Download Generalized anxiety disorder

A 40-year-old female teacher mother of 8 children
comes to your office with one year history of
dizziness, tinnitus, disturbed sleep, facial
numbness, headache, poor concentration, reduced
appetite, excessive sweating, excessive worries
about her children and home duties,. Symptoms
fluctuate in severity but never disappeared.
On physical examination
BP: 130/70
Pulse: 104/min
-thyroid gland within normal limits and non tender
-her cardiac examination reveals no abnormalities
other than tachycardia
-her neurological examination is normal.
The remainder of P/E is normal.
 Q – 1 What is the most likely diagnosis?
 A- panic disorder.
 B- major depressive disorder.
 C- generalized anxiety disorder.
 D-hyperthyroidism.
 E-hypochondiasis.
Dr. Khalid Saad Al-Ghamdi
 Definition
 Diagnostic criteria
 Prevalence
 Epidemiology
 Risk factors
 Symptoms
 Diagnosis
 Treatment
 Referral indication
Every one experiences feelings of anxiety
during their lifetime.
For example, you may feel worried and
anxious about sitting an examination , or
having a medical test , or job interview .
Feeling anxious sometimes is perfectly normal
For people with generalized anxiety disorder (GAD), feelings
of anxiety are much more constant, and tend to affect their
day- to-day life.
Definition :
Is characterized by excessive worry and anxiety that are
difficult to control and that cause significant distress
and impairment .
In addition patient with GAD may present with somatic
symptoms .
2009 UpToDate
Diagnostic criteria ( from DSM IV ) :
1- Excessive anxiety and worry about a number of events
or activities, occurring more days , not less than 6
months .
2- The person finds it difficult to control the worry .
3- It is associated with several symptoms .
4- It causes significant distress or impairment in daily
live .
American Psychiatric Association, 2009
GAD prevalence is estimated to be between 5 and 8
percent in the primary care setting
2009 Up-to-date
Epidemiology :
The usual age of onset is variable from childhood to
adulthood .
Women two to three times more likely to suffer from
GAD than men .
2009 Up-to-date
Risk factor :
 Stresses of live .
 Fears .
 Substance abuse .
Family history .
2009 Up-to-date
Symptom :
psychological
 Difficulty concentrating .
 Irritability.
 Sleep disturbance .
 Exaggerated response .
 Panic .
 Sensitivity to noise .
2009 Up-to-date
Physical
Motor tension :
 Muscle tension or aching .
 Restlessness.
 Fatigue and tiredness .
2009 Up-to-date
Autonomic over activity :
 Dry mouth .
 Palpitation .
 Sweating / cold hand .
 Difficult swallowing .
 Diarrhoea .
 Frequency of micturition .
 Dizziness .
 Difficulty breathing .
2009 Up-to-date
Diagnosis
1- History .
2- Exclusion of organic disorders .
3- Exclusion of other psychiatric disorder .
American Psychiatric Association, 2009
American Psychiatric Association, 2008
A seven-item anxiety questionnaire (GAD-7) has been
developed and validated in a primary care setting. This
patient self-assessment tool may facilitate screening,
but positive screens (a score of 8 or higher) should be
followed by clinician interview Diagnostic criteria from
the DSM-IV to establish the diagnosis of GAD.
2009 Up-to-date
1.
2.
3.
4.
5.
6.
7.
Feeling nervous, anxious or on edge
Not being able to stop or control worrying
Worrying too much about different things
Trouble relaxing .
Being so restless that it is hard to sit stil.
Becoming easily annoyed or irritable .
Feeling afraid as if something awful might happen
GAD assessment
GAD-7
mild :
5-9
moderate :10-14
sever :
15-21
2009 Up-to-date
Differential diagnosis :
1- Depression .
2- Drug and alcohol dependence .
3- Cardiac arrhythmias .
4- Benzodiazepine dependence .
5- Hyperthyroidism .
6- Caffeine intoxication .
2009 Up-to-date
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Anxiety
Panic attack .
Autonomic
symptom.
Insomnia .
Apprehension .
Worry .
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Depression
Early morning
waking .
Weight loss .
Suicidal thoughts
Feeling of
hopelessness .
Management :
Non-pharmacolgical
pharmacological
Herbal
Reassurance


