Generalised Anxiety Disorder 

Background

Generalised anxiety disorder (GAD) is the most common anxiety disorder worldwide. It affects 4.5% of the adult population in England and is twice as common in females. 

GAD is defined as persistent worry and anxiety about more than one different thing. The worry can be related to anything from the outcomes of day-to-day activities to concerns about the individual’s own health or the health of a loved one. If left untreated it can take a chronic course, which can be as debilitating to the individual as a chronic physical health condition. GAD can have a significant impact on occupational and social functioning, As a result, patients are reported to have a poor quality of life and are at an increased risk of suicide. 

Presentation 

GAD presents with excessive anxiety, worry, and somatic symptoms. These symptoms can include shaking, dizzy spells, palpitations, and sweating. These symptoms must occur on more days than not, for at least a 6-month period, for a diagnosis of GAD. The worry can be about anything and everything. It is not fixated on a particular thing, as is the case in other anxiety disorders such as anxiety induced by a phobia (phobia disorder), by embarrassing social situations (social anxiety disorders), fear of having a serious illness (illness anxiety disorder), or excessive worry due to the presence of one or more physical symptoms (somatic symptoms disorder). 

Patients with GAD are known to frequent healthcare settings, more so than the rest of the population. Their somatic symptoms often distract the patient and clinicians from the underlying psychological cause. Depression is often co-morbid in patients with GAD. However, GAD can also occur without any other comorbid mood disorders. If GAD occurs in isolation, it is referred to as “pure” GAD. 

Investigation

For young patients with physical symptoms such as tachycardia, shortness of breath, weight change or cognitive impairment in addition to psychological symptoms, an organic cause should be ruled out first, e.g., hyperthyroidism. This can include routine blood tests, thyroid function tests, urinalysis, and an ECG. Other mood or anxiety disorders should also be ruled out. 

Patients over the age of 35 years presenting with somatic symptoms and who have had no previous history of GAD should be investigated for a physical cause first. GAD should be considered if they have key symptoms of GAD and there is no physical cause for the somatic symptoms. 

The GAD-7  is a 7-item questionnaire; each question is rated out of 3, with scores ranging from 0-21. This scale is used to measure the severity of anxiety and to monitor response to treatment and is not used as a diagnostic tool. Scores range from 0-4 is minimal, 5-9 is mild, 10-15 is moderate and >15 indicates severe anxiety.  

Diagnosis

According to the DSM 5, for a diagnosis of GAD, patients should present with the following:

 2 key symptoms:

• Disproportionate worry and anxiety about many different activities or events
• Inability to control the worry.

At least 3 of these additional symptoms:

• Difficulty concentrating
• Sleep disturbance
• Restlessness
• Fatigue
• Irritability
• Muscle tension

Management

If untreated, GAD can follow a chronic or relapsing pattern; therefore, treatment should aim to put symptoms into remission in the first instance. The more successful the treatment is at the beginning, the lower the likelihood of relapse. In patients with harmful substance misuse, treating their dependency on illicit substances can help treat their GAD symptoms. In patients who have comorbid anxiety or mood disorder, managing their primary disorder can help improve their GAD symptoms. 

The latest NICE guidelines recommend a “stepped care” approach, where the aim is to provide the least intrusive approach first. Which step of the treatment model is chosen depends on the patient’s symptoms and duration, severity, previous history, comorbidities, and current functionality. The next step is chosen if the patient’s symptoms do not improve with the current intensity of intervention. 

Image Source: Wikimedia Commons (2011). CG123, Licensed under a creative commons licence. Available for free at: https://www.nice.org.uk/guidance/cg123/chapter/1-guidance (Accessed: 6 October 2023).

Step 1

Education and active monitoring if:

• Symptoms are few, intermittent or present for <6 months (diagnostic criteria for GAD not fully met)
• Symptoms only cause mild distress and either no or only some impairment to everyday function.
• No other mood or anxiety disorder
• No history of mood or anxiety disorders

Step 1 treatment strategies

At this stage, providing reassurance, educational material and active monitoring of symptoms can help treat mild presentations and prevent the need for more intensive treatment. Education can involve written or verbal information about GAD and how it can be managed. It can also include material on national organisations and self-help groups where patients can discuss their experiences. Information on what to do in a crisis and who to contact should also be provided to the patient.  

Step 2

Active treatment with low intensity psychological intervention if:

• Symptoms meet the diagnostic criteria for GAD.
• Symptoms cause clinically significant distress and /or cause impairment in the patient’s day to day life and activities. 
• Current diagnosis of another mood or anxiety disorder
• History of a mood or anxiety disorder

Step 2 treatment strategies

CBT themed self-help which involves little input from a healthcare professional, or guided self-help where a healthcare practitioner facilitates the therapy and monitors progress. It can also involve group CBT therapy. 

Step 3

High intensity psychological or pharmacological intervention if:

• There is significant functional impairment.
• Some functional impairment or poor response to the interventions in step 2
• History of a mood or anxiety disorder

Step 3 treatment strategies

• Individual high intensity therapies
• CBT
• Applied relaxation (patients are taught how to apply relaxation techniques  when they encounter anxiety inducing situations)
• Drug treatment can be based on patient factors such as their comorbidities and medications, as well as the patient’s preferences. There is no evidence at present to suggest that one drug class is superior to another. 
• SSRI (Sertraline – recommended by NICE)
• SNRI
• Pregabalin if SSRI / SNRIs are not tolerated. 
• Benzodiazepines are not recommended as a treatment for GAD in primary or secondary care, except in a crisis as an acute therapy. 
• Antipsychotics are not recommended as an initial treatment option as clinical efficacy is believed to be poor. 

