Anxiety Disorders. Dr Simon Christopherson Dr Alison Macrae
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1 Anxiety Disorders Dr Simon Christopherson Dr Alison Macrae 1
2 What is anxiety? Universal fight or flight experience Nerves / fearfulness can boost performance Worries keep you alert & prevent you missing things May be any topic: Health, Growing Old, Death, Money, Work, Loved Ones, Relationships Tense & sweaty as your body readies for action Alert, vigilant, decrease sleep & appetite Protects from potential danger ie. adaptive 11/11/ :06:27 PM 2
3 What is anxiety? Persistent and / or severe anxiety is disruptive Emotionally unable to face normal things Thoughts paralysed by worries Physical discomfort GI, CVS, Muscles & Skin Promotes avoidance Undermine confidence, performance and esteem Ie. Distressing and disabling sometimes debilitating Also embarrassing and under-reported 11/11/ :06:27 PM 3
4 Symptoms of Anxiety Thoughts Feelings Physical Sx Behaviour Worries I m going to die They ll laugh at me Racing thoughts Fear Embarrassment Shame Sweating Palpitations Pallor Shaking Nausea Diarrhoea Fight Run away Avoidance 11/11/ :06:27 PM 4
5 Classification of anxiety disorders F40.0 Agoraphobia F40.1 Social Anxiety Disorder F40.2 Specific Phobia F41.0 Panic Disorder F41.1 Generalised Anxiety Disorder 11/11/ :06:27 PM 5
6 Statistics One Year 10.6 Panic Disorder 1.2 Specific Phobia 1.9 Prevalence (%) Agoraphobia (mild form = 12) GAD 2-5 (account for 30% GP MH consultations) Risk groups: 35-59, female, unemployed / lower income group, with other disability in ethnic minority Independent risk for suicide & amplifies comorbid risks 11/11/ :06:27 PM 6
7 Agoraphobia Anxiety in unfamiliar environments or ones perceived to offer little control Eg, open spaces, crowds, travelling (even short) Often compounded by fear of social embarrassment, ie. appearing distraught in public Avoidance is commonly prominent Panic often associated 11/11/ :06:27 PM 7
8 Social Anxiety Disorder Fear of scrutiny by others Leads to Avoidance of social situations Often with low self esteem / fear of criticism May present as blushing, hand tremor, nausea, urgency of micturation may think these are primary Symptoms may progress to panic 11/11/ :06:27 PM 8
9 Specific Phobia Phobia of highly specific situation Eg. animals, heights, vomiting, enclosed spaces Often associated with avoidance Can evoke panic response Associated with insight into unnecessary nature Can be very disabling (eg cleaner & spiders) 11/11/ :06:27 PM 9
10 Panic Recurrent attacks of severe anxiety (ie. panic) May be linked to trigger situation, or not Sudden onset palpitations, chest pain, choking, shortness of breath, dizziness, depersonalisation Secondary fear of going mad, losing mind, impending doom or death Lasts but a few minutes Primary, associated with other anxiety disorders or depression 11/11/ :06:27 PM 10
11 Generalised Anxiety Generalised and persistent free floating anxiety No restricted or predominant in one circumstance Often persistent nervousness, trembling, muscular tension, sweating, lightheadedness, palpitations, dizziness, epigastric discomfort Often fear they or someone close may become ill 11/11/ :06:27 PM 11
12 Differential Diagnoses & Common Co-morbidity Other Anxiety Disorders including PTSD Depression* Substance misuse* Anxious or other Personality Disorder Other Psychiatric disorders including psychosis Normal anxiety (ie. No psychiatric illness) Physical illness either causal (eg. hyperthyroid) or associated *commonly comorbid 11/11/ :06:27 PM 12
13 History & Examination Be aware of avoidance, unawareness & denial Anxiety often assoc with other physical / psych illnesses Other presentations may be due to anxiety eg GI, headache, tremor, tingling, pain, urinary etc Organic causes hyperthyroid, phaeochromocytoma etc Substance misuse Include caffeine & nicotine Risk assessment Investigations (mainly to rule out differentials) 11/11/ :06:27 PM 13
14 Treatment Mild to moderate without risk = Primary Care No medication for mild anxiety! Reduce complications (eg. caffeine, alcohol etc) Don t promote avoidance or hiding away! Support: Family / Friends / Work (Manager, OH etc) Self Help / Books on prescription Eg Overcoming Anxiety / Panic or Manage your mind Talking therapy Let s Talk, Gloucester Counselling, Listening Post etc 11/11/ :06:27 PM 14
15 Cognitive Behavioural Therapy Model Arachnophobia Vicious Cycle Feelings Scared Terrified! It ll bite I ll die Thoughts Physical Sx Heart pounding Sweating Lightheaded Behaviour Flap arms around wildly Run Away! 11/11/ :06:27 PM 15
16 Cognitive Behavioural Therapy Model Aim to disrupt vicious cycle / build virtuous cycle Challenge negative automatic thoughts Uses Thought Diaries, Relaxation techniques, Graded exposure, experiments, homework etc Its not flooding therapy! Other therapies (eg Mindfulness, CAT, rexation etc) also may be helpful 11/11/ :06:27 PM 16
17 Treatment Moderate to severe or resistant Still: Reduce complications (eg. caffeine, alcohol) Maybe Self Help / Books on prescription ma Still Talking therapy Let s Talk or 2 o care Medication SSRI eg sertraline Maybe Propranolol if very physiological Sx Pregabalin if you have grounds not to use SSRI Avoid regular benzodiazepines 11/11/ :06:27 PM 17
18 Treatment For SSRI Start lower than for depression Probably more likely to get / notice adverse effects May take longer for effects to build (eg 12 weeks) May need higher dose, particularly with obsessions so please do increase dose if tolerated but ineffective 2 nd line Add mirtazepine or switch to SNRI Augmentation also possible 2nd antidepressant, pregabalin or?antipsychotic 11/11/ :06:27 PM 18
19 When to Refer Let s Talk Mild to moderate severity anxiety with minimal risk Intermediate Care Team / Triage nurses Mild to moderate severity or unclear severity Queries about risk or deterioration Resistance to initial treatment Turning Point if substance misuse Substance misuse is not exclusion to other work, but it will likely impair it, so this may be first step Recovery if severe / risky /resistant 11/11/ :06:27 PM 19
20 Patient information bias/anxiety,panicphobias.aspx Self Help Books Manage your Mind Butler Overcoming Anxiety Kennerley Overcoming Panic and Agoraphobia - Silove 11/11/ :06:27 PM 20
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