Week 8- Generalised anxiety disorder + Anxiety Overview, Prescribing and Counselling Advice Flashcards
what is GAD?
is where the anxiety doesn’t go away, lasts for at least 6 months, and where the worry is out of proportion to the riskre the anxiety doesn’t go away, lasts for at least 6 months, and where the worry is out of proportion to the risk
what is the most common type of anxiety?
GAD
what type of symptoms always comes along with GAD?
Depression and managing this is a priority
what is he incidence rate for GAD?
5%
what are some serious symptoms of GAD?
they become desperate and suicidal
whats the difference between panic and GAD ANXIETY?
GAD- anxiety is continous but may fluctuate in intensity
Panic disorder- unrelated to any circumstance
when is the onset of GAD?
early adulthood, tends to change with age as the subject of the anxiety evolves with time
what are symptoms in GAD?
- hyperventilation
- palpitations
- sweating
- trembling
- dry mouth
- dyspnoea
- chest or abdominal -discomfort
- thinking the worst of an event e.g. any ache or pain becomes a serious illness
- fear of losing control
- poor concentration
- irritability
- disturbed sleep
What are some signs on presentation for GAD?
facial straining, restlessness and being close to tears
what are some major symptoms when diagnosing GAD?
-Excessive anxiety and worry about a number of events and activities
Difficulty controlling the worry
-MUST HAVE BOTH MAJOR SYMPTOMS, OCCURING MORE DAYS THAN NOT, FOR ATLEAST 6 MONTHS
what are some additional symptoms for diagnosing GAD?
- Restlessness or feeling keyed up or on edge
- Being easily fatigued
- Difficulty concentrating or mind going blank
- Irritability
- Muscle tension
- Sleep disturbance
- MUST HAVE ATLEAST 3 OUT OF 6 ADDITIONAL SYMPTOMS
what other diseases are related and linked with anxiety and need to be differentiated from?
-Depression
-Schizophrenia
-Dementia
-Substance Misuse
-Physical Illness e.g. –Thyrotoxicosis and
hypoglycaemia (these can have tests done to differentiate.)
How many steps are in the stepped care model for patients with GAD?
4
what is step 1 of the stepped care model for patients with GAD?
STEP 1- Recognise and suspected presentations of GAD, identification and assessment, educate about GAD and look into treatment
what is step 2 of the stepped care model for patients with GAD?
- low-intensity psychological intervention and individual guided self help and educational groups
- diagnosed GAD that hasn’t improved after education and active monitoring in primary care.
what is step 3 of the stepped care model for patients with GAD?
- choice of high intensity psychological intervention (CBT/applied relaxed) or drug treatment
- GAD with an inadequate response to step 2 intervention or marked function impairment
what is step 4 of the stepped care model for patients with GAD?
highly specialist treatment e.g. drug and/or psychological treatment regimens
what are the main drugs for GAD?
First line
-SSRI e.g. sertraline/fluoxetine start at half normal dose then gradually increase. can take 8-12 weeks after treatment dose reached, should be used for at least 12 months, withdrawing is over weeks or months
-Venlafaxine(low dose SSRI and high SNRI)- initially 75mg increased if needed UP TO 225mg, wait 8 before response, treatment for 12 weeks withdraw gradually
-Pregabalin (Schedule 3)- initially 150mg/day in 2/3 dose if needed up to 600mg/day, unclear how long effects take, treatment should be 12months, withdrawal gradually
-
why is pregabalin weird for treatment and where it stands in NICE guidelines?
-should try SSRI first if not worked use another then try SNRI then pregabalin unless patient cant tolerate SSRI
what is the drug used for GAD short term?
benzodiazepines
what is the drug used for GAD combination and treatment resistant cases?
beta-blocker (somatic symptoms)
buspirone
what are two other SSRI drugs that can be used for GAD?
