1. A 40-year-old female teacher mother of 8 children comes to your office with one year history of dizziness, tinnitus, disturbed sleep, facial numbness, headache, poor concentration, reduced appetite, excessive sweating, excessive worries about her children and home duties,. Symptoms fluctuate in severity but never disappeared.

2. On physical examination BP: 130/70 Pulse: 104/min -thyroid gland within normal limits and non tender -her cardiac examination reveals no abnormalities other than tachycardia -her neurological examination is normal. The remainder of P/E is normal.

3. Q – 1 What is the most likely diagnosis? A- panic disorder. B- major depressive disorder. C- generalized anxiety disorder. D-hyperthyroidism. E-hypochondiasis.

4. Dr. Khalid Saad Al-Ghamdi

5. Definition Diagnostic criteria Prevalence Epidemiology Risk factors Symptoms Diagnosis Treatment Referral indication

6. Every one experiences feelings of anxiety during their lifetime. For example, you may feel worried and anxious about sitting an examination, or having a medical test, or job interview. Feeling anxious sometimes is perfectly normal

7. For people with generalized anxiety disorder (GAD), feelings of anxiety are much more constant, and tend to affect their day- to-day life.

8. Definition : Is characterized by excessive worry and anxiety that are difficult to control and that cause significant distress and impairment. In addition patient with GAD may present with somatic symptoms. 2009 UpToDate

9. Diagnostic criteria ( from DSM IV ) : 1- Excessive anxiety and worry about a number of events or activities, occurring more days, not less than 6 months. 2- The person finds it difficult to control the worry. 3- It is associated with several symptoms. 4- It causes significant distress or impairment in daily live. American Psychiatric Association, 2009

10. GAD prevalence is estimated to be between 5 and 8 percent in the primary care setting 2009 Up-to-date

11. Epidemiology :  The usual age of onset is variable from childhood to adulthood.  Women two to three times more likely to suffer from GAD than men. 2009 Up-to-date

12. Risk factor :  Stresses of live.  Fears.  Substance abuse.  Family history. 2009 Up-to-date

13. Symptom : Difficulty concentrating. Irritability. Sleep disturbance. Exaggerated response. Panic. Sensitivity to noise. psychological 2009 Up-to-date

14. Motor tension :  Muscle tension or aching.  Restlessness.  Fatigue and tiredness. Physical 2009 Up-to-date

15. Autonomic over activity : Dry mouth. Palpitation. Sweating / cold hand. Difficult swallowing. Diarrhoea. Frequency of micturition. Dizziness. Difficulty breathing. 2009 Up-to-date

16. 1- History. 2- Exclusion of organic disorders. 3- Exclusion of other psychiatric disorder. Diagnosis American Psychiatric Association, 2009

17. American Psychiatric Association, 2008

19. A seven-item anxiety questionnaire (GAD-7) has been developed and validated in a primary care setting. This patient self-assessment tool may facilitate screening, but positive screens (a score of 8 or higher) should be followed by clinician interview Diagnostic criteria from the DSM-IV to establish the diagnosis of GAD. 2009 Up-to-date

20. 1. Feeling nervous, anxious or on edge 2. Not being able to stop or control worrying 3. Worrying too much about different things 4. Trouble relaxing. 5. Being so restless that it is hard to sit stil. 6. Becoming easily annoyed or irritable. 7. Feeling afraid as if something awful might happen

21. GAD-7 mild : 5-9 moderate :10-14 sever : 15-21 2009 Up-to-date GAD assessment

22. Differential diagnosis : 1- Depression. 2- Drug and alcohol dependence. 3- Cardiac arrhythmias. 4- Benzodiazepine dependence. 5- Hyperthyroidism. Caffeine intoxication. 6- 2009 Up-to-date

23. Anxiety  Panic attack.  Autonomic symptom.  Insomnia.  Apprehension.  Worry. Depression  Early morning waking.  Weight loss.  Suicidal thoughts  Feeling of hopelessness.

