Download Generalised Anxiety Disorder-recognition and diagnosis a general

Generalised Anxiety Disorder-recognition and
diagnosis
a general practice-perspective
Prof André Tylee
MD FRCGP MRCPsych
Section of Primary Care Mental Health
David Goldberg Building
Institute of Psychiatry
Kings College London
Copyright acknowledgement
• Many of the slides in this talk were developed by
a large European panel of GPs and psychiatrists
for “Anxiety in Practice” an educational toolkit on
GAD for GPs funded by Pfizer (AT was chair).
Pfizer have kindly given permission for use in this
session.
Overview of GAD
Background: the condition
GAD is:
Common – accounts for up to 10% of mental disorders
seen in primary care1
Disabling – affects patients physical and emotional
functioning2
Costly – people with GAD have twice as many visits to
primary care physicians as those without GAD3
1. Lieb R, et al. Eur Neuropsychopharmacol 2005;15:445–52; 2. Wittchen HU et al. J Clin Psychiatry 2002;63 (Suppl 8):24–34;
3. Wittchen HU. Depress Anxiety 2002;16:162–71.
How common is GAD?
Prevalence
12-month prevalence in general population is 3.1%1
Lifetime prevalence in general population is 5.1%1
Prevalence of anxiety disorders in the UK is estimated at 17-95 per
1,000 people depending on age2
Primary
care
Most frequent anxiety disorder in primary care3
Mean 1-month prevalence 7.9%4
Affects women more than men, especially in midlife3
Gender
Lifetime prevalence in those over 45 years old: 3.6% (men) vs. 10.3%
(women)3
12-month prevalence ratio 1:2.2 males:females5
Course
Frequently chronic3
Substantial co-occurrence, especially with depression3
Social disability as severe as with chronic physical diseases4
Low remission rates6
Symptoms wax and wane at different times3
Often co-occurs with other psychological disorders and physical
conditions7
1. Wittchen H-U, et al. Arch Gen Psychiatry 1994;51:355–64; 2. Kings Fund 2011. Paying the Price: The cost of mental health care in England to 2026; 3. Wittchen H-U. Depress Anxiety
2002;16:162–71; 4. Maier W, et al. Acta Psychiatr Scand 2000;101:29–36; 5. Vesga-López O, et al. J Clin Psychiatry 2008;69:1606–16; 6. Yonkers KA, et al. Br J Psychiatry 2000;176:544–9;
7. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed, text revision. Washington DC: American Psychiatric Association; 2000.
Patients with GAD are frequent users of
primary care resources
Primary care
Average number of
visits/year
20
Specialist (outpatient)
15
15
14
10
7
5
3
4
2
0
No generalised anxiety
disorder or MDE
(n=16,023)
Pure generalised anxiety
disorder or MDE
(n=666)
MDE, major depressive episode
Wittchen H-U. Depress Anxiety 2002;16:162–71; Wittchen H-U, et al. J Clin Psychiatry 2002;63(Suppl 8):24–34.
Generalised anxiety
disorder and MDE
(n=278)
Lifetime prevalence of generalised anxiety
disorder increases with age
12
Male
Lifetime prevalence (%)
10
10.3%
Female
8
7.2%
7.1%
6.6%
6
4.7%
4.6%
3.6%
4
3.6%
2.5%
2
1.5%
0
15–24
25–34
35–44
Age (years)
Wittchen HU, et al. Arch Gen Psychiatry 1994;16:162–71.
≥45
Total
GAD: burden of illness
GAD is associated with quality of life
impairment
P<0.05, GAD vs no GAD for all domains
P<0.05, GAD vs MDD for general health,
mental health, emotional role, vitality
Wittchen HU et al. Int Clin Psychopharmacol 2000;15:319–328.
GAD patients in primary care: difficulty with usual
activities in past 4 weeks
No difficulty
16%
Incapacitated
2%
Much difficulty
26%
Over 50% of
patients had at
least some
difficulty
A little difficulty
26%
Some difficulty
30%
Data from PCAP (n=142), USA
Maki et al. APA presentation, 2003.
Work impairment is greater in GAD than other
chronic conditions
12
10
Days work impairment* in past month
9.8
9
8.3
8.3
Mean days
8
7.7
7.6
Asthma
Diabetes
6
4
2
0
GAD
MDD
Data from Midlife Development in the US survey (MIDUS)
*Work impairment based on work loss days and work-cutback days
Kessler RC, et al. In: Rossi AS, editor. Chicago: University of Chicago Press. pp403–26.
