Anxiety

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 in severe impairment of normal functionality, and the risk of suicidal ideation, self-harm and self-neglect are increased.

For those interested in the intricacies of management, review the NICE CG 113: Generalised anxiety disorder and panic disorder in adults management (2019 update). In this note we discuss GAD in adult patients.

Generalised anxiety disorder is a common condition experienced globally.

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

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

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

Both the Diagnostic and Statistical Manual of Mental Disorders (DSM, latest iteration DSM-V) and the International Classification of Diseases (ICD, latest iteration ICD-10) can be used to define and diagnose GAD.

Whilst the DSM is developed by the American Psychiatric Association, the ICD is developed by the World Health organisation. We have chosen to present the DSM criteria as this is what is quoted in NICE CG 113: Generalised anxiety disorder and panic disorder in adults management (2019 update). We have however updated it to DSM-V (guidance refers to the older DSM-IV).

• 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

Alternative diagnoses should be considered and excluded where possible.

A number of conditions have considerable overlap with GAD and its presentation, these include:

• Social phobia
• Panic disorder
• Obsessive compulsive disorder
• Post-traumatic stress disorder
• Acute stress disorder

‘Physical’ or ‘organic’ illness may also present with the clinical features of a psychiatric illness. Consider thyroid dysfunction and other endocrine disorders. Perform a medication review to identify any that may be contributing to symptoms. Consider the impact of any alcohol or illicit drug use.

GAD-7 is a self-reported questionnaire that can act as a screening tool and measure of severity for GAD.

It consists of seven questions, each asking the patient whether they have experienced certain symptoms and with what frequency.

Different score thresholds offer different levels of sensitivity and specificity. A cut-off of 10 has an 89% sensitivity and 82% specificity for GAD. It should be noted there can be significant cross-over with other anxiety based disorders. An additional question asking about the extent to which any of these symptoms affected daily living is normally present but not part of the score.

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: All known and suspected presentations of GAD

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: Diagnosed GAD that has not improved after step 1 interventions

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: GAD with marked functional impairment or that has not improved after step 2 interventions

If above measures have failed to adequately treat GAD or if patients present with marked functional impairment, offer one of:

• High-intensity psychological intervention
• Pharmacological treatment

The options should be discussed and patient preference taken into account. Side-effect and discontinuation syndromes associated with medications should be explained. Transient increases in anxiety may be seen at the onset of treatment.

Options for high-intensity psychological intervention include cognitive behavioural therapy (CBT) and applied relaxation.

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 depending on the individual circumstances.

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 for 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.

• 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.