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2. Anxiety disorders
 
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2. Anxiety disorders
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About anxiety disorders

Around one in five Australians experience an anxiety disorder at some point in their lives (McEvoy, Grove, & Slade, 2011). It is worth noting that anxiety and agitation can arise as secondary to other disorders, including depression and substance intoxication and withdrawal, and so these potential primary diagnoses should be considered when assessing veterans. There are a number of different anxiety disorders, with the most common among veterans being:

  • panic disorder
  • agoraphobia
  • generalised anxiety disorder
  • social anxiety.

The causes, symptoms, duration and impact of these disorders on everyday life vary greatly, and each disorder is discussed in more detail below. Information on referral options and resources for anxiety disorder can be found at the end of this chapter.

Panic disorder and agoraphobia

About panic and agoraphobia

A panic attack is characterised by a sudden surge of intense fear or discomfort that is accompanied by a number of somatic and cognitive symptoms such as a racing heart, hyperventilation and fear of dying. Panic disorder involves at least one panic attack, combined with a persistent concern about having another attack or the consequences of the attack. Agoraphobia is a separate diagnosis that involves experiencing marked fear of situations where panic symptoms may occur. The fear of panic attacks can lead to significant avoidant behaviour. For example, a veteran may avoid physical exercise in order not to experience panic-like symptoms such as sweating or accelerated heart rate.

Agoraphobia involves marked fear or anxiety about situations where escape might be difficult or help might not be available in the event of a panic attack. These situations include travelling on public transport, visiting shops or cinemas, standing in a crowd, or being outside of the home alone. A veteran with agoraphobia is likely to avoid such situations or endure them with intense fear or anxiety, or only be able to face them with a trusted friend or relative.

While panic disorder and agoraphobia tend to co-occur, either disorder can be diagnosed in the absence of the other. Approximately one in thirty Australians will suffer from panic disorder at some point in their lives, while one in forty will experience agoraphobia.

Screening and assessment of panic disorder and agoraphobia

There is limited evidence for the effectiveness of screening instruments for most anxiety disorders. No specific screening test is recommended in the recent National Institute for Health and Care Excellence (NICE) guidelines for panic disorder and agoraphobia (2011), however, useful questions to screen for panic disorder from the Mini International Neuropsychiatric Interview (MINI 5.0.0; Sheehan et al., 2004) include:

  • In the past month, have you on more than one occasion had spells or attacks when you suddenly felt anxious, frightened, uncomfortable or uneasy, even in situations where most people would not feel that way?
  • Did the spells peak within 10 minutes?

Veterans may be screened for agoraphobia with a question from the MINI:

  • In the past month, have you felt anxious or uneasy in places or situations where you might have a panic attack or panic-like symptoms, or where help might not be available or escape might be difficult (e.g., being in a crowd, standing in a queue, when you are away from home or alone at home, or when crossing a bridge or travelling in a bus, train, or car)?

If the veteran answers ‘yes’ to any of these questions, the practitioner should then:

  • assess the frequency and nature of the panic attacks
  • rule out other psychiatric disorders, physical conditions, medications or recreational drugs that could account for the panic attacks
  • develop a profile of the veteran’s agoraphobia and avoidance by asking them to describe the activities or places they avoid due to fear of a panic attack.

The Fear Questionnaire (FQ; Marks & Matthews, 1979) is a useful tool for identifying situations that trigger anxiety, and the Depression, Anxiety and Stress Scale (DASS-21; Lovibond & Lovibond, 1995) is a general measure that can help track stress and anxiety as well as counselling outcomes. Neither is a diagnostic measure for panic or agoraphobia. See Appendix C or http://www.at-ease.dva.gov.aufor both these measures, as well as instructions on their administration, scoring and interpretation.

Important assessment considerations

In diagnosing panic disorder, it is important to establish that the panic attacks are occurring unexpectedly and not in the context of another anxiety disorder. For example, a veteran with PTSD might experience panic attacks when watching a documentary on the war in Afghanistan, however this should not be considered indicative of panic disorder, as the panic is occurring in response to a specific and predictable context, rather than occurring unexpectedly.

Practitioners should be mindful of the risk of unnecessary medical investigations to provide reassurance to the veteran, as this can create an unhelpful cycle of anxiety and investigation of medically unexplained or somatic symptoms. Once an appropriate set of investigations has been done, repeating these at the veteran’s request reinforces his or her belief that ‘something was missed’.

