Anxiety Disorders

INTRODUCTION

Anxiety is an uncomfortable inner feeling of fear or imminent disaster. The criterion for anxiety disorder as defined at the International Classification of Health Problems in Primary Care (ICHPPC-2–Defined) is:

Classification of anxiety The following list represents approximately the categories of anxiety disorders recognised by the DSM-5:

• generalised anxiety disorder

• panic disorder with or without agoraphobia

• specific phobia

• social anxiety disorder (phobia)

• phobic disorders

• separation anxiety disorder

• acute stress disorder

• adjustment disorder with anxious mood

• somatoform disorder

• illness anxiety disorder

GENERALISED ANXIETY DISORDER

Generalised anxiety comprises excessive anxiety and worry about various life circumstances occurring more days than not for at least 6 months and is not related to a specific activity, time or event such as trauma, obsessions or phobias. It is associated with three or more of the following six symptoms:

1. restlessness or feeling keyed up or on edge

2. being easily fatigued

3. difficulty concentrating or mind going blank

4. irritability

5. muscle tension

6. sleep disturbance

Management Management applies mainly to generalised anxiety as specific psychotherapy is required in other types of anxiety. Psychological interventions are the first-line therapy. Much can be carried out by the family doctor using brief counselling and support:

• Use non-pharmacological methods

• Give explanation and reassurance

• Promote stress management techniques, incl. meditation

• Give advice on coping skills

• Avoid the use of drugs if possible

• Provide ongoing supportive psychotherapy with specialised psychotherapies, particularly CBT. Consider mindfulness therapy.

Pharmacological treatment

Acute episodes For intermittent transient exacerbations not responding to other measures and especially with more severe symptoms, consider:

• diazepam 2–5 mg (o) as a single dose repeated bd as required or

• diazepam 5–10 mg (o) nocte

Special notes:

• Recommended (if nec.) for up to 2 wks, then taper off to zero over next 4 wks.

• Consider beta blockers in patients with sympathetic activation such as palpitations, tremor and excessive sweating (e.g. propranolol 10–40 mg (o) tds). However, they do not relieve the mental symptoms of anxiety.

Long-term treatment If non-pharmacological treatment is ineffective for persisting disabling anxiety, the drugs of choice are an SSRI such as:

• sertraline 25 mg (o)/d, increasing to 200 mg/day with care; SNRIs also, e.g. venlafaxine (controlled release) 75 mg (o) mane increasing gradually to ...