Assessment and management of generalized anxiety disorder

generalized anxiety disorder is very common in primary health care settings .patients usually have somatic complaints and they do not attribute these symptoms to anxiety.the doctor needs to have a high index of suspicion to be able help the patients.

1. ASSESSMENT AND MANAGEMENT OF GENERALIZED ANXIETY DISORDER DR OGECHUKWU MBANU FAMILY MEDICINE DEPARTMENT AKTH KANO NIGERIA 05 /12 /18

2. outline Introduction ICD- 10 classification Diagnostic criteria – ICD –10 DSM –5 Criteria Epidemiology Risk factors Pathophysiology Symptoms of anxiety Presentation at GOPD History Physical examination Laboratory investigations Scales and screening Treatment Differential diagnosis Co – morbid conditions When to refer Prognosis Summary reference

3. INTRODUCTION Generalized anxiety disorder is anxiety, which is generalized and persistent but not restricted to, or even strongly predominating in, any particular environmental circumstances it is said to be "free-floating“ complaints of continuous feelings of nervousness, trembling, muscular tension, sweating, lightheadedness, palpitations, dizziness, and epigastric discomfort are common

4. INTRODUCTION –2 Anxiety is a ‘normal’ phenomenon It is characterised by a state of apprehension or unease arising out of anticipation of danger. Fear is an apprehension in response to an external danger On the other hand in Anxiety danger is largely unknown (or internal). Normal anxiety becomes pathological when: it causes significant subjective distress and /or impairment in functioning of an individual. Anxiety disorders are common among patients in primary care

5. ICD – 10 Part of the disorders classified under F41 – Other anxiety disorders Sub group under the broad group of NEUROTIC , STRESS – RELATED AND SOMATOFORM DISORDERS ( F40 – F48 ) F41 – includes : F41.0 Panic disorder [episodic paroxysmal anxiety] F41.1 Generalized anxiety disorder F41.2 Mixed anxiety and depressive disorder F41.3 Other mixed anxiety disorders F41.8 Other specified anxiety disorders F41.9 Anxiety disorder, unspecified

6. DIAGNOSTIC CRITERIA – ICD 10 primary symptoms of anxiety most days for at least several weeks at a time, usually for several months. should involve elements of: (a )apprehension (worries about future misfortunes, feeling "on edge", difficulty in concentrating, etc.); (b) motor tension (restless fidgeting, tension headaches, trembling, inability to relax); (c) autonomic overactivity (lightheadedness, sweating, tachycardia or tachypnoea, epigastric discomfort, dizziness, dry mouth, etc.). In children, frequent need for reassurance and recurrent somatic complaints may be prominent must not meet the full criteria for depressive episode , phobic anxiety disorder, panic disorder , or obsessive-compulsive disorder

7. DSM – 5 CRITERIA Excessive worry and about a number of events and activities for at least 6 months The worry is difficult to control Associated with at least three of the following core symptoms: Feeling restless , or on edge Fatiguing easily Difficulty concentrating or the mind going blank Irritability Increased muscle tension Difficulty falling asleep, staying asleep, or restlessness Only one item is required in children symptoms cause significant distress or impairment problems are not attributable to a physical ailment problems are not explained by other mental disorders

8. Epidemiology of GAD Lifetime prevalence ~ 31% 12-month prevalence ~ 3% Women > men 2:1 Modal age of onset is early 20s High comorbidity in clinical and community samples. : “Pure” GAD is rare.

9. RISK FACTORS Chronic medical conditions Low socio economic status Female sex Intolerance to uncertainty Early childhood adversity Family history (there is some heritability component to GAD)

10. PATHOPHYSIOLOGY Psychological Theories Psychological theories form the basis of several therapeutic approaches Worry is the cognitive response to fear and anxiety It involves negative mental images and emotions. Worry appears to be an attempt at self protection from the more catastrophic consequences of the object of anxiety The individual may falsely view worry as an effective coping mechanism. Worry, however, becomes pathologic when it is excessive and is a core feature of GAD.

11. PATHOPHYSIOLOGY -- 2 Neurobiological Theory Connections between the amygdala and areas of the prefrontal cortex regulate the experience of fear and the resulting psychological responses. Motor responses may be controlled by connections with the periaqueductal region of the brain when this system is not regulated appropriately, a clinical anxiety syndrome may result. worry, may be regulated by cortico- striato - thalamo -cortical circuitry (CSTC) These circuits involve neurotransmitters and receptors that may be targets for pharmacotherapy

12. Symptoms of anxiety Psychological arousal Fearful anticipation , Irritability Sensitivity to noise , Restlessness Poor concentration Worrying thought Muscle tension Tremor . Headache Aching muscles Hyperventilation Dizziness Tingling in the extremities Feeling of breathlessness Sleep disturbance Insomnia , Night terror Autonomic arousal Gastrointestinal Dry mouth Difficulty in swallowing Epigastric discomfort Excessive wind Frequent or loose motions Respiratory Constriction in the chest Difficulty inhaling

