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Based on new empirical findings in a large-scale primary care study, the quality of care for the most chronic and debilitating anxiety problem, generalised anxiety disorder, is examined. Following a brief introduction of this disorder, the core findings of the GAD-P study (generalised anxiety and depression in primary care) with more than 20,000 patients of 558 family doctor practices are summarised and measures to improve the quality of care of patients with generalised anxiety disorder, a disorder which is rarely adequately treated, are discussed. This paper particularly emphasises the standard use of time-efficient diagnostic screening instruments, because improved recognition and diagnosis is the prerequisite for appropriate treatment. Further the role of the media to increase awareness of this disorder as well as patient education materials to improve compliance and to enhance treatment outcome effects are highlighted.
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PMID:[Generalized anxiety disorders in primary medical care]. 1455 47

Generalized anxiety disorder is the most common anxiety disorder and is second only to depression as the most common disorder diagnosed in primary care. Because it is potentially disabling due to its high comorbidity with other psychiatric conditions, psychiatric nurses must accurately diagnose GAD and formulate individualized treatment plans that promote positive outcomes for clients with this disorder.
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PMID:Current treatment of generalized anxiety disorder. 1468 28

Adaptation disorders are a heterogeneous group of mental disorders. Although they play a major role in clinical practice, are difficult to treat, and often lead to chronicity and disability, diagnostic algorithms are vague and scientific research is rare. Clinical practice has shown a subtype of adaptation disorder that is characterized primarily by lasting embitterment after exceptional though normal life events which violate basic beliefs. This disorder can be called post-traumatic embitterment disorder (PTED). A case vignette and results of a pilot study are reported. Critical life events were found to be job loss in 38%, conflicts at work in 24%, death of a loved one in 14%, familial strain in 14%, and other events in 10%. When reminded of the critical event, patients report feelings of embitterment (85.7%), sadness (81.0%), anger (76.2%), or helplessness (75.0%). When standardized assessments are made, they fulfill criteria of various comorbid disorders such as GAD (38.1%), depression (33.3%) and dysthymia (33.3%), agoraphobia (28.6%), or panic (19.0%). Of the patients, 81% said they avoid places which remind them of the critical events. Impairments were suffered in work (70%), leisure (65%), and familial relations (57.1%).
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PMID:[Post-traumatic embitterment disorder (PTED). Differentiation of a specific form of adjustment disorders]. 1472 62

Eighty treatment-seeking adults age 60 or over with panic disorder, generalized anxiety disorder, and mixed anxiety states (generalized anxiety with panic attacks, panic disorder with secondary generalized anxiety) completed a clinical assessment and battery of self report measures. Several hypotheses were tested from the domains of distinguishing symptoms, associated features, and rates of comorbidity with other disorders. Greater between- than within-group variance was found on a subset of measures suggesting that the distinction between GAD and PD is generally valid in the older adult population. Higher scores on measures of sympathetic arousal, agoraphobic avoidance, and rates of comorbid somatization disorder and alcohol dependence distinguished those with PD from those with GAD. Higher scores on measures of depression and hostility, but not trait anxiety or worry, distinguished the GAD group. Results indicate that distinguishing features of GAD and PD in older treatment-seeking adults may be fewer and slightly different from those of younger adults.
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PMID:Distinguishing generalized anxiety disorder, panic disorder, and mixed anxiety states in older treatment-seeking adults. 1512 77

A community sample of 2798 8-17-year-old twins and their parents completed a personal interview about the child's current psychiatric history on two occasions separated by an average of 18 months. Parents also completed a personal interview about their own lifetime psychiatric history at entry to the study. Results indicate that informant agreement for overanxious disorder (OAD) was no better than chance, and most cases of OAD were based on only one informant's ratings. Disagreement about level of OAD symptoms or presence of another disorder (mostly phobias or depression) accounted for most cases of informant disagreement: 60% of cases based only on child interview, 67% of cases based only on maternal interview, and 100% of cases based only on paternal interview. OAD diagnosed only by maternal interview was also distinguished by an association with maternal alcoholism and increasingly discrepant parental reports of marital difficulties. Given the substantial overlap in case assignments for DSM-III-R OAD and DSM-IV GAD, these findings may identify sources of informant disagreement that generalize to juvenile GAD.
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PMID:Making sense of informant disagreement for overanxious disorder. 1553 4

Anxiety disorders frequently occur in association with PD and may be important causes of morbidity. Actual prevalence rates are uncertain, but estimates suggest that up to 40% of patients with PD experience substantial anxiety. This percentage is greater than expected, particularly for an elderly population. In addition, the age at onset of anxiety in PD (and particularly panic disorder) is later than would be expected from current information regarding the natural course of anxiety disorders. Virtually all of the types of anxiety disorders have been described in PD, but panic disorder, GAD, and social phobia appear to be the ones most commonly encountered. Although most patients with motor fluctuations experience greater anxiety during the "off" phase, this is not a universal phenomenon. Anxiety frequently develops before the motor features do, suggesting that anxiety may not represent psychological and social difficulties in adapting to the illness but rather may be linked to specific neurobiologic processes that occur in PD. Most evidence points to disturbances in central noradrenergic systems, but other neurotransmitters (e.g., serotonin, dopamine) may be involved as well. Studies suggest that right hemispheric disturbances may be particularly important for the genesis of anxiety, especially panic and OCD. Whether antiparkinsonian medications themselves contribute to anxiety needs clarification. Anxiety and depression frequently coexist in PD. It remains to be determined whether anxiety in patients with PD reflects one of the following pathologies: (a) an underlying depressive mood disorder, (b) a particular subtype of depression (atypical depression, anxious or agitated depression), or (c) an independent psychiatric disturbance. The relationship between anxiety and dementia in PD is not clear, but current evidence suggests that cognitive dysfunction is not related to the presence of anxiety symptoms in this disorder. The optimal pharmacologic treatment for anxiety in patients with PD has not been established, nor has the effect of PD surgery on anxiety symptoms.
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PMID:Anxiety disorders in Parkinson's disease. 1638 11

