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Editors
Anxiety Disorder
Essentials
- Anxiety is a normal emotional state which provides protection against hazardous situations.
- Anxiety disorder denotes a state where anxiety is intense, long lasting and restricts both psychological and social functioning.
- In chronic or intense anxiety, the nature and background factors of the condition should be assessed. Unhurried exploration of the patient's problems, cognitive reconstruction of the cause-effect relationships and analysis of the patient's emotions are all elements of the assessment and treatment strategy of anxiety.
- Temporary medication may be indicated if anxiety causes disability. However, long-term pharmacotherapy may be required in severe chronic anxiety.
- Dissociation is often associated with psychic traumatisation. It may be manifested as both psychological and somatic symptoms. Dissociation is connected with a disturbance in the integration of consciousness, memory, identity and perception.
Prevalence
- Anxiety is one of the most common mental disorders.
- Twenty-five per cent of the population suffers from anxiety at some stage during their lives, women more frequently than men.
Pathogenesis
- The patient will often feel anxious in everyday situations, and the anxiety is often associated with worry relating to ordinary everyday matters.
- Long-term anxiety may lead to secondary avoidance or adjustment with the aid of psychological defence mechanisms or behaviour. Anxiety and its possible causes, including adversity and misfortune, may remain unnoticed or subconscious.
- It is not always easy to differentiate normal anxiety from pathological anxiety. An important criterion is whether the patient maintains the ability to work and function normally.
Symptoms
- Continuous state of anxiety or paroxysmal anxiety that is related to specific situations.
- Fear, difficulties in concentrating, motor restlessness, difficulties in falling asleep.
- Peripheral somatic symptoms are typical: palpitations, tremor, dizziness, sweating, nausea, feeling of choking, urinary frequency, abdominal symptoms, trembling voice and blushing.
- Continuous nervousness, muscle aches, tension in the neck and back, headache, sense of a lump in the throat, tiredness.
- The nature of the disorder should first be identified. The treatment is based on recognising symptoms, making correct diagnosis, increasing the patient's knowledge, clarifying his/her situation and emotions, as well as alleviating his/her current situation.
- Any background factors and the need for medication should be assessed.
- Differences in the lines of pharmacotherapy exist with regard to the treatment of generalised anxiety disorder, panic disorder, obsessive-compulsive disorder Obsessive-Compulsive Disorder (OCD), social phobia and mixed anxiety-depression disorder. In severe, chronic anxiety, long-term pharmacotherapy e.g. with antidepressants is indicated. SSRIs and SNRIs (duloxetine, milnacipran, venlaflaxine) are usually the drugs of choice.
- Long-term benzodiazepine medication should be avoided.
- Cognitive psychotherapy is useful in many cases.
The most common anxiety disorders
Panic disorder
Aims
- Panic disorder must be considered in a patient who presents with excessive anxiety and depression.
- Treatment that leads to as full a response as possible should be chosen. Comorbid depression, suicide risk and alcohol abuse are common and must be borne in mind.
Epidemiology
- Panic disorder is estimated to affect 2-4% of the population.
- Panic disorder is often associated with agoraphobia, i.e. fear of public places.
- Panic disorder is twice as common in women as in men.
- Attacks usually first appear in adolescence or early adulthood, but in some cases they start in childhood.
- About one third of patients can be rehabilitated, but recurrence is usual: 40-50% of patients will have some residual symptoms. About 20% will remain chronically ill.
- Twenty five per cent of adult patients with panic disorder have suffered from school phobia in their childhood.
Symptoms
- Recurrent and unpredictable attacks over four months or longer.
- The attacks are not restricted to any particular situation or set of circumstances.
- No organic factor can be pinpointed as a cause of the attacks.
- An attack will reach its peak in 10 minutes.
- Four or more of the following symptoms should develop during one attack:
- sensation of shortness of breath or choking
- feeling dizzy, unsteady or faint
- palpitations or accelerated heart rate
- trembling or shaking
- sweating
- nausea or abdominal distress
- depersonalisation or derealisation
- paraesthesia, numbness or tingling sensations
- hot flushes or chills
- chest pain or discomfort
- fear of dying
- fear of losing control or going mad.