The effectiveness and side effects of medications should be reviewed within two weeks and, if effective, should be continued for at least a year to avoid the likelihood of relapse. 

At this step, if symptoms have not improved after the completion of a high-intensity psychological regimen, treatment with medication should be offered (and vice versa). If the drug treatment has not helped, an alternative drug should be considered. If symptoms have only partially responded to a drug therapy, an alternative drug treatment should be considered or if high-intensity psychological treatments haven’t been tried, these should be offered. 

Step 4

Referral for psychiatric management if:

• GAD is not improving with CBT and pharmacological treatment. 
• Severe functional impairment
• Suicidal ideation or high risk of self-harm
• Significant psychiatric comorbidities. 

Step 4 treatment strategies

At this stage, a combination of high-intensity psychological and drug therapy is recommended, however, this should only be commenced by specialists. Input from multidisciplinary teams, e.g., the crisis team, community psychiatry etc may also be required. 

References

• Kendall T, Cape J, Chan M, Taylor C. Management of generalised anxiety disorder in adults: Summary of nice guidance. BMJ. 2011;342(jan26 1):c7460–c7460. 
• Hoge EA, Ivkovic A, Fricchione GL. Generalised anxiety disorder: Diagnosis and treatment. BMJ. 2012;345(nov27 2). 
• Bittner A, Goodwin RD, Wittchen H-U, Beesdo K, Höfler M, Lieb R. What characteristics of primary anxiety disorders predict subsequent major depressive disorder? The Journal of Clinical Psychiatry. 2004;65(5):618–26. 
• Introduction: Common mental health problems: Identification and pathways to care: Guidance [Internet]. NICE. NICE; 2011 [cited 2023May1]. Available from: https://www.nice.org.uk/guidance/cg123/chapter/1-guidance 

Panic Disorder

Background

Panic disorder has a lifetime prevalence of 1-5%. Patients with this disorder experience recurrent and persistent panic attacks over one month. Panic disorders are characterised by continuous worry or anxiety about having further panic attacks or fear of developing health problems due to recurring panic attacks (such as heart attacks). Whilst all patients with a panic disorder experience panic attacks, not everyone who experiences a panic attack has a panic disorder. Appropriate management of a panic attack in the first instance can prevent the development of a panic disorder.

Panic attacks can be related to a particular situation or can occur randomly without any cause. Factors which cause a panic attack are referred to as situational triggers; these can be external or internal. External triggers can be environmental, situational, or related to a phobia. Internal triggers include stress, lack of sleep or caffeinated drinks. Panic attacks that occur without a trigger are referred to as being spontaneous. The frequency and severity of these attacks can be highly variable.

Individuals experiencing panic attacks may avoid situations they believe trigger their panic episodes; this type of behaviour change is a key feature of panic disorder. As a result, patients struggle with everyday functioning and experience a poor quality of life. Historically, agoraphobia has been associated with panic disorder, but in the more recent DSM-5, they are referred to separately. Panic disorders can be present with or without agoraphobia, however, those with debilitating panic disorder often have comorbid agoraphobia.

Symptoms

A panic attack is an episode of sudden panic and intense feeling of discomfort, which involves the following:

• Rapid heart rate or pounding chest.
• Palpitations
• Hyperventilation
• Shortness of breath
• Chest tightness or discomfort
• Shaking or trembling
• Paraesthesia
• Abdominal pain 
• Nausea 
• Feeling like the patient is dying or suffocating.

Symptoms can last from minutes to hours. Patients presenting with a panic disorder will have these attacks frequently and without notice. Whilst panic attacks usually occur due to a trigger, in panic disorder they also occur spontaneously, without a trigger. Due to the frequency of these attacks, individuals develop maladaptive behaviours. They become excessively worried about having more attacks in the future and/or are concerned about the consequences of having further attacks. These can be worries about having a heart attack, developing an injury whilst having a panic attack, worry about death due to lack of oxygen going to the brain, or worry about the panic attack not stopping once it starts. Maladaptive behaviours can manifest as excessive use of health services or avoidance behaviours, such as avoidance of people, situations or environments which the patient considers to be a trigger. 

Investigations

Many of the symptoms seen in panic attacks can mimic organic medical conditions, so all individuals with new onset of panic attacks without a clear cause should undergo medical investigations first. 

• Physical examination and measurement of vital signs to assess for hypertension, tachycardia, or shortness of breath. 
• ECG to identify any arrythmia or ischaemic change that could contribute to the symptoms. 
• Blood tests such as full blood count, electrolytes, or thyroid panel. 
• The panic disorder severity scale (PDSS) is a 10-item questionnaire. Each question is rated out of 5, with scores ranging from 0-28. The higher the score, the greater the severity. It is often used to diagnose panic disorders and as a measure of treatment progress. 

