What are the guideline sources, guidelines and references for Generalized anxiety disorder ?
Guideline 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 U.S. Preventive Services Task Force (USPSTF 2022), the Women's Preventive Services Initiative (WPSI 2020), the Anxiety Disorders Association of Canada (ADAC 2014), the British Association for Psychopharmacology (BAP 2014), and the National Institute for Health and Care Excellence (NICE 2011). 1 2 3 4 5 6 7 7 8 9 10 Definition GAD is a chronic disorder characterized by excessive anxiety and worry about a number of events or activities (e.g., work, home, and social) symptoms, and tension, which an individual finds difficult to control. 7 Epidemiology GAD is mostly caused by genetic (altered DNA methylation and single nucleotide polymorphism) and environmental factors (stress, trauma, etc.). 7 Pathophysiology https://web.pathway.md/diseases/recULNMK8C8cNBOuE 1/8 6/24/23, 3:16 AM Generalized anxiety disorder Pathway Pathophysiology The lifetime prevalence of DSM-5 GAD in the United States is estimated at 7800 cases per 100,000 individuals. 8 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). 9 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). 10 Calculator Calculator Generalized anxiety disorder-7 s Hamilton anxiety scale HAM A Guidelines 1. Screening and diagnosis Diagnosis: consider a diagnosis of GAD in patients presenting with anxiety or substantial worry and in patients who attend primary care frequently who have a chronic physical health problem or do not have a physical health problem but are seeking reassurance about somatic symptoms or are repeatedly worrying about a wide range of different issues. E Indications for screening (women): obtain screening for anxiety in adolescent and adult females aged 13 years, including pregnant and postpartum females. E Indications for screening (children): Obtain screening for anxiety in children and adolescents aged 8-18 years. B Insufficient evidence to assess the balance of benefits and harms of screening for anxiety in children aged 7 years. I Indications for screening (general population): do not obtain routine screening for the presence of anxiety symptoms in all patients. D https://web.pathway.md/diseases/recULNMK8C8cNBOuE 2/8 6/24/23, 3:16 AM Generalized anxiety disorder Pathway 2. Diagnostic investigations Assessment: conduct a comprehensive assessment in patients with GAD that considers the degree of distress and functional impairment; the effect of any comorbid mental health disorder, substance misuse, or medical condition; and past response to treatment. E 3. Medical management General principles: offer drug treatment to patients with GAD as a choice of second-line therapy. A Show 3 more Antidepressants: As per ADAC 2014 guidelines, evidence from randomized control trials supports the use of SSRIs (including escitalopram and sertraline), as well as the use of SNRIs (duloxetine and venlafaxine XR) for the treatment of GAD. A As per NICE 2011 guidelines, offer a SSRI to patients with GAD if they choose drug treatment. Consider sertraline first because it is the most cost-effective drug. Offer an alternative SSRI if sertraline is ineffective. A As per NICE 2011 guidelines, offer a serotonin noradrenaline reuptake inhibitor to patients with GAD if sertraline is ineffective. A Anticonvulsants: As per ADAC 2014 guidelines, in patients with GAD, randomized control trials indicate that the anticonvulsant pregabalin was more effective than placebo and as effective as benzodiazepines. A As per NICE 2011 guidelines, consider pregabalin in patients with GAD if they cannot tolerate SSRIs or serotonin noradrenaline reuptake inhibitors. B Antipsychotics: do not offer an antipsychotic for the treatment of patients with GAD in primary care as the evidence for clinical efficacy is poor, while the risk of serious side effects are well- known. D Benzodiazepines: As per ADAC 2014 guidelines: Alprazolam, bromazepam, diazepam, and lorazepam have demonstrated effectiveness to manage GAD. A Do not offer a benzodiazepine for the treatment of patients with GAD in primary or secondary care except as a short-term measure during crises. Buspirone: several randomized control trials show that buspirone was more potent than placebo and as effective as benzodiazepines. A Trazodone: in a randomized control trial, trazodone was as effective as diazepam. B Herbal preparations: https://web.pathway.md/diseases/recULNMK8C8cNBOuE 3/8 6/24/23, 3:16 AM Generalized anxiety disorder Pathway Lavender oil has revealed success comparable to lorazepam to treat GAD. A Galphimia glauca extract has revealed success comparable to lorazepam to treat GAD. B 4. Nonpharmacologic interventions Transcranial magnetic stimulation: in a small open trial, repetitive transcranial magnetic stimulation was effective as monotherapy or as an adjunct to SSRIs for the treatment of GAD. B Exercise training: A randomized control trial of adjunctive resistance training or aerobic exercise demonstrated significant symptomatic improvements compared to a wait-list condition. B Acupuncture: insufficient evidence to determine efficacy of acupuncture in GAD or anxiety neurosis. I Meditation and yoga: adjunctive meditation and yoga-based treatments may be beneficial in patients with GAD, as suggested by open-label studies. B Updated evidence: TAME In adults with a diagnosed anxiety disorder, mindfulness-based stress reduction was noninferior to escitalopram with respect to anxiety levels reduction as assessed with clinical global impression of severity scale. Elizabeth A Hoge et al. JAMA Psychiatry. 