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Unit 457 April 2010

Anxiety disorders
check Anxiety disorders

Medical Editor in Chief


April 2010 Unit 457 Dr Jenni Parsons
Anxiety disorders Medical Editor
Dr Kath OConnor
Program Coordinator
From the editor 2 Sharon Benson
Case 1 Jeffreys persistent worries 3 Graphic Designer
Jason Farrugia
Case 2 Toms social difficulties 7 Illustrator
Christopher Nielsen
Case 3 Amandas panic 11
Authors
Case 4 Jims distressing thoughts 13 Richard Moulding
Maja Nedeljkovic
Case 5 Pauls nightmares and anxiety 17 Michael Kyrios
References 20 Reviewers
Dr Nickolai Titov
Resources 21 Dr Ralph Lewis

QA&CPD Program requirements 22

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5. Organisational and legal dimensions

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From the editor

This unit of check looks at anxiety disorders with clinical scenarios relating to generalised
anxiety disorder (GAD), social anxiety disorder, anxiety disorder not otherwise specified, panic
disorder, obsessive compulsive disorder (OCD) and post-traumatic stress disorder (PTSD).
Anxiety disorders are common, affecting 14.4% of Australian adults in a 12 month period.1
Accurate diagnosis and exclusion of differential diagnoses is important. Management involves
psychoeducation, psychological and stress management strategies and, in some cases,
pharmacological strategies.
The authors are from the Faculty of Life and Social Sciences at Swinburne University of
Technology in Melbourne, Victoria. They bring a wealth of clinical, research and teaching
experience to the topic. The authors of this unit are:
Richard Moulding, BSc(Hons), MPsych, PhD, MAPS, PsyCHE Research Centre, Faculty of Life
& Social Sciences, Swinburne University of Technology, Victoria. His interests include anxiety
disorders, obsessive compulsive spectrum disorders, hoarding, evidence based psychological
therapy and primary care
Maja Nedeljkovic, BSc(Hons), MPsych, PhD., MAPS, PsyCHE Research Centre, Faculty
of Life & Social Sciences, Swinburne University of Technology. Her interests include
depression and anxiety disorders, obsessive compulsive spectrum disorders, hoarding,
e-therapy and public health
Michael Kyrios, BA, DipEdPsych, MPsych, Ph.D, FAPS, Director, Brain Sciences Institute and
Director, PsyCHE Research Centre, Faculty of Life & Social Sciences, Swinburne University of
Technology. His interests include anxiety disorders, obsessive compulsive spectrum disorders,
depression, mental health in chronic medical conditions and primary care.
The learning objectives of this unit are to:
r ecognise the clinical features of GAD, social anxiety disorder, panic disorder, anxiety
disorder not otherwise specified, OCD and PTSD
a
 ppreciate that a number of clinical tools are available to help in the diagnosis and
assessment of anxiety disorders
r ecognise the importance of asking patients with anxiety disorders about depressive
symptoms and risk of harm to self or others
u
 nderstand the importance of psychoeducation and relaxation strategies in the management
of anxiety disorders
a
 ppropriately manage and/or refer patients for management of GAD, social phobia, panic
disorder, anxiety disorder not otherwise specified, OCD and PTSD
a
 ppreciate that a number of clinical tools, including online tools, are available to aid in the
treatment of anxiety disorders.
We hope this unit will assist you to confidently assess and manage patients who present in the
general practice setting with symptoms of anxiety.

Warm regards

Kath OConnor
Medical Editor

1. Australian Bureau of Statistics. National survey of mental health and wellbeing: summary of results.
ABS Cat. no. 4326.0. Canberra: ABS, 2007.

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Case 1

Jeffreys persistent worries Question 1


Jeffrey, aged 46 years, is an IT consultant who is What is the likely diagnosis?
married with two children, aged 10 and 12 years. Due
to the retirement of his previous general practitioner,
he presents to you for the first time with concerns
about his health, family and the future. A letter from
his previous GP details an incident about 2 months ago
in which Jeffrey experienced shortness of breath and
an irregular heart beat while playing tennis. He was
thoroughly investigated for an organic cause (normal
electrocardiogram, Holter monitor, stress test, thyroid
function tests, full blood examination and biochemistry)
and none was found. His GP had no concerns regarding
substance or medication use and abuse. Question 2
Since the incident, Jeffrey has noticed similar What differential diagnoses do you need to consider?
symptoms occurring intermittently. He also describes
other aches and pains over the past few years,
including headaches, and neck and back pain. He
attributed these to general tiredness and stress, and
says that for a number of years he has experienced high
levels of stress and anxiety associated with work and
home responsibilities. He is concerned about the future,
his work performance, money, and his ability to keep his
job and provide for his family.
He says that he constantly feels tired and overwhelmed,
and has barely managed to keep his head above water
Question 3
for the past decade. His previous GP and a counsellor
at work suggested stress management strategies such What further information will help you confirm your
as tennis and morning jogs. He kept fit doing these diagnosis and exclude differential diagnoses?
activities until 2 months ago when he had the episode of
shortness of breath and irregular heart beat. Around the
time of this episode, a colleague of similar age at work,
died suddenly from a heart attack. Since then, this and
all the other worries have been constantly on his mind.
Jeffrey says he trusts his former GPs opinion that he
is physically okay but even the smallest probability of
having a heart attack like his colleague has started a
barrage of thoughts and scenarios running through
his mind. He fears becoming seriously ill and not being
able to support his familys commitments such as the
mortgage, school fees, and even basic needs. He says,
I know its ridiculous to worry so much about all this. Question 4
Despite constant reassurance from his wife, he cannot What clinical tools may help with your further
seem to get any peace from the thoughts. assessment?
Jeffrey says he feels exhausted and overwhelmed, is
constantly preoccupied with his worries, and has trouble
concentrating at work. He feels unable to engage
normally with his family, particularly his children. He has
had enough of the worries and is desperate to find out
what is happening and whether you can help him.

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Case 1

Question 5 Answer 1

Your further assessment supports your diagnosis. What Jeffreys most recent health concerns seem to be
is your management plan? part of a more general pattern of worries over several
years. He describes frequent and persistent worries
about his health, his family and his capacity to provide
for them. The most recent concerns seem to have
been precipitated by the unexpected death of a
work colleague and the experience of physiological
symptoms (irregular heart beat, shortness of breath,
fatigue, muscle tension), emotional symptoms
(irritability, feeling on edge), and cognitive symptoms
(difficulty concentrating, frequent worries). His worries
seem to be persistent, very distressing and interfere
with Jeffreys day-to-day functioning (difficulties
concentrating at work, loss of interest in leisure and
family activities, difficulty sleeping, feeling tense). The
nature of the symptoms and medical investigations
provide no indication of a physical/physiological cause
for the symptoms.
Overall, Jeffreys current difficulties seem consistent
with symptoms of GAD. In Australia, according to the
National Survey of Health and Well-Being,1 GAD is one
of the more common anxiety disorders, affecting 5.9%
of Australian adults in a 12 month period (4.4% males,
7.3% females). Along with panic disorder, GAD tends to
be one of the most common diagnoses in primary care.2
Most individuals with GAD describe being nervous
throughout their lives, although it tends to worsen during
times of stress (Table 1).

Table 1. Abbreviated criteria for GAD in the Diagnostic and Statistical Manual of Mental Disorders, Fourth
Edition Text Revision (DSM-IV)3
A. Excessive anxiety and worry (apprehensive expectation)*, occurring more days than not for at least 6 months, about a number of events or
activities (such as work or school performance)
B. The person finds it difficult to control the worry
C. The anxiety and worry are associated with three (or more) of the following six symptoms**, with at least some symptoms present for more days
than not for the past 6 months.
Note: Only one item is required in children.
Restlessness or feeling keyed up or on edge
Being easily fatigued
Difficulty concentrating or the mind going blank
Irritability
Muscle tension
Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep)
* The anxiety and worry must not be confined to another disorder (eg. being embarrassed in public), be due to the direct physiological effects of a
substance or a general medical condition, and must cause clinically significant distress or impairment
** There may be trembling, twitching, feeling shaky, and muscle aches or soreness associated with the muscle tension. Many individuals also
experience somatic symptoms (eg. sweating, nausea, or diarrhoea) and an exaggerated startle response. Other symptoms of anxiety are also
often present (eg. heart palpitations, shortness of breath, dry mouth, dizziness)