Diagnosis

There is insufficient evidence to support the use of a diagnostic tool, so a thorough history and clinical judgement is used to make a diagnosis of a panic disorder.  Patients presenting with panic disorders often have a psychiatric co-morbidity of depression or substance misuse, which can make the diagnosis of panic disorders difficult.

If a patient presents to A&E or primary care with symptoms of a panic attack, physical causes such as thyroid or coronary artery disease must be ruled out first. If basic investigations rule out a physical problem, the patient is young, has a history of anxiety, has experienced panic attacks in the past or is known to have atypical chest pain, a diagnosis of panic disorder must be considered. 

DSM-5 diagnostic criteria for panic disorder: 

1. Recurrent panic attacks, at least one without a trigger. 
2. At least 1 month of one or both of the following:
   • Persistent worry about future panic attacks or worry about the consequence of further attacks 
   • Maladaptive behaviours like avoidance or overuse of health services
3. No other physical cause identified 
4. No other psychological disorder involved

Management

NICE guidelines recommend a stepped-care approach to panic disorders.

Image Source: Wikimedia Commons (2011). CG113, Licensed under a creative commons licence. Available for free at: https://www.nice.org.uk/guidance/cg113/chapter/Recommendations (Accessed: 6 October 2023).

Step 1 – Recognition and diagnosis of panic disorder

Panic disorders are often masked with the presentation of other medical conditions, as a result, they are often missed or misdiagnosed.  They can be comorbid with other mood disorders like depression, which makes recognition and diagnosis of panic disorders challenging. Common presentation of panic attacks is often individuals presenting to A&E with symptoms of chest pain, tightness, paraesthesia or difficulty breathing. In cases where medical causes of chest pain have been ruled out, the circumstances surrounding the presentation of the symptoms should be investigated and a diagnosis of a panic attack or panic disorder should be considered. Thorough history taking can help identify the factors causing or contributing to the disorder. This can help determine the best management plan for the individuals. The severity can be determined by the effect the symptoms have on day-to-day functioning and the individual’s mood. More debilitating cases of panic disorder may or may not present with agoraphobia. 

Psychoeducation on diagnosis:  the vicious cycles of the perception of fear, exaggerated sympathetic bodily responses and subsequent anxiety/avoidance should be explained to the patient. Patients should be encouraged to manage their anxiety using self-help resources. 

Step 2 – Treatment in Primary care

In the first instance, the following treatments can be offered to patients:

• Lifestyle factors e.g., eating well, good sleep, regular exercise etc
• Individual non-facilitated or facilitated self-help.
• Support groups 

Step 3 – Review the current treatment or offer alternatives. 

In individuals where the low-intensity management options above have been unsuccessful, the following should be offered

• CBT (7-14 hours is recommended and treatment should be completed within 4 months of commencement) is effective in those with or without agoraphobia. For some, shorter, more intensive CBT sessions are effective. 
• Drug therapy:  Antidepressants such as SSRIs, SNRIs and TCA are the only medications recommended for panic disorders.  Benzodiazepines, sedating antihistamines, and antipsychotics do not have good outcomes in this disorder and should be avoided. 

If there is no improvement in symptoms with the antidepressant after 12 weeks, an alternative class of antidepressant should be trialled. 

Step 4 – Referral to specialist services 

If a patient experiences substantial symptoms following two or more of the above interventions (psychological, pharmaceutical or combination) referral to specialist mental health services should be considered. 

Step 5 – Care in specialist mental health services

This often involves:

• Thorough risk assessment
• Management of co-morbid mental health conditions
• CBT
• Pharmacotherapy
• Referral to tertiary centres

References

• Jonge P, Roest AM, Lim CCW, Florescu SE, Bromet EJ, Stein DJ, et al. Cross-national epidemiology of panic disorder and panic attacks in the World Mental Health Surveys. Depression and Anxiety. 2016;33(12):1155–77. 
• Streeruwitz A, Hagger M, Webb S, Walker D, Jakeman N. Anxiety, obsession, and reactions to stress. In: Psychiatry PRN. Oxford, New York: Oxford University Press; 2009. p. 153–6. 
• Roy-Byrne PP. [Internet]. Panic disorder in adults: Epidemiology, clinical manifestations, and diagnosis. Wolters Kluwer; 2009 [cited 2023May1]. Available from: https://www.uptodate.com/contents/panic-disorder-in-adults-epidemiology-clinical-manifestations-and-diagnosis
• Recommendations: Generalised anxiety disorder and panic disorder in adults: Management: Guidance [Internet]. NICE ; 2020 [cited 2023 Oct 6]. Available from: https://www.nice.org.uk/guidance/cg113/chapter/Recommendations 
• 1. BMJ best practice. Panic disorders [Internet]. 2023 [cited 2023 Oct 6]. Available from: https://bestpractice.bmj.com/topics/en-gb/121 

