General treatment guidelines about Generalized Anxiety Disorder
General guidelines about Generalized Anxiety Disorder Generalized anxiety disorder is a mental health disorder that
produces fear, worry, and a constant feeling of being overwhelmedcausing significant distress/functional impairment.
Ø Symptoms should be present for most days for at least several weeks at a time, and usually for several months.
Apprehension: | Motor tension/Physical Symptoms | Autonomic Overactivity |
· Worries about future misfortunes. · Fears that suffer or relative will shortly become ill or have an accident. · Feeling “on edge”. · Difficulty in concentrating. | · Restless fidgeting. · Tension headaches. · Trembling. · Inability to relax. · Breathing difficulty. · Lump in throat sensation. · Chest pain. · Nausea. · Muscle aches. | · Light Headedness · Sweating. · Palpitation. · Dry Month. · Dizziness. · Epigastric discomfort. · Tachycardia. · Tachypnoea |
History taking and examination including MSE Annexure 1 Special emphasis -
· History of thyroid problems and metabolic diseases
· History of substance use
2 a) Investigations required Psychometric assessment: Becks Anxiety
Inventory (BAI), GAD- 7 Laboratory: (if physical complications are present)
a) Comorbidity – Major depressive disorder, other anxiety disorders especially panic disorder.
b) Differential Diagnosis – drug induced conditions, hyper/hypo thyroidism, Substance abuse,
1. Treatment
a) Psychopharmacology
· Treatment with Benzodiazepines and SSRI's
· Symptomatic and supportive
MANAGEMENT MODALITIES
Pharmacological | Non Pharmacological |
v Short term treatment with benzodiazepines (BZD’s) v Withdraw BZD’s after initial 2-4 weeks. v Always taper BZD’s v Long term treatment with antidepressants preferably Selective Serotonin Reuptake Inhibitors (SSRI’s) followed by tricyclic antidepressants and MAO inhibitors | v Psycho education about the disorder v Exploring the concomitant stressors and addressing the worried in a reassuring, emphatic and neutral manner v Cognitive behavioural therapy (CBT) (include relaxation, biofeedback and addressing cognitive distortions) v Supportive psychotherapy v Insight oriented psychotherapy v Regular exercises, yoga, breathing exercises may be advised |
SPECIAL CONSIDERATIONS DISORDER WISE
Phobic anxiety disorder: pharmacotherapy with SSRI’s, beta blockers (performance anxiety) or CBT (systematic desensitization)
Panic disorder: pharmacotherapy with SSRI’s, beta blockers or CBT involving relaxation training and cognitive remodelling
Generalized anxiety disorder: short term management with BZD’s + long term CBT or SRRI’s
Obsessive compulsive disorder: Either CBT as Exposure and Response Prevention (ERP) or
antidepressants (SRRI’s or Clomipramine) or a combination of both
Acute stress disorder: short term BZD’s + Debriefing in groups post trauma or pharmacotherapy Post-traumatic stress disorder: CBT (systematic desensitization), eye movement desensitization
and reprocessing (EMDR) or pharmacotherapy (SSRI’s or imipramine, amitriptyline
COMORBID CONDITOINS WITH ANXEITY DISORDERS
General medical conditions
Endocrine Hyperthyroidism, hypoparathyroidism, Cushing’s syndrome, hypoglycaemia, Pheochromocytoma, Addison’s disease Pulmonary Asthma, hyperventilation Cardiovascular Anaemia, cardiac failures, mitral valve prolapse, hypertension, angina, myocardial infraction Neurological Infarcts, haemorrhage, epilepsy, migraine, Wilson’s disease, basal ganglia disease like Sydenham’s chorea and Huntington’s disease (OCD) Metabolic Dyselectrolytemia, renal/hepatic failures Nutritional Vitamin B 12, Folate deficiency Tumours Cerebral/systemic | Other psychiatric disorders
Substance use disorders Schizophrenia Mood disorders Drugs Withdrawal of Alcohol, opiates, sedatives, hypnotics Intoxication Nicotine, amphetamine, cocaine, theophylline, amyl nitrite, hallucinogens |
The following table is an outline for the use of drugs for treating anxiety disorders.
Group of drug | Dosages (mg/day) | Adverse effects |
Selective serotonin | 50-200 | Sleep disturbance, |
reuptake Inhibitors (SSRI’s) Sertraline Escitalopram* Paroxetine | 10-20 20-50 20-40 20-60 | gastrointestinal side effects, headache anxiety, prolonged bleeding time, hyponatremia, sexual dysfuntion, discontinuation syndrome |
Citalopram | 100-300 |
|
Fluoxetine* Tricyclic antidepressants |
75-300 75-300 | Sedation, hypotension, cardiac side effects mainly prolonged QT interval, anticholinergic effects, |
(TCA) Clomipramine Imipramine* | 75-200 | weight gain |
Amitriptyline |
|
|
Benzodiazepines (BZD’s) | 0.5-2 | On long term use-Tolerance, |
Clonazepam Alprazolam* | 0.5-4 1-4 | dependence and withdrawal, ataxia, dizziness, daytime drowsiness, amnesia, in overdose |
Lorazepam* | 5-15 | respiratory depression |
Beta-blockers Propranolol | 10-20 mg bid or tds | Hypotension, bradycardia, worsening of asthma and hypoglycaemia, GI side effects |
*In National formulary of India
WHEN TO REFER
· If 2 adequate trial of treatments {antidepressant (usually 8-16 weeks) or psychotherapy or combination} fails
· Need for specialized psychological intervention and lack of resources
· Severe or chronic disorders or those with comorbid psychiatric conditions that need multidimensional approach
· Secondary depressive features are severe enough to warrant independent
b) Psychosocial Interventions
Psychoeducation – nature of illness, etiology, progression, consequences, prognosis, treatment.
For patient | For caregiver/guardian |
At the time of consultation | At the time of consultation |
c) Psychotherapy
i. Relaxation Techniques- Breathing exercise
ii. Flooding
iii. Systematic desensitization
iv. Cognitive Behavioural Therapy (CBT)-It help you to change unhelpful or unhealthy ways of thinking, feeling and behaving.
v. Family counselling
d) Combined treatment
2. Follow-up
a. Psychiatry opd/ DMHP
b. Physical check-up at OPD
c. Through telephonic conversation TeleManas14416/18008914416
3. Referrals
a) Depending upon the severity and complications of the patient, he/she may need to be referred to Psychiatry department.
b) To TeleManas
c) To the nearest DMHP
d) To psychiatry OPD at Kulikawn Hospital or ZMC
e) To higher centers outside Mizoram through Referral Board.
References
No references available