It's not GAD

[Celexa]

Seems like every patient I see has generalized anxiety disorder listed in their chart.

Maybe 1/10 or less actually has it. If you actually bother to draw the meaningful distinctions within everything described as "anxiety", turns out most of these people have one or more of PTSD, OCD, social anxiety disorder, Mdd w/anxious distress, bipolar disorder, hell even legit adhd, sometimes acute appropriate situational anxiety (ie...while waiting for a biopsy result...) literally anything else but no goddam GAD.

I do believe GAD is a real diagnosis, I have had patients who legitimately fit the criteria and did not have comorbidities. They tend to do really well with standard dose SSRIs and straightforward CBT. It's not a label that should be slapped willy nilly on every anxious patient.

This abject diagnostic laziness does a major disservice to the patients and to perceptions of mental health care.

This rant brought to you by the novella of a note I just finished on a patient with both ocd (for decades) and ptsd (for years, dating from a very specific and clearly criterion A event) whose psychiatric problem list contained only....GAD. Sigh.

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[shoomer]

It's one of those placeholder diagnoses that gets thrown on a chart and persists indefinitely. Everyone gets it because its criteria are broad enough that anyone can justify it retrospectively.

 

[Celexa]

It's one of those placeholder diagnoses that gets thrown on a chart and persists indefinitely. Everyone gets it because its criteria are broad enough that anyone can justify it retrospectively.

Placeholder implies an intent to put something else in its place. Doesn't seem very place-holder-y if no new diagnosis is ever made.

 

[Candidate2017]

Placeholder implies an intent to put something else in its place. Doesn't seem very place-holder-y if no new diagnosis is ever made.

It's definitely a placeholder, but not the way you think:

It's one of those placeholder diagnoses that gets thrown on a chart and persists indefinitely. Everyone gets it because its criteria are broad enough that anyone can justify it prescribing benzos retrospectively indefinitely.

 

[VA Hopeful Dr]

Seems like every patient I see has generalized anxiety disorder listed in their chart.

Maybe 1/10 or less actually has it. If you actually bother to draw the meaningful distinctions within everything described as "anxiety", turns out most of these people have one or more of PTSD, OCD, social anxiety disorder, Mdd w/anxious distress, bipolar disorder, hell even legit adhd, sometimes acute appropriate situational anxiety (ie...while waiting for a biopsy result...) literally anything else but no goddam GAD.

I do believe GAD is a real diagnosis, I have had patients who legitimately fit the criteria and did not have comorbidities. They tend to do really well with standard dose SSRIs and straightforward CBT. It's not a label that should be slapped willy nilly on every anxious patient.

This abject diagnostic laziness does a major disservice to the patients and to perceptions of mental health care.

This rant brought to you by the novella of a note I just finished on a patient with both ocd (for decades) and ptsd (for years, dating from a very specific and clearly criterion A event) whose psychiatric problem list contained only....GAD. Sigh.

I suspect those of us in primary care are the most guilty of this (or at least I hope we are). All I can say is a) we're generally more time limited than y'all are so there's limits as to what we can do and b) SSRIs work for most of what you've listed that wasn't generalized anxiety. To my knowledge I've yet to have my diagnosis changed to bipolar when I've called it anxiety. ADHD is a real possibility, but teasing out anxiety v. adhd is something that very very few PCPs are trained to do.

 

[Celexa]

I suspect those of us in primary care are the most guilty of this (or at least I hope we are). All I can say is a) we're generally more time limited than y'all are so there's limits as to what we can do and b) SSRIs work for most of what you've listed that wasn't generalized anxiety. To my knowledge I've yet to have my diagnosis changed to bipolar when I've called it anxiety. ADHD is a real possibility, but teasing out anxiety v. adhd is something that very very few PCPs are trained to do.

It is common from primary care and I'm more sympathetic to that. And if SSRIs were all they needed the distinctions are less important. But I'm a consultant psychiatrist both inpatient and outpatient and most of the people I see are a) incredibly sick and b) have received some type of mental health care other from someone other than their PCP. And yet. GAD. And even if SSRIs help, the distinctions are often going to be most meaningful in choosing psychotherapeutic interventions, but I rarely see therapists interrogate the diagnosis.

As an aside switching a diagnosis from anxiety to bipolar isn't the most common thing but as a numbers game you probably have at least a handful of patients who have been tagged with anxiety and/or unipolar depression who actually have bipolar 2. I don't expect primary care to be able to make that distinction though, it's a challenging diagnosis to make with a lot of nuance that takes a lot of interview time to sort out.

