Download Anxiety disorders

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Generalised anxiety disorder
Panic disorder
Phobias
Somatoform disorders
Management of SMI in primary care
Developments in medication
Generalised anxiety disorder
Core symptoms
• Tension
• Worry
• Apprehension
Autonomic arousal symptoms
• Palpitations
• Sweating
• Trembling
• Dry mouth
Generalised anxiety disorder
Symptoms concerning chest and abdomen
• Difficulty breathing
• Feeling of choking
• Chest pain or discomfort
• Nausea or abdominal distress
Symptoms concerning brain and mind
• Dizziness
• Derealization/Depersonalisation
• Fear of losing control, going crazy, or passing out
• Fear of dying
Generalised anxiety disorder
Symptoms of tension
• Muscle tension or aches and pains
• Restlessness
• Feeling on edge
• Dysphagia
General symptoms
• Hot flushes or cold chills
• Numbness/tingling
Other non-specific symptoms
• Easily startled
• Difficulty concentrating
• Irritability
• Difficulty getting to sleep because of worry
Generalised anxiety disorder (DSM5)
• having a number of different worries that are
excessive and out of proportion to a particular
situation
• difficulty controlling worries
• other symptoms
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Restlessness or feeling keyed up or on edge.
Being easily fatigued.
Difficulty concentrating or mind going blank.
Irritability.
Muscle tension.
Sleep disturbance.
NICE: Consider diagnosis of GAD in…
• people presenting with anxiety or significant
worry
• in people who attend primary care frequently
who:
– have a chronic physical health problem or
– do not have a physical health problem but are seeking
reassurance about somatic symptoms (particularly
older people and people from minority ethnic
groups) or
– are repeatedly worrying about a wide range of
different issues.
NICE: Treatment of GAD
• Self help
• Psychological treatment
– CBT
– Applied relaxation
• Medication
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SSRI
SSRI or SNRI
Pregabalin
(Antipsychotics)
(Benzodiazepines)
• (Psychosocial stressors)
Panic attack
• Sudden onset
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Intense apprehension, fear, or terror
Feelings of impending doom
Feelings of unreality
Fear of dying, losing control, or going mad
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Palpitations
Chest pain
Choking sensations
Dizziness
Panic disorder
Persistent panic attacks
with
Fear of future attack
and/or
Maladaptive change in behaviour to avoid
attack
NICE: Treatment of panic disorder
• Self help
• CBT
• Medication
– SSRI (?high doses)
– Imipramine/Clomipramine
(12 week trials)
• (Psychosocial stressors)
Phobic (expected) anxiety
• Specific triggers
• Anticipatory anxiety
• Avoidance
Agoraphobia
Social phobia
Specific phobia
 Treat with CBT
Trigger
Perceived threat
Anxiety
Catastrophic
misinterpretation
Physical/mental
symptoms
Co-morbidities
• Depression
• Alcohol/substance misuse (inc. caffeine&nicotine)
• Somatoform disorders/Hypochondriasis
• Timelines
• Severity
• Treat alcohol/substance misuse first (if possible)
Somatoform disorders (MUPS)
• Focus on therapeutic relationship
– feel understood
– broaden agenda
– make links
– agree further treatment
• Reduce iatrogenic harm
• Stress reduction
• CBT
Primary Care follow up of SMI
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Condition stable
Self-management established
Clear treatment plan
Relapse signature/contingency plan
Rapid access to secondary care
SMI annual review
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How is your mental health?
And your physical health?
Are you facing any major stresses?
Any new side effects from medication?
Are you happy with your treatment?
Offer annual physical health check
Developments with medication:
Antipsychotics
Atypical antipsychotics
• Treatment of bipolar depression
• Prophylaxis of bipolar disorder
• Augmentation of antidepressants
All antipsychotics increase risk of stroke
Atypical vs conventional?
Developments with medication:
Antidepressants
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Moderate to severe/chronic depression only
Bleeding
Teratogenicity
New drugs
– Agomelatine
– Vortioxetine
– Escitalopram
Developments with medication: Mood
Stabilisers
Lithium
• First line for prophylaxis of bipolar disorder
Valproate
• No longer first line in bipolar disorder
• High teratogenic risk
Lamotrigine
• Treatment of bipolar depression