Past Case 6: GAD + Panic disorder

Question 1

You are an intern in the Emergency Department. You are asked to evaluate a 17 year old student named Chloe. She was brought in after cutting her wrist for the first time following an argument with her mother. She tells you she is very worried about her upcoming HSC exams. Even though she studies hard and completes all the academic assignments on time, she is constantly preoccupied with the thought that she won’t do well in the exams and might even fail. She is very apprehensive and fearful all the time, feels exhausted and tearful and is worried that her concentration is not as good as it was before. These symptoms have been present from childhood but have become worse in the past 2-3 years, and particularly in the past few weeks as her HSC exams are coming up. Before her trial English exam two weeks ago, she had an episode where she felt overwhelmed by fear, had chest pain and felt she couldn’t breathe. She also complains of weight gain and dry skin and thinks she has been losing excessive amounts of hair recently. She says she has always been a worrier. When she gets together with friends to study she can still enjoy being with them.

Answer 1

Impression
Summary – presents with recent self-harm in setting of considerable chronic anxiety, and recent likely panic attack. Significant component of anxiety in this presentation, and evidence of impact on generalised ability to function and complete assessment tasks.
Concerned about GAD with superimposed panic attacks/panic disorder given recent attack prior to English exam.

Differential diagnoses to consider in this patient;
- Anxiety disorders – likely GAD
o Panic attacks
o Panic disorder
o OCD – hair loss ?compulsive
- Mood disorder: MDD, ?Bipolar depression/ co-morbid, also consider adjustment disorder given upcoming exams and stressors of school, ?home life stressors
- Co-morbid substance use disorder
- Personality disorder: BPD
- Organic: thyroid dysfunction given weight gain, hair loss, malignancy, IBS/IBD, other autoimmune condition, ?pregnancy
- Could just be normal performance anxiety, learning to cope with school stressors.

Question 2

GAD + Panic Disorder - History

Answer 2

History
History
- Sx: Symptoms of anxiety; worrying, agitation, attention, concentration, tension in muscles, irritability, hyperarousal, restlessness/ on-edge(WATCHERS)
- Panic attack: duration, sx, thoughts/fears about having one, emotions associated
- Try to ascertain what her cognitions are; what exact fears drive her anxiety
- Ask about organic medical sx: hypothyroidism (weight, hairloss, GI changes, neurological changes, skin changes, bradycardia)
- Screen for depression, mania, TOSH/SI (any concrete plans, protective and risk factors), personality, ask about SLEEP and sleep hygiene
- Fam Hx
- Menstrual and sexual? ?pregnancy
- Substances history - ?co-morbid substance use
- Developmental history: schooling, childhood trauma, HEADSSS assessment, home situation

Question 3

GAD + Panic Disorder - Examination

Answer 3

Examination
- General obs + vital signs
- Systems review: screening for organic cause
MSE – will be variable
- A/B: weight, signs of hypothyroidism, restlessness, agitation, teary, distractible
- A/M, normal, reactive, could be depressed
- TF, ?poverty of speech
- TC: ?delusions, ?SI, TOSH, any specific phobias
- Cognitive: intact
- I/J: Normal to impaired

Question 4

GAD + Panic Disorder - Investigations

Answer 4

Investigations
Important to rule out an organic cause of the presentation in this case;
- Bedsides: pregnancy, urine drug screen,
- Bloods: FBC, TFT, UEC, CRP/ESR, vitamins
- Imaging: nil at present

Question 5

GAD + Panic Disorder - Management

Answer 5

Management
For all anxiety disorders, often a mix of psychotherapy and pharmacological agents are utilised.

Risk assessment

• Characterise SI/TOSH, risk of harm to self
• Remove sharps/ other tools for self-harm/suicide at home, would need to have family meeting, discuss with GP

Setting/location
- Would be managed on outpatient basis. If deemed at significant risk to self re TOSH/SI, could manage acutely on inpatient basis, ?voluntary/involuntary depending on patient’s I/J

Biological
- Psychological interventions are first line in the setting of anxiety disorders
- Pharmacological treatment if treatment resistant/significant acute stressors, consider starting SSRI (fluoxetine)
o Takes up to 2 weeks to be efficacious
o May need higher doses than for depression to see effect
o Only prescribe in the setting of concurrent psychological therapy
o Increased risk of suicide once started, would need safety plan for home management
o For GAD
 1) SSRI
 2) SNRI
 3) TCA
 4) BZD – ONLY for short-term crisis, long-term when psychotherapy and other pharmacology has failed
 Consider ß-blocker if significant anxiety for specific scenarios (exams, etc)

Psychological
- Invest in therapeutic alliance throughout consults
- CBT
o Psycho-education
o Cognitive therapy (emotions, thoughts, behaviours)
o De-arousal/relaxation
o Graded exposure and response therapy/de-sensitisation
o Problems solving
- Specific therapies for future panic attacks
o Slow breathing
o Mindfulness
o Square breathing (in, hold, out, hold – 5 seconds each)
- Psychodynamic therapy may be necessary

Social

• Healthy lifestyle modifications
• Sleep hygiene
• Psychology referral
• Phone apps (headspace, moodgym, beyonddblue)