 

[PsyDr]

I think it's a nice signifier for how the authors' values the balance between:
a. the monetary gain from insurance for diagnosing two "problems"
b. the technical aspect of the DSM process of ddx

 

[Stagg737]

I think it's a nice signifier for how the authors' values the balance between:
a. the monetary gain from insurance for diagnosing two "problems"
b. the technical aspect of the DSM process of ddx

Was about to say it's diagnostically low-hanging fruit that's easy to meet criteria for to upcode for billing purposes and as VA said, the common treatment of SSRI + therapy will cover most actual diagnoses that the patients may have. I agree that it's disappointing if therapists (or psychiatrists doing actual therapy with these patients) aren't doing more to tease out what the real root of the anxiety is, since imo it's hugely important for guiding psychotherapeutic modalities to utilize.

I'm probably guilty of over-diagnosing GAD myself, but I do a pretty thorough work-up to at least make sure it's a primary anxiety disorder and not more likely related to PTSD, ADHD, or a PD. Also that it's actual anxiety by asking them to describe it. I'm still baffled by the number of patients who have never been asked that question by the time they get to me but have been treated for "anxiety" for years...

 

[comp1]

If we're triaging incorrect diagnoses, I think we should start with bipolar disorder for borderline PD. There probably aren't a heck of a lot of incorrectly diagnosed GAD patients getting put on 20 mg of olanzapine. Personally, I almost never even see a GAD diagnosis on the chart or in real life, but I guess that's because I'm inpatient.

 

[Celexa]

If we're triaging incorrect diagnoses, I think we should start with bipolar disorder for borderline PD. There probably aren't a heck of a lot of incorrectly diagnosed GAD patients getting put on 20 mg of olanzapine. Personally, I almost never even see a GAD diagnosis on the chart or in real life, but I guess that's because I'm inpatient.

Lol. 20 of olanzapine? No. An SSRI, benzo, stimulant, and seroquel? Alllll the time.

 

[Celexa]

Also that it's actual anxiety by asking them to describe it. I'm still baffled by the number of patients who have never been asked that question by the time they get to me but have been treated for "anxiety" for years...

Yes! The sheer breadth and variety of experiences that people call 'anxiety' is frankly ludicrous. Not only do I get that look from patients, I get it from my own med students and residents when I ask them... They learn pretty quick not to tell me the patisnt has 'anxiety' without having more information. I tell them, would you present to a cardiologist and say the pt has chest pain and nothing else? Anxiety doesn't mean anything without more information.

On the inpatient consult side sometimes 'anxiety' literally ends up meaning 'increasing oxygen requirement, about to crump'....

 

[Sushirolls]

Majority of my chart diagnosis is Unspecified Anxiety Disorder.
Agree with seldom seeing true GAD
I wishfully think it was "anxiety" in the past, but chart documentation morphed into GAD over moves, relocation, etc. Sort of like how Bipolar I becomes II or vice versa.
My disdain for pleathora of "I think I have ADHD" or "I think I have autism" or "I have bipolar" simply overshadows the GAD Dx issues.
I'm not bother by this one.
Maybe some day things will improve and this will be the top of my rants.

 

[Celexa]

Majority of my chart diagnosis is Unspecified Anxiety Disorder.
Agree with seldom seeing true GAD
I wishfully think it was "anxiety" in the past, but chart documentation morphed into GAD over moves, relocation, etc. Sort of like how Bipolar I becomes II or vice versa.
My disdain for pleathora of "I think I have ADHD" or "I think I have autism" or "I have bipolar" simply overshadows the GAD Dx issues.
I'm not bother by this one.
Maybe some day things will improve and this will be the top of my rants.

There's definitely a context to why this bothers me so much, specifically being in a consult clinic embedded in a medical setting. Often patients get in front of me because the mental health care they are receiving isn't working and they are highly somaticizing. So, a high proportion of my 'GAD' label carrying patients have suffered for years with much more complex and undiagnosed psychiatric issues which have been missed/ignored/not looked for while they get treated for 'anxiety' and feel like they are being told their physical symptoms are all in their head. Getting them a mental health diagnosis that actually applies is often a first and necessary step towards weaving together a narrative that lets them acknowledge the connection between their physical and mental symptoms without feeling invalidated.

