Week 8- Generalised anxiety disorder + Anxiety Overview, Prescribing and Counselling Advice

Question 1

what is GAD?

Answer 1

is where the anxiety doesn’t go away, lasts for at least 6 months, and where the worry is out of proportion to the riskre the anxiety doesn’t go away, lasts for at least 6 months, and where the worry is out of proportion to the risk

Question 2

what is the most common type of anxiety?

Answer 2

GAD

Question 3

what type of symptoms always comes along with GAD?

Answer 3

Depression and managing this is a priority

Question 4

what is he incidence rate for GAD?

Answer 4

5%

Question 5

what are some serious symptoms of GAD?

Answer 5

they become desperate and suicidal

Question 6

whats the difference between panic and GAD ANXIETY?

Answer 6

GAD- anxiety is continous but may fluctuate in intensity

Panic disorder- unrelated to any circumstance

Question 7

when is the onset of GAD?

Answer 7

early adulthood, tends to change with age as the subject of the anxiety evolves with time

Question 8

what are symptoms in GAD?

Answer 8

• hyperventilation
• palpitations
• sweating
• trembling
• dry mouth
• dyspnoea
• chest or abdominal -discomfort
• thinking the worst of an event e.g. any ache or pain becomes a serious illness
• fear of losing control
• poor concentration
• irritability
• disturbed sleep

Question 9

What are some signs on presentation for GAD?

Answer 9

facial straining, restlessness and being close to tears

Question 10

what are some major symptoms when diagnosing GAD?

Answer 10

-Excessive anxiety and worry about a number of events and activities
Difficulty controlling the worry
-MUST HAVE BOTH MAJOR SYMPTOMS, OCCURING MORE DAYS THAN NOT, FOR ATLEAST 6 MONTHS

Question 11

what are some additional symptoms for diagnosing GAD?

Answer 11

• Restlessness or feeling keyed up or on edge
• Being easily fatigued
• Difficulty concentrating or mind going blank
• Irritability
• Muscle tension
• Sleep disturbance
• MUST HAVE ATLEAST 3 OUT OF 6 ADDITIONAL SYMPTOMS

Question 12

what other diseases are related and linked with anxiety and need to be differentiated from?

Answer 12

-Depression
-Schizophrenia
-Dementia
-Substance Misuse
-Physical Illness e.g. –Thyrotoxicosis and
hypoglycaemia (these can have tests done to differentiate.)

Question 13

How many steps are in the stepped care model for patients with GAD?

Answer 13

4

Question 14

what is step 1 of the stepped care model for patients with GAD?

Answer 14

STEP 1- Recognise and suspected presentations of GAD, identification and assessment, educate about GAD and look into treatment

Question 15

what is step 2 of the stepped care model for patients with GAD?

Answer 15

• low-intensity psychological intervention and individual guided self help and educational groups
• diagnosed GAD that hasn’t improved after education and active monitoring in primary care.

Question 16

what is step 3 of the stepped care model for patients with GAD?

Answer 16

• choice of high intensity psychological intervention (CBT/applied relaxed) or drug treatment
• GAD with an inadequate response to step 2 intervention or marked function impairment

Question 17

what is step 4 of the stepped care model for patients with GAD?

Answer 17

highly specialist treatment e.g. drug and/or psychological treatment regimens

Question 18

what are the main drugs for GAD?

Answer 18

First line
-SSRI e.g. sertraline/fluoxetine start at half normal dose then gradually increase. can take 8-12 weeks after treatment dose reached, should be used for at least 12 months, withdrawing is over weeks or months
-Venlafaxine(low dose SSRI and high SNRI)- initially 75mg increased if needed UP TO 225mg, wait 8 before response, treatment for 12 weeks withdraw gradually
-Pregabalin (Schedule 3)- initially 150mg/day in 2/3 dose if needed up to 600mg/day, unclear how long effects take, treatment should be 12months, withdrawal gradually
-

Question 19

why is pregabalin weird for treatment and where it stands in NICE guidelines?

Answer 19

-should try SSRI first if not worked use another then try SNRI then pregabalin unless patient cant tolerate SSRI

Question 20

what is the drug used for GAD short term?

Answer 20

benzodiazepines

Question 21

what is the drug used for GAD combination and treatment resistant cases?

Answer 21

beta-blocker (somatic symptoms)

buspirone

Question 22

what are two other SSRI drugs that can be used for GAD?

