Anxiety Disorders: First aid and when to refer on Presenter: Dr - - PowerPoint PPT Presentation

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)

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

28.7 13.3 11.3 7.6 5.3 5.1 3.5

5 10 15 20 25 30

Lifetime Prevalence Rates (%)

All Anxiety Disorders Social Phobia Agoraphobia without Panic Panic Disorders

28.7 13.3 11.3 7.6 5.3 5.1 3.5

5 10 15 20 25 30

Lifetime Prevalence Rates (%)

All Anxiety Disorders Social Phobias Specific Phobias PTSD Agorafobia without Panic GAD Panic Disorders

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

• r

sertraline at the bottom of the antidepressant range to balance side effects and efficacy. BDD – treat initially with psychology. Add buspirone

• r

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

• ften 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

• bservational 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
• r
• 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
• utside 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

• ptions, 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

• nly 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
• r
• 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?

Case scenario 4 - Peter

Answer: If a person’s GAD has not responded to:

• a high-intensity psychological intervention, then offer a drug treatment
• drug treatment, then offer either a high-intensity psychological

intervention or an alternative drug treatment If a person’s GAD has partially responded to drug treatment, consider

• ffering a high-intensity psychological intervention in addition to drug

treatment Peter is still not keen on further psychological treatment and wishes to try another drug. You withdraw the sertraline and start venlafaxine.

Case scenario 5 - Elizabeth

Summary:

• 50 years old, married with two children
• Presenting with extreme tiredness, agitation and pains in chest
• History of GAD and depression
• Tried individual guided self-help 2 years ago with no effect
• Symptoms of GAD have become worse during the past 8 months

and she sometimes feels she might harm herself Question: You confirm GAD − what would you do next?

Case scenario 5 - Elizabeth

Answer: As GAD is markedly interfering with Elizabeth’s functioning and has not improved with a step 2 intervention, offer a step 3 intervention. Offer either:

• an individual high-intensity psychological intervention
• r
• drug treatment

You also need to consider Elizabeth’s alcohol intake. As Elizabeth’s alcohol intake is considered to be non-harmful, she is

• ffered a step 3 intervention. She is not keen on taking any more drugs

and so decides to try a psychological intervention, with individual CBT her preferred option.

Case scenario 5 - Elizabeth

Question: After 15 sessions of CBT, Elizabeth continues to have significant symptoms of anxiety. She is finding it increasingly difficult to manage everyday tasks and is very agitated and frightened a lot of the time. Her family says that she is now unable to be left on her own without threatening to take an overdose and the family is finding this very difficult to deal with. Although Elizabeth denies feeling suicidal when she is seen in the surgery she is worried about the increase in frequency of her suicidal thoughts when she gets very anxious. Her alcohol intake has increased and she is now drinking several glasses of wine each evening. She says she finds it very difficult to put into practice the strategies that she learnt in the CBT sessions. What would you do next?

Case scenario 5 – Elizabeth

Answer: As Elizabeth has not responded to a step 3 intervention, her anxiety is severe, her alcohol intake has increased to harmful levels and she has marked functional impairment and a risk of self-harm, she is

• ffered assessment and treatment at step 4.

When to involve ABT:

• The anxiety disorder is refractory following both CBT/

and drug treatment (two trials of medication) and has reached STEPS 4/5 in NICE guidance

• Multiple psychiatric co-morbidities or significant

complexity

• Very severe functional impairment (such as self

neglect)

• Persistent suicidal thoughts or marked acute self

harming thoughts

Any Questions? Many Thanks for listening