Synonym: anxiety neurosis
This article refers to the International Classification of Diseases 10th edition (ICD-10) which is the official classification system for mental health professionals working in NHS clinical practice. The literature occasionally refers to the Diagnostic and Statistical Manual of Mental Disorders (DSM) classification system which - whilst used in clinical practice in the USA - is primarily used for research purposes elsewhere.
See also the Generalised Anxiety Disorder Assessment (GAD-7) calculator.
The term anxiety neurosis has now been superseded by the International Statistical Classification of Disease and Related Health Problems (known as ICD) 'ICD-10' diagnosis of Generalised Anxiety Disorder (GAD). (Patients may be offended by the label 'neurotic'.)
GAD is a syndrome of ongoing anxiety and worry about many events or thoughts that the patient generally recognises as excessive and inappropriate. The condition can be chronic and debilitating.
Prevalence is difficult to ascertain without precise diagnostic criteria.
- Lifetime prevalence of GAD as defined by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) is estimated to be about 5% and the current prevalence to be about 2-3%.
- Figures are higher for women than for men.
- Differences in rates across cultural groups are evident. This may be due to variation in symptom presentation and the interpretation of symptoms as much as true differences in prevalence.
- The condition is more prevalent in elderly populations than was once thought.
- Being aged between 35 and 54.
- Being divorced or separated.
- Living alone or as a lone parent.
- Being aged between 16 and 24.
- Being married or cohabiting.
Diagnostic criteria: International Classification of Diseases 10th edition
- Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least six months, about a wide range of events or activities (such as work or school performance).
- The person finds it difficult to control the worry.
- The anxiety and worry are associated with three or more (only one for children) of the following six symptoms, with at least some symptoms present for more days than not for the preceding six months: restlessness or feeling keyed up or on edge; being easily fatigued; difficulty concentrating or mind going blank; irritability; muscle tension; sleep disturbance.
- Anxiety and worry owing to panic disorder, social phobia, obsessive-compulsive disorder and separation anxiety disorder are excluded.
At least four of the symptoms below must also be present (at least one of which is from the first group):
- Autonomic arousal symptoms:
- Palpitations or pounding heart.
- Accelerated heart rate.
- Trembling or shaking.
- Dry mouth (not due to medication or dehydration).
- Symptoms involving chest and abdomen:
- Difficulty breathing.
- Feeling of choking.
- Chest pain or discomfort.
- Nausea or abdominal distress (such as churning in stomach).
- Symptoms involving mental state:
- Feeling dizzy, unsteady, faint, or light-headed.
- Feeling that objects are unreal (derealisation) or that the self is 'not really here' (depersonalisation).
- Feeling of losing control, 'going crazy', or passing out.
- Fear of dying.
- General symptoms:
- Hot flushes or cold chills.
- Numbness or tingling sensations.
- Muscle tension or aches and pains.
- Restlessness and inability to relax.
- Feeling keyed up, on edge, or mentally tense.
- A sensation of a lump in the throat or difficulty in swallowing.
- Other nonspecific symptoms:
- Exaggerated response to minor surprises or to being startled.
- Difficulty in concentrating or mind 'going blank' because of worrying or anxiety.
- Persistent irritability.
- Difficulty in getting to sleep because of worrying.
The criteria for panic disorder, phobic anxiety disorder, obsessive-compulsive disorder (OCD), or hypochondriacal disorder must not be met. If the symptoms are due to a physical disorder or organic mental condition or a substance-related disorder, GAD is excluded.
There are a number of related conditions that need to be differentiated at an early stage. There may be confusion and overlap:
- Panic disorder, with or without agoraphobia.
- Post-traumatic stress disorder.
- Phobias - eg, arachnophobia.
- Social phobia, sometimes called social anxiety disorder, or 'SAD'. (This gets it confused with 'seasonal affective disorder' which is totally different).
- Acute stress disorder.
Anxiety is commonly a feature of other disorders.
Other conditions to consider include:
- Schizophrenia. This can present with anxiety. Ask what the patient thinks caused the symptoms. An irrational answer may show unexpressed delusional ideas.
- Dementia. This is often associated with anxiety and often with depression. Check the memory of any middle-aged or older patient presenting for the first time with anxiety. Screening for dementia gives some quick but validated tests.
- Anxiety and depression. These frequently co-exist.Ask about depressive symptoms. Those symptoms that appear first or are most severe determine the diagnosis.
- Alcoholism. Can cause anxiety as a symptom of withdrawal and may be worse in the morning. Abuse of many other drugs can also produce anxiety.
- Physical illness. This is much less likely to present as simply GAD:
There are a number of validated screening tests that can be used, including the Beck's Anxiety Inventory, General Health Questionnaire, Hamilton Anxiety Scale (HAS) and the Hospital Anxiety and Depression Scale (HADS). There are limitations in the use of routine questionnaires but providing these limitations are recognised, the general consensus is that they are worth employing in evaluation and treatment.[6, 7]
Evidence-based guidelines are laid down by the National Institute for Health and Care Excellence (NICE).Relevant issues are as follows:
- Identify the diagnosis and inform the patient as soon as possible so treatment can be commenced.
- The patient's preference for method of treatment.
- Make independent interpreters available if necessary.
- Emphasise to the patient that the disease can be managed and give as much information as possible, including written information and access to self-help and psycho-educational groups.
- Make an assessment of the patient's functional disability and distress.
- Assess past experience and response to previous treatment.
- In terms of long-term effectiveness, the best results are from psychotherapy, followed by medication, followed by self-help.