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Not a serious physical disease , Not insanity , Not lifethreatening
Not a sign of weakness or failure , Not childishness or
overdependence
Set Goals for Therapy
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Decrease level of anxiety and maintain at low level
Modulate future symptom responses
National Institute of Mental Health. Accessed 2009
 Encourage :
 Acceptance of anxiety as a life-long problem
 healthy lifestyle as an adjunct to treatment , Daily Physical
Exercise , Sleep Hygiene, Avoid harmful intakes : Avoid
alcohol , Tobacco , caffeine , Substance Abuse
 Consider new hobbies
National Institute of Mental Health. Accessed 2009
 Psychotherapy
 Teach coping skills and conflict resolution
 Increase self confidence , Increase self control
 Promote emotional growth
 Encourage patient to express themselves
 Practice goal directed behavior
 Redirect energy and creativity
National Institute of Mental Health. Accessed 2009
 Behavioral Therapy
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Progressive muscle relaxation
Relaxation training , stress management
Biofeedback
Systematic desensitization
Breathing retraining (arousal reduction)
 Take a deep breath
 Let breath out through pursed lips
 Cognitive Therapy  Recognize, Reexamine and
replace anxious thoughts
 Meta-analysis : Cognitive behavioral therapy (CBT) is
frequently recommended as first line psychological
treatment for GAD which is more effective reducing
symptoms
Cochrane Database Syst Rev. 2007
 A controlled study of 91 patients with new episodes of
GAD found that family physicians who used brief
supportive psychotherapy had three-month and sixmonth follow-up results similar to those who used
benzodiazepines
2009 Up-to-date
 CBT should be used. A
 CBT should be delivered only by suitably trained and
supervised people who can demonstrate that they adhere
closely to empirically grounded treatment protocols. A
 CBT in the optimal range of duration (16–20 hours in total)
should be offered. A
 For most people, CBT should take the form of weekly
sessions of 1–2 hours and be complete within a maximum of
4 months from commencement. B
 Briefer CBT should be supplemented with appropriate
focused information and tasks. A
Pharmacological Treatment
 First line : ( no abuse or withdrawal symptoms )
 SSRI : paroxitine 20 – 60 mg ( need > 2 weeks to work )
 SNRI: venlafaxine 37.5 – 300 mg ( if + psychosis or
smoking )
 Non-addictive anxiolytics :  Buspirone (Buspar) 15 –
30 mg
 Bupropione : 75 – 150mg
2009 Up-to-date
 Antidepressants
 Several RCTs : have demonstrated the efficacy of
antidepressants in patients with generalized anxiety
disorder, including trials of venlafaxine, paroxetine,
sertraline, citalopram, imipramine, and trazodone.
2009 Up-to-date
 Syst.Rev. : concluded ( NNT = 5 ) with antidepressants
to observe a positive effect.
 five RCTs of venlafaxine for GAD found similar efficacy
and tolerability in younger and older patients.
Venlafaxine may be a particularly good choice for
patients with coexisting psychiatric illness, such as panic
disorder, major depression, or social phobia, or when it is
not clear if the patient has GAD, depression, or both.
2009 Up-to-date
 Unless otherwise indicated, an SSRI should be offered. B
 If one SSRI is not suitable or there is no improvement after a 12-
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

week course, and if a further medication is appropriate, another
SSRI should be offered. D
When prescribing an antidepressant, the healthcare professional
should consider the following.
Side effects on the initiation of antidepressants may be minimised
by starting at a low dose and increasing the dose slowly until a
therapeutic response is achieved. D
In some instances, doses at the upper end of the indicated dose
range may be necessary and should be offered if needed. B
Long-term treatment may be necessary for some people and
should be offered if needed. B
 Alternative Pharmacotherapy
 Tricyclic Antidepressant
 Imipramine(Tofranil) 25 mg – 300 mg
 Desipramine (Norpramin) 25 – 300 mg
 Beta Blockers : Indicated for excessive autonomic
symptoms, or in social phobia : Propranolol (Inderal) ,
Atenolol (Tenormin)
 Long Acting Benzodiazepines : Clonazepam (Klonopin) 0.5
– 6 mg
 acute severe : Short-acting Benzodiazepines :


Alprazolam (Xanax) 0.5 – 10 mg
Lorazepam (Ativan) 0.5 – 6 mg
Herbal
Method
 Studies on the effectiveness of kava kava for the
treatment of GAD have important methodological
flaws and placebo effects are significant . Kava Kava
has been associated with fatal hepatotoxicity and the
FDA has issued a safety alert. We advise against the
use of kava kava for treatment of anxiety.
2009 Up-to-date
indications of referral :
 severe & complicated cases
 child with GAD
 associated with drugs & alcohol dependence
 associated with psychosis
 associated with personality disorders
 GAD is a common problem
frequently seen in primary care .
 Careful history taking and good listening to the patient
help detect this disorder .
 Family physician should be good observer to detect such
cases .
 Immediate treatment should be started ( no need for
psychologist referral )
Thank you