Generalised Anxiety disorder (GAD)

Background

  • Excessive worry- generalised free-floating, persistent anxiety over everyday events, present for most days for several months
  • Most common anxiety disorder (annual prevalence 3-8%; up to 25% of the population will suffer at some point; may be underdiagnosed)
  • Most present in early adulthood to their GP with somatic features (it is important to delve into the cause). Most common in patients aged 35-55.
  • More common in women (2:1)
  • between 50%-90% have another mental disorder (commonly substance abuse or in conjunction with a depressive episode).
  • More prevalent in patients with comorbidity (e.g. stroke, PD, COPD).

Aetiology

  • Genetic heritability ~30%.
  • Chronic stressing factors
    • e.g. domestic violence, unemployment, separation, poverty
  • Past stressors e.g. history of violence/abuse
  • Substance abuse
  • Chronic physical illness

Presentation

  • Often patients will not necessarily present with diagnostic features (below) but may complain of features like
    • Restlessness; fatigue; irritability; muscle tension and chronic headache; poor concentration; sleep disturbance; palpitations
  • Excessive anxiety and worry (apprehensive expectation) occuring more days than not, for at least 6 months, about a number of activities/events.
    • The worry is difficult to control and is NOT a feature of another disorder e.g. OCD/anxious depression OR secondary to substance misuse.
    • It causes clinical distress and functional impairment and is associated with 3 or more of:
      • Restlessness/ on edge
      • Easily fatigued
      • Concentration problems/ mind blanks
      • irritability
      • muscle tension
      • sleep disturbance
      • Might have other features e.g. tremors, sweating, hand-wringing, catastrophic thinking, etc.
  • ASK ABOUT RISK OF SUICIDE; also alcohol, drug and caffeine use
  • Ask about other psychiatric conditions and medications
  • On examination, it is important to exclude other physical causes e.g. asthma, arrhythmia, thyroid disease etc.  Appropriate investigations should be made too (e.g. ECG, TFT, FBC, rule out substance abuse).

Assessment

  • GAD-7 is the recommended test
  • Others include Hospital Anxiety and Depression Scale (HADS); Becks Inventory; FEAR; short anxiety screening test (SAST)

Management

  • In patients with GAD- active monitoring and advice may all that is required and should be offered first line
    • If this does not improve symptoms, or if there is significant impairment of function, offer low-intensity psychotherapy e.g. Self-help CBT/Group based therapy
      • This can be helpful but is often less effective than in other anxiety disorders e.g. phobias
    • Pharmacological treatment should be reserved for severe cases with marked functional impairment or in whom other treatments have failed
      • SSRIs (sertraline is often first line, followed by escitalopram and paroxetine), the SNRIs (venlafaxine and duloxetine- both second line) and pregabalin (occasionally used third line), are useful in anxiety.
        • Trial for 2 months before assessing response
      • Diazepam/lorazepam can rarely be useful in patients with severe somatic symptoms and the beta blocker, atenolol, may be useful if there are CVS symptoms.

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