GAD

Information primarily from DSM and First and Tasman’s DSM-IV-TR MENTAL DISORDERSAs of 12Jul06.

GAD - duration

• Q. DSM-IV criteria expects anxiety and worry more days than not for at least how long before making the dx?

GAD - duration

Ans. Six months.

GAD - signs

• Q. DSM-IV expects to find 3 or more of what 6 signs associated with the anxiety and worry to make the dx of GAD?

GAD - signs

Ans. Expects 3 or more [only one is needed in children to make the GAD dx] of the following:

• 1] restless or chronically keyed up• 2] fatigued• 3] difficulty concentrating• 4] irritable• 5] muscle tension• 6] insomnia

R/O - adults

• Q. For adults, list two very general rule outs of other psychiatric disorders, before one dxes GAD.

R/O - adults

Ans.

• 1] Other anxiety disorders. For example, chronically anxious from OCD or chronically anxious from PTSD is not GAD

• 2] Substances, e.g., coffee.

R/O - children

• Q. List three common specific R/O in children?

R/O - children

• Ans.

• -- separation anxiety disorder

• -- social phobia

• -- OCD

Comorbidity

• Q. Name three most common co-morbidities with GAD.

Comorbidity

Ans.

-- substance-related disorder, especially alcoholism

-- another anxiety disorder

-- MDD/dysthymia

Lifetime prevalence

• Q. What is lifetime prevalence?

Lifetime prevalence

Ans. 5 %. Studies vary, but the right answer should be close to one in twenty.

Familiar?

• Q. Twin studies suggest a genetic contribution?

Familiar?

Ans. Yes. That is as far as DSM is willing to go – no specific figures.

Gender

• Q. Which gender predominates?

Gender

Ans. About 2/3 are women.

Onset

• Q. Most common age of onset?

Onset

Ans. Late adolescents or early 20s is the correct multiple choice answer, but when asked, “all my life” is common answer by pts.

Na+ lactate

• Q. What does Na+ lactate infusion do, if anything? In comparison to those suffering from panic attacks? In comparison to normals?

Na+ lactate

Ans. Infusion of Na+ lactate produces signs of anxiety in normals, but not as high a level as is seen in people with panic disorder.

First-line treatment - meds

• Q. What is first-line meds for GAD? List three general categories.

First line - meds

Ans.

• 1] SSRIs [probably the right answer to examiner’s questions as to first choice]

• 2] CNRIs

• 3] Tricyclics

FDA

• Q. FDA approved for GAD?

FDA

Ans.

-- alprazolam

-- escitalopram

-- paroxetine

-- venlafaxine

Benzodiazepines?

• Q. What is the role of benzodiazepines?

Benzodiazepines

Ans. OK as an adjunct in the failure of first-line meds for acute anxiety reactions, but not for long-term use.

Benzodiazepines – effect

Q. Benzodiazepines act on a subunit of a receptor for?

Benzodiazepines - effect

Ans. GABA

GABA

Q. Main action of GABA?

GABA

Ans. The major inhibitory neurotransmitter in the brain.

Next?

Q. Your pt has not responded to any of the three first-line meds? What medication is next in your list of choices?

Next?

Ans. Buspirone.

How long on meds

Q. Your pt has finally responded to your choice of medications. How long should you continue on the meds before trying to taper and discontinue?

How long on meds

• Ans. At least 6 to 12 months.

Psychotherapy

• Q. Which form of psychotherapy has been shown to be valuable?

Psychotherapy

Ans. CBT.

Relaxation and biofeedback have some empirical support, but examiner is likely to favor CBT

Comparison of meds and CBT

• Q. What did studies find that compared these two approaches?

Comparison of meds and CBT

Ans. Both meds and CBT worked. CBT seem to have a longer efficacy time, i.e., after both treatments had been discontinued, med-treated pts were more likely to have a reoccurrence.