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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