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Generalized anxiety disorder

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Updated 2023 WHO guidelines for the management of generalized anxiety disorder.

Background

Overview

Definition
GAD is a chronic disorder characterized by excessive anxiety and worry about a number of events or activities (such as work, home, and social) symptoms, and tension, which an individual finds difficult to control.
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Pathophysiology
GAD is mostly caused by genetic (altered DNA methylation and single nucleotide polymorphism) and environmental factors (stress, trauma, etc.).
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Epidemiology
The lifetime prevalence of DSM-5 GAD in the US is estimated at 7,800 cases per 100,000 individuals.
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Disease course
Clinical manifestations include restless feeling, fatigue, difficulty concentrating, irritability, muscle tension, sleep disturbance, arguments with relatives or friends, difficulty/inability to complete tasks, restriction of usual activities, with associated autonomic, cardiovascular, respiratory, gastrointestinal, and urinary symptoms decreasing the overall health of the individual. GAD is associated with various comorbidities including depression, dysthymia, bipolar I and II, panic disorder with/without agoraphobia, social phobia, specific phobia, substance use disorder, and personality disorders (avoidant, dependent, obsessive-compulsive, paranoid, schizoid, and antisocial).
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Prognosis and risk of recurrence
Anxiety disorders are associated with an increased risk of death with a natural mortality rate ratio of 1.39 (95% CI 1.28-1.51) and an unnatural mortality rate ratio of 2.46 (95% CI 2.20-2.73).
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Guidelines

Key sources

The following summarized guidelines for the evaluation and management of generalized anxiety disorder are prepared by our editorial team based on guidelines from the European Society of Medical Oncology (ESMO 2023), the Society for Integrative Oncology (SIO/ASCO 2023), the U.S. Preventive Services Task Force (USPSTF 2023,2022), the World Health Organization (WHO 2023), the American Academy of Family Physicians (AAFP 2022), ...
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Screening and diagnosis

Indications for screening, adults
As per USPSTF 2023 guidelines:
Obtain screening for anxiety disorders in adults, including pregnant and postpartum persons.
B
Insufficient evidence to assess the balance of benefits and harms of screening for anxiety disorders in older adults.
I
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  • Indications for screening (children and adolescents)

  • Indications for screening (patients with comorbidities)

  • Diagnosis

Diagnostic investigations

Initial assessment
As per NICE 2020 guidelines:
Obtain a comprehensive assessment in patients with suspected GAD, not solely relying on the number, severity, and duration of symptoms but also considering the degree of distress and functional impairment.
E
Assess how the following factors might have affected the development, course, and severity of the GAD:
comorbid depressive disorder or other anxiety disorder
comorbid substance misuse
comorbid medical condition
history of mental health disorders
past experience of, and response to, treatments
E

Medical management

General principles: as per WHO 2023 guidelines, consider providing collaborative care in adult patients with anxiety and concomitant physical health conditions.
C

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  • Antidepressants

  • Anticonvulsants

  • Benzodiazepines

  • Antipsychotics

  • OTC preparations

Nonpharmacologic interventions

Self-help strategies: as per WHO 2023 guidelines, consider offering stress management techniques, such as relaxation and/or mindfulness training, in adult patients with GAD.
C

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  • CBT

  • Exercise training

  • Meditation and yoga

  • Transcranial magnetic stimulation

  • Therapies with no evidence for benefit

Specific circumstances

Pediatric patients, prevention: as per WHO 2023 guidelines, offer psychosocial interventions, including CBT, psychoeducation, and family-focused treatment approaches, for the prevention of depression and anxiety in children whose parents have mental health conditions.
B

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  • Pediatric patients (treatment)

  • Pregnant patients

  • Elderly patients

  • Patients with substance misuse

  • Patients with cancer (evaluation)

  • Patients with cancer (psychotherapy and pharmacotherapy)

  • Patients with cancer (alternative and complementary therapies)

Patient education

General counseling: as per NICE 2020 guidelines, provide education about the nature of GAD and the options for treatment.
E
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Follow-up and surveillance

Assessment of treatment response: as per AAFP 2022 guidelines, continue antidepressants for at least 6-12 months after achieving treatment response to decrease the rate of relapse.
B

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  • Management of treatment failure