Generalized anxiety disorders

Introduction

Anxiety is a common symptom that occurs in all psychiatric disorders including depressive illness and most psychoses.
Physical diseases like hyperthyroidism, cardiac disease or hypertension may also present with anxiety and therefore must be excluded.
There are various forms of anxiety disorders (e.g. generalized anxiety disorders, panic disorders, phobias, obsessive compulsive disorder, acute stress disorder, post traumatic stress disorder, etc.), but the common ones seen in general practice are generalized anxiety disorders and panic disorders.
In all cases of suspected anxiety disorders, it is important to assess the scope of the anxiety, including the antecedents, behaviour and consequences of anxiety for the patient through an indepth interview.
It is also important to ask about the presence of obsessive thoughts and/or compulsions as these are increasingly common and tend not to be reported out of embarrassment but which lead to much personal distress.
In this case refer to a psychiatrist.
In generalized anxiety disorders, there is excessive anxiety and worry about events or activities, such as performance at school or work, occurring on most days, for at least 6 months.
A panic disorder refers to a pattern of recurrent unexpected attacks of intense fear or discomfort over a discrete period more than 3 times a week.
During attacks 4 or more of the symptoms listed below develop abruptly and reach a peak within 10 minutes.
Panic disorders are accompanied by persistent concern about having another attack or worrying about implications of having an attack.
In children especially, partial complex seizures may mimic panic attacks.
Medications are required to treat panic disorders only if the attacks occur frequently enough to cause distress.

Causes of generalized anxiety disorders

The following are the causes of generalized anxiety disorders

  1. Multiple negative life experiences
  2. Environmental factors
  3. Personality trait
  4. Genetic predisposition

Symptoms of generalized anxiety disorders

The symptoms of generalized anxiety disorders include the following:

  1. Excessive anxiety and worry occurring on most days, for at least 6 months
  2. Anxiety or worry associated with at least 3 of the following:
    • Muscle tension (often reported as pain in various parts like neck, trunk or headaches)
    • Crawling and burning sensation around the body
    • Restlessness or feeling on edge
  3. Being easily fatigued
  4. Difficulty concentrating or mind going blank
  5. Irritability
  6. Sleep disturbance (difficulty falling asleep or frequent wakening)
  7. Palpitations

Signs of generalized anxiety disorders

The signs of generalized anxiety disorders are

  1. Restlessness
  2. Sweating
  3. Anxious mood
  4. Tachycardia
  5. Tremors

Investigations

  • None to confirm the diagnosis.
  • Tests to exclude probable differential diagnoses such as hyperthyroidism, phaeochromocytoma, cardiac arrhythmias etc.

Treatment for generalized anxiety disorders

Treatment Objectives

The treatment objectives of generalized anxiety disorders are:

  1. To reduce anxiety
  2. To attain relief of somatic symptoms

Non-pharmacological treatment

  • Reassurance about the absence of physical diseases once they are ruled out
  • Teach relaxation methods
  • Encourage regular physical exercise if possible
  • Encourage healthy social activities
  • Cognitive Behaviour Therapy

Pharmacological treatment

A. For anxiety with somatic complaints
1st Line Treatment
Evidence Rating: [B]
Sertraline, oral,
Adults: 50 mg as a single oral evening dose; then increase by 25 mg at 1 week intervals, if necessary, to a max. of 200 mg
Children:

  • 12-18 years; 50 mg daily
  • 6-12 years; 25 mg daily
  • < 6 years; Not recommended

Or

Fluoxetine, oral,
Adults: 10 mg daily, then increase up to 60 mg daily if necessary
Children:

  • 7-18 years; 10 mg daily then increase to 20 mg after 1-2 weeks if necessary

Or

Amitriptyline, oral,
Adults: 25-50 mg daily (as a single evening dose)
Children:

  • > 12 years; 20 mg

Or

Imipramine, oral,
Adults: 25-50 mg daily (as a single evening dose)
Children: Not recommended for this indication

B. For anxiety with prominent somatic complaints

Propranolol, oral,
Adults: 10-80 mg 12 hourly

C. Additional treatment for anxiety with significant distress

Diazepam, oral,
Adults: 2-5 mg 12 hourly for 2 weeks and gradually tailed off over the next 2 weeks.

(Do not give for more than one month continuously)

Children

  • 1-12 years; 1.25-5 mg 6 hourly as needed

Referral Criteria

  • Refer to a clinical psychologist for Cognitive Behaviour Therapy and other non-pharmacological treatment modalities.
  • Refer to a psychiatrist in severe cases not responsive to drug treatment.