Anxiety disorders

F40.0-2/F40.8-9/F41.0-3/F41.8-9/F42.0-2 + (F10.0-F19.9/R45.0-8/Z65.0-5/Z65.8-9/Z81.0-4/ Z81.8)

DESCRIPTION

Anxiety is an emotional response to an apparent stress. It is diagnosed as a disorder when it is excessive or persistent and impacts daily functioning.
Anxiety disorders are associated with an increase in cigarette smoking, alcohol use and various medical illnesses.
Anxiety may present in various forms:

  • Physical symptoms – anxiety may present with medically unexplained symptoms like: muscle tension, headache, abdominal cramps, nausea, palpitations, sweating, a choking feeling, shortness of breath, chest pain (non-cardiac), dizziness, numbness and tingling of the hands and feet.
    • Panic attacks are abrupt surges of intense anxiety with prominent physical symptoms. They may occur in anxiety, mood, psychotic and substance use disorders and are a marker of increased severity.
  • Psychological symptoms: panicky feelings, excessive worry, mood changes, irritability, tearfulness, distress, and difficulty concentrating.
    • Phobias are diagnosed when the anxiety is caused by a specific situation or object. e.g.: social phobia is the fear of social interactions. Thoughts are of negative evaluation by others and usually start in adolescence. Self-medication with alcohol or other substances before and during a social event is common: substance misuse may be the presenting feature.
    • Obsessive thoughts and/or compulsive behaviours are a core feature of Obsessive Compulsive Disorder but may also occur in other anxiety, mood, developmental and psychotic disorders.
    • In people with intellectual disability , anxiety may present with aggression, agitation and demanding behaviour.

GENERAL MEASURES

  • Assess severity of the condition.
  • Maintain an empathic and concerned attitude.
  • Educate the patient and family regarding the nature of the anxiety.
  • Exclude underlying medical conditions and optimise treatment for comorbid medical conditions (e.g. heart disease, hypertension, COPD, asthma, GORD, inflammatory bowel disease, thyroid disease, epilepsy).
  • Screen for and manage underlying or co-morbid substance use, e.g. nicotine, alcohol, over the counter analgesics, benzodiazepines.
  • Explore and address psychosocial stressors:
    • Stress management/coping skills – refer to counselling services.
    • Relationship and family issues – refer to counselling services. Refer to a social worker if abuse is evident.
    • Accommodation and vocational issues – refer to labour/social development.
  • Assess social support and refer to a social worker if needed.
  • Refer to local support groups and provide self-help literature.

MEDICINE TREATMENT

  • Offer a choice of psychotherapy (if available) or medication.
  • Review every 2–4 weeks for 3 months, then 3–6 monthly.
  • If response only partial, may combine medication with psychotherapy (if available).
  • If medication is effective, continue for at least 12 months to prevent relapse.
  • Patients with severe conditions should be assessed by a doctor.

  • Fluoxetine, oral.
    • Initiate at 20 mg alternate days for 2 weeks.
    • Increase to 20 mg daily after 2–4 weeks.
    • Delay dosage increase if increased agitation/panicky feelings occur.

LoEI [6]

OR

If fluoxetine is poorly tolerated:

  • Alternative SSRI e.g.:
  • Citalopram, oral.
    • Initiate at 10 mg daily for the 1st week.
    • Then increase to 20 mg daily.

LoEI [7]

CAUTION
SSRIs (e.g. fluoxetine, citalopram) may cause agitation initially.
This typically resolves within 2-4 weeks.
LoEIII [8]
Ask about suicidal ideation in all patients, particularly adolescents and young adults. (See Suicide risk assessment ).
If suicidal ideation present, refer before initiating SSRI.
Once started, monitor closely for clinical worsening, suicidality, or unusual changes in behaviour. Advise families and caregivers of the need for close observation and refer as required.

Note: Continue treatment for a minimum of 12 months. Consider stopping only if patient has had no/minimal symptoms and has been able to carry out routine daily activities. Prolong treatment if:

  • Previous episode/s of anxiety (extend treatment to at least 3 years).
  • Any of: severe anxiety, suicidal attempt, sudden onset of symptoms, family history of bipolar disorder (extend treatment to at least 3 years).
  • If ≥ 3 episodes of anxiety (advise lifelong treatment).

LoEIII [9]

For severe panic attacks:

  • Benzodiazepines, e.g.:
  • Diazepam, oral.
    • 2.5–5 mg, immediately.
    • Continue with 2.5–5 mg at night, for a maximum of 10 days for severe anxious distress.
    • Start definitive treatment with psychotherapy/SSRI.

LoEII [10]

LoEI [11]

CAUTION - BENZODIAZEPINES

  • Associated with cognitive impairment – reversible with short-term use and irreversible with long-term use.
  • Elderly are at risk of over-sedation, falls and hip fractures.
  • Dependence may occur after only a few weeks of treatment.
  • Prescribe for as short a period of time as possible.
  • Warn patient not to drive or operate machinery when used short-term.
  • Long-term use is associated with irreversible cognitive decline.
  • Avoid use in people at high risk of addiction: e.g. personality disorders and those with previous or other substance misuse.

LoEIII [12]

REFERRAL

  • High suicide risk.
  • Any risk of harm to self or others.
  • Comorbid severe mental or physical conditions.
  • Poor response to treatment.
  • Repeated panic attacks.
  • Children and adolescents.