Anxiety Disorders

 

• Signs and symptoms

  Mood and thought:

  • Tension
  • Agitation
  • Fear of loss of control.
  • Dread
  • Irritability
  • ↓Concentration
  • Depersonalisation and derealisation.
  • Obsessions and compulsions.

  Physical symptoms:

  • Somatization
  • Headache
  • Insomnia, especially onset insomnia.
  • GI: bowel and bladder changes, butterflies in stomach, nausea, ↓appetite, globus.

  Panic attacks:

  • Physical: palpitations, sweating, trembling.
  • Fear they are going mad, or fear they are dying (angor animi).
  • Last no more than a few minutes.
  • Hyperventilation. Can lead to tetany, tingling, parasthesia, chest pain, and respiratory alkalosis.

• Risk factors

  Risk factors for most anxiety disorders:

  • Family history (mild).
  • Women are at higher risk, except OCD and social anxiety disorder.
  • Onset is usually in teens and 20s. However, may rumble on untreated for years. Exception is GAD, which is commonest in 40s and 50s.
  • Life stressors. This can include physical illness.

• Prognosis

  • In general, anxiety disorders run a chronic course if untreated, but respond very well to treatment.
  • GAD tends to have a slightly worse prognosis, with 70% having long-term residual symptoms.

• Generalised anxiety disorder (GAD)

  Definition and epidemiology

  • Definition: generalised and persistent anxiety lasting >6 months which is not situational (i.e. not a phobia).
  • May occur in the context of a chronic health problem, and conversely, anxiety may present with somatic symptoms.
  • Depression may also be present, in which case treat whichever is most prominent first.
  • Epidemiology: commonest anxiety disorder. Commoner in women.

  Management

  Psychological

  The NICE stepped-care model, using the lowest effective step possible:

  1. Psychoeducation for patient and family for all those with known or suspected GAD.
  2. Low-intensity psychological intervention for 6 weeks, either self-help CBT or group psychoeducation.
  3. High-intensity psychological intervention for 12 weeks, either weekly CBT or applied relaxation. Offer to those with marked functional impairment or failure to improve on lower steps. Drug treatment is an equally effective alternative.
  4. Combine psychological and drug treatment, provide intensive MDT management, and consider inpatient admission.

  Biological

  An alternative treatment for those needing high-intensity psychological intervention:

  • 1st line: SSRI. Sertraline is most cost-effective.
  • 2nd line: alternative SSRI or SNRI. 3rd line: pregabalin.
  • Warn that drugs will take 1 week to take effect, and may initially cause transient increases in anxiety or agitation. Discuss suicide risk if under 30, offer PPI if on NSAIDs or aspirin, and warn against sudden cessation due to withdrawal effects.
  • Continue for at least 12 months if effective.
  • Benzodiazepines should be avoided, except for short-term relief during crises.

  Social

  • Peer support groups.
  • Support with returning to work or training if needed.

• Panic disorder and agoraphobia

  Signs and symptoms

  • Episodic and recurrent panic attacks which are not situational.
  • Often several attacks per month.
  • May interpret their symptoms as a physical health problem.
  • Can lead to situational fear e.g. agoraphobia. However, unlike social phobia, they don't fear being with other people.
  • Depression may also be present.

  Agoraphobia

  • Fear of public places, and fear that they will find it hard to escape from such places and/or have a panic attack.
  • Present in around 50% of those with panic disorder, and management is essentially the same.

  Management

  Initial psychological and biological treatment can be done in primary care. Secondary referral is only needed for those who have failed at least 2 treatments.

  Psychological:

  • Psychoeducation for patient and family. This also applies to patients presenting with a panic attack in A&E, and may involve written information to take away with them.
  • Self-help or computerised CBT.
  • Individual CBT: 7-14 weekly sessions.
  • For agoraphobia, graded exposure therapy can be used. Home-based treatment may be necessary initially.

  Biological treatments are an equally effective alternative to psychological therapy:

  • 1st line: SSRI. Allow 12 weeks to see if effective. Counsel as always on side effects.
  • 2nd line: TCA (imipramine or clomipramine).
  • Continue for at least 6 months if effective.
  • Other drugs: benzodiazepines should be avoided, except for short-term crises. There is little evidence for propranolol.

