Generalised anxiety disorder

 

Diagnosis of GAD

The DSM-5 criteria for a diagnosis of GAD includes the following symptoms for at least 6 months:

  • Excessive worry about everyday issues in a manner in which anxiety is disproportionate to risk
  • At least 3 of the following:
    • Nervousness/restlessness
    • Fatigue and tiredness all the time
    • Poor concentration
    • Irritability 
    • Muscle tension e.g. in neck and shoulders – this can manifest as tension headaches
    • Disturbed sleep or insomnia

A validated questionnaire can be used to help identify the presence of these features, including:

  • The GAD-2 questionnaire 
  • The GAD-7 questionnaire 
    • 7 questions scoring 0-3
      • 5 = mild GAD
      • 10 = moderate GAD
      • 15 = severe GAD

 

Management of Generalised Anxiety Disorder

NICE recommend the following stepwise process in the management of GAD

Step 1: Education and active monitoring

Step 2: Low-intensity psychological intervention 

  • Individual, non-facilitated self help
  • Individual guided self help
  • Psychoeducational groups - group therapy based on CBT principles 

Step 3: For patients with GAD with marked functional impairment OR GAD which has not responded to steps 1 and 2 - offer high-intensity psychological intervention OR pharmacological intervention

  • Psychological interventions include
    • Individual high intensity CBT 
    • Applied relaxation - A therapy which focuses on relaxing mind and muscles in situations that would normally trigger anxiety
  • Pharmacological management
    • 1st Line: SSRI – Sertraline
    •  2nd line: Alternative SSRI (escitalopram/paroxetine) or SNRI (duloxetine/venlafaxine)
      • If these are contraindicated consider pregabalin 

Step 4: Specialist referral

Note: Current guidance states that if the patient is improving with an antidepressant, it should be continued for at least 12 months to reduce the risk of relapse.

 

Panic disorder

Panic disorder is a type of anxiety disorder characterised by sudden attacks of panic. These can occur at any time and for no clear reason. Symptoms/signs include:

  • Palpitations and tachycardia 
  • N&V
  • Chest pain
  • Hyperventilation/ SOB
  • Paraesthesia

Management - NICE guidance:

NICE advocates a stepwise approach 

Step 1: Recognition and diagnosis of panic disorder

Step 2: Management within primary care – either:

  • Mild to moderate panic disorder:
    • Low intensity interventions - individual facilitated/non-facilitated self-help
  • Moderate to severe panic disorder:
    • CBT or
    • An antidepressant - SSRI (sertraline) 

Nb. In panic disorder, after improvement, continue the antidepressant for a minimum of 6 months before tapering, to reduce the risk of relapse.

  

Agoraphobia

An anxiety disorder which is characterised by an irrational fear of open spaces and crowds. Patients have a phobia of leaving home, for fear of being in situations where there is no immediate safe place to escape to. 

 

References and Further Reading 

 

NICE CKS: Generalised Anxiety Disorder [2023]. Available at URL: https://cks.nice.org.uk/topics/generalized-anxiety-disorder/

 

NICE: Generalised Anxiety Disorder and Panic Disorder in Adults [CG113] 2020. Available at URL: https://www.nice.org.uk/guidance/cg113/chapter/Recommendations#principles-of-care-for-people-with-panic-disorder