Kembara Xtra - Medicine - Generalized Anxiety Disorder

Kembara Xtra - Medicine - Generalized Anxiety Disorder 
​Persistent, excessive, and difficult-to-control worry that is accompanied by significant symptoms of motor tension, autonomic hyperactivity, and/or sleep or concentration disturbances. Affected systems include the nervous system (increased sympathetic tone and catecholamine release), the cardiac system (tachycardia), the pulmonary system (dyspnea), and the gastrointestinal system (nausea, irregular bowel movements).

Lifetime prevalence of epidemiology in the United States is between 5.1 and 11.9%.
 May begin at any age, but usually does so in adulthood; in the US, the median age of beginning is 31 years.
Male:female ratio is 2:1.
 Posttraumatic stress disorder (PTSD) and anxiety are more common in COVID-19 survivors; they are typically chronic and recurrent in nature and fluctuate in severity.

ETIOLOGY AND PATHOPHYSIOLOGY Serotonin, norepinephrine, and gamma-aminobutyric acid (GABA) neurotransmitter system disorders may have a role in pathophysiology.
 Linked to changed regional brain activity (increased amygdala and prefrontal cortex activity)
Genetics GAD may be influenced by the serotonin transporter gene (5HT1A).
Unfavorable life circumstances (sickness, poverty, etc.)
• Comorbid psychiatric disorders • Family history

DURATIONAL PREVENTION
Cardiorespiratory fitness and physical activity are linked to lower levels of generalized anxiety and sadness.
In young children with early anxiety, cognitive-behavioral therapy (CBT) and family involvement may offer protection from GAD.


Major depressive disorder (>60%), dysthymia, bipolar disorder, schizophrenia Alcohol/drug abuse; teenage cigarette smoking Panic disorder, agoraphobia, phobia, social anxiety disorder, anorexia nervosa, PTSD, obsessive-compulsive disorder (OCD), ADHD Somatoform and pain disorders 

DISEASE HISTORY
The history is used largely for diagnosis. It's important to distinguish between pathologic anxiety and typical anxiety reactions.
The DSM-5 requirements are as follows:
- For at least six months, symptoms of excessive anxiety and worry are present more often than not.
- Inability to control concern - Adults must meet at least three additional criteria for a diagnosis of GAD, whereas children must only meet one.
agitation, tenseness, or feeling on edge; easily worn out; trouble focusing or losing one's train of thought
- Sleep disruptions (difficulty falling or staying asleep) - Irritability - Muscle tension - Persistent concern must significantly disrupt functioning in social, professional, or other areas.
Focus of worry and anxiety is unrelated to PTSD and is not associated with or restricted to the prevalence of other mental diseases.
– The presence of a substance, another illness, or another DSM-5 diagnostic does not cause symptoms.
MEDICAL ANALYSIS
helpful in determining other possible differential diagnosis. GAD sufferers may display irritation, bitten nails, tremor, or clammy palms; there are no unique physical features associated with GAD.

Cardiovascular DIFFERENTIAL DIAGNOSIS: congestive heart failure, ischemic heart disease, mitral valve prolapse, cardiomyopathies, and arrhythmias
Pulmonary: pulmonary embolism, chronic obstructive pulmonary disease, and asthma
Metabolic and hormonal conditions include hyper- or hypothyroidism, pheochromocytoma, adrenal insufficiency, Cushing syndrome, hypokalemia, hypoglycemia, and hyperparathyroidism. CNS conditions include stroke, seizures, dementia, migraine, vestibular dysfunction, and neoplasms.

Alcohol, sympathomimetic drugs (cocaine, amphetamine, caffeine), corticosteroids, herbal products (ginseng), and sedative-hypnotic drugs are used to treat drug-induced anxiety. Psychiatric disorders include panic disorder, OCD, PTSD, social phobia, adjustment disorder, and somatization disorder.

DETECTION & INTERPRETATION OF DIAGNOSIS

Initial examinations (lab, imaging)
Tests in the lab are typical. Thyroid-stimulating hormone, CBC, BMP, urine drug screen, and ECG are a few possible initial testing.
GAD-2: a two-question scale with a 22 percent positive predictive value (PPV) and a 78 percent negative predictive value (NPV).
PHQ-4 offers a quick screening for both depression and anxiety.

