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Generalized Anxiety Disorder

Definition

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Note: I copy the "definition" of something straight from the book. I find it's best to have an all-encompassing definition in order to better orient myself when I am studying.

(Show DSM-V Diagnosis Criteria for GAD)
  1. Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance).
  2. The individual finds it difficult to control the worry.
  3. The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms having been present for more days than not for the past 6 months):
    1. Note: Only one item required in children.
    2. Restlessness, feeling keyed up or on edge.
    3. Being easily fatigued.
    4. Difficulty concentrating or mind going blank.
    5. Irritability.
    6. Muscle tension.
    7. Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep).
  4. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
  5. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism).
  6. The disturbance is not better explained by another medical disorder (e.g., anxiety or worry about having panic attacks in panic disorder, negative evaluation in social anxiety disorder [social phobia], contamination or other obsessions in obsessive-compulsive disorder, separation from attachment figures in separation anxiety disorder, reminders of traumatic events in posttraumatic stress disorder, gaining weight in anorexia nervosa, physical complaints in somatic symptom disorder, perceived appearance flaws in body dysmorphic disorder, having a serious illness in illness anxiety disorder, or the content of delusional beliefs in schizophrenia or delusional disorder).

Generalized anxiety disorder (GAD) is a condition, exhibited by excessive worry, tension, apprehension, and uneasiness from anticipated events or activities, that is present on most days of the week for at least six months. It is the “fight or flight” response that is part of the survival instinct. Anxiety is distinguished from fear in that fear is a response to consciously recognized external danger. The source of anxiety is largely unknown or unrecognized.

Normal anxiety allows us to get in touch with de- velopmental learning that is part of our human growth. Anxiety in its chronic form is maladaptive and is considered a psychiatric disorder. Many cases of anxiety.

When a client presents with anxiety, it is often comorbid with other psychiatric disorders, particularly depression. Anxiety may act as a predispositional factor to early-onset depression (before age 26 years) and to increased frequency of depressive episodes. Clients also present clinically with only anxiety, in one of its many forms, such as GAD, posttraumatic stress disorder (PTSD), obsessive-compulsive disorder (OCD), adjustment disorder with anxious mood, phobic disorders, acute anxiety, or panic disorder, with or without agoraphobia.

Incidence/Prevalence

Likely not important for NAC OSCE exam.

Pathogenesis

Likely not important, however:

  1. Thought to be caused by a cumulation of anxiety-provoking events in one's lifetime. Note: Don't forget to distinguish between fear and anxiety.

Predisposing factors

  1. Female; onset usually at 20 to 30 years of age.
  2. Single.
  3. Lower socioeconomic status.
  4. A childhood anxiety disorder.
  5. Excessive worrying.
  6. Unresolved unconscious conflict.

Common Findings

  1. I divide them into Cognitive vs. Somatic symptoms.
  2. Cognitive Sx:
    1. Anxiety
    2. Inability to control anxiety, resulting in malfunctioning.
    3. Feelings of apprehension.
  1. Somatic Sx:
    1. Motor tension
    2. Autonomic hyperactivity vigilance
    3. Sleep disturbance
    4. Dyspnea, Tachycardia, Tachypnea
    5. Dizzines, Diaphoresis, Nausea
    6. Tremors

Note:The DSM-V criteria requires presence of **specific** somatic sx that are listed here, but a patient with GAD may present with somatic sx that are not listed in DSM-V criteria.

History

  1. HPI:
    1. How often does anxiety occur?
  2. ROS:
  3. ALL/MEDS/HIITS: (What are HIITS? - Click to expand)
  4. PMH/FAMHx/OBGYN:
    1. Hx of anxiety and age of onset
  5. SOCHx:
    1. Assess suicidality/homicidality
    2. Check for caffeine use in addition to rec. drug use b/c this can precipitate anxiety
    3. Discuss stressful life events, coping mechanisms

Physical Exam

Coming soon.

Diagnostic Tests

  1. Blood alcohol level, if indicated.
  2. Thyroid profile.
  3. Blood glucose.
  4. Medication level (e.g., theophylline) if applicable.
  5. Urine drug screen.

DDx

  1. Substance/medication-induced anxiety disorder.
  2. Psychiatric syndromes: (click to expand)
    1. Mood disorders: Bipolar, Depression.
    2. Psychotic disorder.
    3. Somatoform disorders.
    4. Personality disorders.
    5. ADHD.
  3. Medical conditions. Anxiety syndromes mimic many medical illnesses, including intracranial tumours, menstrual irregularities, hyper-/hypo-thyroidism, hypoglycemia, hyper-/hypo-parathyroidism, postconcussion syndrome, psychomotor epilepsy, and Cushing’s disease.

Plan

  1. General: Encourage client to perform self-calming techniques: deep breathing/relaxation, meditation, exercise.
  2. CBT, then pharmacotherapy.
  3. SSRIs/SNRIs.
    1. Take 4 -6 wks to work
    2. Don't stop taking without taper
  4. Buspirone - a non-benzodiazepine anxiolytic.
    1. Not for under age 18
    2. May take time to work like SSRI
  5. Short-acting benzodiazepine.
    1. only prescribe for short time to prevent dependence
  6. ?? Long-acting benozdiazepine ??

Follow-up

Reassess 1- 2 wks. Assess suicidality every visit.

Consultation/Referral

Likely not important for NAC OSCE exam.

Individual Considerations

Underdiagnosed in geriatric populations. Start with Rx at lowest if needed.


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