Anxiety: Generalized Anxiety Disorder Management (Mental/Behavioral Health) - CE/NCPD

ALERT

Chronic pain conditions can increase the risk of suicide in patients with co-occurring generalized anxiety disorder (GAD).^{undefined#ref15">15}

Although benzodiazepines have demonstrated effectiveness in the treatment of GAD, they are not considered first-line treatment due to the risk of dependence.⁶

OVERVIEW

GAD is one of the most common anxiety disorders. The chief symptom is the experience of persistent and excessive worry about general events that are out of proportion to the reality of the patient’s situation. The worrying thoughts can lead to significant dysfunction. Presenting symptoms may also be physical, such as headaches or abdominal distress.¹⁴ According to the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5), the defining diagnostic criteria (300.02 [F41.1]) include:²

• Excessive anxiety and worry (apprehensive expectation) that occurs more days than not for at least 6 months about a number of events or activities (e.g., work, school performance).
• The patient finds it difficult to control the worry.
• The anxiety and worry are associated with three (or more) of these six symptoms (with at least some symptoms being present for more days than not for the past 6 months):
  • Restlessness or feeling keyed up or on edge
  • Being easily fatigued
  • Difficulty concentrating or the mind going blank
  • Irritability
  • Muscle tension
  • Sleep disturbance (difficulty falling or staying asleep or restless, unsatisfying sleep)
• The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

In addition, the signs and symptoms of GAD are not due to another condition or in response to medications or substance use.² Conditions that may have some symptoms similar to GAD include hyperthyroidism and substance use or withdrawal.³

GAD is a chronic condition, in most cases affecting women, that can cause significant disability and higher use of emergency services.⁵ GAD affects physical, cognitive, emotional, and behavioral aspects of a patient’s life. Patients can experience physical symptoms such as headaches, abdominal distress, sleep disturbances, and muscle tension. In most cases, these are the primary presenting symptoms described by the patient.¹⁴ Cognitive aspects include difficulty concentrating or an inability to focus. Emotional and behavioral aspects may involve restlessness and avoidance.³

Treatment of GAD involves a variety of psychotherapeutic interventions as well as psychopharmacologic interventions. Many patients prefer psychotherapy to pharmacologic treatments.⁷ If patients do not respond to monotherapy (i.e., either psychotherapy or pharmacotherapy), a combination of the two modalities may be effective.⁴

Psychotherapeutic modalities used to treat GAD include cognitive behavioral therapy (CBT), which is considered a first-line treatment for patients with GAD. The focus of treatment involves assisting patients with understanding the negative consequences of their unrealistic fears. It aims to help patients realize their potential to cope with those fears and reframe the fears to more accurately reflect reality. It also involves helping patients develop relaxation and productive coping skills to manage their anxiety symptoms.⁷

Medications used to treat GAD include antidepressants, primarily selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs), anticonvulsants, and anxiolytics. Although benzodiazepines can be used in the treatment of anxiety disorders, they are not recommended due to the high risk of dependency and abuse associated with their use.⁴ Venlafaxine, an SNRI; pregabalin, an anticonvulsant; escitalopram, an SSRI; and duloxetine, an SNRI, are generally considered the drugs of choice for the treatment of GAD. Sertraline and fluoxetine, both SSRIs, and buspirone, a nonbenzodiazepine anxiolytic, may also be considered as first line treatment.¹⁴ Low doses of quetiapine, an antipsychotic medication, may be considered for the treatment of GAD; although, the drug should be used with caution due to adverse side effects.¹¹

