Comorbidity and the Treatment of GAD
GAD is often accompanied by other concurrent psychiatric dis-orders,
specifically anxiety and mood disorders. The presence of these comorbid
conditions may reflect more severe loading for psychopathology, and may have
important implications on the course and treatment response of the primary
disorder. In the National Comorbidity Survey, more patients with comorbidity
experienced interference with daily activities than did patients with pure GAD
(Wittchen et al., 1994). The presence
of a comor-bid anxiety disorder and major depressive disorder is frequently
associated with a poorer overall outcome than for patients with a single
psychiatric disorder (Kessler et al.,
1999). Currently, there are treatment options that can target both GAD and
major de-pressive disorder simultaneously. The use of SSRIs and the SNRI
venlafaxine is recommended as the first-line treatment for co-morbid GAD and
depression.
Social anxiety disorder frequently complicates the course GAD takes.
With the recent data indicating that the SSRIs such as sertraline and
paroxetine are effective in the treatment of so-cial anxiety, these agents may
be useful in the treatment of co-morbid social anxiety disorder and GAD. The
benzodiazepines that have been established as effective in the treatment of patients
with GAD also appear to be effective in the treatment of patients with social
anxiety disorder. Thus, these agents (considering the caveats associated with
their use described earlier) may have a therapeutic role in patients with GAD
and coexisting social pho-bia. Finally, patients with GAD and concurrent panic
disorder or panic attacks may be effectively treated with SSRIs, TCAs and
benzodiazepines. However, buspirone is probably ineffective in the treatment of
panic disorder.
Concurrent alcohol and substance abuse tend to confuse the clinical
picture of GAD and can interfere with the thera-peutic efforts. Additionally,
symptoms associated with alcohol withdrawal or other sedative–hypnotics may
mimic the under-lying anxiety disorder. If a substance abuse problem exists,
the clinician and the patient should take the necessary steps to discontinue
the use of the abused substance. This may well in-clude specific substance
abuse treatment. Specifically, the need for detoxification should be assessed and
discussed with the pa-tient. Following cessation of substance abuse the
patient’s symp-tomatology should be reevaluated. The use of benzodiazepines in
these patients may be contraindicated, and alternative treat-ments with SSRIs,
SNRIs, TCAs, buspirone, or gabapentin may be needed.
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