Generalised Anxiety Disorder (GAD) Flashcards
Definition
- At least 6 months of excessive, difficult to control worry about everyday issues, that is disproportionate to any inherent risk, and causes distress, or impairment – worry not due to mental disorder, substance abuse, other condition
- Free floating anxiety with no specific threat lasting more than 6 months
- Duration: at least 6 months
- Symptoms: at least 3 of the following, most of the time:
- Restlessness/nervousness
- Being easily fatigued
- Poor concentration
- Irritability
- Muscle tension
- Sleep disturbance
- Restlessness/nervousness
Epidemiology
- Very common, affects women around twice as much as men
Aetiology
- Genetics
- Early experiences and life events
o Childhood adversity predisposes to anxiety disorders
o Life events can trigger anxiety disorders, especially if they are threatening - Neurochemical theories
o Central neurotransmitters such as serotonin, noradrenaline, GABA are dysregulated
o These are targets for drugs that successfully combat anxiety symptoms:
-Serotonin- SSRIs
-Noradrenaline- TCAs
-GABA- benzodiazepines - Behavioural and cognitive theories
o Classical conditioning- repeated pairing of a neural stimulus with a frightening one
o Negative reinforcement-behaviours that relieve anxiety (e.g. running away) are repeated. This prevents habituation (getting used to the stimulus and calming down), so escaping from a fearful stimulus maintains the fear response.
o Cognitive theories- worrying thoughts are repeated in an automatic way which both induces and maintains the anxiety response
o Attachment theory- quality of attachment between children and their parents affects their confidence as adults (insecure attachment results in anxious adults) - Most often concerns family, health, finances, and school or work
- The symptoms are NOT a manifestation of another health condition and are NOT due to the effects of a substance or medication on the CNS
- It is NOT triggered by a specific stimulus but is instead continuous and generalised
- Risk Factors
o Females
o Aged 35-54 years
o Living alone
o Being divorced or separated
o Being a lone parent
o Family history of psychiatric disorders
o Childhood adversity:
- Maltreatment
- Parental problems with intimate partner violence, alcoholism, drug use and/or mental illness
- Exposure to overprotective or overly harsh parenting style
- Bullying or peer victimisation among youths
o Environmental stressors:
- Physical or emotional trauma
- Domestic violence
- Unemployment
- Low socioeconomic status - Protective factors: being married or cohabiting, 16-24 years
Symptoms and signs
Autonomic
- Palpitations, sweating, trembling/ tremor, dry mouth, tachypnoea
Chest/abdomen
- Difficulty breathing, choking sensation, chest pain, nausea, stomach pains/ butterflies, flatulence
Brain/mind
- Dizziness, headache (usually tension), light headedness, tinnitus, circumstantiality, derealisation/depersonalisation, fear of losing control, fear of dying/illness*
General
- Hot/cold flush/chill, numbness/tingling sensation, urinary frequency, erectile dysfunction, amenorrhoea
Tension Muscle tension/aches/pains (esp around neck and back), restlessness, feeling on edge/unable to react, lump in throat
Other Exaggerated startle response, difficulty concentrating, persistent irritability, difficulty sleeping, night terrors, motor restlessness
- Summary of Key Features:
o Defining features: free floating anxiety no specific threat >6 months
o Symptoms: look at table
o Coping mechanisms: avoidance, ETOH, drugs depression
- IMPORTANT: in primary care, GAD may present solely with physical symptoms and may not readily report worry or psychological stress
Summary of key features
Defining features: free floating anxiety no specific threat >6 months
Symptoms: look at table
Coping mechanisms: avoidance, ETOH, drugs depression
IMPORTANT: in primary care, GAD may present solely with physical symptoms and may not readily report worry or psychological stress
Investigations
ICD-10 diagnostic criteria:
- Anxiety which is generalised and persistent but not restricted to or even strongly predominating in any particular environmental circumstances
- Variable dominant symptoms including persistent nervousness, trembling, muscle tension, sweating, light-headedness, palpitations, dizziness and epigastric discomfort
- Expression of fears such as the person or a relative will shortly become ill or have an accident
GAD questionnaire (GAD-7)
- Consists of 7 questions
- Score calculated by assigning scores 0-3 to the response categories adding to 21.