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Case 1

Answer 2 Major depression


Differential diagnoses to consider include: A diagnosis of major depression also needs to be
Other anxiety disorders discounted. Patients presenting with depression are
also preoccupied with negative thoughts. However, in
These include panic disorder, specific phobias, social
such cases, depressed patients are preoccupied with
phobia, OCD, acute and PTSDs, substance induced
past events, express self criticism and guilt, and also
anxiety disorder, and anxiety disorder due to general
experience anhedonia (loss of pleasure) and/or lowered
medical condition. Generalised worries are the central
mood. Nonetheless, psychiatric comorbidity between
symptom of GAD, and include worries about the long
GAD and major depression is common, with the most
term effects of worrying itself (ie. worrying is dangerous;
recent Australian data indicating that having GAD
worrying can be harmful to my health; worrying means
increases the likelihood of having depression (odds
my thoughts are out of control). By contrast, in other
ratio of 28.9).4
anxiety disorders, the anxiety is focused on specific
thought content such as misinterpretation of physiological Ceasing benzodiazepine use
symptoms in panic disorder; specific objects (eg. animals) Ceasing benzodiazepine use can be associated with
or situations (eg. storms, heights, enclosed spaces) in anxiety, sensitivity to sound, light, smell and taste,
specific phobias; fear of negative social judgments and feelings of imbalance, gastointestinal symptoms,
embarrassment in social phobia (social anxiety disorder); aches, pains and muscle spasms, vertigo and rebound
themes such as contamination, personal responsibility insomnia. In Jeffreys case, there is no history to
and morality, and doubts about safety in OCD; and an suggest benzodiazepine withdrawal.
actual or threatened traumatic event where death or
serious injury, or threat to the physical integrity of self/ Answer 3
others was evident in acute and PTSDs.3 More detailed history around the main symptoms (ie.
At this stage, Jeffreys symptoms seem to be better nature, content and extent of worries) and the history
explained as part of a more general set of worries of worrying is required. Generalised anxiety disorder
(although this needs to be confirmed). Panic disorder often has an early onset, multiple episodes over the
is unlikely as Jeffrey does not misinterpret specific lifetime often associated with stressful life events,
cardiovascular symptoms as indicative of impending and a waxing and waning course. Information about
death, nor does he experience repeated unexpected Jeffreys response to the worries throughout his life is
panic attacks. Social phobia is unlikely as Jeffreys important for diagnostic clarification and to determine
symptoms do not occur not in response to social the treatment approach.
situations. Obsessive compulsive disorder can be It is important to gauge the level of insight Jeffrey
discounted as there are no specific concerns about has regarding his health concerns in order to exclude
contamination and morality, causing harm, or the hypochondriasis. Does he believe he has a heart
experience of a pivotal sense of personal responsibility condition or recognise that his concerns are anxiety
over issues relating to the prevention of dangerous driven? Does he try to cope by seeking to have more
outcomes and/or the need to compensate for them. tests to confirm a physical diagnosis or is looking for
There is no indication of substance induced anxiety anxiety relief? A drug history asking about prescribed
disorder, although substance abuse needs to be and over-the-counter medication use, alcohol intake
specifically enquired about. Anxiety disorder due to and other drug use is important to exclude substance
general medical condition is unlikely in the setting of induced anxiety disorder. Further questioning about
normal investigations from Jeffreys previous GP. depressive symptoms is also important.
Hypochondriasis
Answer 4
Hypochondriasis is a somatoform disorder where the
To quantify Jeffreys level of anxiety, an anxiety
individual has a preoccupation with the idea of having
checklist or self report inventory such as Depression
(or the idea that one has had) a serious disease, based
Anxiety Stress Scales-215 or the Penn State Worry
on the persons misinterpretation of bodily symptoms
Questionnaire6 may be useful. These types of
as indicative of a specific serious disease, where the
questionnaires can be used to track the severity of
preoccupation persists despite medical evaluation and
symptoms over time. Other questionnaires include the
reassurance. Jeffrey seems to have some insight about
K-10 which measures general distress and the Patient
his health concerns and the lack of a physiological basis
Health Questionnaire-9, which assesses depression.7
for them, and has not engaged in excessive search
for evidence of heart problems. This provides further
support for GAD rather than hypochondriasis.

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Case 1

Answer 5 cardiac disease, eg. the difference in the sharp pain of a


Jeffreys management plan could include: panic attack compared to the crushing or distributed pain
usually accompanying a heart attack.2 If there are any
Psychoeducation
avoided activities, then gradual exposure to feared events
Psychoeducation about the nature of anxiety, its purpose or stimuli may help. Structured problem solving can help
and how it can present is important when dealing with deal with real life stressors and has been shown to be
someone with any anxiety disorder, and particularly with effective; it can be easily administered by GPs.9
GAD. In most cases, on top of their presenting worries
General practitioner assisted bibliotherapy (the use of
(eg. health problems, finances, family), individuals with
books to address emotional or behavioural issues) or
anxiety problems will also suffer worry about worry
computerised treatment may be helpful (see Resources).
(eg. that anxiety is dangerous, that they are going crazy
A range of internet resources for GAD are available,
or losing it), which clearly exacerbates any anxiety
including the National e-Therapy Centre for Anxiety
problem, and is suggested to be one perpetuating factor
Disorders (see Resources) which includes a diagnostic
in GAD.8 For this reason, psychoeducation itself may
tool and a 12 week treatment for GAD that can be self
help alleviate some of the symptoms. Psychoeducation is
directed, assisted by an online therapist, or monitored by
also an important lead-in to some treatment options (eg.
a GP or other mental health professional.
relaxation, cognitive behaviour therapy [CBT], exercise,
yoga). General practitioners are in an excellent position Referral to a clinical psychologist for psychotherapy
to provide such information, as a trusted and authoritative can be extremely helpful and is supported by Medicare
source of information about health and physiology. through the Better Access to Mental Health Services
scheme (see Resources). In particular, CBT is effective,
Explain to Jeffrey that he is experiencing normal anxiety
focusing on addressing beliefs that may underlie
symptoms and they are not dangerous, despite being
the anxiety, increasing the individuals intolerance
somewhat unpleasant. On the contrary, anxiety is
of uncertainty and developing more adaptive beliefs
essential to avoid danger and moderate anxiety actually
about worry (eg. worrying will not likely help me solve
improves performance (eg. exams, work).
problems rationally or worrying cannot kill me). Applied
It may help to describe the fight/flight model of anxiety, relaxation is also effective for GAD, although it is not as
and refer specifically to Jeffreys individual symptoms effective for other problems such as panic disorder.10
and their purpose. For example, the experience of
Pharmacological
difficulty breathing can be explained as an increase in
breathing frequency in order to increase the amount of Specific serotonin reuptake inhibitors (SSRIs) are
oxygen entering the body as well as a rapid heartbeat the treatment of choice, and paroxetine, venlafaxine,
which allows the body to transport oxygen to the muscles and escitalopram have been indicated for GAD by
for energy and remove waste products more quickly. the Therapeutic Goods Administration. However, only
These changes are designed to help the body respond to escitalopram is listed on the Pharmaceutical Benefits
a threat. However, during hyperventilation the increased Scheme (PBS) for this indication (Table 2).
oxygen in the bloodstream and increased expulsion of
Table 2. PBS listing for SSRIs used in anxiety
carbon dioxide can actually reduce the level of oxygen
disorders*
supplied to the heart and lungs (Bohr Effect). This can
lead to heart and chest pain and arrhythmias such as Escitalopram Listed as a restricted benefit for the treatment of
major depressive disorder (MDD) and treatment of
those experienced by Jeffrey. Other symptoms (eg.
moderate to severe GAD in a patient who has not
shakiness, fatigue, tenseness, blurred vision, dry mouth, responded to nonpharmacological therapy, and
hot flushes, sweating), may be linked to anxiety and the for whom a GP Mental Health Care Plan, as
fight/flight reaction, or to the effects of hyperventilation. described under Item 2710 of the Medicare
Psychological and stress management strategies Benefits Schedule, has been prepared, or
who has been assessed by a psychiatrist
Basic relaxation methods (eg. progressive muscle
Fluoxetine and Listed as a restricted benefit for MDD and OCD
relaxation) and breathing control can help to reduce the
Fluvoxamine
physical symptoms of anxiety. Planning these activities
Paroxetine Listed as a restricted benefit for MDD, OCD and
can also reduce the focus on stressors. Activities that
panic disorder
involve moderate physical activity or breathing control
Sertraline Listed as a restricted benefit for MDD, OCD and
can be particularly useful as they can help reduce
panic disorder where other treatments have
physiological symptoms of anxiety. failed or are inappropriate
While heart disease has been excluded in Jeffreys case, * Refer to www.pbs.gov.au
it may be helpful to explain to him the differences between
physical symptoms of exercise/anxiety and those of

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Case 2

Toms social difficulties Tom is the first of two children in his family; his sister is
Tom is a 13 year old boy who has just finished his first 2 years younger than him. From reports by the parents
year of high school. He presents with his parents who and Tom, and your observations, it seems that the family
are concerned about his increasing social difficulties. relationships are loving and warm. Toms parents seem
They tell you that over the past year Tom has become supportive and have encouraged him to socialise more.
increasingly withdrawn. He has been spending more However, this seems to have had the opposite effect,
time at home and in his room, where he hides if with Tom becoming even more avoidant. His marks
someone outside his extended family is visiting the at school have deteriorated, particularly for subjects
house. Toms teachers are concerned that he has not requiring greater class participation (eg. English).
participated in class or group activities. He avoids Despite his difficulties, Tom has continued to attend
speaking in front of the class and seems to find it school regularly. He reports having stomach aches
difficult to socialise during class breaks. He tends to before going to school, particularly on days when he
spend most of his nonclass time with one other boy may be required to speak in front of the class. Tom has
rather than with a range of his peers. always been a bit shy but his anxiety has increased
dramatically over the past year, coinciding with the start
Tom is difficult to engage but after a few minutes and
of high school.
numerous empathetic statements from you, he is able
to overcome his evident shyness. You ask him how he
feels around people he doesnt know well. He says he Question 1
feels self conscious, uncomfortable and nervy, and
What is your provisional diagnosis?
constantly worries what they think about him. Tom
describes fear in any situation where there is a crowd or
he may be the focus of other peoples attention including
meeting new people, speaking in front of the class,
talking to teachers or peers, using the toilets at school
or shopping centres, lining up for tickets at the cinema
and eating in public.
You ask Tom what he is afraid of. He says he fears
saying or doing the wrong thing or not knowing what
to say or do, and that others will think badly of him
as a result. The fear is so intense that he can get
into a complete panic and needs to get out of the Question 2
situation immediately. When he is in a panic, he has What differential diagnoses would you need to consider?
an increased heart rate, chest discomfort, shortness of
breath, sweating, and feels like he is going completely
blank. He believes others can see these symptoms and
would think he is pathetic for having them. Tom says he
has two good friends he feels comfortable with, one is
a neighbour and the other attends the same school as
him. However, Toms parents noted that he has been
going out less over the past few months. Tom says it
takes too much energy to work out what to wear: he is
very concerned about his appearance and how he may
appear to others.
Question 3
What further information would help you formulate your
diagnosis and exclude differential diagnoses?

