Anxiety disorders in Adults

Question 1

Definition

Answer 1

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:

• generalised and persistent anxiety or anxious mood,
• which cannot be associated with, or is
• disproportionately large in response to a specific psychosocial stressor, stimulus or event.

Question 2

Classification of anxiety

Answer 2

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
• obsessive-compulsive disorder
• post-traumatic stress disorder
• acute stress disorder
• adjustment disorder with anxious mood
• somatoform disorder

Question 3

Generalised anxiety disorder

Answer 3

Comprises excessive anxiety and worry;

• about various life circumstances occurring more days than not for at least six months
• and is not related to a specific activity, time or event such as trauma, obsessions or phobias.

It is associated with 3 or more of the following 6 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

Question 4

Important checkpoints

Answer 4

5 self-posed questions should be considered by GP before Rx;

Is this hyperthyroidism?

Is this depression?

Is this normal anxiety?

Is this mild anxiety or simple phobia?

Is this moderate or severe anxiety?

Question 5

Management

Answer 5

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 GP using brief counselling and support:

• Use non-pharmacological methods
• Give explanation and reassurance
• Promote stress management techniques, inc. 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.

Question 6

Pharmacological treatment, Acute episodes

Answer 6

For intermittent transient exacerbations not responding to other measures and especially with more severe symptoms.

• 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 pts with sympathetic activation such as palpitations, tremor and excessive sweating

• e.g. propranolol 10–40 mg (o) tds).
• they do not relieve the mental symptoms of anxiety.

Question 7

Pharmacological treatment, Long-term

Answer 7

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

Sertraline 25 mg (o) daily, increasing to 200 mg/day with care;

SNRIs also, e.g. venlafaxine (controlled release) 75 mg (o) mane

• increasing gradually to 225 mg/d continue for several wks after symptoms subside
• wean off after 6 mths or

Duloxetine 30 mg (o) daily initially, increasing as necessary to max. 120 mg/d