Generalized Anxiety Disorder: Clinical Features and Diagnosis Flavio Guzman, MD

Overview Introduction Epidemiology Diagnosis: DSM V Rating scales Differential diagnosis

GAD – Concept Overview Excessive and inappropriate worrying Baldwin, David S., et al. "Evidence-based pharmacological treatment of anxiety disorders, post-traumatic stress disorder and obsessive-compulsive disorder: A revision of the 2005 guidelines from the British Association for Psychopharmacology." Journal of Psychopharmacology 28.5 (2014): 403-439.

GAD - Concept Overview Additional symptoms Excessive and inappropriate worrying Baldwin, David S., et al. "Evidence-based pharmacological treatment of anxiety disorders, post-traumatic stress disorder and obsessive-compulsive disorder: A revision of the 2005 guidelines from the British Association for Psychopharmacology." Journal of Psychopharmacology 28.5 (2014): 403-439.

GAD - Concept Overview Additional symptoms Often comorbid Excessive and inappropriate worrying Baldwin, David S., et al. "Evidence-based pharmacological treatment of anxiety disorders, post-traumatic stress disorder and obsessive-compulsive disorder: A revision of the 2005 guidelines from the British Association for Psychopharmacology." Journal of Psychopharmacology 28.5 (2014): 403-439.

Epidemiology

Epidemiology Epidemiological Catchment Area Study: DSM V: DSM III criteria for GAD Twice as common in women than in men 12-month prevalence rate: 3.8%, 2.7% DSM V: Adolescents: 12-month prevalence rate of 0.9% Adults: 12-month prevalence rate of 2.9% Lifetime morbid risk: 9 % Stein, Dan J., Eric Hollander, and Barbara Olasov Rothbaum. Textbook of anxiety disorders. 2nd ed. Washington, DC: American Psychiatric Pub., 2010. Diagnostic and statistical manual of mental disorders: DSM-5.. 5th ed. Washington, D.C.: American Psychiatric Association, 2013.

Diagnosis

Generalized anxiety disorder: DSM V Occurring more days than not for at least 6 months Excessive anxiety and worry: apprehensive expectation Diagnostic and statistical manual of mental disorders: DSM-5.. 5th ed. Washington, D.C.: American Psychiatric Association, 2013.

Generalized anxiety disorder: DSM V Health Finances Excessive anxiety and worry: apprehensive expectation Job responsibilities Diagnostic and statistical manual of mental disorders: DSM-5.. 5th ed. Washington, D.C.: American Psychiatric Association, 2013.

Generalized anxiety disorder: DSM V Safety/health of family members Excessive anxiety and worry: apprehensive expectation Diagnostic and statistical manual of mental disorders: DSM-5.. 5th ed. Washington, D.C.: American Psychiatric Association, 2013.

Generalized anxiety disorder: DSM V Excessive worry over minor matters (daily hassles and time management) “Do you worry excessively about minor matters?” Effective for ruling out the diagnosis of GAD Excessive anxiety and worry: apprehensive expectation (Dugas et al 2005)

Nonpathological anxiety vs GAD Generalized anxiety disorder Worries Not excessive, manageable Interfere with psychosocial functioning Pervasive, longer duration, occur without precipitants Physical symptoms Much less frequent Common Diagnostic and statistical manual of mental disorders: DSM-5.. 5th ed. Washington, D.C.: American Psychiatric Association, 2013.

GAD in DSM V 3 of 6 symptoms: Additional symptoms Restlessness or feeling keyed up or on edge Being easily fatigued Difficulty concentrating or mind going blank Irritability Muscle tension Sleep disturbance Additional symptoms In children, only 1 of 6 is required Diagnostic and statistical manual of mental disorders: DSM-5.. 5th ed. Washington, D.C.: American Psychiatric Association, 2013.

Comorbidity in GAD More than 2/3 of patients with GAD: Additional axis I disorder Depression Social phobia Panic disorder OCD More than 2/3 of patients with GAD: More than 2/3 of patients with GAD Wittchen, Hans-Ulrich, et al. "DSM-III-R generalized anxiety disorder in the National Comorbidity Survey." Archives of general psychiatry 51.5 (1994): 355-364. Stein, Dan J., Eric Hollander, and Barbara Olasov Rothbaum. Textbook of anxiety disorders. 2nd ed. Washington, DC: American Psychiatric Pub., 2010.

Rating Scales

Rating scales for GAD Rating instruments: Penn State Worry Questionnaire GAD-7 Hamilton Rating Scale for Anxiety Spitzer, Robert L., et al. "A brief measure for assessing generalized anxiety disorder: the GAD-7." Archives of internal medicine 166.10 (2006): 1092-1097. Stein, Dan J., Eric Hollander, and Barbara Olasov Rothbaum. Textbook of anxiety disorders. 2nd ed. Washington, DC: American Psychiatric Pub., 2010.

Differential diagnosis

Differential diagnosis Depression OCD Panic disorder Adjustment disorders Anxiety disorder due to a medical condition Substance/medication-induced anxiety disorder Baldwin, D. Generalized anxiety disorder: Epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis In: UpToDate, Stein MB, UpToDate, Waltham, MA.(Accessed on October 1, 2014.) Diagnostic and statistical manual of mental disorders: DSM-5.. 5th ed. Washington, D.C.: American Psychiatric Association, 2013.

GAD vs Depression GAD Depression Insidious onset Protracted course Worry about future possible events Think self-critically on previous events and circumstances Hopelessness Early morning awakening Suicidality Stein, Dan J., Eric Hollander, and Barbara Olasov Rothbaum. Textbook of anxiety disorders. 2nd ed. Washington, DC: American Psychiatric Pub., 2010.

Key Points Epidemiology Diagnosis Comorbidity More common in women than in men Lifetime morbid risk: 9% Diagnosis Worry and anxiety: Excessive, difficult to control At least 6 months Physical symptoms: 3 of 6: restlessness, fatigue, difficulty concentrating, irritability, muscle tension, and sleep disturbance. GAD-7 can be useful Comorbidity Common: two-thirds of patients