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Case 2

Answer 1

Question 4 Toms presentation is consistent with a diagnosis of


social phobia (social anxiety disorder), generalised type.
What clinical tools may help with your further
He reports a fear of embarrassment across a range
assessment?
of situations, and has experienced intense anxiety
at times in the form of a panic attack. Tom reports
concerns about how he is perceived by others and
feeling embarrassed at the anxiety symptoms, along with
physiological symptoms consistent with panic (Table 3).
In Australia, 3.8% of males and 5.7% of females have
social phobia over a 12 month period, according to the
latest survey.1 Social phobia typically begins in the mid
teenage years, sometimes following childhood shyness.
Social phobia often is continuous and lifelong. There is
some evidence for a familial pattern in occurrence.
Question 5
Your further assessment supports your diagnosis of Table 3. Abbreviated DSM-IV criteria for social
social phobia (social anxiety disorder). What is your
phobia3
management plan? A. A marked and persistent fear of one or more social or performance
situations in which the person is exposed to unfamiliar people
or to possible scrutiny by others. The individual fears that he or
she will act in a way (or show anxiety symptoms) that will be
humiliating or embarrassing.
Note: in children, there must be evidence of the capacity for age
appropriate social relationships with familiar people and the anxiety
must occur in peer settings, not just in interactions with adults
B. Exposure to the feared social situation almost invariably provokes
anxiety, which may take the form of a situationally bound or
situationally predisposed panic attack
Note: in children, the anxiety may be expressed by crying,
tantrums, freezing, or shrinking from social situations with
unfamiliar people
C. The person recognises that the fear is excessive or unreasonable.
Note: in children, this feature may be absent
D. The feared social or performance situations are avoided or else
are endured with intense anxiety or distress

Answer 2
There are several differential diagnoses to consider
in Tom:
Normal anxiety
Some normal anxiety would be expected in the
transitional period of moving from primary to high
school. In deciding whether Toms difficulties warrant
a diagnosis of social phobia, you need to consider the
level of intensity of the anxiety, extent of the avoidance
and extent to which these interfere with his functioning.
Panic disorder
The symptoms that Tom reports when his anxiety
is intense (eg. rapid heart beat, chest discomfort,
shortness of breath, sweating, blushing) are consistent
with a panic attack. In Toms case, his panic attacks are
likely to be features of social phobia because they occur
in social situations and are triggered by his intense fear
of negative social evaluation. If the attacks occurred in
other situations (eg. unexpectedly while at home alone)

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Case 2

and Tom showed a persistent fear of further attacks (ie. social cues will aid in treatment planning (eg. in order
a fear of panic), panic disorder could be considered as to create a fear hierarchy as will be discussed later). It
a diagnosis. is also important to consider the impact of the current
Separation anxiety disorder difficulties on Toms social, school and leisure activities
and ask about symptoms of more generalised anxiety
Toms symptoms began before 18 years of age so this
and depression. Further information regarding his school
diagnosis can be considered. However, Toms fears
life may be helpful, particularly asking about any major
relate to social embarrassment rather than separation,
difficulties such as teasing and bullying which often
so social phobia is a more appropriate diagnosis.
precipitate and exacerbate social anxiety. If there is any
Avoidant personality disorder suggestion of abuse this should be assessed further.
If Toms symptoms continue into early adulthood, then As with other emotional disorders, it is important
the personality disorder diagnosis, avoidant personality to assess for possible predisposing, precipitating,
disorder, may also be applicable. Avoidant personality perpetuating and protective factors. It is likely that a
disorder is very similar to generalised social phobia range of biological and environmental factors have made
and concerns a pattern of social inhibition, feelings of Tom vulnerable to developing his current difficulties.
inadequacy, and hypersensitivity to negative evaluation. It is possible that there is a biological vulnerability to
Depression developing anxiety (such as an inherited tendency to
Tom has not volunteered any specific depressive develop anxiety under stress).11,12 It is important during
features, but it is important to ask about these as this is the history taking process to gather more information
an important diagnosis which should not be missed and regarding a possible history of anxiety difficulties in the
may interfere with treatment. family. Even if no such history is reported, the indication
by Toms parents that he has always been a shy child
Generalised anxiety
provides some indication of a temperamental factor or
In Toms case, social phobia is more likely as his anxiety biological vulnerability.
is triggered in social situations by his intense fear of
The anxiety seems to have increased over the past year,
negative social evaluation. However, it is important to
which coincides with Tom transitioning from childhood
ask about more general anxiety symptoms as these may
to adolescence; this is common in social phobia. This
interfere with treatment.
transition is accompanied by major biological, physical,
Substances/drugs psychological and social changes. Physically, there is
Use of substances or drugs does not necessarily increased awareness of ones changing body and an
preclude a diagnosis of social phobia these more increased concern with how one is perceived socially.
commonly follow the problem and work as maladaptive Also, environmental or social demands increase
coping mechanisms. dramatically during this period. Peer relationships
Schizophrenia prodrome become increasingly important and the transition into
The median age of onset for psychosis is typically a new environment (eg. primary to secondary school)
around 21 years in males and older in females but places further challenges in terms of forming and/or
can occur in individuals as young as Tom (or even maintaining such relationships. These are likely to have
younger). Unfortunately, the prodromal symptoms precipitated Toms difficulties, eg. he expressed concern
of schizophrenia tend to be nonspecific (eg. social about what he wore and how he appeared to others
withdrawal, cognitive decline, anxiety, and perhaps to such an extent that this often prevented him from
some limited psychotic symptoms). However, if there is participating in social activities.
no family history of psychosis in first degree relatives Toms problems may be maintained by avoidance
and no developmentally abnormal psychotic symptoms, behaviours and possibly by unhelpful thinking styles
a prodrome is unlikely in this case. (cognitive factors). It has been suggested that people
with social phobia have a range of distorted thoughts
Answer 3 (cognitions) concerning what might happen in social
Enquiring about the specific focus of Toms concerns situations (eg. Im bound to make a fool of myself) and
can be helpful in distinguishing social phobia from panic regarding their self evaluation of how they performed
disorder. For example, panic attacks in social phobia are in the situation (eg. they could see I didnt know what
usually triggered by an extreme concern about being I was talking about). The cognitive aspect of social
negatively evaluated by others. More information about phobia frequently involves fear of negative evaluation
the extent of the fear of negative social evaluation will by others, selective attention to negative aspects of
help clarify the diagnosis and specific details about the how one responded in a social situation and very high
type of feared situations and the misinterpretation of standards for how one should behave and appear in

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Case 2

these contexts.13 For example, Tom says he is concerned Breathing control and general relaxation exercises
about how he appears to others and that he is worried may be useful. Again, pharmacological treatments,
others will think badly of him because he might not particularly SSRIs (Table 2), are available and have been
know what to say, or he would say the wrong thing in used in adolescents. However, the authors recommend
a situation. Consequently, he avoids these situations. caution: specialist advice may be needed before these
This avoidance is viewed as a key maintaining feature medications are commenced in this age group.
in social phobia. As with other anxiety disorders, such A referral to a clinical psychologist for a course of CBT
avoidance prevents the person from learning to be treatment can be considered. Psychological treatments
nonfearful in difficult situations. If they are able to have been shown to be as effective as medication for
actually confront the feared situation, the person can social phobia and CBT have the greatest evidence for
start to disconfirm negative predictions of what might efficacy.
happen). More information about the situations that
The aim of CBT is to help the patient understand how
are avoided and the predominant cognitions in these
and why anxiety symptoms develop, what triggers
situations can help the clinician to plan treatment.
them and what unhelpful responses maintain the
Answer 4 symptoms. Also, patients are taught coping strategies
(cognitive and behavioural) to assist them to manage
Self report measures such as the Brief Fear of Negative
their symptoms. The main behavioural component of the
Evaluation Scale14 or the Liebowitz Social Anxiety
treatment is graded exposure to feared social situations,
Scale15 may be helpful. An age appropriate scale to
in which the patient gradually confronts feared or
assess anxiety in adolescents has been developed by
avoided situations without their usual safety behaviours
Spence and associates in Australia16 (see Resources).
until their anxiety reduces.
These scales provide quantitative information on the
level of anxiety symptoms. The cognitive component involves identifying Toms
thoughts about himself which contribute to his fear and
Diary methods whereby the patient or, in the case of
avoidance of social situations. He can then be helped
socially anxious children, parents or teachers and
in challenging these unhelpful thoughts. He can use
even peers monitor the situations in which the anxiety
these strategies along with relaxation and other anxiety
occurs, can help gather information about the specific
management strategies when confronting anxiety
type of feared situations and the misinterpretation of
situations.
social cues. This method can also be used to gather
information about the cognitive and behavioural A number of CBT programs, in the form of books and
processes that occur in such situations. For example, CDs, have been developed for use with children.17,18
along with the types of situations in which Tom Internet based treatments for childhood and adolescent
experiences anxiety, he can also record what is going anxiety have also been developed.19 Cognitive
through his mind in such situations, as well as his behaviour therapy for social phobia can also be
responses to the situations. undertaken in a group format. Group treatments can
be particularly effective as they provide a unique
In social phobia, as with all of the anxiety disorders,
opportunity for exposure to social interaction with other
the anxious individual will often demonstrate safety
group members and support from peers in the often
behaviours which aim to help minimise the anxiety (eg.
challenging exposure exercises.
standing away from the social group, volunteering to
be assessed via essay rather than class presentation, Other referrals may be appropriate depending on
staying away from school on sports days, avoiding social Toms needs. He may wish to see a school counsellor
events and other avoidance strategies). Rather than to discuss any ongoing issues with his peers (eg.
constituting coping strategies that are helpful in the long bullying, teasing). Some individuals with social phobia
run, such safety behaviours act to maintain the social also may require social skills training, either in general
anxiety (ie. the individual never has the opportunity conversation skills, specific skills (eg. public speaking),
to learn that such situations are not as dangerous as or general assertiveness training.
they perceive), and can make the person more likely to
experience rejection.

Answer 5
There are a number of possible treatment approaches
for Tom. As with all anxiety disorders, the patient
should be provided with detailed education regarding
what anxiety is, in order to normalise their experience.

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Case 3

Amandas panic Question 2


Amanda, aged 26 years, she is a previously well, What is your assessment of Amanda now?
recently divorced mother of a 2 year old son. She
presents complaining that she often feels in a panic
when she is home alone at night.

Question 1
What questions will you ask to find out what Amanda
means when she says panic?

