuracy of the information or the consequences arising
from the application, use, or misuse of any of the information contained herein,
including any injury and/or damage to any person or property as a matter of
product liability, negligence, or otherwise. No warranty, expressed or implied,
is made in regard to the contents of this material. No claims or endorsements
are made for any drugs or compounds currently marketed or in investigative use.
The reader is advised to check product information (including package inserts)
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interactions, and contraindications before administering any drug, herb, or
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