Answer 22

Start slowly e.g. Paroxetine 5-10mg/d or Escitalopram 5mg/d for a week or so, then increasing stepwise over several weeks as tolerated. Allow 8/52
for response.

Question 23

why is escitalopram superior over paroxetine?

Answer 23

relapse prevention has been shown

Question 24

what are some short term, adjuncts and second line drugs for GAD?

Answer 24

• Benzodiazepines short-term
• Beta-blockers low dose short-term
• Antihistamines low dose short-term
• Antipsychotics low dose short-term
• Venlafaxine/ Mirtazapine
• Pregabalin
• Buspirone

Question 25

what are the different types of anxiety?

Answer 25

``` • Generalised anxiety disorder (GAD) • Obsessive compulsive disorder (OCD) • Post-traumatic stress disorder (PTSD) • Panic disorder • Phobic anxiety disorders - Specific phobia - Social phobia (social anxiety disorder; SAD) -Agoraphobia ```

Question 26

what is the prevalence for anxiety?

Answer 26

ranged between 0.9-28.3% when looked at over 47 countries

Question 27

what is the aetiology of anxiety disorders?

Answer 27

``` • Genetic factors - some individuals are resilient and others are vulnerable • Environmental (childhood trauma) • Psychosocial factors • Relationship problems • Unemployment • Social isolation • Co-morbidity (depression +substance misuse) ```

Question 28

what are some clinical features of anxiety?

Answer 28

``` Fearful Anticipation Irritability Worrying thoughts Dry Mouth Constriction of Chest Palpitations Tremor Headache Hyperventilation Breathlessness Insomnia ```

Question 29

what are the main treatments for anxiety disorders?

Answer 29

-SSRI’s -first line for all types -Benzodiazepines (BDZs, e.g. Lorazepam, Diazepam, Oxazepam, Clobazam ) -Antipsychotics (e.g. Risperidone, Olanzapine, Quetiapine, Pericyazine) -Venlafaxine and Duloxetine -Tricyclic Antidepressants (Clomipramine, Imipramine) -Pregabalin (controlled drug)

Question 30

what are the other treatment used for anxiety disorder?

Answer 30

-Mirtazapine (unlicensed) if they have depression/sleep issues also used for that) -Buspirone ( not commonly used) -Beta-Blockers (e.g. Propranolol) -Antihistamines (e.g. Promethazine and Hydroxyzine)

Question 31

what is the number one treatment for anxiety?

Answer 31

-SSRI (Escitalopram and Paroxetine are licensed; other SSRIs likely to have similar efficacy and are widely used)

Question 32

what are some counselling point for SSRIs?

Answer 32

- reposnse is not immediate can take 12wks - initial worsening of symptoms is common with SSRI and venlafaxine so start low dose and increase when adverse effects subside - long term treatment may occur - stopping suddenly can give discontinuation symptoms e.g. restlessness, trouble sleeping, sweating. - patients under 30yrs offered SSRI or SNRI can experience increased risk of suicidal thinking and self harm

Question 33

how do you reduce the frequency of increased anxiety when starting ssri ESPEICALLY AT ANTIDEPRESSANT DOSE?

Answer 33

-start with low dose • Escitalopram 5mg/d (can use the liquid or halved tablets) • Fluoxetine 5-10mg/d (can use the liquid or orodispersibletablets) • Paroxetine 5-10mg/d (can use the liquid or halved tablets) • Sertraline 25mg/d (use half 50mg tablet) • Citalopram 5-10mg/d (can use the liquid or halved tablets) -then increase dose every 2 weeks -Short-term benzodiazepines can help this initial anxiety and if only used for a few weeks carry little if any dependence liability

Question 34

what is the example for why withdrawal/coming off from anxiety treatment is important?

Answer 34

-must be done slowly -Diazepam has a long half-life and so the effects of a dose reduction have not become fully apparent until about 4 weeks after that dose. Leave plenty of time between dose reductions -With Diazepam, the last few mg can be the hardest to stop, with psychological dependence a component.

Question 35

what are some non-pharmacological interventions of anxiety?

Answer 35

-Psychotherapeutic approaches: • Counselling • Cognitive based therapy (CBT) • Anxiety management ``` Self-help • Dietary - caffeine avoidance or at least reduction • Relaxation techniques • Self-help groups/ books • Lifestyle changes ```