Treatment of panic disorder and agoraphobia

Psychological interventions

Cognitive behavioural therapy (CBT) is the most effective psychological treatment for panic disorder and agoraphobia. Clear explanations of panic disorder and/or agoraphobia, how it is conceptualised, and the rationale for treatment are critical to forming a solid basis for this phase of treatment. Talking to a veteran, together with the veteran’s family, about his or her anxiety is the start of treatment. A summary of useful information to be conveyed to the veteran and his or her family is included in the text box below. Whilst CBT has some general techniques applicable across a range of disorders, specific CBT techniques for targeting panic and/or agoraphobia are:

  • Exposure to internal symptom cues or interoceptive exposure – In panic disorder, the fear is often associated with the symptoms themselves. As such, when conducting exposure it is the internal physical symptoms that the veteran needs to confront. An example of such exposure would be to gradually get the veteran to hyperventilate in session to induce some of the sensations associated with panic, and then repeat this exercise until the veteran’s distress and fear associated with the symptoms subsides.
  • Cognitive therapy – This approach is beneficial for addressing misinterpretations of symptoms such as fears of going mad, of having a heart attack or of losing control. In panic disorder, ‘catastrophic misinterpretation’ of the physical symptoms appears to be central to the maintenance of the disorder.
  • Anxiety management – Breathing retraining and hyperventilation control strategies are important treatment components. A breathing retraining exercise can be found in Appendix H.
  • In vivo exposure – This involves assisting the veteran to gradually confront and reintegrate activities and places that he or she has been avoiding due to the associations with panic. Prior to engaging in in vivo exposure, the veteran should have: 1) a good understanding of the nature of panic disorder and/or agoraphobia; 2) learned to effectively manage the symptoms through cognitive and breathing strategies; and 3) had exposure to the internal cues for panic and learned to manage his or her response.

The strategies outlined above are targeted at managing acute panic and anxiety, and helping the veteran to resume avoided activities. It is also important to assist the veteran in reducing their baseline level of arousal through exercise, general relaxation training and the scheduling of pleasant activities.

Providing psychoeducation is the first step to effective treatment. A summary of useful information to be conveyed to the veteran and his or her family is included in the text box below, and a client handout about symptoms can be found in Appendix L.

Psychoeducation and self-management strategies

The aim of psychoeducation is to explain and demystify symptoms so that the veteran can regain a sense of control, and a sense of hope. It is also important to talk about common misconceptions veterans may have about panic attacks, such as mistaking symptoms for a heart attack or stroke. Practitioners need to discuss:

  • the nature of anxiety and the fight–flight response, i.e., explain that although panic attacks may feel dangerous, they are not
  • the relationship between hyperventilation and panic
  • breathing retraining and hyperventilation control
  • common fears held by people who have panic attacks, e.g., any medical-related fears the veteran may have regarding their physiological panic symptoms
  • the prevalence of panic disorder and agoraphobia.

It is helpful to discuss treatment goals with the veteran, namely:

  • control and cessation of panic attacks
  • control and cessation of fear-driven avoidance
  • reducing vulnerability to relapse.

If substance use is a problem, including benzodiazepine misuse, encourage the veteran to reduce his or her substance use. This is a significant issue as 20 per cent of Australians with panic disorder and 13 per cent of those with agoraphobia also have an alcohol use disorder. A brief intervention that includes education about substance use can be effective (see Chapter 8 on substance use disorders). If benzodiazepines are used, they should be taken on a regular schedule as far as possible, rather than on an ‘as needed’ or ‘prn’ basis. CBT-based self-help resources are also effective in treatment. A list of self-help resources is included at the end of this chapter.

Psychological treatment setting and duration

Panic or agoraphobia is typically treated in an outpatient setting. Treatment duration will vary from 7 to 14 sessions, sometimes more depending on the severity, and will most commonly be in the form of weekly sessions of 1–2 hours. Treatment would normally be completed within a maximum of four months (National Institute for Health and Care Excellence, 2011). Practitioners could also consider briefer versions of CBT (approximately seven hours), as an adjunct to the use of self-help material. Telephone-administered treatment may be considered for those who cannot attend face-to-face treatment. Treatment of panic disorder or agoraphobia rarely requires hospitalisation, unless there is concurrent severe depression, suicidal intent or substance use requiring detoxification.

Pharmacological interventions

Psychological interventions are the preferred approach for the treatment of panic and agoraphobia. However, pharmacotherapy may be considered in moderate to severe cases, where psychological treatment is not acceptable or available, or fails to produce a sufficient response. The evidence is strongest for the use of antidepressant medications but there is little evidence that pharmacotherapy has a lasting role after completion of a course of treatment. Selective serotonin reuptake inhibitors (SSRIs) and serotonin-noradrenaline reuptake inhibitors (SNRIs) are recommended as the first line of pharmacotherapy.

