Generalised Anxiety Disorder (neurotic disorders)

Question 1

Who does GAD affect?

Answer 1

-Current prevalence = 2-3%
-Lifetime prevalence = 5%
-More common in women
-More prevalent in elderly than previously thought
-Differences in cultural groups though this may be attributed to different presentations

Question 2

What causes GAD?

Answer 2

-Ongoing anxiety and worry
-Not necessarily specific to any environment or circumstance
-Prominent tension and feelings of apprehension about everyday events
ICD-10 diagnostic criteria:
-Excessive and uncontrollable anxiety and worry occurring most days for at least 6 months

Question 3

What risk factors are there for GAD?

Answer 3

-Living alone / as a lone parent
-Being aged 35-55
-Being divorced

Question 4

How does GAD present?

Answer 4

3+ of the following symptoms:
-Restlessness / feeling on edge
-Being easily fatigued
-Difficulty concentrating / mind going blank
-Irritability
-Muscle tension
-Sleep disturbance
4+ of the following physical symptoms:
-CV: palpitations, increased HR, sweating, tremor, dry mouth
-Chest/abdo: difficulty breathing, feeling of choking, chest pain, nausea
-Neuro / psycho: feeling dizzy or faint, derealisation, depersonalisation, fear of dying
-General: hot flushes/ chills, numbness / tingling, muscle tension, aches / pains, lump in the throat

Question 5

What are the differential diagnoses for GAD?

Answer 5

-Panic disorder
-PTSD
-OCD
-Phobias
-Social anxiety disorder (social phobia)
-Acute stress disorder

Question 6

How would you investigate a patient with GAD?

Answer 6

-Exclude other mental illness eg schizophrenia, dementia, depression, alcoholism
-TFTs, U+Es, FBC, BG to exclude organic cause eg thyrotoxicosis, pheochromocytoma, hypoglycaemia
-Screening tools eg Beck’s, Hamilton anxiety scale, HADS

Question 7

What treatment would you consider for someone with GAD?

Answer 7

NB Best results are from psychotherapy followed by medication followed by self-help
-Step 1: identification, assessment, education, monitoring
-Step 2: Low-intensity psychological support eg self-help, psychodeducational groups
-Step 3: CBT / applied relaxation, or drug treatment
-Specialist psychological and drug treatment, crisis intervention

Question 8

What pharmacological therapy would you consider?

Answer 8

-1st line = SSRIs or venlafaxine as recommended by NICE
-Escitalopram and paroxetine are licensed, sertraline is un-licensed but recommended
-Review every 2-4 weeks for first 3 months, then every 3 months
-Beta-blockers and MAOIs are only recommended for control of tremors / palpitations

Question 9

What psychological therapy would you consider?

Answer 9

-CBT is the technique of choice
-16-20 weeks
-Active - patients required to do ‘homework’
1. Define problem
2. Set goals
3. Develop a formulation
4. Monitor eg diary, experiments
5. Help learn