2022 Nov 9. Bright light therapy: in a randomized control trial, there were no significant improvements with initiating bright light therapy compared with placebo. B Active monitoring: monitor the symptoms and functioning of patients with GAD. Active monitoring may improve less severe presentations and avoid the need for further interventions. E Over-the-counter preparations: insufficient evidence to recommend over the counter preparations to patients with GAD. Discuss the use of over the counter preparations, explain the potential for interactions with other medications (for example, St John's wort with oral contraception). I First-line therapy: Offer one or more of the following first-line, low-intensity interventions to patients with GAD guided by the patient's preference, if symptoms have not improved after education and active monitoring: individual non-facilitated self-help (usually involving minimal contact with a healthcare professional) individual guided self-help (supported by a trained practitioner, who facilitates the program and reviews progress and outcome) https://web.pathway.md/diseases/recULNMK8C8cNBOuE 4/8 6/24/23, 3:16 AM Generalized anxiety disorder Pathway participation in psychoeducational groups (conducted by trained practitioners and based on the principles of CBT; groups with a ratio of one therapist to about 12 participants). B Include printed or electronic materials of a readability level suitable for the individual based on the treatment principles of CBT in the individual non-facilitated and guided self-help. B Second-line therapy: Offer a choice of the following to patients with GAD if functional impairment is marked or symptoms have not improved after low intensity interventions: an individual, high-intensity psychological intervention - CBT or applied relaxation, in which patients learn to apply relaxation skills in anxiety provoking situations B drug treatment. A Show 2 more 5. Specific circumstances Patients with comorbid mental health conditions: Treat the primary disorder first in patients with a comorbid depressive or other anxiety disorder - that is, the first is the one that is more severe and treatment of which is more likely to improve overall functioning. E Treat the substance misuse first in patients with harmful and dependent substance misuse, as it may lead to substantial improvement in the symptoms of GAD. E Patients with cancer (evaluation): obtain regular screening and assessment for anxiety in all patients with cancer in all phases of illness. B Show 3 more Patients with cancer (management): offer a combination of psychotherapeutic and psychopharmacological modalities for the treatment of anxiety in patients with cancer. A Show 4 more 6. Patient education Patient education: educate patients with known and suspected presentations of GAD about their disorder and the treatment options. Education may improve less severe presentations and avoid the need for further interventions. E 7. Follow-up and surveillance Follow-up: offer drug treatment to patients with GAD if the condition has not responded to a full course of a high-intensity psychological treatment. E Show 4 more Likelihood Ratios https://web.pathway.md/diseases/recULNMK8C8cNBOuE 5/8 6/24/23, 3:16 AM Generalized anxiety disorder Pathway Pertinent positives The following findings increase the probability of generalized anxiety disorder in adults. -1 Finding LR+ Value Positive GAD-7 score 5.1 (4.3-6.0) Positive BAI-PC score 4.6 (2.3-8.9) Positive ADS-GA score 3.2 (1.3-8.0) Positive SDDS-PC score 2.6 (1.6-4.1) Show 2 more Pertinent negatives The following findings decrease the probability of generalized anxiety disorder in adults. -1 Finding LR- Value Negative PRIME-MD score 0.12 (0.05-0.29) Negative GAD-7 score 0.13 (0.07-0.26) Negative GAD-Q-IV score 0.18 (0.1-0.5) Negative BAI-PC score 0.19 (0.05-0.68) Show 1 more References 1. L Grassi, R Caruso, M B Riba et al. Anxiety and depression in adult cancer patients: ESMO Clinical Practice Guideline. ESMO Open. 2023 Apr;8 2 101155. Epub 2023 Mar 14. Open 2. Tim Kendall, director, visiting professor et al. 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