Generalised Anxiety Disorder
Atiya Khalid
GPST2
What Is GAD
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GAD is characterised by excessive, exaggerated
anxiety & worry about everyday life events with
no obvious reasons for worry
Curriculum statement 13
Care of people with mental health problems
Diagnostic Criteria DSM-IV
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Excessive anxiety and worry, occurring more
days than not for at least six months, about a
no. of activities or events
Difficulty controlling worry
3 of 6 symptoms are present for more days than
not : restlessness ,easily fatigued, difficulty
concentrating, irritability, muscle tension, sleep
disturbance
Epidemiology
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Lifetime prevalence 5 % ( Europe ),12
month prevalence 1-2%
Co-morbidity with major depression 60 %
of cases
Only 40 % seek help ; 5 yrs remission rate
is 38-41%
Risk Factors :
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Being aged between 35 and 54
Being divorced or separated
Living alone or as a lone parent
Protective Factors:
Aged between 16 and 24
Married or in relationship
Differential Diagnosis

Panic disorder, with or without agoraphobia

Post-traumatic stress disorder
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Obsessive-compulsive disorder

Phobias,
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Social phobia, sometimes called social anxiety disorder
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Acute stress disorder
Contd.
Anxiety is commonly a feature of other disorders.
Other conditions to consider include:
Schizophrenia
 Dementia
 Anxiety and depression
 Alcoholism
 Physical illness
(much less likely to present as simply GAD):
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Thyrotoxicosis. May produce irritability, restlessness,
tremor and tachycardia.
Phaeochromocytoma. Normally is part of multiple
endocrine neoplasia- usually MEN2.
Hypoglycaemia. This is usually part of failure of control of
diabetes but insulinoma can be part of MEN
SYMPTOMS :
Autonomic arousal
palpitations, sweating, trembling & dry mouth
 Chest & abdominal discomfort
difficulty breathing, feeling of choking, chest pain
& nausea
 Mental state changes
dizziness, feelings of unreality, fear of losing
control & fear of dying
 General:
hot flushes or cold chills, numbness or tingling,
muscle tension, aches & pain, restlessness & an
inability to relax & sensation of lump in throar
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MANAGEMENT
Evidence-based guidelines by NICE
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The patient's preference for method of treatment.
Emphasise that the disease can be managed and
give as much information as possible, including
written information and access to self-help groups.
In terms of long-term effectiveness, the best
results are from psychotherapy, followed by
medication, followed by self-help.
Treatment should be available in primary care with
only the most difficult cases requiring referral.
Psychological Therapy
CBT is the technique of choice for an effective and
lasting response.
 It must be delivered by appropriately trained
professionals.
 The optimum duration of therapy 16 to 20
hours, delivered in a weekly session of 1 or 2
hours and completed within four months.
 If offering briefer CBT, it should be about 8-10
hours, and should be designed to integrate with
structured self-help materials.

Anxiety management treatment
Is a structured therapy involving
> education
> relaxation training (involves practising
techniques that lead to muscular or bodily
relaxation)
> exposure (entails graded, repeated
confrontation (through visualisation,
image, or the stimulus) with a stimulus
that causes anxiety.
Pharmacological treatment
Before prescribing consider:
 Age of patient
 Previous treatment response
 Risks of deliberate self-harm or accidental overdose
 Tolerability
 Possible interactions with existing medications
 The patient's preference
 Cost, where equal effectiveness
NICE recommends a selective serotonin reuptake inhibitor
(SSRI) or venlafaxine as the first choice
If one SSRI is not suitable or there is no improvement after
a 12-week course, and if a further medication is
appropriate, another SSRI should be offered. Long-term
treatment and doses at the upper end of the indicated
dose range may be necessary
At the start of treatment, patients should be informed about:
 Potential side-effects (including transient increase in
anxiety at the start of treatment)
 Possible discontinuation/withdrawal symptoms
 Delay in onset of effect
 Time course of treatment
 Need to take medication as prescribed
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If there is no benefit in 12 weeks an
antidepressant from a different class may be
tried.
SSRIs and venlafaxine should be tailed off,
sudden discontinuation can produce withdrawal.
There is no evidence to guide duration of
therapy.
Any form of medication should be reviewed at 2,
4, 6 and 12 weeks after starting
beta blockers, MOA inhibitors, and antipsychotic
medication are not effective
Monitoring

