6. Generalised Anxiety Disorder

Question 1

What are the possible causes of anxiety?

Answer 1

Medical = COPD, asthma (ability to breath), MI, cancer, DM, hypo/hyperthyroidism, vit b12/folate def

Drug withdrawal = alcohol, tobacco, cannabis, benzodiazepines, opioids, caffeine, cocaine

Stressful upcoming life event

Question 2

Outline the pathophysiology of anxiety

Answer 2

Neural circuitry involving the amygdala (regulates anxiety and fear, stimulating the HPA Axis and sympathetic nervous system) and hippocampus (emotional memory along with the amygdala)

Decreased GABA (inhibitory neurotransmitter) levels in the cortex

Increased serotonin may stimulate serotonin receptors in hippocampus = neuroprotection, neurogenesis and reduction of anxiety

Question 3

Name the types of anxiety

Answer 3

Generalised anxiety disorder
- excessive symptoms for most days for 6m

Panic Disorder
- recurrent panic attacks

Phobias

• irrational + intense
• limited to certain situations
• leads to avoidance + anticipatory anxiety

Obsessive compulsive disorder

Post traumatic stress disorder

Question 4

What signs and symptoms are associated with anxiety?

Answer 4

WATCHERS

• Worry = excessive, uncontrollable
• Autonomic hyperactivity = sweating, increased pupil size, increased HR
• Tension in muscles/Tremor
• Concentration diff/Chronic aches
• Headache/Hyperventilation
• Energy loss
• Restlessness
• Startled easily/Sleep disturbance

Question 5

How is anxiety diagnosed?

Answer 5

ICD-10 criteria for GAD:

• 6m prominent tension, worry, feelings of apprehension
• At least 4 of the following Sx with at least 1 Sx of autonomic arousal (palpitations, sweating, shaking, tremor, dry mouth):
• Chest: diff breathing, chocking feeling, chest pain
• Abdo: nausea, pain, loose motions
• Neuro: dizzy, fear of dying, derealization, depersonalisation, headache
• Tension: muscles, restlessness, feeling on edge
• Non-specific: startles, conc diff, irritability, sleep probs

Question 6

How should anxiety be managed?

Answer 6

Education about anxiety and active monitoring

Lifestyle = regular exercise, prioritise sleep, relaxation, healthy eating, avoid alcohol/drugs, quit smoking/coffee, meditation

Therapy = CBT, progressive relaxation training (type of behavioural therapy), behavioural, hypnosis

Medication:

1. SSRI = sertraline
2. SNRI = duloxetine, venlafaxine, TCA amitriptyline
3. pregabalin (GABA analogue, 6w max, weight gain)

Beta-blockers - propranolol

Benzo (diazepam) - no more than 6w, potentiate GABA, therefore reduce excitability of neurones, reserved for Tx when 3 other meds not worked

Question 7

What makes up the stress response?

Answer 7

The limbic system

Limbic-hypothalamo-pit-adrenal axis

Question 8

What is the limbic system?

Answer 8

Set of structures either side of the thalamus: hippocampal formation, septal area, amygdala, prefrontal cortex, cingulate gyrus

Function = emotion, behaviour, motivation, long-term memory, olfaction

Question 9

What is GAD?

Answer 9

Ongoing, incontrollable, widespread worry (6m)

• specific content of (type 1) worries
• includes ‘worries about worries’ (type 2)
• low level physical Sx (insomnia, muscle tension, GI probs, headache)
• often maintained by belief that worry is useful

Question 10

Which patient questionnaire is used as a screening tool and severity measure for generalised anxiety disorder (GAD)?

Answer 10

GAD-7

Question 11

How should suspected anxiety be investigated?

Answer 11

Bloods: FBC (infection, anaemia), TFT (hyper), glucose (hypo)

ECG: may show sinus tachy

Questionnaires: GAD-2, GAD-7, Beck’s anxiety inventory, Hospital Anxiety and Depression Scale