Question 3
What will you do next?

Further history
Amanda describes apprehension, frequent negative
thoughts and increasing anxiety. She has experienced
shortness of breath and palpitations all night over the
last 2 nights and this is what prompted her visit. Her
levels of anxiety have increased over the past week,
particularly in the afternoon in anticipation of putting
her son to bed, with the panic increasing after she puts
him to bed and has her dinner. She cannot recall exactly
when the symptoms started but reports that the feelings
have been gradually getting stronger over the past few
months following the break up of the relationship with
her partner. She says that before the divorce she was an
easy going person and these symptoms are very unusual
for her.
Amanda does not drink alcohol or take any over-the-
counter medications, prescribed medications or illicit
drugs. She does not take excessive caffeine, sugar or
sugar replacements such as aspartame. She denies
symptoms of depression and there are no specific
symptoms suggestive of an organic cause. Basic
investigations (including thyroid function tests and
electrocardiogram) are normal.

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Case 3

Answer 1 Offering general support may be all that is needed in the


It is helpful to start with open questions asking what first instance. As with any anxiety symptoms, providing
Amanda means when she describes panic. Patients who information about the nature and purpose of anxiety and
complain of feeling panic do not necessarily have a panic fear can be useful. It may help to encourage Amanda
attack or panic disorder. The term panic is often used in a to take part in activities that are either distracting (eg.
general, exaggerated sense by patients to describe feeling hobbies, enjoyable activities), or potentially anxiety
stressed or overwhelmed. This is a common problem in the relieving (eg. yoga, exercise, martial arts, tai chi).
diagnosis of many anxiety disorders because there are so Structured problem solving may help Amanda to remove
many lay terms used to describe varying degrees of anxiety or deal with some of the difficulties in her life.
and its accompanying physical symptoms (eg. patients with General supportive counselling may be useful, either
preoccupations or minor superstitions may report they have from the GP if there is sufficient time, or from an
OCD or refer to their obsessions). Furthermore, patients alternative professional (eg. counsellor, social worker,
may use terms to express their anxiety in a way that is very psychologist). Amanda should be educated about
different from the way the term is used by clinicians. the impact of the excessive use of caffeine and other
The essential feature of a panic attack is the occurrence stimulants on anxiety symptoms. Amandas anxiety
of a discrete period of intense fear or discomfort, usually should be monitored regularly in order to ensure that her
lasting for several minutes and accompanied by at least symptoms do not worsen. At this stage, benzodiazepines
four physiological and/or psychological (eg. palpitations, or other psychotropic medications are not indicated.
sweating, trembling or shaking, shortness of breath, Sleep problems may develop with increasing anticipatory
feelings of choking, chest pain, abdominal discomfort, anxiety. If this occurs, relaxation techniques or cognitive
derealisation, dizziness, fear of losing control, fear of behavioural strategies for sleep problems may help.
dying), which develop abruptly and reach a peak of
intensity within few minutes. It is important to probe Table 4a. Abbreviated DSM-IV criteria for panic attack3
a little further and ask about specific symptoms A discrete period of intense fear or discomfort in which four (or more) of the
such as shortness of breath, heart palpitations, following symptoms developed abruptly and reached a peak within 10 minutes:
chest pain and sweating to determine whether palpitations, pounding heart, or accelerated heart rate
Amanda is having a true panic attack (Table 4). sweating
Self report questionnaires such as the Beck Anxiety trembling or shaking
Inventory (BAI) or Depression Anxiety Stress Scales sensations of shortness of breath or smothering
(DASS) (see Resources) may be helpful. feeling of choking
chest pain or discomfort
Answer 2 nausea or abdominal distress
While some of Amandas symptoms seem feeling dizzy, unsteady, lightheaded, or faint
characteristic of a panic attack, they develop derealisation (feelings of unreality) or depersonalisation (being detached from
oneself)
gradually and remain throughout the night, which
is not typical, and they do not seem to meet the fear of losing control or going crazy
criteria for panic attacks or panic disorder (Table fear of dying
4). There is no suggestion of specific phobias, paresthesias (numbness or tingling sensations)
social phobia, OCD, acute and PTSDs, substance chills or hot flushes.
induced anxiety disorder or anxiety disorder Note that panic attacks are common across several anxiety disorders, and also
occur occasionally in up to 50% of the population at times of stress, illness or
due to general medical condition. Amanda does under the influence of a substance. In addition, if fewer than four symptoms
not appear to reach the criteria for a disorder. occur, it can be termed a limited symptom attack
However, her symptoms are causing significant
Table 4b. Abbreviated DSM-IV criteria for panic disorder3
distress and need addressing. The main differential
Both (1) recurrent, unexpected panic attacks; (2) at least one of the attacks has
diagnoses are anxiety disorder not otherwise
been followed by one month or more of:
specified or simply anxiety symptoms secondary
(a) persistent concern about having additional attacks
to life stress.
(b) worry about the implications of the attack or its consequences (eg. losing
control, having a heart attack, going crazy)
Answer 3
(c) a significant change in behaviour related to the attacks.
It is important to gather some more details about Note: Panic disorder must be coded as either panic disorder with agoraphobia
Amandas current difficulties. This can help you to (where the person avoids or tolerates with extreme anxiety places or situations
understand what specific stressors precipitated her where escape may be difficult in the event of a panic attack, or where help might
symptoms and which strategies might help her to not be forthcoming), or panic disorder without agoraphobia (where there is no
manage these difficulties. agoraphobic avoidance or anxiety).

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Case 4

Jims distressing thoughts Further history


Jim is a construction worker who is 36 years of age. You enquire further about the nature of Jims thoughts.
He presents looking very distressed and explains that He reluctantly reveals that they involve him causing
over the past 23 months he has been having awful unwanted harm to his family. He starts crying saying
thoughts about something bad happening to his wife that he loves his family and that he would rather die
and children. He said that he has tried to stop thinking before causing his family any harm. The thoughts firstly
the thoughts to get rid of them but he keeps checking to occurred while watching a television program which
make sure that the dreaded events have not occurred. involved a brutal murder. He said that the image kept
The thoughts are becoming more frequent and more playing on his mind the whole evening and somehow
distressing. He reports severe sleep disturbance over he started thinking about whether he may lose control
the past few weeks, accompanied by a significant and harm his wife or children. He was repulsed by the
decrease in appetite and frequent absences from work. thought and tried to reassure himself that he was being
He described experiencing strong feelings of anxiety (eg. silly, but in the evening while helping with the dinner,
rapid breathing, choking sensations, heart palpitations, he found himself having the thought as he was holding
sweating and headaches). a knife. He said that he immediately left the room and
has not held a knife in the presence of his family since.
He said that he could not sleep that night and as the
Question 1 days went on, he became more concerned that he was
Based on this brief description, what do you think might going crazy. As the thoughts became more frequent,
be happening to Jim? he is now at the point where he finds it very difficult to
be around his family and not feel anxious. He has not
told his family about the thoughts. However, they have
noticed his increasing agitation around them and are
very concerned about him.

Question 3
What is your assessment of Jim now?

Question 2
What differential diagnoses would you consider?

Further history
Jim is relieved that you can explain his symptoms in
terms of a treatable anxiety disorder. He describes
mild to moderate depressive symptoms but no suicidal
thoughts. Your risk assessment is that he is currently not
at risk of harming himself or others. He denies further
obsessions and compulsions.

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Case 4

Question 4 Answer 1

What will you do next? Jims symptoms are characterised by persistent,


unwanted, distressing thoughts which he finds difficult to
control and seem to be associated with strong anxiety.
As such, they are consistent with the DSM-IV definition
of obsessions. Furthermore, Jim reports checking that the
dreaded events that he anticipates have not occurred.
The checking behaviours are consistent with the DSM-IV
definition of compulsions. The presence of obsessions
and/or compulsions is indicative of OCD (Table 5).
In Australia, OCD has a 12 month prevalence of 1.6% in men
and 2.2% in women.1 Onset is typically in late adolescence
to early adulthood, although subclinical symptoms typically
predate the disorder. It has a waxing and waning course
if left untreated. It is associated with a great level of
impairment to quality of life, greater than that in panic
disorder, social phobia or diabetes.20,21 It often leads to role
limitations, unemployment and problems in relationships.

Question 5 Table 5. Abbreviated DSM-IV criteria for OCD3


What are your management options? A. Obsessions
Recurrent and persistent thoughts, impulses, or images that are
experienced, at some time during the disturbance, as intrusive
and inappropriate and that cause marked anxiety or distress
The thoughts, impulses, or images are not simply excessive
worries about real life problems
The person attempts to ignore or suppress such thoughts,
impulses or images, or to neutralise them with some other
thought or action
The person recognises that the obsessional thoughts, impulses
or images are a product of his or her own mind (not imposed
from without as in thought insertion)
B. Compulsions
Repetitive behaviours (eg. hand washing, ordering, checking)
or mental acts (eg. praying, counting, repeating words silently)
that the person feels driven to perform in response to an
obsession, or according to rules that must be applied rigidly
The behaviours or mental acts are aimed at preventing
or reducing distress or preventing some dreaded event or
situation; however, these behaviours or mental acts either are
not connected in a realistic way with what they are designed to
neutralise or prevent or are clearly excessive
Except in children, the person must recognise at some point in
the disorder that the obsessions or compulsions are excessive or
unreasonable.The obsessions or compulsions must also cause
marked distress, be time consuming (take more than 1 hour a day), or
significantly interfere with the persons normal routine, occupational/
academic functioning or usual social activities or relationships

Answer 2
Other disorders that should be considered include GAD
and MDD. Generalised anxiety disorder shares some
similarities with OCD, particularly if the individual reports
that they cannot control their worrisome thoughts.
However, worries differ from obsessions in that they
are more verbal, less often in the form of an urge or an
image, often an apprehension about a more reality based

