 Good evening everybody and welcome to this MHPN webinar on an interdisciplinary approach to caring for people living with generalised anxiety disorder. My name's Steve Trumbull and I'll be your facilitator tonight. I'm a GP by background and I will introduce the rest of the panel very shortly. But I did want to firstly acknowledge the traditional custodians of the land, seas and waterways across Australia upon which our webinar presenters and participants are located. I'm personally on Wurundjeri country here in Melbourne. We wish to pay our respects to Elders past, present and future for the memories, the traditions, the culture and hopes of Aboriginal and Torres Strait Islander Australia. So as I said, my name is Steve Trumbull. I'm a GP, but my main work is at the University of Melbourne where I'm head of medical education. I'll introduce the panel though now. The bios have been circulated with the materials along with the webinar invitation. So I won't go into too much detail, in fact very little detail at all, but I'll introduce first of all Dr. Cathy Andronis. So Cathy, you're a GP here in Victoria as well as me. I've got a question for you just to introduce you to the group. How common is generalised anxiety disorder in general practice? Thanks Steve. Generalised anxiety disorder is very common in general practice. Prevalence in the community and incidents at 3% and 6% is probably double or triple in our rooms because these people present quite often because they have a lot of anxiety about life in general. So that's why it's an important topic. Okay, so often with physical symptoms I guess as well? Yes. Because in the case we're looking at tonight, Leanne had some physical symptoms, so we'll explore that soon. Well thank you and welcome. It's great to have you. Next is Lisa Lab... Lisa, there you are. So Lisa, you're a psychiatrist based in New South Wales. We've had a hell of a two years, have we not? I'm just curious, has generalised anxiety disorder increased during this COVID-19 pandemic? Well the results might surprise you because anxious people have been somewhat more anxious but there's been actually a much greater increase in anxiety and indeed depression and people who didn't have a pre-existing history of anxiety or depression. And there's been, as you can imagine, an enormous amount of research done looking at reactions to COVID. And actually on some measures people with pre-existing anxiety and depression didn't actually score as badly in terms of increases as people without it. So it's an interesting result which is not necessarily actually more anxiety. That's fascinating. I mean I guess for some of us who are now getting back into going into the workplace again, you realise just how complex life is sometimes and so maybe we're seeing some of that. I'm sure we'll talk about that more later on. Thanks very much. Great to have you too. And also Natasha Davis now, Natasha, you're a clinical psychologist based in New South Wales. Welcome. The question I've got for you is actually to find out more about a program you've developed, a virtual reality program, which is about delivering evidence-based emotion regulation strategies to high school students. That sounds fascinating. Can you tell us a bit about that? I'd love to. In 2019 I engaged in a project to deliver and design a social and emotional skills program to kids, parents and teachers in high school using virtual reality technology. It was a wonderful experience to work alongside educators and animators to create this immersive virtual reality experience in which this animated character basically coached along the participant with the core emotional, cognitive and behavioural strategies that we'd be teaching them in the therapy room. Unfortunately, our RCT and rollout was disrupted by COVID, but I am pleased to say that it was eventually evaluated and since been adopted in some schools in Australia and in the US. Fantastic. You'd never find a more critical audience for virtual reality animations and things like that than people in that age group. I'm sure you've got some frank and fearless feedback from them. We certainly did. Yeah, but I guess if they've engaged with it, that's absolutely fabulous. Okay, so thanks for that. So this is our panel for tonight. It's three plus me, so we're going to move pretty briskly through the case and plenty of time for your questions. We now need to think about what we're actually doing this evening and what we're doing is accessing this fabulous panel to help meet these learning outcomes. We want to look at the biological and environmental factors that increase the risk of developing generalized anxiety disorder and also the comorbidities. We want to look at how we identify, assess and diagnose GAD. We're going to look at the therapeutic approaches that have proved successful because obviously we don't want to be working with those that haven't been successful and finally elaborating on the importance of collaboration, which is always really important with MHPN and which referrals are most appropriate when assisting people who are living with generalized anxiety disorder. So there are learning outcomes and now we will move into the case. You've had a chance to look at the case. I hope the case of Leanne, a woman who's living with generalized anxiety disorder with some physical symptoms as well as some long-standing emotional concerns. And where the case finishes up is that her friend suggests she goes to see her general practitioner about her headaches and stomach pain and her friend packs her off to the GP to get something to help her sleep, which if nothing else will at least give her a good night's sleep. So, Kathy, this is probably a scenario that you're familiar with. Leanne and people like her have come through your door many, many times. What are you going to do? Oh, absolutely. Thanks, Steve. Well, do a thorough assessment and take a good history and talk about things. But if I can just go through an overview of what we would do. I think this is the second slide. Can you go back a slide? This one, GAD. So GAD in general practice is number one. Yes, OK. This is a very common scenario in general practice. So because in general practice now at least 50% of our consultations do include a mental health issue and anxiety is the most common one. These people with generalized anxiety disorder typically present quite frequently multiple times, various problems and over many years and can be very difficult to reassure. And they come in with all sorts of problems from work, study, everyday life, but particularly with physical symptoms. So very similar to the presentation of Leanne that is very typical. And of course, as an anxiety disorder, they will have problems with concentrating, often feel tired and have chronic pains and insomnia, irritable bowel. So somatic symptoms are very, very common presentations in patients with generalized anxiety. And they can be quite challenging for us to manage. Next slide, please. The GAD diagnosis. Yes, OK. So what we typically see is a patient who will say that I'm a warrior. I've always been a warrior. What we normally have to do is exclude physical courses. There are lots of screening tools, as we mentioned earlier. It's a fairly high prevalence and incidence of generalized anxiety disorder in our community, but in general practice, it's probably two or three times higher than that. And we see women more than men, usually over 30, and they will often have chronic diseases as well. So just like everybody else, when they do develop chronic diseases, they do worry more about them. I'll often have a family history, including past history, if you take a good history of