Psychiatry - Neurosis/Generalised Anxiety Disorder

Question 1

Generalised Anxiety Disorder?

Answer 1

• Excessive worry’ and feelings of apprehension about everyday events or problems,
• with symptoms of muscle and psychic tension, causing significant distress or functional impairment
• Symptoms present for most days for at least 6 months

Question 2

Generalised Anxiety Disorder?

DSM-5

Answer 2

DSM-5 - at least 3 / 1 in children

• Restlessness or feeling keyed up or on edge
• Easy fatiguability
• Concentration difficulties or ‘mind going blank’
• Irritability
• Muscle tension
• Sleep disturbance

Question 3

Generalised Anxiety Disorder?

ICD-10

Answer 3

ICD-10 - at least 4 plus at least 1 from ‘autonomic arousal’

• Symptoms of autonomic arousal
• ‘Physical’ symptoms e.g. breathing difficulties, choking sensation, chest pain etc
• Mental state symptoms e.g. derealisation/depersonalisation
• General symptoms e.g. hot flushes/cold chills; numbness or tingling.
• Symptoms of tension e.g. muscle tension/aches and pains, restlessness, on edge, difficulty swallowing
• Other e.g. exaggerated responses to minor surprises/being startled
• Concentration difficulties

Question 4

Generalised Anxiety Disorder?

Differential Diagnosis?

Answer 4

• Depression
• Other anxiety-like disorders

Medical conditions associated with anxiety-like symptoms
• CVS: Arrhythmias, IHD, mitral valve disease, cardiac failure
• Respiratory: Asthma, COPD, HVS, PE, hypoxia
• Neurological: TLE, vestibular nerve disease
• Endocrine: Hyperthyroidism, hypoparathyroidism, hypoglycaemia, phaeochromocytoma
• Miscellaneous: Anaemia, porphyria, SLE, carcinoid tumour, pellagra

Medications causing anxiety-like symptoms
• CVS: Antihypertensives, anti-arrhythmics
• Respiratory: Bronchodilators, α1/β-adrenergic agonists
• CNS: Anaesthetics, anticholinergics, anticonvulsants, anti-Parkinsonian agents, antidepressants, antipsychotics, withdrawal from BDZs and other sedatives
• Miscellaneous: Levothyroxine, NSAIDs, antibiotics, chemotherapy

Question 5

Generalised Anxiety Disorder?

Management?

Answer 5

Psychological

• Not so effective, some evidence for CBT

Pharmacological

• Psychic symptoms—buspirone (beneficial effects may take 2–4wks)
• Somatic symptoms—BDZs
• Depressive symptoms—ADx
• Cardiovascular symptoms or autonomic symptoms—β-blockers / pregabalin

Question 6

Generalised Anxiety Disorder?

Course?

Answer 6

• Chronic and disabling
• Prognosis generally poor
• Remission rates low (~30% after 3yrs, with treatment); 6-yr outcome—68% mild residual symptoms, 9% severe persistent impairment
• Often comorbidity becomes more significant (esp. alcohol misuse) which worsens prognosis