Benzodiazepines are no longer recommended for the treatment of panic disorder or agoraphobia, as they do not treat the underlying condition and pose a risk of dependency. If benzodiazepines are considered necessary for control of severe symptoms, the course of treatment should be kept as short as possible. Benzodiazepines should not be taken to manage symptoms during in vivo exposure as their use negates any positive effect of exposure-based treatments.

Generalised anxiety disorder

About generalised anxiety disorder

Approximately six per cent of Australians are likely to experience generalised anxiety disorder (GAD) in their lifetime (McEvoy et al., 2011). The essential feature of GAD is excessive and persistent anxiety and worry about a number of different life domains, such as family, health, finances, and work difficulties. These anxieties or worries are present more days than not, and may be accompanied by a number of additional symptoms such as:

  • restlessness
  • being easily fatigued
  • difficulty concentrating
  • irritability
  • muscle tension
  • disturbed sleep.

Screening and assessment of generalised anxiety disorder

There is currently limited evidence supporting a specific screening instrument for most anxiety disorders, and no screening test has been developed specific to generalised anxiety disorder. However, the following questions adapted from the MINI (Sheehan et al., 2004) can be useful in screening for GAD:

  • Have you worried excessively or been anxious about several things over the past six months?
  • (If yes) Are these worries present most days?

If the veteran answers ‘yes’ to each of these questions, assess for symptoms of GAD. It is important to consider whether the veteran’s anxiety is restricted to, or better explained by, another disorder. It is also important to ask the client about any major stressor or life change in the past six months (e.g., new job, new relationship, divorce, illness, etc.).

The Penn State Worry Questionnaire (PSWQ; Meyer et al., 1990) is a specific measure of worry, and the Depression, Anxiety and Stress Scale (DASS-21; Lovibond & Lovibond, 1995) is a general measure that can help track stress and anxiety as well as counselling outcomes. Neither is a diagnostic measure for GAD. See Appendix C or www.at-ease.dva.gov.au for both these measures, as well as instructions on their administration, scoring and interpretation.

Treatment of generalised anxiety disorder

Psychological interventions

Cognitive behavioural therapy

Whilst CBT has some general techniques applicable across a range of disorders, specific CBT techniques for targeting GAD are:

  • Cognitive therapy – This involves challenging the negative and catastrophic beliefs that trigger and maintain worry, as well as beliefs about the nature and usefulness of the worrying process.
  • Structured problem solving – This can help the veteran address feared problems and consequences using a more helpful method than worrying.
  • Anxiety management – This includes strategies such as progressive muscle relaxation and breathing retraining, to help manage the physical consequences of worry.

As GAD reflects a generalised and persisting anxiety, it is important for veterans to learn cognitive, physiological and behavioural strategies through treatment, which they can apply in a range of circumstances and situations. This differs from strategies for other anxiety disorders, where there is a greater focus on the fears and responses to specific stimuli.

Talking to a veteran together with the veteran's family about his or her GAD is the start of treatment. A summary of useful information to be conveyed to the veteran and his or her family is included in the following text box.

Psychoeducation and self-management strategies

Psychoeducation is important as it helps to demystify the veteran’s symptoms, restore a sense of control and create hope for change. It is also important to encourage the veteran to do the following:

  • Reduce substance use, including benzodiazepine misuse. This is a significant issue amongst individuals with GAD, as 17 per cent of Australians with GAD also have an alcohol use disorder. A brief and early intervention that includes education about substance use can be effective (see Chapter 8 on substance use disorders). If benzodiazepines are used, they should be taken on a regular schedule as far as possible, rather than on an ‘as needed’ or ‘prn’ basis.
  • Maintain (or re-establish) their daily routine and current roles (e.g., work, family). Helping veterans to think about treatment goals in the context of what relationships and roles they would like to see improve can help motivate them.

CBT-based self-help resources are also effective in treatment. A list of self-help resources is included at the end of this chapter.

Psychological treatment setting and duration

Generalised anxiety disorder can be treated in an outpatient setting and does not usually require admission to a psychiatric hospital unit. Psychological treatment for GAD will usually involve 12-15 weekly one-hour sessions of CBT. In more difficult and complex cases, a longer course of CBT may be required.

