Generalised anxiety disorder

Question 1

Define anxiety.

Answer 1

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

Question 2

Define generalised anxiety disorder.

Answer 2

Excessive and uncontrolled anxiety NOT triggered by a specific stimulus

Question 3

How long do symptoms need to be present to diagnose GAD?

Answer 3

Present for most days over 6 months (ICD-10)

Question 4

What scale can be used to diagnose GAD? What score is diagnostic?

Answer 4

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…

1. feeling nervous, anxious, on edge
2. not being able to stop or control worrying
3. worrying too much about different things
4. trouble relaxing
5. being so restless taht it is hard to sit still
6. becoming easily annoyed or irritable
7. feeling afraid as if something awful might happen

Question 5

How common is GAD? Who is most affected?

Answer 5

• F>M (2:1)
• 1 yr prevalence 3-8%
• More common in 20’s

Question 6

What are the phsyical symptoms of anxiety?

Answer 6

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

Question 7

What are the psychological symptoms of anxiety?

Answer 7

• Subjective worry
• Incrceased viligance
• Poor concentration
• Irritability
• Depersonalization / derealization
• Insomnia

Question 8

List 4 organic causes of anxiety.

Answer 8

• Idiopathic
• Hyperthyroidism
• Heart disease
• Drugs (salbutamol, SSRIs, caffeine, steroids)

Question 9

What are the risk factors for GAD?

Answer 9

Biological:​

• Substance abuse
• Chronic painful illnesses

Psychological:

• History of physical / emotional trauma

Social:

• Low socioeconomic status

Question 10

What investigations can be done in GAD?

Answer 10

• Rule out organic causes
  
  • Urine drug screen
  • Medications
  • ECG
  • TFTs
  • FBC
• Rating scales (e.g. GAD-7)

Question 11

What medications can cause anxiety?

Answer 11

• salbutamol
• theoophylline
• corticosteroids
• antidepressants
• caffeine

Question 12

What are the steps to managment of GAD?

Answer 12

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.

Question 13

What are the differential diagnoses for GAD?

Answer 13

• Depression
• Dementia
• Caffeine
• Alcohol / drugs
• Organic causes

Question 14

What kind of questions do you ask in anxiety?

Answer 14

• 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?

Question 15

What is trait anxity vs state anxiety? How does this cause anxiety illness?

Answer 15

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.