Chapter 81: Anxiety disorders

Anxiety is a normal human physiological response that helps us respond to potential threats or dangers. We cannot get by without it. With an increase in anxiety, our performance should increase accordingly (e.g. preparing for exams). When we have too much anxiety, however, a further increase in anxiety will lead to our performance dropping off, described by the Yerkes–Dodson curve (see FIG. 81.1). The optimal place to be on the curve is to the left of the peak, so we have a positive response in our performance to an increase in stress. Being at the peak or to the right will make us vulnerable to stress.

Anxiety becomes a problem when the stressor overwhelms us, resulting in poor performance, or if the unwanted consequences of the anxiety response give us undesirable physiological consequences. The stressor causes limbic activation, which in turn leads to autonomic and neuro-endocrine activity (down-regulation) that causes various physiological responses, including activation of the hypothalamic–pituitary axis. Blood flows from the gut to the skeletal muscles, smooth muscle contracts in the bowels and increases nausea, muscle tension increases, pupils dilate, the heart rate increases and blood pressure rises. These changes account for various somatic symptoms commonly seen in anxiety disorders (e.g. tension headaches, palpitations, eye strain and irritable bowel-like symptoms). In high stress situations, a flight–fright–freeze response can ensue.

The physiological role of anxiety and the way in which excess anxiety can cause these physical symptoms can be explained to patients suffering from anxiety disorders—and the GP is very well placed to conduct such psycho-education. Patients suffering from somatic symptoms are often unaware of the physiological consequences of anxiety and usually find this clarification comforting. It can help motivate patients to pursue strategies to reduce them.

Anxiety disorders affect 14% of the population,¹ with many people fulfilling the criteria for multiple anxiety disorders and/or a common co-diagnosis of depression.² The criteria for defining anxiety, as for many mental health disorders, have broadened over time, so it is difficult to compare historic prevalence figures. Specific phobia is the most commonly reported anxiety-related diagnosis (1 in 5 women and 1 in 10 men), and PTSD is the most common disorder (over 6%).¹ Anxiety disorders listed in the DSM-5 are:³

• separation anxiety disorder

• selective mutism

• specific phobia

• social anxiety disorder (social phobia)

• panic disorder

• panic attack (specifier)

• agoraphobia

• generalised anxiety disorder

• substance/medication-induced anxiety disorder

• anxiety due to another medical condition

• other specified anxiety disorder

• unspecified anxiety disorder

Other conditions discussed in this chapter include:

• obsessive–compulsive disorder

• body dysmorphic disorder (see CHAPTER 45)

• post-traumatic stress disorder

• acute stress disorder

• adjustment disorder with anxious mood

• somatic symptom disorder

Generalised anxiety disorder

Generalised anxiety comprises excessive anxiety and worry about various life circumstances and is not related to a specific activity, time or event such as trauma, obsessions or phobias. It affects up to 5% of the population. There is an overlap between generalised anxiety disorder (GAD) and other anxiety disorders.

General features:

• persistent unrealistic and excessive anxiety

• worry about a number of life circumstances for 6 months or longer

Clinical features

Psychological

• Apprehension/fearful anticipation

• Irritability

• Exaggerated startle response

• Sleep disturbance and nightmares

• Impatience

• Panic

• Sensitivity to noise

• Difficulty concentrating or ‘mind going blank’

Physical

• Motor tension:

  • – muscle tension/aching

  • – tension headache

  • – trembling/shaky/twitching

  • – restlessness

  • – tiredness/fatigue

• Autonomic overactivity:

  • – dry mouth

  • – palpitations/tachycardia

  • – sweating/cold, clammy hands

  • – flushes/chills

  • – difficulty swallowing or ‘lump in throat’

  • – diarrhoea/abdominal distress

  • – frequency of micturition

  • – difficulty breathing/smothering feeling

  • – dizziness or lightheadedness

Symptoms and signs according to systems

• Neurological: dizziness, headache, trembling, twitching, shaking, paraesthesia

• Cardiovascular: palpitations, tachycardia, flushing, chest discomfort

• Gastrointestinal: nausea, indigestion, diarrhoea, abdominal distress

• Respiratory: hyperventilation, breathing difficulty, air hunger

• Cognitive: fear of dying, difficulty concentrating, ‘mind going blank’, hypervigilance

Diagnosis of generalised anxiety disorder

The diagnosis is based on:

• history—it is vital to listen carefully to what the patient is saying

• exclusion of organic disorders simulating anxiety by history, examination and appropriate investigation

• exclusion of other psychiatric disorders, especially depression and adjustment disorder with anxious mood

Note: Anxiety and major depression often co-exist.

