The basics - Anxiety

Dr Raj Thakkar explains how anxiety can manifest itself and present in different forms.

Anxiety is, for most people, a normal response to a stressful situation. Patients experience cognitive features including fear, impending doom and the feeling of loss of control.

In addition, they experience somatic features related to sympathetic nervous system activity, namely sweating, tremor and tachycardia.

It is when this anxiety affects functioning, occurs in the absence of a stressor or is related to a significant psychiatric or medical condition that we as GPs need to intervene.

The condition is commonplace in general practice and the key to its successful management is recognising when the patient requires medical help, understanding the type of anxiety the patient is experiencing and whether there are any underlying conditions.

There are many forms of anxiety disorders and the most common forms are discussed here. Having a basic understanding of these and their aetiologies will go a long way when managing these sometimes challenging patients.

GAD
One form we are all probably familiar with is generalised anxiety disorder (GAD). In this condition, patients have anxiety but do not have agoraphobic or obsessive-compulsive components. In addition, patients do not experience panic attacks or worry about panic when subjected to a social situation.

The acute form tends to be triggered by a stressor, unlike the chronic form, which has a poorer prognosis.

Panic disorder
Panic disorder can only be diagnosed in the absence of other psychiatric illnesses. Women in their twenties, thirties and forties are particularly affected.

In this condition, patients experience sudden onset and recurrent panic attacks without an obvious trigger. Those who panic only in certain situations, for example at heights, do not have panic disorder.

A number of neurochemical and cognitive theories have been suggested as possible aetiologies.

Phobia
Anxiety, which may culminate in a panic attack, in relation to a particular situation that in itself is not dangerous, is termed a phobia. Patients often become anxious when they know they are due to face particular situations and this may lead to avoidance behaviour.

Without avoidance, patients are not considered to have a phobia. The anxiety is out of proportion to the given stimulus and the patient cannot be talked down.

OCD
Obsessive-compulsive disorder (OCD) affects females more than males. The condition peaks in early teens and again in the early 20s. It has a strong genetic component, with concordance between monozygotic twins being twice as high as dizygotic twins.

It describes recurrent intrusive thoughts that cause anxiety. