Anxiety and panic disorders
Dr Tim Webb answers GP Dr Peter Stott's questions on anxiety and panic disorders
Dr Tim Webb answers GP Dr Peter Stott's questions on anxiety and panic disorders
1 For many people anxiety is a normal reaction to a difficult situation – like job insecurity or marital problems. If they ask for a mild tranquilliser, I am usually sympathetic and will prescribe one along with instructions to use sparingly. In these situations where there is a clearly identifiable problem, am I doing the right thing?
I compare anxiety to pain. Usually it is a symptom, not a syndrome. It is important to establish a diagnosis before recommending treatment.
Ask why the patient is seeking to medicalise this if the cause is so obvious and practical. It may be force of habit but could also be that they do not believe their own explanation. The cultural perception that anxiety and depression have their origins in life problems leads us to nominate a cause when we experience them. For example, work is stressful, therefore it makes me anxious. However, it may be the other way around: I have become anxious, therefore work is now stressful. About 70% of people who present with anxiety have enough depressive symptoms to be considered depressed. Always screen for depression and treat where necessary. Always consider alcohol, amphetamines and cannabis use too. Anxious people often use anxiogenic drugs such as these to calm them in the short term. Minor tranquillisers and hypnotics do not treat anxiety, they mask it briefly. They can encourage the sufferer to avoid seeking a solution to its causes. Their numbing effects can be so seductive that psychological dependence occurs. Avoid. Where the anxiety is genuinely short-term and problem-related, medicalising it does not help the patient and may make a rod for your own back.
2 I have older patients with intractable social phobia who drink to excess to self-medicate. They really do seem to be impossible to treat and work options and relationships are limited. What advice can you give to help GPs treat these patients?
The practice of medicine is often about the art of the possible.
Obviously you are obliged to give them best advice, even in the knowledge that it will be ignored. Avoid the temptation to collude by sanctioning what they are doing. Doctors are often manipulated into supplying drugs for the patient to use to avoid the less pleasant effects of alcohol abuse. However, manipulation can work both ways and may offer you a lever of change. Is it ethical to be coercive in the patient's best interests? I think so, provided you act with care. Often in these situations we do not know what the person's optimum level of functioning is. This can make it difficult to assess how impaired they are. It is easy to assume that a low level of functioning is caused by permanent decay rather than a combination of intoxication, treatable depression and other reversible factors.
3 Major forms of obsessive compulsive disorder (OCD) are rarely seen in general practice but are relatively common as part of a depressive illness or anxiety. At what point should a GP refer?
Full-blown OCD is indeed a rare condition but obsessive compulsive features arise frequently in other more common mental disorders. The threshold for referral to mental health services is a bone of contention nationally and is set a lot higher than for referral of most physical conditions. The commonest is when two or more different treatments given at therapeutic level for at least six weeks have failed to make an impact on a disabling condition.
For reasons that are unclear, the presence of OCD symptoms often suggests the patient will respond best to high-dose SSRIs, such as citalopram or fluoxetine at up to 60mg daily. Concurrent psychological treatment, especially if started a few weeks after drug treatment, is helpful too. In areas that have efficient triaging systems, mental health services will usually know which cases are so severe as to warrant tertiary referral to a specialist centre.
4 Post-traumatic stress disorder (PTSD) gets a lot of press after major incidents. But GPs most commonly see it after road traffic accidents and other more minor incidents. How should we recognise it in a patient and what are the therapeutic options?
PTSD can follow any damaging or potentially damaging life event. Its clinical significance is not so much its immediate symptoms as the high number of victims who go on to develop more serious mental disorders. Some clinicians use the term PTSD to describe any condition that may be reactive to past events. In my view this confuses the issue, diluting the concept to the point of uselessness.
PTSD features nightmares, daytime flashbacks and intrusive thoughts about an event, a state of over-arousal and a tendency to avoid activities associated with the event. Specific trauma-focused therapy (TFT) and other techniques such as Eye Movement Desensitisation and Reprocessing (EMDR) can be highly effective in reducing symptoms and stopping the condition developing. Cognitive behaviour therapy (CBT) has a role too, but general counselling does not appear to work and can worsen prognosis.Where symptoms of more major mental disorders arise, my advice is to deal with these in their own right, separately from any PTSD-specific interventions. And in chronic severe cases, always consider substance misuse as a factor.
5 Many of my anxious patients ask me about CBT, but this is virtually unavailable in our area. What are the major principles behind teaching this in general practice and can you direct me to a good source of information on the topic?
CBT is today's must-have talk treatment. More direct in its approach and averse to using psychobabble, CBT operates from what might be termed a three-storey building.
On the top floor are the one-to-one therapists, helping individual patients to overcome specific problems. On the middle floor is the IT department, offering the e-based programmes. On the ground floor is the education department, helping professionals, including GPs, to bring CBT principles into the way they practise. Many GPs already use some of these principles in their consultation skills, often without knowing it. The British Association for Behavioural and Cognitive Psychotherapies is a good starting point to find out about training for GPs. Contact details can be found on its website – www.babcp.com.
6 In managing anxiety, I often use a combination of ß-blockers to control physical symptoms, plus an anxiolytic to manage psychological symptoms, and an antidepressant if there is a concomitant depression. I have used this combination for the past 30 years to good effect. Is there something more modern?
The use of ß-blockers for anxiety is a British habit, coming from medical folklore rather than evidence. Others countries consider this eccentric. That said, and at the risk of upsetting NICE, I suspect they work in some cases. In theory they break the biofeedback loop of anxiety causing tachycardia and awareness of this causes more anxiety.
