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Anxiety Care Pathway Overview

Anxiety disorders can exist in isolation but more commonly occur with other anxiety and depressive disorders.

1 week prevalence rates in the UK in 2007:

  • generalised anxiety disorder (GAD) 4.4%
  • phobias 1.4%
  • panic disorder 1.1%
  • obsessive compulsive disorder (OCD) 1.1%
  • post traumatic stress disorder (PTSD) 3.0%

  • untreated anxiety disorders can become chronic, causing significant disability and distress
  • often the course of the anxiety disorder will wax and wane, being especially severe at times of stress

Please click the relevant flowchart box to be taken directly to textual information:

                 

Red Flags
If any urgent concern consider GP led pharmacological intervention, discussion and referral. Referrer Information for Mental Health Services - Gloucestershire including the Contact Centre, Mental Health Acute Response (MHARS) (formerly Crisis Resolution and Home Treatment Teams) can be found here. 
2gether- A Guide to Suicide Risk Assessment and Management in Primary Care can be found here
Presentation

General presentation: 

  • anticipatory anxiety and worry - worry may be excessive and last six months or more
  • restlessness or nervousness
  • being easily fatigued
  • sleep disturbance
  • poor concentration
  • irritability
  • palpitations
  • hyperventilation
  • sweating
  • flushing
  • muscle tension
  • lightheadedness
  • dizziness
  • epigastric discomfort
  • health anxiety
  • body dysmorphic disorder
  • obsessional thinking
  • medically unexplained symptoms
    • e.g. pains in the muscles or joints, headaches, tiredness etc.

Presentation of specific conditions:

Specific phobia:

  • marked and persistent fear of a specific object or situation
  • person recognises fear as being excessive or irrational
  • exposure may lead to extreme distress or panic attack
  • often leads to avoidance behaviour, though may be endured with dread
  • interferes with normal routine and functioning and/or causes high levels of distress
  • sometimes full-blown panic attacks are experienced in response to the phobic stimulus, especially when the person must remain in the situation or believes that escape may be impossible
  • fainting may occur with exposure to blood, injection, injury, or medical phobias
  • common fears include:
  • animals
  • insects
  • blood
  • injections
  • injury
  • closed spaces
  • water
  • heights
  • storms
  • dental procedures
  • driving
  • flying
  • elevators
  • vomiting
  • choking

 

Social phobia:

  • persistent and marked fear of social or performance situations
  • person fears embarrassing themselves or showing anxiety in front of other people
  • person recognises their fear is excessive or unreasonable
  • exposure to feared situation may lead to anxiety, including panic attacks
  • person will avoid situations or experience intense anxiety during them
  • avoidance, anxious anticipation or distress interferes with normal routine and functioning
  • common situations include:
    • eating in public
    • speaking in public
    • using public toilets
    • social situations where they may say or do something foolish
    • situations where they may blush or appear anxious

 

Agoraphobia:

  • anxiety in situations where the environment is perceived to be unsafe with no easy way to get away
  • Situations might include being out of the home, or outside of places felt “safe”
  • person recognises fear as being excessive or irrational
  • exposure may lead to extreme distress or panic attack
  • often leads to avoidance behaviour, though may be endured with dread
  • interferes with normal routine and functioning and/or causes high levels of distress

Please see the NICE Pathway on Social Anxiety for further guidance

Definition:

  • at least two unexpected (without warning) panic attacks, followed by:
    • worry about having more attacks
    • concern about implications of attack
    • change in behaviour as a result of attacks
  • panic attacks include at least four of the following symptoms and peak within 10 minutes of symptom onset:
    • palpitations, pounding heart, or accelerated heart rate
    • sweating
    • shaking or trembling
    • shortness of breath or smothering sensation
    • choking feeling
    • chest pain or discomfort
    • nausea or abdominal pain
    • feeling dizzy, light headed, unsteady, or faint
    • depersonalisation or derealisation
    • fear of losing control or going crazy
    • fear of dying
    • numbness or tingling sensation
    • chills or hot flushes
  • panic attacks are not due to the direct physiological effects of a substance or a general medical condition

Agoraphobia commonly occurs concurrently:

  • anxiety about situations where a panic attack might occur, and it would be difficult or embarrassing to escape, or help might be unavailable
  • agoraphobia is rarely diagnosed without panic disorder, and may be a consequence of the severity of a primary panic disorder

Please see the NICE Pathway on Panic Disorder for further guidance.

