QuestionSBA
QuestionChoice
The patient meets the diagnostic criteria for generalised anxiety disorder. CBT has been shown to be highly effective and should be trialled in all patients before moving on to pharmacotherapy. Other psychological interventions may include counselling, support groups and relaxation training
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a
Refer for cognitive behavioural therapy (CBT)
QuestionChoice
This is a selective serotonin reuptake inhibitor (SSRI), the class of drugs that would be recommended as first-line in the pharmacological treatment of generalised anxiety disorder. However, before escalating to pharmacotherapy, it would be more appropriate to try psychological interventions first
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c
Start paroxetine
QuestionChoice
This would only be appropriate to use in an acute anxiety attack. It is not recommended for long term use in patients with anxiety as it may result in benzodiazepine dependence
32169
b
A short course of lorazepam
QuestionChoice
This would provide pain relief for her tension headache but would not be addressing the root cause of her problem, which is generalised anxiety disorder
32171
d
Start paracetamol and ibuprofen as required
QuestionChoice
This is a specialised form of cognitive behavioural therapy shown to be most effective in treating obsessive compulsive disorder. This would involve exposing patients to situations that provoke their obsessions whilst helping them overcome their compulsive responses. It would not be relevant in treating generalised anxiety disorder in this case
32172
e
Refer for exposure and response prevention therapy
QuestionComment
i know its not an option, but surely check TFTs etc?
25225
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Syndrome Biopsy
QuestionComment
she lost her job cos of her symptoms - this would be enough to start meds
28841
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Nicu Prone
QuestionComment
Surely this stem can't be enough to diagnose her with anxiety?? What if she has idiopathic tension headaches and then suffered with the poor sleep and concentration as a consequence?
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Acute Myopathy
QuestionComment
Im losing 50/50s all over the pitch
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Gabriel Magalhaes
Concept
Chapter
# Summary 

Anxiety disorders constitute a range of psychiatric conditions, including generalized anxiety disorder (GAD), specific phobias, panic disorder, obsessive-compulsive disorder (OCD), and post-traumatic stress disorder (PTSD). These disorders are typified by excessive fear, worry, and physical symptoms such as insomnia, restlessness, and gastrointestinal symptoms. Key diagnostic steps include history-taking, clinical examination, and the utilization of rating scales like the Beck Anxiety Inventory and the Hospital Anxiety and Depression Scale. Management strategies encompass counseling, cognitive behavioral therapy (CBT), and pharmacotherapy with SSRIs, SNRIs, and benzodiazepines. 


# Generalised Anxiety Disorder (GAD)

Generalized Anxiety Disorder (GAD) constitutes a chronic and pervasive condition characterized by excessive, uncontrollable worry extending across various life domains. GAD encompasses physical symptoms such as restlessness, muscle tension, and fatigue, accompanied by cognitive manifestations like difficulty concentrating and disrupted sleep patterns. Prevalent in middle age, affecting 3-5% of the population, GAD's aetiology involves a complex interplay of biological, psychological, and environmental factors. D. Cognitive-Behavioral Therapy and pharmacotherapy, particularly with SSRIs, form integral components of its multifaceted management.


## Definition

**ICD-11 Criteria:**

- Excessive worry and apprehension.
- Difficulty controlling worry.
- Associated symptoms: Restlessness, muscle tension, fatigue.
- Duration: At least 6 months.

**DSM-V Criteria:**

- Excessive anxiety and worry about various domains.
- Difficulty controlling worry.
- Associated symptoms: Restlessness, muscle tension, fatigue, irritability.
- Duration: At least 6 months.


## Epidemiology 

* Predominantly affects females.
* Affects up to 10% of the general population.
* Commonly comorbid with depression, substance misuse, and personality disorder.
* An onset beyond the age of 35-40 years is more likely indicative of depressive disorder or organic disease.
* Associated risk factors include lower socioeconomic status, unemployment, divorce, renting rather than owning a home, lack of educational qualifications, and urban living.