  Social:

  • Peer support groups.

• Social anxiety disorder

  Aka social phobia.

  Signs and symptoms

  • Fear and avoidance of meeting people and daily activities such as speaking by telephone, going to the shops, or eating and drinking in company.
  • Poor eye contact.
  • Low self-esteem and fear of criticism.
  • Panic attacks may occur.
  • In children, it may involve selective mutism.

  Management

  Psychological therapy is usually 1st line:

  • Individual CBT. Usually involves psychoeducation, and graded exposure, either during sessions or as homework.
  • In adults, CBT may use the Clark and Wells model, which involves video feedback to correct negative self-imagery, and shifting from self-focused to externally-focused attention.
  • As an alternative to individual CBT, offer self-help CBT, group CBT, or psychodynamic therapy. Group CBT is particularly useful in children and young people.

  Biological:

  • 1st line: SSRI e.g. sertraline, escitalopram.
  • 2nd line: a different SSRI or venlafaxine.
  • 3rd line: MAOIs e.g. phenelzine, moclobemide.
  • May be needed long-term, depending on response.
  • Other drugs, including benzodiazepines, should not be routinely used.
  • Pharmacotherapy should not be routinely used in children and young people with anxiety disorders.

  Social:

  • Difficult social situations may contribute to the condition and should be addressed e.g. for children, bullying in school or family problems.

  Other considerations:

  • A validated scale such as the Social Phobia Inventory (SPIN) should be used for the initial assessment and to monitor treatment response.
  • Offer clinic appointments at less busy times, and private waiting areas if possible. Home-based appointments and treatment may be necessary.
  • If depression is the primary disorder, treat that first.
  • Children in particular may be at risk of self-harm.

• Simple or specific phobia

  Signs and symptoms

  • Anxiety which is specific to objects or situations.
  • Anticipatory avoidance and anxiety.
  • Panic attacks may occur.

  Management

  • CBT involving graded exposure therapy and anxiety management.
  • Drugs have little role.

• Obsessive compulsive disorder (OCD)

  Signs and symptoms

  • Obsessional thoughts e.g. around contamination, security.
  • Compulsive acts: repetitive behaviours which provide temporary relief but don't give pleasure.
  • May be co-morbid with depression, substance misuse, or eating disorders.
  • There is a risk of self-harm and suicide.

  Management

  Psychological:

  • CBT which includes exposure and response prevention (ERP). In ERP, subjects confront the stimuli for their obsessions and are encouraged to resist acting out their compulsions e.g. touching something 'dirty' and not washing their hands.
  • Low-intensity CBT is 1st line for mild disease: either self-help with brief sessions, or group CBT. Guided self-help and family support can be tried first in children with OCD.
  • High-intensity individual CBT is an alternative 1st line to an SSRI in moderate disease, or used in combination with an SSRI in severe disease.

  Biological:

  • SSRIs are 1st line for moderate or severe disease: fluoxetine, paroxetine, sertraline, or citalopram. In children, only use them if other treatment fails, and monitor carefully due to the risk of suicidality.
  • Increase dose if no response after 4-6 weeks. Continue for at least 12 months if effective.
  • 2nd line: switch to another SSRI or clomipramine, but first try adding CBT to the SSRI. 3rd line: add an antipsychotic.
  • ECT can be used in suicidal or severely incapacitated patients.

  Social:

  • Family should be involved in the management, especially for children.
  • Support might be needed for children of adult patients, especially if it is interfering with the parent's ability to care for them.
  • Provide support regarding return to work and benefits if employment is affected.
  • MDT approach: OT can help return to normal activities, and social worker can advise on childcare and benefits.

  Prognosis

  Follows the rule of thirds: 1/3 significantly improve, 1/3 moderately improve, 1/3 have chronic course.

• Post-traumatic stress disorder (PTSD)

  Definition and risk factors

  • Psychological distress following extreme traumatic event, often involving threat to life or physical integrity e.g. assault, trauma, rape. Can also occur postnatally.
  • Typically presents within 6 months of event, but can be later.
  • Risk factors: female, refugees, first responders. Experienced by 1/20 soldiers after combat.

