Anxiety Disorders: First aid and when to refer on Presenter: Dr Roger Singh, Consultant Psychiatrist, ABT service, Hillingdon Educational resources from NICE, 2011 NICE clinical guideline 113
What is anxiety? ICD-10 (WHO) states :- “Neurotic, stress-related and somatoform disorders” F40: Agoraphobia +/- panic disorder Simple/Specific Phobia Social Phobia F41 Panic Disorder (episodic anxiety) Generalized Anxiety Disorder F42 Obsessive-Compulsive Disorder ( thoughts and compulsions) F43 Acute Stress Reaction Post-Traumatic Stress Disorder Adjustment Disorder (various types) F44-F45 Dissociative and Somatoform disorders e.g. medically unexplained symptoms, Hypochondriacal Disorder F48 Other neurotic disorders: e.g. Neurasthenia (Chronic Fatigue Syndrome)
Epidemiology of anxiety disorders (National Co-morbidity Survey data) 30 30 28.7 28.7 Lifetime Prevalence Rates Lifetime Prevalence Rates 25 25 20 20 (%) (%) 15 15 13.3 13.3 11.3 11.3 10 10 7.6 7.6 5.3 5.3 5.1 5.1 5 5 3.5 3.5 0 0 All Anxiety Social Agoraphobia Panic All Anxiety Social Specific PTSD Agorafobia GAD Panic Disorders Phobia without Disorders Disorders Phobias Phobias without Disorders Panic Panic Lifetime Prevalence of DSM-IV/WMH-CIDI Disorders in the Total NCS-R Sample (1995,2005) Archives of General Psychiatry : Kessler et al. 2005;62:593-602
Medication in anxiety disorders •Most anxiety is normal e.g. sitting exams, meeting the parents in law •The spectrum of anxiety disorders respond to SSRIs and also SNRIs •Benzodiazepines have special usage
Special consideration •Benzodiazepines should only be used for anxiety that is “severe, disabling, or subjecting the individual to extreme distress”. Only a very small number of patients benefit from long term use but they should not be denied treatment •NICE recommends that benzodiazepines should not treat Panic Disorder •Use the lowest effective dose and a maximum of 4 weeks duration
SSRIs GAD – prescribe half of the normal dose and titrate to antidepressant doses – response usually takes 6 weeks, evaluate over 6 months Panic- Use a low dose of clomipramine, citalopram or sertraline at the bottom of the antidepressant range to balance side effects and efficacy. BDD – treat initially with psychology. Add buspirone or SSRI to improve outcome.
NICE guidelines available for Generalised Anxiety Disorder , PTSD , panic disorder and OCD . Overall Prognosis: Anxiety disorders tend to be chronic and treatment is often only partially successful. Evidence suggests 8-18 months of treatment.
Case scenario 1 - Sharon Summary: • 42 years old, divorced, two children, carer for her mother • Frequently makes appointments with the GP and practice nurse • History of depression 5 years ago which was improved with counselling • Complains of feeling stressed and worried all the time which has become much worse in the last 12 months Question: You suspect GAD – what would you do to confirm this?
Case scenario 1 - Sharon Answer : •Conduct a comprehensive assessment •Sharon’s complaints of repeated worrying and frequent attendance in primary care suggest GAD Question: You confirm GAD − what would you do next?
Case scenario 1 - Sharon Answer: Start with step 1 interventions: •Identify and communicate the diagnosis of GAD •Provide education and monitor symptoms and functioning Question: After 4 weeks of education and active monitoring there is minimal improvement in Sharon’s functioning and distress. What are the next steps?
