Generalised anxiety disorder Flashcards
Define anxiety.
Anxiety is an unpleasant emotional state involving subjective fear, discomfort and physical symptoms.
The problem occurs when anxiety caused autonomic hyperarousal and becomes distressing impairing function
Define generalised anxiety disorder.
Excessive and uncontrolled anxiety NOT triggered by a specific stimulus
How long do symptoms need to be present to diagnose GAD?
Present for most days over 6 months (ICD-10)
What scale can be used to diagnose GAD? What score is diagnostic?
Generalise Anxiety Disorder Assessment (GAD-7) scored out of 21
- Mild = 6-10
- Moderate = 11-15
- Severe = 16-21
Questions include: over the last 2 weeks how often have you been bothered by…
- feeling nervous, anxious, on edge
- not being able to stop or control worrying
- worrying too much about different things
- trouble relaxing
- being so restless taht it is hard to sit still
- becoming easily annoyed or irritable
- feeling afraid as if something awful might happen
How common is GAD? Who is most affected?
- F>M (2:1)
- 1 yr prevalence 3-8%
- More common in 20’s
What are the phsyical symptoms of anxiety?
Autonomic hyperactivity:
Skeletal muscle
- Tremor
- Headache
- Restlessness
GI system
- Nausea
- Dry mouth
- Frequent / loose motions
Respiratory
- Tachypnoea /hyperventilation
- SOB
- Chest tightness
Cardiac
- Chest discomfort
- Palpitations
Urogenital
- Urinary frequency
- Erectile dysfunction
- Amenorrhea
What are the psychological symptoms of anxiety?
- Subjective worry
- Incrceased viligance
- Poor concentration
- Irritability
- Depersonalization / derealization
- Insomnia
List 4 organic causes of anxiety.
- Idiopathic
- Hyperthyroidism
- Heart disease
- Drugs (salbutamol, SSRIs, caffeine, steroids)
What are the risk factors for GAD?
Biological:
- Substance abuse
- Chronic painful illnesses
Psychological:
- History of physical / emotional trauma
Social:
- Low socioeconomic status
What investigations can be done in GAD?
- Rule out organic causes
- Urine drug screen
- Medications
- ECG
- TFTs
- FBC
- Rating scales (e.g. GAD-7)
What medications can cause anxiety?
- salbutamol
- theoophylline
- corticosteroids
- antidepressants
- caffeine
What are the steps to managment of GAD?
Step 1: advice + low intensity psychological interventions e.g. CBT over 4-12 weeks
- relaxation training
- meditation training
- sleep hygiene education,
- exercise
- self-help information
Step 2: high intensity psychological intervention +/- drug treatment
- 1st line: sertraline
- If taking SSRI- weekly follow up for first month in patients <30years due to increased risk of suicidal thinking and self-harm
- +/- beta-blockers e.g. propranolol to treat adrenergic symptoms (e.g. tremor and palpitations)
- 2nd line: other SSRI or SNRI
- 3rd line: pregabalin (GABA-B agonist not TCA)
- 4th line: TCA (clomipramine, imipramine)
- 5th line: buspirone (partial serotonin agonist)
Step 4: specialist assessment
NB: never give benzodiazepines in anxiety as there is a high risk of dependence.
What are the differential diagnoses for GAD?
- Depression
- Dementia
- Caffeine
- Alcohol / drugs
- Organic causes
What kind of questions do you ask in anxiety?
- Cna you tell me what you worry about?
- Is there anything specific that you are scared of? Any particular situations?
- How do you feel in your body when you are worrying?
- Do you feel your heart racing? Do your palms get sweaty? Do you sometimes find it hard to breathe?
- Do you avoid particular things/situations because of the unpleasant feeling?
- How do you cope in these situations?
What is trait anxity vs state anxiety? How does this cause anxiety illness?
Trait anxiety - individual’s potential to experience state anxiety. Usually useful.
State anxiety - the problem with this is that it
- (1) causes avoidance, so you cannot unlearn –> makes the anxiety worse.
- (2) Attentional and cognitive bias occurs –> the way you perceive the world changes.
- (3) Negative automatic thoughts is where your brain generates these constantly. This again leads to…
- (4) poor sleep. Each of the factors causes perpetuation of anxiety.
Enough trait anxiety with state anxiety can lead to mental illness of anxiety.