Generalized Anxiety Disorder (GAD) Clinical Overview
I. The "On-Call" Snapshot
Clinical Significance in Malaysia
Anxiety disorders are extremely common. The 2015 National Health and Morbidity Survey (NHMS) found that 29.2% of Malaysian adults suffer from mental health issues, with anxiety and depression being major components. Your job on-call is to differentiate an anxiety attack from a life-threatening organic cause (e.g., ACS, PE, thyrotoxicosis) and manage acute agitation safely.
High-Yield Definition
(DSM-5) Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance). The individual finds it difficult to control the worry.
Clinical One-Liner
This is your 'professional worrier'—a patient with chronic, uncontrollable worry about everything (health, money, family), who now presents with physical symptoms like fatigue, muscle aches, and poor sleep.
II. Etiology & Risk Factors
Etiology
Multifactorial. A combination of:
Neurobiology: Amygdala hyperactivity (threat detection) with poor top-down control from the prefrontal cortex. Key neurotransmitters involved are Serotonin, GABA, and Norepinephrine.
Genetics: Family history is a strong predictor.
Environmental: Adverse childhood events, chronic medical illness, and ongoing psychosocial stressors.
Risk Factors
Female (2:1 ratio)
Family history
Low socioeconomic status (Local data suggests higher rates in low-income households)
Chronic medical illness (e.g., CVD, diabetes, COPD)
Other psychiatric co-morbidities (especially MDD)
Significant life stressors or trauma
III. Quick Pathophysiology
Think of it as a faulty "threat-detection" circuit.
The amygdala (alarm system) is hyper-responsive, and the prefrontal cortex (the 'brake' or rational control center) is underactive. This leads to a constant state of perceived threat, causing chronic sympathetic nervous system activation (palpitations, sweating) and HPA-axis dysregulation (cortisol release), which manifests as both the psychological (worry) and somatic (fatigue, muscle tension) symptoms.
IV. Classification
"Anxiety Disorder" is an umbrella term. We use the DSM-5. The main types you'll see are:
Generalized Anxiety Disorder (GAD): Chronic, pervasive worry. (Our focus).
Panic Disorder: Recurrent, discrete, unexpected panic attacks.
Social Anxiety Disorder (Social Phobia): Marked fear of social situations and negative evaluation.
Specific Phobias: Irrational fear of a specific object or situation.
Agoraphobia: Fear of situations where escape might be difficult (e.g., crowds, public transport).
Substance/Medication-Induced Anxiety Disorder
Anxiety Disorder Due to Another Medical Condition
V. Clinical Assessment
🚩 Red Flags & Immediate Actions
Chest Pain / Severe Shortness of Breath:
Action: Full ABCDE approach. Get an ECG, cardiac enzymes, D-dimer (if indicated).
Reason: Never assume chest pain is "just anxiety" until ACS and PE are ruled out.
Sudden Onset in Patient >40 years (no prior history):
Action: High index of suspicion for an organic cause. Work up fully.
Reason: Atypical presentation for new-onset GAD. More likely cardiac, pulmonary, or endocrine.
Altered Mental Status, Confusion, or Seizures:
Action: Check RBS, BUSE, toxicology screen.
Reason: Suggests metabolic, neurologic, or substance-induced cause, not primary GAD.
Active Suicidal Ideation or Intent:
Action: Immediate 1-to-1 observation, secure the environment (remove ligatures), escalate to MO/Specialist, and refer to the Psychiatry team.
Reason: High co-morbidity with depression. Patient safety is paramount.
History
Key Diagnostic Clues (Pathognomonic/Classic Presentations)
For GAD: The key is the duration (>6 months) and the pervasive nature of the worry. The patient will say, "I'm always worried," "I can't stop worrying," and the worry is about multiple domains (not just one thing).
Symptom Breakdown by Frequency (GAD - DSM-5 Criteria)
Patient must have 3 or more of the following:
Common (>50%):
Restlessness or feeling "keyed up" or "on edge"
Being easily fatigued
Difficulty concentrating (mind "goes blank")
Irritability
Muscle tension (very common; e.g., neck, shoulder, back pain)
Sleep disturbance (difficulty falling/staying asleep, restless sleep)
Pertinent Negatives
No discrete, sudden, peaking attacks: Argues against Panic Disorder.
No specific social trigger: Argues against Social Anxiety Disorder.
No obsessions or compulsions: Argues against OCD.