trauma, including adverse childhood events. And many of them will say this is how I am. It's part of my personality. Next slide, please. So there's obviously a prescription and a non-prescription way of managing patients with generalized anxiety disorder. And the non-prescription sort of ways is, of course, to take a good biopsychosocial approach history and in your management so that it's holistic. So you want to examine for physical comorbidities how much exercise they get, what their diet is like, are they taking any medications that have side effects. Sleep hygiene is something we commonly need to cover. Like Leanne, a lot of people who worry don't sleep well because they're ruminating or they've got lots of somatic symptoms that are keeping them awake. But they also, like everybody else, can have relationship work and domestic issues, cultural issues, financial problems, but they may worry about them more than some other people. So sometimes we just help them to identify simple solutions, problem solving. And of course, like anybody else, they can have psychological other comorbidities that can make the anxiety worse. Some GPs are trained to be FPS providers and can do behavioral treatments and offer CBT, relaxation, mindfulness in their practice because some patients are happy to just see the GP and don't want to go anywhere else. Psychoeducation, explaining what generalized anxiety is and how it affects people's lives is a very important part of the treatment and why it can cause somatic symptoms. Now, self-compassion, you know, using yoga, walking, social prescribing, they're very important things. Social prescribing, especially COVID isolation has shown how important it is for us to be connected to other people. Some people like to head to e-health options, like head to health website and beyond Blue and BlackDoc Institute have apps and programs which can be very helpful for some people to do it at home by themselves. So we want to really empower people as much as possible to manage themselves, their psychological and psychic symptoms, but also to refer them for assessment by other psychiatrists or psychologists and we can obviously want to discuss the risks and benefits of doing that. PERMA there is a common little tool that we use in general practice to emphasize for patients that they should aim for positive experiences, engagement with life and the things around them, for instance, going out with their friends, making sure that they have good relationships and that they build their relationship if there's a problem, to look for meaning in their life and to celebrate their achievements and accomplishments. Next slide, please. Now, GPs don't just prescribe medication for anxiety, but of course there are times when it's helpful and the most common one that we tend to use as an SSRI, we try to avoid using bed-to-day as a pings, so sometimes they can be helpful for special occasions, things like fear of flying, people who've got to get on a flight and because it's really important and they just are absolutely petrified of having panic attacks. Recently, there've been a few patients where I've heard it's been helpful to have it before their COVID vaccine because they've just been terrified about the vaccine. So it's been an interesting new indication. Increasingly, we're seeing patients who off-label treatments like prototype and pro-panelol and hypnotics have been used. These aren't as often initiated by GPs, but often patients will have used these in the past and may ask for them. The problem is in Australia that we rate above average in our prescription rate usage and so we're very mindful of trying to use non-medication strategies as much as possible. And bear in mind that with these patients, it's important to have a risk-and-benefit conversation about medication. They're often surprisingly reluctant to take medication because they may have a very fixed mindset or opinion that medication is not a good thing. So the next slide please. So I just want to finish off by talking about the self-care of the GP. Now you might think, why would we be talking about the GP when we're talking about generalised anxiety disorder, presentations and general practice? It's because they are often perceived as being very difficult patients by GPs and GPs often become very anxious and stressed when they see them. I think it's important for GPs to have some guidelines about how they manage patients who are excessively anxious. One of them is to make sure that you rule out the physical causes for their presentation, physical illnesses, particularly looking for red flags. Once you've done that, make sure that you are reviewing these patients regularly, have a screening and a review schedule for them. You do that in collaboration with the patients so they don't feel like they're being pawned off or that their concerns aren't important. We often can use a broken record approach of reassurance that's just rice, like the Goldilocks approach, which is that we're confident and rational in the way we present our reassurance, allowing Skype, of course, for that regular review and offering as much empathy, empathy as we can. Now, we need to be mindful. We need to be self-aware. We need to be conscious of transference, counter-transference issues and to stay compassionate and try to avoid this difficult patient attitude. And so that's something we can do by trying to model mindfulness in our sessions so it's benefit to us and also for the patient, so of us when we stay calm and when we're prepared before they walk in and to also perhaps do a debrief, self-debrief afterwards so that we don't carry that anxiety through to other patients because if we can stay calm and then we're more likely to be able to reassure them and we don't sort of escalate their anxiety. So being very honest and realistic about the risks and benefits, whatever treatment and being clear with our boundaries, empowering patients are probably the most important things that we can do as well and of course, reverse. So we shouldn't have to see ourselves as being able to manage everything on our own. We share our care with a team care approach. There are lots of established parameters for that, so better access allows us to share the responsibility with psychologists, with psychiatrists and we make that decision in collaboration with the patient. So for Leanne, a lot of these issues will be relevant and I know other presenters will be presenting some of the things that I've gone through very quickly and I look forward to some conversation later. Thank you. Thanks very much indeed, Cathy. And I think you made it clear that medication is certainly not the first thing for even if Leanne walks in and says, my friends told me to come and get some Tomazopam from you. That's a very seductive thing to respond to but clearly that's not the approach you would expect a general practitioner to take and to work through the physical side. But for the purposes of the case, and we'll obviously have a conversation once everybody's presented their view, but for the purposes of the case, we'll say that Leanne does end up moving on to a psychiatric review and goes to see Lisa. So Lisa, what's your approach to the management of Leanne? Thanks, Steve and thanks, Cathy. So first of all, I'm going to be very focused on diagnosis and I know that Natasha has a very similar approach as a clinical psychologist. To me, it's the mention of worry that instantly raises the potential diagnosis of generalized anxiety disorder to me. I see a lot of confusion out there that people who have lots of anxiety are often said to have generalized anxiety disorder. Another example of DSM giving a terrible name to something that