Social Anxiety Disorder

Background

Social anxiety disorder, also known as social phobia, is associated with a constant fear of being humiliated, judged, or embarrassed. It often occurs in a social setting or where some sort of performance is required. It can include meeting or talking to new people, social gatherings, eating in public, giving a presentation or anything involving being in public. Whilst these situations can induce anxiety in the average person, in individuals with social anxiety disorder this fear is often out of proportion and they will worry excessively before, during and after these situations. This can be due to a previous experience or fear of potential outcomes from a scenario. They can worry about saying or doing the wrong thing, coming across negatively, or humiliating themselves. It is also common in children and young adults and may present with crying, freezing, or having tantrums when in social situations.  It is associated with distress and anxiety, which leads to avoidance of social settings, which can impact the individual’s ability to go to work, school and socialise. It is also associated with somatic symptoms such as tachycardia, palpitations, sweating, shaking, nausea, and panic attacks. Due to the debilitating nature of social anxiety disorder, there is substantial comorbidity between this and depression, substance misuse, panic disorder, GAD and PTSD.  The average age of onset is believed to be 13 years. Most sufferers don’t seek treatment, and if they do, they may wait decades after onset to do so. Social anxiety disorder is often undiagnosed in primary care settings due to poor recognition or awareness. Often, individuals will be diagnosed with depression, anxiety or panic disorders without the underlying social anxiety disorder being identified or addressed. 

 Risk factors include female gender, a family history, shyness in childhood and being behaviourally inhibited. 

Presentation

• Fear of other people noticing that they are overly anxious.
• Avoidance of social situations
• Avoidance behaviours such as not making eye contact or not starting conversations.
• Individuals may concentrate on things they feel they have done incorrectly, berate themselves, and feel depressed as a result. 
• Show symptoms of panic or have a panic attack in a social setting e.g., eating in public
• Negative emotions

Investigations

If a social anxiety disorder is suspected, the 3-item Mini-Social Phobia Inventory (Mini-Spin) or the following two questions can be asked as screening tools:

2 questions used for screening:

• Do you avoid social settings or activities?
• Do you become scared or embarrassed in social situations?

If the patient answers yes to one of the above questions or scores >6 on the Mini-Spin tool, they should be referred for further testing. 

Social anxiety disorder assessment tools: 

• The Social Phobia Inventory (SPIN) is sensitive and specific for social anxiety disorder – It is a 17-item questionnaire, with each question rated out of 5. Scores range from 0-68. A SPIN score of 21-30 = mild social phobia, 31-40 = moderate phobia, 41-50= severe phobia and >50= very severe phobia
• The Liebowitz Social Anxiety Scale (LSAS) assesses how much of an impact social anxiety disorder has on different activities of daily living. It is commonly used to measure response to treatment. It is a 24-item questionnaire, scores range from 0-144.  A score of 0-29 indicates no social anxiety disorder, 30-49 indicates mild social anxiety, 50-64 moderate social anxiety, 65-79 marked social anxiety, 80-94 severe social anxiety and >95 very severe social anxiety.

Diagnosis

Diagnosis is made by considering both the patient’s symptoms and diagnostic tools such as SPIN and LSAS.

Individuals with suspected social anxiety disorder may find it difficult to attend appointments in person. Therefore, alternative ways of initial assessment should be used, for example, online or telephone consultations. 

A thorough history should be taken including what the patient fears, their levels of avoidance, and the level of impairment to day-to-day activities. Many patients have comorbid mood, anxiety, personality and alcohol and substance misuse disorders. These should also be considered on assessment. 

Social anxiety disorder can be subtyped into generalised or performance social anxiety disorder. In the former, symptoms occur in a social/public setting, whereas in the latter, symptoms are only present when an individual needs to perform e.g. speaking in front of people or performing for an audience.

Management 

CBT

First line management is CBT which has been developed specifically for social anxiety disorder. It is based on the Clark and Wells model or Heimberg model. 

• The Clarks and Wells model: 14 sessions lasting over 90 mins each for approx. 4 months. It focuses on the following concepts:
  • Providing education about social anxiety
  • Exercises to show patients the downsides of SAD related safety seeking / avoidance behaviours and self-focus.
  • Video feedback so patients can see how they come across, which challenges a negative self-image
  • Dealing with any memories of social trauma 
  • Identifying and modifying negative core beliefs
  • Prevention of relapse
  • Training in externally focused attention 
• The Heimberg model. It focuses on the following concepts:
  • Providing education about social anxiety 
  • Cognitive restricting 
  • Gradual / graded exposure to situations the individual fears
  • Identifying and modifying negative core beliefs

Supported CBT

If CBT is declined or another option is sought, supported (self-help) CBT should be offered. Supported self-help consists of 9 sessions over approx. 4 months where patients are guided through a CBT based self-help book. 

Pharmacological management 

Pharmacological management should be started if CBT has been ineffective.

• 1st line – Selective Serotonin Reuptake Inhibitors (SSRIs) e.g., Sertraline or Escitalopram. If these aren’t tolerated, alternative SSRIs can be given, e.g., Paroxetine. 
• 2nd line – Serotonin Noradrenaline Reuptake Inhibitor (SNRIs) e.g., Venlafaxine. If symptoms don’t improve after 10-12 weeks, consider individual CBT.
• 3rd line – Monoamine oxidase inhibitor e.g., Moclobemide

Psychodynamic psychotherapy 

Patients who decline CBT or pharmacological treatment can be offered psychodynamic psychotherapy aimed at SAD. However, this has limited effectiveness and is not cost effective, so is used as the last line of management. 

It involves up to 30 sessions, each lasting up to 50 minutes for 6-8 months, and focuses on the following concepts:

• Providing education about social anxiety 
• Focusing on shame
• Encouraging patients to face social scenarios that they fear outside of sessions.
• Promoting self-affirmation
• Improving social skills. 

