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What is the definition of GAD (Generalised anxiety disorder)
Generalized anxiety disorder (GAD) is a syndrome of ongoing, uncontrollable, widespread worry
about many events or thoughts that the patient recognizes as excessive and inappropriate.
Symptoms must be present on most days for at least 6 months duration
Biological aetiology of GAD
Genetic: Concordance rate greater for monozygotic twins, 5 times more likely if GAD in 1st degree relatives of GAD patients
Neurophysiological: Dysfunction of autonomic NS, exaggerated responses in amygdala and hippocampus, GABA alterations, serotonin and noradrenaline
Epidemiology of GAD
GAD has a prevalence of 2–4% in the general population.
It is more common in ♀ at a ratio of 2:1.
Environmental aetiology of GAD
Stressful life events: child abuse, relationships, illness, employment or finances
Substance dependence or exposure to organic solvents
RFs for GAD
Predisposing: Genetics, childhood upbringing, personality type and demands for high
achievement. Being divorced. Living alone or as a single parent. Low
socioeconomic status.
Precipitating: Stressful life events such as domestic violence, unemployment, relationship
problems and personal illness (e.g. chronic pain, arthritis, COPD).
Maintaining: Continuing stressful events, marital status, living alone and ways of thinking
which perpetuate anxiety (e.g. ‘What will happen if others notice that I am
anxious?’).
Symptoms of GAD
Breathing difficulty
Choking feeling
Nausea
Dizzy
Fear of dying
Derealisation and depersonalisation
Hot flushes
Numbness
Headaches
Muscle tension
Restlessness
Feeling on edge
Sleep problems
Irratibility
Common features of presentation specific GAD (WATCHERS)
Worry (excessive, uncontrollable)
Autonomic hyperactivity (sweating,
↑ pupil size, ↑ HR)
Tension in muscles/Tremor
Concentration difficulty/Chronic aches
Headache/Hyperventilation
Energy loss
Restlessness
Startled easily/Sleep disturbance (difficulty getting to sleep then intermittent awakening and
nightmares).
ICD-10 criteria for GAD
A. A period of at least 6 months with prominent tension, worry and feelings of apprehension
about everyday events and problems.
B. At least four of the following symptoms with at least one symptom of autonomic arousal:
Symptoms of autonomic arousal: palpitations, sweating, shaking/tremor, dry mouth.
History of GAD?
‘Talk me through a normal day in your life.’ (open question to identify anxiety)
‘Do you ever feel worried with your current state of affairs?’, ‘Do you worry excessively
about minor things on most days of the week?’, ‘Would you say you are an anxious
person?’, ‘Recently, have you been feeling anxious or on edge?’ (generalized worry)
‘Have you noticed any problems with your memory or concentration?’ (↓
concentration)
‘Do you ever lie awake at night worrying, or intermittently wake from sleep?’, ‘Do you
ever have unpleasant dreams or nightmares?’ (sleep disturbance)
Ask about somatic symptoms, e.g. ‘Do you ever feel the sensation of your heart
beating abnormally fast or pounding on your chest?
MSE for GAD
Appearance
and
behaviour
Face looks worried with brow furrowed. Restless with tremor. Sweaty when
you shake their hand. Hyperventilating. Lip biting. Pallor. Tense posture.
Speech Trembling. Slow rate.
Mood Anxious.
Thought Repetitive worrying thoughts. Thoughts may concern personal health,
safety of others or excessive worry about everyday events, e.g.
relationships, finances.
Perception No hallucinations.
Cognition May complain of poor memory and reduced attention/concentration.
Insight May or may not have insight.
Investigation for GAD
Blood tests: FBC (for infection/anaemia), TFTs (hyperthyroidism), glucose
(hypoglycaemia).
ECG: may show sinus tachycardia.
Questionnaires: GAD-2, GAD-7, Beck’s Anxiety Inventory, Hospital Anxiety and
Depression Scale.
DDs for GAD
panic
disorder, specific
phobias, OCD, PTSD.
Depression.
Schizophrenia.
Personality disorder
(e.g. anxious PD,
dependent PD).
Excessive caffeine or alcohol consumption.
Withdrawal from drugs.
Organic: anaemia, hyperthyroidism,
phaeochromocytoma, hypoglycaemia
Biological treatment for GAD
first-line drug treatment of choice is an SSRI (sertraline is recommended)
which has anxiolytic effects. If this does not help an SNRI (e.g. venlafaxine or duloxetine)
can be offered. If both of these are ineffective or not tolerated, pregabalin may be used.
Medication should be continued for at least a year. Benzodiazepines should not be offered
except as short-term measures during crises as they can cause dependence
Psychological management for GAD
Psychoeducational groups are a low intensity form of psychological
intervention. High intensity includes cognitive behavioural therapy and applied relaxation
Social management for GAD
: Include self-help methods (such as writing down worrying thoughts and analysing
them objectively) and support groups. Exercise should be encouraged and may benefit.
NICE stepped care model for interventions with GAD
Step 1: Identification and assessment - Psychoeducation about GAD and active monitoring
Step 2: Low intensity psychological interventions (self help, psychoeducational group-based therapy)
Step 3: High intensity psychological interventions (CBT or applied relaxation)
Step 4: Highly specialist input eg Multi-agency teams, combination of drug and psychological therapies, crisis team
What is the definition of a phobia?
is an intense, irrational fear of an object, situation, place or person that is recognized as
excessive (out of proportion to the threat) or unreasonable.
What is the definition of agoraphobia?