Start slowly e.g. Paroxetine 5-10mg/d or Escitalopram 5mg/d for a week or so, then increasing stepwise over several weeks as tolerated. Allow 8/52
for response.
why is escitalopram superior over paroxetine?
relapse prevention has been shown
what are some short term, adjuncts and second line drugs for GAD?
- Benzodiazepines short-term
- Beta-blockers low dose short-term
- Antihistamines low dose short-term
- Antipsychotics low dose short-term
- Venlafaxine/ Mirtazapine
- Pregabalin
- Buspirone
what are the different types of anxiety?
• Generalised anxiety disorder (GAD) • Obsessive compulsive disorder (OCD) • Post-traumatic stress disorder (PTSD) • Panic disorder • Phobic anxiety disorders - Specific phobia - Social phobia (social anxiety disorder; SAD) -Agoraphobia
what is the prevalence for anxiety?
ranged between 0.9-28.3% when looked at over 47 countries
what is the aetiology of anxiety disorders?
• Genetic factors - some individuals are resilient and others are vulnerable • Environmental (childhood trauma) • Psychosocial factors • Relationship problems • Unemployment • Social isolation • Co-morbidity (depression +substance misuse)
what are some clinical features of anxiety?
Fearful Anticipation Irritability Worrying thoughts Dry Mouth Constriction of Chest Palpitations Tremor Headache Hyperventilation Breathlessness Insomnia
what are the main treatments for anxiety disorders?
-SSRI’s -first line for all types
-Benzodiazepines (BDZs, e.g. Lorazepam, Diazepam,
Oxazepam, Clobazam )
-Antipsychotics (e.g. Risperidone, Olanzapine, Quetiapine, Pericyazine)
-Venlafaxine and Duloxetine
-Tricyclic Antidepressants (Clomipramine, Imipramine)
-Pregabalin (controlled drug)
what are the other treatment used for anxiety disorder?
-Mirtazapine (unlicensed) if they have depression/sleep issues also used for that)
-Buspirone ( not commonly used)
-Beta-Blockers (e.g. Propranolol)
-Antihistamines (e.g. Promethazine
and Hydroxyzine)
what is the number one treatment for anxiety?
-SSRI (Escitalopram and Paroxetine are
licensed; other SSRIs likely to have similar
efficacy and are widely used)
what are some counselling point for SSRIs?
- reposnse is not immediate can take 12wks
- initial worsening of symptoms is common with SSRI and venlafaxine so start low dose and increase when adverse effects subside
- long term treatment may occur
- stopping suddenly can give discontinuation symptoms e.g. restlessness, trouble sleeping, sweating.
- patients under 30yrs offered SSRI or SNRI can experience increased risk of suicidal thinking and self harm
how do you reduce the frequency of increased anxiety when starting ssri ESPEICALLY AT ANTIDEPRESSANT DOSE?
-start with low dose
• Escitalopram 5mg/d (can use the liquid or halved tablets)
• Fluoxetine 5-10mg/d (can use the liquid or orodispersibletablets)
• Paroxetine 5-10mg/d (can use the liquid or halved tablets)
• Sertraline 25mg/d (use half 50mg tablet)
• Citalopram 5-10mg/d (can use the liquid or halved tablets)
-then increase dose every 2 weeks
-Short-term benzodiazepines can help this initial anxiety
and if only used for a few weeks carry little if any
dependence liability
what is the example for why withdrawal/coming off from anxiety treatment is important?
-must be done slowly
-Diazepam has a long half-life and so the effects of
a dose reduction have not become fully apparent
until about 4 weeks after that dose. Leave plenty
of time between dose reductions
-With Diazepam, the last few mg can be the
hardest to stop, with psychological dependence a component.
what are some non-pharmacological interventions of anxiety?
-Psychotherapeutic approaches:
• Counselling
• Cognitive based therapy (CBT)
• Anxiety management
Self-help • Dietary - caffeine avoidance or at least reduction • Relaxation techniques • Self-help groups/ books • Lifestyle changes