Pharmacological interventions

Medication is usually not recommended for mild GAD, in preference to psychological interventions. However, antidepressants may be considered for veterans with moderate or severe anxiety, adjunctive to, or followed by, psychological treatment. Newer generation antidepressants should be the first-line pharmacological approach. Benzodiazepines are not recommended for long-term management of GAD, but may be considered in the initial stages of treatment for veterans who require rapid relief from severe anxiety symptoms. If benzodiazepines are prescribed, they should not usually be used beyond approximately four weeks. There is some evidence to suggest that atypical antipsychotics may have a role as an adjunct treatment for veterans with GAD who show an incomplete response to antidepressants. However, NICE recommend not using antipsychotics in a primary care setting.

Social anxiety

About social anxiety

People with social anxiety fear any social or performance situations in which they may be scrutinised or negatively evaluated by other people. Fears of being embarrassed in social situations or of public speaking are widespread in the community. With social anxiety, the fear interferes significantly with the person’s normal routine, social activities or occupational functioning. Approximately one in twelve Australians will experience social anxiety at some point in their lives (McEvoy et al., 2011).

Social anxiety can be generalised or related to performance only. The performance only subtype involves fears associated with performing in public or in front of an audience (for example, public speaking), and generalised where there is a fear of most social and performance situations. Veterans may go out of their way to avoid the feared situation, or suffer intense fear and anxiety when exposed to it. Situations that are commonly feared by people with social anxiety include speaking in public, speaking to strangers or meeting new people. People with social anxiety may also fear eating or drinking in public, using public toilets or writing in public (e.g., filling in a form).

Screening and assessment of social anxiety

As noted above, social anxiety is relatively common, yet it is often undiagnosed as veterans may be reluctant to talk about their fears. In some cases, being in the clinical setting may itself stimulate anxiety symptoms and a veteran’s fear of being scrutinised, humiliated or embarrassed. A missed diagnosis can also occur if the practitioner confuses the veteran’s symptoms with shyness or mistakenly judges secondary comorbid conditions, such as substance abuse and depression, to be the primary disorder. To ensure that a diagnosis of social anxiety is not overlooked, practitioners should consider the disorder whenever a veteran refers to feeling anxious in social situations. On the other hand, the practitioner should be careful to exclude the possibility that avoidance of social situations is associated with PTSD or agoraphobia.

The following questions are recommended in the National Institute for Health and Care Excellence (NICE) guidelines for social anxiety disorder (2013):

  • Do you find yourself avoiding social situations or activities?
  • Are you fearful or embarrassed in social situations?

Veterans who respond ‘yes’ to either question should be assessed further for symptoms of social anxiety. Practitioners may need to ask specifically about fear of a range of social and performance situations, as the person with social phobia is unlikely to spontaneously report the full range of their social fears.

The Fear Questionnaire (FQ; Marks & Matthews, 1979) is a useful tool for identifying situations that trigger anxiety, and the Depression, Anxiety and Stress Scale (DASS-21; Lovibond & Lovibond, 1995) is a general measure that can help track stress and anxiety as well as counselling outcomes. Neither is a diagnostic measure for social anxiety. See Appendix C or www.at-ease.dva.gov.au for both these measures, as well as instructions on their administration, scoring and interpretation.

Treatment of social anxiety

Psychological interventions

CBT is the psychological treatment of choice for social anxiety. Talking to a veteran, together with the veteran's family about his or her social anxiety is the start of treatment. A summary of useful information to be conveyed to the veteran and their family is included in the following text box.

Psychoeducation and self-management strategies

Psychoeducation is important as it helps to demystify the veteran’s symptoms, restore a sense of control and create hope for change. It is also important to encourage the veteran to do the following:

  • Reduce substance use. This is a significant issue amongst individuals with social anxiety as using a substance (e.g., alcohol) prior to or during a social event is a common, but unhelpful, way of coping with the stressful situation. Indeed, almost 20 per cent of Australians with social anxiety have an alcohol use disorder. Early advice on reducing substance use is effective, and if benzodiazepines are used, they should be taken on a regular schedule as far as possible, rather than on an ‘as needed’ or ‘prn’ basis.
  • Increasing avoidance of social situations is a significant feature of social anxiety, so encourage the veteran not to withdraw further from their routine, social supports and current roles (e.g., work, family).

