The essential feature of generalized anxiety disorder is excessive anxiety and worry about a number of events or activities, occurring most days over 6 months. Patients have difficulty controlling the worry, report subjective distress, and may experience difficulties in social or occupational functioning. The intensity, duration, or frequency of the worry is out of proportion to the actual likelihood or impact of the feared event. Patients must have at least three associated physical symptoms, including restlessness, irritability, muscle tension, disturbed sleep, fatigability, and difficulty concentrating. The list of associated symptoms can be thought of as symptoms of inner tension (restlessness or edginess, irritability, muscle tension) and symptoms associated with the fatiguing effects of chronic anxiety (fatigue, concentration difficulties, sleep disturbance) (Box 47-3).
Panic attacks, a collection of distressing physical, cognitive, and emotional symptoms, may occur in a variety of anxiety disorders, such as specific phobias, social phobias, PTSD, and acute stress disorder. Panic attacks are discrete periods of intense fear in the absence of real danger, accompanied by at least 4 of 13 cognitive and physical symptoms (Box 47-4). The attacks have a sudden onset, build to a peak quickly, and are often accompanied by feelings of doom, imminent danger, and a need to escape. Symptoms of panic attacks can include somatic complaints (e.g., sweating, chills), cardiovascular symptoms (pounding heart, accelerated heart rate, chest pain), neurologic symptoms (trembling, unsteadiness, lightheadedness, paresthesias), GI symptoms (choking sensations, nausea), and pulmonary symptoms (shortness of breath). In addition, patients with panic attacks may worry they are dying, "going crazy," or have the sensation of being detached from reality.
Patients with panic disorder experience recurrent, unexpected panic attacks, followed by at least 1 month of persistent worry that they will suffer another panic attack. Panic disorder patients may begin to avoid places where a prior attack occurred or where help may not be available; such avoidance can lead to the development of agoraphobia and typically worsens their psychosocial functioning (Box 47-5).
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