Anxiety disorders

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:
  • 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
Screenshot 2022 01 29 at 14.51.27
GAD-7 questionnaire; 5-9 = mild, 10-14 = moderate, 15-21 = severe

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)

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