Main differential diagnoses (note that this conforms to the seven masquerades list):

• depression

• alcohol or drug (including benzodiazepine) dependence/withdrawal

• hyperthyroidism

• angina and cardiac arrhythmias

• iatrogenic drugs

• caffeine intoxication

Management

The management applies mainly to generalised anxiety, as specific psychotherapy is required in other types of anxiety. Much of the management can be carried out successfully by the family doctor using brief counselling and support. Cognitive behaviour therapy (CBT), in which maladaptive thinking, feelings, perceptions and related behaviours are identified, assessed, challenged and modified, can be of considerable benefit.⁴ Exercise, both low or high intensity, has been shown to decrease anxiety symptoms. Hence psychological therapy and non-drug strategies are first-line therapy for most anxiety disorders.⁵

Principles of management

• Psychological interventions (e.g. ‘life coaching’ and CBT) are first line.

• Give careful explanation and reassurance:

  • – explain the reasons for the symptoms

  • – be aware that patients often ‘worry about worrying’ (e.g. that anxiety is dangerous, that they are going crazy or ‘losing it’)⁶

  • – reassure the patient about the absence of organic disease (can only be based on a thorough examination and appropriate investigations)

  • – direct the patient to appropriate resources to give insight and support

• Provide practical advice on ways of dealing with the problems.

• Advise on the avoidance of aggravating substances such as caffeine, nicotine and other drugs.

• Advise on general measures such as stress management techniques, relaxation programs, mindfulness and regular exercise and if possible organise these for the patient (don’t leave it to the patient).

• Advise on coping skills, including personal and interpersonal strategies, to manage difficult circumstances and people (in relation to that patient).

• Provide ongoing supportive psychotherapy.

TABLES 81.2 and 81.3 list a number of good sources of reliable information about anxiety.⁷

Pharmacological treatment^8,9

The key principles of using medication for anxiety disorders are:

• Non-pharmacological management is first line for a reason. Do not rush into using medication and repeatedly reassess whether to continue prescribing.

• Of the medications, SSRIs are regarded as first line and other antidepressants such as SNRIs, e.g. duloxetine and venlafaxine, have shown some benefit in anxiety disorders (see TABLES 81.4 and 81.5), but their benefits are not as long-lasting as psychological and behavioural approaches.^10,11

• Assess efficacy of antidepressants after at least 12 weeks (in contrast to 6–8 weeks when treating major depression) and, if of clear benefit, treat for at least 6 months.

• The cessation of an SSRI commonly causes withdrawal symptoms. A common trap (for doctor and/or patient) is to interpret these symptoms as a recurrence of the underlying anxiety and as evidence that the drug continues to be required.

• Propranolol is of benefit in social anxiety disorder, particularly with anticipated stressful events (e.g. public speaking, presenting at work events).

• Benzodiazepines have a limited role in anxiety disorders. If used, they should be reserved for people who have not responded to at least 2 therapies (e.g. psychological therapy and antidepressant) and used only in the short term (stop within 6 weeks). They can also be used for specific phobias (e.g. fear of flying, agoraphobia and MRI machines).

• Consider buspirone, which has negligible potential for tolerance or dependence.

