Armando Hasudungan
Biology and Medicine videos

Generalised Anxiety Disorder

DSM V categorise these as seperate disorders

  • Depressive disorders
  • Bipolar disorders
  • Anxiety disorders

Anxiety Disorders

  • Generalised Anxiety Disorder
  • Specific Phobia
  • Agoraphobia
  • Social Anxiety Disorder
  • Panic Disorder

This will mainly focus on Generalised Anxiety Disorder and touches on Panic Disorder

Overview

Overview Generalized anxiety disorder (GAD) can be defined as anxiety and worry about several events and activities for a majority of the day over a 6-month time period. The anxiety and worry associated with GAD can be distinguished from normal anxiety by their excessive nature, the difficulty involved in controlling them, and their interference in everyday life. 10% of people have an anxiety disorder and it is more common in females.

Definition
Phobia: Persistent, irrational, exaggerated, and pathologic fear of a specific situation or stimulus that results in conscious avoidance of the dreaded circumstance
Compulsions: Repetitive behavior or mental acts that a person feels driven to perform in response to an obsession according to a rigid set of rules.
Obsessions: Recurrent and persistent thoughts or images that are experienced as intrusive and inappropriate and cause marked anxiety or distress.
Anxiety:
Generalised Anxiety disorder: disorder of chronic uncontrollable worry, compounded by physiological symptoms such as disturbed sleep, muscle tension, and difficulty concentrating.
Panic disorder: Spontaneous occurrence of severe panic attacks (periods of fear which peak within ~10minutes_. These should be accompanied by four or more of tachycardia, sweating, trembling or shaking, shortness of breath, a feeling of choking, chest pain, dizziness, etc.
Panic attack: Discrete period of intense fear or discomfort

Panic disorder (PD) is characterized by episodic, unexpected panic attacks that occur without a clear trigger. Panic disorder can lead to panic attacks which are defined by the rapid onset of intense fear (typically peaking within about 10 minutes) with at least four of the physical and psychological symptoms in the DSM-5 diagnostic criteria.

Remember The hallmark of GAD is excessive, out-of-control worry, and PD is characterized by recurrent and unexpected panic attacks.

Risk Factors

  • Family history
  • Physical or emotional stress
  • History of physical or emotional trauma
  • Other anxiety disorders
  • Female gender
  • Diabetes
  • Adolescence or early adulthood

Psychiatric History and Examination

Interview

History

  • History of presenting Illness
  • Medical history – Psychiatric as well
    • Admissions
  • Medication history
  • Drug and Alcohol
  • Forensic History
  • Social History
    • Relationship
    • Work
  • Developmental history
  • MSE

Mini State Examination (MSE) Findings in Anxiety disorders
Appearence and Behaviour Ranges from fastidious to disheveled. Possible pscyhomotor agitation, tremor.fidgety/hyper-vigilant vs. “frozen” with fear, intesnse vs. avoidant eye contact, limited cooperation vs. solicitous
Speech Pressure of speech but interruptible or not speech at all!
Mood and affect Likely congruent with modd, anxious, scared, labile, irritable or maybe even angry.
Thought form and though content Though process: perseverative, ruminative, circumstantial. Thought content notable for ruminations, obsessions, worries, concerns regarding danger.
Cognition ↓concentration and attention but generally intact
Insight Anxiety is often fear out of proportaion to the realistic level of threat, so insight not necessarily that great
Perception May be impaired

Mental State Examination (ABCDEFGHIJ)

  • Appearence and Behaviours
  • Cognition
  • Delusion (Thought content) 
  • Emotion (mood and affect) 
  • Thought Form
  • Gab (speech)
  • Hallucinations and illusions (perception)
  • Insight and Judgement

Signs and Symptoms

Side note When assessing someone with suspected anxiety make sure to exclude medical causes (hyperthyroidism, cardiopulmonary disease, neurological conditions, TIA) and other psychiatric conditions as well as medication induced (caffeine, decongestants or substance withdrawal).

Watchers

  • Worry (Core symptom)
  • Anxiety (Core symptom)
  • Tension of muscles
  • Concentration difficulty
  • Hyper-arousability
  • Energy loss/easily fatigued
  • Restlessness
  • Sleep disturbance
Remember GAD typically present with excessive anxiety about ordinary, day-today situations. The anxiety is intrusive, causes distress or functional impairment, and often encompasses multiple domains (e.g., finances, work, health)

Diagnosis

Generalised anxiety disorder (1 Core symptom + 3 other symptoms)

  • Worry (Core symptom)
  • Anxiety (Core symptom)
  • Tension of muscles
  • Concentration difficulty
  • Hyper-arousability
  • Energy loss/easily fatigued
  • Restlessness
  • Sleep disturbance

6 months most days and doesn’t fit another more specific disorder

Side note Complicating the diagnosis of GAD (and PD) is that many conditions in the differential diagnosis are also common comorbidities. Additionally, many patients with GAD or PD meet criteria for other psychiatric disorders, including major depressive disorder and social phobia.

Differential Diagnosis

  • Hyperthyroidism
  • Drug induced
  • Hypoglycemia
  • Hypoparathyroidism
  • TIAs/TBIs
  • AMI/PE/Angina
  • Palpitations
  • Sjorgen syndrome
Remember Generalized anxiety disorder is almost always accompanied by another mental disorder; the physician should inquire about symptoms of depression, traumatic stressors, panic attacks, and substance abuse.

Investigation

  • FBC
  • Electrocardiogram (ECG)
  • Thyroid function Test
  • Drug screen

Management

Side note Psychotherapy can be as effective as medication for GAD and PD. Cognitive behavior therapy has the best level of evidence. Physical activity is a cost-effective treatment for GAD and PD.

General

  • Physical activity
  • Good diet

Psychotherapy (Mild-Moderate)

  • CBT
  • Applied relaxation – mindfulness based stress reduction
  • +/- psychiatric referral

Pharmacotherapy (Moderate -Severe)

  • SSRI
  • SNRI
  • Buspirone
  • Benzodiazepines
Remember To avoid relapse, medication should be continued for 12 months after symptoms improve before tapering.
Pharmacology Buspirone is a non-sedating nonbenzodiazepine anxiolytic and works as a partial seratoinin 1A agonist. Two to four weeks are required for a successful therapeutic effect, and adverse effects include restlessness, insomnia, and nervousness. Buspirone is as effective as diazepam in treating anxiety. Buspirone does not repress respiration in individuals with lung disease and sleep apnea like benzodiazepines do.

Complication and Prognosis

Remember GAD increases the risk of major depression, so preventive approaches should be put in place

Complications

Prognosis Generalised anxiety disorder is a long term condition. It often begins before or during young adulthood and can be a lifelong problem. Spontaneous remission is rare

Panic Disorder

Overview Panic Disorder is characterized by episodic, unexpected panic attacks that occur without a clear trigger