Generalised Anxiety Disorder

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CASE: THE ANXIOUS SALESMAN

Mr. R, 31-years-old successful salesman presents to the physicians clinic. He complains of

muscle tension, headaches and difficulty sleeping. The symptoms have gone worse since the last

15 days and he is unable to concentrate on his job.

On enquiry, Mr. R was apparently alright till his marriage 2 years ago. His symptoms started

after the birth of his child a year back. Initially the symptoms were off and on, about once a

week. But recently they come every other day. He worries about not having enough money for

his family in the event he dies suddenly or is fired from his job. He worries about job stability

and feels he would be unable to get another job that would pay him as well. Mr. R is the eldest of

4 children, his father was a electrician.

Mr. R is an introvert; he had perfectionist traits and used to excel in his studies. He wanted to

become an engineer but could not do so because he had to support his family.

1. Based on the above history, your diagnosis would be; a. Anxiety disorder

b. Major depression

c. Psychosis

The correct answer is a. Anxiety disorder

Anxiety is a diffuse, unpleasant, vague sense of apprehension with or without associated

autonomic symptoms. Normal anxiety alerts an individual of impending danger and

enables him to take precautionary or corrective measures. Pathological anxiety is

characterised by an exaggerated response to stressor anxiety in the absence of stress.

In major depression, depressed mood/melancholia is prominent. The patient also may

have psychomotor retardation/agitation, perceptual and thinking disturbances, loss of

pleasure and interest in daily activities, fatigue, inability to concentrate, lack of

appetitive, insomnia and suicidal ideation.

Psychosis is characterised by lack of touch with reality which causes problems in daily

functioning. Symptoms include delusions, hallucinations, disorganised speech,

disorganized behavior and negative symptoms.

2. The type of anxiety disorder the patient has is; a. Panic disorder

b. Obsessive-compulsive disorder

c. Generalised anxiety disorder

The correct answer is c. Generalised anxiety disorder

GAD is characterised by persistent anxiety, unrelated to a specific event. People suffering

from GAD cannot help worrying about anything and everything, even in calm situations.

They have difficulty relaxing, falling asleep, and/or concentrating, and tend to be

impatient and irritable. Physical symptoms accompanying GAD include sweating; an

upset stomach; diarrhoea; frequent urination; cold, clammy hands; a lump in the throat; a

dry mouth; shortness of breath; headaches; and dizziness

Panic attacks are sudden, unexplainable waves of panic that seem to come out of the

blue. A person who has experienced one or more panic attacks often develops a fear of

having one again. The individual may even try to stay away from anything that reminds

him or her of the last attack to avoid having another one. People can have panic attacks

with or without agoraphobia. These attacks include symptoms such as heart palpitations,

shortness of breath, chest pain, feelings of choking or smothering, nausea, dizziness,

sweating and trembling. An afflicted person might also be overwhelmed by a fear of

dying, going crazy or losing control.

Obsessive-Compulsive Disorder is a disorder in which the mind is flooded with

involuntary thoughts, or in which an individual feels compelled to repeat certain acts over

and over again (for example, hand washing). This disorder can interfere significantly with

everyday living, and usually leads to concern and/or resentment among friends, family,

and co-workers.

3. What are the various types of anxiety disorders? The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision

(DSM-IV-TR) classifies the anxiety disorders into the following categories:

Diagnostic criteria for generalised anxiety disorder

Excessive anxiety and worry (apprehensive expectation), occurring more days than not

for at least six months, about a number of events or activities (such as work or school

performance).

The person finds it difficult to control the worry.

The anxiety and worry are associated with three (or more) of the following six symptoms

(with at least some symptoms present for more days than not for the past six months).

NOTE: Only one item is required in children.

o Restlessness or feeling keyed up or on the edge

o Being easily fatigued

o Difficulty concentrating or mind going blank

o Irritability

o Muscle tension

o Sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying

sleep)

The focus of the anxiety and worry is not confined to features of an Axis I disorder, e.g.,

the anxiety or worry is not about having a panic attack (as in Panic Disorder), being

embarrassed in public (as in Social Phobia), being contaminated (as in Obsessive-

Compulsive Disorder), being away from home or close relatives (as in Separation

Anxiety Disorder), gaining weight (as in Anorexia Nervosa), having multiple physical

complaints (as in Somatization Disorder), or having a serious illness (as in

Hypochondriasis), and the anxiety and worry do not occur exclusively during Post-

traumatic Stress Disorder.

The anxiety, worry or physical symptoms cause clinically significant distress or

impairment in social, occupational or other important areas of functioning.

The disturbance is not due to the direct physiological effects of a substance (e.g., a drug

of abuse, a medication) or a general medical condition (e.g., hyperthyroidism) and does

not occur exclusively during a mood disorder, a psychotic disorder, or a pervasive

developmental disorder.

4. The symptoms associated with generalised anxiety disorder include; a. Restlessness

b. Insomnia

c. Worries

d. All of the above

The correct answer is d. All of the above

5. What are the differentiating features between generalized anxiety disorder, panic

disorder and major depression?

Case history contd...

