Aetiology: Theaetiology of anxiety disorders is multifactorial involving both environmentaland genetic factors. There are a number of risk factors which put a person atan increased risk of developing an anxiety disorder, these include: · Female sex.· Family history of psychiatric disorders.
· Childhood adversity such as:o Maltreatment (for example, sexual or physical abuse).o Parental problems with intimate partner violence, alcoholism,drug use, and/or mental illness.o Exposure to an overprotective or overly harsh parenting style.o Bullying or peer victimization among youths.· Environmental stressors such as:o Physical or emotional trauma.o Domestic violence.o Unemployment.o Low socioeconomic status.
· Substance dependence or exposure to organic solvents — these canexacerbate the development of anxiety disorders Morrow et al, 2000.· Chronic and/or painful illness such as arthritis· Genetic factorsSymptoms: The symptoms of anxiety include shortness of breath,dizziness, increased heart rate, an exaggerated startle response, dry mouth,nausea, sleeping difficulties, heart palpitations, and cold, sweaty numb ortingling hands and/or feet etc.These symptoms can leadto serious disability and impaired quality of life (the burden of disabilitycaused by anxiety disorders is equivalent to that of chronic conditions such asasthma and diabetes Wittchen,2002; NICE, 2011; Hogeand Fricchione, 2012). They canalso result in impaired social and occupational functioning. Anxiety disordersput people at an increased risk of comorbidities such as depression, socialanxiety disorder and alcohol and drug misuse. Physical health problems are alsomore common in people with anxiety disorders e.g.
chronic pain syndromes,asthma, or COPD, and inflammatory bowel disease. Suicidal ideation and attemptsare increased in people with anxiety disorders. Differentialdiagnosis: Situational anxiety, adjustment disorder, depression, panicdisorder, social phobia, obsessive-compulsive disorder, post-traumatic stressdisorder, somatoform disorders, anorexia nervosa, substance and alcoholmisuse/withdrawal, medication-induced anxiety, cardiac disease, pulmonarydisease, hyperthyroidism, anaemia, infection, irritable bowel syndrome andphaeochromocytoma. Signs: Experiencing any of the symptoms of anxiety, constantlyfeeling ‘on edge’, with shortness of breath and a dry mouth etc., may suggestthat the patient does in fact have an anxiety disorder. · Diagnosticcriteria: Generalisedanxiety disorder is defined, and it’s severity categorized, by one of two mainclassification systems: the fifth edition of the American PsychiatricAssociation’s Diagnostic and Statistical Manual of Mental Disorders(DSM-V) American PsychiatricAssociation, 2013, or the tenth revision of the International Classification ofDiseases (ICD-10) WHO, 1992. The DSM-V criteria require core symptoms of excessive widespread worry for more days than not, which is difficult to control and present for at least 6 months American Psychiatric Association, 2013. The ICD-10 criteria require symptoms of anxiety to be present for most days for several months and should include elements of apprehension, motor tension and autonomic overactivity WHO, 1992.
In determining whether a patient does in fact have anxiety, they can be asked to complete the generalized anxiety disorder questionnaire (GAD-7) which consists of 7 questions. This involves the patient answering questions by assigning scores of 0, 1, 2, or 3 to response categories. Scores of 5, 10 and 15 are the cut-off points for mild, moderate, and severe anxiety respectively. If a patient has the symptoms suggestive of anxiety, follows the DSM-V and/or ICD-10 criteria with a score of 5 or above on the GAD-7 questionnaire; it is likely that they are in fact suffering from anxiety. Consider the number, severity and duration of symptoms, degree of distress and functional impairment as well.
· Management:If the anxiety symptoms aremild, a period of active monitoring should initially be undertaken.· Ifsymptoms have not resolved following a period of active monitoring, alow-intensity psychological intervention which includes individual facilitatedor non-facilitated self-help or psychoeducational group therapy should beoffered.· In thepresence of marked functional impairment, or if symptoms have not resolved withlow-intensity psychological interventions, either a high-intensity psychologicalintervention (such as applied relaxation or cognitive behavioural therapy), ordrug therapy should be offered, depending on the person’s wishes.o If theperson chooses drug therapy, selective-serotonin reuptake inhibitors (SSRIs)are recommended first-line.o If anSSRI cannot be tolerated, a serotonin-noradrenaline reuptake inhibitor (SNRI)is a possible alternative.
o IfSSRIs and SNRIs are contraindicated or not tolerated, pregabalin can beconsidered.· Referralfor specialist treatment should be arranged if GAD is complex and there is aninadequate response to treatment (high intensity psychological interventionsand drug treatments) or very marked functional impairment or high risk ofself-harm, suicide or self-neglect.Prognosis:Generalized anxiety disorder (GAD) is a chronic condition which may fluctuatein severity Hoge and Fricchione, 2012.
· Predictions regarding prognosis are complicated by thefrequent comorbidity with other psychological and medical conditions, andsubstance abuse.o GAD with comorbid depression is known to have the worstprognosis, with more associated symptoms and disability than depression oranxiety disorders alone NICE, 2011.· Cognitive behavioural therapy has been shown to significantlyreduce anxiety symptoms in GAD Ost and Breitholtz, 2000 Arntz, 2003.
· Treatment of GAD with selective serotonin-reuptake inhibitors(SSRIs) and serotonin–norepinephrine reuptake inhibitors (SNRIs) leadsto response rates in the range of 30 to 50% Reinhold and Rickels, 2015; Kapczinski et al, 2003.· Full recovery from GAD occurs in some (but not all) people andthere is a possibility of remission post-recovery.