just creates confusion because GAD is actually quite a specific thing. If you have a look at the DSM-5 criteria there, it's excessive anxiety and worry. They may or may not have panic attacks. So somebody who's really focused on having panic attacks and worries about having panic attacks may well have a panic disorder, not a generalized anxiety disorder. So GAD is worry about anything and everything, not just one particular thing like, say, illness, but as Leanne actually exemplifies, worry about all sorts of things, which is perceived as difficult to control. People recognize it's probably excessive and they can certainly tell that they worry a lot more than other people they know, but they just can't control it. And then the DSM requires that in addition, you've got to have a number of other physical type symptoms. So fatigue, irritability, not really a physical symptom, but you can see the list is there. There's a couple of screeners that can be helpful. And I just want to remind people that a screener is not a diagnostic tool. So if somebody comes up positive on a screener, the whole purpose of the screener is actually to identify people that are worth a closer look. And I just mentioned that, because I know that their screen is out there for all sorts of things, for example, ADHD as well. And just to remind people that that doesn't say they've got a diagnosis. Now the cutoff I've given you there, a cutoff of 10 means that you identify everybody who might have GAD and is worth another look. If you go a bit higher and you had a cutoff of 15, now it's more likely that the people that are scoring 15 and more probably actually have GAD and not some other type of anxiety disorder. So the GAD7 is nice because it's just seven questions. Next slide. I really like the Penn State worry questionnaire if I'm treating people. I don't know that you'd want to use it that much in general practice, although it does have a really interesting list of questions. But you can see if people are improving and it is a very nice tool in clinical practice. You might also want to screen for depression because GAD and depression are really kissing cousins. So there's a very strong overlap between them. So you can use, again, you can use a screening tool. The DAS, I think Cathy mentioned as well, or there's actually some interesting research quoted by the RACGP that just those two screening questions there can really be quite effective as well. Next slide. So as I mentioned, GAD and depression are really close relatives and there's a shared, there's very typically a shared vulnerability factor. So you can see it's moderately heritable, more so than depression on its own actually. And the risk factor is probably a temperamental tray of what is referred to as negative emotionality. But what that, the way I explain that to my patients is I say it's being highly sensitive and reactive to things. And I also like to say that that's not all bad because that degree of sensitivity and reactivity actually often makes people very good people, people. But unfortunately, it tends also to create a certain vulnerability to anxiety and depression. Now the really interesting thing is they've done some great longitudinal studies in New Zealand. And if we're talking about people with GAD, then by the age of 32, 75% of women and 50% of men have also already had an episode of major depressive disorder. So people with GAD have probably or will probably also have depression at some stage. And a small number, maybe 12% of people with GAD may well have a depression at the same time. And I think GPs are actually really good at picking up the depression. But sometimes maybe we don't follow people up enough to check was there an anxiety disorder there all the time as well. So did they just get anxious because they became depressed or do they really have that joint vulnerability to both anxiety and depression? So always screen for depression in people with GAD. And it's not a bad idea to screen for anxiety in people with depression. Next slide. Now thinking about Leanne and GAD more generally, there's some other differentials that I would consider. So Leanne is quite nervous about being away from her family in case something happens to them. And the DSM-5 has actually brought separation anxiety disorder into the anxiety disorders as an adult diagnosis. And there's some research that's been done in Australia that has demonstrated that there can be an adult onset of separation anxiety disorder. So we typically think about it as being a disorder of childhood. And in fact, that's where it was classified. But in some people it can persist into adulthood and some people can get it for the first time in adulthood. And the key diagnostic feature of separation anxiety is anxiety about being separated from loved ones. But interestingly, it's because of a fear that something will happen to the loved one, not so much that some harm will happen to the individual. So I guess that's something I'd wanna keep in mind. I mean, I think Leanne's got a much wider range of symptoms. She doesn't only worry about leaving her family, but I put it there because we don't often think about it in adults. I think we need to think about personality factors and there may well be some personality traits. I think of obsessive compulsive because that's people who like things to be controlled and ordered and predictable. And of course, there is some overlap of that with anxiety. I also would think of dependent traits with Leanne because she really seems to go along with people to keep them happy, worrying that maybe her friends won't like her anymore or her husband will leave her. And that can raise a suggestion or a dependent personality where people will subjugate their own needs and wishes to prevent somebody else leaving them, mainly because of belief that they don't feel they could cope independently. I certainly wanna check on self-esteem because again, that's something somebody with low self-esteem can do. And I'm thinking about lack of assertiveness for Leanne. And then of course, the husband, you do just... I think we always do need to keep in mind could there be some domestic violence and maybe this type might be more the coercive control style. So obviously not all of these are other diagnoses but they're other considerations when I'm coming up with a formulation of what I think is going on in this case. Next slide. From a treatment perspective, psychological treatment really is first line for anxiety disorders. Definitely at mild to moderate level, at moderate to severe level, we can think about adding in pharmacotherapy of which first line is antidepressants, either SSRIs or SNRIs. Now, all antidepressants have an anxiolytic action but they take a lot longer to work for anxiety than they do for depression. So we were always taught, for 30, 40 years we've been taught you should see some improvement in depression between 10 to 14 days. You can throw that out the window for anxiety. Anxiety takes four to six weeks to see much improvement. So we don't want to be escalating the dose prematurely because they don't seem to be responding. And that's where Kathy's advice about staying calm and managing your own anxiety is really important. Again, you don't have to choose a really sedating drug to try to get that anxiety under control right away. It's better to choose something that somebody can live with in the longer term because you're going to want them to take their medication for six to 12 months. Anxious people are often extremely sensitive to side effects, so start low and go slow. And there really isn't any evidence of a need for higher doses in GAD or indeed most of the other anxiety