26. Management : Non-pharmacolgical pharmacological Herbal

27. Reassurance Not a serious physical disease, Not insanity, Not life- threatening Not a sign of weakness or failure, Not childishness or overdependence Set Goals for Therapy Decrease level of anxiety and maintain at low level Modulate future symptom responses National Institute of Mental Health. Accessed 2009

28. Encourage : Acceptance of anxiety as a life-long problem healthy lifestyle as an adjunct to treatment, Daily Physical Exercise, Sleep Hygiene, Avoid harmful intakes : Avoid alcohol, Tobacco, caffeine, Substance Abuse Consider new hobbies National Institute of Mental Health. Accessed 2009

29.  Psychotherapy  Teach coping skills and conflict resolution  Increase self confidence, Increase self control  Promote emotional growth  Encourage patient to express themselves  Practice goal directed behavior  Redirect energy and creativity National Institute of Mental Health. Accessed 2009

30. Behavioral Therapy Progressive muscle relaxation Relaxation training, stress management Biofeedback Systematic desensitization Breathing retraining (arousal reduction) Take a deep breath Let breath out through pursed lips Cognitive Therapy  Recognize, Reexamine and replace anxious thoughts

31.  Meta-analysis : Cognitive behavioral therapy (CBT) is frequently recommended as first line psychological treatment for GAD which is more effective reducing symptoms Cochrane Database Syst Rev. 2007

32. A controlled study of 91 patients with new episodes of GAD found that family physicians who used brief supportive psychotherapy had three-month and six- month follow-up results similar to those who used benzodiazepines 2009 Up-to-date

33. CBT should be used. A CBT should be delivered only by suitably trained and supervised people who can demonstrate that they adhere closely to empirically grounded treatment protocols. A CBT in the optimal range of duration (16–20 hours in total) should be offered. A For most people, CBT should take the form of weekly sessions of 1–2 hours and be complete within a maximum of 4 months from commencement. B Briefer CBT should be supplemented with appropriate focused information and tasks. A

34. Pharmacological Treatment

35.  First line : ( no abuse or withdrawal symptoms )  SSRI : paroxitine 20 – 60 mg ( need > 2 weeks to work )  SNRI: venlafaxine 37.5 – 300 mg ( if + psychosis or smoking )  Non-addictive anxiolytics :  Buspirone (Buspar) 15 – 30 mgBuspar  Bupropione : 75 – 150mg 2009 Up-to-date

36. Antidepressants Several RCTs : have demonstrated the efficacy of antidepressants in patients with generalized anxiety disorder, including trials of venlafaxine, paroxetine, sertraline, citalopram, imipramine, and trazodone. 2009 Up-to-date

37. Syst.Rev. : concluded ( NNT = 5 ) with antidepressants to observe a positive effect. five RCTs of venlafaxine for GAD found similar efficacy and tolerability in younger and older patients. Venlafaxine may be a particularly good choice for patients with coexisting psychiatric illness, such as panic disorder, major depression, or social phobia, or when it is not clear if the patient has GAD, depression, or both. 2009 Up-to-date

38. Unless otherwise indicated, an SSRI should be offered. B If one SSRI is not suitable or there is no improvement after a 12- week course, and if a further medication is appropriate, another SSRI should be offered. D When prescribing an antidepressant, the healthcare professional should consider the following. Side effects on the initiation of antidepressants may be minimised by starting at a low dose and increasing the dose slowly until a therapeutic response is achieved. D In some instances, doses at the upper end of the indicated dose range may be necessary and should be offered if needed. B Long-term treatment may be necessary for some people and should be offered if needed. B

39.  Alternative Pharmacotherapy  Tricyclic Antidepressant  Imipramine(Tofranil) 25 mg – 300 mgTofranil  Desipramine (Norpramin) 25 – 300 mgNorpramin  Beta Blockers : Indicated for excessive autonomic symptoms, or in social phobia : Propranolol (Inderal), Atenolol (Tenormin)Inderal  Long Acting Benzodiazepines : Clonazepam (Klonopin) 0.5 – 6 mgKlonopin  acute severe : Short-acting Benzodiazepines :  Alprazolam (Xanax) 0.5 – 10 mgXanax  Lorazepam (Ativan) 0.5 – 6 mgAtivan

41. Herbal Method

43. Studies on the effectiveness of kava kava for the treatment of GAD have important methodological flaws and placebo effects are significant. Kava Kava has been associated with fatal hepatotoxicity and the FDA has issued a safety alert. We advise against the use of kava kava for treatment of anxiety. 2009 Up-to-date

44. indications of referral : severe & complicated cases child with GAD associated with drugs & alcohol dependence associated with psychosis associated with personality disorders

45. GAD is a common problem frequently seen in primary care. Careful history taking and good listening to the patient help detect this disorder. Family physician should be good observer to detect such cases. Immediate treatment should be started ( no need for psychologist referral )