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1. SEMINAR
ON
GENERALISEDANXIETY
DISORDER
BY:-
MR. SUNIL KUMAR
FINAL YEAR M.SC
B.V.C.O.N.PUNE

2. ANXIETY
DEFINITION:-
• A FEELING OF WORRY, NERVOUSNESS, OR UNEASE
ABOUT SOMETHING WITH AN UNCERTAIN
OUTCOME.

3. ANXIETY DISORDER
Anxiety disorder: A chronic condition characterized by
an excessive and persistent sense of apprehension,
with physical symptoms such as sweating, palpitation,
and feelings of stress.

4. CLASSIFICATION OFANXIETY
DISORDER
1. Panic disorders
2. Generalised anxiety disorders
3. Phobic disorders
4. Obsessive-compulsive disorders
5. Post-traumatic stress disorders
6. Related disorders

6. • Generalised anxiety disorder (GAD) is usually characterised by
chronic anxiety unrealistic and excessive anxiety and worry,
that is uncomfortable to the point of interfering with daily life.
• A person with GAD worries excessively and feels highly
anxious at least 50 per cent of the time for six months or more.

8. ETIOLOGYOF GAD
• As with many mental health conditions, the exact cause of
generalized anxiety disorder isn't fully understood, but it may
include genetics as well as other risk factors.
RISK FACTORS-
• These factors may increase the risk of developing generalized
anxiety disorder:
• Personality. A person whose temperament is timid or negative
or who avoids anything dangerous may be more prone to
generalized anxiety disorder than others are.
• Genetics. Generalized anxiety disorder may run in families.
• Being female. Women are diagnosed with generalized anxiety
disorder somewhat more often than men are.

9. MEDICAL CONDITION:-
The following medical conditions have been associated to a
greater degree with individuals who suffer from GAD than in
general population:
• Abnormalities in the hypothalamic-pituitary-adrenal and
hypothalamic-pituitary-thyroid axes.
• Acute myocardial infarction.
• Phenochromocytomas.
• Substance intoxication and withdrawal (cocaine, alcohol,
marijuana, opioids).
• Hypoglycaemia.
• Caffeine intoxication.
• Mitral valve prolapses.
• Complex partial seizures.

10. SIGNAND SYMPTOMS OF GAD
The symptoms of generalized anxiety disorder fluctuate. You may
notice better and worse times of the day.
Not everyone with generalized anxiety disorder has the same
symptoms. But most people with GAD experience a combination
of a number of the following emotional, behavioural, and
physical symptoms.

11. EMOTIONALSYMPTOMS OF
GENERALIZEDANXIETYDISORDER
• Constant worries running through your head
• Feeling like your anxiety is uncontrollable; there is nothing you
can do to stop the worrying
• Intrusive thoughts about things that make you anxious; you try
to avoid thinking about them, but you can’t
• An inability to tolerate uncertainty; you need to know what’s
going to happen in the future
• A pervasive feeling of apprehension or dread

12. BEHAVIOURALSYMPTOMS OF
GENERALIZEDANXIETYDISORDER
• Inability to relax, enjoy quiet time, or be by yourself
• Difficulty concentrating or focusing on things
• Putting things off because you feel overwhelmed
• Avoiding situations that make you anxious

13. PHYSICALSYMPTOMS OF
GENERALIZEDANXIETYDISORDER
• Feeling tense; having muscle tightness or body aches
• Having trouble falling asleep or staying asleep because your
mind won’t quit
• Feeling edgy, restless, or jumpy
• Stomach problems, nausea, diarrhoea

14. ICD-10 criteria
• ICD-10 Generalized anxiety disorder "F41.1"
Note: For children different criteria may be applied (see
F93.80).
A period of at least six months with prominent tension,
worry and feelings of apprehension, about everyday events
and problems.
B. At least four symptoms out of the following list of items
must be present, of which at least one from items (1) to (4).

15. • Autonomic arousal symptoms
• (1) Palpitations or pounding heart, or accelerated heart
rate.
• (2) Sweating.
• (3) Trembling or shaking.
• (4) Dry mouth (not due to medication or dehydration).

16. • Symptoms concerning chest and abdomen
• (5) Difficulty breathing.
• (6) Feeling of choking.
• (7) Chest pain or discomfort.
• (8) Nausea or abdominal distress (e.g. churning in
stomach).

17. • Symptoms concerning brain and mind
• (9) Feeling dizzy, unsteady, faint or light-headed.
• (10) Feelings that objects are unreal (derealisation), or that
one's self is distant or "not really here" (depersonalization).
• (11) Fear of losing control, going crazy, or passing out.
• 12) Fear of dying.
• General symptoms
• (13) Hot flushes or cold chills.
• (14) Numbness or tingling sensations.

18. • Symptoms of tension
• (15) Muscle tension or aches and pains.
• (16) Restlessness and inability to relax.
• (17) Feeling keyed up, or on edge, or of mental tension.
• (18) A sensation of a lump in the throat, or difficulty with
swallowing.