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Case 4

future concern, and more acceptable to the person. discomfort caused to Jim by the thoughts and this is
The most common worries are about competence at characteristic of obsessions. Importantly, Jim is aware that
work, academic performance, health issues, financial the thoughts are the product of his own mind (however
circumstances, and intimate relationships. By contrast distressing they may be), distinguishing them from thought
common OCD themes include: insertion delusions characteristic of psychotic disorders
contamination concerns and cleaning obsessions such as schizophrenia or, if the criteria for schizophrenia
are not met, overvalued ideas and a schizotypal
o
 bsessive doubts and overt or covert checking
personality, which constitute negative prognostic factors.
compulsions (includes compulsively asking for
reassurance this can be a common way that people Answer 4
check through others, ie. they ask: Is it clean? Are you
It is important to educate Jim about the possible diagnosis
sure its clean? Is it okay?)
of OCD and describe to him the symptoms, onset and
c
 oncerns about moral matters and an inflated sense of treatment of the condition. It is now well established that
personal responsibility for preventing harm to oneself the symptoms of OCD (obsessions and compulsions) exist
or others on a continuum in the population. Specifically, studies have
u
 nacceptable thoughts and covert compulsions (eg. repeatedly shown that the type of thoughts experienced
suppressing thoughts, compulsive praying, self criticism) by OCD patients are experienced by the majority of the
a
 dysfunctional need for symmetry and order; and population, but may differ in the frequency and distress
compulsive hoarding. they cause. This information may serve to normalise
Jims experience and provide him with reassurance that
Obsessive compulsive disorder also tends to be
he is not losing his mind but is rather experiencing an
distinguishable due to the occurrence of obsession which
anxiety problem, which is treatable. In addition, there is
is followed by a compulsion to undo or in some way put
now considerable empirical and clinical evidence that
right or avoid the obsession (eg. washing after a cleaning
the way people react to such thoughts impacts on their
obsession, checking after a doubt, thought suppression
frequency and intensity. That is, if such thoughts are
after a personally unacceptable intrusive thought), which
associated with great anxiety and specific behaviours (ie.
typically does not occur in other disorders.
compulsions, thought suppression, avoidance), they are
Obsessive compulsive disorder frequently presents more likely to increase in frequency and intensity, and
with other comorbid mental health problems (eg. other become obsessions. Providing Jim with a list of commonly
anxiety disorders, depression, impulse control disorders), experienced intrusive thoughts could also help reduce the
neurological conditions (eg. Tourette syndrome) or health anxiety associated with the thoughts. For example, Clark22
problems (eg. dermatological conditions due to excessive reported endorsement of thoughts by nonclinical student
washing). With OCD and other anxiety disorders, the and community samples (Table 6). Such information can
individual should also be screened for the occurrence of be very anxiety relieving for individuals experiencing OCD.
MDD. At least half of patients presenting with OCD will
It is important to ascertain whether Jim is experiencing
also experience significant depression at some time in
comorbid symptoms of depression, and the severity
their lives. While MDD tends to have a common element
of these symptoms, given the common co-occurrence
of rumination, it is distinguished by the loss of ones ability
of OCD and depression. While the depression is likely
to experience pleasure or increased negative mood. In
to be secondary to his OCD (and will thus resolve with
particular, the sleep and appetite reported by Jim may
successful treatment), it may be useful to treat this
indicate that there is also a mood disorder present, which
separately if the depression precludes successful
could potentially worsen the obsessive symptoms.
treatment of the OCD, or if it is associated with significant
Answer 3 suicide risk. If suicidal ideation is present, then the usual
risk management strategies should be put in place.
Jims description of his symptoms provides further evidence
Given the nature of Jims obsessions, it is also important
that he is experiencing obsessions; his thoughts are
to determine that there is no history of psychosis or of
unwanted, repugnant and have a sudden, intrusive quality.
violence of the type that he describes. However, such
They are accompanied by strong anxiety and persistent
enquiries should be done sensitively, as generally in OCD
unsuccessful attempts to eliminate them, mental checking
the fear is that I may be violent. In Jims case, there is no
of events over the day to feel certain he has not harmed
real risk of the behaviours being carried out so you should
any family members, reassurance seeking (eg. persistent
take care not to reinforce such fears.
telephone calls to make sure family members are well), as
well as avoidance of potential triggers (ie. knives). The presence of some symptoms of OCD may be
indicative that other OCD symptoms are also present.
Jims thoughts are egodystonic, which means alien to the
While individuals with OCD tend to present with some
individuals sense of self. This is evident from the obvious

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Case 4

specific concerns, it is often useful to assess for the what anxiety is, along with specific patient support
full range of OCD symptoms. While Jim readily reports materials about OCD (see Resources)
intrusive thoughts and some compulsions relating to his r elaxation: some general stress reduction or anxiety
family, there may be other intrusive symptoms that cause control strategies may help Jim with his symptoms
him great shame. While he has insight into the intrusive
p
 sychological approaches: there is good evidence for
nature of the thoughts relating to his family, there may be
the efficacy of psychological approaches (ie. CBT). The
less insight with respect to other symptoms. Treatment
UK National Institute of Health and Clinical Excellence
outcome is often associated with greater insight by
(NICE) recommend CBT as a first line treatment.23 If
affected individuals into the intrusiveness of obsessions
the OCD is severe, then it is probably advisable to
and compulsions.
refer the patient for specialist treatment by a clinical
As it is less common for the first onset of OCD to be psychologist or psychiatrist who is experienced with
experienced after the age of 2530 years, it is useful to get the disorder. The CBT treatment uses graded exposure
a lifetime history of OCD symptoms in affected individuals, and response prevention (ERP) as the cornerstone of
although the presentation of OCD may wax and wane over treatment, augmented by psychoeducation on anxiety
the lifetime with stressful life events, as may the type of and OCD, and techniques targeting beliefs within the
symptoms that the individual might experience. disorder (Table 7). In ERP, the patients obsessions are
provoked in a graded fashion and then they are asked
Table 6. Common intrusive thoughts in people to refrain from using compulsions to neutralise the
without OCD22 obsession. For example, for Jim he may first be asked
Thought % % to watch the news, then violent films, then to be in a
women men room with knives, then to hold a knife, then to hold a
Did I leave heat, stove, lights on that could cause 79 62 knife while the therapist is in the room, and so forth, all
a fire? while refraining from performing any compulsions. In
Left the door unlocked, an intruder could be inside 77 65 this way, he will learn that his obsessive fear that he is
While driving, impulse to run the car off the road 64 53 dangerous is unfounded and the intensity of his OCD
I could get a sexually transmissible infection from 60 40 related anxiety will diminish
touching a toilet seat or handle
Even though the house is tidy, an impulse to check 52 40 p
 harmacological approaches (ie. SSRIs): NICE
that absolutely everything is put away recommends SSRIs as a second line treatment for OCD
Feel sudden impulse to say something rude or 59 55 if CBT is initially unsuccessful23 (Table 2)
insulting to a friend even though Im not angry at o
 ther: while specialist treatment is advisable for any
him
OCD of moderate severity, other treatment modalities
Impulse to say something rude or insulting to a 50 55
could include co-treatment of the patient by GP and
stranger
While driving, the impulse to swerve the car into 55 49
psychologist, referral to a group treatment program, or
oncoming traffic guided internet based interventions. Australian research
The thought of having sex in a public place 55 67 with GPs has indicated a preference for referral to a
The thought of having sex with an authority figure 51 62 specialist who understands OCD.24 Furthermore, the
(eg. minister, boss, teacher) National e-Therapy Centre for Anxiety Disorders includes
While driving, the thought of running over 46 51 a diagnostic tool and a 12 week treatment for OCD that
pedestrians or animals can be self directed, assisted by an online therapist, or
When talking to people, intrusive thought of their 44 63 monitored by a GP or other mental health professional
being naked (see Resources).
Impulse to indecently expose myself by lifting my 14 24
skirt or slipping down my pants
Impulse to masturbate in public 11 18 Table 7. Beliefs within OCD that may be targeted
When I see a sharp knife, the thought of slitting 20 22 by CBT
my wrist or throat Inflated sense of responsibility for causing or preventing harm or
When in a public place, the thought of becoming 35 23 danger
dirty or contaminated from touching doorknobs Overestimation of threat in situations
Beliefs about the importance of thoughts in evaluations of the
Answer 5 individuals sense of worth
Your management options include the following: Unrealistic beliefs about the degree of control one should have
f urther education about OCD and anxiety disorders in over ones thoughts
general. As with every anxiety disorder, it is important to An intolerance of uncertainty
provide the patient with general information regarding An inflated need for perfectionism

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Case 5

Pauls nightmares and anxiety Question 2


Paul is 55 years of age and a father of four children. He What differential and/or comorbid diagnoses do you
presents with difficulties sleeping and concentrating. He need to consider?
says that he wakes up in a cold sweat every night after a
nightmare and he finds it difficult to fall asleep because
of anxiety. The nightmare is always the same: a car
accident like the one he experienced 10 years ago.
Paul was driving from the hardware shop with his then
8 year old son and was suddenly hit on the side of the
car and swerved onto the side road. He remembers
time slowing down as the car was sliding off the road,
thinking this is it and turning to see his son leaning
toward the window. He had wanted to reach out and
grab him but had to keep his hands on the wheel and
regain control of the car. He said that it was probably
the most intense and scariest few seconds of his life.
Question 3
No-one was injured and at the time Paul felt relieved,
thinking for some time later how lucky they were that the What further history do you want to take from Paul?
car stopped before crashing into a nearby tree.
Paul says he has not thought much about the accident
until 2 months ago when his son came home with
his new drivers licence. He says he felt anxious and
worried about his son driving, despite telling himself
that his son is a safe driver. Every time his son goes out
with the car, he has difficulty concentrating on anything
else and is generally jumpy and on edge. Then about
a month ago the nightmares started. In the nightmares
he sees the accident, feels time slowing down and sees
his sons head smash into the window. He wakes up
sweating, his heart palpitating, breathing heavily and in
complete panic. He describes the whole experience as
so real that often in the morning he is overcome with a Further history
strong sense of grief. Paul denies symptoms of other anxiety disorders,
He is not sure whether it is the lack of sleep or the dreams, complains of moderate depressive symptoms but denies
but he has been walking around home like a zombie and suicidal thoughts. He admits to drinking a fair bit most
not really feeling quite there. He finds it difficult to feel nights sometimes he gets through three-quarters of a
positive about any activities and feels numb toward his bottle of wine on his own. He denies other substance use.
wife. He describes the situation as unbearable.

