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What is generalized anxiety disorder?
Generalized anxiety disorder (GAD) is a condition in which you have fears and uncontrollable worries that last for at least 6 months. If you have GAD, you worry a lot about everyday problems. You feel tense and nervous much of the time. You worry that something bad is going to happen even when there is little reason to think that way. You know that you worry too much, but you are not able to stop.
GAD can last many years and sometimes your entire lifetime.
What is the cause?
The exact cause of this disorder is not known.
- The brain is made up of cells called neurons, and chemicals called neurotransmitters. These chemicals affect your mood, emotions and behaviors. The brain cells need the right balance of these chemicals to function normally. People with this disorder often have too little or too much of some of these chemicals in their brain.
- Generalized anxiety disorder tends to run in families. It is not known if this is caused by genes passed from parent to child. It may also be that parents fear and worry a lot, and children learn this behavior from their parents.
- Stressful life events and situations also play a major part. Anxiety can be triggered by alcohol or some drugs. Medical conditions can also cause anxiety. Heart problems, breathing problems, lack of vitamins, or thyroid problems can cause anxiety symptoms.
- Some medicines can cause anxiety or make it worse. These include asthma medicines, caffeine and stimulant medicines, and steroids such as prednisone.
- Anxiety is more common if you have few friends, family, and activities. Poor diet and lack of daily exercise may also make anxiety disorders more likely.
What are the symptoms?
Symptoms include too much worrying that you can’t control about many things. You may be short-tempered and unable to focus or concentrate because of the worrying. Physical symptoms may include:
- Muscle tension
- Sleep problems
- Nausea, sweating or shaking
- Having a very fast heartbeat
- Feeling out of breath or like you are going to faint
- Needing to go to the bathroom often
How is it diagnosed?
Your healthcare provider or therapist will ask about your symptoms. He or she will make sure you do not have a medical illness or drug or alcohol problem that could cause the symptoms.
How is it treated?
Several types of medicines can help treat anxiety. Your healthcare provider will work with you to select the best medicine. You may need to take more than one type of medicine.
Seeing a therapist can help. There are several kinds of therapy that can help a person with anxiety. Support groups are also very helpful.
Claims have been made that certain herbal and dietary products help control anxiety symptoms. Supplements are not tested or standardized and may vary in strength and effects. They may have side effects and are not always safe. Talk with your provider before you try herbs or dietary supplements to treat your condition.
Learning ways to relax may help. Yoga and meditation may also be helpful. You may want to talk with your healthcare provider about using these methods along with medicines and psychotherapy.
How can I take care of myself?
- Get support. Talk with family and friends. Consider joining a support group in your area. Go to a stress management class in your local community.
- Learn to manage stress. Ask for help at home and work when the load is too much to handle. Find ways to relax, for example take up a hobby, listen to music, watch movies, or take walks. Try deep breathing exercises when you feel stressed.
- Take care of your physical health. Try to get at least 7 to 9 hours of sleep each night. Eat a healthy diet and don’t skip meals. Low blood sugar can make you feel more nervous. Limit caffeine. If you smoke, quit. Avoid alcohol and drugs. Exercise according to your healthcare provider’s instructions. Regular exercise can help calm you and make it easier for you to deal with stress.
- Check your medicines. To help prevent problems, tell your healthcare provider and pharmacist about all the medicines, natural remedies, vitamins, and other supplements that you take.
- Contact your healthcare provider or therapist if you have any questions or your symptoms seem to be getting worse.
For more information, contact:
National Institute of Mental Health 866-615-NIMH (6464) http://www.nimh.nih.gov/
Mental Health America800-969-NMHA (6642)http://www.mentalhealthamerica.net/
Corticosteroid-induced mania: Prepare for the unpredictable
Can corticosteroids “unlock” hidden potential for mania, or are steroid-induced mood symptoms a temporary reaction? And when these mood symptoms occur, what is the best way to treat them?
Psychiatric symptoms develop in 5% to 18% of patients treated with corticosteroids. These effects—most often mania or depression—emerge within days to weeks of starting steroids. To help you head off manic and mixed mood symptoms, this paper examines how to:
- treat steroid-induced mania or mixed bipolar symptoms
- reduce the risk of a mood episode in patients who require sustained corticosteroid therapy.