- Patients with mild learning disability or mild acquired cognitive impairment should be offered the same services as other people with GAD, making appropriate adjustment for the disability.
- People with GAD and a moderate-to-severe learning disability or moderate-to-severe acquired cognitive impairment should be offered specialist referral.
- Placebo response can vary from 20% to over 50%.
- Treatment should be available in primary care with only the most difficult cases requiring referral.
- Make the patient aware of the hazards of over-the-counter medications.
- Provide contact details in the event of a crisis.
The stepped-care modelNICE recommends the following approach:
Step 1: all known and suspected presentations of GAD
Identification, assessment, education, monitoring.
Step 2: diagnosed GAD that has not improved after education and active monitoring in primary care
Low-intensity psychological support, non-facilitated or guided self-help, psycho-educational groups.
Step 3: GAD with an inadequate response to step 2 interventions or marked functional impairment
Cognitive behavioural therapy (CBT)/applied relaxation or drug treatment.
Step 4: complex treatment-refractory GAD and very marked functional impairment, such as self-neglect or a high risk of self-harm
Specialist drug and/or psychological treatment, multi-agency teams, crisis intervention, outpatient or inpatient care.
There are frequently comorbid conditions - eg, depression, substance abuse - which may need treating too. NICE recommends that the most severe condition be treated first.If treating a child or adolescent, be much more reluctant and cautious about prescribing.
CBT is the technique of choice for an effective and lasting response:
- It must be delivered by appropriately trained professionals.
- The optimum duration of therapy would seem to be about 16-20 hours, delivered in a weekly session of one or two hours and completed within four months.
- If offering briefer CBT, it should be about 8-10 hours and should be designed to integrate with structured self-help materials.
Anxiety management treatment is also better than no treatment and its efficacy may equal that of CBT. It is a structured therapy involving education, relaxation training, and exposure. Relaxation involves practising techniques that lead to muscular or bodily relaxation. Exposure entails (over a period of time) graded, repeated confrontation (through visualisation, image, or the stimulus) with a stimulus that causes anxiety.
Recently a simplified protocol for the treatment of a wide range of psychological conditions - transdiagnostic CBT - has been used to good effect in the management of GAD.
Before prescribing, consider:
- Age of patient.
- Previous treatment response.
- Risks of deliberate self-harm or accidental overdose.
- Possible interactions with existing medications.
- The patient's preference.
- Cost, where equal effectiveness.
Where a rapid response is required:
- The sedative antihistamines may be effective or the benzodiazepines. The latter should not be used beyond four weeks. Apparent dependence may be because the disease has returned as the drug is withdrawn or there may be a physical dependence.
- It has been suggested that buspirone is less sedative and less addictive than benzodiazepines but it should be used with similar caution.
Antidepressants are often good at alleviating anxiety, even if there is no true depression.They take longer to work than benzodiazepines but they can be continued for longer.
- NICE recommends a selective serotonin reuptake inhibitor (SSRI) or venlafaxine as the first choice. If one SSRI is not suitable or there is no improvement after a 12-week course and if a further medication is appropriate, another SSRI should be offered. Long-term treatment and doses at the upper end of the indicated dose range may be necessary. NICE recommends sertraline first-line but acknowledges that this is an unlicensed use. SSRIs licensed for the treatment of GAD in the UK are escitalopram and paroxetine.
- At the start of treatment, patients should be informed about:
- Potential side-effects (including transient increase in anxiety at the start of treatment).
- Possible discontinuation/withdrawal symptoms.
- Delay in onset of effect.
- Time course of treatment.
- Need to take medication as prescribed.
- If there is no benefit in 12 weeks an antidepressant from a different class may be tried.
- SSRIs and venlafaxine should be tailed off, as sudden discontinuation can produce withdrawal.
- Pregabalin may be considered in patients who cannot tolerate SSRIs.
- Duloxetine, although not mentioned by NICE, is licensed for the treatment of GAD and has been found effective.
- There is no evidence to guide duration of therapy.
One systematic review found that kava extract was a moderately effective short-term option for GAD.
NB: beta-blockers and monoamine-oxidase inhibitors are not usually considered appropriate options for GAD.
- Self-help interventions are effective but are best used as part of a stepped-care approach.
- NICE advocates instructing the person to work through the materials systematically over a period of six weeks. Occasional contact with a therapist is advocated (eg, a five-minute telephone call).
- Internet-based self-help CBT has proved effective but the evidence base is currently small.
- One study reported that resistance or aerobic exercise training was a possible effective short-term treatment for GAD when used as an adjunct to other therapies and was worthy of further study.
- If one form of therapy does not work, another may be tried. More than one style may be used simultaneously.
- If two interventions have been tried without success then referral to mental health services is required.
- Primary healthcare professionals should monitor progress. Review interval should be determined on a case-by-case basis but is likely to be every 4-8 weeks.
- For patients on medication, NICE recommends a review every 2-4 weeks for the first three months and three-monthly thereafter.
- Medication should be continued for a minimum of one year.
- A short, self-complete questionnaire should be used to monitor outcomes wherever possible.
It is usually a chronic disease that is controlled rather than cured but the ambience of the doctor should be positive towards a favourable result.
It often pursues a waxing and waning course and long-term support and education are required.
Studies of older individuals with GAD report a duration of 20 years or more. Significant quality of life impairment and increased burden of healthcare cost have been noted in older adults. Chronic anxiety conditions are associated with increased morbidity, possibly due to cardiovascular complications and insulin resistance linked to an acceleration of the ageing process.
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