Case scenario 1 - Sharon Answer: Move up to step 2 interventions and discuss the options with Sharon. Offer one or more of the following: •individual non-facilitated self-help •Individual guided self-help •psychoeducational groups
low intensity psychological interventions (step 2)? (provision from IAPT) Self-help •Include written or electronic material of a suitable reading age •These should be based on principles of CBT •Instructions to work through the material over 6 weeks •Minimal therapist contact e.g. occasional telephone call >5 minutes
Other low intensity psychologies: Guided self-help •As Self help but be supported by a trained practitioner who facilitates the self-help programme and reviews progress and outcome •5-7 weekly or fortnightly sessions, face-to-face or telephone each lasting 20-30 minutes
Case scenario 2 - Cherry Summary: •20 years old, in employment •Feels anxious most of the time, feelings of anxiety started 4 years ago •Low mood but no suicidal thoughts •No significant past medical or mental health history Question: You suspect GAD − what would you do to confirm this?
Case scenario 2 - Cherry Answer : •Conduct a comprehensive assessment •Cherry’s complaints of feeling anxious most of the time suggests GAD Question: You confirm GAD and moderate depression, with GAD being the more severe condition – what would you do next?
Case scenario 2 - Cherry Answer: Start with step 1 interventions for GAD as this is the primary disorder. •Identify and communicate the diagnosis of GAD •Provide education and monitor symptoms and functioning Question: Cherry’s symptoms have not improved after 4 weeks of active monitoring and education. What are the next steps?
Case scenario 2 - Cherry Answer: Discuss the options for step 2 interventions. Offer one or more of the following: •individual non-facilitated self-help •Individual guided self-help •psychoeducational groups Cherry’s preference is to attend a psychoeducational group as feels she would benefit from meeting people who have similar problems.
Psychoeducational groups Psychoeducational groups Based on interactive design and encourage observational learning ( Include presentations and self- help manuals) Ratio of 1 therapist to 12 participants; 6 weekly sessions CBT principles ; Have an each lasting two hours For guided self-help and psychoeducational group practitioners should receive regular, high-quality supervision
Case scenario 3 - Alan Summary: •48 years old, unemployed for 8 years due to severe anxiety •20 year history of GAD •Has tried step 2 interventions that have helped ‘a bit’ Question: You confirm GAD − what would you do next?
Case scenario 3 - Alan Answer: As Alan has marked functional impairment that has not improved with a step 2 intervention, offer a step 3 intervention. Offer either: •an individual high-intensity psychological intervention or •drug treatment After a discussion of the options, Alan chooses a psychological intervention and shows a preference for individual cognitive behavioural therapy (CBT).
High intensity psychology High intensity psychological interventions CBT – based on the treatment manuals used in clinical trials of CBT for GAD; delivered by trained, competent practitioners 12-15 weekly sessions (fewer if recovers sooner, more if clinically required) each lasting one hour … and/or Applied relaxation (based on treatment manuals)
Case scenario 4 - Peter Summary: •29 years old, in employment •Feels stressed and exhausted all the time •Persistent worries about threats of redundancy at work and events outside work and has taken sick days off work due to anxiety Question: You suspect GAD – what would you do to confirm this?
Case scenario 4 - Peter Answer : •Conduct a comprehensive assessment •Peter’s complaints of feeling stressed and worried all the time suggest GAD Question: You confirm GAD − what would you do next?
Case scenario 4 - Peter Answer: Start with step 1 interventions •Identify and communicate the diagnosis of GAD •Provide education and monitor symptoms and functioning Question: After discussing the nature of GAD and talking about treatment options, Peter is keen to start treatment straight away. What are the next steps?
Case scenario 4 - Peter Answer: Discuss the options for step 2 interventions. Offer one or more of the following: •individual non-facilitated self-help •Individual guided self-help •psychoeducational groups After considering the options, Peter decides that he would prefer individual guided self-help. Question: After completion of the individual guided self-help sessions there is only minor improvement and Peter’s symptoms remain very troubling. He continues to have frequent days off work. What would you do next?
Case scenario 4 - Peter Answer: Discuss the options at step 3. Offer either: •an individual high-intensity psychological intervention or •drug treatment Peter is not keen on a psychological intervention because of his concerns about taking time off work so he decides to try drug treatment. You prescribe sertraline* Question: Peter takes sertraline for 6 weeks. He tolerates the medication well. However, his symptoms are only minimally improved and he continues to take time off work because of anxiety-related symptoms. What are the possible options?
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