Generalized Anxiety Disorder View online at http://pier.acponline.org/physicians/diseases/d086/d086.html Module Updated: 2013-04-15 CME Expiration: 2016-04-15 Authors Christopher Gale, MB, ChB, MPH (Hon), FRANZCP Jane Millichamp, PhD Table of Contents 1. Prevention .........................................................................................................................2 2. Screening ..........................................................................................................................3 3. Diagnosis ..........................................................................................................................5 4. Consultation ......................................................................................................................8 5. Hospitalization ...................................................................................................................9 6. Therapy ............................................................................................................................10 7. Patient Education ...............................................................................................................18 8. Follow-up ..........................................................................................................................19 References ............................................................................................................................20 Glossary................................................................................................................................24 Tables ...................................................................................................................................26 Quality Ratings: The preponderance of data supporting guidance statements are derived from: level 1 studies, which meet all of the evidence criteria for that study type; level 2 studies, which meet at least one of the evidence criteria for that study type; or level 3 studies, which meet none of the evidence criteria for that study type or are derived from expert opinion, commentary, or consensus. Study types and criteria are defined at http://smartmedicine.acponline.org/criteria.html Disclaimer: The information included herein should never be used as a substitute for clinical judgement and does not represent an official position of the American College of Physicians. Because all PIER modules are updated regularly, printed web pages or PDFs may rapidly become obsolete. Therefore, PIER users should compare the module updated date on the offical web site with any printout to ensure that the information is the most current available. CME Statement: The American College of Physicians is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing education for physicians. The American College of Physicians designates this enduring material for a maximum of 1 AMA PRA Category 1 CreditTM. Physicians should claim only credit commensurate with the extent of their participation in the activity. Purpose: This activity has been developed for internists to facilitate the highest quality professional work in clinical applications, teaching, consultation, or research. Upon completion of the CME activity, participants should be able to demonstrate an increase in the skills and knowledge required to maintain competence, strengthen their habits of critical inquiry and balanced judgement, and to contribute to better patient care. Disclosures: Christopher Gale, MB, ChB, MPH (Hon), FRANZCP, current author of this module, was on speakers bureau for Astra-Zeneca, Janssen, and Lilly; and and consulted for Lilly. Jane Millichamp, PhD, current author of this module, has no financial relationships with pharmaceutical companies, biomedical device manufacturers, or health-care related organizations. Deborah Korenstein, MD, FACP, Co-Editor, PIER, has no financial relationships with pharmaceutical companies, biomedical device manufacturers, or health-care related organizations. Richard B. Lynn, MD, FACP, Co-Editor, PIER, has no financial relationships with pharmaceutical companies, biomedical device manufacturers, or health-care related organizations. PIER is copyrighted ©2013 by the American College of Physicians. 190 N. Independence Mall West, Philadelphia, PA 19106, USA. Generalized Anxiety Disorder Top 1. Prevention Recognize that brief interventions may prevent further anxiety symptoms in children, but no similar data exist for adults. 1.1 Reserve preventive strategies for children at higher risk. Recommendations • Recognize that there are no strategies to prevent GAD in adults. • Consider CBT and parent education to prevent the development of GAD in children who exhibit withdrawn or inhibited behavior or early signs of anxiety, such as separation anxiety or simple phobia. • Consider family-based CBT for children who have a parent with a diagnosed anxiety disorder. Evidence • A 2009 systematic review of prospective studies identified 23 papers, 7 of which reported on anxiety, depression with anxiety, or internalizing disorders (disorders relating to distress and fear). Of the studies on anxiety, two noted an association with abuse or neglect, and one found no relationship (1). • A randomized trial compared a 10-week, school-based CBT program with a parental intervention component to monitoring in children who showed early signs of anxiety disorders as determined by self-report and teacher report. Both groups showed improvements immediately after intervention; however, at the 6-month follow-up, only the intervention group maintained improvement, with reduced rates of existing anxiety disorders and prevention of the onset of new anxiety disorders. Results showed that although the intervention and control groups converged at 12 months, the intervention group showed superior gains at the 2-year follow-up (2; 3). • A randomized trial compared a six-session parent education program with cognitive-behavioral components to no intervention in preschool children who displayed inhibited or withdrawn behaviors, a known risk factor for later anxiety disorders. Children whose parents received the educational intervention showed a significantly greater reduction in anxiety diagnoses at the 12- month follow-up but no significant change in measures of inhibition or withdrawal (4). • A randomized trial evaluated the long-term effectiveness of a universal prevention program using CBT components (the Friends program) in school children. Schools were randomly assigned to either intervention or control and 737 children from grades 6 and 9 were enrolled. At 3-year follow- up, 6th graders who received the CBT prevention program had significantly fewer anxiety and depression symptoms than those in the control condition (5). • A randomized trial evaluated the effects of an 8-week preventive intervention (family-based CBT) on children aged 7 to 12 years whose parents had been diagnosed with an anxiety disorder. At 1- year follow-up, 30% of children in the waitlist control condition had developed an anxiety disorder, compared with 0% of children in the family-based CBT condition (6). Rationale • Cognitive-behavioral interventions in children may be helpful in preventing later development of GAD. Comments • There are no data on the prevention of GAD in patients aged over 14 years. The pediatric trials use any anxiety disorder as the outcome. • Internet-based family CBT programs may be useful for young people and their families who cannot access specialist services. PIER is copyrighted ©2013 by the American College of Physicians. 190 N. Independence Mall West, Philadelphia, PA 19106, USA. Page 2 of 36 Generalized Anxiety Disorder Top 2. Screening Consider using appropriate instruments to screen all adults in primary care settings and in children with risk factors. 2.1 Consider screening adults in primary care settings. Recommendations • Consider screening at-risk adults including those with unexplained symptoms, chronic illnesses, comorbid psychiatric disorders, or family history of anxiety disorders. • Screen adults for GAD in primary care settings by: Asking one question, e.g., “Are you bothered by nerves?” Asking the two questions which comprise the GAD-2: o Do you feel nervous, anxious, or on edge? o Are you unable to stop or control worrying? Using other instruments such as the GAD-7 or the patient questionnaire PRIME-MD • See table GAD-2 Screening Instrument. • See the GAD-7 Screening Instrument. Evidence • The National Comorbidity Survey Replication estimated that 6.1% of the U.S. population will have GAD during their lifetime, and that 2.9% will have GAD in any 12-month period. (7). • A 2007 study measured the accuracy of brief screening tools compared with a structured psychiatric interview in 965 primary care patients. Overall, 19.5% of patients had an anxiety disorder and 7.6% had GAD. For GAD, a GAD-7 score of ≥7 had sensitivity of 95% and specificity of 70%; a GAD-2 score of ≥2 had sensitivity of 95% and specificity of 64%, and a score of ≥3 had sensitivity of 86% and specificity of 83% (8). • A review of 15 epidemiologic studies of GAD in Europe estimated that the 12-month prevalence is between 0.1% to 2.1%, and the 1-month prevalence is in the range of 0.2% to 1.0%. (9). • One question (“Are you bothered by nerves?”) was used to screen for GAD in 801 primary care patients who then were interviewed using the CIDI. When compared with the CIDI, this question was 100% sensitive and 59% specific