Mood Disorders

Question 1

What is the ICD-10 criteria for generalised anxiety disorder?

Answer 1

• Anxiety which is generalized and persistent but not restricted to, or even strongly predominating in, any particular environmental circumstances.
• Variable dominant symptoms including persistent nervousness, trembling, muscle tension, sweating, lightheadedness, palpitations, dizziness, and epigastric discomfort.
• Expression of fears such as that the person or a relative will shortly become ill or have an accident.

Question 2

What is generalised anxiety disorder?

Answer 2

A person who reports chronic, excessive worry which is not related to particular circumstances, and symptoms of physiological arousal such as restlessness, insomnia, and muscle tension.

Question 3

Name some medical differential diagnosis for GAD

Answer 3

• Thyrotoxicosis/ hyperthyroidism
• Arrythmia e.g. atrial fibrillation, atrial flutter
• Hypoparathyroidism
• Hypoglycaemia
• Carcinoid tumour
• Serotonin syndrome
• Phaechromocytoma
• Alchol/ drug withdrawal

Question 4

What are the risk factors for GAD?

Answer 4

• Female sex.
• Family history of anxiety.
• Current physical or emotional stress.
• History of physical or emotional trauma.
• History of other anxiety disorders such as panic disorder, social phobia, or specific phobias.
• Chronic pain or physical illness (such as arthritis, cancer, coronary heart disease, cerebrovascular accident, or chronic obstructive airway disease).
• History of substance abuse.
• Repeated visits with the same physical symptoms which do not respond to treatment (for example insomnia, headache, or fatigue).

Question 5

How common is GAD in the UK?

Answer 5

5% of the population suffer from GAD. It is more common in females and mean age of onset is 21.

Question 6

What is the first line management of GAD?

Answer 6

• Individual non facilitated self help
• Individual guided self help
• Psychoeducation

Question 7

What is the second line treatment for GAD?

Answer 7

• High intensity psychological interventions e.g. CBT
• Sertraline is recommended as the first line pharmacological therapy

Question 8

What is the pharmacological treatment for GAD?

Answer 8

• SSRI should be generally considered as the first line treatment. Sertraline should be offered.
• If Sertraline is ineffective, offer either (a) alternative SSRI or (b) SNRI (for example Venlafaxine)
• If SSRI and SNRI are both contraindicated/ not tolerable, consider offering Pregabalin
• Benzodiazepine should NOT be routinely offered for treatment of GAD with the exception of short term use in crisis
• Antipsychotic medication (for example Quetiapine) should NOT be offered as routine treatment of GAD in primary care

Question 9

What are the common side effects of SSRI?

Answer 9

• Hyponatraemia
• GI bleeding
• QT interval prolongation
• Mania
• Serotonin syndrome

Question 10

What is activation syndrome?

Question 11

What is serotonin syndrome?

Answer 11

• Sertraline is a selective serotonin reuptake inhibitor (SSRI) while Venlafaxine is a serotonin and noradrenaline reuptake inhibitor (SNRI).
• Both SSRI and SNRI works by increasing the extracellular concentration of serotonin by limiting the reabsorption (reuptake) of serotonin into the presynaptic nerve cell, increasing the level of serotonin in the synaptic cleft available to bind to the post synaptic receptors.
• As such, taking a SSRI and SNRI in combination increases the theoretical risk of serotonin syndrome.
• Serotonin syndrome is caused by serotonin excess in the CNS and is characterised by a myriad of symptoms including tachycardia, diaphoresis, myoclonus, hyperreflexia, mydriasis, hypertension, hyperthermia and hypertension.
• This can be treated with a serotonin antagonist such as cyproheptadine.