  • excessive worry and apprehension about a number of different events or activities, occurring more days than not and lasting for at least 6 months
  • accompanied by at least three of the following symptoms:
    • feeling wound up, tense, or restless
    • easily becoming worn out or fatigued
    • concentration problems
    • irritability
    • muscle tension
    • difficulty with sleep
  • anxiety, worry, or physical symptoms cause clinically significant distress or impair functioning

Please see the NICE Pathway on Generalised Anxiety Disorder for further guidance.

  • recurrent obsessions or compulsions that are excessive or unreasonable, time-consuming and cause marked distress
  • Insight is usually retained - at some point during course of disorder, the person recognises and tries to resist obsessions and compulsions:
  • people with OCD are often ashamed and embarrassed by their condition and may find it difficult to discuss their symptoms with healthcare professionals, friends, families, or carers

 

Obsessions:

  • recurrent and persistent thoughts, impulses, or images that are intrusive and inappropriate and cause marked anxiety or distress
  • person attempts to ignore or suppress them with other thoughts or actions
  • person recognises they are a product of their own mind
  • common obsessional themes include fear of contamination from:
    • dirt
    • germs
    • viruses
    • bodily fluids
    • chemicals
    • sticky or dangerous substances
  • fear of harm, eg door locks are not secure
  • excessive attention to order or symmetry
  • obsession with body or physical symptoms
  • religious, sacrilegious, or blasphemous thoughts
  • sexual thoughts
  • desire to hoard worn-out or useless possessions
  • violent or aggressive thoughts

 

Compulsions:

  • repetitive behaviours or mental acts that the person feels driven to perform in response to an obsession or rigid self-rules
  • they are aimed at preventing or reducing distress but are not realistic and clearly excessive
  • common compulsions include:
    • checking, e.g. gas, taps, locks
    • cleaning, washing
    • repetition of special words or prayers
    • ordering, symmetry, exactness
    • hoarding or collecting
    • counting
  • resultant limit to functional ability may cause anxiety and distress
  • they are time consuming (take more than one hour per day)

Please see the NICE Pathway on Obsessive compulsive disorder for further guidance.

  • transient disorder, between 2 days and 4 weeks in response to a traumatic event in which both of the following were present:
    • the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others
    • the person's response involved intense fear, helplessness, or horror
  • either while experiencing or after experiencing the distressing event, the person has three or more of the following dissociative symptoms:
    • a subjective sense of numbing, detachment, or absence of emotional responsiveness
    • a reduction in awareness of his or her surroundings, eg "being in a daze"
    • derealisation
    • depersonalisation
    • dissociative amnesia, eg inability to recall an important aspect of the trauma
  • other symptoms include:
    • re-experience of the traumatic event, eg recurrent images, thoughts, dreams, illusions, flashbacks
    • distress on exposure to reminders of the traumatic event
    • avoidance of situations or thoughts that are reminders of traumatic event
    • marked symptoms of anxiety or increased arousal:
    • difficulty sleeping
    • irritability
    • poor concentration
    • hypervigilance
    • easily startled by loud noises or sudden movement

 

Adjustment disorder:

  • development of emotional or behavioural symptoms within 3 months of a significant life change or stress:
    • marked distress in excess of what would be expected
    • significant impairment in social or occupational function
    • symptoms include:
    • depressed mood
    • tearfulness and feelings of hopelessness
    • worry or anxiety
    • inability to cope with life or plan for the future
    • insomnia
    • physical symptoms, eg headaches, chest pain, palpitations
  • typical life change or stress include:
    • business difficulties
    • redundancy
    • loss of a loved one (bereavement or otherwise)
    • marriage or separation
    • birth of a baby
    • children going to school
    • leaving home
    • retirement
    • release from jail
    • leaving hospital
    • returning to home country after period of absence

  • characteristic symptoms develop following a stressful event or situation of an exceptionally threatening or catastrophic nature, in which both of the following were present:
    • the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others
    • the person's response involved intense fear, helplessness, or horror  can affect people of all ages
  • symptoms include:
    • re-experiencing of traumatic event:
      • flashbacks
      • repetitive nightmares
  • intense psychological distress and/or physiological reactivity at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event
  • avoidance of reminders of trauma, indicated by three (or more) of the following:
    • efforts to avoid thoughts, feelings, or conversations associated with the trauma
    • efforts to avoid activities, places, or people that arouse recollections of the trauma
    • inability to recall an important aspect of the trauma
    • markedly diminished interest or participation in significant activities
    • feeling of detachment or estrangement from others
    • restricted range of effect, eg unable to have loving feelings
    • sense of foreshortened future
  • hyperarousal state:
    • irritable
    • overly alert
    • difficulty falling or staying asleep
    • difficulty concentrating
    • anger outbursts
  • full symptom picture must be present for more than one month
  • disturbance causes clinically significant distress or impairment

Please see the NICE Pathway on Post-traumatic stress disorder for further guidance. 

