Generalised_Anxiety_Disorder_and_Panic_Disorder_Flashcards

Question 1

What is the central feature of anxiety disorders according to NICE?

Answer 1

The central feature of anxiety disorders is an ‘excessive worry about a number of different events associated with heightened tension.’

Question 2

What should always be considered when diagnosing a psychiatric disorder like anxiety?

Answer 2

When diagnosing a psychiatric disorder like anxiety, it is important to look for a potential physical cause.

Question 3

What are some important alternative causes of anxiety disorders?

Answer 3

Important alternative causes of anxiety disorders include hyperthyroidism, cardiac disease, and medication-induced anxiety.

Question 4

Which medications may trigger anxiety?

Answer 4

Medications that may trigger anxiety include salbutamol, theophylline, corticosteroids, antidepressants, and caffeine.

Question 5

What is the stepwise approach suggested by NICE for the management of generalised anxiety disorder (GAD)?

Answer 5

NICE suggests a stepwise approach for the management of generalised anxiety disorder (GAD): education about GAD + active monitoring, low-intensity psychological interventions, high-intensity psychological interventions or drug treatment, and highly specialist input.

Question 6

What is the first step in the management of GAD according to NICE?

Answer 6

The first step in the management of GAD according to NICE is education about GAD and active monitoring.

Question 7

What are low-intensity psychological interventions for GAD?

Answer 7

Low-intensity psychological interventions for GAD include individual non-facilitated self-help, individual guided self-help, and psychoeducational groups.

Question 8

What are high-intensity psychological interventions for GAD?

Answer 8

High-intensity psychological interventions for GAD include cognitive behavioural therapy or applied relaxation.

Question 9

What is the first-line drug treatment for GAD recommended by NICE?

Answer 9

The first-line drug treatment for GAD recommended by NICE is sertraline.

Question 10

What should be done if sertraline is ineffective for GAD?

Answer 10

If sertraline is ineffective for GAD, an alternative SSRI or a serotonin-noradrenaline reuptake inhibitor (SNRI) should be offered.

Question 11

What are some examples of serotonin-noradrenaline reuptake inhibitors (SNRIs)?

Answer 11

Examples of serotonin-noradrenaline reuptake inhibitors (SNRIs) include duloxetine and venlafaxine.

Question 12

What should be considered if a person cannot tolerate SSRIs or SNRIs for GAD?

Answer 12

If a person cannot tolerate SSRIs or SNRIs for GAD, pregabalin should be considered.

Question 13

What specific advice does NICE give for patients under the age of 30 years regarding drug treatment for GAD?

Answer 13

NICE recommends warning patients under the age of 30 years of the increased risk of suicidal thinking and self-harm when starting drug treatment for GAD. Weekly follow-up is recommended for the first month.

Question 14

What is the stepwise approach for the management of panic disorder?

Answer 14

The stepwise approach for the management of panic disorder includes recognition and diagnosis, treatment in primary care, review and consideration of alternative treatments, review and referral to specialist mental health services, and care in specialist mental health services.

Question 15

What is the first step in the management of panic disorder according to NICE?

Answer 15

The first step in the management of panic disorder according to NICE is recognition and diagnosis.

Question 16

What are the treatment options in primary care for panic disorder?

Answer 16

The treatment options in primary care for panic disorder include cognitive behavioural therapy or drug treatment.

Question 17

What is the first-line drug treatment for panic disorder?

Answer 17

The first-line drug treatment for panic disorder is SSRIs.

Question 18

What should be offered if SSRIs are contraindicated or there is no response after 12 weeks for panic disorder?

Answer 18

If SSRIs are contraindicated or there is no response after 12 weeks for panic disorder, imipramine or clomipramine should be offered.

Question 19

summarise GAD and panic disorder

Answer 19

Generalised anxiety disorder and panic disorder

Anxiety is a common disorder that can present in multiple ways. NICE define the central feature as an ‘excessive worry about a number of different events associated with heightened tension.’

Always look for a potential physical cause when considering a psychiatric diagnosis. In anxiety disorders, important alternative causes include hyperthyroidism, cardiac disease and medication-induced anxiety (NICE). Medications that may trigger anxiety include salbutamol, theophylline, corticosteroids, antidepressants and caffeine

Management of generalised anxiety disorder (GAD)

NICE suggest a step-wise approach:
step 1: education about GAD + active monitoring
step 2: low-intensity psychological interventions (individual non-facilitated self-help or individual guided self-help or psychoeducational groups)
step 3: high-intensity psychological interventions (cognitive behavioural therapy or applied relaxation) or drug treatment. See drug treatment below for more information
step 4: highly specialist input e.g. Multi agency teams

Drug treatment
NICE suggest sertraline should be considered the first-line SSRI
if sertraline is ineffective, offer an alternative SSRI or a serotonin-noradrenaline reuptake inhibitor (SNRI)
examples of SNRIs include duloxetine and venlafaxine
If the person cannot tolerate SSRIs or SNRIs, consider offering pregabalin
interestingly for patients under the age of 30 years NICE recommend you warn patients of the increased risk of suicidal thinking and self-harm. Weekly follow-up is recommended for the first month

Management of panic disorder

Again a stepwise approach:
step 1: recognition and diagnosis
step 2: treatment in primary care - see below
step 3: review and consideration of alternative treatments
step 4: review and referral to specialist mental health services
step 5: care in specialist mental health services

Treatment in primary care
NICE recommend either cognitive behavioural therapy or drug treatment
SSRIs are first-line. If contraindicated or no response after 12 weeks then imipramine or clomipramine should be offered

Question 20

Following the 2011 NICE guidelines on the management of panic disorder, what is the most appropriate first-line drug treatment?

