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 1st 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(pseudo
ephedrine ,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 of 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

45. REFRRENCE
• Kessler RC et al. Arch Gen Psychiatry. 1994;51:8 DSM-IV. Washington,
DC: American Psychiatric Association, 1994
• Fernandez et al. J Clin Psychiatry. 1995;56(suppl 2): 20–29.Kirkwood
et al. Anxiety disorders. In: DiPiro et al, eds. Pharmacotherapy: A
Pathophysiologic
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• Coplan et al JCP 154 (supp) 63-74,1993; Pollack et al, Biol Psychiatry
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• Generalized Anxiety Disorder by R. Bruce Lydiard

46. REFRRENCE
• Buist A, Gotman N, Yonkers K. Generalized anxiety disorder: course and
risk factors in pregnancy. J Affect Disord 2011;131:277-83
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pregnancy and postpartum. Psychiatr Clin North Am 2010;33:273-93.
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dwelling elderly: prevalence and clinical characteristics. J Affect Dis
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disorder. Harv Rev Psychiatry 2016;24:243-56.

47. REFRRENCE
• Katzman M, Bleau P, Blier P, et al. Canadian clinical practice
guidelines for the management of anxiety, posttraumatic stress and
obsessive-compulsive disorders. BMC Psychiatry 2014;14(suppl
1):S1-S83
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burden of generalized anxiety disorder in North America and Europe.
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48. REFRRENCE
•Nita V Bhatt, Anxiety Disorders Clinical ; Medscape May
17, 2018
•Anxiety disorders by Katherine A Tacker
•Paul H. Philip C. Tom B. Mina F. Shorter oxford textbook
of psychiatry .7th .Oxford university press ; United
kingdom ; 2018
•Anxiety disorders: Screening and referral
https://www.porticonetwork.ca