Generalised anxiety disorder

What is the term used to describe a disorder where patients feel anxious most of them time - worry about many things, avoid situations and overworrying about certain events?

Generalised anxiety disorder

What are some symptoms of generalised anxiety disorder?

Restlessness, fatigue, excessive anxiety and worry, increased muscle aches or soreness, impaired concentration, irritability, difficulty sleeping

What are some considered differentials for GAD?

Stimulant drugs, withdrawal of Z drugs/benzodiazepines, metabolic disturbances, temporal lobe lesions, different anxiety disorder

What questionnaire can be used to diagnose GAD?

GAD-7

How many steps are there in care for GAD?

4

What is step 1 in GAD?

All known and suspected presentations of GAD

What is step 2 in GAD?

Diagnosed GAD that has not improved after education and active monitoring in primary care

What is step 3 in GAD?

GAD with an inadequate response to step 2 interventions or marked functional impairment

What is step 4 in GAD?

Complex treatment refractory GAD and very marked functional impairment, such as self-neglect or a high risk of self harm

What patients may be suspected to have GAD?

Patients presenting with anxiety, chronic health problems or somatic symptoms e.g., elderly, BAME, repeated worrying

How is assessment for GAD done?

Impact of life, function of impairment, think about comorbidities

What should not be considered when looking at GAD?

Severity, number or duration of symptoms

What does step 2 of GAD involve?

Low intensity psychological interventions

What are the 3 different types of low intensity psychological interventions?

Individual non-facilitated self help, individual guided self help, psychoeducational groups

What is the type of low intensity psychological intervention where written or electronic materials are provided for someone of a suitable reading age, based on CBT and include instructions for patients to work through for 6 weeks by themselves?

Individual non-facilitated self help

What is the type of low intensity psychological interventions which is based on CBT, has support of a trained practitioner that reviews progress through written/electronic materials for 5-7 sessions, done on a weekly basis?

Individual guided self-help

What is the type of low intensity psychological intervention which encourages presentations, has self-help manuals and is based on CBT in a group setting with around 12 people and lasts 2 hours, occurring on a weekly basis?

Psychoeducational groups

What should you do in step 3 of GAD in consideration to treatments?

Speak about different therapies available and benefits/risks of them and base on patient presence

What are the two types of treatment in stage 3 of GAD?

Drug therapy or high intensity psychological intervention

What is the high-intensity psychological intervention in stage 3 GAD treatment?

CBT, applied relaxation delivered by trained practitioners for 12-15 sessions occurring once a week

What is the first line pharmacotherapy of GAD?

SSRI - sertraline

What use is sertraline in GAD?

Off-label

What should be monitored when using sertraline first line for GAD?

Monitor frequently for ADRs

What is 2nd line GAD pharmacotherapy?

Another SSRI or SNRI e.g., venlafaxine

What is the 3rd line pharmacotherapy for GAD?

Pregabalin

What patients may benefit from PPI cover when on a SSRI?

Elderly, those taking other drugs that affect clotting or drugs affecting the gastric mucosa

What patients should be monitored more frequently for SSRIs or SNRIs due to their increased risk of suicidal thoughts and feelings when treatment is initiated?

Use in under 30s

How often is pharmacotherapy treatment reviewed for GAD?

Every 2-4 weeks for first 3 months then 3 monthly thereafter

What is the minimum length of time pharmacotherapy should be continued for in step 3 if proven to be effective?

One year

What is involved in step 4 GAD treatment?

Specialist assessment and treatment, evaluates impact of illness on friends and family and puts a full comprehensive plan in place

When are benzodiazepines used in GAD?

NOT recommended in primary care but can be used in crises