Propranolol
Selective serotonin reuptake inhibitor
Benzodiazepine
Imipramine
Amitriptyline

Answer 20

The correct answer is Selective serotonin reuptake inhibitor (SSRI). According to the 2011 NICE guidelines, SSRIs are recommended as first-line pharmacological treatment for panic disorder. They have been shown to be effective in reducing the frequency and severity of panic attacks and also in improving patient’s overall quality of life. SSRIs work by increasing the levels of serotonin in the brain which helps to reduce anxiety and improve mood.

The option Propranolol is incorrect. While propranolol, a beta-blocker, can be used for symptomatic relief of physical symptoms of anxiety such as palpitations or tremors, it is not recommended as a first-line treatment for panic disorder according to NICE guidelines. It doesn’t address the underlying cause of panic attacks and has not been proven to be effective in preventing future episodes.

Benzodiazepines are also not considered a first-line treatment for panic disorder according to NICE guidelines. Although they provide rapid relief from acute symptoms of anxiety, their long-term use is associated with significant drawbacks including dependency, withdrawal symptoms and cognitive impairment. Therefore, they are typically reserved for short-term or emergency use only.

The tricyclic antidepressant Imipramine was once considered a first-line treatment for panic disorder before the advent of SSRIs. However, due to its side effect profile which includes anticholinergic effects like dry mouth and constipation, orthostatic hypotension, weight gain and potential cardiac toxicity, it is now generally considered second-line therapy after SSRIs or if SSRI treatment fails.

Similarly, Amitriptyline, another tricyclic antidepressant, has fallen out of favour due to its side effect profile despite its efficacy in treating panic disorder. Moreover, both imipramine and amitriptyline require careful monitoring due to their risk of toxicity which makes them less suitable than SSRIs as a first-line therapy.

Question 21

You are working in a GP surgery and your next patient is Susan, a 30-year-old woman with a diagnosis of generalised anxiety disorder (GAD). She is currently prescribed sertraline 200mg daily.

On review of her symptoms today, she states that she does not feel like the sertraline is helping, and she remains anxious almost all of the time. She experiences frequent episodes where she feels her heart pounding in her chest and her head is spinning. Furthermore, she notes that she often struggles to get to sleep and can lie awake for hours at night.

As you observe Susan, she appears obviously distressed. She seems unable to sit still in her chair and is trembling slightly.

What would be the next step in Susan’s management?

Change the prescription to duloxetine
Change the prescription to mirtazapine
Change the prescription to pregabalin
Increase the sertraline dose
Prescribe diazepam

Answer 21

Change the prescription to duloxetine

If a first line SSRI such as sertraline is ineffective or not tolerated, try another SSRI or an SNRI for GAD

The correct answer is to change the prescription to duloxetine. This is because in the management of generalised anxiety disorder (GAD), if first-line management with a selective serotonin reuptake inhibitor (in this case sertraline) is ineffective, an alternative selective serotonin reuptake inhibitor (SSRI) or a serotonin-norepinephrine reuptake inhibitor (SNRI) should be offered. Duloxetine is an SNRI.

Mirtazapine is a noradrenaline and serotonin selective antidepressant (NaSSA). It is sometimes used in the treatment of depression as an alternative for a poorly tolerated/ineffective antidepressant or as an augment to ongoing treatment. It has been shown to have an effect on controlling the symptoms of anxiety, but at present, it is not part of the NICE guidance for drug treatment of GAD.

Pregabalin may be considered if the patient cannot tolerate either an SSRI or an SNRI. This is not yet the case with Susan.

Increasing the sertraline is not an option because she is already on the maximum dose of 200mg per day.

NICE guidelines suggest that a benzodiazepine (such as diazepam) should not be offered for the treatment of GAD in primary or secondary care except as a short term measure during a crisis.

Question 22

While working in psychiatry you are taking a history from a patient with a new diagnosis of generalised anxiety disorder (GAD). You take a thorough past medical history. Which of the following is a risk factor for GAD development.

Living with other people
Being under 20-years-old
Atrial fibrillation
Being divorced or separated
Hyperthyroid disease

Answer 22

Being divorced or separated

Being divorced or separated is a risk factor for generalised anxiety disorder

Risk factors for the development of GAD include;

Aged 35- 54
Being divorced or separated
Living alone
Being a lone parent

Protective factors include;

Aged 16 - 24
Being married or cohabiting

Having a hyperthyroid disease or atrial fibrillation may result in symptoms similar to GAD but are not a risk factor for its development.