 

[BiscoDisco]

There's definitely a context to why this bothers me so much, specifically being in a consult clinic embedded in a medical setting. Often patients get in front of me because the mental health care they are receiving isn't working and they are highly somaticizing. So, a high proportion of my 'GAD' label carrying patients have suffered for years with much more complex and undiagnosed psychiatric issues which have been missed/ignored/not looked for while they get treated for 'anxiety' and feel like they are being told their physical symptoms are all in their head. Getting them a mental health diagnosis that actually applies is often a first and necessary step towards weaving together a narrative that lets them acknowledge the connection between their physical and mental symptoms without feeling invalidated.

How do you work with these highly somatic patients? Any specific treatment tips you've got from your experiences.

 

[romanticscience]

Criterion F people. I mean I hate on DSM for breeding “apparent” co-morbidity but come on.

I’m a big hierarchical diagnosis person.

The Concept of a Diagnostic Hierarchy

AbstractThe concept of a diagnostic hierarchy implies that certain diagnoses should not be made when other are present. This approach contrasts with the DS

academic.oup.com

 

[erg923]

Seems like every patient I see has generalized anxiety disorder listed in their chart.

Maybe 1/10 or less actually has it. If you actually bother to draw the meaningful distinctions within everything described as "anxiety", turns out most of these people have one or more of PTSD, OCD, social anxiety disorder, Mdd w/anxious distress, bipolar disorder, hell even legit adhd, sometimes acute appropriate situational anxiety (ie...while waiting for a biopsy result...) literally anything else but no goddam GAD.

I do believe GAD is a real diagnosis, I have had patients who legitimately fit the criteria and did not have comorbidities. They tend to do really well with standard dose SSRIs and straightforward CBT. It's not a label that should be slapped willy nilly on every anxious patient.

This abject diagnostic laziness does a major disservice to the patients and to perceptions of mental health care.

This rant brought to you by the novella of a note I just finished on a patient with both ocd (for decades) and ptsd (for years, dating from a very specific and clearly criterion A event) whose psychiatric problem list contained only....GAD. Sigh.

bunk diagnosis. Seems silly.

 

[Celexa]

How do you work with these highly somatic patients? Any specific treatment tips you've got from your experiences.

There's so much I could say and also a lot I'm still figuring out. I don't really consider myself an expert yet but a few things:

1. I do an detailed and essentially from scratch diagnostic exam. I read the chart to understand how the patient ended up in front of me and what their interactions with the healthcare system is like, but I pretty much disregard prior psychiatric diagnosis unless it's by a person I know and trust.

1a. This includes medical hx. There's a fine line here--I can't let them hijack the contents of the interview going on and on about their physical symptoms. But I do get enough to be reasonable confident that their medical needs are being attending to fairly. This cannot be assumed. If they aren't following the recs or have delayed an important diagnostic piece (ie sleep study), we talk about why and I educate on why it's important to follow through. I do a lot of basic medical education (ie, OSA means your brain doesn't get enough oxygen at night. Your brain thinks it is in danger all night long and tries to wake you up. Constantly being flooded with stress signals is why you never feel rested in the morning". Also a lot of psycho education on substance use. I check cbc, cmp, tsh, b12, iron studies, recommend empiric vitamin D due to our latitude, to make sure there's no easy explanations being missed and all possible low hanging fruit optimized. I don't go on a fishing expedition though--no CRPs, ESR, etc.

2. I ask the patient what prior psychiatric diagnoses they've been given, not what they have. Then I ask them some combination of what their understanding of those diagnoses is, whether they agree, and if there are other diagnoses they've wondered of they have and why. I explain the diagnoses I give and why I think they have them. Lots of psychoeducation about trauma and anxiety responses.

3. If the patient is on a diagnostic quest of some type, convinced that the doctors just haven't found what's wrong etc, I try and steer them away from the idea that an answer would fix their problems. I lean strongly into that question of what do they want their life to look like and how can we get there even if we don't know what their medical problem is. We talk about mind body connections. I don't try and convince them they don't have a medical problem. Ever. Edit--to be clear, if they think they have a specific diagnosis that makes no sense, I'll give them a clear language explanation of why that particular diagnosis doesn't apply. But I don't try and dissuade them from the idea they have *some* medical diagnosis.

4. When it comes to recommendations, I say that I will tell them my recommendations for both medication and psychotherapy and I will tell them why I think what I am recommending will help with. BUT--I also tell them that I don't have to prescribe anything in the visit. That if they want time to think about what I said, they can make a follow up appt in a month or two. These patients are so used to someone prescribing meds and then them not working, OR being sent off to therapists who don't understand medicine enough to understand why the doctors think the symptoms are psychosomatic. I try and break that paradigm. I'm also very clear about what a proper medication trial is, as well as framing getting better as a multistage process. If there's another major change happening (ie, pt is getting their Cpap machine next week) I'll tell them OK, let's see what changes that causes. Making a med change at the same time would confuse our picture. Etc. I also talk about side effects and deprescribe when possible.

