Anxiety and Generalised Anxiety Disorder (GAD)

Original article by Tom Leach | Last updated on 24/1/2016
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Generalised Anxiety Disorder (GAD)

Epidemiology

  • Very common. Prevalence:
    • Men – 2-4%
    • Women 3-4.5%
  • Accounts for 1/3 of all psychiatric diagnosis
  • Accounts for 10% of all GP consultations
  • Closely related to depressionand many patients move between the two states. Often patients satisfy the criteria for both anxiety and depression
    • Shares recognised genetic variables with depression
    • Shares similar underlying neurochemistry to depression
  • Episodes tend to have relatively short duration
 

Aetiology

  • Many factors similar to depressionSimilar genetic factors to depression
  • Stressful live events – likely to be perceived as a ‘threat’, whereas in depression likely to be perceived as a ‘loss’
  • In general practice, often anxiety results from a perceived threat to the individuals own health.
  • Lack of confiding relationships, small social circle
 

Clinical features

  • Often present with somatisation of a single symptom. For example, they may feel a slight palpitation one day, and become anxious about it. Everytime they think they feel it, their anxiety grows. The anxiety fuels the symptom, and vice-versa.
  • Persistent anxiety that is out of proportion to actual events or circumstances. It is usually difficult to control, and leads to reduced and altered functioning. Typically, the worrying will involve everyday matters, e.g. work, money, family etc.
  • Apprehension – always feeling on edge
  • Motor tension muscle stiffness, tension headaches, inability to relax, tremor, muscular aches, restless, shakes
  • Increased sympathetic activity - Tachycardia, sweating, mydriasis (excessive dilation of the pupils), dizziness, parasthesia, hot and cold spells, frequent micturation, diarrhoea, nausea, dry mouth
  • Hypervgilance – irritability, insomnia, trouble sleeping (can’t get to sleep, only sleeps for short periods), poor concentration
  • Panic attacks
 

Pathology

  • Increased levels of arousal
  • Increased sympathetic activity - Tachycardia, sweating, mydriasis (excessive dilation of the pupils).
  • Fear, apprehension, and other unpleasant emotions
Though to be related to overactivity of ascending noradrenergic neurons – particularly those that innervate the limbic system and neocortex. This increases levels of arousal. In addition to this, excessive activity of 5-HT neurons leads to enhanced responses to nerve stimuli.
So, these mechanisms involve similar pathways to that of depression, however, in anxiety, there is overactivity of these pathways, but in depression, there tends to be underactivity.
 

Differentials

 

Treatment

In practice, anxiety often co-exists with depression, and in these cases, the treatment plan usually follows that of the depression.
In GAD-only cases, CBT is favoured over medication.
First line - In mild to moderate cases, this may involve the patient being guided through self-taught CBT by a clinician. This is highly effective in selected individuals.
Second-line – if the above has failed, consider referral to a CBT therapist
Third line – drug treatments. In the past, benzodiazepines were widely used, but led to problems of dependence, and are generally now not advised.
  • Drugs that reduce anxiety are known as anxiolytics.
  • GABA is the main inhibitory NT found in these systems.
  • Benzodiazepines - These bind to receptors and increase the amount of GABA released. There are other agents that bind to the same receptors, but have the opposite effect, and cause a decrease in GABA release, which could exacerbate an anxiety state.
 

Other interventions

Anxiety is usually managed in a GP setting. Important factors to bear in mind are:
  • Reassure the patient it is a common condition, that does not indicate serious disease
  • Advise that relaxation classes, yoga, and meditation are often helpful for many patients.
  • Perhaps discuss underlying problems (the perceived ‘threats’) with the patient. The GP will have to decide if the patient needs to see him, or other professionals again to discuss and help with these underlying issues. This often may not be health care professionals, but other professionals, perhaps those involved with social care, or the Citizen’s Advice bureau for example.
 

Management of a panic attack

At the early signs of a panic attack:
  • Sit down, try to relax
  • Control the breathing rate. Count to 4 between breathing in and breathing out. Take slow deep breaths.
  • Paper bag breathing is controversial. If hyperventilation is truly involved, then it may be helpful at controlling oxygen and carbon dioxide levels, but otherwise, it can lead to hypoxia and hypercapnia, which inturn can exacerbate the situation.
 

Prognosis

  • Most acute cases remit
  • BUT – recurrence is common
  • Many patients with a chronic anxiety state have social problems that need to be resolved with appropriate social interventions
  • Many patients with chronic symptoms will eventually develop depression as well