Psychiatry >
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
- Cognitive:
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
- High-intensity psychological intervention) or pharmacological
- 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