Agoraphobia literally means a ‘fear of the marketplace’. It is a fear of public
spaces or fear of entering a public space from which immediate escape would be difficult in the
event of a panic attack.
What is the definition of a social phobia (social anxiety disorder)
A fear of social situations which may lead to humiliation,
criticism or embarrassment.
What is the definition of specific (isolated) phobia:
A fear restricted to a specific object or situation (excluding
agoraphobia and social phobia).
Aetiology of phobias
Agoraphobia Maintained by avoidance which prevents deconditioning and sets up a vicious
cycle of anxiety.
Social phobia
Uncertain aetiology. Usually begins in late adolescence, an age at which people
are concerned about the impression they make on others.
Specific phobia
Conditioning event in early life, i.e. a frightening experience. Possibly a role for
learned behaviour, e.g. from parents
Epidemiology of phobic anxiety disorders
Agoraphobia - 25-30 years, 2:1 male to female ration
Social phobia - Adolescence - 1:1
Specific phobia - Childhood but can develop later in life- 1:1
RFs for phobia’s
Aversive experiences (prior experiences with specific objects or situations)
Stress and negative life events
Other anxiety disorders
Mood disorders
Substance misuse disorders
Family history
What are the biological clinical features of phobias?
Tachycardia is the usual autonomic response, however in phobias of blood, injection
and injury, a vasovagal response (bradycardia) is produced, commonly leading to fainting
(syncope)
What are the psychological clinical features of phobias?
Include unpleasant anticipatory anxiety, inability to relax, urge to avoid the feared
situation and, at extremes, a fear of dying
What is agoraphobia strongly linked to?
panic disorder. Indeed the ICD-10 divides agoraphobia into:
agoraphobia with panic disorder and agoraphobia without panic disorder.
ICD-10 criteria for agoraphobia
A. Marked and consistently manifest
fear in, or avoidance of, at least
two of the following:
1. Crowds
2. Public spaces
3. Travelling alone
4. Travelling away from home
B. Symptoms of anxiety in the feared
situation with at least two
symptoms present together (and
at least one symptom of
autonomic arousal).
C. Significant emotional distress due
to the avoidance, or anxiety
symptoms. Recognized as
excessive or unreasonable.
D. Symptoms restricted to (or
predominate in) feared situation.
ICD-10 criteria for social phobia
A. Marked fear (or marked
avoidance) of being the
focus of attention, or fear
of acting in a way that will
be embarrassing or
humiliating.
B. At least two symptoms of
anxiety in the feared
situation plus one of the
following:
1. Blushing
2. Fear of vomiting
3. Urgency or fear of
micturition/defecation
C. Significant emotional
distress due to the
avoidance or anxiety
symptoms.
D. Recognized as excessive
or unreasonable.
E. Symptoms restricted to
(or predominate in) feared
situation.
ICD-10 criteria for a specific phobia
A. Marked fear (or
avoidance) of a
specific object or
situation that is not
agoraphobia or
social phobia
B. Symptoms of
anxiety in the
feared situation.
C. Significant
emotional distress
due to the
avoidance or
anxiety symptoms.
Recognized as
excessive or
unreasonable.
D. Symptoms
restricted to the
feared situation.
History questions asked to patients with phobias?
‘What situations cause you anxiety or embarrassment?’ (specific phobia)
‘Do you get symptoms in situations from which escape would be difficult?’, ‘Do you get
symptoms in places or situations where help may not be available?’, ‘Do you get
symptoms while being in a crowd or travelling on public transport?’ (agoraphobia)
‘Do you ever worry about what people think of you? Does this worry ever lead to you
avoiding certain situations?’ (social phobia)
‘Do you avoid any situation because you know you will feel panicky?’ (anticipatory
anxiety)
What are the features that distinguish phobic anxiety disorders to GAD? (SS, AA, AA)
- Anxiety occurs in Specific Situations:
Agoraphobia – Public transport, supermarkets (especially waiting in queues), cinemas,
empty streets.
Social phobia – Social gatherings, parties, public speaking, meetings, classrooms, eating
in public. - There is Anticipatory Anxiety when there is a prospect of encountering the feared situation.
- There is Attempted Avoidance of circumstances that precipitate anxiety.
How would an MSE look for phobias?
ppearance &
Behaviour
Restless and wanting to escape. Pale, sweaty, hyperventilating. May
lose consciousness (blood or injection phobia).
Speech May be trembling or they may become speechless.
Mood Anxious.
Thought Unpleasant feelings towards threat. Fear of situation. Desire to escape.
Fear of dying.
Insight Poor when feared stimulus present. Good when separated from
stimulus.
Investigations for phobias
As symptoms occur in a defined situation, diagnosis is usually straightforward with minimal
need for investigations. Questionnaires include the Social Phobia Inventory and Liebowitz
Social Anxiety Scale.
DDs for phobias
Psychiatric: Panic disorder, PTSD, anxious personality disorder, somatoform
disorders, adjustment disorder, depression, schizophrenia (may avoid socializing
because of paranoid delusions).
What are some general points in managing patients with phobias?
Try to establish a good rapport with the patient. Remember, particularly with social phobia, it
may have been very challenging for the patient to attend the appointment.
Advise avoidance of anxiety-inducing substances, e.g. caffeine.
Screen for significant co-morbidities such as substance misuse and personality disorders.
Refer to a specialist if there is a risk of self-harm, suicide, self-neglect or significant co-morbidity
Management for agoraphobia
CBT is the psychological intervention of choice. The behavioural component
includes graduated exposure and desensitization. Graduated exposure
techniques such as walking increased distances from home day by day, can
be used.
SSRIs are the first-line pharmacological agent.
