Transcript Clinical Slide Set. Generalized Anxiety Disorder.

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© Copyright Annals of Internal Medicine, 2013
Ann Int Med. 159 (9): ITC5-1.
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© Copyright Annals of Internal Medicine, 2013
Ann Int Med. 159 (9): ITC5-1.
in the clinic
Generalized
Anxiety Disorder
© Copyright Annals of Internal Medicine, 2013
Ann 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, 2013
Ann 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 In those with withdrawn behavior / early anxiety signs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, 2013
Ann 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, 2013
Ann 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, 2013
Ann 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, 2013
Ann 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, 2013
Ann 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, 2013
Ann 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, 2013
Ann 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, 2013
Ann 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, 2013
Ann 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, 2013
Ann 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, 2013
Ann 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, 2013
Ann 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, 2013
Ann 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
© Copyright Annals of Internal Medicine, 2013
Ann Int Med. 159 (9): ITC5-1.