Generalised Anxiety Disorder

• excessive anxiety and worry 
• majority of days over at least months
• about multiple events or activities (e.g. – school or work difficulties, relationships, finances) 
• Epidemiology:
  • Lifetime prevalence 4 – 7%
  • ↑ rates in: Fs, African-Americans & age < 30yrs
• Clinical presentation:
  • Onset: bimodal age of onset: before 20 or middle adulthood 
  • Chronic condition
  • Sx fluctuate in severity
  • ¼ of pts with GAD → panic disorder

Risk Factors

• Temperamental traits including
  • behavioural inhibition
  • negative affectivity (neuroticism)
  • harm avoidance
• Adverse childhood events and parental overprotection are associated with GAD

Symptoms

• The person finds it difficult to control the worry
• Associated symptoms – least 3 of the 6 symptoms (with at least some symptoms present for more days than not for the past 6 month
• restlessness or feeling keyed up or on edge
• being easily fatigues
• difficulty concentrating or mind going blank
• irritability
• muscle tension
• sleep disturbance

BE-SKIM 

• B – Blank mind 
• E – Easily fatigued 

• S – Sleep disturbance
• K – Keyed Up/Restless/On-edge
• I – Irritability 
• M – Muscle tension 

• clinically significant distress or impairment in social, occupational, or other important areas of functioning
• disturbance is not attributable to the physiological effects of a substance (e.g. – a drug of abuse, a medication) or another medical condition (e.g. – hyperthyroidism)

DDx

• Anxiety or worry about having panic attacks – (panic disorder)
• Negative evaluation –  (social anxiety disorder)
• Contamination or other obsessions – (obsessive-compulsive disorder)
• Separation from attachment figures – (separation anxiety disorder)
• Reminders of traumatic events-  (post-traumatic stress disorder)
• Gaining weight – (anorexia nervosa)
• Physical complaints – (somatic symptom disorder)
• Perceived appearance flaws – (body dysmorphic disorder)
• Having a serious illness – (illness anxiety disorder)
• The content of delusional beliefs – (schizophrenia or delusional disorder)

Assessment

• The nature, severity and duration of symptoms, avoidance behaviours and use of safety behaviours;
• The degree of distress and functional impairment;
• The presence of substance use disorders and medical conditions;
• The presence of comorbid depressive or anxiety disorders;
• Personal and family history of mental disorders;
• Experience of, and response to, past treatments;
• The quality of interpersonal relationships, living conditions and employment;
• The patient’s goals and expectations.

Complications:

• major depression
• substance abuse

Management:

• lifestyle: avoid caffeine and EtOH, sleep hygiene 
• 1st line
  • Cognitive behavioural therapy (CBT) – is an effective first-line option for the treatment of GAD and is as effective as pharmacotherapy. Internet-based and computer-based CBT have also demonstrated efficacy.
    • cognitive restructuring
    • relaxation techniques
    • mindfulness
• Psycho-Education
  • chronic nature of condition
  • Sx can fluctuate esp with external stressors
  • advice on lifestyle factors (e.g. healthy eating, good sleep, regular exercise and reduced use of caffeine, tobacco and alcohol).
• behavioural therapy – recognise & control anxiety Sx
• relaxation training, breathing exs & progressive muscle relaxation

The evidence does not support the routine combination of CBT and Pharmacotherapy, but when patients do not benefit from CBT, a trial of pharmacotherapy is advisable, and vice versa.

Medication

1st line	Monotherapy: agomelatine, duloxetine, escitalopram, paroxetine, paroxetine CR, pregabalin, sertraline, venlafaxine XR
2nd line	Monotherapy: alprazolam*, bromazepam*, bupropion XL*, buspirone, diazepam*, hydroxyzine, imipramine, lorazepam*, quetiapine XR*, vortioxetine
3rd line	Monotherapy: citalopram, divalproex chrono, fluoxetine, mirtazapine, trazodone
Adjunctive therapy	Second-line: pregabalin Third-line: aripiprazole, olanzapine, quetiapine, quetiapine XR, risperidone Not recommended: ziprasidone
Not recommended	Beta blockers (propranolol), pexacerfont, tiagabine

• *Note: Each of these 2nd-line treatments have distinct mechanisms, efficacy and safety profiles. Within these second-line agents, benzodiazepines would be considered first in most cases, except where there is a risk of substance abuse
  • acute exacerbation:
    • diazepam: 2 – 5 mg orally
    • Tx for 2 wks & then gradually ↓ the dose to 0 within 6 wks
    • Subsequent use – prescribed on a ‘as required basis’
    • Beware of the potential for abuse

Child and Adolescent Considerations

• For children and adolescents, psychological treatments are generally preferred over pharmacotherapy, or if warranted combination therapy may be an option. 
• Psychological therapies for children often need to be adapted to suit the chronological and developmental ages of young patients and to include parental involvement. 
• Meta-analyses support the efficacy of CBT for the treatment of anxiety and related disorders in children and adolescents.
• When pharmacotherapy is warranted, SSRIs are generally preferred, but all antidepressants should be used with caution in due to the risk for increased suicidal ideation and behaviours associated with antidepressant use in youth.