GAD Flashcards
What is GAD?
GAD is a syndrome of ongoing anxiety and worry about many events or thoughts that the patient generally recognises as excessive and inappropriate. The condition can be chronic and debilitating.
What is the presentation of GAD?
Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least six months, about a wide range of events or activities (such as work or school performance).
The person finds it difficult to control the worry.The anxiety and worry are associated with three or more (only one for children) of the following six symptoms, with at least some symptoms present for more days than not for the preceding six months: restlessness or feeling keyed up or on edge; being easily fatigued; difficulty concentrating or mind going blank; irritability; muscle tension; sleep disturbance.
Anxiety and worry owing to panic disorder, social phobia, obsessive-compulsive disorder and separation anxiety disorder are excluded.
How is GAD diagnosed according to ICD-10?
At least four of the symptoms below must also be present (at least one of which is from the first group):
Autonomic arousal symptoms:
-Palpitations or pounding heart.
-Accelerated heart rate.
-Sweating.
-Trembling or shaking.
-Dry mouth (not due to medication or dehydration).
Symptoms involving chest and abdomen:
- Difficulty breathing.
- Feeling of choking.
- Chest pain or discomfort.
- Nausea or abdominal distress (such as churning in stomach).
Symptoms involving mental state:
- Feeling dizzy, unsteady, faint, or light-headed.
- Feeling that objects are unreal (derealisation) or that the self is ‘not really here’ (depersonalisation).
- Feeling of losing control, ‘going crazy’, or passing out.
- Fear of dying.
General symptoms:
- Hot flushes or cold chills.
- Numbness or tingling sensations.
- Muscle tension or aches and pains.
- Restlessness and inability to relax.
- Feeling keyed up, on edge, or mentally tense.
- A sensation of a lump in the throat or difficulty in swallowing.
Other nonspecific symptoms:
-Exaggerated response to minor surprises or to being startled.
- Difficulty in concentrating or mind ‘going blank’ because of worrying or anxiety.
- Persistent irritability.
- Difficulty in getting to sleep because of worrying.
What are the differentials of GAD?
Panic disorder with PTSD OCD Phobias Social phobia Acute stress disorder Schizophrenia Dementia Anxiety and depression Alcoholism
What is the management of GAD?
NICE recommends the following approach:
Step 1: all known and suspected presentations of GAD
-Identification, assessment, education, monitoring.
Step 2: diagnosed GAD that has not improved after education and active monitoring in primary care
-Low-intensity psychological support, non-facilitated or guided self-help, psycho-educational groups.
Step 3: GAD with an inadequate response to step 2 interventions or marked functional impairment
-Cognitive behavioural therapy (CBT)/applied relaxation or drug treatment.
Step 4: complex treatment-refractory GAD and very marked functional impairment, such as self-neglect or a high risk of self-harm
-Specialist drug and/or psychological treatment, multi-agency teams, crisis intervention, outpatient or inpatient care.
There are frequently comorbid conditions - e.g., depression, substance abuse - which may need treating too. NICE recommends that the most severe condition be treated first.If treating a child or adolescent, be much more reluctant and cautious about prescribing.
Primary healthcare professionals should monitor progress. Review interval should be determined on a case-by-case basis but is likely to be every 4-8 weeks.
For patients on medication, NICE recommends a review every 2-4 weeks for the first three months and three-monthly thereafter.Medication should be continued for a minimum of one year.
A short, self-complete questionnaire should be used to monitor outcomes wherever possible.
What is the treatment when a rapid response is required in a patient with GAD?
The sedative antihistamines may be effective or the benzodiazepines. The latter should not be used beyond four weeks. Apparent dependence may be because the disease has returned as the drug is withdrawn or there may be a physical dependence.
It has been suggested that buspirone is less sedative and less addictive than benzodiazepines but it should be used with similar caution.
What is the drug treatment for GAD?
Antidepressants are often good at alleviating anxiety, even if there is no true depression. They take longer to work than benzodiazepines but they can be continued for longer.
