Generalized Anxiety Disorder Physical Symptoms

Symptoms of Anxiety  

Patients with generalized anxiety present with a wide variety of symptoms and range of severity. Some patients may emphasize a special symptom (e.g., insomnia) and not report other symptoms of generalized anxiety that are usually associated with GAD. Some patients may not complain of anxiety or specific worries but present with exclusively somatic symptoms such as diarrhea, palpitations, dyspnea, abdominal pain, headache or chest pain. 

These patients warrant a full medical evaluation because there may be no indication that generalized anxiety is the etiology. Conversely, physicians should include a psychiatric disorder in the differential diagnosis when generalized anxiety symptoms are vaguely described, do not conform to known pathophysiologic mechanisms, persist after a negative work-up and are not resolved by reassurance.

Patients with this clinical profile should be asked as early in the evaluation as possible about worries, "nerves," or anxiety, acute or chronic stressors, and about the presence of generalized anxiety disorder symptoms.

Nonpsychiatric disorders must be ruled out before generalized anxiety disorder can be diagnosed as the etiology of a patient's complaint of anxiety. Neurologic and endocrine diseases, such as hyperthyroidism and Cushing's disease, are the most frequently cited medical causes of anxiety.

Other medical conditions commonly associated with the symptoms of anxiety include mitral valve prolapse, carcinoid syndrome and pheochromocytoma.

It must be stressed that these conditions, although often cited, are clinically uncommon, and all patients who present with the complaint of anxiety do not require an extensive work-up to exclude these other medical conditions.

Medications such as steroids, over-the-counter sympathomimetics, selective serotonin reuptake inhibitors (SSRIs), digoxin, thyroxine and theophylline may cause anxiety. The physician should also inquire about the use of herbal products or vitamins. If possible, all exogenous substances should be removed before initiating treatment of patients with generalized anxiety disorder.

Use of and withdrawal from addictive substances can cause anxiety. The physician should inquire about the patient's use of alcohol, caffeine, nicotine and other commonly used substances (including those given by prescription). Corroborative history from family members may be necessary.
Evaluation for Other Psychiatric Disorders

The evaluation for other psychiatric disorders is probably the most challenging aspect of patient evaluation because the symptoms of generalized anxiety disorder overlap with those of other psychiatric disorders (e.g., major depression, substance abuse, panic disorder) and because these disorders often occur concomitantly with generalized anxiety disorder.

Generally, generalized anxiety disorder should be considered a diagnosis of exclusion after other psychiatric disorders have been ruled out. Because of the overlap and comorbidity associated with other psychiatric disorders, some authors have questioned whether generalized anxiety disorder is a distinct entity and have posited that it is a variant of panic disorder or major depression.

Symptoms of generalized anxiety disorder can occur before, during or after the onset of the symptoms of major depression or panic disorder. Some patients have symptoms of anxiety and depression but do not meet the full criteria as delineated in DSM-IV, for generalized anxiety disorder, panic disorder or major depression.

In these cases, the term "mixed anxiety-depressive disorder" can be applied, although it is not yet part of the official nosology. Despite the confusion, anxious patients should be asked about the symptoms of panic attacks and the neurovegetative symptoms (including suicidal ideation) that are associated with major depression. When more than one psychiatric condition exists, an attempt should be made to determine which disorder occurred first.

Obsessive-compulsive disorder and social phobia should also be considered in the evaluation for comorbid disorders. The key symptom of obsessive-compulsive disorder is recurring, intrusive thoughts or actions. Social phobia is characterized by intense anxiety provoked by social or performance situations.

Because patients with generalized anxiety disorder may present with mostly somatic complaints, somatization disorder is also a consideration. The distinguishing feature of this disorder is chronic, multiple physical complaints that involve several organ systems. Patients with exclusively generalized anxiety disorder have a much more limited range of physical complaints.