GPs should monitor progress.
Review interval; on a case-by-case basis,
likely to be every 4-8 weeks.
If one form of therapy does not work,
another may be tried
If two interventions have been tried without
success, then referral to mental health
services is required
PROGNOSIS
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A chronic disease that is controlled rather
than cured
Long-term follow-up studies suggest that
GAD is a condition that worsens the
prognosis for any other condition, and that
people who have only GAD are likely to
develop further conditions.
Stepped care
Step
1
Identification and assessment; education
about GAD and treatment options; active monitoring
Step 2
Low-intensity psychological interventions:
individual non-facilitated self-help, individual guided selfhelp and psychoeducational groups
Step 3
Choice of a high-intensity psychological
intervention (cognitive behavioural therapy/applied
relaxation) or a drug treatment
Step 4
Highly specialist treatment, such as complex
drug and/or psychological treatment regimens; input
from multi-agency teams, crisis services, day hospitals or
inpatient care
Step 1: Identification
For all known and suspected presentations of
GAD:
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Identify and communicate the diagnosis of GAD
early.
Consider a diagnosis of GAD in people
presenting with significant worry or who attend
primary care frequently because of a chronic
physical health problem or somatic symptoms.
Step 1: Education,
treatment and monitoring
Following
assessment and diagnosis of GAD:
provide education about GAD and options for
treatment
 monitor symptoms and functioning (known as
active monitoring).

Discuss
the use of over-the-counter
medications and preparations.
Step 2: Low-intensity
psychological interventions
For
people with GAD that has not
improved after education and active
monitoring in step 1, offer one or more of
the following, guided by the person’s
preference:

individual non-facilitated self-help

individual guided self-help
Step3:High intensity T/M
For people with GAD with marked functional impairment or
that has not improved after step 2 interventions offer
either:
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an individual high-intensity psychological intervention using
either CBT or applied relaxation or
drug treatment using a selective serotonin reuptake inhibitor
(consider offering sertraline first because it is the most
cost-effective drug)
Do not offer antipsychotics for GAD in primary care.
Do not offer benzodiazepines except as a short-term crisis
measure.
Inadequate response to step3
If
a person’s GAD has not responded to:
a high-intensity psychological intervention, then
offer a drug treatment

drug treatment, then offer either a high-intensity
psychological intervention or an alternative drug
treatment.

If
a person’s GAD has partially responded to
drug treatment, consider offering a highintensity psychological intervention in addition
to drug treatment.
Referral to step 4
Consider
referral to step 4 if the person has
severe anxiety with marked functional
impairment and:
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a risk of self-harm or suicide or
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significant comorbidity or
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self-neglect or
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an inadequate response to step 3 interventions.
Step 4: Highly specialist treatment
Consider
offering combinations of treatment:
psychological and drug treatments or
 combinations of antidepressants or
 augmentation of antidepressants with other
drugs

But
exercise caution and be aware of the lack
of evidence of effectiveness and increased risk
of side effects.
References
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Carter RM, Wittchen HU, Pfister H, et al
Slade T, Andrews G
Alonso J, Angermeyer MC, Bernert S, et al
Gilbody SM, House AO, Sheldon TA
Durham RC, Chambers JA, MacDonald RR, et al
Ballenger JC, Davidson JR, Lecrubier Y, et al
Hawkridge SM, Stein DJ
Schmitt R, Gazalle FK, Lima MS, et al
Pittler MH, Ernst E
Bower P, Richards D, Lovell KJorm AF, Christensen H, Griffiths KM, et
al
Gale C, Davidson O
NICE Guidelines
InnovAiT