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 factors.

• Traumatic early life experiences
• Anxious mother
• Stress, depression, other psychiatric conditions
• Life situations (social or financial problems)

• Muscle tension
• Tachycardia
• Hypervigilance
• Dyspnea
• Dizziness/near-syncope
• Palpitations
• Trembling
• Sweating
• Feelings of unreality
• Fatigue
• Impaired concentration
• Irritability
• 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, nutritional deficiencies
• Anxiety caused by medications, including psychostimulants, sympathomimetic agents, theophylline, and indomethacin
• Caffeine, alcohol, or cocaine use

The patient may appear nervous, irritable, or tense. With generalized anxiety disorder, there will be no specific findings on physical exam.

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 disorder.

Conduct a detailed medical history, focusing on substance use, and life stresses. The DSM-IV states six diagnostic criteria, which are listed below.

• Excessive anxiety and worry occurring more often than not for months
• 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 nervosa, etc.).
• 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 conditions.

• Special tests: EEG for patients over 40 to rule out other conditions; EEG for patients with prominent episodic neurological symptoms

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 helpful—even necessary—while the patient undergoes counseling and learns self--control techniques.

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

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 anxiety.

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 stress.

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 anxiety.
• St. John's wort (Hypericum perforatum) for anxiety associated with depression.
• Passionflower (Passiflora incarnata) for anxiety with insomnia.
• Oatstraw (Avena sativa) nourishes the nervous system.
• 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 nervous system.

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 ball.

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 midnight
• Phosphorus for anxiety when alone and fear that something bad will happen

Acupuncture can be very effective in reducing anxiety.

Therapeutic massage can be very effective in reducing anxiety and alleviating stress.

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 symptoms.

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 symptoms

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 dependence.

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 pregnant patient.

• Benzodiazepines contraindicated (U.S. FDA safety category D)
• 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 category C)

While the herbal tea earlier described is safe in pregnancy, the dried extracts of kava kava and St. John's wort should be avoided.

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