Question 4
Question 1 What is your management plan?
What is your provisional diagnosis?

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Case 5

Answer 1 Answer 2
Pauls symptoms appear to meet the criteria for PTSD The main differential diagnoses to consider for PTSD
(Table 8). He was exposed to a life threatening event are adjustment disorder and acute stress disorder.
that involved intense fear. While not experiencing Adjustment disorder is characterised by distress and
symptoms at the time, his symptoms have recently emotional disturbance following a significant stressor
emerged, consistent with PTSD, with delayed onset or life event, lasting up to 3 months. However, as Paul is
(where over 6 months pass between the event and PTSD reporting that he experienced a life threatening event
symptoms).3 He has been re-experiencing the event in and is currently feeling numb, has increased arousal
the form of nightmares, numbing (detachment from his and is re-experiencing the event, PTSD is a more
life, lack of interest in activities, lack of affect) and has appropriate diagnosis. Acute stress disorder is similar to
had increased arousal (difficulty falling asleep, being PTSD, except that symptoms must occur within 1 month
jumpy or increased startle response). In Australia in of a stressor and can last for up to 1 month. However, as
2007, 4.6% of men and 8.3% of women will report having Pauls symptoms began over a month after the stressor,
PTSD within a 12 month period, making it the most a diagnosis of acute stress disorder is not appropriate.
common anxiety disorder in Australia.1 Some level of stress symptoms is common after a life
threatening event or situation, but
3 tends to spontaneously resolve, or
Table 8. Abbreviated DSM-IV diagnostic criteria PTSD
resolve with support and general
A. The person has been exposed to a traumatic event in which: stress management. However, if
the person experienced, witnessed or was confronted with an event or events that involved the symptoms do persist into PTSD,
actual or threatened death or serious injury, or a threat to the physical integrity of self or
others, and specialist referral and treatment is
the persons response involved intense fear, helplessness, or horror. recommended.
Note: in children, this may be expressed instead by disorganised or agitated behaviour Comorbidity is common in PTSD.
B. The traumatic event is persistently re-experienced in one (or more) of the following ways: Rates of alcohol use are similar in
recurrent and intrusive distressing recollections of the event, including images, thoughts, or individuals with PTSD and those
perceptions. with other anxiety disorders (odds
Note:in young children, repetitive play may occur in which themes or aspects of the trauma ratio of 3.3). However, rates of
are expressed substance use are higher (odds
recurrent distressing dreams of the event. ratio of 8.3). In addition, rates of
Note: in children, there may be frightening dreams without recognisable content depression are especially high
acting or feeling as if the traumatic event were recurring (includes reliving the (odds ratio of 29.3). Individuals
experience,illusions,hallucinations, and dissociativeflashbackepisodes, including those that
occur on awakening or whenintoxicated). with PTSD are also more likely to
Note:in young children, trauma specific re-enactment may occur experience other anxiety disorders
intense psychological distress at exposure to internal or external cues that symbolise or (panic disorder, social phobia, GAD,
resemble an aspect of the traumatic event and OCD odds ratios of 20.8 to
physiological reactivity on exposure to internal or external cues that symbolise or resemble 37.5).4
an aspect of the traumatic event
C. Persistent avoidance of stimuli associated with the trauma andnumbingof general Feedback
responsiveness, as indicated by three or more of the following: When an individual presents with
efforts to avoid thoughts, feelings, or conversations associated with the trauma a mental illness, it is important
efforts to avoid activities, places, or people that arouse recollections of the trauma to keep in mind that psychiatric
inability to recall an important aspect of the trauma comorbidity is the norm, not the
markedly diminished interest or participation in significant activities exception. In the 1997 national
feeling of detachment or estrangement from others survey, Andrews, et al4 noted
restricted range ofaffect(eg. unable to have loving feelings) that 13.2% of the sample had
sense of a foreshortened future (eg. does not expect to have a career, marriage, children, or a one disorder, while 4.4% had
normal life span) two and 3.8% had three or more.
D. Persistentsymptomsof increased arousal, as indicated by two or more of the following: However, those individuals with
difficulty falling or staying asleep two disorders were almost three
irritabilityor outbursts of anger times as likely to seek help as those
difficulty concentrating with a single disorder, and those
hypervigilance with three mental illnesses were
exaggerated startle response over six times as likely; with the
E. The disturbance must last at least 1 month result that the majority of those

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Case 5

seeking a mental health consultation are experiencing should be addressed together in specialist treatment.
psychiatric comorbidity (60%). Furthermore, psychiatric For the GP, it is probably also useful to provide some
comorbidity leads to a substantial rise in the disease general education regarding alcohol or drugs and
burden, and treatment of one mental disorder may not to implement basic risk monitoring and/or reduction
necessarily impact on the other. Finally, three-quarters strategies. Problem solving and motivational interviewing
of those consulting anyone for their mental health approaches may also be helpful.
problem will see their GP, with half only seeing their
GP for their problem, although this may have changed
since the introduction in 2007 of Medicare rebates for
psychological consultations with allied health providers
(psychologists, social workers, occupational therapists).4

Answer 3
Given the likelihood of comorbidity, it is important to
screen for other anxiety disorders, depression and
substance use when an individual presents with PTSD.
In particular, suicidal risk should be assessed, as the
depression and substance abuse sometimes associated
with PTSD can increase risk.

Answer 4
Patients with PTSD should be referred to a specialist
who is knowledgeable about the disorder, and has
experience treating it.
Medication (usually with SSRIs Table 2) and CBT are
often used simultaneously. Cognitive behaviour therapy
for PTSD involves confronting memories, experiences
and situations associated with the traumatic event:
real life or imaginary, and targeting beliefs about
safety, competence and control in order to develop a
more rational view of dealing with possible threats.25
Eye movement desensitisation and reprogramming
(EMDR) is a specialised technique that has yet to find
definitive evidence for its efficacy, but remains popular.
More recent treatment approaches have incorporated
acceptance techniques and promoting post-traumatic
personal growth.
Meanwhile, as with all the anxiety disorders, supportive
counselling and a safe and trusting doctor-patient
relationship is important. It would be useful to inform
Paul about the nature of anxiety in general, and PTSD
specifically. It can be anxiety relieving for patients to
know that they are facing a real problem, that they are
not going crazy, that their experiences (eg. a sense of
a foreshortened future, dissociative feelings) are part of
the diagnostic picture of PTSD, and effective treatment is
available. Practical strategies include general relaxation
exercises to deal with heightened arousal, planning
activities that may be anxiety relieving and/or distracting,
and focussing on the possible positive aspects of the
traumatic event (eg. developing a closer relationship with
his son, opportunity for personal growth).
Concomitant use of substances (termed dual diagnosis)
usually indicates a more severe case of PTSD. Both

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References

1. Australian Bureau of Statistics. National survey of mental health and wellbeing:


summary of results. ABS Cat. no. 4326.0. Canberra: ABS, 2007.
2. C ollaborating Centre for Evidence in Mental Health Policy: World Health
Organization. Management of mental disorders: Treatment Protocol Project. 4th
edn. Darlinghurst: WHO, 2004.
3. American Psychiatric Association. Diagnostic and statistical manual of mental
disorders 4th text revision edn. Washington, DC: APA, 2000.
4. Andrews G, Slade T, Issakidis C. Deconstructing current comorbidity: data from
the Australian National Study of Mental Health and Well-Being. Br J Psychiatry
2002;181:30614.
5. Lovibond SH, Lovibond PF. Manual for the depression anxiety stress scales. 2nd
edn. Sydney: Psychology Foundation of Australia, 1995.
6. Meyer TJ, Miller ML, Metzger RL, et al. Development and validation of the Penn
State Worry Questionnaire. Behav Res Ther 1990;28:48795.
7. Kyrios M, Hegarty K. Self monitoring and psychometric tools. In: Blashki G, Judd
F, Piterman, editors. Common problems in general practice psychiatry. North Ryde:
McGraw-Hill, 2007;35672.
8. Wells A. Cognitive therapy of anxiety disorders: a practice manual and conceptual
guide. Chichester: John Wiley & Sons, 1997.
9. Pierce D, Gunn J. Using problem solving therapy in general practice. Aust Fam
Physician 2007;36:2303.
10. Siev J, Chambless DL. Specificity of treatment effects: cognitive therapy and
relaxation for generalized anxiety and panic disorders. J Consult Clinl Psych
2007;75:51322.
11. Kagan J, Reznick S, Snidman N. Biological bases of childhood shyness. Science
1988;240:16771.
12. Kagan J, Snidman N. Infant predictors of inhibited and uninhibited profiles.
Psychological Science 1991;2:404.
13. Heimberg RG, Dodge CS, Becker RE. Social phobia. In: Michelson L, Ascher M,
editors. Cognitive behavioral assessment and treatment of anxiety. New York:
Plenum, 1987;280309.
14. Leary MR. A brief version of the fear of negative evaluation scale. Pers Soc Psychol
Bull 1983;9:3715.
15. Liebowitz MR. Social phobia. Mod Probl Pharmacopsychiatry 1992;22:14173.
16. Spence SH, Barrett PM, Turner CM. Psychometric properties of the Spence
Childrens Anxiety Scale with young adolescents. J Anxiety Disord 2003;17:60525.
17. Cunningham MJ, Wuthrich VM, Rapee RM, et al. The cool teens CD-ROM for
anxiety disorders in adolescents: A pilot case series. Eur Child Adolesc Psychiatry
2009;18:1259.
18. Rapee RM, Wignall A, Hudson JL, et al. Treating anxiety in children and
adolescents: an evidence based approach. California: New Harbinger, 2000.
19. March S, Spence SH, Donovan CL. The efficacy of an internet-based cognitive-
behavioral therapy intervention for child anxiety disorders. J Pediatric Psychology
2009;34:47487.
20. Lochner C, Mogotsi M, du Toit PL, et al. Quality of life in anxiety disorders: a
comparison of obsessive-compulsive disorder, social anxiety disorder, and panic
disorder. Psychopathology 2003;36:25562.
21. Koran LM, Thienemann ML, Davenport R. Quality of life for patients with
obsessive-compulsive disorder. Am J Psychiatry 1996;53:7838.
22. Clark DA. Cognitive-behavioral therapy for OCD. New York: Guilford Press, 2004.
23. National Institute for Health and Clinical Excellence. Core interventions in the
treatment of OCD and BDD. London: BPS/Royal College of Psychiatrists, 2006.
24. Kyrios M, Jones B, Moulding R. Obsessive-compulsive disorder: integration of
cognitive-behaviour therapy and clinical psychology care into the primary care
context. Aust J Public Health. In press 2010.
25. Tiller J, Kyrios, M, Bennett P. Post-traumatic stress disorder. Aust Fam Physician
1996;25;156973.