19. • Other non-specific symptoms
• (19) Exaggerated response to minor surprises or being
startled.
• (20) Difficulty in concentrating, or mind going blank,
because of worrying or anxiety.
• (21) Persistent irritability.
• (22) Difficulty getting to sleep because of worrying.

20. DIFFERENCE B/W NORMALWORRY
AND GAD
NORMAL “WORRY”
• Your worrying doesn’t get in the
way of your daily activities and
responsibilities.
• You’re able to control your
worrying.
• Your worries, while unpleasant,
don’t cause significant distress.
• Your worries are limited to a
specific, small number of realistic
concerns.
• Your bouts of worrying last for
only a short time period.
GENERALISED ANXIETY
DISORDER
• Your worrying significantly
disrupts your job, activities, or
social life.
• Your worrying is uncontrollable.
• Your worries are extremely
upsetting and stressful.
• You worry about all sorts of
things, and tend to expect the
worst.
• You’ve been worrying almost
every day for at least six months.

21. DIAGNOSTIC CRITERIAFOR GAD
To help diagnose generalized anxiety disorder, your health
provider may:-
• Do a physical exam to look for signs that your anxiety might be
linked to an underlying medical condition
• Order blood or urine tests or other tests, if a medical condition
is suspected
• Ask detailed questions about your symptoms and medical
history
• Use psychological questionnaires to help determine a diagnosis

22. DSM-5 criteria for generalized anxiety
disorder include:
• Excessive anxiety and worry about several events or activities
most days of the week for at least six months
• Difficulty controlling your feelings of worry
• Anxiety or worry that causes you significant distress or
interferes with your daily life

23. • At least three of the following symptoms in adults and one of
the following in children:
1. Restlessness,
2. Fatigue,
3. Trouble concentrating,
4. Irritability,
5. Muscle tension or
6. Sleep problems
• Anxiety that isn't related to another mental health condition,
such as panic attacks or post-traumatic stress disorder (PTSD),
substance abuse, or a medical condition

24. • Generalized anxiety disorder often occurs along with other
mental health problems, which can make diagnosis and
treatment more challenging. Some disorders that commonly
occur with generalized anxiety disorder include:
• Phobias
• Panic disorder
• Depression
• Substance abuse
• PTSD

25. TREATMENT AND DRUGS:-
• The two main treatments for generalized anxiety disorder
are psychotherapy and medications. You may benefit
most from a combination of the two. It may take some trial
and error to discover which treatments work best for you.

27. PSYCHOTHERAPY
• Also known as talk therapy or psychological counselling,
psychotherapy involves working with a therapist to reduce your
anxiety symptoms. It can be an effective treatment for
generalized anxiety disorder.
• Cognitive behavioural therapy is one of the most effective
forms of psychotherapy for generalized anxiety disorder.
Generally a short-term treatment, cognitive behavioural therapy
focuses on teaching you specific skills to gradually return to the
activities you've avoided because of anxiety. Through this
process, your symptoms improve as you build on your initial
success.

28. MEDICATIONS
The drugs used for GAD will be:
• Benzodiazepines
• Buspirone (anti-anxiety medication)
• Alpidem (Alpidem (Ananxyl) is an anxiolytic drug from the
imidazopyridine family, related to the more well-known
sleeping medication zolpidem)
• Tricyclic drug or beta-adrenergic antigens (e.g., propranolol).

29. NURSING MANAGEMENT:-
• The assessment for GAD will be on the basis of following
essential features of disorders:
• Excessive anxiety and worry about a number of events that the
individual finds difficulty to control
• Restlessness or feeling keyed up or on edge
• Being easily fatigued
• Difficulty concentrating or mind “going black”
• Irritability
• Muscle tension
• Sleep disturbance (difficulty – falling or staying asleep or
restless, unsatisfying sleep).

30. NURSING DIAGNOSIS
• Panic anxiety related to real or perceived threat to biological
integrity or self- concept evidenced by any or all of the physical
symptoms identified by the DSM-IV-TR as being descriptive of
GAD.
• Powerless related to impaired cognition evidenced by verbal
expressions of no control over life situation and
nonparticipation in decision making related to own care or life
situation.
• Hopelessness
• Impaired social communication
• Irritability

31. PLANNING:
The following criteria may be used for measurement of outcomes in the
care of the client with GAD . The same may be used as an objective, in
which the client:
Is able to recognise signs of escalating anxiety.
Is able to intervene so that anxiety does not reach the panic level.
Is able to discuss long-term plan to prevent panic anxiety when
stressful situation occurs.
Practices techniques of relaxation daily.

32. Engages in physical exercise three time a week
Perform activity of daily living independently.
Express satisfaction for independent functioning.
Is able to maintain anxiety at manageable level without use of
medication.
Is able to participant in decision making, thereby maintaining
control over life situation.
Verbalised acceptance of life situations over with he or she has
no control.

