Anxiety

Notes

Introduction

Generalised anxiety disorder (GAD) is a pervasive uncontrolled anxiety, that may be chronic and affect normal life.

GAD is a commonly experienced mental health illness. It represents the continuation of a spectrum of feelings commonly experienced that become uncontrolled and damaging. 

It can result is severe impairment of normal functionality, and risk of suicidal ideation, self-harm and self-neglect are increased. 

For those interested in the intricacies of management, you can review the NICE guidelines here. In this note we discuss GAD in adult patients.

Epidemiology

Generalised anxiety disorder is a commonly condition experienced globally.

Anxiety disorders are common and experienced globally. The World Health Organisation estimate that 3.6% of the worlds population are affected and is seen in women twice as often as men. 

The UK is affected in a similar manner with estimates of prevalence ranging from approximately 3-5%.

Risk factors

Women are approximately twice as likely to experience GAD compared to men.

  • Female sex
  • Family history
  • Childhood abuse and neglect
  • Environmental stress (e.g. redundancy, divorce)
  • Emotional trauma
  • Substance abuse

DSM-V Criteria

DSM-V is a classification of mental health disorders published by American Psychiatric Association.

  • Excessive anxiety and worrying (more days than not for six months or longer)
  • The worry and anxiety is difficult to control
  • Three of the following have been present (more days than not for six months):
    • Restlessness
    • Easily fatigued
    • Sleep disturbance
    • Irritability
    • Muscle tension
    • Trouble concentrating

In addition the following must be present:

  • Symptoms cause significant distress and impair normal function
  • Symptoms or episode not caused by another condition of substance
  • Episode not better explained by other mental health illnesses

Management

NICE guidelines outline a stepwise approach to GAD management.

Assess suicide risk

Patients should be asked about suicidal thoughts and ideation. This is a key part of any assessment. This NICE CKS page has a framework for assessing suicide risk.

Any patient deemed to be at risk should be discussed immediately with the local specialist mental health services for further assessment and a management plan. 

Step 1

Identify patients who present with anxiety that appears pervasive or affects quality of life. Consider the use of assessment questionnaires like GAD-7

Once identified, explain the diagnosis and its meaning to the patient. Provide written information that will allow the patient to understand their illness better. Assess severity, duration and impact on normal life. Evaluate for coexisting depression or other mental health illnesses.

Chronic co-morbidities should be reviewed and management optimised. Environmental stressors and substance abuse issues that may exist must be addressed. Sleep hygiene advice should be given.

Step 2

If measures have not improved symptoms, offer low-intensity psychological interventions taking patient preference into account.

These include individual non-facilitated self-help, individual guided self-help and psychoeducational groups

Step 3

If above measures have failed to adequately treat GAD, offer one of high-intensity psychological intervention or drug treatment.

The options should be discussed and patient preference taken into account. Side-effect and discontinuation syndromes associated with medications should be explained.

Drug treatment is normally with an SSRI (e.g. sertraline). SNRIs (e.g. venlafaxine) may be used as an alternative. Medications should be reviewed one to twice a month for the first three months, then less regularly (e.g. every three months.

NOTE: SSRIs and SNRIs have been implicated in an increased risk of suicide, suicidal ideation and self-harm, particularly below the age of 30. All patients commenced in this age group should have review within one week of starting therapy with weekly reviews for at least one month.

Step 4

Referral to specialist care should be considered, particularly those at risk of self harm or suicide, significant co-morbidities or self neglect. Also refer patients in whom the first three steps have not managed their symptoms.

Further reading

  • NICE Clinical Guidance 13: Generalised anxiety disorder and panic disorder in adults: management.
  • MIND: A mental health charity, provides information and support for those with mental health illness.
  • Anxiety UK: A UK based charity providing support for those with anxiety, stress and anxiety based depression.

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