ANXIETY

Anxiety is a normal physiological response, which enables a person to take steps to deal with a threat. When anxiety
is prolonged or interferes with normal functions of the individual, it constitutes the clinical condition of an anxiety
disorder.

Causes

  • Not fully understood: possibly external traumatic events may trigger anxiety in predisposed people
  • Association with other mental conditions e.g. depression, alcohol and substance abuse

Types and clinical features

  • Generalized anxiety: Unrealistic and excessive worry about almost everything
  • Panic attacks: Episodes of sudden onset of intense apprehension or fear; anxiety symptoms usually peak
    within 10-15 minutes and resolve in a few minutes to one  hour
  • Phobia: An excessive fear of a known stimulus (object or situation) e.g. animals, water, confined space) causing the person to consciously avoid the object or situation
  • Obsessive-compulsive disorder: Repeated disturbing thoughts associated with time-consuming actions to
    reduce the anxiety
  • Post-traumatic stress disorder: Where a person who experienced a major life-threatening event begins
    to experience the same, either in dreams or in clear consciousness later in life and tries to avoid being
    reminded of it and have anxious feelings so intense that their lives are disrupted.

Each of the above clinical types will have one or more of the following manifestations:

  • Sleep, mood and concentration problems
  • Palpitations, dizziness, shortness of breath
  • Shakiness or tremors, excessive sweatiness
  • Easily frightened
  • Other symptoms: urinary frequency, hesitancy, or urgency, diarrhoea

Differential diagnosis

  • Consider organic conditions e.g. hyperthyroidism, hypoglycaemia, phaeochromocytoma

Management

  • Psychosocial interventions: counselling, psychotherapy

For an acute episode or intense prolonged anxiety

  • Benzodiazepines e.g. diazepam 5 mg 1-2 times daily
    • Increase if necessary to 15-30 mg daily in divided doses
      Elderly: Give half the above dose
    • Duration of therapy 1-2 weeks, tapering off to zero within 6 weeks

If poor response: refer to specialist

  • Fluoxetine 20 mg once a day for long term management of the anxiety disorder
    • Continue antidepressant for 4 to 6 weeks then evaluate the response
Caution
  • Diazepam is addictive and abrupt cessation can cause withdrawal symptoms. Use for short periods and
    gradually reduce the dose. Avoid alcohol
Notes
  • Diazepam is NOT appropriate for treating depression, phobic or obsessional states, or chronic psychoses (see
    relevant sections for more information)
  • Antidepressants: May be useful in managing panic disorders and other anxiety disorders which require long
    term treatment

Prevention

  • Good personality development
  • Good stress management