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symptoms:

       Reduction in self-esteem or self-confidence

       Poor concentration

       Sleep disturbance (either sleeping more or less than usual)

       Worthlessness

       Guilt

       Significant changes in appetite or weight

       Psychomotor agitation or retardation (moving more restlessly or more slowly than usual)

       Irritability

       Tearfulness

       Decreased libido

       Thoughts that life is not worth living or of suicide.

      When reaching a probable diagnosis of depression, symptoms of anxiety can also be common. Therefore, whether depression has impacted functioning and this in turn has led to anxiety or worry, or whether anxiety has led to avoidance of activities leading to depressive symptoms, it is important to determine the primary presenting problem.

      Anxiety Disorders

      An evidence base exists across a range of anxiety disorders treated with LICBT interventions (Part II) at Step 2 of a stepped care model (Chapter 1). However, the evidence base does not include social anxiety, post-traumatic stress disorder or health anxiety, which should be treated at Step 3. However, it is important that LICBT practitioners are aware of these disorders as they will present at assessment. Before considering specific anxiety disorders it is also important to first appreciate what constitutes a panic attack as this can inform subsequent diagnosis and can occur in the context of many anxiety disorders.

      Key Point

      Characteristics of a panic attack:

       A sudden period of intense fear or anxiety

       Physical symptoms, such as a pounding heart or shortness of breath

       Is often, but not always, associated with cognitive symptoms such as a belief that something awful is about to happen

       Anxiety peaks around 10 minutes before slowly abating.

      Panic attacks occur in the context of many anxiety disorders and therefore should not necessarily lead to a probable diagnosis related to panic disorder. Appropriate use of questioning during assessment should enable triggers to panic attacks to be identified, informing subsequent diagnosis (Chapter 3).

      Generalised Anxiety Disorder

      Generalised anxiety disorder (GAD) is the most frequently occurring anxiety disorder (McManus et al., 2016) but is often missed as a probable diagnosis (Allgulander, 2006). It rarely occurs as a single diagnosis with up to 90 per cent of patients meeting diagnostic criteria for GAD also meeting criteria for one or more other common mental health disorders (CMDs), most often depression, social phobia or panic disorder (Kessler et al., 2005).

      Key Point

      Core symptoms:

       Excessive anxiety

       Uncontrollable and excessive worry about a number of different situations

       At least three common symptoms present for at least six months.

      Common symptoms:

       Restlessness

       Fatigue

       Poor concentration or mind going blank

       Irritability

       Persistent nervousness or feeling on edge

       Muscle tension

       Sleep disturbance.

      When reaching a probable diagnosis, however, it is particularly important that worry is recognised as excessive, not limited to situations that would reasonably lead to worry and is disproportionate to the situation(s).

      People with GAD may label themselves as having always been a worrier with worries perceived as uncontrollable and leading to significant distress or impairment in functioning.

      Worry is often coupled with an intolerance of uncertainty (IoU), but neither worry nor IoU are unique to GAD, being experienced in many other anxiety disorders. As many patients with GAD consider worrying to be a part of their character, they may seek help or are referred to LICBT services after becoming depressed rather than experiences of anxiety. This can lead to GAD being missed in assessments.

      Panic Disorder

      To meet diagnostic criteria for panic disorder (PD), panic attacks are experienced as spontaneous and not always linked to a single situation in which significant episodes of anxiety have occurred in the past.

      Key Point

      Core symptoms:

       Frequent unexpected panic attacks or less severe limited symptom attacks

       Occur for at least one month.

      Common symptoms:

       Worry about the consequences of the attacks or the occurrence of attacks in future – for example, what they may mean or interpreted as a sign that one is ‘going mad’

       Change behaviour in an attempt to mitigate or avoid having further attacks.

      When people associate certain experiences with having a panic attack, they may avoid that situation in future or only go through it with support from someone who they believe can help mitigate any consequences. This can become widespread and impair functioning in daily life and be captured as a diagnosis of PD with agoraphobia.

      Agoraphobia

      Given that the symptoms associated with agoraphobia may present a significant barrier to accessing mainstream service provision, it is rarely seen in mental health services without PD. However, it can be helpful to be aware of the main symptoms of agoraphobia to facilitate a more comprehensive probable diagnosis.

      Key Point

      Core symptoms:

       Intense fear of places or situations that might lead to a panic attack or where there is no easy way to escape from a situation without causing oneself embarrassment.

       Complete avoidance of the feared situation(s) or only being able to endure them when accompanied by a particular trusted individual.

      The key determinants to arriving at the probable diagnosis of agoraphobia without PD is firstly that someone has not had panic attacks in the past, and secondly that the fear they experience relates to incapacitation or humiliation in open or public spaces or situations due to panic-like symptoms (rather than an actual panic attack).

      Obsessive Compulsive Disorder (OCD)

      OCD is commonly co-morbid with CMDs such as depression, GAD, PTSD and health anxiety, although health anxiety does not include a sense of personal responsibility for the occurrence of feared events. It can also present as co-morbid to conditions such as autistic spectrum disorder (Lenzenweger et al., 2007; Ruscio et al., 2010).

      Key Point

      Core symptoms:

       Obsessional thoughts: repetitive intrusive thoughts, impulses or images, which are experienced as inappropriate, unpleasant and cause anxiety

       Compulsions:

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