Whilst CBT has some general techniques applicable across a range of disorders, specific CBT techniques for targeting social anxiety are:

  • Cognitive therapy – This involves addressing any unhelpful beliefs about the self and others which may have contributed to the development of social phobia and continue to contribute to its maintenance.
  • Anxiety management – This includes relaxation activities, breathing retraining, and self-instruction training, and provides the veteran with skills to manage the anxiety arising from confronting feared social situations.
  • Social skills training, if appropriate – This can include training in assertiveness and/or conversational skills.
  • In vivo exposure – This is considered the cornerstone of social anxiety treatment. It involves graded in vivo exposure to feared social or performance situations. During exposure exercises, the veteran is discouraged from using safety behaviours (or unhelpful coping strategies), such as avoiding eye contact for fear of signs of disapproval or negative judgment.

Psychological treatment setting and duration

Social anxiety seen in clinical settings is often a severe and chronic disorder, requiring specialist treatment. Social anxiety can be treated in an outpatient setting. Treatment duration will vary between 8–15 sessions, although more sessions will likely be required for more severe or difficult cases. Treatment of social anxiety does not require hospitalisation, unless there is concurrent suicidal depression or substance use requiring detoxification.

Consideration should be given to the treatment of social anxiety on a group basis when this opportunity is available. Because the condition involves a fear of social and performance situations, group membership itself can be an important part of treatment, providing exposure to a feared situation. However, the intervention should be targeted to the needs of the individual, and group therapy may be too confronting for some in the first instance.

Pharmacological interventions

Mild social anxiety will generally respond well to psychological intervention, however pharmacotherapy may be considered for moderate to severe cases. Newer generation antidepressants are the recommended first line pharmacological treatment; veterans who fail to respond may benefit from monoamine oxidase inhibitors (MAOIs). As with all anxiety disorders, benzodiazepines are not recommended for the treatment of social anxiety due to the potential for tolerance and dependency. If benzodiazepines are considered necessary to bring about control of acute anxiety symptoms, the course of treatment should be kept as short as possible.

Referral and coordinated care for anxiety disorders

  • VVCS – Veterans and Veterans Families Counselling Service (VVCS): This service provides veterans and their families with counselling and group programs Australia-wide. VVCS can be contacted 24 hours a day on 1800 011 046. (www.vvcs.gov.au)
  • Psychiatrist: For specialist management of more severe, chronic or complex problems. Some psychiatrists specialise in psychological treatments; they can review or prescribe medication, provide diagnoses, and manage co-occurring physical health problems. Allied health providers should liaise with GPs to arrange a referral. GPs can access a list of private psychiatrists at http://www.ranzcp.org/Resources/find-a-psychiatrist.aspx.
  • If hospitalisation is required, there are veteran specific mental health wards and treatment programs. To find out their location phone DVA on 133 254 or 1800 555 254.
  • A treatment plan should be developed collaboratively with the veteran and their family, and coordinated across service providers.
  • Consider psychosocial and/or vocational rehabilitation services from the beginning of treatment. DVA can offer extensive rehabilitation services for entitled veterans (www.dva.gov.au/rehabilitation).

Self-management resources for anxiety disorders

  • Veterans Line (1800 011 046) can be reached 24 hours a day across Australia for crisis support and counselling. This service is provided by VVCS.
  • The At Ease portal (www.at-ease.dva.gov.au) contains mental health and wellbeing resources, including websites, mobile apps and information booklets for both veterans and clinicians.
  • Mental Health Online (www.mentalhealthonline.org.au) is an internet-based treatment clinic affiliated with Swinburne University.
  • Useful materials are available from beyondblue (www.beyondblue.org.au), the Clinical Research Unit for Anxiety and Depression (www.crufad.org) and SANE (www.sane.org).
  • Barlow, D.H. & Craske, M.G. (2004). Mastery of your anxiety and panic (MAP-3) client workbook for anxiety and panic (3rd ed.). New York: Oxford University Press.

Practitioner resources for anxiety disorders

  • Andrews, G., Creamer, M., Crino, R., Hunt, C., Lampe, L. & Page, A. (2003). The treatment of anxiety disorders: Clinician guides and patient manual (2nd ed.). New York: Cambridge University Press.

This Advice Book has the following resources in the appendices that may be useful to use with veterans who are experiencing symptoms of anxiety disorders:

  • further explanation of CBT elements (Appendix B)
  • veteran psychoeducation handout for each anxiety disorder and general psychoeducation script outline (Appendix D and Appendix L)
  • self-monitoring sheets including thoughts and feelings records, distress thermometer (SUDS) and daily activity schedule (Appendix E)
  • pleasant events list (Appendix F)
  • progressive muscle relaxation (Appendix G)
  • breathing retraining instructions (Appendix H)
  • information on where veterans can get more help, e.g., Veterans Line, DVA funded psychological and rehabilitation services (Appendix J).