Jane Pauley, NBC’s Today Show broadcaster, described in her autobiography how hypomania developed within weeks after she started corticosteroids for idiopathic urticaria edema: “I was so energized that I didn’t just walk down the hall, I felt like I was motoring down the hall. I was suddenly the equal of my high-energy friends who move fast and talk fast and loud. I told everyone that I could understand why men felt like they could run the world, because I felt like that. This was a new me, and I liked her!”1
Pauley’s hypomania led to a manic episode and eventually to depression. She was started on antidepressants, which triggered another manic episode. Pauley—who had no history of bipolar disorder—spent 3 weeks in a New York psychiatric hospital.1
Diagnostic symptoms. Corticosteroids’ psychiatric effects—cognitive, mood, anxiety, and psychotic symptoms—were first described as “steroid psychosis.” Psychosis can occur, but mood symptoms are more common:
Steroid-induced symptoms emerge from 3 to 4 days to a median of 11 days after a patient starts corticosteroid therapy. After steroids are discontinued, depressive symptoms persist approximately 4 weeks, mania 3 weeks, and delirium a few days. Approximately one-half of patients with steroid psychosis improve in 4 days and one-half within 2 weeks.2,6
Who is at risk?
Corticosteroids include the steroids produced in the adrenal gland (such as corticosterone) and their synthetic—and often more potent—analogues (such as prednisone).7 Because of their glucocorticoid, immunosuppressant, mineralocorticoid, and anti-inflammatory properties, steroids are used as replacement therapy and to treat a wide variety of illnesses (Table 1).
Medical conditions for which corticosteroids are commonly used
|Disorder||Indications for corticosteroids|
|Acute adrenal insufficiency||Acute; replacement therapy|
|Addison’s disease||Chronic; replacement therapy|
|Asthma||Acute and chronic; anti-inflammatory|
|Inflammatory bowel disease||Acute; anti-inflammatory|
|Multiple sclerosis||Acute; exacerbations, immunosuppressant|
|Organ transplant||Chronic; immunosuppressant|
|Rheumatoid arthritis||Chronic; anti-inflammatory|
|Systemic lupus erythematosus||Acute; severe exacerbation, immunosuppressant (high doses are used)|
Age and gender. Patient age appears unrelated to development of psychiatric symptoms after corticosteroid use.2 One study suggested women are twice as likely as men to develop psychiatric symptoms (77 versus 38 cases in 115 patients),3 but many illnesses that require corticosteroid treatment occur more frequently in women. Other researchers found a slight female predominance (58% versus 42% of cases) when they excluded patients with systemic lupus erythematosus and rheumatoid arthritis, which are more common in women than in men.2
Dosage. Higher corticosteroid dosages increase the risk of psychiatric symptoms. In patients taking prednisone, the Boston Collaborative Drug Surveillance Project8 found the incidence of psychiatric side effects to be:
- 1.3% in patients taking
- 4.6% in those taking 41 to 80 mg
- 18.4% in those taking >80 mg.
Psychiatric history. Past psychiatric illness does not seem to be a risk factor for psychiatric side effects of corticosteroids,9 although patients with a history of posttraumatic stress disorder are more likely to suffer depression while taking corticosteroids.10
Corticosteroid exposure. Patients who did not experience psychiatric side effects with corticosteroids in the past appear not to be protected if corticosteroids are used again. One report examined 17 cases of steroid-induced psychiatric illness in patients with previous exposure to corticosteroid therapy. Six patients had previous psychiatric side effects while taking corticosteroids, and 11 did not.2
Do corticosteroids’ acute psychiatric side effects have long-term sequelae? Longitudinal evidence is scarce, but a few reports suggest corticosteroids could play a role in the onset of primary bipolar I disorder:
- A 28-year-old woman with no known mood symptoms before a short course of prednisone experienced six episodes of mania and depression when not taking corticosteroids during the subsequent 18 months.11
- Among 16 patients with first-onset mood symptoms after corticosteroid use, a retrospective chart review found 7 had recurrent manic and depressive symptoms unrelated to additional corticosteroid use.12
Prednisolone 20mg Tablets
Measles Patients should be advised to take particular care to avoid exposure to measles, and to seek immediate medical advice if exposure occurs. Prophylaxis with intramuscular normal immunoglobulin may be needed. Administration of Live Vaccines Live vaccines should not be given to individuals on high doses of corticosteroids, due to impaired immune response. Live vaccines should be postponed until at least 3 months after stopping corticosteroid therapy. (See also Section 4.5 ‘Interaction with other medicinal products and other forms on interaction’). Ocular Effects Prolonged use of corticosteroids may produce posterior subcapsular cataracts and nuclear cataracts (particularly in children), exophthalmos, or increased intraocular pressure, which may result in glaucoma with possible damage to the optic nerves. Establishment of secondary fungal and viral infections of the eye may also be enhanced in patients receiving glucocorticoids. Corticosteroids should be used cautiously in patients with ocular herpes simplex because of possible perforation. Systemic glucocorticoid treatment can cause severe exacerbation of bullous exudative retinal detachment and lasting visual loss in some patients with idiopathic central serous chorioretinopathy (See Section 4.8 ‘Undesirable effects’). Cushing’s disease Because glucocorticoids can produce or aggravate Cushing’s syndrome, glucocorticoids should be avoided in patients with Cushing’s disease.There is an enhanced effect of corticosteroids in patients with hypothyroidism. Psychic derangements may appear when corticosteroids, including prednisolone, are used, ranging from euphoria, insomnia, mood swings, personality changes, and severe depression, to frank psychotic manifestations (see Section 4.8 ‘Undesirable effects’). Raised intracranial pressure Raised intracranial pressure with papilloedema (pseudotumour cerebri) associated with corticosteroid treatment has been reported in both children and adults. The onset usually occurs after treatment withdrawal (See section 4.8 ‘Undesirable effects’).
