Generalized anxiety disorder (GAD)

Trigger
• 45 y/o man, present with excessive worrying about financial issue, local & world events, as a
result he had sleep difficulty for 8 months. He unsure why he so anxious
Definition
• Excessive, persistent, uncontrollable worry about most daily problem & events, accompanied
with physical symptoms
Epidemiology
• Incidence: 4.3%
• MC age group: > 65 y/o (15%)
• Age onset: 20 – 30 y/o
• MC gender: F 3X > M
• Higher in socioeconomic class
Clues for diagnosis
• Worry about everything (e.g., career, family, future, relationships, money) at the same time
• Symptoms not dramatic as in panic disorder
Questions that need to be asked

Assess Questions
Anxiety • Physical: Palpitations, sweating, shakiness, dyspnea, chest discomfort, nausea, light
symptoms headedness, dizziness, dry mouth, restlessness
• Psychological: Feeling unreal, fear of going crazy, fear of losing control over one’s
self, feeling that death is imminent, inability to relax, nervousness
• Onset, duration, frequency of symptoms
Circumstances • Generalized anxiety disorder: Anxiety symptoms present all the time without real
of symptoms trigger, worry about everyday things for at least 6 months
• Panic disorder: Discrete episodes that arise spontaneously & abruptly without
identifiable causes that last for few minutes
• Agoraphobia: Episode of anxiety occur when in crowded place, public place or place
away from a safe place (home)
• Social phobia: Fear of being the focus of attention or any embarrassment
• Specific phobia: Marked anxiety in response to specific object, place, situation – Ex
cockroaches, blood, water
Psychosocial • Avoid any specific situation or object due to fear?
impact • Impact on daily living & social life – jobs & friends
• Any use of alcohol & illicit substance to relief anxiety ?
• Any depressive symptoms ?
Others • Ask about hyperthyroidism symptoms (weight loss, heat intolerance, excessive
sweating) – Hyperthyroidism also can cause anxiety
 • Current medication & also to rule out benzodiazepine dependence to cope with
anxiety
• Presence of anticipatory anxiety
• Does this anxiety is severe enough that can hurt patient itself? (Risk assessment)

Clinical features of GAD

Autonomic arousal Chest & Abdomen Mental General Others

• Palpitation • Dyspnea • Giddiness & • Hot flushes/ cold • Irritability
• Tachycardia • Choking Syncope • Numbness/ tingling • Insomnia
• Diaphoresis sensation • • Fatigue • Night terror
• Trembling • Chest pain Depersonalization • Muscle tension • Poor
• Dry mouth • Nausea • Fear of losing • Restlessness concentration
control or dying • Lump in throat

DSM-5 Criteria

A. Excessive anxiety & worry for most of the day, everyday for at least 6 months (Core)
B. Difficult to control excessive worry
C. Have at least 3 of following symptoms (Mnemonic BE RIMS)
D. This cause significant impairment in function
E. Not cause by substance use, medical condition
F. No cause by mental d/o
Mnemonic: BE RIMS
• B – Blank mind – difficult concentration – overthinking
• E – Easy tried – less sleep
• R – Restlessness – overthinking
• I – Irritability – less sleep
• M – Muscle tension – somatic symptoms
• S – Sleep difficulty – overthinking

Must rule out Medical & Substance causing anxiety !

+ Differential diagnosis of anxiety

Disease Substance
• Hyperthyroidism • Food: Caffeine
• Brain tumor • Illicit drug use: Amphetamines, Cocaine
• Multiple sclerosis • Nicotine
• Vitamin B12 deficiency • Alcohol withdrawal
• Anemia • Medication: Antidepressant drug, Penicillin
• Pheochromocytoma or sulfonamides
• Hypoglycemia • Poisoning: Mercury or arsenic toxicity,
• Hypoxia Organophosphate toxicity
Comorbidities
Must ask history related to comorbidities
• Concurrent depression (80%) – Most common
• Concurrent panic disorder (25%)
#Concurrent = At the same time
Investigation

Investigation Reason – TRO causes of anxiety

TFT • Thyrotoxicosis
Blood glucose • Hypoglycemia
ECG • Atrial fibrillation, Arrythmia
Urine drug screen • Drug stimulant usage
Lung function test • Hypoxia in COPD
24 hr urine catecholamine • Pheochromocytoma

Treatment

Classification Treatment About

Psychotherapy Cognitive behavior • Prognosis: Good in 2/3rd of
therapy patient after 6 months follow
up
Relaxation technique
Pharmacotherapy 1st line treatment • SSRI
2nd line • Hydroxyzine
Indication (antihistamine)
• Severe anxiety If no respond to 2 • Venlafaxine (SNRI)
• Impairment of social, occupational previous drug #A/E: Hypertension, must
& function check BP
• Concurrent depression Frequent relapse • Maintenance therapy

Prognosis
After treatment
• 70% - Mild or no impairment
• 9% - Severe impairment – d/t severe anxiety, frequent syncope, derealization, suicide attempt
Reference
• UMSLE STEP 2 secret, Mastering , Toronto