Panic attack⁸

A panic attack is defined³ as a discrete period of intense fear or discomfort in which four (or more) of the following symptoms develop abruptly and reach a peak within 10 minutes:

• shortness of breath or smothering sensations

• dizziness, unsteady feelings, lightheadedness or faintness

• palpitations or accelerated heart rate

• trembling or shaking

• sweating

• feeling of choking

• nausea or abdominal distress

• depersonalisation or derealisation

• numbness or tingling sensations (paraesthesia)

• flushes (hot flashes) or chills

• chest pain or discomfort

• fear of dying

• fear of going crazy or of doing something uncontrolled

Organic disorders that simulate a panic attack are hyperthyroidism, phaeochromocytoma and hypoglycaemia.

Note: A single panic attack is not synonymous with panic disorder, which is characterised by recurrent panic attacks. Some 40% of young people have had at least one spontaneous panic attack. Panic disorder is when there are recurrent attacks that are followed by at least a month of worrying about future attacks and/or the consequences of them. Panic disorder can occur with or without associated agoraphobia, though >90% of people with agoraphobia develop it as a result of recurrent panic attacks.¹⁰

Management

Reassurance, explanation and support (as for generalised anxiety). This is the mainstay of treatment. A patient who is experiencing a panic attack should be taught breathing techniques to help control hyperventilation (e.g. timing breaths, breathing through nose, slow inspiration, measured medium-sized breaths). Relaxation techniques can also be employed, such as progressive muscle relaxation, and patients can teach themselves these techniques via online resources (see TABLES 81.2 and 81.3). Rebreathing into a paper bag is rarely indicated in a general practice setting^9,10 as the hyperventilation has usually settled by the time the patient presents. The above breathing techniques can be used by the patient anywhere and are more socially acceptable than breathing noisily into a paper bag when an attack is feared.

The danger in a panic attack is the danger to the self by the self⁸ (e.g. fleeing into danger, non-intentional overdose).

Cognitive behaviour therapy (CBT)

(See CHAPTER 5.)

CBT aims to reduce anxiety by teaching patients how to identify, evaluate, control and modify their negative, fearful thoughts and behaviour. If simple psychotherapy and stress management fail then patients should be referred for CBT, usually to a psychologist (or occasionally psychiatrist), although some GPs have a particular interest in providing CBT.

Patients’ fears, especially if irrational, need to be clearly explained by the therapist, examined rationally and challenged, then replaced by positive calming thoughts.

Pharmacological treatment

Pharmacological treatment is rarely of benefit in the acute attack, as the attacks occur too quickly for their effect to be of use. For ongoing treatment of panic disorder with or without agoraphobia, there is little good quality evidence comparing medication to CBT.⁹

Continual use of benzodiazepines (BDZs, e.g. alprazolam or clonazepam) has previously been utilised in panic and other anxiety disorders but is now no longer recommended.¹⁰ Problems associated with benzodiazepine use include:

• impaired alertness, oversedation

• dependence

• increased risk of accidents

• adverse effects on mood and behaviour

• interaction with alcohol and other drugs

• potential for abuse and overdose

• risks during pregnancy and lactation

• muscle weakness

• sexual dysfunction

• diminished motivation

• lowered sense of competency

• lower self-esteem

Some principles of using BDZs in anxiety disorders¹⁰ are:

• always check for a history of problem alcohol or drug use

• be wary of prescribing to unfamiliar patients, especially if asking for a particular drug by name (may indicate drug-seeking behaviour)

• carefully discuss the potential for addiction with the patient

• avoid using short-acting drugs as they are the most highly addictive

• prescribe only small quantities of medication at a time

• use only as short-term treatment

• ensure regular review of the patient and continuity of care

If already being used, BDZs should be tapered very slowly (this may take 6–12 months or longer). A benzodiazepine withdrawal syndrome, which can include rebound anxiety, depression, confusion, insomnia and seizures, may occur. However, the doctor’s fear of being responsible for a withdrawal syndrome has also been used as leverage by those seeking drugs. If in doubt, seek specialist drug and alcohol advice.

Phobic disorders

In phobic states, the anxiety is related to specific situations or objects. Phobic disorders include agoraphobia, social anxiety disorder (otherwise known as social phobia) and specific phobias. Patients avoid these objects or situations, become anxious when they anticipate having to meet them and/or endure them with intense distress.

