• Approximately 4% of ex-serving Navy, Army and Air force members were affected by Generalised anxiety disorder (GAD) in the last year.
• Questions adapated from the Mini-International Neuropsychiatric Interview (MINI) can be useful in screening for GAD.
• Cognitive behavioural therapy (CBT) has strong evidence for treating Generalised anxiety disorder. Available through Open Arms counselling.

About generalised anxiety disorder

The essential feature of GAD is excessive and persistent anxiety and worry about a number of different life domains, such as family, health, finances, and work difficulties. These anxieties or worries are present more days than not, and may be accompanied by symptoms such as:

• restlessness
• feeling on edge
• being easily fatigued
• difficulty concentrating
• irritability
• muscle tension
• disturbed sleep

Prevalence

• Approximately 6% of Australians are likely to experience generalised anxiety disorder (GAD) in their lifetime (McEvoy et al., 2011).
• Around 3% of Australians experience GAD within a given year (Andrews et al., 2018).
• Around 4% of transitioned veterans experience GAD within a given year.

Screening and assessment of generalised anxiety disorder

There is currently limited evidence supporting a specific screening instrument for most anxiety disorders, and no screening test has been developed specific to generalised anxiety disorder. However, the following questions adapted from the Mini-International Neuropsychiatric Interview (MINI) and can be useful in screening for GAD:

• Have you worried excessively or been anxious about several things over the past six months?
• (If yes) Are these worries present most days?

If the veteran answers ‘yes’ to each of these questions, assess for symptoms of GAD. It is important to consider whether the veteran’s anxiety is restricted to, or better explained by, another disorder. It is also important to ask the client about any major stressor or life change in the past six months (e.g. new job, new relationship, divorce, illness, etc.).

• Generalized Anxiety Disorder 7 (GAD-7) is a self-report questionnaire which provides an indication of GAD symptom severity – however, it cannot be used as a diagnostic instrument in place of clinical assessment.
• Penn State Worry Questionnaire (PSWQ) is a specific measure of worry.
• Depression, Anxiety and Stress Scale (DASS-21) is a general measure that can help track stress and anxiety.

GAD and depression have a high comorbidity. Therefore patients with a suspected GAD diagnosis should also be screened for depression (Andrews et al., 2018).

Psychological interventions

As GAD reflects a generalised and persisting anxiety, it is important for veterans to learn cognitive, physiological and behavioural strategies through treatment, which they can apply in a range of circumstances and situations. This differs from strategies for other anxiety disorders, where there is a greater focus on the fears and responses to specific stimuli.

Cognitive behavioural therapy

Talking to a veteran together with the veteran's family about his or her GAD is the start of treatment. While CBT has some general techniques applicable across a range of disorders, specific CBT techniques for targeting GAD are:

• Cognitive therapy – this involves challenging the negative and catastrophic beliefs that trigger and maintain worry, as well as beliefs about the nature and usefulness of the worrying process.
• Structured problem solving – this can help the veteran address feared problems and consequences using a more helpful method than worrying.
• Anxiety management – this includes strategies such as progressive muscle relaxation and breathing retraining, to help manage the physical consequences of worry.

Cognitive behavioural therapy (CBT) has Level I evidence for its efficacy in treating GAD. (Andrews et al., 2018). 

CBT-based self-help resources are also effective in treatment.

Psychoeducation and self-management strategies

Psychoeducation is important as it helps to demystify the veteran’s symptoms, restore a sense of control and create hope for change. It is also important to encourage the veteran to do the following:

• Reduce substance use, including benzodiazepine misuse. This is a significant issue amongst individuals with GAD, as 17% of Australians with GAD also have an alcohol use disorder. A brief and early intervention that includes education about substance use can be effective. If benzodiazepines are used, they should be taken on a regular schedule as far as possible, rather than on an ‘as needed’ or ‘prn’ basis.
• Maintain (or re-establish) their daily routine and current roles (e.g., work, family). Helping veterans to think about treatment goals in the context of what relationships and roles they would like to see improve can help motivate them.

CBT-based self-help resources are also effective in treatment.

Psychological treatment setting and duration

Generalised anxiety disorder can be treated in an outpatient setting and does not usually require admission to a psychiatric hospital unit. Psychological treatment for GAD will usually involve 8-12 weekly one-hour sessions of CBT. In more difficult and complex cases, a longer course of CBT may be required.

Pharmacological interventions

Medication is usually not recommended for mild GAD, in preference to psychological interventions. However, antidepressants may be considered for veterans with moderate or severe anxiety, adjunctive to, or followed by, psychological treatment. Sertraline is recommended as the first-line therapy of choice due to its high acceptability and risk-to-benefit ratio, though there is also evidence for the efficacy of certain serotonin-norepinephrine reuptake inhibitors (SNRIs) such as venlafaxine and duloxetine (Andrews et al., 2018).

There is some evidence to suggest that atypical antipsychotics may have a role as an adjunct treatment for veterans with GAD who show an incomplete response to antidepressants. However, NICE recommends not using antipsychotics in a primary care setting.

Benzodiazepines are not recommended as a treatment for GAD, as they are relatively ineffective and associated with extensive adverse side effects.

See also