On clinical examination, pulse - 96/min, regular, blood pressure - 130/90 mmHg

Patient was seen by a psychiatrist

His cognitive behavioral model was as follows;

Patient was treated with psychotherapy for 2 weeks. He was taught coping skills specific to fears

and to correct misperceptions of danger. He was given supportive psychotherapy to eliminate

obstacles for success. He learnt skills to decrease anxiety and eliminate symptoms. He was

treated simultaneously with flupenthixol (0.5 mg) and melitracen 10 mg.

Case history contd...

Mr. R was able to work out a plan with a financial advisor and not second guess it. He is sleeping

well, and reports success in recognising and employing coping strategies to manage anxiety

symptoms.

CASE: THE STRESSFUL RETAIL CLERK

Mrs G, a 32-year-old retail clerk, says she has experienced a lot of stress and is tired all of the

time. The Tsunami of 2005 had destroyed all her belongings in her house as well as the local

store where she had worked for 3 years. She was relocated on a bus to a place 400 miles from her

original home where she does not know anyone. She has received assistance finding a job in a

restaurant where she runs a cash register. She worries constantly that her cash register won't

balance at the end of her shift. Her supervisor frequently asks her to focus on her work since

Mrs. G often seems distracted. She reports insomnia as well as feeling hopeless about her life.

1. Based on the above history, your diagnosis would be; a. Phobia

b. Generalised anxiety disorder

c. Social phobia

d. Post traumatic stress disorder

The correct answer is b- Generalised anxiety disorder

Our patient has indeed suffered from severe mental trauma but rather than persistent

reexperience of the event, her main symptom is excessive worry and anxiety which fits into a

diagnosis of GAD

Generalised anxiety disorder is characterised by excessive anxiety and worry.

Worrying is difficult to control. Anxiety and worry are associated with at least 3 of the

following symptoms:

o Restlessness

o Being easily fatigued

o Difficulty concentrating or mind going blank

o Irritability

o Muscle tension

o Sleep disturbance

Phobias are attempts to compartmentalise fear into a few situations that can be avoided.

By attaching all the panicky feelings onto a few situations, the person can avoid those

situations and go on with life. Some of the more common phobias include claustrophobia

(fear of closed spaces), agoraphobia (fear of public places, sometimes related to panic

attacks), and acrophobia (fear of heights).

Social phobia is characterised by

o Marked and persistent fear of social or performance situations to the extent that

person's ability to function at work or in school is impaired.

o Exposure to social or performance situation always produces anxiety.

o Fear/anxiety recognised as excessive

o Social or performance situations are avoided or endured with intense anxiety.

Post traumatic stress disorder PTSD is a severe trauma that is experienced that

includes (1) actual or threatened death or serious injury or threat to personal integrity of

self or others, and (2) responses that include intense fear, helplessness, or horror. (Life-

threatening experiences and the attendant loss of control are key elements.)

o Persistent re-experience of the event occurs by at least 1 of the following:

Recurrent and intrusive recollections

Recurrent distressing dreams/nightmares

Feelings of reliving traumatic event, i.e., flashbacks

Intense psychological distress with internal or external cues to the trauma

o Physiological reactivity on exposure to trauma cues

2. In evaluating a patient with an anxiety disorder, one has to; a. Evaluate for medical illness

b. Evaluate for substance abuse

c. Evaluate for symptoms of worry, panic attacks and depression

d. All of the above

The correct answer is d- All of the above

Assessment of patients with anxiety: After obtaining a patient history, the physician should try

to categorise the anxiety as acute (or brief or intermittent) or persistent (or chronic).Acute

anxiety lasts from hours to weeks and is usually preceded by a stressor. Persistent anxiety lasts

for months to years.

Algorithm for evaluating patients with complaints of anxiety (GAD = generalised anxiety

disorder) *--If some symptoms of major depression and GAD are present but do not meet the

full criteria for either, treat for mixed anxiety-depressive disorder.

3. The co-morbidities of GAD are; a. Major depression

b. Panic disorders

c. Alcohol or other substance abuse

d. All of the above

The correct answer is d - All of the above

In the majority of cases, GAD presents co-morbidly with other psychiatric conditions including

major depression, dysthymia, bipolar disorder, panic or other anxiety disorders, as well as

alcohol or other substance abuse; 90% of patients with GAD have a lifetime history of other

psychiatric disorders. Depression is the most common co-morbidity associated with GAD,

affecting roughly two thirds of patients conversely, 20 to 30% of patients with major depression

may have GAD. The onset of GAD typically precedes the development of depression in

individuals with co morbid conditions, raising the possibility that treatment of anxiety disorder

may prevent or attenuate the development or severity of the co-morbid condition.

Case history contd…

Two weeks later, Mrs. G has returned for a follow-up visit. She was offered both medication and

applied relaxation. She was prescribed a combination of flupenthixol (0.5 mg) and Melitracen

10mg, which she has been taking for a month now. She has reported an improvement in her

symptoms and the medicine is being continued.

