Generalised Anxiety Disorder (GAD)

Definition | Aetiology | Risk Factors | Clinical Presentation | Investigations | Management | When to Refer | References

Definition

Generalised Anxiety Disorder (GAD) is a chronic mental health condition characterised by excessive, uncontrollable worry about a wide range of everyday situations. This persistent anxiety is often disproportionate to the actual likelihood or impact of the anticipated event and can significantly impair daily functioning.

Aetiology

The exact cause of GAD is not fully understood, but it is believed to result from a combination of genetic, environmental, and psychological factors:

• Genetic Predisposition: A family history of anxiety disorders increases the likelihood of developing GAD.
• Neurobiological Factors: Dysregulation of neurotransmitters such as serotonin, norepinephrine, and gamma-aminobutyric acid (GABA) is thought to contribute to anxiety symptoms.
• Psychosocial Factors: Stressful life events, childhood adversity, and personality traits such as perfectionism or high sensitivity can increase the risk.
• Environmental Factors: Chronic stress, including work-related stress or relationship issues, can trigger or exacerbate GAD.

Risk Factors

Several factors increase the likelihood of developing GAD:

• Family History: A family history of anxiety disorders or other mental health conditions.
• Personality Traits: Individuals with traits such as perfectionism, high sensitivity, or a tendency to avoid conflict may be more prone to GAD.
• Chronic Stress: Long-term exposure to stressful situations, such as financial difficulties or ongoing work pressure.
• Gender: Women are more likely to be diagnosed with GAD than men, possibly due to a combination of biological, psychological, and sociocultural factors.
• Childhood Trauma: Early life experiences such as abuse, neglect, or significant loss can increase vulnerability to anxiety disorders later in life.

Clinical Presentation

GAD presents with a variety of psychological and physical symptoms that can be pervasive and distressing:

Psychological Symptoms

• Excessive Worry: Persistent and excessive worry about various aspects of life, such as work, health, finances, or family.
• Restlessness: A feeling of being "on edge" or unable to relax.
• Difficulty Concentrating: Trouble focusing on tasks or experiencing a "blank mind."
• Irritability: Increased sensitivity to stress or irritability over minor issues.
• Sleep Disturbances: Difficulty falling asleep, staying asleep, or experiencing restful sleep due to ongoing worries.

Physical Symptoms

• Muscle Tension: Chronic muscle tension, particularly in the shoulders, neck, or back.
• Fatigue: Persistent tiredness, even after adequate sleep.
• Headaches: Frequent tension headaches or migraines.
• Gastrointestinal Issues: Symptoms such as nausea, diarrhoea, or irritable bowel syndrome (IBS) are common in GAD.
• Palpitations: Sensation of an irregular or fast heartbeat, often linked to anxiety episodes.

Investigations

The diagnosis of GAD is primarily clinical, based on a detailed history and mental health assessment. However, additional investigations may be conducted to rule out other conditions:

• Psychiatric Assessment: A thorough mental health evaluation, often using structured interviews or questionnaires such as the Generalised Anxiety Disorder-7 (GAD-7) scale.
• Medical History and Examination: A complete medical history and physical examination to rule out underlying medical conditions that could contribute to anxiety symptoms.
• Laboratory Tests: Blood tests such as thyroid function tests, full blood count (FBC), and electrolyte levels to exclude physiological causes of anxiety, such as hyperthyroidism.

Management

The management of GAD involves a combination of psychological therapies, pharmacological treatments, and lifestyle modifications:

Psychological Therapies

• Cognitive Behavioural Therapy (CBT): The first-line treatment for GAD, CBT helps patients identify and challenge negative thought patterns and behaviours, reducing anxiety symptoms.
• Mindfulness-Based Therapies: Mindfulness practices, such as mindfulness-based stress reduction (MBSR), can help individuals manage anxiety by focusing on the present moment.
• Relaxation Techniques: Techniques such as progressive muscle relaxation, deep breathing exercises, and guided imagery can reduce physical symptoms of anxiety.

Pharmacological Treatments

• Selective Serotonin Reuptake Inhibitors (SSRIs): Medications such as sertraline or citalopram are commonly prescribed as first-line pharmacotherapy for GAD.
• Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs): Venlafaxine and duloxetine are alternatives to SSRIs, particularly if there is a partial response or intolerance to SSRIs.
• Benzodiazepines: Short-term use may be considered for acute anxiety episodes, but they are not recommended for long-term use due to the risk of dependence.
• Pregabalin: An anticonvulsant that can be effective in treating GAD, particularly in patients who cannot tolerate SSRIs or SNRIs.
• Beta-Blockers: Propranolol may be used to manage physical symptoms such as palpitations and tremors, particularly in performance-related anxiety.

Lifestyle Modifications

• Regular Exercise: Physical activity can help reduce anxiety symptoms by releasing endorphins and improving overall well-being.
• Healthy Diet: A balanced diet with adequate hydration can support mental health. Reducing caffeine and sugar intake may help minimise anxiety symptoms.
• Sleep Hygiene: Establishing a regular sleep routine and creating a restful environment can improve sleep quality and reduce anxiety.
• Stress Management: Techniques such as time management, relaxation exercises, and setting realistic goals can help manage stress levels.

When to Refer

Referral to a specialist or mental health service may be necessary in the following situations:

• Severe or treatment-resistant GAD that does not respond to initial therapies or requires more intensive management.
• Co-occurring mental health conditions such as major depressive disorder, substance abuse, or other anxiety disorders.
• Significant impairment in daily functioning, including difficulties at work, in social settings, or in personal relationships.
• Need for specialised psychological therapies, such as CBT, that are not available in primary care settings.

References

1. NHS (2024) Generalised Anxiety Disorder (GAD). Available at: https://www.nhs.uk/conditions/generalised-anxiety-disorder/ (Accessed: 26 August 2024).
2. National Institute for Health and Care Excellence (2024) Generalised Anxiety Disorder and Panic Disorder in Adults: Management. Available at: https://www.nice.org.uk/guidance/cg113 (Accessed: 26 August 2024).
3. British Medical Journal (2024) Generalised Anxiety Disorder: Clinical Review. Available at: https://www.bmj.com/content/350/bmj.h3366 (Accessed: 26 August 2024).

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