Generalized Anxiety Disorder - Anatomy of Psych

What is generalized anxiety disorder?

Generalized anxiety disorder is an anxiety disorder disorder characterized by persistent, unrealistic, and excessive anxiety and worry over every day activities. The median age of onset of GAD is 31 years, and individuals from developed countries are more likely to develop GAD than individuals from non-developed countries. Women are 2-3 times more likely to develop GAD than men.

What does GAD look like?

Signs & Symptoms

Persistent worrying or anxiety about a number of areas that are out of proportion to the impact of the events
Overthinking plans and solutions to all possible worst-case outcomes
Perceiving situations and events as threatening, even when they aren't
Difficulty handling uncertainty
Indecisiveness and fear of making the wrong decision
Inability to set aside or let go of a worry
Inability to relax, feeling restless, and feeling keyed up or on edge
Difficulty concentrating, or the feeling that your mind "goes blank"
Fatigue
Trouble sleeping
Muscle tension or muscle aches
Trembling or feeling twitchy
Nervousness or being easily startled
Sweating
Nausea, diarrhea, or irritable bowel syndrome
Irritability

DSM-5 Criteria

Criterion A. Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance).

Criterion B. The individual finds it difficult to control the worry.

Criterion C. The anxiety and worry are associated with at least 3 of the 6 symptoms, with at least some symptoms present for more days than not for the past 6 months (Note: only 1 symptom is required for children):

Blanking out or difficulty concentrating
Easily fatigued
Sleep changes (difficulty falling or staying asleep, or restless, unsatisfying sleep)
Keyed up, on edge, or restless
Irritability
Muscle tension

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

Criterion E. The disturbance is not attributable to the physiological effects of a substance (e.g. drug or medication) or another medical condition (e.g. hyperthyroidism).

Criterion F. The disturbance is not better explained by another mental disorder:

Anxiety or worry about having panic attacks (panic disorder)
Negative evaluation (social anxiety disorder)
Contamination or other obsessions (obsessive-compulsive disorder)
Separation from attachment figures (separation anxiety disorder)
Reminders of traumatic events (post-traumatic stress disorder)
Gaining weight (anorexia nervosa)
Physical complaints (somatic symptom disorder)
Perceived appearance flaws (body dysmorphic disorder)
Having a serious illness (illness anxiety disorder)
The content of delusional beliefs (schizophrenia or delusional disorder)

Specifiers

Specifiers:

Panic attacks
- Recurrent unexpected panic attacks. An abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and during which time at least 4 of the following symptoms occur (Note: The abrupt surge can occur from a calm state or an anxious state):
  - Sweating
  - Trembling or shaking
  - Unsteady, dizziness, light-headed, or feeling faint
  - Derealization (feelings of unreality) or depersonalization (being detached from one self)
  - Excessive/accelerated heart rate, palpitations, or pounding heart
  - Nausea or abdominal distress
  - Tingling, numbness, parathesesias
  - Shortness of breath
  - Fear of losing control or “going crazy”
  - Fear of dying
  - Choking feelings
  - Chest pain or discomfort
  - Chills or heat sensations

Risk Factors

Temperamental factors such as behavioral inhibition, high neuroticism, and harm avoidance
Adverse childhood events
Parental overprotection
Low socioeconomic status
Family history of anxiety disorders

Psychological theories of GAD:

Psychodynamic: conflict between the id, ego, and superego leads to anxiety
Cognitive: distorted thinking patterns lead to dysfunctional appraisal of situations

Differential Diagnosis

Anxiety disorder due to another medical condition
Substance/medication-induced anxiety disorder
Social anxiety disorder
Obsessive-compulsive disorder
Post-traumatic stress disorder
Adjustment disorder
Depressive disorders
Bipolar disorders
Psychotic disorders
Other childhood disorders

How is GAD investigated?

Labwork: CBC, fasting glucose, fasting lipid profiles, electrolytes, liver enzymes, serum bilirubin, serum creatinine, thyroid stimulating hormone (TSH)
Urinalysis, urine toxicology for substance use

Screening/Scale	Rater	Description
Generalized Anxiety Disorder 7 (GAD-7)	Client	7 questions for screening, with severity measure for general anxiety disorder
Beck Anxiety Inventory (BAI)	Client	21 questions for screening, with severity measure for general anxiety disorder

How is GAD treated?