Diagnostic techniques and additional psychological tests
GAD-7: offers more specific treatment information (29% PPV/71% NPV); may also be a sign of panic disorder (GAD-7: 29% PPV/71% NPV)
The Hamilton Anxiety Scale (HAM-A) with the IVth edition of the Anxiety Disorders Interview Schedule
Children: Screen for Child Anxiety Related Emotional Disorders (SCARED), Multidimensional Anxiety Scale for Children (MASC), and ADIS-IV Parent and Child Version


GENERAL MEASURES/TREATY
Check for suicidal thoughts.
Recognize and address psychological disorders and substance abuse that coexist.
When compared to individuals who receive treatment within a year after symptom onset, delayed treatment may lead to worse clinical outcomes.
Remission might not happen for 4 to 6 months after starting treatment. twelve months to treat.
Psychotherapy techniques
- According to number needed to treat (NNT), psychological therapies are effective in treating GAD.
- CBT: the best researched psychological treatment; when accessible, treatment of choice; may improve coexisting disordersTraining in mindfulness and relaxation are two prerequisites for psychodynamic therapy, which involves the patient verbalizing underlying issues.

First Line: MEDICATION

SSRIs and SNRIs are widely tolerated, do not lead to misuse or dependence, and effectively treat comorbid depression. There are not many data points to compare agents.

 The choice of medication is based on the side effect profile, drug-drug interactions, and/or the treatment preferences or history of the patient.
Start with the lowest effective dose of an SSRI or SNRI, increase it every two to four weeks, and utilize the highest tolerable FDA-approved dose for at least four to six weeks before declaring it useless or switching to a different SSRI or SNRI. Taper gently until you stop.
● Without the proper dosage or length of therapy, switching between drugs can result in poor treatment.
Drug interactions, weight gain, and sexual side effects (decreased libido, delayed orgasm) are frequent adverse effects of SSRIs. Common side effects of SNRIs include nausea, dizziness, sleeplessness, drowsiness, constipation, sweating, and blood pressure rise.
Escitalopram (Lexapro): initially 10 mg/day; may be increased to a maximum of 20 mg/day; SNRIs: duloxetine (Cymbalta): initially 30 mg/day; may be increased by 30 mg/day qwk to a maximum of 120 mg/day; doses greater than 60 mg/day rarely more effective Pregabalin (Lyrica): improves anxiety ratings and lessens relapse at 75 to 300 mg BID; less sexual dysfunction and sleep disruption than SSRIs. Venlafaxine XR (Effexor XR): initially 37.5 to 75.0 mg; may titrate up by 75 mg every 4 days to a maximum of 225 mg/day. Rapid beginning of effect with a taper to cease (off-label) 

Next Line
Sertraline (Zoloft): starting dose of 25 mg/day; may titrate by 25 to 50 mg/day qwk to a maximum of 200 mg/day; Azapirones: starting dose of 15 mg/day divided BID-TID; maximum of 60 mg/day divided BID-TID; buspirone (BuSpar): less dependence risk;
Fluoxetine (Prozac): 10–20 mg per day; up to 60 mg per day (off-label) may be titrated 
The most frequent side effect of mirtazapine (Remeron) is sleepiness (off-label). The recommended starting dose is 15 mg per night, and the maximum daily dose is 45 mg.
Paroxetine (Paxil): 10 to 20 mg daily at first; up to 50 mg daily (no additional benefit above 20 mg daily); effective but ill tolerated 
Quetiapine (Seroquel): 150 mg/day is the recommended dosage.
more effective than SSRIs, but less well tolerated. Think of it as an addition.
Citalopram (Celexa), however it lacks an FDA indication, probably works well for GAD.
Benzodiazepines are beneficial in the short term but less effective over the long run and have a risk of abuse and dependence.[A]
- Klonopin (clonazepam): 0.25 mg BID, with a possible increase to 4 mg/day distributed BID
Alprazolam (Xanax): 0.25 mg TID; may increase to 4 mg/day. Hydroxyzine (Vistaril, Atarax): CNS depressant, antihistamine, anticholinergic; decreased risk of dependence. Diazepam (Valium): 2 to 5 mg BID-QID; may increase to a maximum of 40 mg/day. Lorazepam (Ativan): 0.5 mg BID-TID; may Usual dosage: 50–100 mg PO QID; avoid using in elderly people.

