Anxiety (GAD)

Question 1

GAD

What is GAD?

Answer 1

a disorder characterised by excessive worry and feelings of apprehension, which are generalised, free-floating, and persistent – therefore following a chronic course

Question 2

GAD

How is GAD diagnosed (ICD-10 criteria)?

Answer 2

According to the ICD-10, diagnosis can be made if at least four of the following are present for most days for at least six months:

** Symptoms of autonomic arousal**
* Palpitations
* Sweating
* Tremor
* Dry mouth
Physical symptoms
* Shortness of breath
* Choking sensation
* Chest pain
* Nausea
* Dysphagia
Mental state symptoms
* Pre-syncope
* Derealisation/depersonalisation
* Fears of losing control
* Fears of dying
* Insomnia
* Irritability
Symptoms of tension
* Muscle tension/aches
* Restlessness
* Feeling on edge
* Exaggerated startle response
Cognitive symptoms
* Difficulty concentrating
* Poor memory

Question 3

GAD

What is GAD-7 and how is it scored?

Answer 3

Screening tool - scored out of 21

5-9 mild
10-14 moderate
15+ severe.

Question 4

GAD

GAD is a diagnosis of exclusion, so what other investigations might you do to rule out physical causes?

Answer 4

• routine blood tests such as FBC, U&Es, TFTs to exclude physical illness with hyperthyroidism particularly mimicking anxiety symptoms
• Depending on the symptoms, cardiac investigations such as an ECG may be indicated, and investigations into an underlying respiratory cause if these symptoms are prominent

Question 5

GAD

What medications are used to manage?

Answer 5

1st line drug: SSRI (sertraline)
2nd line: other SSRI or SNRI (duloxetine / venlafaxine)
other: neuropathic agents (pregabalin)

Benzodiazepine drugs are not indicated for long-term use in GAD due to their addictive potential. They may be prescribed for very short courses, when a patient is in crisis, in order to provide immediate relief of symptoms

Question 6

GAD

What are some non-prescribing management options?

Answer 6

first-line management of GAD is non-pharmacological

• mild: low-intensity psychological interventions (self-help, patient education, and support groups)
• more severe: high intensity psychological interventions (CBT, relaxation therapy)

Pt education is key

Question 7

GAD

Referral to secondary care is not common, but when might you refer someone to psychiatric services?

Answer 7

• Risk of self-harm/suicide
• Significant psychiatric comorbidities (i.e. substance misuse, depression)
• Self-neglect
• Failure of response to initial measures

Specialist management may include combination drug treatments of different classes of antidepressants or augmentation with antipsychotics – but this treatment would only be started by a psychiatrist.