Generalized Anxiety Disorder - Clinicals, Diagnosis, and Management

Anxiety disorders

Clinicals - History

Fact Explanation
Excessive anxiety and worry. Occurring most of the days for 6 month period, about number of events or activities. The intensity and the duration of the anxiety is very much out of proportion to the actual likelihood and the impact of the feared situation. Excessive anxiety and worry. Occurring most of the days for 6 month period, about number of events or activities.
The intensity and the duration of the anxiety is very much out of proportion to the actual likelihood and the impact of the feared situation.
The person finds its difficult to control the worry. Repetitive worrying thoughts are characteristic of generalized anxiety disorder. The person finds its difficult to control the worry.
Repetitive worrying thoughts are characteristic of generalized anxiety disorder.
The anxiety or worry is associated with 3 or more of the following symptoms: restless, feeling keyed up or on edge, being easily fatigued, difficulty in concentrating or mind going blank, irritability, muscle tension, sleep disturbance (difficulty in falling or staying asleep or restless unsatisfying sleep). Patients with poor concentration sometimes complain of poor memory, but true memory impairment does not occur. If it is present, consider the possibility of an organic cause. The anxiety or worry is associated with 3 or more of the following symptoms: restless, feeling keyed up or on edge, being easily fatigued, difficulty in concentrating or mind going blank, irritability, muscle tension, sleep disturbance (difficulty in falling or staying asleep or restless unsatisfying sleep).
Patients with poor concentration sometimes complain of poor memory, but true memory impairment does not occur. If it is present, consider the possibility of an organic cause.
The focus of the anxiety or worry is not confined to features of an Axis 1 disorder. Panic attacks (panic disorder), worry of being embarrassed in public
(social phobia), being contaminated (Obsessive compulsive disorder), worry of being away from home or closed people (separation anxiety disorder), worry about gaining weight (anorexia nervosa), having multiple physical complaints ( somatization disorder) worry about having a serious illness (hypochondriasis).
The focus of the anxiety or worry is not confined to features of an Axis 1 disorder.
Panic attacks (panic disorder), worry of being embarrassed in public
(social phobia), being contaminated (Obsessive compulsive disorder), worry of being away from home or closed people (separation anxiety disorder), worry about gaining weight (anorexia nervosa), having multiple physical complaints ( somatization disorder) worry about having a serious illness (hypochondriasis).
The anxiety, worry or physical symptoms cause clinically significant distress or impairment in function of the person. Social, occupational functioning is impaired. The anxiety, worry or physical symptoms cause clinically significant distress or impairment in function of the person.
Social, occupational functioning is impaired.
The disturbance is not due to a direct physiological effect of a substance (drug abuse, a medication) or a general medical condition (hyperthyroidism) and not exclusively due to another psychiatric disorder (mood disorder, psychotic disorder, pervasive developmental disorder) Substance use/abuse (eg, caffeine, amphetamines, marijuana, cocaine) and withdrawal (eg, from alcohol) can cause anxiety symptoms. And medications with anxiogenic effects (β-adrenergic agonists,theophylline, corticosteroids, thyroid hormone, sympathomimetics,psychostimulants) Hyperthyroidism, Congestive heart failure,
Cardiac arrhythmia, Chronic obstructive pulmonary disease, Hyperventilaton, Pulmonary embolism, Pheochromocytoma, Hyperadrenalism can cause anxiety symptoms.
The disturbance is not due to a direct physiological effect of a substance (drug abuse, a medication) or a general medical condition (hyperthyroidism) and not exclusively due to another psychiatric disorder (mood disorder, psychotic disorder, pervasive developmental disorder)
Substance use/abuse (eg, caffeine, amphetamines, marijuana, cocaine) and withdrawal (eg, from alcohol) can cause anxiety symptoms. And medications with anxiogenic effects (β-adrenergic agonists,theophylline, corticosteroids, thyroid hormone, sympathomimetics,psychostimulants) Hyperthyroidism, Congestive heart failure,
Cardiac arrhythmia, Chronic obstructive pulmonary disease, Hyperventilaton, Pulmonary embolism, Pheochromocytoma, Hyperadrenalism can cause anxiety symptoms.