33. IMPLEMENTATION:-
• Maintain safety for the client and the environment.
• Assess own level of anxiety and make a conscious effort to
remain calm. Anxiety is readily transferable from one person to
another person.
• Recognise the client’s use of relief behaviours (pacing writing
of hands) as indicators of anxiety. Early intervention help to
manage anxiety before symptoms escalate to more serious
levels.
• Inform the client of the important of limiting caffeine, nicotine,
and other central nervous system stimulant. Limiting these
substances prevents/ minimizes physical symptoms of anxiety,
such as rapid heart rate.

34. • Teach the client to distinguish between that is
connected to identifiable objects or sources (illness
prognosis, hospitalization known stressors) and
anxiety for which there is no immediate identifiable
objects or source. Knowledge of anxiety and its related
components increases the client control over the
disorders.

35. • Instruct the client in the following anxiety reducing
strategies. These help lessen anxiety in a variety of
ways and distract the client from focusing on the
anxiety.
• Progressive relaxation technique
• Mindful meditation
• Slow deep-breathing exercise
• Focusing on a single object in the room
• Listening of soothing music and relaxation tapes
-Visual imagery or natural related DVD productions

36. • HELP THE CLIENT build on coping methods that the client
used to manage anxiety in the past. Coping methods that were
previously successful with generally be affective in
subsequently situation.
• Activate the client to identify support persons who will help the
client perform personal tasks and activities that current
circumstances make difficulty (such as a partial hospitalization
program or a short stay hospitalization). A strong support
system will help the client avoid anxiety-provoking
situations/activities.

37. • Assist the client in gaining control of overwhelming feelings
and impulses through brief direct verbal interactions. Individual
interactions executed at appropriate intervals will
reduce/manage client’s anxious feeling/impulses.
• Help the client structure the environment so that it is less noisy.
A less stimulating environment creates a calming stress-free
atmosphere that reduces anxiety.

38. • Assess the presence and degree of depression and suicidal
ideation in all clients with anxiety and related disorders. A
through assessments result in early intervention that will
possibly prevent self-harm.
• Administer anxiolytic (antianxiety) medication as a least
restrictive measure. Medication is often the first appropriate
method to reduce debilitating anxiety.
• Help the client to understand the importance of the medication
regimen and to take it as prescribed. Medication is an effective
addition to other psychosocial therapeutic interventions when
necessary.

39. ACASE OF GAD
A case of 50 years old man, MR. RP was admitted to the Psychiatric
Hospital for treatment of a generalised anxiety disorder.
On clinical initial assessment, the student nurse noted that Mr RP was
• 1. Quite restless
• 2. Sitting on the edge of the bed.
• 3. Fidgeting with his gown.
• 4. He constantly rearranged his personal items on the bedside stand.
• 5. Complaints of dizziness, an upset stomach, insomnia and frequency
of urination noted.
• 6. Mr.RP appears to be easily distracted as people walk into the room.
• 7. He was impatient with the student nurse taking vitals signs. His
hands are cold and clammy and the radial pulse was 120 beats/min.

40. • During post clinical conference, the students nurse shared her
feelings of irritation about RP. She also state that the client’s
anxiety was “infectious” and that she found herself becoming
tense although she tried to remain calm during the admission
procedure. Another student stated that she would have given RP
a sedative first to allow him to settle down and then would have
attempted to carry out initial assessment. The group discuss
interpersonal reaction with persons who exhibit clinical
symptoms or GA. And how easy it would be to avoid contact
with the patient.

41. RESEARCH
• According to pim cuijpers at all, in their study The efficacy of
psychotherapy and pharmacotherapy in treating depressive and
anxiety disorders: a meta-analysis of direct comparisons,
researcher Although psychotherapy and antidepressant
medication are efficacious in the treatment of depressive and
anxiety disorders, it is not known whether they are equally
efficacious for all types of disorders, and whether all types of
psychotherapy and antidepressants are equally efficacious for
each disorder..

42. So researcher conducted a meta-analysis of studies in which
psychotherapy and antidepressant medication were directly
compared in the treatment of depressive and anxiety disorders
RESULT:-
The overall effect size indicating the difference between
psychotherapy and pharmacotherapy after treatment in all
disorders was g=0.02 (95% CI: −0.07 to 0.10), which was not
statistically significant.
So researcher got both are effective but there is no comparison
between both.

43. REFERENCE:-
• Louise R. Basics Conceptsof Psychiatric-Mental Health
Nursing.6th ed. Philadelphia.Williams and Wilkins.2005.p.300-
3.
• Mary A. Psychiatric Nursing: Contemporary Practice.2nd
ed.Philadelphia.Williams and Wilkins.2002.p.491-8
• BT Basavanthappa.Essentials of Mental Health Nursing.New
Delhi.Jaypee Brothers Medical Publishers.2011.p.334-8
• BT Basavanthappa.Essentials of Mental Health Nursing.New
Delhi.Jaypee Brothers Medical Publishers.2000.p.13.1-10.
• https://en.wikipedia.org/wiki/Anxiety_disorder
• http://www.medicinenet.com/script/main/art.asp?articlekey=994
8
• http://www.adaa.org/generalized-anxiety-disorder-gad