  • Marked preoccupation with an imagined defect in appearance
  • If a slight physical anomaly is present, the person’s concern is excessive
  • The preoccupation causes clinically significant distress or impairment in social, occupational or other important areas of functioning
  • The preoccupation is not better accounted for by another mental disorder (eg. Dissatisfaction in body shape and size associated with Anorexia Nervosa)

Please see the NICE pathway on Body Dysmorphic Disorder for further guidance.

Differential Diagnosis

Medical or other psychiatric disorders:

may have similar symptoms as anxiety or enhance anxiety symptoms include:

  • endocrine and metabolic causes
  • gastrointestinal (GI) causes
  • cardiopulmonary causes
  • neurological causes
  • others:
    • urinary tract infection (UTI; in the elderly)
    • anaemia
    • adverse effects of medication
    • excessive stimulant intake, including caffeine and nicotine
    • excessive alcohol intake or withdrawal

  • Attention Deficit Hyperactivity Disorder (ADHD) (link to be added when pathway complete)
  • Autism Spectrum Disorder (ASD) (link to be added when pathway complete)
  • substance abuse (See Alcohol Misuse / Drug Misuse)
  • depressive disorders
  • psychotic or delusional disorders (link to be added when pathway complete)
  • eating disorders (link to be added when pathway complete)
  • personality disorder 
  • somatisation disorder
  • impulse control disorder
  • health anxiety

When a medical condition is the suspected cause of anxiety symptoms, initiate treatment for the medical disorder - once this has been stabilised, consider treating any remaining anxiety symptoms.

Features more common in depression:

that help to distinguish primary depression from anxiety disorders are:

  • low mood
  • loss of interest or pleasure

  • loss of libido
  • agitation
  • slowed speech, thought processes, and response times
  • low energy
  • changes in appetite
  • changes in weight
  • sleep disturbance - early morning waking or oversleeping
  • feelings of guilt or worthlessness
  • suicidal thoughts

Depressive episodes are accompanied by clinically significant distress or impairment in social, occupational or other important areas of functioning. 

See Full Local Depression pathway.

Drug and Alcohol Misuse

A significant proportion of anxiety presentations are related to drug and alcohol misuse:

  • establish whether anxiety is related to drug and alcohol misuse
  • refer for treatment of the alcohol or drug misuse first as this may lead to significant improvement in symptoms

  • alcohol
  • caffeine
  • nicotine
  • cannabis
  • cocaine
  • decongestants
  • cardiovascular medications
  • corticosteroids
  • anticonvulsants
  • benzodiazepines stopped abruptly
  • opiate withdrawal
  • side effects or withdrawal from tricyclic antidepressants (TCAs) and selective serotonin reuptake inhibitors (SSRIs)

  • a high intake of alcohol or marijuana
  • a pattern of substance use to relieve anxiety
  • a history of benzodiazepine or barbiturate abuse
  • a family or personal history of alcohol or drug problems
  • poor compliance with treatment for anxiety
  • poor results from treatment for anxiety and depression

NB: It is important to be aware that if the person with anxiety also has substance use problems and depression, they are more at risk of suicide or self-harm.

Initial Primary Care Assessment

Immediate steps in primary care:

  • respectful probing and reflective listening:
    • help the patient feel understood and valued
    • promote optimism and motivation while assessment, diagnosis, and strategies are negotiated and actioned
    • this in itself is therapeutic

Assessment for type of anxiety

The following screening tools may be useful:

Perform a mental health assessment to review the person's mental state and associated functional, interpersonal, and social difficulties.

