Anxiety Disorders

1. Anxiety Disorders Marta Buszewicz GP in North Camden; Senior Lecturer in Primary Care, UCL Judy Leibowitz Consultant ClinicalPsychologist Clinical Lead, Camden PsychologicalTherapiesService

2. 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?

3. Topics to be covered • Prevalence of Anxiety Disorders • Associated morbidity and co-morbidity • Identification and differential diagnosis • Management approaches in primary care

4. Prevalence of Common Mental DisordersAdult Psychiatric Morbidity Survey in England 2007 Has there been an undue emphasis on detecting depressive disorders?

5. 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

6. 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

7. 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.

8. 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).

9. 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.

10. 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

11. 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

12. 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

13. 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)

14. 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

15. 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.

16. 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

17. 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%)

18. 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.

19. Management of Anxiety Disorders

20. STEP 4: Complex treatment–refractory GAD and very marked functional impairment such as self-neglect or high risk of self-harm , STEP 1: All known and suspected presentations of GAD Management of GAD – the stepped care model 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

21. 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?

22. 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

23. 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)

24. GAD – worry about worry • Worrying a lot • What is wrong with me that I am worrying so much

25. GAD – intolerance of uncertainty • Worry about X happening • It will be terrible if X happens • I must work out how to stop X happening

26. 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

27. 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 self-help 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

28. Management of GAD – step 3 (inadequate response to step 2 or marked functional impairment) Check whether patient would prefer Psychological intervention Pharmacological intervention OR

29. 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

30. 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

31. 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

32. 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

33. Panic Disorder – effect of thoughts • Heart racing • Chest pain • I am having a heart attack

34. Panic Disorder – effect of avoidance • Escape home to safety • Avoidance of going out • Reduced panic attacks • “Avoiding going out keeps me safe”

35. 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

36. 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

37. 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”

38. Management of Obsessive-Compulsive Disorder Step 1 – general public recognitionStep 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

39. OCD – thoughts • Thoughts of harming vulnerable people • I am dangerous – could hurt someone • I must control these thoughts

40. OCD – behaviour/compulsions • Repeated checking of doors and gas taps • Reduced immediate worry • “Checking keeps the house safe”

41. 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

42. 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)

43. 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

45. 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.

46. 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)

47. 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?