Download Learning In 10: Generalized Anxiety Disorder Psychiatry Celeste

Learning In 10: Generalized Anxiety Disorder Psychiatry Celeste Ong Slide 1:
So for this session, we are going to talk about generalized anxiety disorder. Slide 2:
I've listed here some of the learning objectives pertaining to this session. We want to understand the etiology and pathogenesis of generalized anxiety disorder, to describe briefly the epidemiology of generalized anxiety disorder, to recognize the clinical manifestations when a patient we suspect with generalized anxiety disorder presents to us, to understand how to assess such a patient and come up with the diagnoses of generalized anxiety disorder, and lastly, to describe the treatment options available. Slide 3:
And here is the outline of the topics that we will cover in order to achieve those learning. Objectives I will start with a quick introduction to the definitions of generalized anxiety disorder, describe briefly the epidemiology, and then move on to the pathogenesis and clinical manifestations of the disease. Then I will talk about the assessment and diagnosis, as well as the treatment options. Slide 4:
So what is generalized anxiety disorder? According to the Diagnostic and Statistical Manual of Mental Disorders, DSM, fifth edition, generalized anxiety disorder is characterized by excessive and persistent worrying that is hard to control. It's associated with three or more of following six symptoms­­ restlessness or feeling keyed up or on edge, being easily fatigued, difficulty concentrating or mind going blank, irritability, muscle tension, as well as sleep disturbance. Three are more of these symptoms should be present on more days than not for at least six months. It should cause significant distress or impairment in social, occupational, or other important areas of functioning of the patient. It is not secondary to effects of a substance or medical condition. And it is not better explained by another mental disorder. Slide 5:
Generalized anxiety disorder is a common problem that is encountered in a clinical setting, especially in the elderly over 65 years old and in women. According to the Singapore Mental Health Study conducted in 2010, the prevalence rate of generalized anxiety disorder in Singapore is 3.6%. Comorbidity with major depression or other anxiety disorders have been observed in a majority of cases of generalized anxiety disorder. For example, these patients can have concurrently social phobia, specific phobia, or panic disorder. These patients usually have more severe and prolonged course of illness, greater functional impairment, as well as a poorer prognosis. Another concern about patients with generalized anxiety disorder is that they are associated with increased rates of substance abuse. Slide 6:
So what are some of the risk factors that can give rise to generalized anxiety disorder? Three studies have shown that genetic factors appear to predispose individuals to development of generalized anxiety disorder, although the data have been inconsistent. Some other studies have also shown that generalized anxiety disorder shares a common heritability with major depression. Slide 7:
Developmental factors also have a part to play, where adversity and undesirable life events can exacerbate the symptoms of generalized anxiety disorder. The psychanalytical theory postulates that generalized anxiety disorder arises from unresolved, unconscious conflicts, while the cognitive behavioral theory thinks that generalized anxiety disorder comes about due to the misperception of danger or threat and the feeling of having less control over the threat, hence, giving them the anxiety symptoms. Slide 8:
What are the clinical features that we should look out for in patients with suspected generalized anxiety disorder? Excessive and persistent worrying is the pathognomic symptom of generalized anxiety disorder. Patients with generalized anxiety disorder are found to have a greater number of worries, as well as a greater extent of worry over minor matters. Many also complain of symptoms like poor sleep, fatigue, and difficulty relaxing, headaches, and having pain in the neck, shoulders, and back. And it is very common for these patients to make multiple visits to the doctor because of the anxiety they felt and of the physical symptoms described earlier. Slide 9:
Generalized anxiety disorder is considered to be a potentially chronic illness, fluctuating in symptom severity over time as evidenced by longitudinal studies in treatment seeking patients. Patients with an early onset of disease tend to have a more protracted course of illness and present with comorbid depression and other disorders. On the other hand, patients with late onset usually present abruptly and is associated with clearly identifiable stressors in life. Patients with both generalized anxiety disorder and major depression are shown to have greater impact function and a worse prognosis. Slide 10:
So what do we do in a clinic when a patient with suspected generalized anxiety disorder presents to us? The assessment of such a patient should include a careful history to evaluate for symptoms of generalized anxiety disorder as well as alternative or comorbid psychiatric disorders. We should assess for the possibility of substance abuse since it is a major concern in patients with generalized anxiety disorder. We should also find out more about the psychiatric history of the patient's family because as discussed earlier, genetic factors appear to predispose one to the development of generalized anxiety disorder. Lastly, social history is also of utmost important as it helps to screen for stressful life events that could have accounted for the patient's anxiety symptoms. In addition to a comprehensive history, a complete physical examination as well as appropriate blood tests is to be conducted to rule out any organic causes of anxiety. Slide 11:
After assessment and evaluation of the patient, we need to consider what are some of the differential diagnoses. Because the majority of the anxiety symptoms are not specific to generalized anxiety disorder, it is important to exclude the other mental disorders before making the diagnosis. Differentials that we need to consider include depression and in which distinguishing generalized anxiety disorder from major depression or dysthymia may be difficult as they share common features such as an insidious onset, protracted cause, prominent dysphoria, and anxiety symptoms. Other differentials that we need to entertain include hypochondriasis, as well as panic disorder. Slide 12:
So how do we treat patients with generalized anxiety disorder? Generalized anxiety disorder can be effectively treated with medications, psychotherapy, or a combination of the two modalities. Slide 13:
For pharmacotherapy, the selective serotonin re­uptake inhibitors, SSRI's, or the serotonin norepinephrine reuptake inhibitors, the SNRI's, are the first line medication treatment for generalized anxiety disorder. It is recommended for patients with good clinical response to an SNRI or a SSRI to continue the medication for at least 12 months. The second line medications include the tricyclic anti­depressants, benzodiazepines, and pregabalin. And it should be noted with caution that benzodiazepines are to be avoided in patients with a history of substance abuse. Slide 14:
For non­pharmacotherapy treatment, cognitive behavior therapy, which is a multimodal intervention, is recommended. Specific techniques used in therapy include education, self­monitoring, relaxation training, cognitive restructuring, exposure to imagery and anxiety­producing situations, as well as relapse prevention. Therapy is generally provided in 10 to 15 sessions lasting 60 minutes each. However, additional sessions can be conducted depending on the patient's level or severity of disease, the presence of comorbidity, patient's resistance to the treatment approach, as well as the therapist's competence. Slide 15:
So in summary, generalized anxiety disorder is characterized by excessive worry and anxiety that are difficult to control, causes significant distress and impairment, and occur on more days than not for at least six months, as described in the DSM V. It is a relatively common disorder, most often with onset during adulthood, and has a chronic course of disease. However, it can be effectively treated with medications, cognitive behavioral therapy, or a combination of the two modalities. Slide 16:
Here are some references which I have used for those who are interested to find out more. Slide 18:
Thank you very much.