We examined differences in self-reported anxiety and depression according to the number and pattern of DSM-IV comorbid diagnoses in 172 children and adolescents (mean age=11.87, S.D.=2.67; range=7-17) with a primary diagnosis of social phobia. Three hypotheses were tested: (1) children with comorbid anxiety disorders would show significantly higher scores than children with social phobia-only on self-report measures, (2) self-report measures would significantly differentiate between children with social phobia and comorbid internalizing versus externalizing disorders, and (3) self-report measures would significantly differentiate children according to the type of anxiety comorbidities present. Multinomial logistic regressions showed that children with three anxiety disorders scored significantly higher than children with one and two diagnoses on two of three self-report measures used. Logistic regressions revealed that children's scores on measures did not differ according to the nature of the comorbid diagnoses (internalizing vs. externalizing). Finally, ROC curves showed that the MASC and the SPAI-C accurately classified children with additional diagnoses of SAD and GAD, respectively. The potential of self-report measures to further our understanding of childhood anxiety comorbidity and the clinical implications of their use to screen for comorbidity are discussed along with suggestions for further study.
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PMID:Self-report measures in the study of comorbidity in children and adolescents with social phobia: research and clinical utility. 1788 22

The GAD is an important psychiatric disorder with high comorbidity and often chronic course. The differentiation against depression is not easy. In this review evidence based standards of therapy are discussed. The complex etiology and pathogenesis give a rationale for an integrative therapeutic approach, but this does not necessarily mean a combination of pharmacotherapy and psychotherapy for every patient. The pharmacotherapy with SSRI, SNRI, opipramol, buspirone and pregabalin allows an effective treatment. The empirical validated behaviour therapy is alternatively possible. Both approaches include a respectable number of therapy non-responders.
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PMID:[Generalized anxiety disorder (GAD)--diagnosis and therapy]. 1806 31

"Pathologic worry" is a new term in the ICD-10 and DSM-IV-classification of anxiety disorders. Worry is a common symptom in psychiatric disorders, special in depression and specific for GAD. The new scales DANDTE (self-Rating-Inventory) and BOEAS (observer Rating Scale) were developed for the clinical routine and provide an economic and precise rating also for other anxiety symptoms. In the pharmacotherapy SSRI and SNRI are the first line, but also Buspiron, Opipramol and Pregabalin are possible agents in the short-term and long-term therapy. Cognitive behaviour therapy is a proofed psychotherapeutic alternative approach.
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PMID:[Pathologic worry]. 1807 53

Knowledge concerning the classification of mental disorders progressed substantially with the use of DSM III-IV and IDCD 10 because it was based on observed data, with precise definitions. These classifications a priori avoided to generate definitions related to etiology or treatment response. They are based on a categorical approach where diagnostic entities share common phenomenological features. Modifications proposed or discussed are related to the weak validity of the classification strategy described above. (a) Disorders are supposed to be independent but the current coexistence of two or more disorders is the rule; (b) They also are supposed to have stability, however anxiety disorders most of the time precede major depression. For GAD age at onset, family history, biology and symptomatology are close to those of depression. As a consequence broader entities such as depression-GAD spectrum, panic-phobias spectrum and OCD spectrum including eating disorders and pathological gambling are taken into consideration; (c) Diagnostic categories use thresholds to delimitate a border with normals. This creates "subthreshold" conditions. The relevance of such conditions is well documented. Measuring the presence and severity of different dimensions, independent from a threshold, will improve the relevance of the description of patients pathology. In addition, this dimensional approach will improve the problems posed by the mutually exclusive diagnoses (depression and GAD, schizophrenia and depression); (d) Some disorders are based on the coexistence of different dimensions. Patients may present only one set of symptoms and have different characteristics, evolution and response to treatment. An example would be negative symptoms in Schizophrenia; (e) Because no etiological model is available and most measures are subjective, objective measures (cognitive, biological) and genetics progresses created important hopes. None of these measures is pathognomonic and most appear to be related to risk factors especially at certain periods when associated with environmental events. One of the major aims for a classification of patients is to identify groups to whom a best possible therapeutic strategy can be proposed. Drugs may improve fear extinction while the genetic and/or acquired avoidance may be called phobia. The basic mechanism and or the corresponding phenotype should appear in the classification. Progresses in early identification of disturbances by taking into account all the information available (prodromal symptoms, cognitive, biological, imaging, genetic, family information) are crucial for the future therapeutic strategy: prevention.
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PMID:Refinement of diagnosis and disease classification in psychiatry. 1834 44


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