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There may be no future for generalized anxiety disorder if the profession cannot agree on what is generalized anxiety disorder. We can no longer afford to have too discrepant views on generalized anxiety disorder and have one ''version'' of generalized anxiety disorder for use by clinical psychologists and the other for use by psychiatrists. It is an embarrassing paradox that generalized anxiety disorder is apparently one of the most common psychiatric disorders in the general population, while being recognized relatively infrequently and diagnosed rarely without the presence of other psychopathology. This can only mean that the current diagnostic concept of generalized anxiety disorder is seriously flawed.

If generalized anxiety disorder continues to be conceptualized as a constellation of more or less nonspecific features, its perception as a somewhat artificial construct will not change and it will not be taken seriously. If generalized anxiety disorder exists, at the very minimum it should be clearly defined, so that it can be recognized. And recognizing generalized anxiety disorder will be possible insofar as its specific characteristics are emphasized in the conceptualization. At the same time, it is important to promote longitudinal diagnostic assessment, which would treat generalized anxiety disorder and related disorders as cross-sectional ''snapshots,'' while recording changes in clinical presentation and psychopathology over time.

Once we have an unambiguous, research- and consensus-derived description of generalized anxiety disorder, it will be possible to gradually address some of the most salient issues. These include the relationship between pathological worry and generalized anxiety disorder, types of chronic anxiety, and links between generalized anxiety disorder, depression, personality disturbance, and other anxiety disorders. It is likely that generalized anxiety disorder will be classified along with depression and outside of the group of anxiety (or fear) disorders. This, however, would not necessarily mean that generalized anxiety disorder is equated with depression. Our currently fragmented understanding of the pathogenesis of generalized anxiety disorder will improve through a greater dialogue between researchers of neurobiological and cognitive mechanisms that lead to generalized anxiety disorder.

We cannot be satisfied with treatment results in generalized anxiety disorder using our currently available pharmacological and psychological interventions. There is a need for developing new pharmacological agents for generalized anxiety disorder because the effectiveness of current medications for generalized anxiety disorder seems to have reached a plateau. Novel targets for pharmacological treatment of anxiety may include certain neuropeptides, especially corticotropin-releasing factor receptors antagonists.

In addition to being effective and generally well tolerated, novel medications for generalized anxiety disorder would specifically need to be able to target both somatic and cognitive anxiety symptoms, as well as symptoms of depression; other requirements for these medications are to work quickly, not to be habit-forming, and not to be associated with significant withdrawal symptoms upon discontinuation. The challenge for psychological treatment of generalized anxiety disorder will be to make the most use of the worry- and tension-targeted approaches, focus on further identification of the most effective ingredients of cognitive and behavioral treatments packages, and better address the underlying personality issues, while also developing novel strategies.

References:

1. Ninan PT, Koran LM, Kiev A, et al. 2006. High-dose sertraline strategy for nonresponders to acute treatment for obsessive-compulsive disorder: A multicenter double-blind trial. Journal of Clinical Psychiatry, 67: 15--2.Pfefferbaum B, Pfefferbaum RL, North CS, et al. 2002. Does television viewing satisfy criteria for exposure to posttraumatic stress disorder? Psychiatry, 65: 306--309.

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