Hypertension/s
troke
Arthritis
Recognition of GAD
GAD often not recognised in primary care
Mental disorder recognised
but generalised anxiety
disorder not diagnosed
Mental disorder not recognised
28%
38%
34%
Specific generalised anxiety
disorder diagnosis
Survey conducted in Germany (n=558 physicians)
Patients (n=17,739) completed a diagnostic screening questionnaire for GAD (5.3% had
generalised anxiety disorder [DSM-IV])
Wittchen HU. J Clin Psychiatry 2002;63(Suppl 8):24–34; DSM-IV, Diagnostic and Statistical Manual of Mental Disorders, 4th ed,
criteria
Recognition of GAD
Generalised anxiety disorder is diagnosed in
approximately one-third of patients with the disorder1
Low rate of diagnosis can be attributed to several
factors2:
competing demands and time pressures during
consultation
Investigating physical symptoms
waxing and waning symptoms
co-occurrence with other anxiety and depressive disorders
1. Wittchen H-U, et al. J Clin Psychiatry 2002;63(Suppl 8):24–34; 2. Culpepper L. J Clin Psychiatry 2002;63(Suppl 8):35–42.
Overlap in symptoms between generalised
anxiety disorder and depression
Generalised anxiety
disorder
Anticipatory anxiety
Uncontrollable worry
Irritability
Muscular tension
Tension pains
Physical symptoms
Major depressive
disorder
Fatigue
Poor concentration
Sleep disturbances
Restlessness
Agitation
Depressed mood
Apathy
Withdrawal
Loss of interest
Worthlessness/guilt
Weight loss
Suicidality
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed, text revision. Washington DC:
American Psychiatric Association; 2000.
Anxiety is often not the primary complaint
in GAD
Few patients with generalised anxiety disorder
seek help because anxiety is their primary complaint
60
47.8%
Patients (%)
50
40
34.7%
32.5%
26.8%
30
20
15.5%
13.3%
10
0
Anxiety
Physical
symptoms
Pain
Wittchen H-U, et al. J Clin Psychiatry 2002;63(Suppl 8):24–34.
Depression
Insomnia
Follow-up
consultation/
prescription renewal
GAD often co-occurs with other anxiety and
psychiatric disorders: lifetime prevalence
Percentage of population with generalised anxiety disorder
100
Generalised anxiety disorder (%)
90
80
71.6%
70
60
60.9%
57.8%
50
40
37.7%
34.0%
30
34.3%
21.8%
20
10
0
Any other
anxiety
disorder
Social
phobia
Panic
disorder
Data from international surveys in 4 countries (DSM-III-R criteria)
Subset of population with generalised anxiety disorder
Kessler RC, et al. Psychol Med 2002;32:1213–25.
Any
mood
disorder
Major
Dysthymia
Any
depression
substance use
disorder
Diagnosis of GAD
DSM-IV diagnostic criteria for GAD
Criteria
A: Excessive anxiety and worry (apprehensive expectation) occurring more days than not
for at least 6 months, about a number of events or activities
B: The individual finds it difficult to control worry
C: The anxiety and worry are associated with three (or more) of the following six symptoms
(with at least some symptoms present for more days than not for the past 6 months):
1) Restlessness or feeling keyed up or
on edge
4) Irritability
2) Being easily fatigued
6) Sleep disturbance (difficulty falling asleep,
staying asleep or restless unsatisfying sleep)
3) Difficulty concentrating or mind
going blank
5) Muscle tension
D: The focus of the anxiety and worry is not confined to features of another axis 1 disorder
E: The anxiety, worry or physical symptoms cause clinically significant distress or
impairment in social, occupational or other important areas of functioning
F: The disturbance is not due to the direct physiological effects of a substance (e.g. a drug of abuse, a
medication) or a general medical condition (e.g. hyperthyroidism), and does not occur exclusively
during a mood disorder, a psychotic disorder or a pervasive developmental disorder
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed, text revision. Washington DC: American Psychiatric Association; 2000.
ICD-10 classification for GAD
Anxiety is generalised and persistent, and is not associated with a particular environmental
circumstance (i.e. it is free-floating)
The sufferer must have primary symptoms of anxiety most days for at least several weeks
at a time, and usually lasting several weeks
These symptoms should usually involve elements of:
a) Apprehension (worries about future misfortunes, feeling ‘on edge’, difficulty in
concentrating)
b) Motor tension (restless fidgeting, tension headaches, trembling, inability to relax)
c) Autonomic over activity (light headedness, sweating, tachycardia, or tachypnoea,
epigastric discomfort, dizziness, dry mouth, etc.)
In children, frequent need for reassurance and recurrent somatic complaints may be
prominent
The transient appearance (for a few days at a time) of other symptoms, particularly
depression, does not rule out generalised anxiety disorder as a main diagnosis, but the
sufferer must not meet the full criteria for depressive episode (F32), phobic anxiety
disorder (F40), panic disorder (F41.0), or obsessive–compulsive disorder (F42)
Includes: Anxiety neurosis, anxiety reaction, anxiety state. Excludes: Neurasthenia
World Health Organization. International Classification of Diseases. 10th revision. Geneva: World Health Organization; 1992.