5. In general among my medical colleagues I try very hard to discourage them from treating sending to mental health as a patient transfer. I educate around boundaries etc to help them manage the patient in clinic but as a psychiatrist your knees are cut out from under you if the patient feels they've been pawned off by their medical doctor.

This is all outpatient setting. In contrast, on inpatient medicine these folks actually need a lighter, more distant hand because you don't want them to start associating inpatient settings as where they get the most attention.

 

[DOswag]

Majority of my chart diagnosis is Unspecified Anxiety Disorder.
Agree with seldom seeing true GAD
I wishfully think it was "anxiety" in the past, but chart documentation morphed into GAD over moves, relocation, etc. Sort of like how Bipolar I becomes II or vice versa.
My disdain for pleathora of "I think I have ADHD" or "I think I have autism" or "I have bipolar" simply overshadows the GAD Dx issues.
I'm not bother by this one.
Maybe some day things will improve and this will be the top of my rants.

This x 1000. I've had more "I saw a tik tok video and I think I have ADHD/Autism" patients just in the past 1.5 months since starting my civ job than I had in 4 years in the military (although I did have a few while in the military as well). I just want to put a sign on my door that says "You don't have autism or ADHD, stop watching videos and taking online quizzes".

It irks me for sure to see someone diagnosed with bipolar that is clearly a raging borderline but I've had many of them either disagree with the diagnosis or at least understand when I explain that I don't believe they have bipolar. But people want that ADHD diagnosis because "I took someone's adderall once and it helped sooooo much". I have a patient today that was sent to me by an NP for ADHD eval that they started on stimulant just to see if it would help and by golly it did so the patient must have ADHD.

 

[vanfanal]

Patients coming in seeking ADHD and stims is one thing. I can live with that in a world where I can say sorry you don't have it, and that's the end of it. What irks me is that they can just go literally anywhere else (PCP, mid-level, online pill mills) and get what they want. I feel like that makes me look inept - I don't think I am, but they think...well this person thinks I have it and you don't, do what's wrong with you?

 

[Psych19]

I wonder if GAD often gets added to the problem list for billing purposes. If a patient has MDD and GAD (two stable chronic diagnoses) and they're on prescription medication, you can justify billing 99214 at each encounter.

 

[DOswag]

I wonder if GAD often gets added to the problem list for billing purposes. If a patient has MDD and GAD (two stable chronic diagnoses) and they're on prescription medication, you can justify billing 99214 at each encounter.

Absolutely it does because it's so easy to justify it with documentation based on dsm criteria and if someone has MDD, we know anxiety is a common comorbid condition and it's not going to change treatment significantly. I know this because I'm guilty of it for sure. We all play the game to some extent...

 

[Celexa]

Absolutely it does because it's so easy to justify it with documentation based on dsm criteria and if someone has MDD, we know anxiety is a common comorbid condition and it's not going to change treatment significantly. I know this because I'm guilty of it for sure. We all play the game to some extent...

But that's my point. These patients are treated as though they have MDD and GAD when they don't. Even if it doesn't change pharmacologic management (and I would argue it does--I've seen miracles with prazosin, a little mood stabilizer, convincing them to use their cpap...) it absolutely changes psychotherapy management, not just for referrals but for interventions in the med management visit.

Last week I was the first person to tell someone with textbook OCD that the intrusive, violent thoughts she had about her family were OCD symptoms and not her fault. As far as I can tell I was the first person to ask her about the categories of OCD symptoms people feel intense shame about. How much good did it do her to be labeled as GAD for years because she was anxious? How much self recrimination and guilt and underdosed SSRIs? It's not a benign mistake when diagnosis is that shallow.

 

[MedMan80]

we need to be careful pathologizing normal human emotion...

 

[Celexa]

we need to be careful pathologizing normal human emotion...

Yeah. The normal human emotion people don't make it into my outpatient clinic. It's pretty much the sickest of the sick there. Definitely get that on the inpatient side though. Always fun to figure out a new diplomatic way to say "the patient is sad and anxious because you just told them they have cancer"... Those people end up with GAD in their charts too....

