Anxiety disorder

• Anxiety disorder is common. GPs encounter patients with anxiety disorders everyday, so it is important to have some basic understanding of the disorder and also management plans

• Anxiety disorders include: general anxiety disorder, phobias, OCD, PTSDs, panic attack, substance induced anxiety and anxiety secondary to general medical condition

• My personal approach is that I do not prescribe benzodiazepam to anyone who comes in with anxiety disorder. As it is often lifelong and most patients ended up becoming dependent on benzodiazepam. I will usually bring this straight up during the first consultation, which prevents them from coming in for benzodiazepam prescription in the future

• Use DASS 21 or K10 to assess level of distress 

• Substance abuse or comorbid psychiatric disorders are common in this population, make sure you screen for them 

• Management plan
• Avoid benzodiazepam. You are not doing the patient any good by prescribing them. 
• Psychoeducation 
• It is the key to many psychological condition 
• use the flight/fight model to explain the purpose of anxiety
• Cognitive behavioural therapy
• Essential to mention this in the exam 
• Do a mental health plan and refer to psychologist 
• National e-therapy centre for anxiety
• Medications
• Some SSRIs have anti anxiety effect but only escitalopram is currently listed to use in GAD 
• Avoid Paroxetine in young women who have not completed their family

   

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Approach to tiredness/fatigue

Tiredness/chronic fatigue: diagnostic strategy model

Probability diagnosis

• Stress and anxiety
• Depression
• Viral/postviral infection 
• Sleep-related disorder (e.g. sleep apnoea)

Serious disorders not to be missed

• malignant disease
• cardiac arrhythmia (e.g. sick sinus syndrome)
• cardiomyopathy
• anaemia 
• hidden abscess
• haemochromatosis
• HIV infections 
• Hepatitis C

Pitfalls

• 'Masked' depression
• Food intolerance
• Coeliac disease
• Chronic infection (e.g. lyme disease)
• Incipient CCF
• Fibromyalgia
• Lack of fitness
• Drugs: alcohol, prescribed, withdrawal
• Menopause syndrome
• Pregnancy
• Neurological disorders
• post-head injury
• CVA
• Parkinson disease
• Kidney failure
• Metabolic (e.g. hypokalaemia, hypomagnesaemia)
• Chemical exposure (e.g. occupational)
• Rarities
• Hyperparathyroidism
• Addison disease
• Cushing syndrome
• Narcolepsy
• Multiple sclerosis
• Autoimmune disorders

Minimal investigations from John Murtagh General practice 5th edition:

• FBE
• ESR/CRP
• TFTs
• Coeliac serology
• LFT
• CMP
• BSLs
• Iron studies
• Urine MCS

Depression

Condition	Depression
Demographics	10% of the population have significant depressive illness  Lifetime risk: 12% for men and 25% for women
Murtagh Triad	No Murtagh Triad but 2 questions particularly helpful : In the past month, have you been bothered by feeling down, depressed or hopeless? In the past month, have you often been bothered by little interest or pleasure in doing things?
History features	Trying to see whether the patient’s symptoms fit into the criteria of depression and also determine the severity.  It is also important to exclude other diagnoses, such as adjustment disorder, bipolar and psychotic depression.  **The most important thing is risk assessment** If you don’t ask this in the exam, you will definitely fail  Major Depression Diagnostic criteria
Examination	Mental state examination: Appearance: varies greatly depend on severity Behaviour: psychomotor retardation or agitation Mood: low  Affect: poor eye contact, tearful  Thought stream: normal to slow  Thought form: usually normal, sometimes blocking Thought content: guilt, worthlessness, hopeless, suicidal ideation Perception: Hallucination congruent with the depressive process Cognition: disordered, intact most of the time but disinterested Attention and concentration: may be poor
Investigations	Mainly to exclude organic causes. Suggested investigations: FBE, UEC, LFT, CRP, ESR, TSH, Vit D, Folate/B12  Objective measurement tool to assess depression: K10, DASS
Management	Non pharmacological treatment: Lifestyle changes (e.g. exercise, eat healthy), CBT (online or face to face) Pharmacological: SSRI (1st line), SNRI (2nd line), TCA (not recommended in elderly people), MAOI (specialist area)