No history of major trauma: Argues against PTSD.
No symptoms of mania/hypomania: Argues against Bipolar Disorder.
No significant weight loss / heat intolerance: Argues against Hyperthyroidism.
Physical Examination (OSCE Approach)
General Inspection
Patient may appear restless, fidgety, sighing frequently.
May have poor eye contact or appear visibly distressed.
Look for signs of sympathetic overdrive (sweaty palms, tremor).
Vitals
Often normal, but may show mild sinus tachycardia or transient hypertension.
Disease-Specific Examination (System-based)
Psychiatric: Assess mood (often "anxious," "worried"), affect (may be constricted), and thought content (ruminations on worries). Must screen for suicidal ideation.
Neurological: Check for fine tremor (sympathetic overdrive). Assess power, tone, reflexes (often normal, but muscle tension may be present).
Cardiovascular & Respiratory: Auscultate heart and lungs. Tachycardia may be present, but listen for murmurs or crackles to rule out organic causes.
Examination for Differentials
Thyroid: Check for goitre, lid lag, exophthalmos, or a fine tremor (to rule out Thyrotoxicosis).
Cardio/Resp: A thorough exam is non-negotiable to rule out ACS, PE, or arrhythmia.
Clinical Pearl
Your most important job in the first encounter is not to diagnose GAD, but to rule out the killers. A normal ECG and normal TFT are your best friends.
VI. Diagnostic Workflow
Differential Diagnosis
1. Organic Causes (The "Can't-Miss" List)
Points For: New onset, older patient, prominent physical symptoms (e.g., palpitations, sweating, SOB).
Points Against: Long-standing history, clear psychosocial stressors, normal physical exam and vitals.
How to Differentiate:
CVS: ECG, Troponins (Rule out ACS, arrhythmia).
Resp: D-dimer, CXR (Rule out PE).
Endo: TFTs (Rule out Hyperthyroidism), RBS (Rule out Hypoglycemia).
Neuro: CT Brain (if focal deficits), Urine Tox Screen (Rule out substance/caffeine intoxication or withdrawal).
2. Major Depressive Disorder (MDD)
Points For: High co-morbidity (~50-60%). Overlapping symptoms like poor sleep, fatigue, poor concentration.
Points Against: In GAD, the core is active, apprehensive worry ("What if..."). In MDD, the core is pervasive low mood and anhedonia, with worry often being more passive or hopeless.
How to Differentiate: Careful history. Use screening tools: PHQ-9 for depression, GAD-7 for anxiety.
3. Panic Disorder
Points For: Both have anxiety.
Points Against: GAD is a chronic, "background" worry. Panic Disorder is defined by discrete, attacks of intense fear that peak within minutes, often with a fear of dying or "going crazy."
How to Differentiate: Ask: "Is your anxiety always there, or does it come in sudden, intense waves that go away?"
Investigations Plan
Bedside / Initial (First 15 Mins):
ECG: Mandatory to rule out arrhythmia or ischemia.
RBS: Rule out hypoglycemia.
First-Line Labs:
TFT: Mandatory to rule out hyperthyroidism.
FBC, RP, LFTs (Baseline before starting medications).
Urine Drug Screen (if substance use is suspected).
Confirmatory / Gold Standard:
There is no lab test for GAD. It is a clinical diagnosis based on DSM-5 criteria after all relevant organic causes have been excluded.
Use the GAD-7 scale to objectively score severity.
VII. Staging & Severity Assessment
We use the GAD-7 (Generalized Anxiety Disorder 7-item) scale.
Score 0-4: Minimal anxiety
Score 5-9: Mild anxiety
Score 10-14: Moderate anxiety
Score 15-21: Severe anxiety
This score guides management: Mild cases may respond to psychotherapy alone. Moderate-to-Severe cases usually require psychotherapy + pharmacotherapy.
VIII. Management Plan
A. Principle of Management
Two-pronged approach based on Malaysian CPGs:
Pharmacotherapy: To reduce acute symptoms and biological drive.
Psychotherapy: To provide long-term coping skills (CBT is first-line).
Always address patient safety (suicide risk) first.
B. Immediate Stabilisation (The Acute Panic Attack / Severe Agitation)
(This is for the acute presentation, not long-term GAD management)
1. Exclude organic causes: (ECG, RBS as above).
2. De-escalate: Use a calm voice, move patient to a quiet room.
3. Coach breathing: If hyperventilating, guide them in slow, deep breaths.
4. Pharmacotherapy (if needed): For severe distress, a short-term anxiolytic is appropriate.
PO Diazepam 2-5mg stat OR PO Lorazepam 0.5-1mg stat.