disorders. Again, that's a bit of a myth that's out there. I might have one more slide. I might not. Just there's a list of other medications here. I put them down because people always ask me about them. None of them are first line. I see a lot of metazepine being used out there, but there really isn't that much evidence for it. And there's a bunch of other stuff which you can have a look at there, which I do see being used from time to time. But I think the take home is SSRIs and SNRIs first line. Final slide. These are the clinical practice guidelines that were put out by the Royal Australian and New Zealand College of Psychiatrists. And just to summarize, what's not recommended is symptomatic prescribing, i.e. prescribing for just one symptom, like treating sleep. Polypharmacy, adding something for this symptom and something for that symptom. Don't need to routinely start a benzodiazepine with an SSRI if you start low and go slow and give plenty of advice and appropriate reference. And beta blockers are not recommended in anxiety disorders either. So that's me for now. Thanks, Lisa, you and Cathy, both taking me back to 1979 first year medicine when beta blockers were just released and one of my colleagues insisted on taking one for his nerves before anatomy oral and did the whole thing prone because he kept on fainting when he stood up. So for me, that's been a reminder of the inappropriateness of using medications or flable. Anyway, a little diversion back into ancient history there. Thank you so much. I was really also reminding myself that to ask people to post your questions, even if you did send questions through before the webinar, please do pop the questions, use the little voice bubble thing to pop your questions in so that the panel can answer them when we get to the end of the presentations. So thanks so much, Lisa. I think you and Cathy, you've both built on each other or you've built on Cathy's beautifully. And now, as Lisa said, the first thing is psychological interventions. So Natasha, what have you got for us? This is really nice to follow Cathy and Lisa because I think they've covered so much of what I'm going to breeze over very quickly and I'm gonna focus a lot more on the treatment today. So what I see is the steps to giving good clinical care, well, a good diagnosis, a solid formulation that's constantly updated and treatment planning fitting into that. So the first step is the identification system and diagnosis process. And as Lisa has said, the key component of GAD is worry. To pick up on what Lisa has mentioned about, you know, the cousin of worry being depression, I think one of the things that's helpful to think about here is both the rumination. The rumination with worry is linked to danger, threat-related attributions, whereas the rumination with depression is related to loss, hopelessness and failure. So that can be quite useful to keep in mind. And we also wanna rule out the other comorbidities which Lisa has gone through in quite a bit of detail and we'll get to talk about more with the case, the couple of the ones that came up were social anxiety disorder for my mind and dependent personality disorder which Lisa has touched on. So where to from there? Just on the next slide, if you don't mind, Steve. True fix. So this is just to the problem formulation, are we there? Yeah, the use of interview schedules and measures to a diagnosis. So Lisa's actually gone through quite a bit of this already. So I won't touch on most of these. The one that I just wanna highlight is the metacognition questionnaire. So this will play out when we look at the formulation and wanting to understand what some of the maintaining factors are for Leanne and also others who may have GAD. But this world's tool I find very effective in helping you to identify what are some of the beliefs that might be driving the worry process for the individual. It breaks it down into five key factors. So there's positive beliefs about worry, negative beliefs about uncontrollability and danger associated with the worry. Also cognitive confidence and need for control and cognitive self-consciousness. So how much they're actually monitoring their thinking process. So I find that incredibly helpful in being able to tailor what we then are going to do in treatment and of course, build out that formulation. Next slide, if you don't mind, Steve. These measures are in the resources list at the back. And as Lisa pointed out, we also have the very effective tool of NOBO Psy, which can help us to distribute a large number of questionnaires. And certainly the GAD7, the screener, the Penn State Warrior questionnaire and the DAS to name a few of them. But as I mentioned in that resources list, you'll also see others in there. So where to then? We've got step two, which is building out a formulation. I've included this diagram in here just because this is the way that I tend to think about it. And it's a model that I find helpful to present with clients and to work on together to give us almost like a nice framework to start bringing those pieces of information. So of course, we want to be looking at what are the predisposing factors? As both Kathy and Lisa have mentioned, Leigh-Anne's very typical of clients with GAD where they've always been a warrior. Dating back to probably when they're in their early primary school years is when you'd find a high level of conscientiousness. And I've always wanted to do the right thing in fear of making a mistake. They're just some of the things that you might assess. And then we want to look at what are the precipitating factors? What's coming up now? What's made this an issue for her? And we'll go through a little bit more in that when we talk about the case. And then, as I mentioned, we want to identify what are the perpetuating factors? And that's when those measures, the metacognition questionnaire is particularly helpful at identifying those solutions that are already outlined. And then what's got to the prognostic factors here? What are the risk and protective factors that we might want to have a little look at? So just going on to the next slide, if you would remind Steve. These all I find you can think about it in terms of that a classic formulation or you might want to think about GAD within a framework that has been shown to be effective for the treatment. So on the right-hand side, you'll see that there's a model there, the metacognitions therapy model, metacognitive therapy model, sorry, that represents those different beliefs within a framework where you can incorporate with a client and discuss how you're going to build in the treatment plan around that. So this is the third stage of what I'd be suggesting, which is treatment planning and implementation. First of all, I find with clients with GAD, some motivational interviewing may be needed to determine the goals and specific targets for change. I often find that they're very motivated to address the mood-related concerns that they may have, but may not be so willing to address some of the other factors that might be part of their generalized anxiety profiles, such as dealing with uncertainty or being able to reduce their sense of control over situations and are more likely to say that the worry actually helps them in some way. So coming up with a good, solid set of goals, and in terms of treatment options from there, well, CBT is the gold standard treatment and most popular. It addresses content and processes that you might be addressing in the treatment. And then, as I've already mentioned, the metacognitive therapy and CT is a modified CBT intervention and it focuses on the processes themselves, as I mentioned, like positive beliefs about worry