A 31-year-old woman comes to the office due to headaches, intermittent diarrhea, dizziness, poor sleep, and fatigue. She describes muscle tension in her shoulders and neck, frequent tension headaches, and nonspecific gastrointestinal distress. Her symptoms have been ongoing for the past year but are worse since she separated from her husband 3 months ago. The patient has difficulty falling asleep, frequently lying awake in bed for several hours worrying about her health, finances, work deadlines, and lack of social life. During the day she is anxious and irritable and has low energy and difficulty concentrating at work. She rarely goes out with her friends as she is too tired at the end of the day. The patient was evaluated 6 months ago for similar symptoms. She says, "I was reassured that everything was normal, but I am still worried something was missed." The patient does not use alcohol or illicit drugs. She has a history of asthma treated with albuterol as needed.
The patient is afebrile; blood pressure is 130/72 mm Hg, pulse is 88/min, and respirations are 14/min. BMI is 22 kg/m². Physical examination is unremarkable.
Serum TSH level, complete blood count, and urinalysis are normal.
Which of the following is the most likely diagnosis?

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11ec193a_98bf_15aa_853d_9bec32a1f1dd_MD0002_00 This patient's multiple worries, muscle tension, fatigue, sleep disturbance, irritability, and difficulty concentrating are consistent with generalized anxiety disorder (GAD), one of the most common psychiatric disorders. Patients with GAD frequently have insomnia and physical manifestations of anxiety (eg, headaches, gastrointestinal distress, dizziness) and are high utilizers of health care resources. GAD is characterized by excessive, uncontrollable anxiety about multiple issues or events (eg, work, health, finances, safety of family members, minor matters). Although 6 months is required for diagnosis, many patients describe lifelong anxiety with exacerbation during stressful periods. There is significant symptom overlap between major depressive disorder and GAD (eg, fatigue, insomnia, impaired concentration) and the conditions are frequently comorbid. However, this patient does not exhibit additional depressive symptoms required to diagnose a major depressive episode (eg, depressed mood, loss of interest or pleasure, appetite disturbance, feelings of worthlessness or guilt, suicidal ideation) (Choice D). (Choice A) Adjustment disorder is not diagnosed when the patient meets criteria for another disorder. This patient's GAD symptoms predated her marital separation. (Choice C) In illness anxiety disorder (formerly known as hypochondriasis), the patient has minimal or no actual symptoms but is preoccupied with having a serious, undiagnosed, specific disease (eg, a brain tumor). This patient has multiple anxiety-related somatic symptoms that are characteristic of GAD, and her anxiety is not restricted to health concerns. (Choice E) Although this patient has multiple somatic symptoms, these are better explained as physical manifestations of GAD. Somatic symptom disorder involves excessive preoccupation with >1 unexplained somatic symptom(s) and would not explain this patient's anxiety about multiple nonsomatic issues. Educational objective: Generalized anxiety disorder is characterized by excessive, uncontrollable worry about multiple issues lasting >6 months. It commonly presents with insomnia and anxiety-related somatic symptoms. __________ References: Diagnosis and management of generalized anxiety disorder and panic disorder in adults. (http://www.ncbi.nlm.nih.gov/pubmed/25955736) Anxiety disorders in primary care. (http://www.ncbi.nlm.nih.gov/pubmed/27262005)

A 31-Year-Old Woman Comes to the Office Due to Headaches