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Physiopaedia contributors (2023) Generalized anxiety disorder, Physiopedia. Available at: https://www.physio-pedia.com/Generalized_Anxiety_Disorder (Accessed: April 30, 2023).

Ahulu, L.D., Gyasi-Gyamerah, A.A. and Anum, A. (2019) “Predicting risk and protective factors of generalized anxiety disorder: A comparative study among adolescents in Ghana,” International Journal of Adolescence and Youth, 25(1), pp. 574–584. Available at: https://doi.org/10.1080/02673843.2019.1698440.

Newman, M.G., Shin, K.E. and Zuellig, A.R. (2016) “Developmental risk factors in generalized anxiety disorder and panic disorder,” Journal of Affective Disorders, 206, pp. 94–102. Available at: https://doi.org/10.1016/j.jad.2016.07.008.

NHS contributors (2022) Symptoms - Generalised Anxiety Disorder in adults, NHS choices. NHS. Available at: https://www.nhs.uk/mental-health/conditions/generalised-anxiety-disorder/symptoms/ (Accessed: April 30, 2023).

Tyrer, P. and Baldwin, D. (2006) “Generalised anxiety disorder,” The Lancet, 368(9553), pp. 2156–2166. Available at: https://doi.org/10.1016/s0140-6736(06)69865-6.

NHS contributors (2022) Treatment Generalised anxiety disorder in adults , NHS choices. NHS. Available at: https://www.nhs.uk/mental-health/conditions/generalised-anxiety-disorder/treatment/ (Accessed: April 30, 2023).

NICE guidelines (2022) CKS is only available in the UK, NICE. Available at: https://cks.nice.org.uk/topics/back-pain-low-without-radiculopathy/background-information/prevalence/ (Accessed: April 30, 2023).

Ho, E. et al. (2020) “Psychological interventions for chronic non-specific low back pain: Protocol of a systematic review with network meta-analysis,” BMJ Open, 10(9). Available at: https://doi.org/10.1136/bmjopen-2019-034996.

DeMartini, J., Patel, G. and Fancher, T.L. (2019) “Generalized anxiety disorder,” Annals of Internal Medicine, 170(7). Available at: https://doi.org/10.7326/aitc201904020.

Geosc (2023) Updated osteopathic practice standards, Updated Osteopathic Practice Standards - General Osteopathic Council. Available at: https://www.osteopathy.org.uk/news-and-resources/document-library/osteopathic-practice-standards/updated-osteopathic-practice-standards/ (Accessed: April 30, 2023).

Mayo Clinic (2017) Generalized anxiety disorder, Mayo Clinic. Mayo Foundation for Medical Education and Research. Available at: https://www.mayoclinic.org/diseases-conditions/generalized-anxiety-disorder/diagnosis-treatment/drc-20361045 (Accessed: April 30, 2023).

Parsons, J. and Marcer, N. (2014) Osteopathy models for diagnosis, treatment and Practice. Johanneshov: MTM. Pages 9 -10

https://www.mentalhealthgeneral.com/the-biopsychosocial-model-in-mental-health/

https://www.inc.com/david-finkel/anxiety-is-common-among-entrepreneurs-here-are-4-tips-to-help-soothe-your-nerves.html https://cpd.osteopathy.org.uk/

https://cpd.osteopathy.org.uk/

https://www.aclandstreetphysiotherapy.com.au/physio-st-kilda-injury-prevention-blog/physio-opinion-what-commonly-causes-low-back-pain

https://www.nextstep.doctor/generalized-anxiety-disorder/

https://www.istockphoto.com/de/foto/junge-medizinische-arbeiter-meditation-w%C3%A4hrend-pause-gm156431166-22056939

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https://www.psychiatrictimes.com/view/uspstf-makes-historic-anxiety-and-depression-draft-screening-recommendations

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The Interventional Orthopaedics of Atlanta state that there are physical and chemical reactions that take place in the body when stress or anxiety takes place. Cortisol and Adrenaline are the primary hormones released and typically are the cause of an involuntary tightening of the muscles. This phenomenon might happen in the lower back, or other areas of the body. Therefore if anxiety is “maintained” so might the lower back pain due to the pathophysiology of the hormones release behind the process.