BAP guidance for exploring a suspected
anxiety disorder
Specific anxiety-related symptoms and impaired function
Yes
Also moderate/severe depression?
Persistent anxiety symptoms
despite adequate
trial of antidepressant
treatment
No
Trauma history
and
flashbacks?
Check for
post-traumatic
stress disorder
Obsessions
with/without
compulsions
Check for
obsessive–
compulsive
disorder
Treat depression
Uncontrollable
worry about
several areas
Intermittent panic/anxiety attacks
and avoidance
Fear of social
scrutiny
Discrete object/
situation
Some uncued/
spontaneous
Check for
social phobia
Check for
specific phobia
Check for
panic disorder
Check for
generalised
anxiety
disorder
Note: more than one anxiety disorder may
be present in an individual concurrently
Adapted from Baldwin D, et al. J Psychopharmacol 2005;19:567–96.
Screening tools for
generalised anxiety
disorder
GAD-2: screening questionnaire
Over the last 2 weeks, how often have you been
bothered by the following problems?
Not at
all
Several
days
More than
half the
days
Nearly
every
day
1
Feeling nervous, anxious or on edge
0
1
2
3
2
Not being able to stop or control worrying
0
1
2
3
Total score =
=
Add columns
+
+
A quick and easy to use screening tool for generalised anxiety
disorder
A cut-off value of 3 has a sensitivity of 86% and a specificity of 83%
for generalised anxiety disorder
If the total score is ≥3 then refer to other screening and diagnostic
tools to make a definitive diagnosis of GAD
Kroenke K, et al. Med Care 2007;146:317–25.
GAD-7: screening questionnaire
Over the last 2 weeks, how often have you been
bothered by the following problems?
Not at
all
Several
days
More than
half the
days
Nearly
every
day
1
Feeling nervous, anxious or on edge
0
1
2
3
2
Not being able to stop or control worrying
0
1
2
3
3
Worrying too much about different things
0
1
2
3
4
Trouble relaxing
0
1
2
3
5
Being so restless that it is hard to sit still
0
1
2
3
6
Becoming easily annoyed or irritable
0
1
2
3
7
Feeling afraid as if something awful might
happen
0
1
2
3
Total score =
=
Add columns
+
+
If you checked off any problems, how difficult have these problems made it for you to do your work, take
care of things at home or get along with other people?
Not difficult at all
Somewhat difficult
Spitzer RL, et al. Arch Intern Med 2006;166:1092–7.
Very difficult
Extremely difficult
Interpreting the GAD-7 results
GAD-7 score
0–4
5–9
10–14
15–21
Level of anxiety Intervention
Minimal
–
Mild
–
Undertake
Moderate
diagnostic
Severe
evaluation
Detects a probable diagnosis of generalised anxiety disorder
A cut-off score of 10 points demonstrates strong sensitivity (89%)
and specificity (82%) for generalised anxiety disorder
Spitzer RL, et al. Arch Intern Med 2006;166:1092–7.
Hospital Anxiety and Depression Scale
(HADS)
Feelings in the past week
1
2
3
4
5
I feel tense or ‘wound up’
I still enjoy the things I used to
enjoy
I get a sort of frightened feeling
as if something awful is about to
happen
I can laugh and see the funny
side of things
Worrying thoughts go through
my mind
8
I feel as is if I am slowed down
9
I get a sort of frightened feeling
like ‘butterflies’ in the stomach
10
I have lost interest in my
appearance
I feel restless as if I have to be
on the move
I look forward with enjoyment
12
to things
11
6
I feel cheerful
13 I get sudden feelings of panic
7
I can sit at ease and feel relaxed
14
I can enjoy a good book or radio
or television programme
= anxiety items;
= depression items
Each item scored 0 to 3 with some ‘reverse’ scoring; HADS anxiety and depression subscales 0–21
Zigmond A, Snaith RP. Acta Psychiatr Scand 1983;67:361–7..
Hospital Anxiety and Depression Scale
(HADS)
•
•
•
•
•
•
Self-administered questionnaire1
Two subscales: one for anxiety and one for depression1
– Each subscale comprises seven items
– Four-point rating: 0–3 with some reverse scoring; range
0–
21
Both subscales evaluate psychic symptoms, not physical symptoms1
Anxiety subscale focuses on generalised anxiety1
Depression subscale focuses on lost interest and diminished
pleasure1
Subscale scoring: 0–7 = normal; 8–10 = mild;
11–14 = moderate;15–21 = severe symptoms2
1. Zigmond A, Snaith RP. Acta Psychiatr Scand 1983;67:361–70; 2. Cameron IM, et al. Br J Gen Pract 2008;58:32–36.
Conclusion
• GAD presents in a variety of symptoms
• Commonly co- morbid
• The frequent co-occurrence with other
disorders can cause the diagnosis of
generalised anxiety disorder to be
overlooked
• The GAD-2 and GAD-7 are validated
screening tools to help with the
recognition of GAD