Generalised anxiety disorder

Question 1

GAD - dx

Answer 1

A. Excessive anxiety and worry, occurring more days than not for at least 6mo, about a number of events or activities (e.g. work or school performance)
B. Difficulty in controlling the worry
C. Associated with three or more of the following symptoms, with at least some symptoms having been present for more days than not for the past 6mo (only one item required in children:
1. Restlessness/feeling keyed up or on edge
2. Easily fatigued
3. Difficulty concentrating or mind going blank
4. Irritability
5. Muscle tension
6. Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep)
D. Clinically significant distress, or functional impairment (social, occupational or other)
E. Not due to a substance or another medical condition
F. Not better explained by another mental disorder

Question 2

GAD - other notes

Answer 2

1. Overlap between GAD and other anxiety disorders
2. Often co-exists with and may mask MDD or PDD
3. Organic factors (e.g. hyperthyroidism, caffeine intoxication, stimulant use, alcohol/drug discontinuation syndrome), or adverse effects of prescribed drugs or OTC medication must be excluded
4. Adjustment disorder must be excluded
5. In older pts who first present with anxiety symptoms, exclude depression or dementia as the primary cause

Question 3

GAD - mx

Answer 3

On the available evidence, both psychological interventions and pharmacotherapy options are of moderate efficacy

Psychological interventions (first-line therapy)

1. Information about the anxiety disorder. Education on relaxation techniques and coping skills. Stress management techniques
2. More specialised psychotherapies - esp. CBT (should be provided by experienced, trained clinician)

Pharmacotherapy (when symptoms more severe/psychological interventions do not provide sufficient benefit)
*Note: while many patients with GAD require long-term tx, a trial of reduction and cessation of medication should be attempted after the pt has been symptom free for >6mo
3. SSRIs = most effective pharmacotherapy (use citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine or setraline), or use SNRI (venlafaxine or
duloxetine)
4. Other alternatives = TCAs (not first-line bc adverse effects, e.g. imipramine), buspirone, pregabaline
5. Benzodiazepines = may be used as a short-term measure during crises, where anxiety is severe and disabling (e.g. diazepam). Tx up to 2 weeks with gradual reduction of dose to zero within 6 wks. Adverse effects = dependence, cognitive impairment, psychomotor effects (including increased falls risk in older pts). Long-term tx with BZD only when both psychological and pharmacological interventions have failed to provide significant improvement. Need specialist review