Differential diagnosis
- Other psychiatric illness
- Phobias, anxiety, depressive disorders
- Cardiovascular disease
- Anaemia, tachyarrhythmia, angina pectoris
- Hormonal causes
- Hyperthyroidism, hypoglycaemia and hyperglycaemia, menopause
- Respiratory causes
- Asthma, hyperventilation, pulmonary embolism, pulmonary oedema
- Neurological disease
- Withdrawal symptoms
- Alcohol, caffeine, amphetamine
- An overdose of sympathomimetics used in the treatment of asthma may trigger a panic attack.
- Phaeochromocytoma: attacks are characterised by flushing, palpitations and significantly increased blood pressure Rare Endocrine Tumours.
Investigations
- Physical examination
- ECG
- Serum TSH concentration
- Other investigations or neurological consultation as considered necessary
- Blood counts, blood glucose, plasma calcium
Principles of treatment
- The risk of suicide must be assessed and borne in mind.
- In many cases, the treatment will consist of a combination of pharmacotherapy and psychotherapy.
- Antidepressant medication combined with exposure is more effective short-term therapy than other therapy forms for patients in whom panic disorder is associated with agoraphobic avoidance.
- It is important that the physician assumes a supportive and encouraging attitude. The problem should be analysed with the patient and the innocent nature of the physical symptoms explained.
- If alcohol abuse is also a problem, an attempt should be made to treat it, for example with the aid of a brief intervention Brief Interventions for Risky Use of Alcohol. Alcohol worsens panic symptoms.
- Brief cognitive psychotherapy, given either as individual or group therapy, has been shown to be effective.
- Exposure therapy
- Guided imagery
- Discussion and relaxation groups
Social phobias
- The characteristic feature is intense anxiety, and associated avoidance behaviour, in social situations.
- The estimated prevalence is 4% of the general population.
- The phobia is frequently associated with:
- eating or drinking in public
- dealing with people in authority or strangers
- public speaking or performance
- working while being observed
- social gatherings.
Differential diagnosis
- Panic disorder
- Anxious (avoidant) personality disorder
Generalised anxiety disorder
- The life time prevalence is about 4-7%, but only 20-30% of patients receive adequate treatment for their symptoms.
- Symptoms include continuous, excessive anxiety including stress and worry about everyday matters and the future. The anxiety is difficult to control.
- The patient often experiences internal tension, sleeplessness, difficulties in concentrating and muscle tension.
- Anxiety is not restricted to any particular circumstance and is not episodic.
- Generalised anxiety disorder is often seen in conjunction with other psychiatric illnesses.
Differential diagnosis
- Many physical illnesses may simulate anxiety and vice versa (e.g. anaemia, heart disease, chronic pulmonary embolism, asthma, hyperthyroidism and other endocrine disorders, infections etc.)
- Certain medicines and intoxicants may cause anxiety (sympathomimetics, caffeine, illegal drugs, symptoms of alcohol and sedative withdrawal).
- Other anxiety disorders and depression
- These disorders often occur simultaneously.
- Normal worrying must be differentiated from anxiety that causes disability.
Pharmacotherapy
- Generalised anxiety disorder is a chronic condition that impairs the patient's functional capacity, and drug therapy is often indicated. Any underlying factors must be identified (stress, excessive use of medication or coffee etc.).
- SSRIs and serotonin-norepinephrine reuptake inhibitors (SNRIs; duloxetine, milnacipran, venlafaxine) are the drugs of choice and more useful than benzodiazepines in the long-term treatment of anxiety.
- The most common adverse effects of benzodiazepines are sedation, worsening of psychomotor functions and transient memory disorders.
- Benzodiazepine derivatives may be used when antidepressants are initiated, using the lowest possible dose for a short duration (4-6 weeks). Benzodiazepines must always be withdrawn carefully in order to reduce the incidence of possible adverse effects.
- Buspirone is an azapirone derivative. As with antidepressants, its therapeutic effects appear 1-3 weeks after the treatment was started. It is indicated in chronic anxiety states where immediate symptom relief is not necessary. No withdrawal symptoms after discontinuing medication have been noted, nor any effects on the psychomotor or cognitive functions.
- Pregabalin may also be used in generalised anxiety disorder.
Simple phobias (specific phobias)
- The most common triggers are high places, darkness, enclosed places, snakes and insects.
- The role of pharmacotherapy is not as significant as in other anxiety disorders.
- If the patient is motivated, exposure therapy can be used.
Post-traumatic stress disorder
Obsessive-compulsive disorder
Evidence Summaries ⬆