SUPPLIES

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EDUCATION

• Provide developmentally and culturally appropriate education based on the desire for knowledge, readiness to learn, and overall neurologic and psychosocial state.
• Establish a rapport with the patient, family, and designated support person that encourages questions. Answer them as they arise.
• Consider the patient’s, family’s, and designated support person’s values and goals in the decision-making process.
• Assist the patient, family, and designated support person to recognize signs and symptoms of acute exacerbation of the illness.
• Explain the manifestations of the illness and expected progression of symptoms if the patient experiences a relapse. Describe what the family and designated support person are likely to see, hear, and experience (e.g., persistent worry, irritability, jitteriness, somatic symptoms such as headache, nausea, sleep disturbances, difficulty concentrating or making decisions). Advise the patient, family, and designated support person of steps to take if relapse occurs.
• Explain to the patient, family, and designated support person that the main goal is to provide a safe, secure place to receive treatment.
• Explain how the behavioral health unit may be different than other settings. Interaction is promoted between patients and staff, and group meetings are encouraged. To ensure the patients’ safety, they are checked on frequently throughout the day.
• Educate the family and designated support person regarding the nature of psychiatric illness and expected signs and symptoms (e.g., persistent worry, irritability, jitteriness, somatic symptoms, such as headache, nausea, sleep disturbances, difficulty concentrating or making decisions).
• Assist the patient, family, and designated support person to engage and participate as drivers of the plan of care.
• Explain the importance of following the medication regimen as ordered. The patient should not alter the dose or stop taking the medication even if symptoms have subsided and the patient is feeling better. Include information about each medication, including its purpose and action, precautions to take, and potential side effects.
• Educate the patient, family and designated support person about the chronic nature of the disorder.
• Educate the patient, family, and designated support person about the risks of self-harm and suicide that are associated with GAD.
• Educate the patient, family, and designated support person about emergency resources.

ASSESSMENT

1. Perform hand hygiene. Don appropriate personal protective equipment (PPE) based on the patient’s need for isolation precautions or risk of exposure to bodily fluids.
2. Introduce yourself to the patient, family, and designated support person.
3. Verify the correct patient using two identifiers.
4. Assess the patient’s mental status and ability to understand information and participate in decisions. Include the patient as much as possible in all decisions.
5. Assess the patient for suicidal or homicidal ideation or thoughts of self-harm. Use an organization-approved standardized tool for suicide assessment.¹⁰ A patient with GAD may experience a sense of helplessness and become suicidal or engage in self-harm behaviors.⁷
6. Evaluate the patient’s, family’s, and designated support person’s understanding of the patient’s illness.
7. Assess and discuss the patient’s goal for treatment.
8. Collaborate with the patient, family, and designated support person to develop a plan of care.
9. Identify the patient’s psychiatric advance directives, if available.
10. Determine the patient’s desire for the family or designated support person to be kept informed and involved in treatment.
11. Determine the family’s or designated support person’s ability to support the patient during treatment.
12. Assess the patient for specific symptoms of anxiety disorder, including physical, emotional, behavioral, and cognitive signs and symptoms, such as sleep disturbance, irritability, and difficulty concentrating.⁴
13. Assess the patient for other mental health issues. In many cases, a patient with GAD experiences co-occurring depression or panic disorder.³
14. Assess the patient for co-occurring chronic medical conditions, such as chronic obstructive pulmonary disease, inflammatory bowel disease, and chronic pain conditions, which may complicate treatment of GAD.⁷
15. Assess the patient for the experience of recent life stressors, which can exacerbate symptoms of GAD.³
16. Assess the patient’s use of alcohol, nicotine, or illicit substances. In many cases, a patient with GAD will self-medicate with alcohol or other substances to reduce symptoms.⁷

STRATEGIES

1. Perform hand hygiene. Don appropriate PPE based on the patient’s need for isolation precautions or risk of exposure to bodily fluids.
2. Verify the correct patient using two identifiers.
3. Assess the patient for suicidal or homicidal ideation or thoughts of self-harm. Use an organization-approved standardized tool for suicide assessment.¹⁰ If homicidal or suicidal ideation is present, implement appropriate precautions based on the patient's status.

   Rationale: Patients with GAD and chronic pain conditions are at heightened risk for suicide.¹⁵

4. Explain the strategies to the patient, family, and designated support person and ensure that they agree to treatment. Ensure that the patient understands the information presented.

   Rationale: GAD may interfere with a patient’s ability to understand information. It is important to ensure that the patient’s level of anxiety allows for the processing of information.³

5. Maintain a calm, collaborative communication approach, avoiding the use of coercion. Provide information and encouragement to engage the patient in treatment.

