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Anxiety
Anxiety

Anxiety

Before we begin to talk about anxiety, let’s discuss what a neuroses is:

A neuroses is defined as a relatively mild mental illness that is not caused by disease. It involves symptoms of stress (anxiety, depression, obsessive behaviour) but no radical loss of insight of reality. Anxiety disorders often fall under neuroses.

When we talk about anxiety, we are referring to generalised anxiety disorder (GAD). The essential feature of GAD is excessive anxiety and worry out of proportion of the likelihood or impact of the anticipated event. They tend to worry about everyday, routine life and their competence or quality of their performance.

Other anxiety disorders include phobias, panic disorder, OCD, PTSD. However, these will be covered in the GP CCC of anxiety disorders.

🏘 Epidemiology

The median age for onset of anxiety is ~30 years old, however, individuals report having felt anxious/nervous their entire lives.

It affects mostly females, but about 1.6% of the population is affected.

⚠️ Risk factors

  • Lower SES and unemployment.
  • Divorce
  • Renting not owning
  • Lack of education
  • Urban living

It is a comorbidity with depression, substance misuse and personality disorder.

There is a suspected genetic component as family history is seen in many patients.

ACEs are also a risk factor.

😷 Presentation

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A little bit of anxiety is normal, but what separates non-pathological anxiety from GAD?
  1. Excessive worrying that interferes significantly with psychological functioning
  2. Worries are more pervasive, pronounced and persistent (>6 months). They should be present for more days than not.
  3. The worries are accompanied by at least 3 of the following (psychological) symptoms:
    1. Restlessness
    2. Feeling on edge
    3. Fatigued easily
    4. Difficulty concentrating/mind going blank
    5. Irritability
    6. Muscle tension
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We can divide the other manifestations of anxiety that may be felt by a system classification:
  • Motor symptoms - restlessness, fidgeting, feeling on edge.
  • Neuromuscular - tremor, tension headache, muscle ache, dizziness, tinnitus.
  • GI - dry mouth, dysphagia, nausea, indigestion, butterflies, flatulence, frequent/loose motions.
  • CVS - chest discomfort, palpitations, raised BP.
  • Respiratory - difficulty inhaling, tight/constricted chest.
  • GU - urinary frequency, erectile dysfunction, amenorrhoea.
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ICD-11’s criteria for GAD can be simpler to classify GAD:
  • Apprehension - worrying, feeling on edge, difficulty concentrating. It should not be restricted to a particular environmental circumstance.
  • Motor tension - restless fidgeting, tension headaches, trembling, inability to relax.
  • Autonomic overactivity - light-headedness, sweating, tachycardia, epigastric discomfort, tachypnoea.
  • The symptoms are not transient and persist for at least several months, for more days than not; are not better accounted for by another mental disorder; are not a manifestation of another medical condition and are not due to the effects of a substance or medication on the central nervous system. The symptoms should result in significant distress and impairment of personal, family, social, educational or occupational life or other important areas of functioning. Functioning should only be maintained through significant additional effort.

💭 Differential diagnosis

A potential physical cause always needs to be considered with a psychiatric diagnosis. For GAD this includes:

  • Hyperthyroidism - look for a goitre, tremor, tachycardia, weight loss, arrhythmia, exophthalmos.
  • Iatrogenic causes
    • Salbutamol
    • Theophylline
    • Corticosteroids
    • Antidepressants
    • Caffeine
  • Cardiac disease
  • Substance misuse
  • Early dementia and early schizophrenia

🧰 Management

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NICE recommends a “step-wise approach” to treating anxiety:
  1. Step 1 - Educating the patient about GAD, as well as active monitoring of the progression of the disorder.
  2. Step 2 - Low-intensity psychological intervention (non-facilitated or guided self-help).
  3. Step 3 - High-intensity psychological intervention (CBT or applied relaxation) or medication (discussed below)
    1. 🥇 Sertraline is first-line.
    2. 🥈 Other SSRIs or an SNRI is second-line.
    3. 🥉 Pregabalin is third-line.
  4. Step 4 - Specialist input.
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Medical management:
  • SSRI - inhibit the serotonin reuptake transporter to allow increased post-synaptic activity on the 5-HT1a receptor.
    • 🥇 Sertraline is first line, given 25mg PO OD. Gradually increasing according to response, with maximum 200mg/day.
    • Citalopram
      • Adverse effects: anticholinergic effects (dry mouth, blurred vision, constipation, urinary retention).
  • SNRI - inhibits the noradrenaline reuptake transporter to allow increased post-synaptic activity on the 5-HT1a receptor.
    • 🥈 Duloxetine
    • 🥈 Venlafaxine
      • Adverse effects: has tendency for withdrawal, overdose (serotonin syndrome).
  • 🥉 Pregabalin - if the patient is intolerant of SSRIs or SNRIs. HVA CCB, prevents Ca2+ dependant vesicle release to inhibit neuronal signalling. It is typically an anti-epileptic but can be used for anxiety.
  • Buspirone - can sometimes be used for short term management. It is a 5HT1a agonist.
    • Adverse effects: dizziness, headache, nausea.

Young patients are at increased risk of suicidal thinking and self-harm early on, so weekly follow-up is recommended within the first month.

SSRIs with CBT is better than either alone.

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Adverse effects of SSRIs and SNRIs:
  • CNS - sleep disturbance, weight gain, impotence and low libido.
  • GI - diarrhoea, nausea.
  • CVS - bleeding disorders.
  • Serotonin syndrome - caused by overdose. Symptoms are hyperthermia, mydriasis, shivering, hypertonia, hypertension.