Generalized Anxiety Disorder

What is Anxiety according to the APA?

Ubiquitous human emotion that usually does not usually require treatment

What two drug classes are the mainstay of treatment for GAD?

SSRIs

SNRIs

How long might medications take to see maximum effect?

4-6 weeks

------------ are useful only for short-term use; long term use may lead to tolerance and tachyphylaxis

BENZODIAZEPINES are useful only for short-term use; long term use may lead to tolerance and tachyphylaxis

Psychotherapy is often as effective as pharmacotherapy in relation to GAD?

(T/F)

True

When does anxiety/a cluster of anxiety symptoms become a disorder?

It causes marked impairment in functioning, social activities, quality of life

What are some cognitive symptoms of GAD?

excessive worry, feeling on edge, trouble concentrating, mind going blank

What are some physical symptoms of GAD?

restlessness, fatigue, muscle tension, sleep disturbance, irritability

What is the pathophysiology of anxiety?

(3 major things)

1. Hypersensitive ANS (amygdala, locus ceruleus)

2. Cortisol Dysregulation

3. Abnormal Functioning of Neurotransmitter Systems

Regarding GAD, what type of psychotherapy should be used?

Cognitive Behavioral Therapy

Regarding GAD, what class is typically used first-line?

SSRIs

When initiating a SSRI for GAD, what is important to remember regarding dosing and titration?

For GAD, SSRIs are started at lower initial doses than other disease states (MDD, Depression) and titrated up if needed

(GO LOW, GO SLOW, NO BENZO)

What is the typical length of treatment for GAD?

Generally at least 12 months

(Acute treatment and 6+ months maintenance treatment)

How do you differentiate GAD from normal worrying?

•Intensity, duration, frequency are disproportionate to stimulus

•Inability/difficulty stopping the worry

•Interferes with functioning

What are the risk factors for GAD? (7)

•Family history (FH)/ genetics

•Onset early childhood to elderly- mean age 21 years

•Women >> men (2 x)

•Genetic predisposition and neurobiological adaptations leading to vulnerability to anxiety- along with stressors

What are the risk factors for GAD? (7)

•Lower socioeconomic status (more stressful events and less poised to deal with the stress factors)

•Stressful events ( see above)

•Rx and OTC Medications/illicit stimulants/caffeine

What are some medications associated with GAD? (6)

•Anticonvulsants

•Antidepressants

•Steroids

•Dopamine agonists

•Stimulants (licit and illicit) or caffeine

•NSAIDs

What does Criterion A entail regarding the DSM-5?

Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 MONTHS)

What does Criterion B entail regarding the DSM-5?

The person finds it difficult to control the worry

What does Criterion C entail regarding the DSM-5?

The anxiety and worry are associated with 3 (or more) of the following six symptoms (with at least some symptoms present for more days than not for the past 6 MONTHS)

1. Arousal / on edge

2. Fatigue

3. Difficulty concentrating

4. Irritability

5. Muscle tension

6. Insomnia

What does Criterion E entail regarding the DSM-5?

The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning

What does IMFAST stand for? (symptoms of GAD made simple)

•Irritable

•Muscle tension

•Fatigue

•Arousal

•Sleep disturbances

•Thinking/ concentrating

Generally speaking, a person has GAD when...

3 or more of the IMFAST symptoms are present more days than not for 6 months or greater

What are the short-term goals of therapy for GAD?

Goals of therapy (acutely) are to decrease severity and duration of anxiety symptoms and improve overall function and QoL

What monitoring tool can be used to assess results of treatment in the short-term?

GAD-7

How often should patients follow up for monitoring appointments in the short-term?

Every 2 weeks

What are the long-term goals of therapy for GAD?

•Remission with minimal to no anxiety symptoms

•No functional impairment

Initial GAD therapy can be with psychotherapy (CBT), medications, or a combination

(T/F)

True

What are the first line agents for GAD?

SSRIs: paroxetine, sertraline, escitalopram

SNRIs: duloxetine and venlafaxine XR (IR can be considered)

(Pregabalin can also be used, but choose SNRI or SSRI first)

Symptoms may initially worsen with ---- therapy, so we should start low and titrate slow

SSRI

If there is no response to initial therapy for GAD, what should be done?