   Rationale: Patients’ experience of being coerced or forced can lead to feelings of humiliation and diminished self-confidence.¹³

6. Create an environment of trust that allows the development of a therapeutic relationship.
7. Orient the patient to the unit. Include discussion of unit routines, guidelines, patients’ rights and expectations, and schedules. Explain that patients are checked on frequently throughout their stay.
8. Create an environment that advocates for the patient’s needs using an interdisciplinary team. Engage the team in collaborative assessment and treatment planning with the patient.
9. Provide the patient information related to healthy life factors, including healthy diet, exercise, and good sleep hygiene. Discuss the need to reduce the use of caffeine, tobacco, or alcohol (if relevant).

   Rationale: It is important to ensure that patients understand the impact lifestyle issues have on their experience of anxiety symptoms. Helping patients develop healthier lifestyles by reducing caffeine, alcohol, and tobacco use can also reduce anxiety symptoms.³

10. Engage the patient in treatment, including participation in therapeutic groups and individual sessions.

    Rationale: CBT, relaxation, mindfulness, and acceptance therapies have demonstrated effectiveness in the treatment of GAD. The cognitive reframing and altering of distorted thinking taught in CBT can reduce cognitive symptoms. Use of relaxation techniques can help reduce some of the physical symptoms of anxiety. Mindfulness and acceptance therapy can help patients develop self-awareness and challenge their need to avoid situations.³

11. Administer psychiatric medications as ordered and monitor the patient’s response to the medications.
12. Monitor the patient’s responses and social interactions in the milieu; reinforce appropriate social skills.
13. Implement appropriate precautions based on the patient’s status.
14. Respond to crisis in a calm, therapeutic, and nonthreatening manner. Use the least restrictive interventions to prevent harm to patients or staff.
15. Recognize co-occurring GAD when treating a patient for major depressive disorder.

    Rationale: For patients with major depressive disorder, co-occurring GAD can lead to greater severity of depressive symptoms and poorer outcomes.⁸

16. Collaborate with the patient, family, designated support person, and team in planning for patient discharge and follow-up care.
17. Provide the appropriate education related to medications, crisis management, and follow-up care to the patient, family, and designated support person at the time of discharge.
18. Explain to the patient, family, and designated support person that ongoing treatment is vital to continuing recovery. Making and keeping follow-up appointments is critical.

    Rationale: Medications used to treat GAD may cause adverse side effects, leading to a patient’s lack of cooperation with treatment.³

19. Remove PPE and perform hand hygiene.
20. Document the strategies in the patient’s record.

REASSESSMENT

1. Reassess symptoms of GAD and the patient’s response to treatment.
2. Assess the patient’s ability to recognize the symptoms of GAD.
3. Assess the patient’s ability to comprehend and retain instructions and information.
4. Reassess the patient’s pain status and provide appropriate pain management (e.g., medication, relaxation, mindfulness skills).

EXPECTED OUTCOMES

• Patient experiences a reduction or resolution of symptoms of GAD.
• Patient identifies and uses productive coping skills to reduce symptoms of GAD.

UNEXPECTED OUTCOMES

• Patient experiences worsening signs and symptoms of GAD.
• Patient experiences negative side effects to medications used in treatment.

DOCUMENTATION

• Education
• Patient behaviors and response to interventions
• Patient’s progress toward goals
• Assessment of pain, treatment if necessary, and reassessment

ADOLESCENT CONSIDERATIONS

• GAD is one of the most common anxiety disorders experienced by adolescents. Treatment should include family involvement to enhance positive outcomes.⁹

OLDER ADULT CONSIDERATIONS

• Older adults with GAD typically have more sleep disturbances than younger patients with the disorder.¹ They may also experience an increased risk of stroke and cardiovascular disease.¹ There is also evidence indicating that advanced age may have a negative impact on patient outcomes.⁵

SPECIAL CONSIDERATIONS

• GAD may go unrecognized in pregnancy and postnatally and can have a negative impact on maternal-child bonding. Treatment during pregnancy should focus on psychotherapeutic modalities. Medications should only be used in moderate-to-severe cases. An assessment of the risks related to maternal or fetal harm must be weighed against the benefits of the treatment.¹²

