Behavioral Health

When worry is excessive: Easing the burden of GAD

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Work with patients and family toward a diagnosis

Despite the potential benefits of early identification and treatment of GAD,13 the average elapsed time from symptom onset to initial medication treatment is 7 years.14 Multiple factors likely account for this delay. Clinical presentations can be highly variable,6 with 1 patient presenting primarily with sleep complaints and another with gastrointestinal symptoms. Some medical conditions (TABLE 1)15 and substances (TABLE 2)16-18 can cause secondary anxiety symptoms, and their presence should prompt a thorough ­evaluation.

Medical conditions with secondary anxiety symptoms

Address the mind-body connection. Because uncertainty and ambiguity surrounding a diagnosis often drive worry,19 anxious patients or their family members commonly seek additional medical visits and tests in search of answers. In such instances, it helps to explain the physiologic connection between somatic complaints and anxiety.8 Describe how areas of the brain that manage fear and stress can also cause muscle tension, gastrointestinal complaints, hyperarousal, or sleep disturbance.

Classes of substances that may induce anxiety

Despite the potential benefits of early identification and treatment of generalized anxiety disorder, the average elapsed time from symptom onset to initial medication treatment is 7 years.

Empathy and early psychoeducation on the reason anxiety is being considered can decrease stigma and enable appropriate follow-up and treatment. You might introduce the connection between health complaints and GAD specifically by exploring the amount of worry surrounding the presenting symptoms, followed by a question such as, “Sometimes your worry will fit the situation and sometimes it’ll be too much. Has anyone ever told you that you worry too much?” The patient’s response to such a question could signal a need to use the GAD-7 screening tool1 as an aid to diagnosis and as a baseline measure for monitoring subsequent treatment progress.

Psycho- and pharmacotherapy aspects of management

Helping someone understand a GAD diagnosis and treatment options can test a clinician’s communication skills. Avoid trying to reason patients out of their worries or fears (TABLE 3). Instead, rely on psychoeducation about the mind-body connection and on focused counseling (TABLE 4) to help patients and their family members understand effective next steps.8,20 At a minimum, ensure that everyone involved understands how anxiety is influenced by unhealthy lifestyle choices such as poor sleep hygiene and caffeine misuse.

Preferred style of communicating when counseling patients with GAD

Let patients choose from among various coping strategies. Be prepared to offer patients user-friendly handouts, reading material, or links to educational Web sites. Many patients are interested in using smartphone applications to learn and practice coping strategies. Although these apps can encourage the regular practice of coping skills, caution teens and parents about privacy issues and the lack of evidence supporting this approach as stand-alone therapy.21 Offering several choices (TABLE 4) can increase the sense of ownership an individual experiences when choosing the next step.

Coping strategies to teach patients (tailor to the individual)

Continue to: For patients who remain focused...


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