Clinicals - Examination

Fact Explanation
Cardiovascular examination Symptoms of anxiety are seen in patients with ischemic heart disease and arrhythmia. Therefore a detailed examination of the cardiovascular system should be performed. Possible findings include: tachycardia, irregular pulse, tachypnoea. Cardiovascular examination
Symptoms of anxiety are seen in patients with ischemic heart disease and arrhythmia. Therefore a detailed examination of the cardiovascular system should be performed. Possible findings include: tachycardia, irregular pulse, tachypnoea.
Respiratory system examination Hyperventilation is a sign that can be seen in patients with bronchial asthma and in generalized anxiety disorder. Respiratory system examination findings should be normal in anxiety disorders. Respiratory system examination
Hyperventilation is a sign that can be seen in patients with bronchial asthma and in generalized anxiety disorder. Respiratory system examination findings should be normal in anxiety disorders.
Signs of hyperthyroidism Tachycardia, irregularly irregular pulse, tachypnoea, lid retraction, sweaty palms, hand tremors , restlessness can be seen in both hyperthyroidism and anxiety disorder. Thyroid goiter, exophthalmos, opthalmoplegia, fine hair due to hair loss, are specific to thyroid disease. Signs of hyperthyroidism
Tachycardia, irregularly irregular pulse, tachypnoea, lid retraction, sweaty palms, hand tremors , restlessness can be seen in both hyperthyroidism and anxiety disorder. Thyroid goiter, exophthalmos, opthalmoplegia, fine hair due to hair loss, are specific to thyroid disease.
Mental State Examination: Appearance The face looks strained,with furrowed brow. Posture is tensed tremors and sweating may be seen in the hands and the patient is restless.
Also exclude co-morbid conditions like depression, where vertical furrows in the brow can be seen.
Mental State Examination: Appearance
The face looks strained,with furrowed brow. Posture is tensed tremors and sweating may be seen in the hands and the patient is restless.
Also exclude co-morbid conditions like depression, where vertical furrows in the brow can be seen.
Mental State Examination: Speech Normal. May speak slowly if the patient has co morbid depression. Mental State Examination: Speech
Normal. May speak slowly if the patient has co morbid depression.
Mental State Examination: Mood. Associated symptoms like palpitations, dry mouth, tremor. Mental State Examination: Mood.
Associated symptoms like palpitations, dry mouth, tremor.
Mental State Examination: Thoughts Preoccupations of reasons for anxiety and fear of a catastrophic event may prolong the disorder. Mental State Examination: Thoughts
Preoccupations of reasons for anxiety and fear of a catastrophic event may prolong the disorder.
Mental State Examination: Perception. They do not have any illusions or hallucinations. Mental State Examination: Perception.
They do not have any illusions or hallucinations.
Mental State Examination: Depersonalization/ Derealization Depersonalization can occur during an anxiety attack. The patient will feel detached from their own body, and will experience a sense of 'unreality' about themselves. Mental State Examination: Depersonalization/ Derealization
Depersonalization can occur during an anxiety attack. The patient will feel detached from their own body, and will experience a sense of 'unreality' about themselves.
Mental State Examination: Cognitive function. Normal. Mental State Examination: Cognitive function.
Normal.
Mental State Examination: Insight Insight is preserved. Mental State Examination: Insight
Insight is preserved.

Investigations - Diagnosis

Fact Explanation
ECG and echocardiogram To exclude any underlying cardiac disease. Conditions like arrhythmia and supra ventricular tachycardia. ECG and echocardiogram
To exclude any underlying cardiac disease. Conditions like arrhythmia and supra ventricular tachycardia.
Thyroid Function Tests. TSH and free T4 levels. To exclude thyroid disease giving rise to anxiety episodes. Thyroid Function Tests.
TSH and free T4 levels. To exclude thyroid disease giving rise to anxiety episodes.

Management - Supportive

Fact Explanation
Exclude a co existant depressive disorder Anxiety symptoms can be present in depressive disorder or patients with GAD can be depressed due to their condition. If depressive symptoms are present, treatment for depression should be started. Exclude a co existant depressive disorder
Anxiety symptoms can be present in depressive disorder or patients with GAD can be depressed due to their condition. If depressive symptoms are present, treatment for depression should be started.
Explain the management plan to the patient and agree to a clear plan. Because the uncertainty of the management options and further proceedings may prolong the anxiety of the patient. Explain the management plan to the patient and agree to a clear plan.
Because the uncertainty of the management options and further proceedings may prolong the anxiety of the patient.
Education of the patient and his family members about the disorder and reassuring them. Anxiety is maintained by the fear about the anxiety symptoms and about the consequence of them. explanation about the condition will remove the anxiety about the symptoms.
Education of the family members will create a friendly home environment to the patient.
Education of the patient and his family members about the disorder and reassuring them.
Anxiety is maintained by the fear about the anxiety symptoms and about the consequence of them. explanation about the condition will remove the anxiety about the symptoms.
Education of the family members will create a friendly home environment to the patient.
Advice about necessary lifestyle changes. Advice against alcohol use smoking and use of substance (cannabis, cocaine, amphetamines).
Advice on managing time,taking time to relax.
Advice about necessary lifestyle changes.
Advice against alcohol use smoking and use of substance (cannabis, cocaine, amphetamines).
Advice on managing time,taking time to relax.

Management - Specific

Fact Explanation
Self- help methods. Identify stressors and reduce or remove them.Identify stressors by keeping a diary and reporting the events at which the patient felt anxious.
Encourage the patient to think of ways to deal with them. consider each problem and things that can be done to resolve the worry.
Self- help methods.
Identify stressors and reduce or remove them.Identify stressors by keeping a diary and reporting the events at which the patient felt anxious.
Encourage the patient to think of ways to deal with them. consider each problem and things that can be done to resolve the worry.
Anxiolytic medication Benzodiazepine (alprazolam) - For concomitant treatment with an antidepressant until the onset of the antidepressant effect (to short term relief of anxiety).
adverse effects of benzodiazepines-physiological and psychological dependence,
potential fatalities upon withdrawal, impaired cognition and coordination, a potentially lethal overdose when they are mixed with alcohol or opioids, inhibition of memory encoding, which can interfere with the efficacy of concomitant psychotherapy.

