© Copyright Annals of Internal Medicine, 2013Ann Int Med. 159 (9): ITC5-1.

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© Copyright Annals of Internal Medicine, 2013Ann Int Med. 159 (9): ITC5-1.

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© Copyright Annals of Internal Medicine, 2013Ann Int Med. 159 (9): ITC5-1.

in the clinic

Generalized Anxiety Disorder

© Copyright Annals of Internal Medicine, 2013Ann Int Med. 159 (9): ITC5-1.

Which patients are at elevated risk for generalized anxiety disorder?

Women (GAD twice as common in women vs. men)

Comorbid psychiatric disorders

Obesity

History of substance abuse

History of trauma

Family history of GAD

© Copyright Annals of Internal Medicine, 2013Ann Int Med. 159 (9): ITC5-1.

Are preventive measures useful for patients at elevated risk?

Adults

No evidence on effectiveness but may benefit

Children

CBT + parent education can prevent GAD

In those with withdrawn behavior / early anxiety signs

© Copyright Annals of Internal Medicine, 2013Ann Int Med. 159 (9): ITC5-1.

Should clinicians screen patients for GAD if they are at increased risk? If so, how?

Yes: GAD is underdiagnosed and undertreated

Screening tools

“Are you bothered by nerves?”: 100% sensitive, 59% specific

2-item GAD-2: 86% sensitive, 83% specific

GAD-7 and PRIME-MD: anxiety + symptom severity

4-item PHQ: anxiety + depression

If screen is positive

Assess whether patient meets diagnostic criteria

© Copyright Annals of Internal Medicine, 2013Ann Int Med. 159 (9): ITC5-1.

CLINICAL BOTTOM LINE: Screening… Screen adults who are at increased risk

Screening tools have similar sensitivity and specificity

OK to use a tool with as few as 1 or 2 questions

© Copyright Annals of Internal Medicine, 2013Ann Int Med. 159 (9): ITC5-1.

What symptoms should prompt clinicians to consider a diagnosis of GAD?

Excess anxiety & worry about everyday issues

Distressed / impaired social, occupational, other functioning

Not attributable to substance or another medical condition

Not better explained by another mental disorder

Plus ≥3 of these symptoms on more days than not (≥6 mos):

Restlessness

Being easily fatigued

Difficulty concentrating

Irritability

Muscle tension

Sleep disturbance

© Copyright Annals of Internal Medicine, 2013Ann Int Med. 159 (9): ITC5-1.

What physical examination findings indicate possible GAD?

Restlessness, irritability, or fatigue

Medically unexplained symptoms

Chest pain

Rapid heart rate

Exam may uncover underlying / co-occurring medical conditions requiring further evaluation

© Copyright Annals of Internal Medicine, 2013Ann Int Med. 159 (9): ITC5-1.

What laboratory tests should clinicians use?

None needed for diagnosis

Routine lab testing has low yield

Consider tests to exclude medical conditions

Thyroid function (thyroid disease)

Hemoglobin measurement (anemia)

Urine drug screen (substance use)

Catecholamine levels (pheochromocytoma)

© Copyright Annals of Internal Medicine, 2013Ann Int Med. 159 (9): ITC5-1.

What other diagnoses should clinicians consider?

Cardiopulmonary disorders

Asthma, COPD, CHF

Endocrine disease

Thyroid disorders, diabetes, hypoglycemia

Mood disorders

Major depressive disorder, bipolar disorder

Other anxiety disorders

Simple or social phobia, panic, OCD, PTSD, acute stress

Misuse of substances

Alcohol, benzodiazepines, caffeine, nicotine, stimulants

© Copyright Annals of Internal Medicine, 2013Ann Int Med. 159 (9): ITC5-1.

CLINICAL BOTTOM LINE: Diagnosis… A thorough history is the key to diagnosis

Assess each patient for co-morbid mental illness

No lab testing unless underlying medical disorders suspected

Consult mental health specialist if diagnosis is uncertain

© Copyright Annals of Internal Medicine, 2013Ann Int Med. 159 (9): ITC5-1.

What nondrug therapies should clinicians recommend for GAD?

Cognitive behavioral therapy

Short-term psychodynamic psychotherapy

Worry exposure or exposure therapy

Relaxation training

Self-help and self-examination therapy

© Copyright Annals of Internal Medicine, 2013Ann Int Med. 159 (9): ITC5-1.

How should clinicians choose and dose drug therapy?

Use drug therapy when nondrug therapy is…

Unavailable

Ineffective

Or patient is uninterested in it

First-line: Second-generation antidepressants (SSRIs)

Second-line: azapironesIn, benzodiazepines

Third-line: atypical antipsychotics, antihistimine, anticonvulsant

© Copyright Annals of Internal Medicine, 2013Ann Int Med. 159 (9): ITC5-1.

How should clinicians monitor patients?

Until stable: in person or by phone every 2 - 4 weeks

During maintenance therapy: every 3 - 4 months

Use PRIME-MD or GAD-7 to monitor symptom severity

Ask consistently about…

Medication adherence

Treatment side effects

Suicide risk

Continue pharmacotherapy 6 - 12 months after response

20% - 40% relapse in 6 - 12 months after discontinuation

Severe chronic anxiety may require long-term medication

© Copyright Annals of Internal Medicine, 2013Ann Int Med. 159 (9): ITC5-1.

When should patients be hospitalized?

When actively suicidal

Assess suicide risk at each follow-up encounter

“Over the last 2 weeks, how often have you been bothered by thoughts that you’d be better off dead or of hurting yourself in some way?”

When symptoms are intractable

For grave disability

To address co-occurring illness

GAD can complicate treatment of co-occurring disorders and adversely affect prognosis

© Copyright Annals of Internal Medicine, 2013Ann Int Med. 159 (9): ITC5-1.

When should clinicians consult a psychologist, psychiatrist, or other specialist?

No improvement after 12 - 16 weeks of CBT

No response after 6 weeks to 1st- or 2nd-line drug Rx

Inability to tolerate drug Rx

Suicidal thoughts expressed

Co-morbid substance, mood, anxiety disorders present

Before prescribing 3rd-line drugs

© Copyright Annals of Internal Medicine, 2013Ann Int Med. 159 (9): ITC5-1.

CLINICAL BOTTOM LINE: Treatment… Primary care physicians play an important role in management

CBT is treatment of choice for most adults

If nondrug therapy is unavailable, ineffective, or if patient uninterested in it: try second-generation antidepressants

Assess suicide risk in all GAD patients

Refer complex GAD patients to mental health specialists