Aspects of Geriatrics
Steer clear of TCAs and long-acting benzodiazepines; they can result in delirium.
Pregabalin may make you feel groggy and sleepy.

Child Safety Considerations

Pediatric patients with mild to moderate GAD should receive CBT as their first line of treatment.
With severe GAD, CBT combined with an SSRI is the primary line of treatment.

Black box warning (SSRIs): Antidepressants increase the risk of suicidal ideation and behavior in children, adolescents, and young adults. Studies also reveal a rise in teenage suicide attempts after stopping SSRIs. SSRIs and SNRIs have all been demonstrated to be effective.

SSRIs are the medication of first resort.
ADHD and anxiety frequently co-occur. Consider using nonstimulating drugs after treating the more severe conditions.

pregnant women's issues
Buspirone: Category B: Breast milk secretion; insufficient research to determine danger

Benzodiazepines: Category D: Avoid breastfeeding if the mother is taking them persistently or in excessive dosages as they may induce lethargy and weight loss in nursing infants.
SSRIs: If at all possible, taper and stop using them. There is an increased risk of pulmonary hypertension, moderate transitory neonatal CNS syndrome, and motor, respiratory, and GI symptoms after 20 weeks of pregnancy. Mixed findings have been found in studies on autism risk. All but one are Category C, including:
- Paroxetine: Category D: Conflicting data on risk of congenital heart abnormalities and other congenital malformations during the first trimester.
- Hydroxyzine: Case reports of neonatal withdrawal, Category C

ALERT Exercise caution
Benzodiazepines are prohibited in people with narrow-angle glaucoma and should be used with caution in people with open-angle glaucoma. They also increase the risk of seizures in people over 65, with respiratory conditions or sleep apnea. usage with caution in patients who have a history of substance misuse since long-term usage has the potential to lead to tolerance and dependence.

Buspirone: therapy with monoamine oxidase inhibitors (MAOIs) for hepatic and/or renal impairment
When combined with other serotonergic medications, SSRIs can raise the risk of serotonin syndrome in people who also have concomitant bipolar illness.

ALTERNATIVE & COMPLEMENTARY MEDICINE

Acupuncture, yoga, massage, tai chi, and aromatherapy all show promise but require further research. Kava has some promise above placebo for treating mild to moderate anxiety but raises questions about potential hepatotoxicity. Manufacturing standards, plant components used, dosage, and interactions with other chemicals all have an impact on safety.
There is compelling evidence that regular exercise considerably reduces anxiety.  Patients who are unable to respond to medication may benefit from routine transcranial magnetic stimulation of the right dorsal lateral prefrontal cortex.
More long-term research are required, although cannabidiol may be helpful in treating COVID-19-associated anxiety as well as problems related to anxiety.
Psilocybin in combination with behavioral therapy may have a significant additive impact, but additional research is required.

CONTINUING CARE AFTERCARE RECOMMENDATIONS
 
patient observation
Every six months, a clinical follow-up with the patient is advised.
Following the first two to four weeks of taking new meds, a follow-up appointment should be scheduled, and it is advised that treatment continue for another 12 months beyond the initial period of response.
Keep an eye on your mental state while taking benzodiazepines to prevent reliance or sudden stopping.
Watch out for suicidal thoughts in all patients, but especially in those taking SSRIs and SNRIs.

Limit caffeine intake and stay away from alcohol and cigarettes, which can interact with medications and cause anxiety.

PATIENT EDUCATION Psychoeducation understanding normal versus pathologic anxiety and the physiology of anxiety can be useful. Regular exercise may be good for anxiety and associated conditions.

PROGNOSIS: There is a 40–60% chance of recovery, but relapse is frequent.
Comorbid mental diseases and strained interpersonal ties increase the risk of relapse.