  • nature, frequency, and intensity of symptoms
  • rate of onset – gradual or rapid
  • recent stressful life events and lack of social support (may precipitate anxiety disorders)
  • situations that trigger or exacerbate symptoms, including first occurrence
  • appearance of autonomic symptoms (palpitations, dizziness, sweating, flushing) in anticipation or in response to feared situation or object
  • avoidance and ritualised behaviour (family and others may be involved in this behaviour to lessen person's distress)
  • personal and family history of anxiety disorders
  • chronic or severe physical illness
  • concurrent substance abuse or withdrawal
  • any self-medication
  • cultural or other individual characteristics that may be important in subsequent care

  • assess whether the person has adequate social support and is aware of sources of help
  • arrange help appropriate to level of risk
  • advise the person to seek further help if the situation deteriorates

  • An accurate history and examination can help to distinguish typical anxiety disorders from the normal worry and fears that many healthy people have experienced - specifically consider:

    • severity of symptoms
    • duration of symptoms
    • associated conditions and symptoms, e.g. sleep disturbance
    • relieving factors

Investigations - consider

  • thyroid function tests

OCD

Social Anxiety

 

  • Do you find yourself avoiding social situations for fear you will be evaluated negatively?                                                                   
  • Recommended measure - Social Phobia Inventory (SPIN) 19+ = cut off

GAD

  • Do you worry excessively about a number of different things and experience anxiety and feel tense a lot of the time?                     
  • Recommended measure - Penn State Worry Questionnaire – short (PSWQ) 45+ = cut off

Panic

  • Do you have sudden attacks of fear and anxiety for several minutes that come out of the blue?                                                       
  • Recommended measures - Panic Disorder Severity Scale: self report version (PDSS) 8+ = cut off

PTSD

 

  • Have you experienced a traumatic event that you can't get out of your mind and is causing you distress? Do you re-experience the trauma, avoid triggers that remind you of it, are hyper-aroused and have emotional numbing?
  • Recommended measure - Impact of Events Scale Revised (IES-R) 33+  = cut off

Body Dysmorphic Disorder (BDD)

  • Do you worry excessively about any aspect of your appearance and do these worries stop you getting on with your life?
  • Recommended measure - BDD-YBOCS
GP Led Self-Management

Provide advice / refer / signpost patients to any of the following self-management services;

Consider referral to or signpost patient to Gloucestershire’s Community Drug & Alcohol Recovery Service

  • Substance misuse is in itself not an exclusion to other work, but it will likely impair it, so this may be first step

Practice Point

The Contact Centre may be contacted for advice at any stage:

Tel: 08000 151 499
Email: 2gnft.FPCC-Admin@nhs.net
Fax: 01452 894418
Address: Tri Service Centre, Waterwells Police HQ, Waterwells Drive, Gloucester, GL2 2BP.

Primary Care Management/Prescribing Guidance

  • shared decision making should take place throughout diagnosis and treatment
  • information on the disorder, its treatment, and self-help options should be provided to patients and their families and carers
  • if appropriate, the impact of the presenting problem on the care of children and young people should also be assessed and if necessary, local safeguarding procedures followed

When a person presents with symptoms of anxiety and depression, assess the nature and extent of symptoms:

  • if predominantly depression with features of anxiety, treat the depressive disorder first (see 'Depression' pathway)
  • if predominantly anxiety disorder and co-morbid depression or depressive symptoms, treat the anxiety disorder first
  • if both anxiety and depressive symptoms with no formal diagnosis, that are associated with functional impairment, discuss with the person the symptoms to treat first and the choice of intervention

Provide advice/refer/signpost patients to any of the following self-management services if not previously considered;

Consider referral to or signpost patient to Gloucestershire’s Community Drug & Alcohol Recovery Service

  • Substance misuse is in itself not an exclusion to other work, but it will likely impair it, so this may be first step

 

CBT is recommended for the treatment of mild to moderate anxiety disorders.

In combination with psychological approaches, medications should only be considered for moderate to severe anxiety disorders.

The effectiveness of medications and psychological approaches may be reduced by alcohol use.

Please see the Local Prescribing Recommendations for Anxiety Disorders in the Prescribing section.

Consider referral to MH ICT for further advice / assessment / support and local services

Please use the MH ICT referral form to access these services.

Contact details and referral advice for 2gether's Contact Centre, Crisis Resolution and Home Treatment Teams and other mental health services that accept direct referral are available here.

Notification of Serious Untoward Incidents (SUIs)

Recent reviews of serious incidents have identified potential system and process changes which could improve the quality and responsiveness of care for people who require secondary care mental health services.

It would be helpful if GPs could please share any information in relation to substance misuse with GHC, particularly when a patient is injecting, as this aids clinical risk assessment and management. It is also really helpful if referrals into mental health services contain an appropriate risk assessment.

In all instances when a patient dies unexpectedly, especially if the cause of death is suspected suicide, GPs should inform GHC as soon as possible. This will allow GHC to quickly put in place support for those bereaved and minimise the risk of appointment letters etc. being sent to the deceased.

Contact: gordonbenson@nhs.net (Assistant Director of Governance & Compliance, GCHNHSFT)

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