Williams, Dr.C. (2020) Can stress cause lower back pain?, Atlanta, GA Orthopedic Specialist. Available at: https://ioaregenerative.com/blog/can-stress-cause-lower-back-pain#:~:text=Cortisol%20and%20adrenaline%20are%20released,more%20specifically%2C%20lower%20back%20pain. (Accessed: 11 May 2023).

So it is widely accepted that emotional stress, or any psychological factors may induce “psychosomatic” chronic low back pain.  There are a variety of different theories about the causes of stress and anxiety related to chronic pain. The Pain cycle theory states that :
1. The patient becomes unnecessarily limited in his day-to-day life due to his GAD and therefore reduces his leisures as well.

2.  The decrease in activity is due to the patient’s fear of pain and injury

3. This fear may be worsened by admonitions from doctors or other therapists that suggest to “take it easy”, following a purely structural diagnosis.

4. And finally, the limitation of movement and muscle engagement lead to physical de-conditioning, and general weakening, which in turn leads to more pain.

As osteopaths, this should make us reflect on our patient management, and the importance to see the broader picture. Treating in a holistic way must include the Psychological aspect of the patient as well !

Dr Sarno’s Theory states that the correlation between the chronicity of the back pain and GAD  would be due to the patient’s personality, feelings and unconscious issues. Key emotions include unconscious rage/ anger and some characteristics include :

- having a strong inner drive to succeed
- Having a great sense of responsibility
- Being self-motivated
- …

… Basically, people that are extremely hard on themselves!

William Deardorff, P.P.-R. (2016) How does stress cause back pain?, Spine. Available at: https://www.spine-health.com/conditions/depression/how-does-stress-cause-back-pain (Accessed: 11 May 2023).

This is where the term “somatisation” comes into play. Which is when the experienced pain is not related to tissue damage or a physical illness,  but to a mental phenomenon which often happens in GAD.

Birket-Smith, M. (2001) ‘Somatization and chronic pain’, Acta Anaesthesiologica Scandinavica, 45(9), pp. 1114–1120. doi:10.1034/j.1399-6576.2001.450911.x.

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NICE Guidelines recommend using the international DSM-5-TR diagnostic criteria mentioned in my slides.  They however also mention the ICD-11 diagnostic criteria which are:

Marked symptoms of anxiety manifested by either general apprehensiveness that is not restricted to any particular environmental circumstance, or excessive worry about negative events occurring in several different aspects of everyday life.

Anxiety and general apprehensiveness or worry accompanied by additional symptoms, such as: muscle tension or motor restlessness; sympathetic autonomic overactivity (for example, frequent gastrointestinal symptoms, palpitations, sweating, trembling, shaking, and/or dry mouth); subjective experience of nervousness, restlessness, or being 'on edge'; difficulty concentrating; irritability; sleep disturbances (difficulty falling or staying asleep, or restless, unsatisfying sleep).

The symptoms are not transient and persist for at least several months, for more days than not; are not better accounted for by another mental disorder; are not a manifestation of another medical condition and are not due to the effects of a substance or medication on the central nervous system.

The symptoms result in significant distress about experiencing persistent anxiety symptoms or significant impairment in personal, family, social, educational, occupational, or other important areas of functioning. If functioning is maintained, it is only through significant additional effort.

NICE guidelines also suggest the use of  the GAD-7 tool.

NICE authors (2023) CKS is only available in the UK, NICE. Available at: https://cks.nice.org.uk/topics/generalized-anxiety-disorder/diagnosis/diagnosis/#b9c87f7f-63e2-4cdf-942c-3019a65c9903 (Accessed: 11 May 2023).

GAD-7 tool is a questionnaire used as a screening tool and a severity measure for GAD.
It can be found at : https://patient.info/doctor/generalised-anxiety-disorder-assessment-gad-7

The GAD-7 questionnaire uses scores from 0-3. 0 being “not at all” and 3 being “nearly every day”. Then the scores of the 7 questions are added together.
This questionnaire has a sensitivity of 89% and a specificity of 82%.

Spitzer, R.L. et al. (2006) ‘A brief measure for assessing generalized anxiety disorder’, Archives of Internal Medicine, 166(10), p. 1092. doi:10.1001/archinte.166.10.1092.

I have chosen to put in my slides the international diagnostic criteria as it is widely used and also gives us a good idea as osteopaths if the patient needs a referral or not. All the assessments tool are however fairly similar and encompass similar symptoms. The questionnaire has the advantage of “quantifying” feelings which can give the medical professional a better idea of the severity of the patient’s GAD.