History

Fact Explanation
Excessive anxiety and worry. Occurring most of the days for 6 month period, about number of events or activities. The intensity and the duration of the anxiety is very much out of proportion to the actual likelihood and the impact of the feared situation. [1]
The person finds its difficult to control the worry. Repetitive worrying thoughts are characteristic of generalized anxiety disorder. [1]
The anxiety or worry is associated with 3 or more of the following symptoms: restless, feeling keyed up or on edge, being easily fatigued, difficulty in concentrating or mind going blank, irritability, muscle tension, sleep disturbance (difficulty in falling or staying asleep or restless unsatisfying sleep). Patients with poor concentration sometimes complain of poor memory, but true memory impairment does not occur. If it is present, consider the possibility of an organic cause. [2]
The focus of the anxiety or worry is not confined to features of an Axis 1 disorder. Panic attacks (panic disorder), worry of being embarrassed in public (social phobia), being contaminated (Obsessive compulsive disorder), worry of being away from home or closed people (separation anxiety disorder), worry about gaining weight (anorexia nervosa), having multiple physical complaints ( somatization disorder) worry about having a serious illness (hypochondriasis). [2]
The anxiety, worry or physical symptoms cause clinically significant distress or impairment in function of the person. Social, occupational functioning is impaired. [2]
The disturbance is not due to a direct physiological effect of a substance (drug abuse, a medication) or a general medical condition (hyperthyroidism) and not exclusively due to another psychiatric disorder (mood disorder, psychotic disorder, pervasive developmental disorder) Substance use/abuse (eg, caffeine, amphetamines, marijuana, cocaine) and withdrawal (eg, from alcohol) can cause anxiety symptoms. And medications with anxiogenic effects (β-adrenergic agonists,theophylline, corticosteroids, thyroid hormone, sympathomimetics,psychostimulants) Hyperthyroidism, Congestive heart failure, Cardiac arrhythmia, Chronic obstructive pulmonary disease, Hyperventilaton, Pulmonary embolism, Pheochromocytoma, Hyperadrenalism can cause anxiety symptoms. [3]
References
  1. BANDELOW B, BOERNER J R, KASPER S, LINDEN M, WITTCHEN HU, MöLLER HJ. The Diagnosis and Treatment of Generalized Anxiety Disorder Dtsch Arztebl Int [online] 2013 Apr, 110(17):300-310 [viewed 11 June 2014] Available from: doi:10.3238/arztebl.2013.0300
  2. LENZE EJ, WETHERELL JL. A lifespan view of anxiety disorders Dialogues Clin Neurosci [online] 2011 Dec, 13(4):381-399 [viewed 12 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3263387
  3. CHEN JP, REICH L, CHUNG H. Anxiety disorders West J Med [online] 2002 Sep, 176(4):249-253 [viewed 11 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1071743

Examination

Fact Explanation
Cardiovascular examination Symptoms of anxiety are seen in patients with ischemic heart disease and arrhythmia. Therefore a detailed examination of the cardiovascular system should be performed. Possible findings include: tachycardia, irregular pulse, tachypnoea. [1]
Respiratory system examination Hyperventilation is a sign that can be seen in patients with bronchial asthma and in generalized anxiety disorder. Respiratory system examination findings should be normal in anxiety disorders. [2]
Signs of hyperthyroidism Tachycardia, irregularly irregular pulse, tachypnoea, lid retraction, sweaty palms, hand tremors , restlessness can be seen in both hyperthyroidism and anxiety disorder. Thyroid goiter, exophthalmos, opthalmoplegia, fine hair due to hair loss, are specific to thyroid disease. [3]
Mental State Examination: Appearance The face looks strained,with furrowed brow. Posture is tensed tremors and sweating may be seen in the hands and the patient is restless. Also exclude co-morbid conditions like depression, where vertical furrows in the brow can be seen. [4]
Mental State Examination: Speech Normal. May speak slowly if the patient has co morbid depression. [4]
Mental State Examination: Mood. Associated symptoms like palpitations, dry mouth, tremor. [4]
Mental State Examination: Thoughts Preoccupations of reasons for anxiety and fear of a catastrophic event may prolong the disorder. [4]
Mental State Examination: Perception. They do not have any illusions or hallucinations. [4]
Mental State Examination: Depersonalization/ Derealization Depersonalization can occur during an anxiety attack. The patient will feel detached from their own body, and will experience a sense of 'unreality' about themselves. [4]
Mental State Examination: Cognitive function. Normal. [4]
Mental State Examination: Insight Insight is preserved. [4]
References
  1. HUFFMAN JC, CELANO CM, JANUZZI JL. The relationship between depression, anxiety, and cardiovascular outcomes in patients with acute coronary syndromes Neuropsychiatr Dis Treat [online] 2010:123-136 [viewed 13 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2874336
  2. MEURET AE, RITZ T. Hyperventilation in Panic Disorder and Asthma: Empirical Evidence and Clinical Strategies Int J Psychophysiol [online] 2010 Oct, 78(1):68-79 [viewed 13 June 2014] Available from: doi:10.1016/j.ijpsycho.2010.05.006
  3. OSTENIUK J, MORGAN D, D’ARCY C. Diagnoses of anxiety and depression in clinical-scenario patients: Survey of Saskatchewan family physicians Can Fam Physician [online] 2012 Mar, 58(3):e144-e151 [viewed 13 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3303667
  4. BANDELOW B, BOERNER J R, KASPER S, LINDEN M, WITTCHEN HU, MöLLER HJ. The Diagnosis and Treatment of Generalized Anxiety Disorder Dtsch Arztebl Int [online] 2013 Apr, 110(17):300-310 [viewed 13 June 2014] Available from: doi:10.3238/arztebl.2013.0300