and that worry might be dangerous in some way. There is also some evidence to support the use of ACT for treatment of GAD as well. Moving on to the next slide, if you wouldn't mind, Steve. Yeah, so I thought I might just draw up a typical CBT treatment for GAD. And what I've done here is I've broken it into two phases. The first phase I would suggest could be doing a combined CBT and metacognitive therapy intervention of roughly around 10 to 15 sessions in length. It may include some of these particular structures. You'll see as we go through this that Kathy has mentioned some of these, as has Lisa in what we'd be wanting to address. So specifically how I would design it is developing and discussing the formulation with Leanne and then breaking it down as both Kathy and Lisa mentioned of psychoeducation about anxiety, mood, sleep and worry itself. And then what I'd be looking to do is using that modeling that I was on the last slide, I'd be looking at doing behavioral experiments with Leanne. Depending on what came out of her metacognitive therapy, metacognitive questionnaire, then I might be looking at the uncontrollability beliefs that she said like, I can't stop worrying or I might be looking at challenging some of the, her use of attention towards things that she fears most. So it might be things like she's concerned about some of her physical symptoms that she reports. We might do some behavioral experiments around what happens when you focus in on those symptoms versus when you shift your attention away from one. Do they intensify or do they reduce, for example? And then I'd move on to looking at perhaps the danger beliefs that she holds. So for example, worrying can cause ABS or cancer and positive beliefs about worry. So it helps because I come up with ideas on how to fix things. I think it was one of the examples given in the case example with Leanne. And then on to structured problem solving. This touches on what Cathy had mentioned. I particularly like the use of imaginal exposure, cognitive challenging for the worst case scenario and catastrophic thinking. So this would be on the belief that she could have cancer, for example. And if there was excessive checking going on, I'd also be targeting that to reduce the checking and reassurance seeking, especially if there were health anxieties as part of it. And then another part of it is accepting uncertainty and managing gains and relapse prevention. So that's sort of a typical CVT treatment that I would suggest for GED. As the first phase, if you wouldn't mind going on to the next slide for me, Steve. Terrific. So in terms of where to from there, I would also like to take the information and particularly from the development history or from the relationship history and maybe draw up a second phase of treatment for Leanne. The goal here would be to address the long-term unhelpful patterns that were identified in the assessment. And you heard Lisa talking about this in terms of some of those personality factors. And a couple of the ones that stood out for me as part of this would be about how she manages herself in relationships. And I would be suggesting a different frequency of sessions for that, which would be roughly two to four weekly for her. And this would be a long-term treatment of 12 to 18 months. And specifically addressing patterns of over-functioning or under-functioning that she displays. We've seen a bit of that in the case study. She's a little ineffective in the way that she's able to negotiate her needs within relationships. So that would be one of the key targets, I would imagine, and identifying and modifying the maladaptive scheme as we've identified a couple of those. They might land on, say, the dependent personality or we also were talking about the obsessive-compulsive personality. So that might fall on the different schemas of unrelenting standards and subjugation. There was actually quite a few that she might fall into from that case example. I guess an important part of all treatments is collaborating with the client and other team members. And so this brings me to the last slide, which is just how important it is to have a shared understanding of the nature of the concerns, particularly if there's health and anxiety, so that we can successfully treat it. And also just to acknowledge that the general practitioners who have a long-term relationship with a patient can often assist with providing a very good medical history that we can use. The tricky thing I've found in working with clients with GAD and particularly if there's a health focus, is that they can otherwise engage health professionals in their safety behaviors, such as the checking and reassurance seeking. So for example, running modern tests, it does reduce the distress in the short term, but it doesn't address those underlying belief structures that we were talking about, like if they have something really wrong with them or that they can't deal with uncertainty and not knowing. And of course, GPs and psychiatrists can assist with describing medication for those comorbid factors, such as mood difficulties and also managing the patient expectation as therapy isn't going to be providing a quick fix. Thank you so much, Natasha, and thank you to all three of you. We now move into the phase of the webinar where we talk about the case and more generally respond to questions. Before we did though, I was just wondering, you mentioned to Natasha about working with the team. Are there any other team members who we might involve in Leanne's care? Do you think at the moment social workers have come up as a team that has special skills to offer? How would we integrate social workers into the care team? Yeah, that's an interesting one. I guess we saw in the case example there was some over functioning that Leanne did with her family members. I think from memory of her son that she was stepping in and looking after quite a bit. So, certainly having a look at the whole system would be very, very helpful. And in terms of some of the interventions I mentioned in that second phase of treatment, certainly social workers are very well skilled in applying any sort of family systems intervention, such as the addressing over functioning and under functioning in the system and helping with some of those relational targets of improving her capacity to sort of self-care relationships. Yeah. Thank you for that. Going back on to Lisa's presentation and there's a question from Julian Taylor asking about at what point do you increase the SSRI? She's made the point that what if it is helping depression after 10 to 14 days but not the anxiety after four to six weeks? Is that where polypharmacy is useful or do you stay the course? No, that's probably where you increase the dose. So, ideally, you start at just the recommended kind of therapeutic minimum and give it a bit of a chance to work. So, if they've got a comorbid depression and that starts improving within a couple of weeks, that's fantastic, sit tight, give it a chance to see if the anxiety is going to respond as well. And then the first thing to do is to think about increasing the dose. Ideally, the patient is also engaged in some psychological strategies because really, anxiety is a long-term game. It tends to be chronic. At the very least, it's recurrent and longer-term psychological strategies are going to have the biggest payoff for people. Okay, well, that's good to know. Thanks for that. Another question on the physical aspect of it, Susan Glaser has asked the question about hormone influence that clearly Leanne is, I think she's perimenopausal here at this stage. Kathy, how do you tease apart sort of those perimenopausal symptoms from what