Nursing Continue Education

​Generalized Anxiety Disorder (GAD)

Prevalence of GAD

​Generalized Anxiety Disorder (GAD) is one of the most common mental illness in the United States encountered by primary care physicians (ER, 2015). Anxiety may be normal in day to day life because people may worry about things like health, family, money, work, and other things. However, individuals with GAD may feel worried excessively or feel nervous about certain things even if there is no reason to (ER, 2015). People with GAD often find it difficult to control their anxiety and stay focused on daily tasks. Despite all these, GAD can still be treated.

​The 12-month prevalence for GAD is 3.1% of US adult population according to the National Institute of Mental Health (NIH, 2018). Again 3.5% of these cases are classified as severe, however, no data is reported on gender distribution of the condition. 12-month Healthcare Use is 43.2% of the patients with the disorder, and 43.7% of those receiving treatment receives less adequate treatment, and this represents 18.9% of those with the disorder (NIH, 2018).

Pathophysiology

​Neurobiological theories are often applied to explain the pathophysiology of GAD. Medications taken for GAD do not cure but suppress activity in the amygdala and other areas of the brain that cause the disorder (Kehoe, 2013). Fear conditioning is centered within the amygdala of the brain. Sensory input is received from brain areas such as sensory cortex, prefrontal cortex, and sensory thalamus. The experience of fear is regulated when there is a connection between the amygdala and areas of the prefrontal cortex (Kehoe, 2013). In addition, this also regulates experience of fear and resulting psychological responses. Motor responses may be controlled by connections with the periaqueductal area of the brain. Combined together they form the responses to fear, however, if the system fails to be effectively regulated it may lead to a clinical anxiety syndrome (Kehoe, 2013).

Physical Assessment and Examination

Patients present with several symptoms from affective, cognitive, behavioral, and somatic (Dunphy, Winland-Brown, Porter, & Thomas, 2015). Patients will display feelings of dread, panic, increased heart rate, irritability, nail biting, restlessness, tense, headaches, and may affect their hygiene and groom (Collins-Bride, Saxe, Duderstadt, & Kaplan, 2017).

​Once a patient presents with suspected symptoms of GAD, a health professional may conduct physical assessment to check blood pressure and temperature, take pulse, listen to the patient lungs and heart, check whether the patients nerves are functioning properly (Kehoe, 2013); for instance, a doctor may tap the patient elbow or knee with a small rubber hammer to determine whether the patient has a quick or slow physical reflexes (Kehoe, 2013). In addition, the provider may also feel the patient’s thyroid gland and take blood or urine samples.

The final diagnosis of GAD is confirmed using criteria provided in the DSM-5. The first step is always obtaining a careful history of the patient’s descriptions and course of symptoms (Kehoe, 2013). One of the easiest ways to assess a GAD patient is to basically ask them “Do you worry too much about minor issues?” The GAD-7 screening tool can be utilized in the most primary care setting, and a score of 10 or more is an indication of GAD, 5 mild, and 15 severe. GAD-2 which is a shorter version of GAD-7 reduce the time that may be needed to diagnose GAD (Kehoe, 2013).

Evidence-Based Treatment plan and Education

​Several evidence-based guidelines are available for GAD treatment, and researchers who came up with EB treatment guidelines have interpreted data from literature report and have drawn a conclusion regarding the effectiveness of the treatment methods and their side effects (ER, 2015). A body of evidence recommends that combining medication and psychotherapy may be more efficient for patients with moderate to severe symptoms of GAD. A number of medications are available as first-line therapies for the treatment of GAD. For instance, Selective Serotonin reuptake inhibitors (SSRIs) are considered first-line therapy for GAD treatment. Tricyclic antidepressants (TCAs), duloxetine, and azapirones are better treatments for GAD (ER, 2015).

Behavioral interventions such as cognitive behavioral therapy and mindfulness-based stress reductant have been proven effective non-pharmacological treatment. CBT changes thinking patterns and mindfulness-based stress reductant promote focused attention. Education and compassionate listening are the key aspects to the commencement of GAD treatment. A provider should always establish a therapeutic alliance between him/her and the patient is important to eliminate fears of interventions and encourage treatment (ER, 2015). Education should be focused on identifying and eliminating common triggers such as stress, diet, nicotine, stimulants, and caffeine and improve sleep quality and engage in regular exercise (ER, 2015).

Follow up and Evaluation

In a study conducted to determine treatment and follow-up time on GAD patients in a clinical-care setting, the researchers found that patients with GAD should have an immediate treatment and follow-up (Kosteniuk et al, 2012). It is recommended that GAD patients should follow-up with their providers after every two weeks to evaluate their treatment. Pharmacological and non-pharmacological treatment of GAD is always expected to be effective, and a patient should be evaluated for any side effects that may result from treatment. In addition, if GAD patient doesn’t improve their symptoms, appropriate drugs and therapy should be recommended different from the current treatment (Kosteniuk et al, 2012).

 

 

 

References

ER, I. (2015). Diagnosis and management of generalized anxiety disorder and panic disorder in adults. Am Fam Physician, 91(9), 617-624.

Collins-Bride, G.M., Saxe, J.M., Duderstadt, K.G., & Kaplan, R. (2017). Clinical Guidelines for Advanced Practice Nursing: An Interprofessional Approach (3rd ed). Jones & Bartlett Learning, Burlington, MA.

Dunphy, L.M., Winland-Brown, J.E. Porter, B.O., & Thomas, D.J. (2015). Primary Care: The Art and Science of Advanced Practice Nursing (4th ed). F.A. Davis Company. Philadelphia, PA.

National Institute of Mental Health (NIH). (2018). Generalized Anxiety Disorder (GAD). Available at: https://ftp.nimh.nih.gov/health/statistics/prevalence/file_148021.pdf

Kehoe, W. A (2013). Generalized Anxiety Disorder. Available at: https://www.accp.com/docs/bookstore/acsap/a17b2_sample.pdf

Kosteniuk, J., Morgan, D., & D’Arcy, C. (2012). Treatment and follow-up of anxiety and depression in clinical-scenario patients: Survey of Saskatchewan family physicians. Canadian Family Physician, 58(3), e152.

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