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Resources

Professional Clinical Research Unit for Anxiety and Depression (CRUfAD).


Available at www.crufad.com this website offers:
Books
patient services that include self help and a virtual clinic providing
Andrews G, Creamer M, Crino, et al. The treatment of anxiety
free internet based education and treatment programs for people
disorders. Cambridge: Cambridge University Press, 2003. A useful
with anxiety and depression
book that includes chapters for both clinicians and patients.
clinician services to help GPs/doctors improve access and
Bourne EJ. The anxiety and phobia workbook. Oakland, CA: New
outcomes in mental health:
Harbinger Pub, 1990. A useful workbook for patients that presents
information about anxiety disorders and treatment strategies. GP Care (www.gpcare.org)
Burns DD. Feeling good: The new mood therapy. Victoria: a series of web based courses to teach patients about managing
McPhersons Printing Group, 1980. A useful workbook for patients their health better (CRUfAD Clinic www.crufadclinic.org)
that presents strategies for dealing with unhelpful thinking styles an interactive e-learning environment for health professionals
and behaviour related to depression and anxiety. (CRUfAD Mental Health www.crufadmh.org).
Collaborating Centre for Evidence in Mental Health Policy: World Beacon (Australian National University Centre for Mental Health
Health Organization. Management of mental disorders: Treatment Research). Beacon is a portal to health online applications for
Protocol Project. 4th edn. Darlinghurst: WHO, 2004. mental and physical disorders, including anxiety disorders. Specific
GPs who have undertaken the Better Outcomes in Mental Health programs are reviewed and rated. Users can also submit their
Care level two training were provided with copies of Management own ratings and comments about each online health application.
of mental disorders, a resource developed by the World Health Available at www.beacon.anu.edu.au.
Organization Collaborating Centre as part of the Treatment Protocol Spence Childrens Anxiety Scale. An appropriate scale to assess
Project. The resource was developed for use by GPs and generalist anxiety in adolescents has been developed by Spence and associates
mental health clinicians working in community mental health services. in Australia. Available at www.scaswebsite.com.
Blashki G, Judd F, Piterman L, editors. General practice psychiatry. Depression Anxiety Stress Scales (DASS). Information is available at
North Ryde: McGraw-Hill, 2006. This publication includes chapters www2.psy.unsw.edu.au/groups/dass/.
on tools for assessing depression and anxiety, self monitoring and Beck Anxiety Inventory (BAI). The BAI manual and answer sheets are
psychometric tools and anxiety as it presents commonly in general available for purchase at www.psychcorp.co.uk/product.aspx?n=1316
practice. &s=1322&cat=1426&skey=2644.
Better Access to Mental Health Services scheme. Information is
Online assessment and treatment for anxiety disorders available at www.racgp.org.au/mentalhealth/betteraccess
Anxiety Online is funded by the Australian governments Department Therapeutic Goods Administration (TGA). Information is available at
of Health & Ageing, Anxiety Online is an initiative of the National www.tga.gov.au.
e-Therapy Centre at Swinburne University of Technology available at Pharmaceutical Benefits Scheme (PBS). Information is available at
www.anxietyonline.org.au and includes: www.pbs.org.au.
high quality information and resources to enable patients to gain a
comprehensive understanding of anxiety generally, and of anxiety
disorders specifically Patient information
clinical assessment: the online Psychological Assessment The Clinical Research Unit for Anxiety and Depression (CRUfAD)
Program (e-PASS) enables patients to complete a comprehensive Offers patient services that include self help and a virtual clinic
psychological assessment online, and providing feedbackas to the providing free internet based education and treatment programs for
type and severity of anxiety, andappropriate recommendations for people with anxiety and depression. Available at www.crufad.com.
addressing anxiety problems
treatment programs: comprehensive evidence based treatment Anxiety Online
programs are available for each of the specific anxiety disorders Provides high quality information and resources to enable patients
(GAD, OCD, panic disorder, PTSD and social anxiety disorder). The to gain a comprehensive understanding of anxiety generally, and of
programs are available in two versions: anxiety disorders specifically. Available at www.anxietyonline.org.au.
self help programs for individuals with mild symptoms, offered
free of charge
therapist assisted programs for individuals with moderate to
severe symptoms, offered at a low cost. Therapist assistance is
in the form of weekly email communication and has been shown
to be more effective than purely self help programs.

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qa&cpd Program requirements (20082010 triennium)

Active learning module This activity must involve at least 2 hours time commitment and details must
be submitted with your evaluation.
In order to qualify for 40 Category 1 QA&CPD points for this ALM:
Choose one community based activity from the following:
Step 1. Undertake this predisposing activity
Facilitate a QA&CPD meeting for your local division on anxiety disorders.
Write answers to the following questions. How common are anxiety Invite local psychologists and/or psychiatrists with experience in
disorders in Australia? How would you diagnose the following management of anxiety disorders. Discuss best practice management
conditions in the general practice setting: generalised anxiety approaches and how communication between GPs and psychologists and/
disorder (GAD), social anxiety disorder, panic disorder, anxiety or psychiatrists may be improved. Discuss relaxation techniques that can be
disorder not otherwise specified, obsessive compulsive disorder taught to patients to help them manage anxiety symptoms.
(OCD), and post-traumatic stress disorder (PTSD)? What clinical
Attend supervision with a local clinical psychologist to discuss your
tools do you know that could help you in the diagnosis, assessment
management approaches to patients you have seen with anxiety disorders.
and management of anxiety disorders? How would you explain to
a patient about the nature of anxiety, its purpose and how it can Contact your local community health service and local allied health providers
present? Outline a management plan for the following conditions and find out what services are available for patients to aid in the treatment
in the general practice setting: GAD, social anxiety disorder, panic of anxiety. Are there any local centres offering yoga, meditation or
disorder, anxiety disorder not otherwise specified, OCD and PTSD? relaxation classes?
Develop a list of at least three personal learning goals for this ALM. Give a presentation at a local sporting club, community organisation, school
It may be helpful to consider the following questions: Why did I or workplace on a topic relating to this unit such as the nature and purpose
choose this topic at this time? What would I like to do differently as of anxiety and how it can present, relaxation exercises or specific anxiety
a result of undertaking this ALM? What would I like to understand disorders.
or appreciate more fully about this topic? What skills or knowledge Write a patient education article for local newspaper on any topic relating
would I like to gain? to this unit, eg. the nature and purpose of anxiety and how it can present, or
about specific disorders such as GAD, social anxiety disorder, panic disorder,
Step 2. Read and complete this unit of check. You do not need anxiety disorder not otherwise specified, OCD and PTSD.
to send in the completed check unit. Please retain your check
Devise your own activity that utilises the knowledge and skills you have
unit and answers for your future reference.
obtained from this unit of check within your local community and addresses
Expected time commitment is approximately 2 hours. your personal learning needs.
Step 3. Undertake one practice based activity and one The activity must involve at least 2 hours time commitment and details must be
community based activity from the list of suggested activities submitted with your evaluation.
below.
Step 4. Fill in the reinforcing activity and evaluation summary
Choose one practice based activity from the following:
Report on the activities you have undertaken and send to the coordinator who
Summarise what you have learned from this unit of check and will coordinate the approval and point allocation process. We encourage you to
give a presentation at a lunchtime practice meeting or journal club. electronically fill in the evaluation summary and email to check@racgp.org.au.
Facilitate a discussion on the clinical features or management of A check Program ALM evaluation summary form can be downloaded from the
one or more of the following: GAD, social anxiety disorder, panic
RACGP website at www.racgp.org.au/check. Alternatively, you can photocopy
disorder, anxiety disorder not otherwise specified, OCD and PTSD.
and fill in the evaluation summary included in this unit and post it. Please
Give a presentation at a lunchtime practice meeting on relaxation allow up to 6 weeks upon receipt of your evaluation summary to receive your
techniques that can be taught to patients to help them to manage certificate of participation.
anxiety symptoms.
With a GP colleague from your practice, review the clinical tools check Category 2 QA&CPD activity
presented in this unit for diagnosis, assessment and management In order to qualify for 6 Category 2 points for this activity in this unit:
of anxiety disorders. Which of these tools would be useful in your read and complete this unit of check, and
own practice? Download files or links to any tools you think would log onto the gplearning website at www.gplearning.com.au and answer the
be useful onto your practice desktop and educate other general 10 multiple choice questions (MCQ) online.
practitioners in the practice about their use. Expected time to complete this activity is 3 hours.
Write a patient education article for your practice newsletter on We encourage you to also complete the online evaluation for this activity.
any topic relating to this unit such as the nature and purpose of
Participants can be awarded QA&CPD points for both the ALM and Category
anxiety and how it can present, or about specific disorders such as
2 activity.
GAD, social anxiety disorder, panic disorder, anxiety disorder not
otherwise specified, OCD and PTSD. Other activities to consider for the QA&CPD Program
Review patient education material you have in your practice on any Small group learning (40 Category 1 points)
topic relating to this unit and make up a resource folder of quality Is this topic one you would like to learn more about with your peers? You could
information and useful referral contacts in your local community. use this unit of check and the resources listed as the basis for a small group
Devise your own activity that utilises the knowledge and skills you learning (SGL). Ask other GPs in your practice or contact your division of general
have obtained from this unit of check within your practice and practice to find others interested in the same topic.
address your personal learning needs. Facilitator training is run regularly by RACGP faculties and will equip you to run
the small group process effectively.
SGL and SCA kits are available with instructions on the Supervised clinical attachment (40 Category 1 points)
RACGP website at www.racgp.org.au or by contacting Consider arranging a supervised clinical attachment (SCA) with a clinical
a professional development officer at your state QA&CPD unit.
psychologist.