References

• Overview: Social anxiety disorder: Recognition, assessment and treatment: Guidance [Internet]. NICE. 2013 [cited 2023Apr25]. Available from: https://www.nice.org.uk/guidance/cg159 
• Bittner A, Goodwin RD, Wittchen H-U, Beesdo K, Höfler M, Lieb R. What characteristics of primary anxiety disorders predict subsequent major depressive disorder? The Journal of Clinical Psychiatry. 2004;65(5):618–26. 
• Mennin DS, Fresco DM, Heimberg RG, Schneier FR, Davies SO, Liebowitz MR. Screening for social anxiety disorder in the clinical setting: Using the Liebowitz Social Anxiety Scale. Journal of Anxiety Disorders. 2002;16(6):661–73. 

Phobia Disorder

Background

Phobia disorder is the most prevalent and most treatable of the psychiatric disorders, with women believed to be three times more likely to be affected. It occurs when there is an excessive fear involving a particular situation/object (phobic stimuli), which is disproportionate to the danger or threat it poses. This results in anxiety, distress, discomfort, and avoidance of the phobic stimuli, all of which can impact an individual’s day to day functioning. Individuals with phobias experience hyperactivation of their amygdala when they are exposed to phobic stimuli. Phobia disorders can also present with physical symptoms due to overactivity of the parasympathetic nervous system, following exposure to the phobic stimuli. For example, the vasovagal syncope that occurs in needle phobic individuals whilst having their bloods. 

Examples of phobic stimuli include:

• Animals – mice, spiders, or dogs 
• Nature – heights, water, darkness, thunderstorms, or fire 
• Medical – procedures, blood taking, injections, or COVID-19 
• Situational – tight spaces, flying on a plane, or lifts 
• Non-specific, e.g clowns, loud noises, etc

Presentation

• Anxiety, fear or dread of a certain object or situation 
• Being repulsed
• Avoidance of phobic stimuli 
• Tachycardia, fainting, sweating, hyperventilation, and other signs of sympathetic nervous system activity. 
• Nausea
• Dizziness
• Becoming overly jumpy

Investigations

The Anxiety Disorders Interview Schedule for DSM-5 (AIDS-5): A structured interview which can be used to diagnose phobia disorders, mood, and a variety of other anxiety disorders. 

This diagnostic interview schedule is usually used in academic settings, however, can also be used in a clinical setting to diagnose phobic disorder. 

Diagnosis 

Diagnosis is usually based on the history. Patients will describe symptoms caused by sympathetic nervous system stimulation when they face the phobic stimuli.  

Organic causes of the physical symptoms should be considered first if a phobic stimulus isn’t obvious on first presentation.

Treatment 

• CBT is the first line treatment, consisting of 1-5 sessions. It involves challenging the negative emotions associated with exposure to the phobic stimuli. 
• Exposure therapy. Used in addition to CBT in those with avoidant behaviours. When an actual threat isn’t present, the body will remain anxious for a short period of time until habituation occurs. This is when anxiety levels or fear begin to decrease. Exposure therapy causes the individual to be exposed to what they fear, without being able to avoid, distract themselves or seek any soothing behaviours, until habituation occurs. With each exposure event, the levels of anxiety are expected to decrease.
  • Direct exposure – phobic stimuli, pictures, video clips or VR are used to produce disgust or fear
  • Interoceptive stimuli – physical sensations feared by individuals are recreated, for example in those fearful of becoming short of breath in certain situations are encouraged to hold their nose to recreate a sense of shortness of breath.  
• Applied tension therapy. Used in those with blood-injection-injury phobias. Individuals are encouraged to repeatedly tense and relax the muscles in their abdomen and limbs. This is thought to increase their blood pressure and heart rate and prevent a vasovagal episode when, for example, having their blood taken. 
• Pharmacotherapy. Benzodiazepines are used in the short term to calm individuals, for example for medical tests e.g. MRI or procedures e.g. endoscopy. SSRIs are used in those with co-morbid mood or anxiety disorders. 

References

• Huberman A. Phobias [Internet]. Phobias – Symptoms, diagnosis and treatment | BMJ Best Practice. 2022 [cited 2023Apr29]. Available from: https://bestpractice.bmj.com/topics/en-gb/693 
• Brown TA, Barlow DH. Anxiety and related disorders interview schedule for DSM-5 (adis-5), Lifetime version: Client interview schedule. Oxford: Oxford University Press; 2014. 
• Streeruwitz A, Hagger M, Webb S, Walker D, Jakeman N. Anxiety, obsession, and reactions to stress. In: Psychiatry PRN. Oxford, New York: Oxford University Press; 2009. p. 154–5. 

Agoraphobia

Background

Agoraphobia is described as worrying about being somewhere where there is no escape or being anxious about having a panic attack where help is not available. This leads to persistent avoidance of a variety of things. Agoraphobic avoidance can range from avoiding crowds or travelling in certain modes of transport to never leaving the house. Agoraphobia is most likely to develop in people with panic disorder; however, it can also occur on its own.  Risk factors include having a panic disorder, presence of phobia or being female. Almost a third of sufferers also struggle with substance misuse. Due to its disabling nature, sufferers struggle with their everyday functions and staying in employment. 