REFERENCES

1. Altunoz, U. and others. (2018). Clinical characteristics of generalized anxiety disorder: Older vs. young adults. Nordic Journal of Psychiatry, 72(2), 97-102. doi:10.1080/08039488.2017.1390607 (Level VI)
2. American Psychiatric Association (APA). (2013). Anxiety disorders. In DSM-5: Diagnostic and statistical manual of mental disorders (5th ed., pp. 189-233). Washington, DC: Author. (classic reference)* (Level VII)
3. Andrews, G. and others. (2018). Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of panic disorder, social anxiety disorder and generalised anxiety disorder. Australian & New Zealand Journal of Psychiatry, 52(12), 1109-1172. doi:10.1177/0004867418799453 (Level VII)
4. Bandelow, B., Michaelis, S., Wedekind, D. (2017). Treatment of anxiety disorders. Dialogues in Clinical Neuroscience, 19(2), 93-107. doi:10.31887/DCNS.2017.19.2/bbandelow
5. Carl, E. and others. (2020). Psychological and pharmacological treatments for generalized anxiety disorder (GAD): A meta-analysis of randomized controlled trials. Cognitive Behaviour Therapy, 49(1), 1-21. doi:10.1080/16506073.2018.1560358 (Level I)
6. Chen, T.R. and others. (2019). Pharmacological and psychological interventions for generalized anxiety disorder in adults: A network meta-analysis. Journal of Psychiatric Research, 118, 73-83. doi:10.1016/j.jpsychires.2019.08.014 (Level I)
7. DeMartini, J., Patel, G., Fancher, T.L. (2019). Generalized anxiety disorder. Annals of Internal Medicine, 170(7), ITC49-ITC64. doi:10.7326/AITC201904020
8. Dold, M. and others. (2017). Clinical characteristics and treatment outcomes of patients with major depressive disorder and comorbid anxiety disorders - results from a European multicenter study. Journal of Psychiatric Research, 91, 1-13. doi:10.1016/j.jpsychires.2017.02.020 (Level VI)
9. Imran, N., Haider, I.I., Azeem, M.W. (2017). Generalized anxiety disorder in children and adolescents: An update. Psychiatric Annals, 47(10), 497-501. doi:10.3928/00485713-20170913-01
10. Joint Commission, The. (2021). National Patient Safety Goals^® for the behavioral health care and human services program. Retrieved August 5, 2021, from https://www.jointcommission.org/-/media/tjc/documents/standards/national-patient-safety-goals/2021/npsg_chapter_bhc_jan2021.pdf (Level VII)
11. Maneeton, N. and others. (2016). Quetiapine monotherapy in acute treatment of generalized anxiety disorder: A systematic review and meta-analysis of randomized controlled trials. Drug Design, Development and Therapy, 10, 259-276. doi:10.2147/DDDT.S89485 (Level I)
12. McAllister-Williams, R.H. and others. (2017). British Association for Psychopharmacology consensus guidance on the use of psychotropic medication preconception, in pregnancy and postpartum 2017. Journal of Psychopharmacology (Oxford, England), 31(5), 519-552. doi:10.1177/0269881117699361 (Level VII)
13. Nyttingnes, O., Ruud, T., Rugkåsa, J. (2016). ‘It’s unbelievably humiliating’—Patients’ expressions of negative effects of coercion in mental health care. International Journal of Law and Psychiatry, 49(Pt. A), 147-153. doi:10.1016/j.ijlp.2016.08.009 (Level VI)
14. Slee, A. and others. (2019). Pharmacological treatments for generalised anxiety disorder: A systematic review and network meta-analysis. The Lancet, (393)10173, 768-777. doi:10.1016/S0140-6736(18)31793-8 (Level I)
15. Sommer, J.L., Blaney, C., El-Gabalawy, R. (2019). A population-based examination of suicidality in comorbid generalized anxiety disorder and chronic pain. Journal of Affective Disorders, 257, 562-567. doi:10.1016/j.jad.2019.07.016 (Level VI)

*In these skills, a “classic” reference is a widely cited, standard work of established excellence that significantly affects current practice and may also represent the foundational research for practice.

Elsevier Skills Levels of Evidence

• Level I - Systematic review of all relevant randomized controlled trials
• Level II - At least one well-designed randomized controlled trial
• Level III - Well-designed controlled trials without randomization
• Level IV - Well-designed case-controlled or cohort studies
• Level V - Descriptive or qualitative studies
• Level VI - Single descriptive or qualitative study
• Level VII - Authority opinion or expert committee reports