Generalised Anxiety Disorder Flashcards
ESSENCE
Excessive worry about everyday events causing functional impairment/disress
EPIDEMIOLOGY
Lifetime prevalence
5.7%
EPIDEMIOLOGY
Male or female greater
F>M
AETIOLOGY
General factors
- Triple vulnerability model
- Genetic
- Neurobiological
- Psychological
AETIOLOGY
Neurobiological
- ?Norepinephrine systems
- Diminished autonomic responsiveness (?down regulation of a2 receptors)
- HPA axis dysfunction (loss of regulatory control of cortisol
- Sustained activated of amygdala and stria terminalis by CRF due to stress
AETIOLOGY
Psychological
- Psychological vulnerability
- Diminished sense of control due to trauma or insecure attachment to primary caregivers
- Parenting - overprotective or lacking warmth
- Stressful life events such as trauma or dysfunctional martial/family relationship
DIAGNOSTIC CRITERIA
- At least 4 (with 1 from automatic arousal) present most days for at least 6 months
- Symptoms autonomic arousal
- Physical symptoms
- Mental state symptoms
- General symptoms
- Symptoms of tension
- Exaggerated responses to minor surprises
- Concentration difficulties, irritability of difficulty getting to sleep due to worrying
DIAGNOSTIC CRITERIA
Examples of autonomic arousal
- Palpitations
- Tachycardia
- Sweating
- Trembling
- Dry mouth
DIAGNOSTIC CRITERIA
Examples of physical symptoms
- Breathing difficulties
- Choking sensation
- Chest pain/discomfort
- Nausea/abdominal distress
DIAGNOSTIC CRITERIA
Mental state symptoms
- Feeling dizzy, unsteady, light headed or faint
- Derealisation/depersonalisation
- Fear of losing control
- ‘Going crazy’
- Passing out
- Dying
DIAGNOSTIC CRITERIA
General symptoms
- Hot flushes/cold chills
- Numbness or tingling
DIAGNOSTIC CRITERIA
Symptoms of tension
- Muscle tension/aches and pain
- Restlessness/inability to relax
- Feeling on edge or mentally tense
- Sensation of lump in throat or difficulty swallowing
DIFFERENTIAL DIAGNOSIS
- Normal worries
- Depression
- Mixed anxiety/depression
- Other anxiety disorders
- Drug and alcohol problems
- Side effects of medication
- Medical conditions
DIFFERENTIAL DIAGNOSIS
Medical conditions
- CVS
- Arrhythmias, IHD, mitral valve disease, cardiac failure
- Resp
- Asthma, COPD, HVS, PE, hypoxia
- Neuro
- TLE, vestibular nerve disease
- Endocrine
- Hyperthyroidism, hypoparathyroidism, hypoglycaemia, phaeochromocytoma
- Misc
- Anaemia, SLE, carcinoid tumour
DIFFERENTIAL DIAGNOSIS
Medication side effects
- CVS
- Antihypertensives, anti-arrhythmics
- Resp
- Bronchodilators, a/B-adrenergic agonists
- CNS
- Anticholinergics, anticonvulsants, anti Parkinsonian agents, antidepressants, antipsychotics, withdrawl from benzodiazepams
- Misc
- Levothyroxine, NSAIDs, antibiotics, chemotherapy
MANAGEMENT
General strategy
- Psychological
- CBT combining behavioural methods and cognitive methods
- Pharmacological - directed towards symptoms
- Psychic symptoms - buspirone
- Somatic symptoms - BDZs (lorazepam, diazepam)
- Depressive symptoms - Trazodone, SNRIs, SSRIs
MANAGEMENT
Guidelines
- 1) CBT or SSRI/SNRI/atypical antidepressant
- 2) TCA or antipsychotic or benzodiazepine
- 3) Switch to alternative or combination therapy
- Adjuct
- Applied relaxation, mindfullness, attention/perception modification/sleep hygiene education, exercise, self help
PROGNOSIS
Remission rate at 3 and 6 years
3 years - 30%
6 years - 68%
PROGNOSIS
% with severe persistent impairment
9%
MANAGEMENT
SSRIs licensed
- Escitalopram
- Paroxetine
MANAGEMENT
SNRIs licensed
- Duloxetine
- Venlafaxine
