Anxiety Disorders

Marta BuszewiczGP in North Camden; Senior Lecturer in Primary Care, UCL

Judy LeibowitzConsultant Clinical Psychologist

Clinical Lead, Camden Psychological Therapies Service

What are your views about anxiety disorders?

How common do you think they are?

What do you think may make them more likely

What is their prognosis

Why do you think they may be under-detected

Do you specifically aim to identify them?

Topics to be covered

oPrevalence of Anxiety Disorders

oAssociated morbidity and co-morbidity

oIdentification and differential diagnosis

oManagement approaches in primary care

Prevalence of Common Mental DisordersAdult Psychiatric Morbidity Survey in England 2007

Has there been an undue emphasis on detecting depressive disorders?

Prognosis, associated morbidity and comorbidity

Research suggests that anxiety disorders are often more chronic than other common mental disorders, presumably because often left untreated

They are frequently co-morbid with depressive disorders, personality difficulties or chronic physical health problems, resulting in worse outcomes

Such co-morbidity is associated with poor quality of life, substance misuse, disability and high health and social costs

Wittchen 2002 - J. Clin. Psychiatry – primary care recognition rates of 34% for pure GAD and 43% if comorbid with depression

Sub-clinical Anxiety Disorder (not being discussed further)

Mixed anxiety and depression Symptoms of both anxiety and depression present, but neither considered separately severe enough for a diagnosis. Often associated with poor quality of life*

*Outcomes of Mixed Anxiety and Depressive Disorder: a prospective cohort study in primary care. Walters K, Buszewicz M, Weich S, King M. British J Psychiatry 2011

Generalised Anxiety Disorder (GAD) Essential characteristic is excessive uncontrollable worry

about everyday things. This constant worry affects daily functioning and can cause physical symptoms.

For a diagnosis to be made, worry must be present more days than not for at least 6 months.

Focus of worry can shift - often job, finances, health of self / family, but can also include more mundane daily issues.

Intensity, duration and frequency of worry disproportionate to the issue.

Often begins at an early age, and signs and symptoms may develop more slowly than in other anxiety disorders.   

Can occur with other anxiety disorders, depressive disorders or substance misuse.

Symptoms of GAD• Difficulty concentrating

• Difficulty controlling worry

• Excessive sweating, palpitations, shortness of breath

• Stomach / intestinal symptoms e.g. nausea / diarrhoea

• Fatigue / Irritability

• Muscle tension - shakiness, headaches

• Restlessness or feeling keyed up or "on the edge“

• Sleep disturbance (difficulty falling or staying asleep or restless, unsatisfying sleep).

Panic Disorder

Recurrent episodes of severe anxiety (panic attacks)

In panic disorder not linked to particular trigger cf. phobia

Symptoms vary, but palpitations, chest pain, choking, dizziness and depersonalisation common.

Almost always associated with a fear of dying, losing control, or going mad.

Attacks usually last minutes, sometimes longer.

Panic Disorder continued

Often crescendo of panic and autonomic symptoms resulting in a hurried exit/escape

Often leads to avoidance of situations where would feel unsafe if panicky and would be difficult or embarrassing to exit quickly - and a clinging to places where feels safe

Therefore panic disorder with agoraphobia is common

Phobias

Agoraphobia/claustrophobia Specific Phobias Social Phobia

Anxiety linked to specific phobic situation or phobic object

Many specific phobias will have been adaptive in evolution (small animals, spiders, heights)

Blood/injury/injection phobias are associated with decrease in BP and fainting

Social Phobia / Social Anxiety Disorder

Usually starts in adolescence Men = women May be discrete (e.g.eating in company) or diffuse Associated with low self-esteem and fear of

criticism Avoidance can be marked

Obsessive-Compulsive Disorder

Obsessions: Recurrent and persistent thoughts that are

experienced as intrusive and inappropriate

The thoughts are not excessive worries about real life problems

The person tries unsuccessfully to ignore or suppress the thoughts or to neutralize them with some other thought or action

The person recognises the thoughts as a product of their own mind (not delusional)

Obsessive-Compulsive Disorder

Compulsions: Repetitive behaviours (e.g. hand washing,

ordering, checking) or mental acts (e.g. counting, repeating words silently) that the person feels driven to perform in response to an obsession

The behaviours or mental acts are aimed at preventing some dreaded event or situation or reducing distress

Post-traumatic Stress Disorder

Distressing intrusive memories/dreams/images of a traumatic event and/or avoidance of places/ conversations that would remind of the event

In month after traumatic event these are common = Acute Stress Disorder; at > 1 month = PTSD

3.0 %of adults screened positive for current PTSD, equating to a conditional probability of 8.9 % of those who had experience of trauma in adulthood

Consider using the 10 item Trauma Screening Questionnaire if symptoms > 4 weeks after the traumatic event.

Health anxiety / Hypochondriasis

Now often viewed as an anxiety disorder

Preoccupation with fears of having a serious disease based on misinterpretation of bodily symptoms

Often associated with frequent checking of the body

Persists despite appropriate medical evaluation and reassurance

What do GAD-7 scores mean?