is generalized anxiety disorder? It's very common during the perimenopause to have increased anxiety symptoms. So that alone is one of the most common menopause symptoms we see. Now, what we're talking about in Leanne's case is generalized anxiety disorder. And so, you know, to distinguish that somebody with menopause symptoms whose actions might necessarily have generalized anxiety disorder, they might be just having a very difficult experience of making that transition during menopause. Nevertheless, it's important to be holistic in the management. So address physical issues. So if a lot of women attending to the menopause symptoms can improve their anxiety because they feel more comfortable. So it might be that they do need HRT or they do have other physical problems, including heavy bleeding, for instance, that may be making them anemic and very tired. So we need to make sure that we manage those things. So we take it seriously. But it was being mentioned by both Natasha and Lisa because patients with generalized anxiety disorder often are difficult to reassure and are looking for reassurance and can become very concerned about anything that's new or different because it seems uncertain because we often can't give them too much reassurance about how long their specific menopause symptoms are going to last. We have to help them to recognize that this is part of a normal process, that it can be difficult but will manage symptoms as we go along, but not to lose track of the bigger picture in her anxiety management. Yes, so definitely we always need to manage the comorbidities just like we put in any patient. Sure, thanks, Kathy. And I think Lisa said that people with GAD often are quite susceptible to the side effect of medication, the adverse effect of medications. And I see Tina in the chat box reminding us not to forget the pharmacist that often the pharmacist will be the port of call that somebody will go to and say, this new medication, you're sold me, I'm having these symptoms. So obviously they're an important part of the team as well to help with the teasing apart of the side effect of medications. Lisa, did you have a comment on Lisa in there? Yeah, I was just gonna say, I think it's well worth exploring with people how anxious they are about the medication when you're talking to them about it. I have had patients where I've been very happy for them to take a nibble out of the tablet for the first few days until they felt a bit less anxious about taking it. So I routinely sat them on half a tablet at the minimum dose and tell them, take that for a few days. When you feel your body is sort of coping with it, then it can increase it to a full tablet because at the end of the day, it's much better, it'd be much better that they took two weeks if you like to get up to the kind of therapeutic dose rather than be frightened off because of a bad experience that might not even be anything out of the ordinary, but just frightening to somebody who's very focused on their health. Sure, understandable. Kathy, what were you gonna say? Yeah, I was gonna say something very similar. I think we need to validate that there is genuine anxiety for everybody when they start a medication. We can't guarantee how things are going to turn out for that person. And so we need to validate that there is reason to be cautious when you're prescribing something that may be unpredictable. And I find this very important to empower the patient to make the decision about it's their body. They can choose whether they take something or not take it. And that is often a very powerful therapy in its own right to validate it and to empower people to feel that they are able to manage themselves. Absolutely, and that takes me to a question that I'm gonna bring together and a number of questions that have been asked, both in the pre-submitted ones. There you go, that doesn't work. And also the ones that have popped up this evening. What does it feel like? I mean, we've all felt anxious. I feel anxious at the moment in hoping that this platform is going to serve its purpose, which it is. But that's minor, I mean, obviously those with lived experience can give a more vivid description, but what words have you heard used to describe the feeling of what is GAD rather than just being worried? I had a patient once who talked to Bouch. It feels like I've drunk a glass of worry water and suddenly I'm overwhelmed. It's just like worry is overwhelming me and rushing through my body and I can't control them. I thought that was a kind of interesting analogy of worry water like as if, you know, something just comes over them. So it can be quite an overwhelming experience, I think. And a very physical experience, by the sound of it, hence the somatic symptoms. It's not just a little bit of back-of-the-mind niggling. This is a whole-of-body experience, I suppose, with the vagal nerve getting involved. Is this a moment when I can ask if anybody can tell us about polyvagal therapy? Natasha's come off mute. Thanks, Steve. Yes, so in terms of effectiveness for GAD, there is limited evidence to support the use of the polyvagal theory or polyvagal approach with clients. It's a very popular type of therapy that clinicians often find that clients can really understand the mechanism from the use of the diagrams as well as the exercises that can be used in therapy. But unfortunately, in terms of research, there isn't the support to back up the use of it as an evidence-based treatment. I've included two resources in our Q&A further reading section of our resources, which just goes through a recent article that brought together a paper that was written in 2016 which challenged each of the three premises that the original author, Paul, just postulated. And I think the limitation here is that they're trying to attach psychological therapy to a biomedical model. And I think we've got other very well-grounded psychological therapies that we can appeal to instead. And there's a view that I've listed tonight. Thanks, Natasha. Various other therapies have come up in the questions that people have asked, asking about exercise therapy, maybe using an exercise physiologist or neurofeedback or art therapy, or what else have we got there? Psychodrama, various things like that to engage the right side of the brain. What's the panel's thoughts about some of those other approaches? I believe that exercises, being outside, being in nature is critical. We know that that's probably one of the most important things that we're programmed to do as humans is to move and to be commuting with the real world. And I think that one of the problems that happens from too much inside work, too much social media, is that it perpetuates, it becomes a perpetuating factor, as well sometimes a precipitating factor in people's generalized anxiety. And so the more we can get people to be calmer through being active, then the better it is for their health and the better it is for their mental state. Great, you do sound like my GP, Kathy. Thanks for that. I'll take all that on board. What about the others, Natasha or Lisa? Any thoughts about those? Yeah, I mean, certainly in dealing with some of the symptoms from that tension and irritability that was scribed with the DSM diagnostic criteria that Lisa presented, of course. You know, certainly exercise, healthy sleep habits. I guess the challenge here is that some people may not understand that doing excessive exercise will not get rid of GAD, will not get rid of worry. And in fact, I've seen a number of clients present where they have tried to address the sleeping difficulties and their tension by just exercising more and they're just exhausted by the time they come. And