Anxiety Disorders

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Everyone feels worried and anxious from time to time. This is normal particularly in response to major threats such as food insecurity.  However, if these feelings result in physical and behavioural changes that interfere with daily life, they can become an ‘anxiety disorder’.

The term anxiety disorder is a blanket term covering a number of different conditions. Panic attacks, phobias and generalized anxiety disorder share a number of key features and are therefore covered together in this brief section.

Signs and Symptoms

Psychological symptoms such as: feeling tense (‘on edge’) and worrying a lot about things. Feeling restless, irritable and impatient. Finding it hard to concentrate.

Physical symptoms such as: heart racing (palpitations), sweating, chest pains or difficulty breathing, feeling dizzy, lightheaded or faint. Nausea, diarrhoea, headache, muscle aches and tension are all common.

Types

  • Panic disorder: when some of the above symptoms come on very quickly, are severe, and last about 10-30 minutes (‘panic attacks’) then stop.
  • Phobias: An overwhelming fear of an object, place, situation etc. Examples include spiders, enclosed spaces and public transport.
  • Generalized anxiety disorder (GAD): when some of the above symptoms are present most of the time regardless of the situation.

Assessment

  • Ask about psychosocial stressors
  • Ask about alcohol and drug use (including caffeine)
  • physical examination (and investigations) to rule out other causes such as thyrotoxicosis, asthma, etc.

Treatment

  • Psychoeducation: Explain anxiety to patient especially the link between physical and psychological symptoms. Give health advice such as reducing or stopping substance use, good diet, exercise etc.
  • Relaxation methods such as breathing exercises are especially helpful in a panic attack.
  • Consider using problem solving therapy to reduce stressors (see psychosocial treatments section).

If symptoms are severe:

Refer for Psychotherapy such as cognitive behavioural therapy (CBT) or interpersonal therapy (IPT), if available.

If not available or medication needed, prescribe:

1st line: Prescribe Fluoxetine 20mg once daily (morning) PO. Can gradually increase every few weeks to 60mg. Continue until symptoms resolve – usually at least 6 months.

2nd line: Prescribe Amitriptyline 50-150mg nocte PO. Can gradually increase every few weeks to 150mg. Continue until symptoms resolve – usually at least 6 months.

If palpitations are a major symptom, prescribe a beta blocker such as Propranolol 40mg OD. Increase if necessary to 40mg 3 times a day.

If anxiety symptoms worsen initially on starting Fluoxetine or Amitriptyline, a short dose of Diazepam 2 - 5mg up to max of four times daily PO for a maximum of 5-7 days is acceptable.

Red Flags

For referral to if there is significant comorbid physical illness or the symptoms are interfering with activities of daily living.

Anxiety is often associated with depression and substance misuse. Consider admission if the patient is suicidal with no significant psychosocial support at home

Follow-Up

  • Review patient once a week until symptoms resolve
  • Once symptoms resolve, continue treatment for 6 months (except Diazepam which is only recommended for 5 to 7 days) and consider stopping thereafter
  • Assess for substance use and other psychosocial stressors