First-line medications:

Melatonin agonists: agomelatine
Anticonvulsant: pregabalin
Selective serotonin reuptake inhibitors: escitalopram, paroxetine, paroxetine CR, sertraline
Serotonin-norepinephrine reuptake inhibitors (SNRI): duloxetine, enlafaxine XR

Second-line medications:

Benzodiazepines: alprazolam, bromazepam, diazepam, orazepam
Norepinephrine and dopamine reuptake inhibitors (NDRI): bupropion XL
Anxiolytics: buspirone
Antihistamines: hydroxyzine
Tricyclic antidepressants: imipramine
Atypical antipsychotics: quetiapine XR
Selective serotonin reuptake inhibitors: vortioxetine

Third-line medications:

Selective serotonin reuptake inhibitors (SSRI): citalopram, fluoxetine
Anticonvulsants: divalproex chrono
Tetracyclic antidepressants: mirtazapine
Serotonin agonist and reuptake agonists (SARI): trazodone

Special Considerations

Children & Teenagers

Psychotherapy should always be the first option for treatment of GAD in youth. Cognitive behavioral therapy has proven to be effective when it is adjusted to the developmental level of the child. Parental involvement in psychotherapy treatment for children is also beneficial.

Older Adults

Older adults with GAD report greater severity of sleep disturbance compared to any other age group diagnosed with GAD.

The fear of falling is correlated with GAD and anxiety symptoms in general.

Nursing Management

Anxiety

Causes & Behaviors:

Excessive worrying
Difficulty concentrating; decreased attention span
Feeling discomfort, apprehension, or helplessness
Restlessness, hyperactivity, or pacing
Impulsivity
Inability to discriminate harmful stimuli or situations

Interventions:

Maintain a calm, non threatening manner while working with the client
Reduce stimuli in the environment
Provide reassurance and comfort measures
Offer PRN medications for high levels of anxiety, and monitor for side effects
Encourage client to participate in relaxation techniques

Powerlessness

Causes & Behaviors:

Lifestyle of helplessness
Fearing disapproval from others
Receiving consistent negative feedback
Apathy
Dependence on others that may result in irritability, resentment, anger, and/or guilt
Verbal expressions of having no control
Nonparticipation in care or decision making when opportunities are provided
Reluctance to express true feelings

Interventions:

Encourage the client to take as much responsibility for own self-care practices
Help the client set realistic goals, as unrealistic goals can lead to failure and feeling powerless
Help the client identify areas of life situation that are not with his ability to control and encourage verbalization of these feelings as a form of radical acceptance
Encourage the client to identify ways and opportunities to participate in activities to enhance self-esteem

References

[1] American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.

[2] Boyd, M. A. (2019). Psychiatric & mental health nursing for Canadian practice. Wolters Kluwer.

[3] Bradford, A., PhD., Cully, J., PhD., Rhoades, H., PhD., Kunik, Mark,M.D., M.P.H., Kraus-Schuman, C., Wilson, Nancy, M.A., L.M.S.W., & Stanley, M., PhD. (2011). Early response to psychotherapy and long-term change in worry symptoms in older adults with generalized anxiety disorder. The American Journal of Geriatric Psychiatry, 19(4), 347-56.

[4] Brenes, G. A., PhD., Miller, M. E., PhD., Stanley, M. A., PhD., Williamson, J. D., M.D., Knudson, M., M.D., & McCall, W. V. (2009). Insomnia in older adults with generalized anxiety disorder. The American Journal of Geriatric Psychiatry, 17(6), 465-72.

[5] Payette, M., Bélanger, C., Benyebdri, F., Filiatrault, J., Bherer, L., Bertrand, J., Nadeau, A., Bruneau, M., Clerc, D., Saint-Martin, M., Cruz-Santiago, D., Ménard, C., Nguyen, P., Vu, T. T. M., Comte, F., Bobeuf F., & Grenier , S. (2017). The association between generalized anxiety disorder, subthreshold anxiety symptoms and fear of falling among older adults: Preliminary results from a pilot study. Clinical Gerontologist, 40(3), 197-206.

[6] Payne, S., Bolton, D., & Perrin, S. (2011). A pilot investigation of cognitive therapy for generalized anxiety disorder in children aged 7-17 years. Cognitive Therapy and Research, 35(2), 171-178. https://doi.org/10.1007/s10608-010-9341-z

[7] Townsend, M. C. (2015). Psychiatric mental health nursing. F.A. Davis.