Presentation

The primary presentation is avoidance of certain places due to worry about being suddenly incapacitated and not being able to escape, with individuals often displaying symptoms of panic. Common situations include public areas such as stadiums, parks, supermarkets or anywhere with a large crowd.  Individuals may often avoid places where they feel they could become trapped, which is called agoraphobic avoidance. Agoraphobic avoidance is most likely in those who have panic symptoms, as sufferers become worried about having a panic attack somewhere where they will have no control or feel like they will die because they can’t get help or escape. 

Individuals often report having a zone of safety that they feel comfortable being within, such as their home or local area. They feel distressed if they are out of the safety zone and avoid leaving this area. Agoraphobia can occur independently, soon after a panic attack or over time. 

Investigations

Assessment tools include:

• The Diagnostic Assessment Research Tool (DART) 
• Agoraphobia subscale of the Fear Questionnaire
• Anxiety and Related Disorder Interview Schedule for DSM-5 (AIDS-5) – a thorough, often time-consuming tool mostly used in a mental health setting.

The severity of symptoms can be assessed using:

• The mobility inventory helps assess the level of avoidance by listing 26 different situations.
• The severity measure for Agoraphobia
• The Oxford Agoraphobic Avoidance Scale

Diagnosis

Agoraphobia is defined by the DSM-5 as having the following:

1. Fear or anxiety about being in >2 situations where the individual can’t escape, such as: 
   • Being in a mode of transportation, for example in cars, buses, trains, planes or ships
   • Being in open spaces e.g. car parks, markets, parks
   • Being alone outside the house
   • Being in a queue or in a crowd
   • Being in enclosed public settings such as shops, libraries, or cinemas
2. Avoidance of being in these places due to fear of being trapped or not being able to get help if they develop a panic attack or lose control or something embarrassing happens.
3. Presence of fear or anxiety whenever they are physically in one of the agoraphobic locations (as mentioned in point no 1)
4. Active avoidance of agoraphobic location
5. Fear or anxiety is disproportionate to what should be expected.
6. Symptoms present for >6 months.
7. If a health condition is present, the fear avoidance is disproportional to the threat to their health
8. The fear, anxiety or avoidance is not due to another anxiety or mood disorder.

Management 

The treatment for agoraphobia is the same as for panic disorders, described above. 

Antidepressants, particularly SSRIs, are usually the first line drug treatment for agoraphobia. They are effective in reducing the intensity and frequency of panic attacks and can substantially improve a patient’s quality of life. 

If SSRIs are contraindicated or ineffective, clomipramine or imipramine may be trialled. If the treatment is effective after 3 months, it should be continued for at least 6 months in total.

References

• Streeruwitz A, Hagger M, Webb S, Walker D, Jakeman N. Anxiety, obsession, and reactions to stress. In: Psychiatry PRN. Oxford, New York: Oxford University Press; 2009. p. 152–153. 
• Introduction: Common mental health problems: Identification and pathways to care: Guidance [Internet]. NICE. NICE; 2011 [cited 2023May1]. Available from: https://www.nice.org.uk/guidance/cg123/chapter/1-guidance 

Obsessive-Compulsive Disorder

Background

Obsessive-compulsive disorder (OCD) is a mental health disorder characterised by obsessions and impulses, followed by compulsion or repetitive behaviours. OCD is a serious mental illness that often has a debilitating effect on the individual’s quality of life and day to day function. It affects 2% of the population and occurs in men and women equally. Neuroimaging has shown a reduction in inhibition in the frontal lobe in OCD sufferers, making it more difficult for them to resist distressing and intrusive thoughts.

Presentation

Obsessions

These are unwanted and intrusive thoughts, ideas, or impulses which sufferers would find disturbing, unsettling and difficult to get rid of despite trying to resist. The patient will often recognise these thoughts as being irrational and as being their own, unlike in other mental health disorders where there may be thought insertion or delusional beliefs. As OCD becomes chronic, the ability to resist these ideas or impulses can decrease or disappear.

There are common themes with these obsessions:  aggression (thoughts of harming others), contamination, infection, and morality (religion /sex)

Whilst having unpleasant thoughts can occasionally be normal, in persons with OCD these thoughts cannot be ignored or resisted. These obsessions make the patient feel unsettled, distressed and worried about what they’ll do if they keep having these thoughts or the danger their thoughts pose to them and their loved ones. 

Compulsions

A compulsion is the action patients feel they need to undertake to decrease or neutralise the obsession or intrusive thought. It is a safety strategy to prevent the frightening consequences caused by their obsession. These compulsions, also known as OCD rituals, are usually repetitive and usually follow a set of rules. The person usually recognises these rituals to be pointless and initially, they try to resist. These compulsions or rituals can be physical or mental tasks the patient needs to do to get rid of the obsessional thought or thoughts.

These compulsions or rituals can be put into 4 main categories:

1. Repeating actions e.g., patients checking locks a certain number of times to protect themselves from an intruder or repeating a word in their head constantly
2. Rituals to decontaminate e.g. excessive cleaning, showering several times a day, repeatedly washing hands.
3. Ordering and arranging e.g. mentally reviewing lists
4. Constant checking and reassurance seeking e.g. patients analysing or reanalysing things they’ve done or said several times in their head until it is perfect

These rituals can often take hours to perform and have a negative impact on the patients’ quality of life as they feel compelled to do these rituals to get rid of the distress caused by the obsessional thoughts. They often recognise these actions to be irrational or completely unrelated to the intrusive thought but feel compelled to carry them out anyway. 

