Generalised Anxiety Disorder Flashcards
What is generalised anxiety disorder (GAD?)
Generalized anxiety disorder (GAD) is a syndrome of ongoing, uncontrollable, widespread worry about many events or thoughts that the patient recognizes as excessive and inappropriate. Symptoms must be present on most days for at least 6 months duration.
What are the biological causes of GAD?
Genetic
Concordance rate greater for monozygotic than dizygotic twins. 5-fold ↑ in GAD in first degree relatives (parent, sibling, offspring) of patients with GAD.
Neurophysical
Dysfunction of autonomic nervous system, exaggerated responses in the amygdala and hippocampus. Alterations in GABA, serotonin and noradrenaline.
What are the environmental causes of GAD?
Stressful life events: history of child abuse, problems with relationships, personal illness, employment or finances.
Substance dependence or exposure to organic solvents.
How common is GAD in the general popualtion?
2-4%.
Is GAD more common in males or females?
More common in females (ratio of 2:1).
What are the predisposing risk factors for GAD?
Genetics, childhood upbringing, personality type and demands for high achievement.
Being divorced.
Living alone or as a single parent.
Low socioeconomic status.
What are the precipitating risk factors for GAD?
Stressful life events such as domestic violence, unemployment, relationship problems and personal illness (e.g. chronic pain, arthritis, COPD).
What are the perpetuating risk factors for GAD?
Continuing stressful events, marital status, living alone and ways of hinking which perpetuate anxiety (e.g. ‘What will happen if others notice that i am anxious?’)
What are the clinical features of GAD?
- Symptoms concerning chest and abdomen
- Symptoms concerning the brain and mind
- General symptoms
- Symptoms of tension
- Non-specific symptoms
Symptoms concerning chest and abdomen: difficulty breathing, feeling of choking, chest pain or discomfort, nausea, abdominal distress or pain and loose motions.
Symptoms concerning the brain and mind:feeling dizzy or light headed, fear of dying, fear of losing control and derealization and depersonalization.
General symptoms: hot flushes or cold chills, numbness or tingling and headache.
Symptoms of tension: muscle tension, aches or pains, restlessness, feeling on edge, difficulty swallowing and sensation of lump in throat.
Non-specific symptoms: being startled, concentration difficulty and mind blanks, persistent irritability and sleep problems.
What are the common features of presentation specific to GAD?
Note: WATCHERS
- Worry (excessive, uncontrollable)
- Autonomic hyperactivity (sweating, ↑ pupil size, ↑ HR)
- Tension in muscles/Tremor
- Concentration difficulty/Chronic aches
- Headache/Hyperventilation
- Energy loss
- Restlessness
- Startled easily/Sleep disturbance (difficulty getting to sleep then intermittent awakening and nightmares)
Briefly describe the ICD-10 Criteria for diagnosing GAD
A period of at least 6 months with prominent tension, worry and feelings of apprehension about everyday events and problems.
At least four of the following symptoms with at least one symptom of autonomic arousal:
- Symptoms of autonomic arousal: palpitations, sweating, shaking/tremor, dry mouth.
- Feelins dizzy or light headed; fear of dying; fear of losing control; hot flushes or cold chills; numbness or tingling; headache; muscle tension; aches or pains; restlessness; feeling on edge; difficulty swallowing; sensation of lump in throat; being startled; concentration difficulty; irritability and sleep problems.
Briefly describe the MSE for GAD
Appearance and behaviour: face looks worried with brow furrowed, restless with tremor, sweaty when you shake their hand, hyperventilating, lip biting, pallor and tense posture.
Speech: trembling and slow rate.
Mood: anxious.
Thought: repetitive worrying thoughts, thoughts may concern personal health, safety of others or excessive worry about everyday events, e.g. relationships, finances.
Perception: no hallucinations.
Cognitiong: may complain of poor memory and reduced attention/concentration.
Insight: may or may not have insight.
Note: observations may reveal a raised heart rate, respiratory rate and blood pressure.
What are the investigations for GAD?
Blood tests: FBC (for infection/anaemia), TFTs (hyperthyroidism), glucose (hypoglycaemia).
ECG: may show sinus tachycardia.
Questionnaires: GAD-2, GAD-7, Beck’s Anxiety Inventory, Hospital Anxiety and Depression Scale.
Briefly describe the biological management of GAD
The first-line drug treatment of choice is an SSRI (sertraline is recommended) which has anxiolytic effects. If this does not help an SNRI (e.g. venlafaxine or duloxetine) can be offered. If both of these are ineffective or not tolerated, pregabalin may be used.
Medication should be continued for at least a year.
Benzodiazepines should not be offered except as short-term measures during crises as they can cause dependence.
Briefly describe the psychological management of GAD
Psychoeducational groups are a low intensity form of psychological intervention. High intensity includes cognitive behavioural therapy and applied relaxation (practising techniques that lead to muscular or bodily relaxation, which can be applied in situations that trigger anxiety and worry).
Briefly describe the step care model for the manage of GAD (NICE)
Compare and contrast GAD, panic disorders and phobic anxiety
- Age of onset
- When does it occur?
- Associated behaviour
- Cognition
- Associations