Visual disturbance may be reported with systemic and topical corticosteroid use. If a patient presents with symptoms such as blurred vision or other visual disturbances, the patient should be considered for referral to an ophthalmologist for evaluation of possible causes which may include cataract, glaucoma or rare diseases such as central serous chorioretinopathy (CSCR) which have been reported after use of systemic and topical corticosteroids.
Use in the elderly
Treatment of elderly patients, particularly if long term, should be undertaken with caution bearing in mind the more serious consequences of the common side-effects of corticosteroids in old age, especially osteoporosis, diabetes, hypertension, hypokalaemia, susceptibility to infection and thinning of the skin. Close clinical supervision is required to avoid life threatening reactions.
Corticosteroids cause growth retardation in infancy, childhood and adolescence, which may be irreversible, and therefore long-term administration of pharmacological doses should be avoided. If prolonged therapy is necessary, treatment should be limited to the minimum suppression of the hypothalamo-pituitary adrenal axis and growth retardation. The growth and development of infants and children should be closely monitored. Treatment should be administered where possible as a single dose on alternate days.
Before taking prednisone,
- tell your doctor and pharmacist if you are allergic to prednisone, any other medications, or any of the inactive ingredients in prednisone tablets or solutions. Ask your doctor or pharmacist for a list of the inactive ingredients.
- tell your doctor and pharmacist what prescription and nonprescription medications, vitamins, and nutritional supplements you are taking or plan to take. Be sure to mention any of the following: amiodarone (Cordarone, Pacerone); anticoagulants (‘blood thinners’) such as warfarin (Coumadin); certain antifungals such as fluconazole (Diflucan), itraconazole (Sporanox), ketoconazole (Nizoral) and voriconazole (Vfend);aprepitant (Emend); aspirin; carbamazepine (Carbatrol, Epitol, Tegretol); cimetidine (Tagamet); clarithromycin (Biaxin, in Prevpak); cyclosporine (Neoral, Sandimmune); delavirdine (Rescriptor); diltiazem (Cardizem, Dilacor, Tiazac, others); dexamethasone (Decadron, Dexpak); diuretics (‘water pills’); efavirenz (Sustiva); fluoxetine (Prozac, Sarafem); fluvoxamine (Luvox); griseofulvin (Fulvicin, Grifulvin, Gris-PEG); HIV protease inhibitors including atazanavir (Reyataz), indinavir (Crixivan), lopinavir (in Kaletra), nelfinavir (Viracept), ritonavir (Norvir, in Kaletra), and saquinavir (Fortovase, Invirase); hormonal contraceptives (birth control pills, patches, rings, implants, and injections); lovastatin (Altocor, Mevacor); medications for diabetes; nefazodone; nevirapine (Viramune); phenobarbital; phenytoin (Dilantin, Phenytek); rifabutin (Mycobutin), rifampin (Rifadin, Rimactane, in Rifamate); sertraline (Zoloft); troleandomycin (TAO); verapamil (Calan, Covera, Isoptin, Verelan); and zafirlukast (Accolate).Your doctor may need to change the doses of your medications or monitor you carefully for side effects.
- tell your doctor what herbal products you are taking or plan to take, especially St. John’s wort.
- tell your doctor if you have an eye infection now or have ever had eye infections that come and go and if you have or have ever had threadworms (a type of worm that can live inside the body); diabetes; high blood pressure; emotional problems; mental illness; myasthenia gravis (a condition in which the muscles become weak); osteoporosis (condition in which the bones become weak and fragile and can break easily); seizures; tuberculosis (TB); ulcers; or liver, kidney, intestinal, heart, or thyroid disease.
- tell your doctor if you are pregnant, plan to become pregnant, or are breast-feeding. If you become pregnant while taking prednisone, call your doctor.
- if you are having surgery, including dental surgery, or need emergency medical treatment, tell the doctor, dentist, or medical staff that you are taking or have recently stopped taking prednisone. You should carry a card or wear a bracelet with this information in case you are unable to speak in a medical emergency.
- do not have any vaccinations (shots to prevent diseases) without talking to your doctor.
- you should know that prednisone may decrease your ability to fight infection and may prevent you from developing symptoms if you get an infection. Stay away from people who are sick and wash your hands often while you are taking this medication. Be sure to avoid people who have chicken pox or measles. Call your doctor immediately if you think you may have been around someone who had chicken pox or measles.