1. 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

2. Lifetime Prevalence of Mental Illnesses
Risk of any disorder
46.4 %
2 or more disorders
27.7 %
3 or more disorders
17.3 %
Kessler, Ronald C, et al. Arch Gen Psychiatry 2005;62: 2

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
Talking Points for this slide:
As the majority of the audience has a limited understanding of DSM-IV based classification of anxiety disorders, this slide introduces them (very briefly) to the various anxiety disorders 3

4. 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
Talking Points for this slide:
This is a continuation of the previous slide and completes the list of DSM –IV anxiety disorders. Please note I will spend very little time going into a detailed description of each and every disorder. This, as well ass the previous slide is just a high level view of the various anxiety disorders. 4

5. GAD has a lifetime prevalence of 5
GAD has a lifetime prevalence of 5.7% and may occur at any point in life*
These data are based on the US National Comorbidity Survey Replication (NCS-R), a general population survey of adults aged 18 years or older in US households between 2001–20031
Lifetime prevalence was estimated as the proportion of respondents who had ever had GAD up to their age at interview1
Using the current Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria for GAD, with symptoms for at least 6 months, the estimates indicate that the lifetime prevalence of GAD in the total US population is 5.7%1
Furthermore, prevalence estimates increased from the youngest group (18–29 years of age) to the higher aged groups (45–59 years of age)1 although for the oldest age group (60 years), prevalence was lowest1
Data from European studies are relatively consistent with data from the US NCS-R survey2
In a review of European studies, the lifetime prevalence of GAD (DSM-IIIR, DSM-IV, ICD­10) ranged from 0.1% to 6.4%2
References
Kessler RC, et al. Arch Gen Psychiatry. 2005; 62: 593–602.
Lieb R, et al. Eur Neuropsychopharmacol. 2005; 15: 445–452.
*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.
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6. Beekman AT et al. Int J Ger Psychiatry 1998; 13: 717-726
Anxiety disorders in later life 6-month prevalence findings from the Longitudinal Aging Study Amsterdam
N = 3056
N = 1138
N = 954
N = 964
Beekman AT et al. Int J Ger Psychiatry 1998; 13:

7. Criteria for GAD DSM-IV –TR definition: ICD-10 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

8. Symptoms of GAD are both somatic and psychological
Type of symptom
Manifestation
Somatic
(Motor tension)
Trembling, twitching, shakiness; muscle tension, aches or soreness; restlessness; easily fatigued
(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
Mental distress or excessive worry that impairs the patient’s ability to function is the most conspicuous feature of GAD
Physical/somatic manifestations of tension include muscle tightness, which frequently causes pain. Many of these symptoms reflect autonomic hyperarousal (e.g. tachycardia, palpitations, sweating and trembling)
Disturbed sleep is a common symptom of GAD. Many patients complain of having trouble falling asleep, having broken sleep, or waking up feeling un-refreshed
Patients suffering from GAD frequently complain of gastrointestinal symptoms, such as nausea and diarrhoea
Some of the symptoms of GAD may be confused with gastrointestinal, musculoskeletal, cardiovascular, respiratory or thyroid disorders. For this reason, such conditions must be ruled out before GAD is diagnosed
Reference
Buskey RH. JAAPA. 2004; 17: 19–24.
Buskey RH. JAAPA. 2004; 17: 19–24.
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9. 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)

10. 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?

11. 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