GP - Anxiety

Question 1

What is Generalised Anxiety Disorder (GAD)?

Answer 1

GAD is a syndrome of ongoing anxiety and worry about everyday issues that the patient generally recognises as excessive, uncontrollable, and inappropriate (disproportionate to inherent risk)

Question 2

What conditions are associated with anxiety?

Answer 2

GAD may co-exist with depression, panic disorder, OCD … etc

Question 3

What is the pathophysiology of GAD?

Answer 3

Not understood but it’s to do with a lack of serotonin in the brain

Question 4

Give 5 risk factors for GAD

Answer 4

Female (2/3rd cases)

FHx of psychiatric disorders

Childhood adversity e.g. physical/ sexual abuse, bullying among youths, parenteral problems (alcoholism, drug use), exposure to an overprotective or overly harsh parenting style

Environmental stressors e.g. domestic violence or unemployment

Chronic physical problem e.g. arthritis, cancer, CVD, COPD, diabetes

Question 5

What are the diagnostic criteria used to diagnose GAD?

Answer 5

DSM-V (used by GP)

ICD-10 (used by GP/ psychiatrist)

Question 6

What is the DSM-V diagnostic criterion for diagnosing GAD?

Answer 6

• At least 6 months of excessive, difficult to control anxiety or worry that is disproportional to any inherent risk, causing significant distress and impairment in social, occupational and other areas of functioning
• The worry is NOT confined by features of another mental disorder (e.g. panic disorder, social phobia, OCD, PTSD), or as a result of medication/ substance abuse or a general physical condition
• At least 3 of the following core symptoms: (RIP My Female Sexual friend)
  
  • Restlessness/ nervousness - patients are described as feeling’ on edge’
  • Irritability
  • Poor concentration
  • Muscle tension
  • Fatigue
  • Sleep disturbance

DSM-V and ICD-10 broadly overlap but here are some symptoms mentioned in ICD-10 that are not present in DSM-V:

Sweating, palpitations, lightheadedness, trembling, epigastric discomfort, and expression of fears as if something awful might happen (e.g. the person or a relative will shortly become ill)

Question 7

What medications will cause anxiety as a side effect?

Answer 7

Salbutamol

Caffeine

Alcohol

Cocaine

Levothyroxine

Corticosteroids (predisolone)

Stimulants e.g. adderall, concerta (long-acting), ritalin (short-acting)

Adderall (amphetamine/ dextroamphetamine), Concerta and ritalin (methylphenidate)

Question 8

What examinations would you do?

Answer 8

Check pulse rate and BP - high

Cardiovascular examination

Respiratory examination

Thyroid examination for hyperthyroidism

Question 9

What tool would you use to assess the severity of GAD?

Answer 9

GAD-7

Scores of 5, 10, and 15 are taken as cut-off points for mild, moderate and severe anxiety respectively

Question 10

When would you assess risk of suicide in a patient with GAD?

Answer 10

If at presentation the patient is showing signs of significant functional impairment, severe depression, and/or ‘severe anxiety’ as indicated in their GAD-7 score –> ASSESS RISK OF SUICIDE

Question 11

What are the differential diagnoses?

Answer 11

Panic disorder

Social phobia

Situational anxiety

OCD

PTSD

Depression

Hyperthyroidism

Phaeochromocytoma

Question 12

What investigations would you do in primary care for GAD?

Answer 12

Tests to rule out physical causes!

• Blood tests - FBC, U&Es (including a urine drug screen), LFTs, TFTs, 24 hrs urine metanephrines
• ECG - MI, arrhythmias
• Lung function tests for asthma and COPD

Question 13

How do you manage a patient with GAD?

Answer 13

Step 1 - For all people with GAD:

• Education about GAD + active monitoring

Step 2 - For people without marked functional impairment who have not improved following step 1 interventions

• Low intensity psychological interventions (individual non-facilitated self help, individual guided self help, psychoeducational groups)

Step 3 - For people with marked functional impairment or those that have not improved following step 2 interventions

• High intensity psychological interventions (CBT) OR drug treatment
  
  • 1st line - SSRI (paroxetine as it’s the least stimulating)
    
    • 2nd line - another SSRI (e.g. sertraline)/ SNRI (duloxetine, venlafaxine)
      
      • If cannot tolerate SSRI/ SNRI, give pregabalin
    • Advise the person about the increased risk of suicidal ideation when taking sertraline, so weekly follow-up is needed for the first month
  • DO NOT OFFER ANTIPSYCHOTIC!
• If a pregnant woman with GAD requires step 3 management, offer high-intensity psychological intervention first! Treatment with SSRI/ SNRI after 20 weeks of gestation may increase the risk of persistent pulmonary hypertension of the newborn or neonatal withdrawal

Step 4 - For severe anxiety and marked functional impairment, or those that have not improved following step 3 interventions, or those at risk of self harm, self-neglect, suicide, and substance abuse

• High specialist input e.g. Multi agency teams, specialist drug

Question 14

Give 3 complications of GAD

Answer 14

MI

Depression

Substance misuse

Question 15

What advice do you give to the patient with GAD?

Answer 15

Advise that GAD and depression may coexist, so be vigilant if there are worsening GAD symptoms or new onset of depression symptoms

Advice on side effects of SSRI, particularly on the risk of suicidal ideation

Advise the person about the importance of attending CBT sessions