I have not prescribed an anxiolytic or hypnotic to a non-addicted patient since October 1983. They mask key symptoms, such as sleep pattern, anxiety level, concentration and motivation. As such they confound diagnosis. Where psychological treatments are not available, I take the view that it is justifiable to try treatment with an antidepressant rather than offer no treatment at all. Experience suggests their efficacy is underrated in anxiety disorders. A one-month trial at standard dose and, if there is no response, a month at higher dose often pays dividends. Published evidence is still catching up with the evidence of experience in many areas of mental health. The latter suggests that best outcomes for maybe half of the cases of anxiety disorder happen with combined and co-ordinated drug and psychological treatments.
7 Many of my anxious patients are also depressed. Which antidepressants would be best in this situation? What are the differences?
SSRIs have become the class of choice because of commercial factors. Companies carried out controlled trials in a wider range of conditions to gain market advantage through obtaining extra licensed indications.
The older antidepressants were never properly trialled, though clomipramine and others had been drugs of choice in OCD and agoraphobia for years. I use the cheapest SSRI as my first-line antidepressant, though I prefer citalopram. The commonest reason why an antidepressant does not work is that the patient has not taken it. The second commonest reason is that they have not taken enough. Where an individual has panic attacks or severe anxiety, a higher dose is often necessary. Where OCD or bulimia is in the picture the dose may need to be at BNF limits. If one SSRI has not worked, published evidence suggests a different SSRI might do so, though this makes little sense in theory. My own second-line choice is something with a different action, such as venlafaxine, lofepramine, mirtazapine or duloxetine.
8 We recently had a GP registrar who had worked in psychiatry. I was having difficulty controlling the symptoms of a patient who had very severe generalised anxiety disorder. The registrar prescribed a small dose of a major tranquilliser, which worked very well. Is use of these agents common in hospital practice?
Low-dose neuroleptics – or major tranquillisers – are perhaps mental health's equivalent to primary care's ß-blockers. There is no evidence base but they work in some cases.
The older drugs tend to cause Parkinsonian tremors that need to be countered with drugs such as procyclidine. They may also sedate. The newer drugs are more likely to cause significant weight gain and other metabolic problems. So neither type should be a regular option. Chlorpromazine up to 150mg per day or trifluoperazine up to 5mg per day, in divided doses, can be worth trying. Of the newer drugs, risperidone, available as a generic shortly, may well be the best option at around 0.5mg twice daily.
9 I am sometimes called to make an urgent home visit during evening surgery by patients with panic attacks. They seem rarely able to come to the surgery. It is difficult to leave surgery at that point to see them. How should I react?
Obviously only you can judge whether the person is having a panic attack and not something more serious. A panic attack is not a medical emergency, though the patient and those around them may not see it that way.
If a panic attack gets out of hand, humans have a built-in shut-down mechanism. Hyperventilation blows CO2 out of our bloodstream and we faint. Having fainted, breathing tends to come back under control and allows the panic feelings to pass. Getting the patient to breathe into a paper bag works sometimes, as the exhaled CO2 re-enters the bloodstream, reducing panicky feelings. Far more important is to ensure that the cause of the panic attack is diagnosed and addressed appropriately, in due course. Most local health economies spend more on putting physically healthy people who have panic attacks into coronary care units than they spend on services to assess and treat people who suffer regular panic attacks.
10 Complementary therapies are very widely used by patients for anxiety. Which are the most popular and what are the main problems in their use that doctors should be aware of?
Complementary therapies have a complex role in managing anxiety. In part, CBT works by giving people confidence to control their symptoms. If a patient gains that confidence through use of a complementary therapy, is that not as good, even if the science of the process is mumbo-jumbo? My usual stance is to say that if it works, carry on.
The only time I object to complementary therapists is when it comes with attitudinal baggage about conventional medicines being bad or dangerous. Although it may be necessary for marketing purposes, it can also be negligent. I am sure there is a role for exertion-based techniques. Sweat-breaking exercise of 30-60 minutes three times weekly is known to reduce anxiety and depressive symptoms. Counterintuitively, the evidence that meditative and relaxation techniques work is less good, though it may be that people for whom these techniques work well do not come our way as often.
Dr Tim Webb is consultant in adult psychiatry at West Suffolk Hospital and medical director, Suffolk health partnership NHS trust
Competing interests Dr Webb is co-organiser of the annual PriMHE event for innovators, sponsored by Wyeth Pharmaceuticals – he was also paid by Wyeth to speak about PriMHE's new guidelines for management of mental disorders
• Minor tranquillisers and hypnotics do not treat anxiety – they mask it briefly, and can encourage the sufferer to avoid seeking a solution. Always consider alcohol, amphetamine and cannabis use too.
• Self-guided CBT delivered on line, with supervision available from a trained therapist as and when necessary, is supposed to now be available across the whole of the NHS.
• If there are obsessive compulsive disorder symptoms the patient may respond best to high-dose SSRIs. Referral is usually when two or more different treatments given at therapeutic level for at least six weeks have failed.
• CBT has a role in post-traumatic stress disorder but general counselling does not appear to work and can worsen prognosis.
• If one SSRI has not worked, published evidence suggests a different SSRI might, though this makes little sense in theory.
• Sweat-breaking exercise of 30-60 minutes three times weekly is known to reduce anxiety and depressive symptoms.
• In severe symptoms low-dose major tranquillisers such as risperidone 0.5mg bd may be of use.
what I will do now
Dr Stott responds to the answers to his questions
• I am struck by how contemplative Dr Webb is in comparison with my own instinctive reactions to situations. Over the years, I have obviously become so used to managing anxiety in a 10-minute consultation that I seem to be in danger of reacting in a stereotypical fashion. Therefore I will take more care to look for the causes of symptoms before offering medication and for the presence of concomitant depression.
• I need to learn more about CBT and now know where to start.
Dr Peter Stott is a GP in Tadworth, Surrey