## Clinical Features

- Psychological: Fears, worries, poor concentration, irritability, depersonalization, derealization, insomnia, night terrors
- Motor symptoms: Restlessness, fidgeting, a feeling of being on edge
- Neuromuscular: Tremor, tension headache, muscle ache, dizziness, tinnitus
- Gastrointestinal: Dry mouth, dysphagia, nausea, indigestion, "butterflies" in the stomach, flatulence, frequent or loose bowel movements
- Cardiovascular: Chest discomfort, palpitations
- Respiratory: Dyspnea, tight/constricted chest
- Genitourinary: Urinary frequency, erectile dysfunction, amenorrhea


## Differential Diagnosis 

- Hyperthyroidism - look for goiter, tremor, tachycardia, weight loss, arrhythmia, exophthalmos
- Cardiac causes - palpitations/arrythmias can either be part of GAD or seperate diagnoses in and of themselves
- Medication-induced anxiety - e.g. overuse of SABA inhalers/nebulisers such as salbutamol
- Substance misuse - intoxication – amphetamines; withdrawal – benzodiazepines, alcohol
- Excessive caffeine intake
- Depression: anxiety is a common feature of depression and vice versa. Identifying which condition appeared first and which is currently more prominent provides useful diagnostic cues. If both conditions are present, a diagnosis of mixed anxiety and depressive disorder is made.
- Anxious (avoidant) personality disorder: the patient describes themselves as an anxious person without a recent significant increase in anxiety levels. (Note, this disorder can predispose the individual to anxiety disorders.)
- Early-stage dementia
- Early-stage schizophrenia


## Management 

- The majority of patients can be treated in a primary care setting
- Advice and reassurance can help prevent early or mild problems from worsening (psycho-education)
- Counselling alone may be highly effective – it addresses patients' worries and provides reassurance about somatic symptoms
- First line - low-intensity psychological interventions:
	- Individual non-facilitated self-help - written/electronic materials that the patient can work through over a period of around 6 weeks, with occasional but minimal therapist contact.
	- Individual guided self-help - written/electronic materials that a patient works through with 5–7 weekly or fortnightly face-to-face or telephone sessions (30 minutes each) with a trained practitioner.
	- Psychoeducational groups - interactive CBT-guided group sessions consisting of 6 weekly 2-hour sessions
- Second line: for people with GAD and marked functional impairment, or with GAD that has not improved following the above:
	- High-intensity psychological intervention such as CBT or applied relaxation
	- Medical management - SSRIs are preferred i.e. sertraline, and if one does not work an alternative can be trialled e.g. escitalopram, paroxetine, or an SNRI (venlafaxine or duloxetine) can be used
		- In the first week of treatment there may be increased anxiety, agitation, and sleeping problems, and in people aged under 30 years that in a minority of people aged under 30 years, SSRIs and SNRIs are associated with an increased risk of suicidal thinking and self-harm. 
		- **Patients under 30 should therefore have a follow-up appointment within 1 week to monitor progress.**
		- Symptomatic management with propranolol for palpitations can also be used.

# Panic Disorder

Panic Disorder, a prevalent anxiety disorder, is characterized by the occurrence of recurrent, unexpected panic attacks, each marked by intense fear or discomfort. These episodes prompt persistent worry about future attacks and may lead to avoidance behaviors, altering one's lifestyle to prevent potential episodes. Onset typically arises in adolescence or early adulthood, and the disorder exhibits a lifetime prevalence of 2-5%. Biological, psychological, and environmental factors contribute to its development. Differential diagnosis involves distinguishing panic disorder from other anxiety and medical conditions with overlapping symptoms. Cognitive-Behavioral Therapy, pharmacotherapy (especially with SSRIs), and lifestyle modifications are essential components of its comprehensive management.

## Definition

**ICD-11 Criteria:**

- Recurrent, unexpected panic attacks.
- At least one attack followed by a month of persistent concern.
- Avoidance behaviors related to attacks.

**DSM-V Criteria:**

- Recurrent, unexpected panic attacks.
- Persistent concern about future attacks.
- Behavioral changes: Avoidance of situations associated with attacks.

## Epidemiology 

- Prevalence of 1-2% in the general population.
- 2-3 times more prevalent in females.
- Bimodal incidence, peaking at ages 20 and 50.
- Agoraphobia is concurrent in 30-50% of cases.
- Increased risk of attempted suicide with comorbid depression, alcohol misuse, or substance misuse.

## Clinical Features

- Difficulties in breathing.
- Chest discomfort.
- Palpitations.
- Hyperventilation, leading to tingling or numbness in the hands, feet, or around the mouth due to hypocalcemia resulting from increased blood pH and calcium binding to albumin. If extreme, carpopedal spasm (curling of fingers and toes) can occur.
- Shaking, sweating, dizziness.
- Depersonalization/derealization.
- May result in fear of situations where panic attacks occur or lead to agoraphobia.
- Development of a conditioned fear-of-fear pattern.

## Differential Diagnosis 

- Other anxiety disorders, such as Generalized Anxiety Disorder (GAD) and agoraphobia.
- Depression (takes precedence if it predates panic disorder or fulfills diagnostic criteria).
- Alcohol or drug withdrawal.
- Organic causes like cardiovascular or respiratory diseases, hypoglycemia, hyperthyroidism. Rarely, pheochromocytoma.