Change to another first-line GAD agent before moving onto second-line

Patients who do not respond to multiple courses of therapy are considered to have -------- --------- GAD (can move to second line agents)

Treatment-Refractory

If partial treatment is achieved (<50% improvement), what should be done?

•Titrate to target dose if tolerated, reevaluate response at later appointment

•If adequate dose and duration, can switch or use adjunct tx

What are some examples of second-line agents?

•Imipramine (TCA), vortioxetine, bupropion (MORE THAN THIS, THIS IS JUST WHATS LISTED)

Also benzodiazepines

What are the benzodiazepines to know?

lorazepam, alprazolam, diazepam

If adjunct therapy is used with benzodiazepines, how long should it last?

When using benzodiazepines, 4 WEEKS OR LESS

Second generation antipsychotics have more side effects than other antidepressants

(T/F)

True

What is the second-line H1 antagonist to know?

Hydroxyzine

Hydroxyzine has similar efficacy to benzodiazepines

(T/F)

True

When would we typically use Hydroxyzine?

For rapid relief (30 minutes) and in patients who cannot use benzodiazepines

What are the third-line agents?

Mirtazapine, Trazodone, other SSRIs (citalopram, fluoxetine), VPA

What does adjunctive therapy mean in relation to GAD?

Adjunctive Therapy = augmentation / add on agents

When should adjunctive therapy be used in GAD?

Consider in patients who have:

•A need form more immediate relief

•Not had an adequate response to SSRI, or

•Had only a partial response to SSRIs

What could adjunctive therapy look like regarding GAD?

Antidepressant plus 1st, 2nd, & 3rd line agents

•Benzodiazepine (risk of dependence; short term use)

•Buspirone (can take 2 weeks to work)

•Hydroxyzine (relief in as little as 30 min)

•Anticonvulsants... (gabapentin, pregabalin, VPA)

•SGA/AAPs (risk benefit analysis needed, should be patient specific)

What is important to know regarding Pregabalin?

Can be considered first line in select patients (targets pain, sleep somatic)

(ALSO AS EFFECTIVE AS BENZODIAZEPINES)

What medication is utilized similarly to Pregabalin in practice as alternative to Benzos?

Gabapentin

Remission of GAD is marked by --% improvement

70%

What is the time period for an adequate trial to evaluate efficacy of medication in GAD?

4-8 weeks

If there is a partial response at 4-8 weeks what should be done?

continue drug, titrate, and reevaluate at week 12

How long does a full response typically take to achieve in GAD?

Full response - may take up to 12 weeks for some; if no improvement at 12 weeks (adequate dose and duration) ---> adjust therapy

What is the general rule for length of therapy after full response in GAD?

•General rule: therapy should be continued for at least 12 months after response/remission for most patients

•Citations previously varied from 6- 24 months

•If/when therapy is discontinued, it should be done...

gradually and over 3 months at a minimum

If symptoms reemerge, what should be done?

Resume last effective dose

How should doses be titrated in GAD?

Doses should be titrated to the recommended dosage range at 1-2-week intervals over 4-6 weeks

•Once at target dose improvement is usually seen over the next -- to -- weeks

•Follow-up should occur at -- week intervals for the first -- weeks and monthly thereafter

•Once at target dose improvement is usually seen over the next 4-8 weeks

•Follow-up should occur at 2-week intervals for the first 6 weeks and monthly thereafter

What does psychotherapy entail as far as appointments and treatment duration?

Weekly appointments for 12-20 weeks

What are the 3 patient education points mentioned for GAD?

•Smoking cessation (limit or stop nicotine)

•Decreasing caffeine intake

•Daily exercise as part of a total therapy plan for GAD

What is Social Anxiety Disorder (SAD)?

Definition: Marked fear or anxiety regarding social situations where the individual is exposed to possible scrutiny

What are the DSM-5 criteria for SAD?

•A marked and persistent fear of one or more social or performance situations

•Person is exposed to unfamiliar people or to possible scrutiny

•The individual fears that he or she will act in a way (or show anxiety symptoms) that will be humiliating or embarrassing

•Typically lasts 6 months or more

•Not related to a substance

What are the first-line agents for SAD?

•SSRI (except citalopram)

•SNRI (venlafaxine ER) or

•Pregabalin