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Mind & Being Links
Generalized Anxiety Disorder
- causes and risk factors
- signs, symptoms, and diagnosis
- pathophysiology
- treatments
- consequences and course
- the patient
- health care team
- community involvement
- resources and references
Generalized Anxiety Disorder (GAD) usually begins during later childhood and early adolescent years. Females (2-9%) have a higher prevalence than males (1-4%).
Anxiety disorders are the most frequent disorders in the general population (Kessler et al, 2005) and have significant impact on social and occupational functioning. People with anxiety disorders are frequent users of the health care system, in part due to many medical symptoms such as chest pain and rapid heart rate.
Causes and Risk Factors
As most people with GAD report having been anxious all their lives, early factors - behavioural inhibition, attachment pattern, parents with anxiety disorder, and parental style/control - appear important.
Risk factors include past history of anxiety or depression, family history, stressful life events, social isolation, femal gender, and co-morbid psychiatric diagnosis.
Genetics
Genetics appear to account for about 1/3 of GAD, though anxiety disorders as a whole tend to be predisposed
High levels of arousability and emotional reactivity (negative affectivity) appear early
People with GAD tend to overestimate probability of danger
Studies have failed to link worry with specific conditioning events; averse life events are not necessary for the devlopment of GAD.
Signs, Symptoms, and Diagnosis
- worry is across a variety of areas and can be difficult to control
- restlessness
- fatigue
- difficulty concentrating
- irritability
- muscle tension
- chronic aches and pains
- sleep disturbance
Assess substance abuse, co-morbid depression, and suicidal ideation.
Screening for Anxiety
A simple screening questionnaire, the GAD-2 has a high sensitivity and specificity for detecting GAD, as well as panic disorder, social anxiety disorder, and PTSD (Kroenke et al, 2007). The two questions asked are:
- are you feeling nervous, anxious, or on edge?
- are you able to stop or control worrying?
However, as anxiety disorders are complex diseases that require considerable expertise in their treatment, screening should only be considered in the context of a collaborative or a stepped care approach to management in primary care (Skapinakis, 2007)
Pathophysiology
Treatments
According to an Australian study, the most cost-effective treatment for anxiety is CBT, although widespread use would require policy change sufficient to increase the number of trained therapists (Heuzenroeder et al, 2004)
Counselling
Educate patients on the commonness of anxiety.
Encourage lifestyle advice: limit caffeine and alcohol intake, exercise more, practice good sleep hygeine, and explore relaxation techniques. Self-help materials can be useful in reinforcing these messages.
Stress-management sessions, either individual or group, can help people learn to cope.
Social supports
Community support groups provide education and social interactions.
Medications
Pharmacotherapy for GAD includes the following:
first line: paroxetine, escitalopram, sertraline, venlafaxine XR
second line: lorazepam, diazepam, alprazolam, imipramine, buproprion XL
third line: adjuctive therapy.
Benzodiazepines should only be used for a short time (ie 1-2 months) due to side effects, dependence, and withdrawal issues.
Don't mention every single side effect of drugs, becuase worried patients tend to develop them (ethics?)
Consequences and Course
People diagnosed with anxiety disorders have important gaps in the mental health care that they receive, including poor adherence to psychoactive medications, poor follow-up by primary care physicians, and "marked underuse" of CBT (Stein et al, 2004).
People with anxiety or depresssion are associated with unhealthy lifestyle choices, such as smoking and lack of exercise, which may contribute to high levels of comorbidity (Bonnet et al, 2005).
The Patient
Health Care Team
Community Involvement
References
Bonnet F, Irving K, Terra JL, Nony P, Berthezene F, Moulin P. 2005. Anxiety and depression are associated with unhealthy lifestyle in patients at risk of cardiovascular disease. Atherosclerosis. 178:339-44.
Heuzenroeder L et al. 2004. Cost-effectiveness of psychological and pharmacological interventions for generalized anxiety disorder and panic disorder. Aust N Z J Psychiatry. 38(8):602-12.
John U, Meyer C, Rumpf HJ, Hapke U. 2004. Smoking, nicotine dependence and psychiatric comorbidity—a population-based study including smoking cessation after three years. Drug Alcohol Depend. 76:287-95.
Kessler et al. 2005. Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 62(6):617-27.
Kroenke K, Spitzer RL, Williams JB, Monahan PO, Löwe B. (2007). Anxiety disorders in primary care: prevalence, impairment, comorbidity, and detection. Annals of Internal Medicine 146(5):317-25.
Rollman BL et al. 2005. A randomized trial to improve the quality of treatment for panic and generalized
anxiety disorders in primary care. Arch Gen Psychiatry. 62:1332-41.
Skapinakis P. 2007. The 2-item Generalized Anxiety Disorder scale had high sensitivity and specificity for detecting GAD in primary care. Evid. Based Med. 2007;12;149.
Stein MB, Sherbourne CD, Craske MG, Means-Christensen A, Bystritsky A, Katon W, et al. 2004. Quality of care for primary care patients with anxiety disorders. Am J Psychiatry. 161:2230-7.