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Anxiety Disorders
Marta Buszewicz
GP in North Camden; Senior Lecturer in Primary Care, UCL
Judy Leibowitz
Consultant 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
o Prevalence of Anxiety Disorders
o Associated morbidity and co-morbidity
o Identification and differential diagnosis
o Management approaches in primary care
Prevalence of Common Mental Disorders
Adult 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 QUESTIONNAIRE
This 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 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
STEP 1: All known and suspected presentations of GAD
Management of GAD – step 1 - Identification
Check for presence of GAD in:
 Patients presenting directly with anxiety or worry
 Patients 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 selfhelp in anxiety disorders (unlike in depression)
GAD – worry about worry
•
Worrying a lot
•
What is wrong with
me that I am worrying
so much
GAD – intolerance of uncertainty
•
Worry about X
happening
•
It will be terrible if X
happens
I must work out how
to stop 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 OR
(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
Useful Resources
Self-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 selfhelp intervention for free / therapist assisted has a fee.
Self-help Groups
Anxiety 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
Pharmacological
intervention
Psychological
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
• Heart racing
• Chest pain
•
I am having a heart
attack
Panic Disorder – effect of avoidance
• Escape home to safety
• Avoidance of going out
•
•
Reduced panic attacks
“Avoiding going out
keeps me safe”
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
•
•
Self-consciousness
Self-focused
attention (e.g. on
blushing, hands or
voice, what to say)
•
People can see I am
anxious
People will think I am
stupid
•
Social Anxiety Disorder - behaviour
•
•
•
•
Not saying anything in
social situations
Drinking before social
occasions
Reduced
embarrassment
“Only if I keep quiet/
drink will I avoid social
exclusion”
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
•
Thoughts of harming
vulnerable people
•
I am dangerous –
could hurt someone
I must control these
thoughts
•
OCD – behaviour/compulsions
•
Repeated checking of
doors and gas taps
•
Reduced immediate
worry
“Checking keeps the
house safe”
•
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: [email protected]
• 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 – [email protected]
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 study
 For 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?