GAD

Question 1

You have just seen a 33 year old woman who often attends with worries over her own health and the safety of her husband and children. She finds the worrying excessive and not easy to control. Describe your approach to discussing the likely diagnosis and management with the patient.

2020 stem #1: 25yo female patient presents with headache, pins and needles and dizziness. She frequently comes to the ED. She also frequently accompanies her mum to the ED, who migrated to Australia and has a history of trauma in her home country + chronic illness. Patient has been extensively investigated with endoscopy and everything was normal. CT brain normal. She is currently on Losec and salbutamol. She has no drug and alcohol history and is a university student. Determine and discuss with the patient their diagnosis. Counsel the patient on how to address her problems. –> Somatisation? Conversion Disorder?

2020 stem #2: 12 year old with mother coming in for acute tonsillitis, but concerned about the girl’s anxiety with school, work, friends, etc. Psychiatrist thinks it’s generalised anxiety disorder. PDx and DDx? How would you explain generalised anxiety disorder to the parent? Outline management of GAD to the mother.

Answer 1

Impression
Stem 1: Think this represents a generalised anxiety disorder given the overwhelming worry about things in life. Would want to screen for elements of other anxiety disorders (panic attacks, OCD, etc). Other affective differentials to consider include depression (+/- psychotic/ melancholic), dysthymia, bipolar disorder. Non-affective Ddx to consider include…

Goals

• prioritise patient safety in initial management (consider inpatient vs outpatient mx, utilisation of MHA.
• Undertake complete psych assessment including Hx, MSE, and other investigations for organic causes.

Question 2

GAD - History

Answer 2

History
- PC: focus on sx of anxiety - WATCHERS (for GAD)
W - worry
A - Anxiety
T - Tension in muscles
C - Concentration reduced
H - Hyperarousal (irritability)
E - Energy loss
R - Restlessness
S - Sleep impaired
- Screen for other features of anxiety: panic attacks, obsessions + compulsions, PTSD, underlying cognitions
- Screen for depressive, psychotic, manic sx, comorbid substance use disorder
- risk assessment
- Rest of psych history

Question 3

GAD - Examination

Answer 3

Examination
Conduct a full Mental State Exam:
A -

Consider variety of scoring surveys for;

• depression (K10)
• anxiety (GAD-7)
• severity assessment (Hospital anxiety and depression scale - HADS)

Question 4

GAD - Investigations

Answer 4

Investigations

• If first psychiatric presentation, then want to rule out organic causes of the presentation:
• Bedside: anthropometric, vitals, ECG, urine too
• Bloods: FBC, UEC, LFT, TFT, B12/Folate, lipid panel, autoimmune panel (if suspicious
• Imaging: ?MRI B (if deemed appropriate)

Question 5

GAD - Management

Answer 5

Management
Safety/location
- consider outpatient vs inpatient mx under MHA, based on findings from risk assessment

Psychological therapy

• CBT: 12 - 20 session
• de-arousal, mindfulness/meditation

Biological
Non-pharm
- relaxation strategies
- avoid caffeine, alcohol

Pharmacological (second line after psychological therapy)

• 1: SSRIs (escitalopram, citalopram)
• 2: SNRI (duloxetine, desvenlafaxine)
• 3: TCA