we've really got to get to, as I was suggesting, some of the beliefs underneath, the worry and the beliefs that are driving some of those symptoms of the excessive rumination or worry with threat-related. So until we get into that challenging of the threat attributions, these are unfortunately gonna be short-term reliefs. Yeah, I think some of those things might be adjuncts. And I think just to clarify, when Natasha says underlying beliefs, we're not talking about what some patients think. You know, I must have some repressed memory or some, you know, deep-seated thing from my past that's driving this. There's actually not that much evidence for it. Certainly some patients may have a history of trauma, but trauma, childhood adversity predisposed to a range of psychological and indeed physical illnesses. It's not kind of specific and it's not like, well, if they've got GAD, we should go looking for something from childhood that is unresolved. But I agree that I think we need to remember that worry is a cognitive strategy and it's probably an attempt to try to manage the intolerance of uncertainty that people have. And so physical strategies that help with physiological diarousal may well be helpful, but I agree with Natasha that I think people need some cognitive strategies to help them keep this condition under control in the longer term. And some of those therapies that you've mentioned, there isn't an evidence base for it. Now, obviously an evidence base tells us what works better than placebo for a group that it's been studied in and it doesn't answer what will be helpful for an individual. But I do think it's good to go with the evidence-based approaches in the first instance. Thanks for that. Now, I'm really pleased that somebody did take the invitation or the implied invitation to put in the chat box what their personal experience of generalized anxiety disorder is. And I'll read it out here. In my experience, it feels like ridiculous worries, things you know are unreasonable in your mind, but you can't stop such as I can't write because what if I forget how to spell or I can't walk down the stairs in case my legs stop working. It was so overwhelming. It felt like I was disconnected from my body. So that seems to resonate with what you've been talking about from the professional end and obviously an overwhelming, somatic psychological experience. So thanks very much for contributing that in the chat box. Look, this question seems really trivial, but I can't let the evening finish without asking if this particular interest does a reduction in neuro-stimulant intake like coffee and tea help? Would that be a very basic thing to do in the beginning, Cathy, just to say reduce your caffeine intake? Or is that a little bit? Well, I think we just, everybody should be encouraged to have a healthy lifestyle. In my experience, patients with generalized anxiety disorder, they've already worked that out for themselves. They usually know what coffee does to them because they watch for effects quite often. And so I usually just validate what they do. But occasionally you will see somebody who might be drinking excessive amounts of caffeine and not realize that it might be making their symptoms worse. But in my experience, they usually do know those things. Thanks for that. I think you're right. So actually, Elise has asked a question. She's an occupational therapy student who's told us that she's got GAD herself and she's wondering about the role of occupational therapy, which I think would probably fit in to that spectrum of other professions that can contribute with things like exercise or art therapy. I guess that fits with what we were saying before about finding a spectrum of therapies that meet the needs of a particular person. And I guess in Leanne's case, it might be that there was a role for guided exercise with an exercise physiologist, occupational therapist or whichever one's most appropriate or art therapy is something to supplement the psychological strategies and the medication. Dave, I would just add that sometimes what people are lacking in their life is they've become so focused on worry and how miserable... And I should say the other thing about GAD is it makes people absolutely miserable. You know, they don't want to live worrying constantly. So sometimes they actually have let go of enjoyable things in their life, of pleasurable things. Natasha talked about how mindfulness and appropriate attention-focusing can be really helpful. So sometimes those other strategies, it's not so much that we should be looking for them to cure the GAD, that they represent kind of healthy things that people can be... They can show people ways to find things to get engaged in, to get a sense of pleasure and meaning and achievement from as well. And I think that's where some of the other health professionals can be particularly useful in helping people maybe add those things in to enrich their lives as well. Okay, and what about within the family? There have been a few questions about family members and their role in supporting people such as Leanne, but also within relationships, partnering and what sort of impact that can have living with and sharing your life with somebody with GAD. Any thoughts about, I guess, the family members in particular, what you might be able to, how you might better recruit family members to assist? Yeah, as well as being a GP, I'm trained as a family therapist, so I thought that that might be an interesting thing for me to answer. I often find that people with generalised anxiety disorder are often seen as being difficult to live with in some families and they get blamed a lot for causing dysfunction in the family. People are sometimes sick of hearing them complained and so sometimes they feel like nobody listens to them and so they can have the normal range of relationship problems that a lot of people have, but this and their excessive worry often will push their kids away. So sometimes it's really helpful to have relationship therapy, you know, couple therapy or family therapy, a lot of social workers and OTs that now do family therapy and are trained to manage those relationship things. And so I think it's really important to have really good relationships because in my experience, a lot of people with generalised anxiety will say, people are sick of me. My family is sick of hearing about me complaining. All I do is complain and I feel like I'm a downer. I feel like I make them feel sad or I make them feel bad and I don't want to be like that. It's really hard. What are your thoughts, Narsha? Yeah, and I think also just to hear what Kathy was saying, that in the case example, we found that Leanne decided to just do things rather than necessarily raise issues with people or to encourage them to do it for themselves as well. So you often do find that they overfunction their doers and they in that having a change in their behaviour is going to have an effect on the rest of the family. So they need to be aware of that and encouraging of that move. And perhaps I'd add that I think one of the things that becomes very difficult for family members is constant reassurance seeking. And we know that one of the strategies that warriors use to try to get certainty and relieve their anxiety is to seek reassurance. They might phone family members 10 times during the day to check they're all right and things like that. So I like to work with the family to explain what is driving that behaviour and to ask the individual to start taking responsibility to resist the urge to ask for reassurance. But I often find that acknowledging how that can put a strain on relationships helps the family members feel heard. And