## Management 

- Cognitive Behavioral Therapy (CBT) effective in 80-100% of cases and is the first-line treatment.
	- Initial education about the nature of panic attacks and fear-of-fear cycles.
	- Cognitive restructuring and detection of logical flaws.
	- Interoceptive exposure techniques such as controlled exposure to somatic symptoms (breathing in CO2 and physical exercise).
	- Treatment of secondary agoraphobic avoidance through situational exposure and anxiety management techniques.
- Selective Serotonin Reuptake Inhibitors (SSRIs) are the first-line drug treatment (second-line to CBT).
- Clomipramine, a tricyclic with a similar action on serotonin, is also effective, and propranolol can be used as needed for symptomatic management.

# Phobias

Phobias, encompassing specific phobia, social anxiety disorder (SAD), and agoraphobia, represent a cluster of anxiety disorders characterized by excessive and irrational fears. Specific phobia involves intense anxiety triggered by a specific object or situation, leading to avoidance behavior. Social anxiety disorder revolves around a marked fear of social scrutiny and performance situations, impeding daily functioning. Agoraphobia entails anxiety about situations where escape might be difficult or help unavailable. These conditions, distinct in their triggering stimuli, share common features of avoidance and significant impairment in daily life. Cognitive-Behavioral Therapy, exposure therapy, and pharmacotherapy, in alignment with NICE guidelines, form the cornerstone of their comprehensive management.


## Definition

 **ICD-11 criteria:** 
- Restricted to highly specific situations such as proximity to particular animals, heights, thunder, flying, exposure to blood, etc.


## Clinical Features

General features of phobias include:

- Usually apparent in early adulthood.
- Leads to avoidance behavior.
- Phobias of blood and bodily injury can result in bradycardia and hypotension upon exposure.
- Severity is dependent on the effect on quality of life (e.g., pilots afraid of flying).
- Always rule out comorbid depression.



## Specific Phobias

### Agoraphobia

- **ICD-11 criteria:** Fear of open spaces and associated factors like the presence of crowds or the perceived difficulty of immediate easy escape to a safe place, usually home (may occur with or without panic disorder).
- Typically begins in 20s or mid-thirties.
- Onset may be gradual or precipitated by a sudden panic attack.
- Comorbid depression is common (beware of reliance on drugs and alcohol for coping).


### Social Phobia/Social Anxiety Disorder (SAD)

- Most common anxiety disorder.
- **ICD-11 criteria:** Fear of scrutiny by others in relatively small groups (as opposed to crowds), resulting in the avoidance of social situations.
- Relatively small groups generally consist of around 5-6 people (usually 1-2 is tolerable).
- May be specific (public speaking) or generalized (any social setting).
- Physical symptoms include blushing, fear of vomiting.
- Symptoms include blushing (characteristic), palpitations, trembling, sweating.
- Can be precipitated by stressful or humiliating experiences, parental death, separation, chronic stress.
- Genetic predisposition is possible.
- May lead to alcohol or drug abuse (perpetuating the problem).
- Mental state examination: may appear relaxed as the phobic object or situation is not present.

## Management 

- CBT is first-line management for all phobias:
	- Exposure techniques are the most widely used, aiming for systematic desensitization (using a graded hierarchy approach, for example).
	- Flooding (exposing someone with a fear of heights to a tower),
	- Modelling (individual observes therapist interacting with phobic stimulus).
- If ineffective/severe functional impairment, SSRIs are first-line medical management. Propranolol can be used if somatic symptoms predominate.


# NICE guidelines 

[NICE CKS - GAD](https://cks.nice.org.uk/topics/generalized-anxiety-disorder/)

# References 

3. The British Psychological Society. (2011). Good Practice Guidelines on the use of psychological formulation.
4. Royal College of Psychiatrists. (2011). Anxiety, panic and phobias.
5. Mental Health Foundation. (2021). How to manage and reduce stress.
6.  UK Psychological Trauma Society (UKPTS). (2012). Post-traumatic stress disorder.

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Differentials of acute stress reaction
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Cognitive behavioural therapy is an effective first-line treatment for generalised anxiety disorder, improving symptoms and functioning before considering medication.
A 50-year-old woman presents to her General Practitioner with a two-week history of intermittent tension headache. She describes having poor sleep and concentration for the past year and has had to leave her job as a result. She also has frequent episodes of palpitations accompanied by shortness of breath at rest.

Physical examination reveals no significant abnormalities. An electrocardiogram shows a normal sinus rhythm.

Which is the next best course of management?
a