Role of flupenthixol+ melitracen Flupenthixol is a type of thioxanthene drug and acts by antagonism of D1 and D2 dopamine

receptors (as well as serotonin). Flupenthixol is a neuroleptic with antidepressant effects when

given in small doses. It is a useful drug in out-patient cases presenting with anxiety and tension

and psychosomatic sequelae. This neuroleptic drug is fast acting, has no sedative effect, and few

side effects with small doses. Side effects are similar to many other typical antipsychotics,

namely extrapyramidal symptoms of akathisia, parkinsonian tremor and rigidity. However,

anticholinergic adverse effects are low. Melitracen is a noradrenaline and serotonin reuptake

inhibitor. Both these drugs act at different sites thereby restoring the imbalance of

neurotransmitters. The efficacy of the combination has been tested and found to be useful in

several clinical trials. In combination the compounds render a preparation with antidepressant,

anxiolytic and activating properties. The combination of Flupenthixol and melitracen does not

seem to influence the pharmacokinetic properties of the individual compounds. The combination

is well tolerated and can be administered once or twice daily.

Suggested reading

1. American Psychiatric Association. Diagnostic and statistical manual of mental disorders.

4th ed. Washington, D.C.: American Psychiatric Association, 1994:435-6.

2. Diagnostic and statistical manual of mental disorders. 4th ed. Washington, D.C.:

American Psychiatric Association, 1994:436, and Noyes R, Woodman C, Garvey MJ,

Cook BL, Suelzer M, Clancy J, et al. Generalized anxiety disorder vs. panic disorder

3. P. E. Van Coller, Flupenthixol in the treatment of psychosomatic disorders in medicine

Psychosomatics 12: 256-259, 1971

4. Grillage M., Neurotic depression accompanied by somatic symptoms: a double-blind

comparison of flupenthixol and diazepam in general practice. Pharmatherapeutica.

1986;4(9):561-70.

5. Jokinen K, Koskinen T, Selonen R, Flupenthixol versus diazepam in the treatment of

psychosomatic disorders: a double-blind, multi-centre trial in general practice.

Pharmatherapeutica. 1984;3(9):573-81.

6. Budde G, Efficacy and tolerability of flupenthixol decanoate in the treatment of

depression and psychosomatic disorders: a multicenter trial in general practice. Prog

Neuropsychopharmacol Biol Psychiatry. 1992 Sep;16(5):677-89.

7. Ovhed I., A double-blind study of flupenthixol general practice. Curr Med Res Opin.

1976;4(2):144-50.

8. Shear MK, Schulberg HC. Anxiety disorders in primary care. Bull Menninger Clin

1995;59:A73-85.

9. Wittchen HU, Hoyer J. Generalized anxiety disorder: nature and course. J Clin

Psychiatry. 2001;62(suppl)11:15-19.

10. American Psychiatric Association. Diagnostic and statistical manual of mental disorders.

3d. Washington, D.C.: American Psychiatric Association, 1980:232-3.

11. American Psychiatric Association. Diagnostic and statistical manual of mental disorders.

4th

ed.Washington, D.C.: American Psychiatric Association, 1994:435-6.

12. Shear MK, Schulberg HC. Anxiety disorders in primary care. Bull Menninger Clin

1995;59:A73-85.

GENERALIZED ANXIETY DISORDER

POST TEST

1. A person who is impatient, irritable, unable to concentrate, with no precipitating event is

suffering from;

a. Psychosis

b. Schizophrenia

c. Obsessive compulsive disorder

d. Generalised anxiety disorder (GAD)

2. Obsessive compulsive disorder is defined as;

a. Mind flooded with involuntary thoughts

b. Sudden, unexplainable waves of panic

c. Vague sense of apprehension

d. Lack of touch with reality

3. GAD is diagnosed in a worried patient with all of the following symptoms, except;

a. Restlessness

b. Fatigue

c. Sleep disturbance

d. Increased concentration

4. A patient with post traumatic stress disorder suffers with;

a. Flashbacks of traumatic event

b. Recurrent nightmares

c. Recurrent recollections

d. All of the above

5. Most common co-morbidity associated with generalised anxiety disorders is;

a. Major depression

b. Substance abuse

c. Psychosis

d. Schizophrenia

For answers refer to next page

GENERALIZED ANXIETY DISORDER

ANSWER KEY

1. A person who is impatient, irritable, unable to concentrate, with no precipitating event is

suffering from;

a. Psychosis

b. Schizophrenia

c. Obsessive compulsive disorder

d. Generalised anxiety disorder (GAD)

2. Obsessive compulsive disorder is defined as;

a. Mind flooded with involuntary thoughts

b. Sudden, unexplainable waves of panic

c. Vague sense of apprehension

d. Lack of touch with reality

3. GAD is diagnosed in a worried patient with all of the following symptoms, except;

a. Restlessness

b. Fatigue

c. Sleep disturbance

d. Increased concentration

4. A patient with post traumatic stress disorder suffers with;

a. Flashbacks of traumatic event

b. Recurrent nightmares

c. Recurrent recollections

d. All of the above

5. Most common co-morbidity associated with generalised anxiety disorders is;

a. Major depression

b. Substance abuse

c. Psychosis

d. Schizophrenia