if everybody knows that there is a plan that is going to help it but it's going to take a little while, then that often can be very helpful for relationships and kind of help the family hang in there and get on side a bit with the treatment. OK, great. Thank you for that. So we're about to round up and I'm sorry we've had many more questions than I expected that have all come through now. There's one more surely reminded us of the importance relating to hesitancy around medication that and this is where remembering the pharmacy comment from earlier that if a patient says they don't like the initial prescribed medication they should come back and discuss alternatives, alternative dosages or formulation of medication rather than dismissing all medications. So that's obviously part of the negotiation with the client to make sure that that happens. OK, so thanks to everybody who has asked questions. There are others there that hopefully will be answered at some stage later on when you look back at the recording. And also there's a question about Natasha's online program, which I think you'll be able to find on the Internet, Natasha, or details about it. Let's just whiz around though and get people. Kathy, what final words would you have about Leanne's case and how you see the future for her or any other thoughts about Leanne's case? My final thoughts are that this is a common presentation and that GPs and everybody who comes into contact with people with GAD professionally need to make some space and allowance for that uncertainty because they often can make us feel very uncertain as well. They can be a very infectious process for both of us and that to go slowly, to reassure them to go slowly and use psychoeducation so that they can learn coping cognitive strategies and behavioural strategies and to be patient, go slowly and look after ourselves as well. There was a question asked about mindfulness as an approach, but I think you mentioned that mindfulness for the clinician is also really important if that's something that people practice to bring it out when you're finding this counter-transference. Thanks very much. So, Lisa, what were your final thoughts and reflections? Look, I'd like to be a bit upbeat and say, I mean, I really like working with people with GAD because it's really treatable. You can really make a difference for people. The cognitive science research has really given us so much more insight about what's going on in GAD. When I first started out, we had almost nothing that was very useful and now we understand it so much better that we can really make a difference. So, I mean, I think it'd be really positive about it. There's a lot that can be done. Right, and I think you've reminded us there's a sort of a fork in the road experience there, isn't there, a sliding noise moment where you can either become overwhelmed by caring for somebody with GAD or say, I can help. And that's got to be one of the biggest buzzers in healthcare, is it not, when you actually say, not only do I know how to help, I can help, and you can see it all happening. It keeps us going, doesn't it? Thanks very much. Natasha, what were your final thoughts or reflections? Yeah, similar to Lisa, I think the saying that there are effective treatments for GAD. There are great tools to use that really guide your formulation and treatment planning process to make it easier for us to assess. So, you're looking for the threat attributions, look at what maintaining factors are, and that can be incorporated in your treatment program quite easily, I think, with this. The other thing I wanted to mention as a take-home is in the resources list, there's lots of online tools, there's lots of applications that we can use. So, phone applications like a worry time application called Reach Out, which allows the client to write in their worries as they pop up, and then it hides away until a set time in the evening where they might look at them and do that structured problem solving. So, we have a lot of tools that we can use with clients to really help them get a handle on their worries and live in a more effective and enjoyable way. Fantastic. Thank you all so much. We are at the end of the webinar now, but please don't leave, everybody. We've got a few more things to go through. But first of all, to thank our fabulous panel so much, Natasha, Lisa, and Kathy, thank you for everything you said. The chat's been really positive. I think people have learned a lot and have contributed a lot to each other as well. And as people have said, it's such an important topic, particularly with what's all going on in the world at the moment, that we're doing whatever we can to assist people, not only with worry, but those with full-on global anxiety disorder. So important. I will, though, ask the participants to make sure that they do complete the exit survey to provide us with feedback as we go. That's the pie chart icon that you will see in the lower right corner of your screen beside the speech bubble. And if you can fill out that survey, that really is very important to us so that we continually improve the webinars. And a message will pop up on your screen after the webcast ends. You will receive a follow-up communication from MHPN that will link you to the recording of this activity and also allow you to access your statement of attendance. This is the last MHPN webinar for 2021. And we're looking forward to a really good 2022 in so many ways. But please make sure you are signed up to the MHPN portal because some of the topics that we will be looking at in 2022 are coercive control, LGBTQI+, and suicide prevention, perinatal anxiety and depression, and Tourette syndrome. And there will also be more emerging minds and older persons webinars in 2022. With the podcast program, it's a fabulous time of the year to be listening to podcasts as we drive around to visit family and all. The new Eating Disorders series has been released, and the podcast team is very keen to hear your thoughts about MHPN podcasts. So if you've listened to one, please go to the website and complete the survey. Now, obviously, if you are... I'm sorry, there we go. Oh, I forgot to mention. In conversation with Dr. Ruth Vine, Australia's Deputy Chief Medical Officer in Mental Health, is available on Spotify and Apple Podcast. How about that? And all those things I mentioned are just there. If I'd clicked the slide, the visual learners could have read what I was talking about. But if you would like to join the discussions with other professionals on a local level, project officers are available to help you and to establish a new one or join an existing MHPN network across metropolitan, regional, rural and remote Australia. There are currently 373 networks, and there's an online map there, which will show you which are close to you, or you can contact the network team, and you can also go to the map, follow the link that will pop up once you've completed the survey. So I wish everybody all the very best for the season coming up, and let's face it, a vastly better 2022 for everybody. So if you haven't had your third dose yet and you're eligible, please have your third dose. And when that comes around, when it's your turn. But live life well, but before I close, I would like to acknowledge the lived experience of people and carers who have lived with mental illness in the past, and those who continue to live with mental illness in the present. So thank you, everybody, including Hailey and Julie Middleton for putting together these webinars that do such a great job, but to all of you for your participation in the broadcast this evening. Thank you so much and farewell to the panel. Good night now.