Differential Diagnoses

Fact Explanation
Anxiety disorder due to general medical condition. 1)Hypo- or hyperthyroidism 2)Congestive heart failure 3)Cardiac arrhythmia 4)Chronic obstructive pulmonary disease 5)Pneumonia 6)Hyperventilaton 7)Neoplasms 8)Encephalitis 9)Pulmonary embolism 10)Pheochromocytoma 11)Hyperadrenalism Causing metabolic and autonomic abnormalities can give rise to anxiety symptoms. [1]
Substance induced anxiety disorder. Substance use/abuse: caffeine, amphetamines, marijuana, cocaine- and withdrawal from alcohol or sedative-hypnotics can cause anxiety symptoms. Severe anxiety that only occurs in the context of the substance use /abuse or during withdrawal. [1]
Another axis 1 disorder. Panic disorder, social phobia, obsessive compulsive disorder, anorexia nervosa, hypochondriasis, somatization disorder, separation anxiety disorder. [2]
Post traumatic stress disorder. Generalized anxiety disorder (GAD) is not diagnosed if the anxiety occurs exclusively during the course of the post traumatic stress disorder. [2]
Adjustment disorder Adjustment disorder is diagnosed only when the diagnosis does not fit for criteria of any other anxiety disorder. In adjustment disorder the anxiety occurs in the presence of a life stressor and does not continue after 6 months of termination or removal of that stressor. [2]
Mood disorders and psychotic disorders Anxiety can occur during the course of mood or psychotic disorders but is not diagnosed separately if it occurs exclusively during the period of the mood or psychotic disorder. [3]
Non pathological anxiety. Differentiation of GAD from non pathological anxiety includes, 1) Anxiety associated with GAD is difficult to control and interferes with the functioning of the person's life.In non pathological anxiety, the anxiety can be controlled and functioning of the person is not affected. 2) In GAD the anxiety is more pervasive. distressing and occurs more frequently. 3) Non pathological anxiety is less likely to cause physical symptoms. [2]
References
  1. CHEN JP, REICH L, CHUNG H. Anxiety disorders West J Med [online] 2002 Sep, 176(4):249-253 [viewed 13 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1071743
  2. BYSTRITSKY A, KHALSA SS, CAMERON ME, SCHIFFMAN J. Current Diagnosis and Treatment of Anxiety Disorders P T [online] 2013 Jan, 38(1):30-57 [viewed 13 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3628173
  3. OLINO TM, KLEIN DN, LEWINSOHN PM, ROHDE P, SEELEY JR. Latent Trajectory Classes of Depressive and Anxiety Disorders from Adolescence to Adulthood: Descriptions of Classes and Associations with Risk Factors Compr Psychiatry [online] 2010, 51(3):224-235 [viewed 13 June 2014] Available from: doi:10.1016/j.comppsych.2009.07.002

Investigations - for Diagnosis

Fact Explanation
ECG and echocardiogram To exclude any underlying cardiac disease. Conditions like arrhythmia and supra ventricular tachycardia. [1]
Thyroid Function Tests. TSH and free T4 levels. To exclude thyroid disease giving rise to anxiety episodes. [2]
References
  1. HUFFMAN JC, CELANO CM, JANUZZI JL. The relationship between depression, anxiety, and cardiovascular outcomes in patients with acute coronary syndromes Neuropsychiatr Dis Treat [online] 2010:123-136 [viewed 13 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2874336
  2. CHEN JP, REICH L, CHUNG H. Anxiety disorders West J Med [online] 2002 Sep, 176(4):249-253 [viewed 13 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1071743