 

[vanfanal]

Yeah. The normal human emotion people don't make it into my outpatient clinic. It's pretty much the sickest of the sick there. Definitely get that on the inpatient side though. Always fun to figure out a new diplomatic way to say "the patient is sad and anxious because you just told them they have cancer"... Those people end up with GAD in their charts too....

how do they screened out?

 

[Celexa]

how do they screened out?

It's a very academic setup. Most of my clinical time is general inpatient consults but my clinic is embedded with a medical specialist who takes referrals of some of the sickest/most challenging patients in their specialty. No one gets onto my schedule unless both of us agree it's warranted.

 

[annoyedpsychiatrist]

I use unspecified anxiety disorder often times on the first meeting because usually the patient has quite a few things going on so I try to fease out where the anxiety focus is. I do diagnose a lot of GAD and I do agree that diagnosis matters, though I tend to like it also because people dont actively seek out GAD labels in the same way they seek out autism, complex ptsd, and ADHD labels. Not saying we should misdiagnose anyone or anything, and often its further complicated by some of my patients having many moving parts happening at once.

Im moreso annoyed at the overdiagnosis of bipolar disorder. Mood swings= bipolar to all of these inexperienced providers, and now you have someone on moderate-high dose antipsychotic therapy plus/minus mood stabilizer for 30 years when they never even had bipolar.

 

[clausewitz2]

Yeah. The normal human emotion people don't make it into my outpatient clinic. It's pretty much the sickest of the sick there. Definitely get that on the inpatient side though. Always fun to figure out a new diplomatic way to say "the patient is sad and anxious because you just told them they have cancer"... Those people end up with GAD in their charts too....

This latter is the equivalent of the teenagers you get in FEP clinics who get referred by their guidance counselors because of 'delusions' and then you spend an hour talking to a kid who is kind of weird and nervous but wants to be a horror novelist and tells you enthusiastically about the very vivid terrible scenes they 'see' with complex plots and can't wait to write a story about. Then you ask how they tell the difference between 'seeing' this and imagining it vividly and they don't understand the question.

"Oh, and your very busy professional parents dropped everything they were doing to be with you that one time you had a panic attack at a party you were uncomfortable at the minute you mentioned these things you were seeing? And you barely get any time with them otherwise?"

Those are at least feel good encounters in the sense you get to tell kids they have a potentially bright creative career ahead of them but you don't think they're especially crazy. Still annoying when they bump someone else who stopped going to school, talking to others, sleeping at night, or doing anything apart from chainsmoke and make rambling posts about the Illuminati for the past six months.

EDIT: and unfortunately stuff like PRIME is very face valid and a certain type of young person is enthusiastic about endorsing all of the items on it, so screening in advance only works if the person doing the screening is pretty experienced and savvy, which they rarely are

 

[SmallBird]

When I worked in a really sophisticated anxiety clinic that was run by a group of psychologists at my training program, they would specify whether patients had issues like 'increased anxiety sensitivity' or 'negative attention bias' or 'parental accommodation of chronic avoidance' to distinguish the diverse ways in which patients might report or have symptoms of an anxiety disorder without in fact experiencing the characteristic heightened fear response which likely underpins anxiety as it is most commonly understood by psychiatrists.

 

[DOswag]

But that's my point. These patients are treated as though they have MDD and GAD when they don't. Even if it doesn't change pharmacologic management (and I would argue it does--I've seen miracles with prazosin, a little mood stabilizer, convincing them to use their cpap...) it absolutely changes psychotherapy management, not just for referrals but for interventions in the med management visit.

Last week I was the first person to tell someone with textbook OCD that the intrusive, violent thoughts she had about her family were OCD symptoms and not her fault. As far as I can tell I was the first person to ask her about the categories of OCD symptoms people feel intense shame about. How much good did it do her to be labeled as GAD for years because she was anxious? How much self recrimination and guilt and underdosed SSRIs? It's not a benign mistake when diagnosis is that shallow.

I don't disagree with you and I should probably clarify my statement to not be as much of a blanket statement. Yes there are patients that come in who have trialed multiple medications, low doses, nothing's worked etc and I then take a step back and reevaluate the diagnosis or the treatment up to that point (for me it's more commonly been the "i was diagnosed with bipolar and I have this laundry list of meds that haven't work" when it's clearly BPD). I should say largely the straight forward depression and anxiety combo is easy to put together based on the general verbiage used in DSM, can easily be justified for documentation purposes for higher billing, and SSRI/SNRI will cover both. Agree that yes therapeutic interventions would likely be changed/modified based on more nuanced approach for diagnostic clarification.