Generalised anxiety disorder (GAD)
GAD is one of the most commonly diagnosed mental health disorders and its symptoms and consequences put pressure on both general practice and emergency departments. It is generally defined as chronic, excessive worry lasting more than six months which is having a disruptive impact on a person’s life. GAD does not include anxiety that is part of another mental health disorder, a result of substance misuse or another health condition (e.g. hyperthyroidism). However, it often occurs in association with major depression. Its management involves a stepped approach including both pharmacological and psychological therapies.
Aetiology
It is not clear exactly what causes GAD and what processes in the brain have become disrupted. It appears to be multifactorial. It often follows past traumatic events, has a genetic component and is more common in those with long term health issues. As well as being caused by drug and alcohol misuse, it can also precipitate these problems. It can also be triggered by regular life stressors, like unemployment, relationship issues and work stress. Psychological management often tries to identify possible triggers.
Diagnosis
The Diagnostic and Statistical Manual of Mental Disorders defines 6 key symptoms of GAD of which three must be present for a diagnosis. These are restlessness or nervousness, easily fatigued, poor concentration, irritability, muscle tension and sleep disturbance. There are autonomic symptoms such as sweating, dizziness or light-headedness, palpitations and nausea.
Management
The first step should be patient education through leaflets and signposting to resources. The arrangement of active monitoring of symptoms should be set up. In the case of a comorbid disorder such as depression, the primary disorder should be managed first.
First line management involves various low intensity psychological interventions guided by patient preference. These are for patients with symptoms but only minor functional impairment. These include:
- Individual non-facilitated or guided self-help. This is usually based on cognitive behavioural therapy principles (CBT) and should be attempted for at least 6 weeks.
- Group therapy. This is also based on CBT sessions and consists of groups of up to twelve people supported by one therapist. This should also be attempted for 6 weeks.
Second line management (the starting point if the patient presents with marked functional impairment) includes:
- High intensity psychological therapy such as individual CBT sessions, for 1 hour weekly lasting at least three months.
- Pharmacological treatments are detailed in the table below. It is worth noting that psychotherapy and pharmacological therapy can be combined.
Pharmacological management in primary care
It is usually advised that treatments be tried for 3 months before assessing effectiveness but patients should be seen after 1 month to assess for adverse effects.
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Selective serotonin reuptake inhibitors (escitalopram, paroxetine) |
The most common first line treatment for GAD. These increase the concentration of serotonin at the synapses by preventing its reuptake by the neurons via the serotonin transporter in the presynaptic terminal. Thought to be beneficial to mood, emotion, and sleep. Two different ones may be tried. Escitalopram is the preferred drug in this class for GAD. |
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Selective serotonin-noradrenalin reuptake inhibitors (duloxetine, venlafaxine) |
These increase both the serotonin and noradrenaline concentration in the synapses. Venlafaxine has been shown in trials to have a much greater benefit versus placebo. |
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This is an anticonvulsant which has been shown to have beneficial effects on anxiety versus placebo. Thought to have calming effect on ‘over-excited’ presynaptic neurons. Can be used alone or as an augmenting agent with other drugs. |
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Tricyclic antidepressants |
Traditionally used to treat GAD. However, have higher rate of adverse events than other agents listed. Imipramine and clomipramine are the preferred agents for anxiety. Caution should be used in patients with suicide ideation as potentially fatal in overdose. |
Additional pharmacological management in secondary care
These drugs tend to only be for patients who are being managed by a specialist.
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Benzodiazepines (diazepam) |
Useful both for GAD and panic disorders. Appears to have particularly beneficial effects on any autonomic symptoms. Tolerance and dependence are potential issues. |
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Second generation antipsychotics (quetiapine) |
Traditionally used to treat psychotic disorders, at lower doses has been shown to be beneficial. However, there is an increased risk of discontinuation due to adverse effects. Not licensed for this use in many countries. Risk of elongated QTc. |
Scenario: Management of a person with generalized anxiety disorder
This a guide from the UK's National Institute for Health and Care Excellence (NICE) that describes best practice in managing adult patients with generalized anxiety disorder.
Treatment of anxiety disorders
This is a published article (from 2017) that summarizes best practice in the treatment of anxiety disorders, including generalized anxiety disorder.
This is an online resource, produced by the British Medical Journal, that is intended for use by healthcare professionals.