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check Program 2010

Activity report and reinforcing activity


Active learning module on anxiety disorders (unit 457)
Eligible for 40 Category 1 points in the RACGP QA&CPD Program. A minimum of 6 hours is required to complete this ALM excluding the time
taken for predisposing and reinforcing activities. Please complete all sections. Upon completion, email to check@racgp.org.au or post to The
RACGP, 1 Palmerston Crescent, South Melbourne, Victoria, 3205, Australia. Please retain a copy for your records.

QA no. _________________ Name ___________________________________________ Contact telephone no. ________________________

Address ________________________________________________________________________________________________________

Have you completed this unit of check? Yes / No Time taken to complete the unit: __________________________________________

1. Activity report
Practice activity
Write a brief description and attach evidence of the activity undertaken within your practice. Evidence includes minutes of meeting, photo of
events, practice newsletter, proformas/guidelines/protocols developed and/or diary entries.

Community activity
Write a brief description and attach evidence of the activity undertaken within your community. Evidence includes a letter of attendance from
the community organisation that you visited, copy of newspaper article, flyer from community talk, diary entries of appointments and/or notes
made of meetings.

2. Reinforcing activity
Refer to your initial answers from the predisposing activity. What differences are there in your answers now that you have completed this unit of check?

What did you learn from this activity?

What will you do differently in your practice as a result of this activity?

continued overleaf

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check Anxiety disorders

check Program 2010 ALM

Evaluation
1. Learning objectives
Please indicate to what extent after completing this activity you are able to meet the stated learning objectives.
Not Partially Entirely
met met met
Learning objective
Recognise the clinical features of GAD, social anxiety disorder, panic disorder, anxiety
disorder not otherwise specified, OCD and PTSD.

Appreciate that a number of clinical tools are available to help in the diagnosis and
assessment of anxiety disorders.

Recognise the importance of asking patients wit h anxiety disorders about depressive
symptoms and risk of harm to self or others.

Understand the importance of psychoeducation and relaxation strategies in the


management of anxiety disorders.

Appropriately manage and/or refer patients for management of GAD, social phobia,
panic disorder, anxiety disorder not otherwise specified, OCD and PTSD.

Appreciate that a number of clinical tools, including online tools, are available to aid in
the treatment of anxiety disorders.

2. Learning needs and relevance to practice


O v erall e v aluat i on

Not Partially Entirely


met met met

Rate the degree to which your own learning needs were met.
Not Partially Entirely
relevant relevant relevant

Rate the degree to which this activity was relevant to your own practice.
3. Other information
Please rate the extent to which you agree with the following statements.
Statement Strongly Strongly
disagree Disagree Agree agree
There was sufficient information and resources for me to complete
this activity well.
The writing and case histories were of a high standard.
This activity increased my knowledge/understanding of this topic.
I am likely to change my clinical practice as a result of this activity.
This activity was of benefit to other members of my practice.
4. What other topics would you like to see covered in check?

5. Do you have any additional comments?

Signed by participant ________________________________________________________________________________ Date __________________________

Office use only Approved Signed __________________________________________________________ Date __________________________


Attendance forwarded to the National QA&CPD Unit Date _______________________________

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Check Category 2 QA&CPD activity

Anxiety disorders This history is MOST consistent with:


In order to qualify for 6 Category 2 points for this activity A. post-traumatic stress disorder
in this unit: B. social phobia
read and complete the unit C. panic disorder
log onto the gplearning website at www.gplearning. D. obsessive compulsive disorder (OCD)
com.au and answer the following 10 multiple choice E. generalised anxiety disorder (GAD).
questions (MCQs) online. If you are not an racgp
member, please contact the gplearning helpdesk on Question 3
1800 284 789 to register in the first instance. You will be
Further assessment confirms a diagnosis of GAD in Bill.
provided with a username and password that will allow
Which of the following is TRUE regarding treatment of
you access to the test
GAD?
complete the online evaluation.
A. Psychoeducation is unhelpful, as knowing more about
Expected time to complete this activity is 3 hours. the nature of anxiety will encourage Bill to focus
Please do not send answers to the MCQs into the check more on his symptoms
office. This activity can only be completed online at B. Selective serotonin reuptake inhibitor (SSRIs) are
www.gplearning.com.au. first line treatment if pharmacological treatment is
If you have any queries or technical issues accessing required
the test online, please contact the gplearning helpdesk C. A benzodiazepine should be prescribed for daily use
on 1800 284 789.
D. Cognitive behaviour therapy (CBT) is an effective
treatment
Question 1
E. B and D.
Wendy, aged 26 years, is a previously well woman
who works full time as an accountant. She is also
Question 4
doing further study to gain certification as a certified
practising accountant (CPA). She says she is having Miroslav, aged 15 years, has recently been diagnosed
trouble with anxiety symptoms, particularly when she with social anxiety disorder (social phobia) and is
thinks about the exam. She complains that she often seeing a psychologist for CBT. In a letter, Miroslavs
feels in a panic. psychologist explains that Miroslav exhibits safety
behaviours, including sitting in the library at lunchtime,
Which of the following historical features would MOST
staying away from school on sports days and avoiding
make you suspect that Wendy is having panic attacks?
social events. Safety behaviours in social anxiety
A. Nightmares disorder:
B. Symptoms that develop gradually A. aim to help minimise anxiety in specific situations
C. Symptoms that reach a peak within 10 minutes B. are useful long term strategies for coping with
D. Repetitive behaviours (eg. hand washing, ordering, anxiety
checking) C. aim to rid patients of recurrent and persistent
E. Concerns about going mad. thoughts
D. provide individuals the opportunity to learn that social
Question 2
situations are not as dangerous as they perceive
Bill, aged 55 years, presents complaining that he feels
E. usually involve excessive cleaning and tidying.
overwhelmed by life. He says he has always been a
worrier but since his younger brother had a heart Question 5
attack 9 months ago, the symptoms have worsened. His
brother is fine but Bill now worries constantly about his Cognitive behaviour therapy to treat social phobia
own health and ability to keep working if he gets sick. involves:
He complains that on most days he feels tense and on A. provoking the patients obsessions in a graded
edge, with intermittent palpitations and shortness of fashion
breath. He describes difficulty falling or staying asleep, B. teaching the patient how to ignore others and enjoy
generalised aches and pains, irritability and persistent their isolation
worries about his health, work and his family. He saw C. helping the patient to understand how and why
a cardiologist who has given him the all clear and told anxiety symptoms develop, what triggers them and
him that his symptoms are related to anxiety. Bill says, I what unhelpful responses maintain them
must be going mad. I spend all my time worrying about
any minor symptom I have and what it might mean. I D. exposure to feared social situations starting with the
worry constantly about my work and whether I will be most fearful situation
sacked, and I also worry about how much worry I have! E. All of the above.

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Check Category 2 QA&CPD activity

Question 6 Question 9
Paul is 55 years of age and a father of four children. He As you assess Sam you consider the difference between
presents with difficulties in sleeping and concentrating. obsessions and worries.
He says that he wakes up in a cold sweat every night Which of the following is TRUE?
after a nightmare about an incident that occurred 6
A. Worries are usually about more reality based
months ago in which he was attacked with a knife at an
concerns about the future
automatic teller machine (ATM). In the nightmares he
relives the incident and each time it feels real. He then B. Unlike worries, the type of thoughts experienced
finds it difficult to fall asleep because of anxiety. by OCD patients are rarely experienced by the
nonclinical population
According to the DSM-IV, one of the requirements for
the diagnosis of PTSD is that the person: C. Worries tend to be in the form of an urge or an image;
obsessions tend to be more verbal
A. experienced, witnessed, or was confronted with a
traumatic event D. Worries are typical of anxiety disorders; obsessions
are typical of psychotic disorders
B. did not feel frightened at the time that the event
occurred E. Benzodiazepines are helpful for worries but not
obsessions.
C. seeks stimuli associated with the trauma
D. has persistently decreased arousal Question 10
E. has symptoms for more than a year. Sam is diagnosed with OCD. Regarding treatment of
OCD, which of the following is TRUE?
Question 7
A. SSRIs are first line treatment
Paul is diagnosed with PTSD. Regarding the treatment of
B. CBT should be used if pharmacological treatment
PTSD, which of the following is true?
fails
A. Specialist referral is usually required
C. Relaxation approaches are not helpful as they
B. Eye movement desensitisation and reprogramming give the patient time and space to focus on their
(EMDR) is a specialised technique with well obsessions
established efficacy
D. Patients should be encouraged to increase their use
C. SSRIs have no place in treatment of compulsions to neutralise the obsession
D. Substance use requires a separate referral to a E. Psychoeducation about anxiety and about OCD is
specialist in treatment of drug and alcohol problems helpful.
as this is unlikely to be related to the PTSD
E. All of the above.

Question 8
Sam, aged 22 years, presents saying, Im worried I might
have obsessive compulsive disorder (OCD)!
Which of the following is NOT a common presentation of
OCD?
A. Contamination fears and washing or cleaning
compulsions
B. Attachment to objects and compulsive hoarding
C. Unacceptable moral doubts and thought suppression
D. Concerns about appearing anxious and losing control
in front of others
E. Obsessive doubts and overt or covert checking
compulsions.

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Notes
check Anxiety disorders

Notes