Common phobias are spiders, people and social situations, flying, open spaces, confined spaces, heights, cancer, thunderstorms, death and heart disease. The problem is seldom encountered in practice and there is usually no call for drug therapy.

Agoraphobia

Avoidance includes staying away from many situations where there are issues of distance from home, crowding or confinement. Typical examples are travel on public transport, crowded shops and confined places. Patients fear they may lose control, faint and suffer embarrassment.

Social anxiety disorder

Social anxiety disorder is experienced in anxiety-provoking social situations in which the person feels subject to critical public scrutiny (e.g. canteens, restaurants, staff meetings, speaking engagements). It can either be generalised (fear of numerous social situations, including both performance and interactional situations) or non-generalised (fear of one or just a few situations or performance type). The treatments for the two subtypes are quite different (see TABLE 81.5). The sufferer may be a shy, self-conscious, premorbid personality. Social phobias, including performance anxiety and symptoms, are often related to sympathetic overactivity.

Management

The basis of treatment for all phobias is psychotherapy that involves behaviour therapy (e.g. graduated exposure therapy) and cognitive therapy.

Obsessive–compulsive disorder (OCD)

Anxiety is associated with obsessive thoughts and compulsive rituals.

The obsessions are recurrent and persistent intrusive ideas, thoughts, impulses or images that are usually resisted by the patient. Compulsions are repetitive, purposeful and intentional behaviours conducted in response to an obsession to prevent a bad outcome for the person (e.g. excessive washing of the genitals).

Mild obsessional or compulsive behaviour can be regarded as normal in response to stress.

Management

Optimal management is a combination of psycho-therapeutic—particularly CBT—and pharmacological treatment, namely:

• cognitive behaviour therapy for obsessions

• exposure and response prevention for compulsions

Body dysmorphic disorder

The person with this disorder has an exaggerated preoccupation with an imagined defect in appearance (see CHAPTER 45).

Patients may be helped by counselling and psychotherapy.

Acute stress disorder

This is defined as a constellation of abnormal anxiety-related symptoms lasting at least 3 days and occurring within 4 weeks of a traumatic event. The symptoms can include a sense of numbing, altered sense of reality, amnesia of the event, intrusive memories or dreams of the event, dissociative reactions, physiological reactions to triggers, avoidance of reminders, sleep disturbance, hypervigilance, anger and aggression, exaggerated startle response and agitation. It is appropriate to provide people with an acute stress reaction with debriefing and counselling (if agreeable); pharmacological intervention is rarely indicated.

Post-traumatic stress disorder (PTSD)

PTSD is defined somewhat differently, in terms of time lapses from the traumatic event. It refers to a similar constellation of symptoms that persist for 1 month after exposure:

• acute PTSD: duration of symptoms <3 months

• chronic PTSD: duration of symptoms ≥3 months

• delayed onset PTSD: onset of symptoms at least 6 months after the stressor

Typical distressing recurrent symptoms:

• intrusive features—recollections, nightmares, flashbacks

• avoidance of events that symbolise or resemble the trauma

• persistent negative alterations in cognitions and mood

• hyperarousal phenomena: exaggerated startle response, irritability, anger, difficulty with sleeping and concentrating, hypervigilance, reckless or self-destructive behaviour

Treatment

This is difficult and involves counselling, the basis of which is facilitating abreaction of the experience by individual or group therapy. The aim is to allow the patient to face up openly to his or her memories. Persistent symptoms are an indication for referral for focused psychological intervention therapy.

Pharmacological treatment

SSRIs have limited evidence of some benefit, but response is slower than for their use in depression (trial for 8–12 weeks) and, if effective, they should be used for at least 12 months.^10,11

Hyperventilation

Hyperventilation syndrome can be a manifestation of anxiety. The main symptoms are:

• lightheadedness, faintness or dizziness

• breathlessness

• palpitations

• sweating

• dry mouth with aerophagy

• agitation

• fatigue and malaise

Other symptoms include paraesthesia of the extremities, peri-oral paraesthesia and carpopedal spasm (see FIG. 81.2).