Question 23

A 21-year-old man presents to the GP with persistent worry and anxiety. Despite experiencing palpitations 2 months ago and subsequent normal ECG findings reviewed by a cardiologist, he remains concerned about his heart health. He has not found relief from cognitive behavioural therapy (CBT) or sertraline.

What is the next step in management for this patient?

Amitriptyline
Bupropion
Duloxetine
Mirtazapine
Moclobemide

Answer 23

Duloxetine

If a first line SSRI such as sertraline is ineffective or not tolerated, try another SSRI or an SNRI for GAD

Duloxetine is the correct answer. This patient has generalised anxiety disorder (GAD) which hasn’t responded to CBT or an SSRI. Duloxetine belongs to the SNRI class of drugs. Its mode of action revolves around inhibiting the reuptake of serotonin and noradrenaline in the synaptic clefts in the central nervous system. NICE recommends this class of drug in GAD if an SSRI hasn’t worked. Besides their role in managing mood disorders like depression and generalised anxiety, they can be used to manage neuropathic pain in conditions like diabetic peripheral neuropathy.

Amitriptyline is incorrect. Amitriptyline is classified as a tricyclic antidepressant primarily indicated for the treatment of depression, with off-label uses extending to the management of neuropathic pain. However, it is not considered appropriate for the treatment of GAD. Potential side effects associated with amitriptyline use include dry mouth, dizziness, and weight gain.

Bupropion is incorrect. Bupropion is classified as an atypical antidepressant and is also considered a dopamine and norepinephrine reuptake inhibitor (DNRI). It is primarily used to treat depression and seasonal affective disorder. Additionally, bupropion is prescribed as a smoking cessation aid under the brand name Zyban. NICE don’t recommend using this type of drug to treat GAD, instead opting for a SNRI or another SSRI.

Mirtazapine is incorrect. Mirtazapine, categorized as a noradrenergic and specific serotonergic antidepressant (NASSA), offers several beneficial side effects including increased appetite (potentially aiding in eating disorders) and improved sleep quality, which can be advantageous for managing depression and anxiety. However NICE recommends considering a serotonin-norepinephrine reuptake inhibitor (SNRI) as an alternative therapeutic option if an SSRI hasn’t worked.

Moclobemide is incorrect. Moclobemide, a monoamine oxidase inhibitor (MAOI), functions by inhibiting the breakdown of neurotransmitters such as serotonin and noradrenaline. However, if treatment with an SSRI proves ineffective, NICE recommends considering an SNRI as an alternative therapeutic option.

Question 24

A 21-year-old woman is re-reviewed by her GP for generalised anxiety disorder (GAD). At her last review, she was given information about GAD and referred for individual guided self-help. Unfortunately, despite these treatments, she still reports feeling worried ‘about most things’ for most of the day. She struggles to relax and her family has noticed that she is more irritable.

The patient is keen to try further treatment, however this time she would rather try a medication.

What medication would be most appropriate to prescribe for this patient?

Citalopram
Diazepam
Fluoxetine
Sertraline
Venlafaxine

Answer 24

Sertraline

Sertraline is the first-line drug for generalised anxiety disorder

This patient displays typical features of GAD including feeling anxious most of the time, feeling restless, and feeling irritable. Once physical causes of anxiety - such as thyroid disease and medication-induced - have been ruled out, GAD is treated in a stepwise approach. Step 1 is to give the patient education about GAD and to monitor their condition. Step 2 is to give the patient a low-intensity psychological intervention. Unfortunately, the patient has completed both of these steps with no improvement. She requires step 3 of treatment. Step 3 is either a high-intensity psychological intervention (such as cognitive behavioural therapy) or drug treatment, depending on the patient’s choice. This patient has made it clear that she would prefer drug treatment. The first line-drug treatment for GAD is a selective serotonin reuptake inhibitor (SSRI). NICE guidelines for GAD (2019) suggest that sertraline should be considered the first-line SSRI for GAD as it is the most cost-effective drug. Sertraline is, therefore, the correct answer.

Citalopram is also an SSRI, however, it is not the SSRI that NICE recommend trialling first for GAD. If a patient with GAD cannot tolerate sertraline or it is not effective, NICE recommend offering an alternative SSRI or an SNRI (serotonin-norepinephrine reuptake inhibitor). In this case, citalopram would be an appropriate choice.

Diazepam is a benzodiazepine. NICE recommend that benzodiazepines should not be given for GAD. This is due to the risk of dependence. The only exception is that they may be given short-term in a crisis. However, this is not applicable to this case.

Like citalopram, fluoxetine is an SSRI that may be used as a second-line treatment for GAD. It is not recommended as a first-line treatment.

Venlafaxine is an SNRI, a similar drug to SSRIs. An SNRI may be offered if a patient does not improve with or cannot tolerate the first-line SSRI, sertraline. It would not be given first-line so is not the correct answer for this patient.