Management - General Measures

Fact Explanation
Exclude a co existant depressive disorder Anxiety symptoms can be present in depressive disorder or patients with GAD can be depressed due to their condition. If depressive symptoms are present, treatment for depression should be started.[1]
Explain the management plan to the patient and agree to a clear plan. Because the uncertainty of the management options and further proceedings may prolong the anxiety of the patient. [2]
Education of the patient and his family members about the disorder and reassuring them. Anxiety is maintained by the fear about the anxiety symptoms and about the consequence of them. explanation about the condition will remove the anxiety about the symptoms. Education of the family members will create a friendly home environment to the patient. [2]
Advice about necessary lifestyle changes. Advice against alcohol use smoking and use of substance (cannabis, cocaine, amphetamines). Advice on managing time,taking time to relax. [3]
References
  1. OLINO TM, KLEIN DN, LEWINSOHN PM, ROHDE P, SEELEY JR. Latent Trajectory Classes of Depressive and Anxiety Disorders from Adolescence to Adulthood: Descriptions of Classes and Associations with Risk Factors Compr Psychiatry [online] 2010, 51(3):224-235 [viewed 13 June 2014] Available from: doi:10.1016/j.comppsych.2009.07.002
  2. CHEN JP, REICH L, CHUNG H. Anxiety disorders West J Med [online] 2002 Sep, 176(4):249-253 [viewed 13 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1071743
  3. SMITH JP, RANDALL CL. Anxiety and Alcohol Use Disorders: Comorbidity and Treatment Considerations Alcohol Res [online] 2012, 34(4):414-431 [viewed 13 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3860396

Management - Specific Treatments

Fact Explanation
Self- help methods. Identify stressors and reduce or remove them.Identify stressors by keeping a diary and reporting the events at which the patient felt anxious. Encourage the patient to think of ways to deal with them. consider each problem and things that can be done to resolve the worry. [1]
Anxiolytic medication Benzodiazepine (alprazolam) - For concomitant treatment with an antidepressant until the onset of the antidepressant effect (to short term relief of anxiety). adverse effects of benzodiazepines-physiological and psychological dependence, potential fatalities upon withdrawal, impaired cognition and coordination, a potentially lethal overdose when they are mixed with alcohol or opioids, inhibition of memory encoding, which can interfere with the efficacy of concomitant psychotherapy. Buspirone - a non benzodiazepine anxiolytic. It is less like to cause dependence when compared to benzodiazepine, but its effects appear more slowly. [2]
Antidepressant medication-Tricyclic antidepressants (TCA) - Amitriptyline. Anticholinergic effects can be present - dry mouth, blurred vision, urinary retention, constipation. Antiadrenergic effects - postural hypotension, ejaculatory delay. Cardiovascular side effects - tachycardia, arrhythmia, sudden death. They are less frequent than in treatment for depression as the required dose (for the anxiolytic effect) is lesser. [2]
Antidepressant medication - Specific serotonin re-uptake inhibitors (SSRIs)- Escitalopram, Paroxetine. Serotonin noadrenaline re- uptake inhibitors (SNRIs)- Duloxetine, Venlafaxine Drugs of first choice. Fewer side effects than TCAs. But may cause increase anxiety and agitation when first taken. Gastrointestinal effects - nausea, vomiting, dyspepsia, constipation, diarrhea. Serious side effects - seizures, hyponatremia, increase suicidal risk in children and adolescents. [2]
Antidepressant medication -Monoamine oxidase inhibitors (MAOIs) Not used today due to the side effects and drug interactions. [2]
Cognitive behavioral therapy (CBT). The goal of treatment is for the patient to develop the ability to recognize, eliminate, and correct his or her dysfunctional assumptions and thoughts in order to to cope more appropriately with various situations. Relaxation - Relaxation of muscle groups one by one, breathing slowly, clearing mind of anxious thoughts by concentrating on a calming image. Techniques for changing anxiety provoking conditions - Teach the nature of the normal anxiety response and explain that the symptoms are harmless. and explain hoe the fearfulness and the concerns of the symptoms give rise to a vicious cycle of anxiety. Teach about using distraction techniques to reduce the anxiety. Exposure - Determine the situations that are avoided. arrange the situations in order of the amount of anxiety generated. Persuade patient to face the situation which brings out the least amount of anxiety, and to stay there until the anxiety is declined. And to repeat the exercise until the situation is faced without the anxiety at all. And advice to move up in the list of situations and face the more difficult situations one by one. Problem-solving techniques- Practicing problem-solving strategies to lessen inappropriate approaches to problems and constant worrying. [3]
References
  1. CHEN JP, REICH L, CHUNG H. Anxiety disorders West J Med [online] 2002 Sep, 176(4):249-253 [viewed 13 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1071743
  2. BANDELOW B, BOERNER J R, KASPER S, LINDEN M, WITTCHEN HU, MöLLER HJ. The Diagnosis and Treatment of Generalized Anxiety Disorder Dtsch Arztebl Int [online] 2013 Apr, 110(17):300-310 [viewed 13 June 2014] Available from: doi:10.3238/arztebl.2013.0300
  3. LENZE EJ, WETHERELL JL. A lifespan view of anxiety disorders Dialogues Clin Neurosci [online] 2011 Dec, 13(4):381-399 [viewed 13 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3263387