Buspirone - a non benzodiazepine anxiolytic. It is less like to cause dependence when compared to benzodiazepine, but its effects appear more slowly.
Anxiolytic medication
Benzodiazepine (alprazolam) - For concomitant treatment with an antidepressant until the onset of the antidepressant effect (to short term relief of anxiety).
adverse effects of benzodiazepines-physiological and psychological dependence,
potential fatalities upon withdrawal, impaired cognition and coordination, a potentially lethal overdose when they are mixed with alcohol or opioids, inhibition of memory encoding, which can interfere with the efficacy of concomitant psychotherapy.

Buspirone - a non benzodiazepine anxiolytic. It is less like to cause dependence when compared to benzodiazepine, but its effects appear more slowly.
Antidepressant medication-Tricyclic antidepressants (TCA) - Amitriptyline. Anticholinergic effects can be present - dry mouth, blurred vision, urinary retention, constipation.
Antiadrenergic effects - postural hypotension, ejaculatory delay.
Cardiovascular side effects - tachycardia, arrhythmia, sudden death.
They are less frequent than in treatment for depression as the required dose (for the anxiolytic effect) is lesser.
Antidepressant medication-Tricyclic antidepressants (TCA) - Amitriptyline.
Anticholinergic effects can be present - dry mouth, blurred vision, urinary retention, constipation.
Antiadrenergic effects - postural hypotension, ejaculatory delay.
Cardiovascular side effects - tachycardia, arrhythmia, sudden death.
They are less frequent than in treatment for depression as the required dose (for the anxiolytic effect) is lesser.
Antidepressant medication - Specific serotonin re-uptake inhibitors (SSRIs)- Escitalopram, Paroxetine. Serotonin noadrenaline re- uptake inhibitors (SNRIs)- Duloxetine, Venlafaxine Drugs of first choice.
Fewer side effects than TCAs.
But may cause increase anxiety and agitation when first taken.
Gastrointestinal effects - nausea, vomiting, dyspepsia, constipation, diarrhea.
Serious side effects - seizures, hyponatremia, increase suicidal risk in children and adolescents.
Antidepressant medication - Specific serotonin re-uptake inhibitors (SSRIs)- Escitalopram, Paroxetine. Serotonin noadrenaline re- uptake inhibitors (SNRIs)- Duloxetine, Venlafaxine
Drugs of first choice.
Fewer side effects than TCAs.
But may cause increase anxiety and agitation when first taken.
Gastrointestinal effects - nausea, vomiting, dyspepsia, constipation, diarrhea.
Serious side effects - seizures, hyponatremia, increase suicidal risk in children and adolescents.
Antidepressant medication -Monoamine oxidase inhibitors (MAOIs) Not used today due to the side effects and drug interactions. Antidepressant medication -Monoamine oxidase inhibitors (MAOIs)
Not used today due to the side effects and drug interactions.
Cognitive behavioral therapy (CBT). The goal of treatment is for the patient to develop the ability to recognize, eliminate, and correct his or her dysfunctional assumptions and thoughts in order to to cope more appropriately with various situations.

Relaxation - Relaxation of muscle groups one by one, breathing slowly, clearing mind of anxious thoughts by concentrating on a calming image.

Techniques for changing anxiety provoking conditions - Teach the nature of the normal anxiety response and explain that the symptoms are harmless. and explain hoe the fearfulness and the concerns of the symptoms give rise to a vicious cycle of anxiety. Teach about using distraction techniques to reduce the anxiety.

Exposure - Determine the situations that are avoided. arrange the situations in order of the amount of anxiety generated. Persuade patient to face the situation which brings out the least amount of anxiety, and to stay there until the anxiety is declined. And to repeat the exercise until the situation is faced without the anxiety at all. And advice to move up in the list of situations and face the more difficult situations one by one.

Problem-solving techniques- Practicing problem-solving strategies to lessen inappropriate approaches to problems and constant worrying.
Cognitive behavioral therapy (CBT).
The goal of treatment is for the patient to develop the ability to recognize, eliminate, and correct his or her dysfunctional assumptions and thoughts in order to to cope more appropriately with various situations.

Relaxation - Relaxation of muscle groups one by one, breathing slowly, clearing mind of anxious thoughts by concentrating on a calming image.

Techniques for changing anxiety provoking conditions - Teach the nature of the normal anxiety response and explain that the symptoms are harmless. and explain hoe the fearfulness and the concerns of the symptoms give rise to a vicious cycle of anxiety. Teach about using distraction techniques to reduce the anxiety.

Exposure - Determine the situations that are avoided. arrange the situations in order of the amount of anxiety generated. Persuade patient to face the situation which brings out the least amount of anxiety, and to stay there until the anxiety is declined. And to repeat the exercise until the situation is faced without the anxiety at all. And advice to move up in the list of situations and face the more difficult situations one by one.

Problem-solving techniques- Practicing problem-solving strategies to lessen inappropriate approaches to problems and constant worrying.

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