13. Symptoms of anxiety – 2 (Autonomic arousal continued) Cardiovascular Palpitations Discomfort in the chest Awareness of missed beat Genitourinary Frequent or urgent micturition Failure of erection Menstrual discomfort

14. PRESENTATION AT THE GOPD Patients may not disclose their symptoms They may focus on somatic complaints and not attribute them to anxiety High index of suspicion and provision of appropriate screening and diagnostic workups Some of the complaints : Gastrointestinal distress Insomnia Fatigue Muscle aches and tension , backaches Headache Cardiovascular complaints

15. HISTORY To rule out anxiety disorders secondary to general medical or substance abuse conditions Review use of: Caffeine-containing beverages (coffee, tea, colas), Over-the counter medications (aspirin with caffeine, sympathomimetics) Herbal “medications,” or street drugs chronicity, course and severity of prior episodes, precipitating factor

16. HISTORY – 2 Are there medical or other conditions that would affect treatment selection? How functionally impaired is the patient Assess for suicide particularly if co – occurring with depression suicidal ideation , suicidal intent , suicide attempt , thoughts of homicide Accessibility to weapons

17. MENTAL STATE EXAMINATION A complete mental status examination should be obtained Appearance: restlessness cooperative Behavior: possible psychomotor agitation, tremor/fidgety/hyper-vigilant Speech: often pressured but interruptible (vs manic speech which is often unable to be interrupted or redirected). Alternatively, a severely anxious person may not speak at all! Mood Mood may be normal. anxious or depressed

18. MENTAL STATE EXAMINATION Affect: likely congruent with mood, anxious, scared, labile, irritable Thought : perseverative, ruminative, circumstantial worries, concerns regarding danger Suicidal / homicidal thoughts Cognition: Poor concentration oriented Insight/Judgment: There is insight Judgment may however be impaired

19. PHYSICAL EXAMINATION Vitals: BP, Pulse, and RR elevated Skin: piloerection, clammy, diaphoretic ,sweaty palms Neurological : pupillary dilatation diffuse hyper- reflexia / but down-going toes

20. LABORATORY INVESTIGATIONS EKG (especially if > 40 years old with chest pain or other cardiac symptoms) CXR EEG PFTs Thyroid function test FBC Upper GI Endoscopy RBS Endocrinological studies (Cushing's – dexamethasone suppression ,pheochromocytoma ) Blood alcohol levels

21. SCALES AND SCREENING Hospital and Anxiety Rating Scale Patient rated 14 items 7 items for anxiety 7 items for depression Equivalence to Hamilton Anxiety Scale shown in large patient sample Beck Anxiety Inventory (BAI) SR 21 items, each scored up to 3 Cut-offs: <7 minimal; 8-15 mild; 16-25 moderate; 26-63 severe Hamilton Rating Scale (HAM-A ) To assess severity OR Traditionally used in clinical trials 14 items, each scored 0-4 Cut-offs: <17 mild; 18-24 mild/moderate; 25-30 moderate/severe Generalized Anxiety Disorder 7-Item scale (GAD-7) Penn State Worry Questionnaire

22. TREATMENT GOALS – ACUTE TREATMENT Reduce severity of symptoms Achieve remission Improve functional status Minimize adverse drug reactions MAINTENANCE TREATMENT Prevent relapse Improve quality of life Minimize adverse drug reactions

23. Treatment options A ) PSYCHOTHERAPY B ) Medications Medications do not cure anxiety disorders They suppress activity in the amygdala and other areas of the brain psychological therapy, probably in an ongoing manner is usually required combination of these two modalities is commonly suggested.

24. PSYCHOTHERAPY Cognitive Behavioral Therapy (CBT) Thought stopping/Substitution Identifying misconceptions relaxation therapy cognitive restructuring, self-monitoring techniques Sleep hygiene Exercise

25. GAD TCAs Buspirone BZDs SNRIs SSRIs PHARMACOTHERAPY Adjuncts

26. GAD Treatments SSRIs and SNRIs Advantages Effective Safety Tolerability No dependence Once-daily dosing DISADVANTAGES Early anxiogenic effects Delayed onset of action Sexual side-effects Dose titration (often) Discontinuation Sx

27. GAD Antidepressant Dosing categoryc Dosage range (mg /d) SSRIs fluoxetine 20 -60 sertraline 100 - 200 paroxetine 20 -40 fluvoxamine 100 - 300 citalopram 20 - 40 escitalopram 10 - 20 SNRIs venlafaxine 75 - 225 duloxetine 60 - 120 TCAs imipramine 100 - 300 clomopramine 50 - 100

28. Treatment Benzodiazepines ADVANTAGES Rapid onset Effective Well-tolerated General anti-anxiety effects Safe in overdose Generics available DISADVANTAGES Withdrawal reactions Sedation Multiple daily dosing often required except clonazepam Abuse potential in patients w/ Hx drug abuse Antidepressant effect unreliable

