Treatment of Generalized Anxiety Disorder – Evidence Reconsidered Prof.R.N.Mohan Consultant Psychiatrist and Associate Medical Director and Director of Clinical Effectiveness and Governance, Birmingham and Solihull Mental Health Foundation Trust

Lifetime Prevalence of Mental Illnesses Kessler, Ronald C, et al. Arch Gen Psychiatry 2005;62: Risk of any disorder46.4 % 2 or more disorders27.7 % 3 or more disorders17.3 %

Anxiety Disorders: The Most Frequently Encountered in Practice Generalized Anxiety Disorder - characterized by at least 6 months of persistent and excessive anxiety and worry Specific Phobia – a clinically significant anxiety provoked by exposure to a specific feared object or situation, often leading to avoidant behavior Social Phobia – a clinically significant anxiety provoked by exposure to certain types of social or performance situations, often leading to avoidant behaviors Separation Anxiety Disorder – excessive anxiety concerning separation from the home or from those to whom the person is attached (must begin before 18 years old) Obsessive-Compulsive Disorder - characterized by obsessions (which cause marked anxiety or distress) and/or by compulsions (which serve to neutralize anxiety) severe enough to be time consuming or cause marked distress or impairment

Other Anxiety Disorders Panic Disorder with or without Agoraphobia – recurrent unexpected panic attacks about which there is persistent concern Posttraumatic Stress Disorder – reexperiencing of an extremely traumatic event accompanied by symptoms of increased arousal and by avoidance of stimuli associated with the trauma Agoraphobia Without History of Panic Disorder Acute Stress Disorder Anxiety Disorders Due to a General Medical Condition Substance-Induced Anxiety Disorder Anxiety Disorder Not Otherwise Specified

GAD has a lifetime prevalence of 5.7% and may occur at any point in life* *Based on a US survey with 9282 respondents. DSM–IV, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition; WMH–CIDI, World Mental Health – Composite International Diagnostic Interview. Kessler RC, et al. Arch Gen Psychiatry. 2005; 62: 593–602.

Anxiety disorders in later life 6-month prevalence findings from the Longitudinal Aging Study Amsterdam Beekman AT et al. Int J Ger Psychiatry 1998; 13: N = 3056 N = 1138 N = 954 N = 964

Criteria for GAD DSM-IV –TR definition: Excessive anxiety and worry about a number of events or activities, which occur more days than not for at least 6 months Person finds it difficult to control the worry At least 3 additional symptoms from: restlessness or feeling keyed up or on edge; Being easily fatigued; Difficulty concentrating or mind going blank; Irritability; Muscle tension; Sleep disturbance ; ICD-10 definition Anxiety generalised and persistent but not restricted to, or even strongly predominating in, any particular environmental circumstances (i.e. “free- floating”) Dominant symptoms variable but include complaints of :Persistent nervousness; Trembling; Muscular tension; Sweating; Light-headedness; Palpitations; Dizziness; Epigastric discomfort 7

Symptoms of GAD are both somatic and psychological Type of symptomManifestation Somatic (Motor tension) Trembling, twitching, shakiness; muscle tension, aches or soreness; restlessness; easily fatigued Somatic (Autonomic hyperactivity) Shortness of breath or smothering sensations; hyperventilation; palpitations or tachycardia; chest pain; sweating or cold clammy hands; dry mouth; dizziness; headache; nausea; diarrhoea; flushes; chills; frequent urination; dysphagia Psychological (Autonomic vigilance and scanning) Feeling keyed up or on edge; exaggerated startle response; fear; difficulty concentrating; disordered sleep; irritability Buskey RH. JAAPA. 2004; 17: 19–24.

Diagnosis (DSM-IV) (most commonly used in research studies) Excessive anxiety and worry for 6 months or more AND 3 or more of the following 6 symptoms: –restlessness or feeling keyed up or on edge –being easily fatigued –difficulty concentrating or mind going blank –irritability –muscle tension –sleep disturbance (difficulty falling asleep or staying asleep, or restless, unsatisfying sleep)

Screening for GAD Are you by nature a worrier? Do you worry more than most other people? When you get worried, do you hold it inside and find it hard to let it go? Does this interfere with your life?

Two-question screening for GAD ‘During the past 4 weeks, have you been bothered by feeling worried, tense or anxious most of the time?’ ‘Are you frequently tense, irritable and having trouble sleeping?’ Ballenger JC et al. Prim Care Compan J Clin Psychiatry 2001; 3: 44-52