An 18-year-old young girl has attacks of restlessness, insomnia, cold sweating and fear. Discuss the differential diagnosis. Outline the principles of management of "generalized anxiety disorder".

Differential Diagnosis

The symptoms described – restlessness, insomnia, cold sweating, and fear – are non-specific and can be seen in a range of conditions. A comprehensive differential diagnosis should include:

• Generalized Anxiety Disorder (GAD): This is a primary consideration given the described symptoms. Diagnostic criteria (DSM-5) include excessive anxiety and worry occurring more days than not for at least six months, along with at least three physical symptoms (restlessness, fatigue, difficulty concentrating, irritability, muscle tension, sleep disturbance).
• Panic Disorder: While the symptoms overlap, panic disorder typically involves sudden episodes of intense fear (panic attacks) with a sense of impending doom. The described symptoms could represent a panic attack, but the chronic nature suggests GAD is more likely.
• Social Anxiety Disorder (Social Phobia): This involves fear of social situations where the individual may be scrutinized. The symptoms could be present in anticipation of or during social interactions.
• Post-Traumatic Stress Disorder (PTSD): If the patient has a history of trauma, these symptoms could be related to PTSD. Flashbacks, nightmares, and avoidance behaviors would be key features.
• Hyperthyroidism: This medical condition can cause anxiety-like symptoms, including restlessness, sweating, and insomnia.
• Cardiac Arrhythmias: Certain heart conditions can manifest as palpitations and anxiety.
• Substance Abuse/Withdrawal: Use of stimulants or withdrawal from depressants can induce anxiety symptoms.
• Depression: Anxiety and depression frequently co-occur. The presence of low mood, anhedonia, and suicidal ideation would suggest depression.

Principles of Management of Generalized Anxiety Disorder

The management of GAD is typically multimodal, integrating psychological and pharmacological interventions.

1. Psychological Interventions

• Cognitive Behavioral Therapy (CBT): This is the first-line psychological treatment. CBT helps patients identify and challenge negative thought patterns and develop coping mechanisms to manage anxiety. Techniques include cognitive restructuring, relaxation training, and exposure therapy.
• Relaxation Techniques: Progressive muscle relaxation, diaphragmatic breathing, and mindfulness meditation can help reduce physical symptoms of anxiety.
• Acceptance and Commitment Therapy (ACT): ACT focuses on accepting anxious thoughts and feelings rather than trying to control them, and committing to values-based actions.
• Psychodynamic Therapy: Explores underlying unconscious conflicts that may contribute to anxiety.

2. Pharmacological Interventions

Medication can be helpful in managing symptoms, particularly when combined with psychotherapy.

• Selective Serotonin Reuptake Inhibitors (SSRIs): These are often the first-line medications for GAD. Examples include sertraline, paroxetine, and escitalopram.
• Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs): Venlafaxine and duloxetine are effective SNRIs used in GAD treatment.
• Buspirone: An anxiolytic medication that works differently from SSRIs/SNRIs. It has a slower onset of action.
• Benzodiazepines: (e.g., alprazolam, lorazepam) These provide rapid relief of anxiety symptoms but have a high potential for dependence and are generally used for short-term management of acute anxiety.
• Beta-Blockers: (e.g., propranolol) Can help manage physical symptoms of anxiety like palpitations and tremors.

3. Lifestyle Modifications

• Regular Exercise: Physical activity has been shown to reduce anxiety symptoms.
• Healthy Diet: A balanced diet can improve overall well-being and reduce anxiety.
• Adequate Sleep: Prioritizing sleep hygiene is crucial for managing anxiety.
• Stress Management Techniques: Yoga, meditation, and mindfulness can help reduce stress levels.
• Avoidance of Caffeine and Alcohol: These substances can exacerbate anxiety symptoms.

4. Monitoring and Follow-up

Regular monitoring of symptoms and medication side effects is essential. Treatment should be individualized and adjusted based on the patient's response.