29. GAD Treatment Benzodiazepines Agent Daily Dosage Benzodiazepines Range(mg) Alprazolam 2-6 Clonazepam 1-3 Lorazepam 4-10 Diazepam 15-20

30. GAD TREATMENTS – OTHER OPTIONS /ADJUNCTS Beta blocker Often propranolol ( Inderal ) Alpha agent prazosin, clonidine • Anticholinergic diphenhydramine ( Benadryl ), hydroxyzine ( Vistaril ) • Antipsychotic typical or atypical agent

31. STRATEGIES FOR REFRACTORY GAD Review psychosocial variables for stress management Add CBT Evaluate treatment intensity Dose and duration of antidepressant Rx? Switch to a second SSRI/antidepressant Add any of the following : benzodiazepine buspirone Anticonvulsants Gabapentin, tiagabine, vigabatrin, topiramate, Low dose atypical neuroleptic (olanzapine, quetiapine, ziprasidone others)

32. SPECIAL POPULATIONS – PREGNANCY The prevalence of GAD during any phase of pregnancy is 9.5% Psychotherapy should be as first line SSRIs – premature birth ,low birth weight ,tachypnea , hypoglycemia , temperature instability ,seizures ,persistent pulmonary hypertension Fluoxetine or citalopram might be preferred when treating depression , which may also apply to GAD

33. SPECIAL POPULATIONS – PREGNANCY -2 Benzodiazepines – cleft palate and lip early trimester , floppy baby syndrome (low APGAR) , withdrawal symptoms in late trimester Paroxetine – cardiovascular malformations SNRIs do not appear to be major teratogens but both duloxetine and venlafaxine are associated with  risk of PPH Venlafaxine –  risk of eclampsia Bupropion and buspirone poses little risk of major malformations

34. CHILDREN AND ADOLESCENTS Prevalence of anxiety disorders among children and adolescents is 9%–32% . CBT is first choice SSRIs Sertraline may be a reasonable 1 st line agent Fluexetine with features of depression Paroxetine may increase risk of suicidality in these population

35. GERIATRIC POPULATION common among the elderly Lifetime prevalence in people 65 and older is 11%, with 24.6% having the first episode after age 50 Primarily CBT – is effective Significant risks with psychotropics. Doses in this age group should be half of usual SSRIs considered first-line agents(sertraline and escitalopram preferable).

36. GERIATRIC POPULATION Benzodiazepines  the risk of falls, are sedating, and cause memory impairment. lorazepam or oxazepam may be preferred because of a lower reliance on hepatic metabolism. Buspirone may be effective and is generally well tolerated in older adults.

37. Differential Diagnosis ( DD) Adjustment disorders Anxiety disorders Panic disorder Phobias Post-traumatic stress disorder (PTSD) Obsessive-compulsive disorder (OCD)

38. DD . MEDICATIONS WHICH CAN CAUSE ANXIETY SYMPTOMS Stimulants (caffeine) Anticonvulsants (carbamazepine , ethosuximide) Thyroid supplementation Herbs (ginseng) Antidepressants Antibiotics (quinolones ,isoniazid) Corticosteroids Drugs of abuse (marijuana) Oral contraceptives(estrogens Bronchodilators Sympathomimetics(pseudoephedrine ,phenylephrine) Decongestants Abrupt withdrawal of CNS depressants Alcohol Barbiturates Benzodiazepines

39. DD MEDICAL CONDITIONS WITH SECONDARY ANXIETY SYMPTOMS Endocrine disorders Thyroid disease Parathyroid diseases Hypoglycemia Cushing's Disease pheochromocytoma Cardio-respiratory disorders Angina Pulmonary embolism Asthma or copd Autoimmune disorders Electrolyte abnormalities Neurological Seizure disorder Substance-related dependence/ withdrawal Nicotine Alcohol Benzodiazepines Opioids

40. CO – MORBID CONDITIONS Other anxiety disorders Depression substance abuse/dependence personality disorders

41. WHEN TO REFERR Complicating comorbidity (substance use or dependence, major depressive disorder) Poor response to standard treatment or if the person is significantly impaired Anxious children/adolescents who are too fearful to attend school or to socialize Adults who cannot get to work or maintain usual activities. When there is serious risk of suicide (or risk to others) Unclear diagnosis and need for further comprehensive evaluation Perceived need for psychotherapy Patient’s preferrence

42. PROGNOSIS Need to treat for long term Full relapse in approximately 25% of patients 1 month after stopping treatment 60%-80% relapse within 1st year after stopping treatment Poor prognostic factors : low overall life satisfaction, poor spousal or family relationships, personality disorder comorbidities (both psychological and medical), substance use disorders, and female sex

43. Summary GAD is common Identification o f target symptoms, including physical symptoms is very important Careful evaluation and patient education key aspects of treatment Medication should be given at Adequate dosages for adequate lengths of time Patients May require long-term treatment

44. Thank you for listening

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