GAD

• Overview:

  • Generalised anxiety disorder is characterised by excessive worry that is generalised, free-floating and persistent
  • Feelings of apprehension about everyday events/problems
  • Symptoms of muscle and psychiatric tension causing significant distress
• GAD is seen in women twice as frequently as men
• Risk factors:

  • Female sex
  • Family history
  • Childhood abuse and neglect
  • Environmental stress
  • Emotional trauma
  • Substance abuse
• Diagnosis:

  • Symptoms must be present more days than not
  • DSM-5
  • ICD-11
  • Validated assessment tool such as GAD-7 questionnaire to determine severity
• A number of conditions have considerable overlap with GAD and its presentation, these include:

  • Social phobia
  • Panic disorder
  • Obsessive-compulsive disorder
  • Post-traumatic stress disorder
  • Acute stress disorder
• Differential diagnosis:

  • Psychiatric - situational anxiety, adjustment disorder, depression (often co-exists), panic disorder, phobias, OCD, substance or drug-induced anxiety
  • CNS depressant withdrawal e.g. alcohol, opiods
  • Cardiac - arrhythmias
  • Respiratory - asthma, COPD, HVS
  • Endocrine - hyperthyroidism, pheochromocytoma
  • Infection
• Drug causes of anxiety:

  • Salbutamol
  • Theophylline
  • Corticosteroids
  • Antidepressants
  • Caffeine
  • Levothyroxine
  • Levodopa
• Emotional and cognitive symptoms of GAD include:

  • Excessive worrying
  • Unable to control the worrying
  • Restlessness
  • Difficulty relaxing
  • Easily tired
  • Difficulty concentrating

   
• Physical symptoms (caused by overactivity of the sympathetic nervous system) include:

  • Muscle tension
  • Palpitations (e.g., a feeling of their heart racing)
  • Sweating
  • Tremor
  • Gastrointestinal symptoms (e.g., abdominal pain and diarrhoea)
  • Headaches
  • Sleep disturbance
• GAD-7:

  • Scores severity
  • Seven questions, each scored depending on how often they symptoms are experienced
  • 5-9 indicates mild anxiety
  • 10-14 indicates moderate anxiety
  • 15-21 indicates severe anxiety
• Management:

  1. Monitoring and screen for other mental health conditions
  2. Low-intensity psychological interventions - individual non-facilitated self help
  3. High intensity psychological intervention (CBT) and/or SSRI (sertraline)
  4. Referral for specialist assessment
• Advise people aged under 30 years that in a minority of people aged under 30 years, SSRIs and SNRIs are associated with an increased risk of suicidal thinking and self-harm. Anyone in this age group receiving an SSRI or SNRI should therefore be seen within 1 week of first prescribing, and the risk of suicidal thinking and self-harm should be monitored weekly for the first month. 
• Propranolol is a non-selective beta blocker often used to treat the somatic symptoms caused by anxiety. It helps reduce sympathetic nervous system overactivity