When used as a screening tool, further evaluation is recommended when the score is 10 or greater.

Using the threshold score of 10, the GAD-7 has a sensitivity of 89% and a specificity of 82% for generalised anxiety disorder.

Moderately good at screening for 3 other common anxiety disorders: - Panic disorder (sensitivity 74%, specificity 81%), - Social anxiety (sensitivity 72%, specificity 80%), - PTSD (sensitivity 66%, specificity 81%)

TRAUMATIC STRESS QUESTIONNAIREThis questionnaire is concerned with your personal reactions to the traumatic event. Please indicate whether or not you have experienced any of the following AT LEAST TWICE IN THE PAST WEEK:

Yes/No answers - Score of 5 or above indicates likely PTSD

1. Upsetting thoughts or memories about the event that have come into your mind against your will.  

2. Upsetting dreams about the event.  3. Acting or feeling as though the event were happening again.  4. Feeling upset by reminders of the event.  5. Bodily reactions (such as fast heartbeat, stomach churning, sweatiness,

dizziness) when reminded of the event. 6. Difficulty falling or staying asleep.  7. Irritability or outbursts of anger  8. Difficulty concentrating.  9. Heightened awareness of potential dangers to yourself and others. 10. Being jumpy or being startled at something unexpected.

Management of Anxiety Disorders

Management of GAD – the stepped care model

STEP 1: All known and suspected presentations of GAD

STEP 4: Complex treatment–refractory GAD and very marked functional impairment such as self-neglect or high risk of self-harm

,

STEP 3: GAD with an inadequate response to step 2 interventions or marked functional impairment

STEP 2: Diagnosed GAD that has not improved after education and active monitoring in primary care

Management of GAD – step 1 - Identification

Check for presence of GAD in:Patients presenting directly with anxiety or worryPatients with chronic physical health problems (due to high co-morbidity with GAD)Patients repeatedly seeking reassurance about somatic symptoms

Ask about the worries the patient experiences:

1. Do you worry about a range of different things or happenings in your life?

2. Do you feel unable to control your worry?

GAD – step 1 – GP Management

Education and ‘active monitoring’ is a process of assessment, information giving, advice and support for people with mild GAD. It may include:

exploring presenting problems and concerns

provision of information about the nature and course of GAD and ? simple self-help techniques

offering follow up in 2 weeks

making contact if the patient does not attend follow-up appointments

Education works for anxiety disorders

Understanding ones disorder and symptoms reduces worry and anxiety

When the disorder is an anxiety disorder this can be curative!

Evidence for effectiveness of non-facilitated self-help in anxiety disorders (unlike in depression)

GAD – worry about worry

• What is wrong with me that I am worrying so much

• What is wrong with me that I am worrying so much

• Worrying a lot• Worrying a lot

GAD – intolerance of uncertainty

• It will be terrible if X happens

• I must work out how to stop X happening

• It will be terrible if X happens

• I must work out how to stop X happening

• Worry about X happening

• Worry about X happening

GAD – Step 2 – if no improvement to step 1

Provide self-help materials about GAD based on CBT and offer follow up in 4 weeks

(Non-facilitated self-help = using self-help materials without health professional contact. There is evidence that this can be helpful in anxiety, less so in depression)

Consider other low-intensity psychological interventions which are available locally (e.g.guided self-help via PCMHW / psycho-educational groups)

Explain to the patient what these entail

Continue to review and support them

OR

Useful ResourcesSelf-help leaflets• Northumberland, Tyne and Wear guide can be downloaded from

www.ntw.nhs.uk/pic/selfhelp• The Moodjuice guide can be downloaded from

www.moodjuice.scot.nhs.uk/anxiety.asp

Computerised Packages• ‘Worry programme’ only produced for research purposes• http://www.anxietyonline.org.au/. Advice and simple self-help

intervention for free / therapist assisted has a fee.

Self-help GroupsAnxiety UK have a very interactive web-site, run a help-line and

produce lots of materials www.anxietyuk.org.uk

Management of GAD – step 3 (inadequate response to step 2 or marked functional impairment)

Check whether patient would prefer

Psychological intervention

Pharmacological intervention

OR

Step 3 – referral for psychological treatment (CBT or Applied Relaxation)

Be aware of the services providing CBT locally and referral pathways (i.e. IAPT if available)

Explain to the patient what is likely to be involved

i.e. waiting list times, need for assessment prior to treatment being offered

Continue to review and support the patient

Applied Relaxation per se not locally available

Step 3 – pharmacological treatment

Explore the patient’s views about pharmacological treatment

Prescribe an SSRI first - consider offering Sertraline

Do not prescribe a benzodiazepine for GAD except as a short-term measure in crisis

Do not prescribe an antipsychotic for GAD at this stage

Step 3: switching treatments when no response

If no response to CBT, offer an SSRI

If partial response to an SSRI, offer referral for CBT

If no response to an SSRI, offer referral to CBT or switch to an SNRI (Venlafaxine , Duloxetine)

If the patient cannot tolerate an SSRI or SNRI and wants pharmacological treatment, offer Pregabalin