Warning: Counsel on sedative effects. This is a short-term bridge, not a long-term solution due to high addiction potential. (Max 2-4 weeks).
C. Definitive Treatment (The Ward Round Plan - for GAD)
(Based on Malaysian CPG for Anxiety Disorders, 2014 & KKM Formulary)
First-Line Treatment (Moderate-to-Severe GAD):
1. SSRIs (Selective Serotonin Reuptake Inhibitors):
Escitalopram: Start 10mg OD (5mg in elderly). Max 20mg/day.
Sertraline: Start 25-50mg OD. Max 200mg/day.
Fluoxetine: Start 20mg OD. (Long half-life).
2. Cognitive Behavioural Therapy (CBT):
This is the gold standard for psychotherapy. Refer to Psychiatry / Clinical Psychologist.
Key Counselling Point: "The SSRI will take 2-4 weeks to start working. You might even feel slightly more anxious in the first week. Do not stop it."
Second-Line Treatment:
If SSRI fails or is not tolerated:
Switch to another SSRI.
Switch to an SNRI (Serotonin-Norepinephrine Reuptake Inhibitor):
Venlafaxine XR: Start 37.5-75mg OD. (Monitor BP).
Adjuncts:
Benzodiazepines: As a short-term bridge (2-4 weeks) while waiting for the SSRI to take effect. Do not use as long-term monotherapy.
Propranolol: (10-40mg TDS prn) Can be useful for prominent somatic symptoms (palpitations, tremor), especially in performance-related anxiety.
D. Long-Term & Discharge Plan
Outpatient clinic follow-up (e.g., in 2-4 weeks) to assess response and side effects.
Continue SSRI for at least 6-12 months after remission to prevent relapse.
Reinforce lifestyle modifications: improve sleep hygiene, reduce/stop caffeine, regular physical exercise.
Link to support services (e.g., social worker, support groups).
IX. Complications
Immediate/Short-Term: Significant impairment in social and occupational functioning. Increased risk of substance use (self-medicating with alcohol or drugs).
Long-Term:
High risk of developing Major Depressive Disorder (MDD).
Development of other anxiety disorders (e.g., Panic Disorder).
Increased risk of suicide.
Worsening of co-morbid chronic diseases (e.g., poor diabetic control, hypertension).
X. Prognosis
GAD is a chronic, relapsing-remitting condition.
Full remission is uncommon, but the goal is functional recovery. Most patients improve significantly with consistent treatment (SSRI + CBT).
Poor prognostic factors: High symptom severity, longer duration of illness, co-morbid MDD or personality disorder, ongoing substance use, poor social support.
XI. How to Present to Your Senior
"Keep it concise. I need to know what you've ruled out and what you want to do."
S: "Sir/Madam, I'm calling about Patient [Name], a 35-year-old male in [Ward], referred from ED for recurrent palpitations."
B: "He has a 6-month history of constant worry about work and health, poor sleep, and muscle tension. No significant past medical history."
A: "His vitals are stable, ECG shows sinus tachycardia. Troponins and TFT are normal. My primary differential is Generalized Anxiety Disorder, severe (GAD-7 score is 16). I have ruled out acute cardiac and thyroid causes."
R: "I plan to start him on Escitalopram 10mg OD and refer to the Psychiatry team for CBT. For his acute distress tonight, I would like to offer one dose of PO Diazepam 2mg. Is that agreeable?"
XII. Summary & Further Reading
Top 3 Takeaways
Rule out Organic Disease First: Your job is to be a physician, not just a psychiatrist. Get the ECG and TFT. Do not miss an ACS or thyrotoxicosis.
GAD is a Clinical Diagnosis: >6 months of pervasive worry + 3/6 somatic symptoms (Restlessness, Fatigue, Poor Concentration, Irritability, Muscle Tension, Sleep Disturbance).
Treat with SSRI + CBT: First-line is an SSRI (e.g., Escitalopram). Benzodiazepines are only a short-term bridge, never a long-term solution.
Key Resources
Malaysian CPG: Management of Anxiety Disorders in Adults (2014)
UpToDate: "Generalized anxiety disorder in adults: Management"
Amboss: "Generalized anxiety disorder"
