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Jul.30.2020

Elsevier Clinical Skills

Anxiety: Generalized Anxiety Disorder Assessment (Mental and Behavioral Health) - CE

ALERT

Many patients with generalized anxiety disorder (GAD) experience helplessness and are at risk for self-harm.15

Patients with GAD typically seek help from primary care practitioners for physical symptoms of the disorder, and the anxiety disorder goes unrecognized.3

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.13 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.4 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.13 Cognitive aspects include difficulty concentrating or an inability to focus. Emotional and behavioral aspects may involve restlessness and avoidance.3

Patients with GAD have a heightened likelihood of experiencing co-occurring psychiatric and medical conditions, including depression, chronic pain conditions, irritable bowel disease, and asthma. A history of abuse is a risk factor for the development of GAD.15

GAD, panic disorder, and phobias have a negative impact on personality functioning, which can become severe for patients with comorbid personality disorders.5

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 dosage or stop taking the medication even if symptoms have subsided and he or she is feeling better.
  • 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.
  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.9 A patient with GAD may experience a sense of helplessness and become suicidal or engage in self-harm behaviors.15
  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’s symptoms of GAD and its impact on his or her ability to function.
  13. Assess the patient for medical conditions that may mimic the symptoms of GAD.
    Rationale: Patients with GAD may experience physical signs and symptoms, somatic signs and symptoms, or both, such as tachycardia, diaphoresis, elevated blood pressure, increased respirations, and pain, stomach distress, headaches, or muscle tension; therefore, it is important to rule out medical conditions that may also manifest these signs and symptoms. 15
  14. Assess the patient for nonverbal expressions of GAD, such as tense facial muscles, fidgeting, restlessness, or guardedness.
  15. Use an organization-approved assessment scale (e.g., Hamilton Anxiety Scale) to assess anxiety.
  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.15
  17. Assess the patient’s need for assistance in performing self-care activities.

STRATEGIES

  1. Perform hand hygiene.
  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.9 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. 14
  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 the patient’s ability to understand information. It is important to ensure that the patient’s level of anxiety allows him or her to process information. 3
  5. Maintain a calm, collaborative communication approach, avoiding the use of coercion.
  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. Inform the patient that he or she will be checked on frequently throughout the 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. Engage the patient in treatment, including participation in therapeutic groups and individual sessions.
  10. Administer psychiatric medications as ordered and monitor the patient’s response to the medications.
  11. Monitor the patient’s responses and social interactions in the milieu; reinforce appropriate social skills.
  12. Implement appropriate precautions based on the patient’s status.
  13. Respond to crisis in a calm, therapeutic, and nonthreatening manner. Use the least restrictive interventions to prevent harm to patients or staff.
  14. Review physical and somatic signs and symptoms in addition to emotional and cognitive signs and symptoms the patient may be experiencing.
    Rationale: Patients with GAD experience debilitating signs and symptoms, which can be physical, cognitive, emotional, and behavioral. Patient’s physical symptoms, such as headaches, abdominal distress, sleep disturbances, and muscle tension, may be the primary presenting symptoms described by him or her. 13
  15. When discussing the patient’s concerns, avoid focusing on specific issues or items that he or she is worried about; focus on the experience of worrying excessively.
    Rationale: Patients frequently seek reassurance about the immediate focus of their concern. It is important to avoid reinforcing that focus and to refocus the patient on the pervasive nature of the anxiety. 3
  16. Assess the methods the patient uses to cope with symptoms of anxiety.
    Rationale: Patients with GAD frequently use maladaptive coping skills, such as hypervigilance, checking behaviors, and avoidance, to reduce their worry. 10
  17. Engage the patient in developing the plan of care and provide support and encouragement as needed.
    Rationale: Patients with GAD frequently become preoccupied with worry and have difficulty functioning. 3
  18. Consider using a standardized assessment scale to determine baseline signs and symptoms.
    Rationale: Use of a standardized tool, such as the Generalized Anxiety Disorder 7 (GAD-7), can benefit in screening the severity of the signs and symptoms as well as the patient’s progress in treatment. 12,15
  19. Evaluate the patient for co-occurring psychiatric and medical conditions that may negatively impact the patient’s status.
    Rationale: Patients with GAD frequently have co-occurring psychiatric and medical conditions such as depression, chronic pain, and irritable bowel disease. These comorbidities can increase the severity of the signs and symptoms the patient experiences. 3
  20. Collaborate with the patient, family, designated support person, and team in planning for patient discharge and follow-up care.
  21. 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.
  22. 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.
  23. Perform hand hygiene.
  24. Document the strategies in the patient’s record.