- MILD= 5-9
- MODERATE= 10-14
- SEVERE= ≥ 15
Beck’s Anxiety Inventory
- Hospital Anxiety and Depressions Scale (HADS)
- Cardiorespiratory examination
- Rule out organic pathology: ECG, TFTs, LFTs, U&Es, glucose, Urine drug screen
Differentials
Hyperthyroidism - goitre, tremor, tachy, weight loss, arrhythmia
Phaeochromocytoma
Substance misuse (amphetamines / alcohol or benz withdrawal)
XS caffeine
Depression (can have mixed anxiety and depressive disorder)
Schizophrenia - may get it in early schizo
Dementia - anxiety may be an early feature of this
Management
RISK ASSESSMENT- if high risk of suicide, refer urgently (same day) to Crisis Resolution Team and Home Treatment Team
1.Treat any other comorbid disorder that is MORE SEVERE first, educate about GAD (info booklet), actively monitor
- E.g. if comorbid depression disorder or other anxiety disorder
- Ensure that any comorbid medical conditions are optimally managed
2.Without Marked Functional Impairment
2.Low Intensity Psychological Therapies
CBT-based
- Individual non-facilitated self-help - 6 wks
- Individual guided self-help - 6 wks, wkly therapist app
- Psychoeducational groups (≤12 per group) - 6 wks
Social Interventions
- Sleep hygiene- sleep and wake up at same time each day, no alcohol after 6pm, no caffeine after 3pm
- Regular exercise benefits
- Practical solutions to environmental stressors contributing e.g. physical or emotional trauma, employment or financial worries, poor living conditions or problems with interpersonal relationships
- Employment and educational services
3.Marked Functional Impairment or No Improvement
Biological Treatment (stepwise approach)
- 1st Line: SSRI- Sertraline, Paroxetine, Escitalopram
- 2nd Line: Different SSRI or SNRI (Duloxetine, Venlafaxine)
When choosing, take into account:
- Tendency of withdrawal syndrome (paroxetine, venlafaxine)
- Side effect profile and potential for drug interactions
- Risk of suicide and likelihood of toxicity in OD (venlafaxine)
- Prior experience of treatment with individual drugs
NOTE: it can take longer for SSRIs to work for anxiety than depression
IMPORTANT: in those < 30 years, review them within 1 week of starting SSRI/ SNRI, monitor risk of suicidal thinking or self-harm weekly for 1st month
3rd Line- Pregabalin can be offered if SSRIs or SNRIs are contraindicated/ not tolerated
- modulate VGCC; up to 450mg OD
4th Line - Quetiapine (unlicenced)
- ADJUNCTANT: Propranolol (physical symptoms)
- Benzodiazepines are NOT offered except as short-term measure during crises
- 2-4 weeks is the maximum accepted duration
High Intensity Psychological Therapies
- CBT - 12-15wks, 16-20hrs per wk
- Testing the predications of worry with behavioural experiments
- Looking further into errors of thinking
- Applied relaxation - 12-15wks
- If pregnant- a high intensity psychological therapy should be offered FIRST
Social Interventions
- As above
4.If any: Severe Anxiety and Marked Functional Impairment , Treatment Refractory, High Risk of Harm or Self-neglect
Refer to specialist care for:
- Complex drug treatment
- Psychological therapy
- Input from multi-agency teams, crisis services, day hospitals or inpatient care
Complications
Serious disability and impaired QoL
Impaired social and occupational functioning
Comorbidities- at increased risk of major depression, social anxiety disorder and drug misuse
Suicidal ideation and attempts
Prognosis
- Chronic condition which may fluctuate in severity
- CBT significantly reduces anxiety symptoms (it has a longer duration of effect than pharmacological therapies)
PACES
Thank you for opening up to me, I understand this can be quite difficult
- We think you are experiencing a type of anxiety disorder called generalised anxiety disorder. This means you tend to find it difficult to control worries about everyday issues.
- Anxiety is a natural response to threats around you, but people with GAD tend to feel at a greater risk to threats than they may actually be at. We have some options to help manage your perception of being at risk to these threats.
- We will take a biopsychosocial approach, which means we will be addressing the needs of your body, mind and social life:
- For your body, we would recommend regular exercise and healthy coping mechanisms, for which we can give you some information booklets. We also have medications that can help called selective serotonin reuptake inhibitors (SSRIs) – these reduce the removal of serotonin (responsible for positive mood) from your brain so more is around. However, these come with significant side-effects and can cause an initial increase in anxiety to begin with.
- For this reason, we may start with therapy for your mind. Cognitive behavioural therapy (CBT) is very effective at helping people better understand the relationships between our thoughts, feelings and behaviours so this would be our first choice. Also, anxiety management provided by a community mental health nurse is often effective.
- Socially, informing your support network of your diagnosis and the journey you’re on to feel more safe and secure will ensure they keep this in mind when interacting with you. We can also put you in touch with the appropriate community support groups to meet others with similar issues and how they’ve overcome them if you’d like.
- Understand the topic is hard to discuss and ask if they would like a break
