Anxiety is a commonly experienced symptom as part of the body’s reaction to stress. It becomes a mental health disorder if exaggerated, lasts >3 weeks and interferes with daily life.

Features

• Psychological:
  • Dread
  • Tension
  • Poor concentration
  • Depersonalisation/derealisation
• Physical:
  • Insomnia
  • Loss of appetite
  • Globus
  • Diarrhoea
  • Urinary urgency
• Panic:
  • Palpitations
  • Dizziness
  • Diaphoresis
  • Breathlessness
  • Chest pain
  • Tetany
• Co-morbid: depression, self-harm, substance misuse

Differential diagnoses

• Psychiatric: generalised anxiety disorder, panic disorder, PTSD, OCD, phobic anxiety disorder, acute stress reaction
• Endocrine: hyperthyroidism, hypoglycaemia, phaeochromocytoma
• Cardiac: ACS, arrhythmia
• Drug-induced: withdrawal

Generalised Anxiety Disorder (GAD)

• Persistent and generalised anxiety for >6 months which is not situation dependent
• Most common anxiety disorder

Panic disorder

• Recurrent and unpredictable panic attacks
• May avoid places or people that cause previous attacks
• Associated with agoraphobia

Post-traumatic stress disorder (PTSD)

• Symptoms of acute stress response to traumatic event persist for >4 weeks
• Triggers can include: abuse (physical, emotional, sexual), trauma, war, severe illness
• Features:
  • Hyperarousal
  • Hypervigilance
  • Re-living (flashbacks, nightmares)
  • Avoidance of reminders
  • Emotional numbness
• Specific management: trauma-focused CBT or eye movement desensitisation reprocessing (EMDR)

Obsessive-compulsive disorder (OCD)

• Obsessions (intrusive distressful thoughts, impulses or images) lead to compulsions (ritualistic acts) to provide temporary egodystonic relief
• Usually begins in childhood or teens
• Differentiate from obsessive-compulsive personality disorder (OCPD) where rituals are egosyntonic (desirable)
• Co-morbid: depression, eating disorders, substance misuse, self-harm, Tourette’s
• Specific management: CBT including exposure and response prevention

Phobic anxiety disorders

• Agoraphobia: ‘fear of the market place’ – fear of public spaces
• Social phobia: significant fear and avoidance of social situations involving meeting people e.g. going shopping, telephone calls, eating in public
• Specific management: CBT including graded exposure therapy

Questions to consider in an anxiety history

• Confirming symptoms: “Tell me what happens when you feel anxious.” “
• Ideas: “Can you think of any reason for feeling like this?”
• Type:
  • “Are you anxious all the time or certain times?”
  • “Do you get intrusive thoughts you find hard to resist?
• Screen for co-morbidites: depression, substance misuse
• Risk assess: “Sometimes people who feel this overwhelmed feel the need to harm themselves, has this happened to you?”

Management (BioPsychoSocial)

• Bio:
  • SSRIs
  • Propranolol for physical symptoms
  • Buspirone/benzodiazepines for short-term
• Psycho:
  • Psychoeducation
  • Self-help
  • Counselling
  • Individual CBT
• Social:
  • Social support e.g. groups
  • Financial aids

Written by Dr Muhammad Zain Haq, Psychiatry Lead (F2)
Reviewed by Dr Patrick Ezeani (Consultant Psychiatrist)