Generalised anxiety disorder Flashcards
Define generalised anxiety disorder
excessive worry about every day issues that is disproportionate to any inherent risk for AT LEAST 6 months, causing significant distress of impairment in functioning. At least 3 of the following:
- Restlessness or nervousness
- Easily fatigued
- Poor concentration
- Irritability
- Muscle tension
- Sleep disturbance
What are the risk factors for generalised anxiety disorder
Female (2x)
35-54yo
Divorced or separated
Living alone, lone parent
Comorbid anxiety disorder e.g. panic, social phobia
FMHx anxiety disorder, depression, psychiatric disorder
Childhood adversity e.g. maltreatment, neglect, DV, bullying
Substance dependence
Chronic physical conditions
What is the epidemiology fo generalised anxiety disorder
More common in high income countries
Anxiety disorders are the most common psychiatric disorders
What are the symptoms of generalised anxiety disorder
Anxiety: chronic, excessive worry, NOT related to particular circumstances
Physiological arousal: restlessness, insomnia, muscle tension
Fear of dying/illness
Physical symptoms:
- Autonomic: palpitations, sweating, trembling/tremor, dry mouth, tachypnoea
- Chest/abdomen: dyspnoea, choking, chest pain, nausea, stomach pain
- Head: dizziness, headache, light headedness, derealisation/depersonalisation
General: hot/cold flush, numbness/tingling, erectile dysfunction, amenorrhoea
Other: difficulty concentrating, exaggerated startled response, difficulty sleeping
What is the ICD-10 criteria for generalised anxiety disorder
Anxiety which is generalised and persistent but not restricted to or even strongly predominating in any particular environmental circumstances
Variable dominant symptoms including persistent nervousness, trembling, muscle tension, sweating, light-headedness, palpitations, dizziness and epigastric discomfort
Expression of fears such as the person or a relative will shortly become ill or have an accident
What are the differentials for generalised anxiety disorder
Organic: hyperthyroidism, phaeochromocytoma, cardiac disease, IBS, substance use
Non-organic: situational anxiety, adjustment disorder, panic disorder, social phobia, OCD, PTSD
What investigations should be done for generalised anxiety disorder
Clinical diagnosis
1. Consider using questionnaires:
- Generalised anxiety disorder assessment (GAD-2 or GAD-7): >5 (mild), >10 (mod), >15 (severe)
- Becks anxiety inventory
- Hospital anxiety and depressions scale (HADS)
2. Risk assessment
3. Exclude organic causes:
- Cardio/resp exam
- ECG, urine tox, 24-h VMA screen
- TFTs, LFTs, U&Es, glucose
What is the management for a patient with generalised anxiety disorder presenting with high risk of suicide
Same day (urgent) referral to crisis resolution team and home treatment team
What is the management for generalised anxiety disorder
- Educate about GAD + active monitoring
- (no improvement) Low intensity psychological intervention
- High intensity psychological intervention OR drug treatment
+ social management: sleep hygiene, regular exercise, practical solutions to environmental stressors, employment and education services
+ monitoring
What does patient education about generalised anxiety disorder and active monitoring involve
Communicate the diagnosis and help them to understand their disorder
Provide information and resources on GAD and treatment options (NICE, NHS website)
Advise on sleep hygiene and regular exercise
Arrange active monitoring of the symptoms and functioning at intervals based on clinical judgement
Follow up in 4-6 weeks
What low-intensity psychological interventions are available for generalised anxiety disorder
Individual non-facilitated self help: written/electronic materials for 6 weeks, may involve short telephone call
Individual guided self-help: written/electronic materials supported by a practitioner, 5-7 weekly f2f fortnightly sessions
Psychoeducation groups: trained practitioner, 1 therapist:12 participants, 6 weekly 2 hour sessions
What high intensity psychological intervention is available for generalised anxiety disorder
CBT-based OR applied relaxation
CBT or applied relaxation
- 12-15 weekly sessions, each lasting 1 hour
- Response is usually not immediate and a prolonged course is usually required to maintain the response
- Offered first if pregnant
What is medication can be used for generalised anxiety disorder
- SSRIs e.g. sertraline, paroxetine, escitalopram
- SNRI e.g. duloxetine, venlafaxine
- Pregabalin
- Quetipiane (unlicensed)
± propranolol for physical symptoms
→ Review effectiveness and adverse effects of the drug every 2-4 weeks during the first 3 months of treatment and every 3 months thereafter
→ <30yo should have a follow up within the first week of starting
→ If a drug is effective, advise the person to continue taking it for at least a year to reduce the risk of relapse.
What is the management for complex, treatment-refractory GAD and very marked functional impairment
Highly specialist input
Offer referral for specialist assessment
Advise carers about right to carer assessment
What are the complications of generalised anxiety disorder
Distress, substantial disability and impaired QOL
Impaired social and occupational functioning
Co-morbid: depression (>50%), substance misuse, anxiety disorder, chronic health problems
Suicidal ideation and attempts
Increased healthcare resource use
