GAD Flashcards
ICD 11 summary of GAD
Generalized and persistent anxiety
Non-specific/ “free-floating”
Possible physical Sx of anxiety (chest pain, palpitations, derealization etc.)
Impairment of functioning
Gad features
Struggling to sleep
Sympathetic overactivity - adrenaline, HR etc
How diagnose GAD?
GAD 7
What is a phobia?
irrational fear or avoidance of an object, place or situation that poses litte to no threat of danger
When is anxiety after a traumatic event a disorder?
Recurring nightmares, flashbacks, emotional numbing related to a traumatic event that occured several months or years before
What to do with all known and suspected GAD
Identification, assessment, education and active monitoring
What medications are contraindicated in treatment of GAD?
Benzodiazapines
Antipsychotics
What to do in GAD if diagnosed and failure to improve after 1 step?
Self help resources
Guided self help
Psychoeducational groups (CBT elements)
Marked functional impairment + failure to improve after step 2 what to do in GAD?
SSRI (sertraline)
High intensity psychological interventions
CBT or applied relaxation
When refer to secondary care with GAD?
If step 2 doesnt work
Self harm
Self neglect
Significatn comorbidity - substance misuse, personality disorder or complex physical health problem
Suicide - refer urgently (same day) to crisis resolution and home treatment team
When consider the diagnosis of GAD?
Chronic physicla health problem
No physical health problme but seeking reassurance about somatic smypotms, esp in old people and minority ethnic groups
Repeatedly worrying about wide range of different issues
What to inform a person with GAD about?
Info to the persons understnading of the nature of GAD and range of treatments available
Infor about family and carer support groups and voluntary organisations
Local and national self help organisations and suppory groupd
Step 1 for GAD management
Identification and assessment
Education adn treatment options, active monitoring
Offered for all known and suspected presentations of GAD
Step 2 for GAD management
Low intensity psychological interventions
Individual non facilitated self help or guided self help and psychoeducational groups
Step 3 GAD management who for
Inadequate response to step 2
Marked functional impariemtn
Step 2 for GAD management who for
For Diagnosed GAD not improved after education and active monitoring in primary care
Step 3 GAD management
Choice of a high intensity psychological intervention (CBT/applied relaxation) or drug treatment
Step 4 GAD treatment who for
Complex treatment-refractory GAD and very marked functional impairment eg self neglect or risk of self harm
Step 4 GAD management
Highly specialist treatment eg complex drug and/or psychological treatment regimens
INput from multi agency teams
Crisis services
Day hospitals or inpatient care
What is individualised non-facilitated self help?
this is a self-administered intervention intended to
treat GAD involving written or electronic self-help materials (usually a book or workbook).
It is similar to individual guided self-help but usually with minimal therapist contact, for
example an occasional short telephone call of no more than 5 minutes.
What to ask about when assessing for GAD?
- any comorbid depressive disorder or other anxiety disorder
- any comorbid substance misuse
- any comorbid medical condition
- a history of mental health disorders
- past experience of, and response to, treatments.
IF people have a comorbid depressive or other anxiety disorder with GAD what do you treat first?
The primary disorder - one thats more severe and more likely that treatment will improve overall functioning
What to consider when people misuse substances with GAD?
Substance misuse may be a complication of GAD
Non harmful substnace use should not be a contraindication to the treatment of GAD
Cocaine and SSRIs contraindicated
How long should individaul non facilitated self help for people with GAD last for?
6 weeks
What is the difference between individual guided self help and non facilitated?
Non facilitated - 5 min telephone call occasionally iwth therapist
Guided - Supported by a trained practitioner who facilitates the programme reviews progress and outcome
How often do therapists contact people undergoing guided self help for GAD?
5-7 weekly or fortnightly face to face or telephone sessions of 20-30 mins
What do psychoeducational groups consist of and how long do yhey go on for?
1:12, therapist to participants
6 weeks of 2 hour sessions per week
How loong does CBT or applied relaxation for GAD often last?
12-15 weekly sessions of 1 hour each
Why is sertraline offered first line?
Its the most cost effective drug and the most effective for GAD and depression
What to consider if offering an alternative SSRI or SNRI than sertraline? what problems with paroxetine, venlafaxine
Tendency for withdrawal syndrome - paroxetine, venlafaxine
Side effect profile and likelihood of toxicity in overdose - venlafaxine
Prior individual history or expereince with drugs
What antidepressants in GAD can cause withdrawal syndrome?
pAROXETINE, venlafaxine
What to offer if person with GAD cant tolerate SSRIs or SNRIs?
Pregabalin
What class substance is pregabalin?
C
What situation do you offer a benzodiazapine in?
Short term measure during crisis
What to talk about with the patient when offering medication for GAD?
the likely benefits of different treatments
* the different propensities of each drug for side effects, withdrawal syndromes
and drug interactions (consult the interactions section of the BNF)
* the risk of activation with SSRIs and SNRIs, with symptoms such as increased
anxiety, agitation and problems sleeping
* the gradual development, over 1 week or more, of the full anxiolytic effect
* the importance of taking medication as prescribed and the need to continue
treatment after remission to avoid relapse.
What physical side effect can SSRIs cause that means you should take care in older people who have polypharmacy?
Increased risk of bleeding
Polypharmacy - drugs that damage GI mucosa or interfere with clotting eg NSAIDs or aspirin
What physical side effect can SSRIs cause that means you should take care in older people who have polypharmacy? What do to combat?
Increased risk of bleeding
Polypharmacy - drugs that damage GI mucosa or interfere with clotting eg NSAIDs or aspirin
Presribe gastroprotective drug
What to warn people under 30 about when offered an SSRI or SNRI?
Warn them that these drugs are ass with increased risk of suicidal thinking and self harm in minority of people under 30
See them within 1 week of first prescribing
Monitor ris of suicidal thinking and self harm for first month
What strategies implement if side effects soon after starting SSRIs?
Monitoring persons symptoms cosely - if mild/acceptable
Reducing dose of drig
Stopping drug and offering alternative or high intensity psychological intervention
How often review drug after first prescribing SSRIs/SNRIs?
every 2-4 weeks during firt 3 months treatment
Every 3 months after
How long advise taking SSRIs if drug is effective?
At least 1 year - risk of relapse is high
Why take SSRIs for around a year after prescribed for GAD?
Risk of relapse is high
When refer someone to step 4 management of GAD?
Severe anxiety with marked functional impairemnt in conjunction with:
Risk of self harm or suicide ir
Significant comorbidity, eg substance misuse, personality disorder or complex physical health problem
Self neglect or
Inadequate response to first 3 steps of intervemtions
What assess when someone with GAD is referred to step 4?
Duration and severity of symptoms, functional impairment, comorbidites, risk to self and self neglect
Formal review of current and past treatments incl adherence to previously prescribed drug treamtents and fidelity of prior psychological interventions and impact on symptoms and functional impariemtnet
Home environemtn Support in the community
Relationshuos with and impact on families and carers
What do at start of stpe 4 treatment plan?
Creat comprehensive care plan in collab with person with GAD that addresses needs, risks functional impairment and has clear treatment plan
What to be aware of if offering cobinations or augmentations of antidepressants?
The evidence for effectiveness of combination treatemnts is lacking
Side effects and interactions are more likely when combining and augmenting antidepressants
