Anxiety Disorders

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Clinical Description

Anxiety disorders refers to a group of disorders that share features of excessive fear / anxiety and the related behavioral and physical disturbances with associated impairment in functioning or subjective distress. 

Types:

  • Phobias: characterized by irrational and excessive fear of objects/ public situations
  • Panic disorder: characterized by recurrent spontaneous panic attacks, subsequent fear of another attack and maladaptive compensatory behaviors
  • Generalized anxiety disorder: excessive worry for six months or more about actual circumstances/ events

Clinical Features

SIGNS AND SYMPTOMS

  • Feeling tense, uncontrollable anxiety and worry
  • Associated physical health symptoms e.g., heart palpitations, Sweating, chest pains, difficulty breathing, poor sleep, restlessness, feeling dizzy, lightheadedness or faint

INVESTIGATIONS

  • Exclude comorbid mental health disorders such as depression and alcohol and drug use
  • Elicit psychosocial stressors from patients as well as guardians
  • Perform a physical examination to rule out other causes of anxiety such as thyrotoxicosis, asthma, etc.

Treatment

NON-PHARMACOLOGICAL

  • Explain anxiety to patient especially the link between physical and psychological symptoms
  • Give good health advice such as reducing or stopping substance use, good diet, exercise etc.
  • Educate on relaxation methods such as deep breathing exercises during panic attack and muscle relaxation techniques
  • The mainstay or first line treatment of anxiety disorders is psychotherapy such as exposure and systematic desensitization or cognitive behavioral therapy.

PHARMACOLOGICAL

  • If symptoms are severe or psychotherapy hasn’t been effective, prescribe antidepressants in conjunction with the psychotherapy
    • 1st line: Give Fluoxetine 20 – 60 mg
    • 2nd line: Give Amitriptyline 50-150 mg nocte 
  • Avoid the use of diazepam and benzodiazepines except as short course medications (should not exceed 14 days)
  • Propanolol (20 – 40mg) PRN may be used for short term symptomatic relief of excessive anxiety symptoms

Red flags

For referral/admission

  • If there is significant comorbid physical illness
  • The symptoms are interfering with activities of daily living
  • The patient is suicidal with no significant psychosocial support at home

FOLLOW UP 

  • Once symptoms resolve, continue treatment for 6 months and consider stopping thereafter
  • Assess for substance use and other psychosocial stressors