World Health Organisation. (1996). Diagnostic and Management Guidelines for Mental Disorders in Primary Care: ICD-10 Chapter V Primary Care Version. Gottingen, Germany: WHO/Hogrefe & Huber Publishers.

Generalised Anxiety - F41.1 Diagnostic and Management Guidelines

The patient may present initially with tension-related physical symptoms (e.g., headache, pounding heart) or with insomnia. Inquiry will reveal prominent anxiety.

Diagnostic features

Multiple symptoms of anxiety or tension:

• mental tension (worry, feeling tense or nervous, poor concentration)
• physical tension (restlessness, headaches, tremors, inability to relax)
• physical arousal (dizziness, sweating, fast or pounding heart, dry mouth, stomach pains)

Symptoms may last for months and recur often. They are often triggered by stressful events in those with a chronic tendency to worry.

Differential diagnosis

• If low or sad mood is prominent, see Depression - F32#.
• If sudden attacks of unprovoked anxiety are present, see Panic disorder - F41.0.
• If fear and avoidance of specific situations are present, see Phobic disorders - F40.
• If heavy alcohol or drug use is present, see Alcohol use disorders - F10 and Drug use disorders - F11#.
• Certain physical conditions (thyrotoxicosis) or medications (methyl xanthines, beta agonists) may cause anxiety symptoms.

Essential information for patient and family

• Stress and worry have both physical and mental effects.
• Learning skills to reduce the effects of stress (not sedative medication) is the most effective relief

Counselling of patient and family

1. Encourage the patient to practise daily relaxation methods to reduce physical symptoms of tension.
2. Encourage the patient to engage in pleasurable activities and exercise, and to resume activities that have been helpful in the past.
3. Identifying and challenging exaggerated worries can reduce anxiety symptoms.
4. Identify exaggerated worries or pessimistic thoughts (e. g., when daughter is five minutes late from school, patient worries that she may have had an accident).
5. Discuss ways to challenge these exaggerated worries when they occur (e. g., when the patient starts to worry about the daughter, the patient could tell him/herself, "I am starting to be caught up in worry again. My daughter is only a few minutes late and should be home soon. I won't call the school to check unless she's an hour late").
6. Structured problem-solving methods can help patients to manage current life problems or stresses which contribute to anxiety symptoms.
7. Identify events that trigger excessive worry (e.g., a young woman presents with worry, tension, nausea and insomnia. These symptoms began after her son was diagnosed with asthma. Her anxiety worsens when he has asthma episodes).
8. Discuss what the patient is doing to manage this situation. Identify and reinforce things that are working.
9. Identify some specific actions the patient can take in the next few weeks, such as:
   1. meet with nurse/doctor/health professionals to learn about the course and management of asthma
   2. discuss concerns with parents of other asthmatic children
   3. write down a plan for management of asthma episodes.
10. Regular physical exercise is often helpful.

Medication

Medication is a secondary treatment in the management of generalised anxiety. It may be used, however, if significant anxiety symptoms persist despite counselling.

• Anti-anxiety medication (e. g., diazepam 5- 1 0 mg at night) may be used for no longer than two weeks. Longer-term use may lead to dependence and is likely to result in the return of symptoms when discontinued.
• Beta-blockers may help control physical symptoms.
• Antidepressant drugs may be helpful (especially if symptoms of depression are present) and do not lead to dependence or rebound symptoms. For details, see Depression - F32#.

Specialist consultation

Consultation may be helpful if severe anxiety lasts longer than three months.