GENERALIZED ANXIETY DISORDER

INTRODUCTION

Anxiety is a normal defensive mechanism of our body to cope with unwanted and threatening situations.

Everyone experiences anxiety at some point in their lives in response to physical and psychological stress.

According to DSM-5, the diagnosis of GAD is made when –

  • Worry and anxiety present for almost six months about an event
  • the individual finds it difficult to control the worrisome thoughts
  • anxiety or worry is present with three or more out of the following six symptoms:

a) restlessness

b) easy fatigue

c) concentration difficulty

d) irritability

e) muscle tension

f) sleep disturbance

  • Anxiety or physical symptoms cause significant impairment in multiple domains of life
  • history of substance abuse or medical condition is ruled out
  • disturbance not explained by other medical disorders such as OCD, PTSD, somatic symptom disorder, social anxiety disorder, and illness anxiety disorder

physical symptoms:

Patients usually present with –

  • palpitations
  • sweating
  • trembling or shaking
  • sensation of shortness of breath or smothering
  • feeling of choking
  • chest pain or discomfort
  • nausea or abdominal distress
  • feeling of dizziness
  • chills or heat sensation
  • derealisation and depersonalisation
    • along with excess out of control worry with irrational intrusive thoughts

A number of scales are available to diagnose and assess the severity of GAD. The GAD-7 has been validated as a diagnostic tool and a severity assessment scale, with a score of 10 or more having good diagnostic sensitivity and specificity. Greater GAD-7 scores correlate with more functional impairment.

Table: GAD-7 Screening Tool

Over the last 2 weeks, how often have you been bothered by the following problems?Not at allSeveral daysMore than half the daysNearly every day
     
Feeling nervous, anxious, or on edge0123
Not being able to stop or control worrying0123
Worrying too much about different things0123
Trouble relaxing0123
Being so restless that it is hard to sit still0123
Becoming easily annoyed or irritable0123
Feeling afraid as if something awful might happen0123
Total Score _____= _______________

*Score 5: Mild

Score 10: Moderate

Score 15: Severe

Differential Diagnosis

Always rule out –

Endocrine disorder:

a) hyperthyroidism

b) pheochromocytoma

c) hyperparathyroidism

Cardiopulmonary disorder:

a) arrhythmias

b) obstructive pulmonary disorder

Neurological disorder:

a) temporal lobe epilepsy

b) transient ischemic attack

c) psychological disorder

d) other anxiety depressive or bipolar disorders

  • also, rule out any history of substance abuse or withdrawal

Management

  • lifestyle recommendations
  • exercise, muscle relaxations
  • mindfulness
  • identify and remove triggers such as caffeine, nicotine and other stimulants

Medications

First-line treatments:

  • Selective Serotonin Reuptake Inhibitor:

a) Escitalopram

b) Fluoxetine

c) Fluvoxamine

  • Serotonin Norepinephrine:

a) Duloxetine

b) Venlafaxine

Second-line treatments:

  • Tricyclic anti-depressants:

a) Amitriptyline

b) Nortryptline

  • Anti-epileptic:

a) Pregabaline

  • Anti-psychotics:

a) Quetiapine

Third-line treatments:

  • MAO Inhibitors:

a) Phenelzine

b) Isocarboxazine

  • Benzodiazepine:

a) Clonazepam

b) Alprazolam

c) Diazepam

d) Lorazepam

Psychotherapies and Relaxation therapies

Cognitive Behavioural Therapy: It’s cognitive helps with changing the thinking patterns and behaviour part helps with training patients to relax deeply. To make the process effective, the therapy should be patient-directed.

Mindfulness-Based Stress Reduction: This promotes attention to individuals’ present emotional state by various meditation techniques.

We should counsel the patients and their families and educate them that anxiety if treated properly with a good support system from the family, a patient can overcome anxiety.

By: Dr Yagika Pareek

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