Can consider offering Pregabalin as augmentation of SSRI or SNRI, but no clear evidence for this strategy

Management of Panic Disorder

• Step 1 – recognition and diagnosis• www.nopanic.org.uk

• Step 2 – offering treatment• Most evidence for a CBT approach

• If request medication SSRIs licensed for panic disorder are drug treatment of choice (e.g. Citalopram, Paroxetine, Sertraline)

• Step 3 – review and consideration of alternative treatments• If no improvement with SSRIs consider Imipramine or Clomipramine

• Step 4 – review and referral to specialist mental health services if no response to 2 courses of treatment

Panic Disorder – effect of thoughts

• I am having a heart attack

• I am having a heart attack

• Heart racing• Chest pain• Heart racing• Chest pain

Panic Disorder – effect of avoidance

• Reduced panic attacks• “Avoiding going out

keeps me safe”

• Reduced panic attacks• “Avoiding going out

keeps me safe”

• Escape home to safety• Avoidance of going out• Escape home to safety• Avoidance of going out

Management of Phobias

Agorophobia and Social Phobia are likely to be more disabling than specific phobias

CBT interventions have the most evidence for them in such cases

Medication such as SSRIs may be indicated in some cases, particularly if co-morbidity

People may also benefit from support groups – e.g. via the web www.anxietyuk.org.uk

www.social-anxiety.org.uk

Social Anxiety Disorder – thoughts

• People can see I am anxious

• People will think I am stupid

• People can see I am anxious

• People will think I am stupid

• Self-consciousness• Self-focused

attention (e.g. on blushing, hands or voice, what to say)

• Self-consciousness• Self-focused

attention (e.g. on blushing, hands or voice, what to say)

Social Anxiety Disorder - behaviour

• Reduced embarrassment

• “Only if I keep quiet/ drink will I avoid social exclusion”

• Reduced embarrassment

• “Only if I keep quiet/ drink will I avoid social exclusion”

• Not saying anything in social situations

• Drinking before social occasions

• Not saying anything in social situations

• Drinking before social occasions

Management of Obsessive-Compulsive Disorder Step 1 – general public recognition

Step 2 – GP recognition and assessment(check for depression, anxiety, substance misuse)

Step 3 – primary care team / CAMHS tier 1 and 2 –brief individual CBT (including exposure and response prevention ERP) individual or group CBT OR SSRI

Step 4 – multidisciplinary team / CAMHS 2 and 3 –CBT (including ERP), SSRI, alternative SSRI, Clomipramine, combined treatments

OCD – thoughts

• I am dangerous – could hurt someone

• I must control these thoughts

• I am dangerous – could hurt someone

• I must control these thoughts

• Thoughts of harming vulnerable people

• Thoughts of harming vulnerable people

OCD – behaviour/compulsions

• Reduced immediate worry

• “Checking keeps the house safe”

• Reduced immediate worry

• “Checking keeps the house safe”

• Repeated checking of doors and gas taps

• Repeated checking of doors and gas taps

Helping avoidance and safety behaviours

Avoidance and safety behaviours are central to all phobias, panic disorder and OCD and can also be a feature of the other anxiety disorders

Avoidance and safety behaviours maintain the anxiety disorder by preventing people from learning that what they fear is groundless – they never or rarely actually face the object they fear for long enough to learn there is nothing to fear

Graded exposure is a step-by-step process of facing fears

Management of Post-traumatic Stress Disorder

No grounds for formal debriefing at < 4 weeks

If symptoms mild and present for < 4 weeks, advocate ‘watchful waiting’ and arrange follow-up within a month

If severe PTSD or symptoms at > 1 month, Trauma Focused CBT or Eye-Movement Desensitisation Therapy (EMDR) are the first choice.

If psychological therapy not wanted / not available consider Mirtazapine or Paroxetine. (Suggest that AMT or Phenelzine to be initiated by specialists)

How to refer to Camden iCope

• Email referrals to: cim-tr.icopecamden@nhs.net• Referral form on Camden CCG website http://

www.camdenccg.nhs.uk/gps/iapt• For further information please go to: http://www.icope.nhs.uk/

or telephone 0203 317 6670

• People can self-refer• Via icope website www.icope.nhs.uk• Via telephone self referral line – 020 3317 5600• Via email – cpts@candi.nhs.uk

What would we like local general practices to do?To agree in principle to prescribe sertraline for any of your patients randomised to that arm of the trial

For any of your patients identified by the LI IAPT service as potentially eligible to check their medical suitability to take part and let the research team know

For any of your patients randomised to the sertraline arm to prescribe this according to the clinical guidelines for this.

Benefits of taking part in the studyFor the patients – best practice treatment for GAD whichever trial arm they are in.

For the practice – reimbursement of £ 30 per patient checked for medical suitability to take part

+ £140 per patient treated in the medication arm (likely to only be one or two patients per practice)

Possible Topics for Discussion

Do you actively look for and diagnose / manage anxiety disorders?

If so, what influences you? If not, why not?

What makes it more likely for you to detect anxiety in a patient?

Do you have clinical cases you would like to discuss?