Risk factors 

• Family history 
• Pregnancy
• Male sex
• Paediatric autoimmune neuropsychiatric disorders associated with streptococcal infection (PANDAS)

Diagnosis

The presentation of OCD overlaps with other psychiatric disorders, such as anxiety and depressive disorders, making diagnosis difficult. On average, it takes 9 years before OCD is correctly diagnosed, with around 17 years between the first onset of symptoms and appropriate treatment.  Patients are often embarrassed and avoid reporting their symptoms. In some cases, they present to health care professionals due to a medical condition which has resulted from their OCD e.g. dermatitis caused by excessive hand washing. 

ICD-10 for OCD diagnosis requires there to be recurrent obsessional thoughts or compulsive actions.

Differentials 

OCD is very similar to anankastic personality disorder. This is where individuals have rigid ways of doing things and have high standards of hygiene and cleanliness, which is often confused with OCD. However, the key difference is the lack of compulsive and repetitive behaviour.

Investigation

• Structured clinical interview for the DSM (SCID-5). This SCID-5 is derived from the DSM-5 and is a tool used to assess whether a patient meets the DSM-5 criteria for OCD. This tool is commonly used in research settings. 
• Yale-Brown Obsessive-Compulsive Scale (Y-BOCS). This is not a diagnostic tool but is used to determine the severity of OCD symptoms. It should be used at the start and during treatment to assess progress. 
• Clinical global impression (CGI)

Management

Treatment, as with other anxiety disorders, consists of a stepped approach. 

Mild functional impairment

• Education and self-help
• Low intensive CBT remains the first-line therapy. In OCD, the CBT intervention used is called exposure and response prevention (ERP). When a patient gets an obsessional thought, they are encouraged to sit with the feeling of anxiety and distress this causes instead of carrying out a compulsion. They are encouraged to discuss the feelings the obsession causes with the therapist. Similar exposure therapy is used in PTSD. This form of CBT is believed to be extremely effective. 

If a patient is unable to undertake low intensity CBT, or is not responsive to it, they should be treated for moderate functional impairment. 

Moderate functional impairment

• A choice of intensive CBT with ERP or drug therapy can be offered. 
• SSRI is the first line for drug therapy. Escitalopram, fluoxetine, sertraline, and paroxetine are all licensed for OCD. Citalopram can also be used as a first line; however, it is currently unlicensed for OCD.
• Clomipramine (TCA) can be given if SSRIs are contraindicated, if the patient prefers the TCA or if they’ve had a better response with it previously. 

Patients who do not receive enough benefit from these treatments should be treated for severe functional impairment. 

Severe functional impairment

• Dual therapy: intensive CBT combined with drug treatment
• Referral to specialist psychiatric services- consider if the OCD is chronic, debilitating and restricting daily life. Also, consider referral in patients who are not improving despite having >2 courses of CBT, including ERP in combination with antidepressants. 

References

• Simpson HB. https://www.uptodate.com/contents/obsessive-compulsive-disorder-in-adults-epidemiology-pathogenesis-clinical-manifestations-course-and-diagnosis?search=ocd&source=search_result&selectedTitle=2~145&usage_type=default&display_rank=2 [Internet]. UpToDate. Wolters Kluwer; 2022 [cited 2023May1]. Available from: https://www.uptodate.com/contents/obsessive-compulsive-disorder-in-adults-epidemiology-pathogenesis-clinical-manifestations-course-and-diagnosis?search=ocd&source=search_result&selectedTitle=2~145&usage_type=default&display_rank=2 
• Streeruwitz A, Hagger M, Webb S, Walker D, Jakeman N. Anxiety, obsession, and reactions to stress. In: Psychiatry PRN. Oxford, New York: Oxford University Press; 2009. p. 15156–157. 
• 1. BMJ best practice. Obsessive-compulsive disorder [Internet]. 2022 [cited 2023 Oct 6]. Available from: https://bestpractice.bmj.com/topics/en-gb/362

Post-Traumatic Stress Disorder

Background

Post-traumatic stress disorder (PTSD) usually occurs following one or more traumatic life events. Whilst the symptoms described in the presentation section below can develop following any traumatic event, in those with PTSD, these symptoms are persistent and have a significant impact on the lives of patients and their loved ones. Those at risk of PTSD include victims of war, torture, abuse, sexual assault and survivors of disasters, serious illness, or traumatic childbirth. It also affects those who serve in the army, the police force and emergency services. It is often comorbid with depression and anxiety. Other risk factors for developing PTSD include a family or personal history of mental health disorders, abuse as a child, the presence of survivors’ guilt or persisting trauma. PTSD sufferers will often relive the traumatic event rather than just simply remember the event due to disruption in the storing and processing of the traumatic event in their memory. The hypervigilance and exaggerated startle response is thought to be due to the hypertrophy of the amygdala, the emotional processing centre of the brain. Despite flashbacks of the event and constant reminders of the trauma, the sufferers may not completely remember all the details relating to the trauma (an atrophied hippocampus, the memory centre, is thought to be a factor). 