Carpopedal spasm: biochemical explanation

• CO₂ loss from hyperventilation

• Equation: H⁺+HCO⁻₃≷CO₂+H₂O

• p CO₂ ↓→ HCO⁻₃↓ and pH↑ (respiratory alkalosis)

• H⁺ depleted and replenished from plasma proteins H(protein)≷H⁺ + Pr⁻

• Protein anions accumulate and take up calcium Ca⁺⁺ + 2 Pr⁻≷Ca(Pr)₂

Thus ionised calcium is depleted causing hypocalcaemic tetany.

Management

• Reassure.

• Encourage patients to identify the cause and then control their rate and depth of breathing.

Adjustment disorder with anxious mood

This term is reserved for patients who present with anxiety symptoms within 3 months of response to an identifiable psychosocial stressor. It is a common presentation of anxiety symptoms and should be regarded as a separate entity to a generalised anxiety disorder.

The symptoms are in excess of the normal expected reaction to the stressor but have persisted for less than 6 months following the removal of the stressor.

The basic treatment is non-pharmacological: counselling, relaxation and stress management. A short-term course of drug treatment, e.g. diazepam for 2 weeks, can be used in severe or persisting cases.

Somatic symptom disorder (DSM–5)

Somatic symptom disorder (SSD) is defined as the tendency to experience, conceptualise and communicate mental states and distress as physical symptoms or altered bodily function. It is associated with excessive illness, worry and abnormal illness behaviour. SSD is persistent with a history of numerous unsubstantiated physical complaints over several years beginning before the age of 30. Previously called somatisation disorder in the DSM-IV-TR, or hysteria in the past, SSD has 2 subtypes: those with predominantly somatic complaints and those with predominantly pain issues (previously known as pain disorder).

Symptoms include:

• gastrointestinal—nausea, vomiting, abdominal pain

• genital/sexual—dysmenorrhoea, dyspareunia, genital pain, anorgasmia

• cardiovascular—palpitations, shortness of breath, chest pain

• pseudoneurological—amnesia, loss of voice, dizziness, difficulty walking/talking/swallowing

• pain—diffuse, neck/back ache, joint/limb pain, headaches

• other—fatigue, globus, fainting

None of these symptoms has an adequate physical explanation. SSD is more common in females. There is persistent refusal to be reassured that there is no explanation for the symptoms. There is associated impaired social, occupational and family functioning.

Management involves skilful counselling, explanation for symptoms, searching for and treating comorbid conditions (e.g. depression, anxiety) and CBT. It is preferable to be managed by a single supportive doctor. It is not malingering.

Anxiety disorders can occur in childhood and, if left untreated, may persist into adolescence and adulthood. Panic attacks are not uncommon. Other disorders include GAD, social phobia, obsessive–compulsive disorder, PTSD, selective mutism and separation anxiety disorder. Non-pharmacological approaches are preferred, and may require input from an educational and developmental psychologist. Separation anxiety disorder for real, threatened or imagined separation is the most common anxiety disorder; if severe and persistent, treatment (under specialist supervision) with one of the SSRIs could be considered.

• If the diagnosis is doubtful

• If drug and alcohol dependence or withdrawal complicate the management

• If psychosis appears to be involved

• Failure of response to basic treatment

Note: The threshold for referral varies depending on the GP’s confidence and experience in dealing with anxiety, and the available referral pathways.

• Get enough sleep and rest.

• Listen to music.

• Do things that you enjoy.

• Look at positives.

• Develop strategies to laugh.

• Go to the movies or a show weekly.

• Consider getting a pet.

• Remember that your job is what you do (not who you are).

• Have regular chats with close friends.

• Exercise for 30 minutes, 4 or 5 times a week.

There is good evidence this helps.

• Learn to meditate.

• Avoid interpersonal conflicts.

• Learn to accept what you cannot change.

Hand-out sheets from Murtagh’s Patient Education 7th edition:

• Anxiety disorder

• Phobias

• Post-traumatic stress disorder

• Stress: coping with stress