Generalised Anxiety Disorder

“Disproportionate, pervasive, uncontrollable, and widespread worry and a range of somatic, cognitive, and behavioural symptoms that occur on a continuum of severity”

Risk Factors

• Family history of psychiatric disorders
• Chronic and/or painful illness
• Female sex
• Environmental stressors such as physical or emotional trauma, domestic violence, unemployment, or low socioeconomic status
• Childhood adversities
• Psychosocial causes
• Substance dependence

Aetiology

• Multifactorial with both genetic and environmental factors

Pathophysiology

• Neurological:
  • Connections between the amygdala and prefrontal cortex not regulated appropriately for the experience of fear leading to clinical symptoms of anxiety
• Genetic predisposition:
  • Exacerbates response to stress
• Social:
  • Life events (losing or gaining a spouse or job, moving house)

Clinical Presentation

• Major symptoms – present for at least 6 months according to DSM-V:
  • Excessive anxiety and worrying for many events and activities
  • Difficulty controlling the worry
• Additional symptoms:
  • Cognitive:
    • Agitation
    • Feelings of impending doom
    • Poor concentration
    • Difficulty getting to sleep (insomnia)
  • Somatic:
    • Trembling
    • Hyperventilation
    • Headaches
    • Sweating
    • Palpitations
    • Nausea
  • Behavioural:
    • Reassurance seeking
    • Avoidance
    • Dependence on a person or object

Investigations

• GAD-7 questionnaire to determine severity

Management

• Step 1:
  • Assess severity of GAD and any other comorbidities
• Step 2:
  • Low-intensity psychological interventions (individual non-facilitated self-help, individual guided self-help, psychoeducation)
• Step 3:
  • High-intensity psychological intervention) or pharmacological
    • First line: SSRI (sertraline, paroxetine, citalopram)
    • SNRI (venlafaxine, duloxetine) if SSRI not tolerable
    • Pregabalin if a patient cannot tolerate SSRI or SNRI
• Step 4:
  • Refer for specialist treatment if patient has not improved with step 3 intervention and/or is exhibiting or at risk of self-harm, self-neglect, suicide, or a significant comorbidity such as substance misuse

Complications

• Serious disability and impaired quality of life
• Impaired social and occupational functioning
• Comorbidities such as increased risk of major depression, social anxiety disorder, and alcohol and drug misuse, and physical health problems such as chronic pain Suicidal ideation and attempts