Anxiety disorder: generalised

Specialties > General practice

Background knowledge 🧠

Definition

Generalised Anxiety Disorder (GAD) is a chronic mental health condition characterized by excessive, uncontrollable worry about a variety of topics.
Worry is disproportionate to the actual situation, pervasive, and lasts for at least six months.
Accompanied by physical and psychological symptoms that impair daily functioning.

Epidemiology

Lifetime prevalence of GAD is estimated at 5-7% in the general population.
More common in females than males, with a ratio of 2:1.
Typically presents in early adulthood but can occur at any age.
Often coexists with other psychiatric disorders, particularly depression and other anxiety disorders.

Aetiology and Pathophysiology

Multifactorial origin: genetic predisposition, environmental factors, and neurobiological influences.
Dysregulation of neurotransmitters, particularly serotonin, norepinephrine, and gamma-aminobutyric acid (GABA).
Hyperactivity of the hypothalamic-pituitary-adrenal (HPA) axis, leading to excessive stress hormone release.
Chronic stress and early life adversity contribute to the development of GAD.

Types

Generalised Anxiety Disorder (GAD): chronic, pervasive anxiety without specific triggers.
Other related disorders include Panic Disorder, Social Anxiety Disorder, and specific phobias, though they differ in their focus and triggers.
GAD is distinguished by its broad and persistent nature.

Clinical Features 🌡️

Symptoms

Excessive worry about various domains (e.g., work, health, social relationships) that is difficult to control.
Restlessness or feeling keyed up or on edge.
Easily fatigued, difficulty concentrating, or mind going blank.
Irritability, muscle tension, and sleep disturbances (difficulty falling or staying asleep, or restless, unsatisfying sleep).
Physical symptoms often include gastrointestinal discomfort, headaches, and palpitations.
Symptoms cause significant distress or impairment in social, occupational, or other important areas of functioning.

Signs

Physical signs are generally nonspecific and may include muscle tension, tremors, and sweating.
Patients may exhibit an exaggerated startle response.
May appear restless or fidgety during examination.
Often no specific findings on physical examination.

Investigations 🧪

Tests

Primarily a clinical diagnosis based on history and symptoms.
Screening tools: GAD-7 questionnaire commonly used to assess severity.
Rule out other conditions: thyroid function tests, complete blood count, and metabolic panel to exclude medical causes of anxiety.
Consider ECG if palpitations or chest pain are present to exclude cardiac causes.
Psychological assessment may be warranted to evaluate comorbid conditions such as depression.

Management 🥼

Management

First-line: Cognitive Behavioural Therapy (CBT) is the gold standard.
Pharmacological: SSRIs (e.g., sertraline) are first-line medications, followed by SNRIs (e.g., venlafaxine) if SSRIs are ineffective.
Pregabalin is an alternative for patients who do not tolerate SSRIs/SNRIs.
Benzodiazepines may be used short-term for severe anxiety but are not recommended long-term due to dependence risk.
Lifestyle modifications: Regular exercise, sleep hygiene, and stress management techniques.
Patient education and self-help resources (e.g., online CBT) are important for long-term management.

Complications

Increased risk of developing comorbid depression.
Higher likelihood of substance misuse as a coping mechanism.
Chronic physical conditions (e.g., hypertension, cardiovascular disease) may worsen due to ongoing stress.
Impaired social and occupational functioning, leading to decreased quality of life.

Prognosis

Chronic condition with a variable course; many patients experience fluctuating symptoms.
Relapses are common, particularly if treatment is discontinued.
Good response to treatment, particularly CBT and medication.
Prognosis improves with early intervention and adherence to treatment.

Key Points

GAD is a common and chronic mental health condition characterized by excessive, uncontrollable worry.
Early recognition and treatment are crucial to prevent complications.
Management typically involves CBT, SSRIs, and lifestyle modifications.
Prognosis varies, but adherence to treatment significantly improves outcomes.

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