REASSESSMENT

  1. Assess the patient for decreased symptoms of GAD.
  2. Assess the patient’s ability to recognize his or her signs and 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

  • Health care team members, patient, family, and designated support person recognize symptoms of GAD and triggers.
  • Patient verbalizes symptoms of GAD.
  • Patient participates in the assessment process.

UNEXPECTED OUTCOMES

  • Patient is unable to verbalize symptoms of GAD.
  • Patient is unwilling or unable to participate in assessment process.
  • Patient is unable to follow directions and retain educational information.

DOCUMENTATION

  • Education
  • Assessment of pain, treatment if necessary, and reassessment
  • Observed signs of GAD
  • Reported symptoms of GAD
  • Standardized tools used to assess GAD
  • Patient’s, family’s, and designated support person’s understanding of GAD
  • Family’s and support person’s involvement in patient’s assessment and care
  • Consultation requests and referrals
  • Patient’s behaviors and response to interventions
  • Patient’s progress toward goals

ADOLESCENT CONSIDERATIONS

  • GAD is a common disorder among adolescents. Risk factors for the development of GAD in adolescents include a history of trauma, exposure to violence, and parental anxiety disorder. The assessment process for adolescents should include the family.7
  • The Screen for Child Anxiety Related Emotional Disorders Revised (SCARED-R) and the Screen for Child Anxiety Related Emotional Disorders (SCARED) are both tools that can be used to screen for GAD in children and adolescents.8

OLDER ADULT CONSIDERATIONS

  • GAD is common in older adults and has significant consequences regarding quality of life, health, and functioning.
  • Older adults with GAD experience more sleep disturbances and depression than younger patients with GAD.1
  • The Rating Anxiety in Dementia (RAID) scale has demonstrated validity and sensitivity in identifying anxiety in patients with dementia.6

SPECIAL CONSIDERATIONS

  • Careful evaluation is required to prevent misidentifying signs and symptoms of the disorder as normal worry and changes experienced during pregnancy.11

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. 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)
  5. Doering, S. and others. (2018). Personality functioning in anxiety disorders. BMC Psychiatry, 18(1), 294. doi:10.1186/s12888-018-1870-0 (Level VI)
  6. Goodarzi, Z. and others. (2019). Detection of anxiety symptoms in persons with dementia: A systematic review. Alzheimer's & Dementia, 11, 340-347. doi:10.1016/j.dadm.2019.02.005 (Level I)
  7. 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
  8. Ivarsson, T. and others. (2018). The validity of the screen for child anxiety related emotional disorders revised (SCARED-R) scale and sub-scales in Swedish youth. Child Psychiatry & Human Development, 49(2), 234-243. doi:10.1007/s10578-017-0746-8 (Level VI)
  9. Joint Commission, The. (2020). National patient safety goals. Behavioral health care accreditation program. Retrieved July 6, 2020, from https://www.jointcommission.org/-/media/tjc/documents/standards/national-patient-safety-goals/2020/npsg_chapter_bhc_jul2020.pdf (Level VII)
  10. Mahoney, A.E.J. and others. (2018). Maladaptive behaviours associated with generalized anxiety disorder: An item response theory analysis. Behavioural and Cognitive Psychotherapy, 46(4), 479-496. doi:10.1017/S1352465818000127 (Level VI)
  11. Misri, S. and others. (2015). Perinatal generalized anxiety disorder: Assessment and treatment. Journal of Women’s Health, 24(9), 762-770. doi:10.1089/jwh.2014.5150
  12. Plummer, F., and others. (2016). Screening for anxiety disorders with the GAD-7 and GAD-2: A systematic review and diagnostic metaanalysis. General Hospital Psychiatry, 39, 24-31. doi:10.1016/j.genhosppsych.2015.11.005 (Level I)
  13. 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)
  14. 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)
  15. Stein, M.B., Sareen, J. (2015). Clinical practice: Generalized anxiety disorder. The New England Journal of Medicine, 373(21), 2059-2068. doi:10.1056/NEJMcp1502514

*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