Presentation

PTSD usually presents within 6 months of the traumatic event occurring. 

Symptoms of PTSD usually fall into 3 categories.

Re-experiencing	Hyperarousal / Emotional numbness	Rumination / Avoidance
Vivid flashbacks of the traumatic event, cause the patient to “relive” the trauma	Emotional numbness or a sense of detachment. This leads to difficulty in forming close relationships	Avoidance of situations which can trigger flashbacks or memories of the event. Can present as avoidance of crowded places, loud noises etc
Nightmares relating to the trauma	Hypervigilance or hyperarousal and difficulty in relaxing	Preoccupation with work or hobbies to avoid memories of the traumatic event
Triggers which remind them of the trauma	Irritability, agitation or angry outbursts without provocation and crying	Negative thoughts or feelings of low self-worth
Repetitive sensory reminders of the trauma e.g. images, smells or sensations which cause distress	Insomnia	Difficulty concentrating on other things apart from the trauma
Intrusive memories of the event, reminding them of the trauma	Amnesia of parts of the traumatic event
	Prominent startle reflex, exaggerated response to something unexpected

The three categories of PTSD, BMJ best practice. Post-traumatic stress disorder [Internet]. BMJ ; 2023 [cited 2023 Jul 11]. Available from: https://bestpractice.bmj.com/topics/en-gb/430/management-approach 

Physical symptoms of gastrointestinal upset, joint pains and headaches can also be present.  Symptoms can be debilitating and distressing and have a substantial effect on day-to-day functioning.  

Diagnosis

PTSD consists of 4 types of symptoms: intrusive symptoms, avoidant behaviours, negative thinking patterns and mood, and changes in arousal and reactivity. The symptoms should be present for over a month and need to have an impact on the functioning of the sufferer for a diagnosis of PTSD to be made. On diagnosis, there is often a comorbidity of anxiety disorders, mood disorders such as depression or substance misuse disorders. 

Diagnostic factors 

The event triggering PTSD could be a threat to life, serious injury or a violent event. It could have involved the sufferer directly, they may have been a witness to the event or found out about the trauma occurring to a close friend or family. Trauma can also include repeated exposure to details of a traumatic event as part of their occupation, e.g. law enforcement.  

Exposure to trauma followed by each of the four symptoms (below) for over 1 month, which affects day to day functioning. 

Image Source: Wikimedia Commons (2018). NG116, Licensed under a creative commons licence. Available for free at: https://www.nice.org.uk/guidance/ng116/informationforpublic (Accessed: 7 May 2023).

A diagnosis can be made in primary care, but referral to specialist services is often required for further management options.  Diagnosis can be made using the DSM–5 or ICD-10.

Investigation

• PTSD Symptom Scale-Interview Version for DSM-5 (PSS-I-5) – A 20-item questionnaire based on DSM-5 description of PTSD symptoms 
• Trauma Screening Questionnaire (TSQ) – 10-item questionnaire which focuses on arousal and flashback symptoms. 
• Posttraumatic Diagnostic Scale (PDS-5) – Looks at the severity of PTSD symptoms 

Management

Non- pharmacological therapies 

• Exposure therapy: the patient is encouraged to remember and describe the traumatic event. By doing so, they repeatedly encounter the trauma that they have been avoiding and which has been causing them distress. 
• Trauma-focused cognitive therapy: helps the patient identify misconceptions and thoughts that are associated with a particular trauma, helping them confront and overcome the things that elicit fear and distress. 
• Eye movement desensitisation and reprocessing (EMDR). An effective therapy where the patient is encouraged to describe or reimagine the original trauma in detail. Whilst doing this, their therapist will move their finger / an object from side to side and patients are encouraged to follow the movement of the stimuli with their eyes. The repetitive movement of the eyes is thought to stimulate the brain and helps with reprogramming the patients’ traumatic memories and the negative emotions attached to them. 

Pharmacological therapies:

These are commenced in patients who have not responded to psychological therapies, who do not want to engage in psychological therapies or who cannot undergo psychological therapies yet due to ongoing trauma. It is also started in combination with other therapies, particularly in those with co-morbid depression.  

• SSRIs: Firstline, for example, Fluoxetine, Paroxetine and Sertraline. 
• SNRIs: Venlafaxine is thought to reduce PTSD symptoms and improve functionality. Used in those who don’t tolerate SSRIs.
• Atypical Antipsychotics: If the above fail, Quetiapine and Risperidone are recommended
• TCA: Amitriptyline or mirtazapine can be used as a last resort if the other drug therapies are ineffective 

If drug therapy is successful, it should be continued for at least 12 months. 

References

• NICE Guidelines. Information for the public: Post-traumatic stress disorder: Guidance [Internet]. NICE. 2018 [cited 2023May7]. Available from: https://www.nice.org.uk/guidance/ng116/informationforpublic 
• Streeruwitz A, Hagger M, Webb S, Walker D, Jakeman N. Anxiety, obsession, and reactions to stress. In: Psychiatry PRN. Oxford, New York: Oxford University Press; 2009. p. 158–9. 
• BMJ best practice. Post-traumatic stress disorder [Internet]. BMJ ; 2023 [cited 2023 Jul 11]. Available from: https://bestpractice.bmj.com/topics/en-gb/430/management-approach