NICE recommends a selective serotonin reuptake inhibitor (SSRI) or venlafaxine as the first choice. If one SSRI is not suitable or there is no improvement after a 12-week course and if a further medication is appropriate, another SSRI should be offered. Long-term treatment and doses at the upper end of the indicated dose range may be necessary. NICE recommends sertraline first-line but acknowledges that this is an unlicensed use. SSRIs licensed for the treatment of GAD in the UK are escitalopram and paroxetine.
What are panic attacks?
Panic attacks must be associated with >1 month’s duration of subsequent, persisting anxiety about recurrence of the attacks, the consequences of the attacks, or significant behavioural changes associated with them.
A panic attack is defined as a discrete episode of intense subjective fear, where at least four of the characteristic symptoms, listed below, arise rapidly and peak within 10 minutes of the onset of the attack:
- Attacks usually last at least 10 minutes but their duration is variable.
- The symptoms must not arise as a result of alcohol or substance misuse, medical conditions or other psychiatric disorders, in order to satisfy the diagnostic criteria.
What is a panic disorder?
Panic disorder is defined as recurrent unexpected panic attacks.
Panic disorder can also be associated with the use of certain medications: selective serotonin reuptake inhibitors (SSRIs), benzodiazepine withdrawal and withdrawal from zopiclone. These should be considered in assessing any patient who presents with panic disorder.
What is the presentation of panic disorders?
Panic disorder manifests as the sudden, spontaneous and unanticipated occurrence of panic attacks, with variable frequency, from several in a day to just a few per year:
- Palpitations, pounding heart or accelerated heart rate.
- Sweating.
- Trembling or shaking.
- Dry mouth.
- Feeling short of breath, or a sensation of smothering.
- Feeling of choking.
- Chest pain or discomfort.
- Nausea or abdominal distress.
- Feeling dizzy, unsteady, light-headed or faint.
- Derealisation or depersonalisation (feeling detached from oneself).
- Fear of losing control or ‘going crazy’.
- Fear of dying.
- Numbness or tingling sensations.
- Chills or hot flushes.
What are the signs of panic disorders?
Examination of the mental status reveals no specific findings other than a reflection of anxiety and/or urgency in their appearance, speech or mood (this is not necessary to make the diagnosis).
The patient’s affect should be congruent with their mental state. Thought processes should be normal and thought content should be essentially normal but may be preoccupied with death or illness.
Thought content should be assessed for suicidal or homicidal ideation, or thoughts of self-harm. Judgement and insight are normally preserved.
Abnormalities in thought processes or content (other than impulsive thoughts of suicide or self-harm) suggest alternative psychiatric diagnoses.
What is the classification of panic disorders?
Those that arise unexpectedly and without any obvious triggering situation or event are characteristic of panic disorder without agoraphobia.
Those that arise in a predictable way as a follow-on to a given anxiety-provoking situation or event usually reflect a specific phobia-type diagnosis, or panic disorder with social phobia if the precipitant is a social phenomenon.
Those that arise in an inconsistent or unpredictable way following exposure to a given anxiety-provoking situation or event suggest panic disorder with agoraphobia.
What are the associated diseases of panic disorder?
Agoraphobia Social phobia Mood disorders such as depression GAD CVD such as mitral valve prolapse, cardiomyopathy and HTN.
What are the differentials of GAD?
Exclude other organic conditions Agoraphobia Social anxiety disorder GAD Bipolar disorder Depression Somatisation disorder Dissociative disorders OCD PTSD Hyperthyroidism MI Phaeochromocytoma Temporal lobe epilepsy
What are the investigations done for panic disorders?
There are no specific investigations to diagnose the condition but clinicians may feel inclined to refer the patient, or carry out tests to exclude underlying physical causes for the symptoms.
Whilst it is important not to miss likely physical causes, one should not endlessly or excessively investigate these patients
After initial exclusion of top-ranking physical causes, with the confirmation of characteristic clinical features of panic disorder, the absence of a physical cause should be clearly explained to the patient.