  Signs and symptoms

  Key features, HARD:

  • Hyperarousal/hypervigilance: autonomic arousal leading to poor sleep, irritability, angry outbursts, extreme startle response, and poor concentration.
  • Avoidance of reminders of the event e.g. certain people or places.
  • Re-living: flashbacks, dreams, or vivid memories of the event, accompanied by distress.
  • Dull/numbed emotions: feeling detached from others.

  Other features:

  • They may forget (or blank out) some aspects of the event.
  • Leads to functional and/or social impairment.
  • Co-morbid conditions: substance misuse, depression, anxiety. May first present with these, so PTSD itself is often undiagnosed.

  Management

  • Trauma-focused CBT: includes psychoeducation, anxiety and anger management, breathing techniques, and exposure to triggers in a controlled environment. 8-12 sessions.
  • Eye movement desensitization and reprocessing (EMDR): eye movements while focusing on the memory.
  • Medication is an alternative if preferred by patient: SSRI (e.g. sertraline) or SNRI (venlafaxine) 1st line. Antipsychotics (e.g. risperidone) can be used as an adjunct/alternative if severe. BZDs should be avoided is possible, but are sometimes used short-term.
  • Treat the PTSD before treating secondary co-morbid conditions, unless they are so severe that they prevent effective PTSD treatment.
  • Prevention: psychological debriefing immediately after trauma may worsen outcomes, but those who actually develop acute stress disorder should be offered trauma-focused CBT or active monitoring.

  Prognosis

  • The vast majority recover, often within 1 year.
  • Worse prognosis with worse symptoms, and up to 1/3 will be chronic.

  Other stress-induced anxiety disorders

  Acute stress disorder

  • PTSD-like symptoms within 1 month following extreme stress (e.g. car accident, assault), with onset typically in minutes to days.
  • Symptoms include dissociation and – like PTSD – hypervigilance, avoidance, intrusive thoughts, and low mood.
  • Known as acute stress reaction in ICD.
  • Management: trauma-focused CBT or active monitoring.

  Adjustment disorder

  • Starts <3 months after major stressor, and lasts <6 months.
  • Symptoms: depression, anxiety, and other disturbed emotions or conduct, leading to impaired functioning, but without meeting full diagnostic criteria for those or other mental disorders.
  • Management: 1st line is psychological treatment; 2nd line is anti-depressants or anxiolytics.

• Benzodiazepines (BZDs)

  Drugs

  Anxiolytics:

  • Lorazepam: rapid-onset, short-acting. Also an anticonvulsant (IV).
  • Oxazepam: rapid-onset, short-acting.
  • Diazepam: rapid-onset, long-acting. Also an anticonvulsant (PR, IV).

  Sedatives:

  • Nitrazepam: rapid-onset, long-acting.
  • Temazepam: slow-onset, short-acting.

  Others:

  • Midazolam: rapid-onset, short acting sedative. Used in procedures, ICU, and palliative care. Also an anticonvulsant (buccal, IM).
  • Chlordiazepoxide: intermediate-onset, long-acting. Used in alcohol withdrawal.
  • Other anti-convulsants: clobazam, clonazepam.

  Mechanism

  • Positive allosteric modulators of GABAA receptors, increasing the effect of endogenous GABA → ↑influx of Cl- → neuron membrane hyperpolarization.
  • This leads to reduced neuronal excitability.

  Side effects

  • Tolerance and dependency.
  • Drowsiness and weakness.
  • Risk of diversion.

  Use

  • They are only indicated for short-term relief (1-4 weeks) of severe, disabling anxiety or insomnia.
  • Use a low dose and ideally short-acting drug, to minimize side effects.
  • Withdrawal in long-term dependency should involve switching to an equivalent dose of diazepam and gradually reducing it over several months. Should not be forced on those not ready to stop; rather, offer them advice about the benefits of doing so.

• Nonbenzodiazepine anxiolytics

  • Buspirone: a 5-HT1A partial agonist, which is not addictive like BZDs.
  • Pregabalin: binds to voltage-gated Ca2+-channels. Potential for abuse and diversion.
  • As with BZDs, should be reserved for short-term crises.