Anxiety Disorders ____________________________________________________________________________
COMORBID DEPRESSION Anxiety symptoms often co-occur with other psychologic symptoms. Depressive symptoms are highly prevalent with more severe anxiety symptoms, with anxiety and depressive symptom severity strongly correlated. Patients with anxiety disorder have high comorbidity rates of major depressive disor- der (almost 50%), schizophrenia, substance use disorders, and physical illness [3; 11]. Overlapping symptoms of anxiety and depression, such as sleep disturbance, fatigue, and difficulty concentrating, make differentiation challenging. Depressive disorders are sometimes termed “anxious-misery” when high levels of sadness and anhedonia are present [2]. Suicidal ideation and rates of suicide attempts are elevated in persons with anxiety disorders, and the suicide risk among patients has been reported as increased by a factor of 10 compared with the general population [54].
female sex, recent adverse life events, and chronic physical (e.g., respiratory and cardiac disorders, dyslipidemia, cognitive impairment) or mental health (e.g., depression, phobia, past GAD) disorders. Other risk factors include poverty, parental loss/separation or low emotional support during childhood, and history of parental mental health problems. Late-onset GAD is described as a multifactorial, stress-related affective disorder resulting from proximal and distal risk factors of which some are potentially modifiable by healthcare intervention [14]. Clinical Course The course of GAD tends to be chronic with fluctuating symp- tom severity, and GAD may “switch” to other diagnoses, par- ticularly depression and somatoform disorders [15; 16]. GAD is associated with impairments in psychosocial functioning, role functioning, work productivity, and health-related quality of life comparable to major depressive disorder or panic disor- der. Patients with GAD and comorbid major depression show significantly greater impairment in health-related quality of life than in either disorder alone. Primary care patients with GAD showed significantly higher annual medical costs than patients without GAD (median $2,375 versus $1,448) and higher mean annual medical costs ($2,138) than patients with other anxiety disorders. GAD is frequently under-recognized in primary care, and only 20% to 32% of patients receive adequate treatment. Suboptimal treatment adds to the health-related quality of life burden of this disorder [17].
SPECIFIC DISORDERS Generalized Anxiety Disorder Epidemiology
Studies show that GAD has a 6.2% lifetime prevalence and a 2.0% to 3.1% past-year prevalence in the U.S. population [350]. The lifetime and past-year prevalences are 3.6% and 2.0% in men/boys and 6.6% and 4.3% in women/girls. Most persons with GAD diagnoses are female. The reported prevalence for GAD in primary care patient panels range 3.7% to 14.8% [54]. Childhood or adolescent onset was found in more than 50% of those seeking help for anxiety, reflecting the chronicity of the disease [2]. Risk Factors No single etiology has been identified for GAD, but it likely involves the interaction of multiple familial/genetic and envi- ronmental risk factors. A review of twin and family studies found significant associations between GAD, other anxiety disorders, and depression, suggesting a common underlying genetic basis. A significant number of patients and their first-degree relatives develop GAD (odds ratio 6:1) [12]. Civil- ian trauma (e.g., motor vehicle accidents, physical or sexual assault, sudden unexpected loss of a loved one, bullying or peer victimization in childhood or adolescence) is a risk factor for GAD [13]. The presence of another anxiety disorder (e.g., panic disorder, SAD, specific phobia) is another possible factor. Panic disorder is comorbid in 25% of patients with GAD [13]. Older adults are the fastest-growing age demographic in the United States. Although late-onset GAD (on or after 65 years of age) is uncommon, clinicians should bear in mind that age-related propensity for anxiety, including the emergence of anxiety disorder, may change over the course of a lifetime. The concerns of aging that may lead to excessive worrying include personal health, the welfare of loved ones, dwindling income, loss of independence, and ability to manage one’s affairs at home. The primary predictors of anxiety in the elderly include
Panic Disorder Epidemiology
In the United States, 4% to 28% of the population experience panic attacks at some time during life. The 2.4% 12-month prevalence of panic disorder in the United States is among the highest worldwide [7; 18]. Panic disorder prevalence in primary care is approximately 7%, and substantially higher in patients presenting with cardiac or gastrointestinal symptoms. Relative to white patients, the odds of developing panic attacks and panic disorder are higher in Native Americans, and lower in Asian, Hispanic, and black patients [18; 19]. Panic attacks are most likely to develop in patients who are in their mid-20s and slightly earlier in men than women. Panic disorder age of onset is usually between late adolescence and 35 years of age, while the age of onset for panic disorder with agoraphobia spans the early 20s to early 30s. Panic dis- order is more common among women, with a 2:1 ratio and increasing to 3:1 with panic disorder with agoraphobia. Panic symptoms during adolescence elevate risks for other anxiety and mood disorders in adulthood. Depressive disorders are highly comorbid (33% to 85%), especially among those with agoraphobia [2; 20]. Panic disorder is highly comorbid with other anxiety, mood, and substance use disorders, including nicotine dependence, and cigarette smoking may increase the risk for later-onset panic disorder [21].
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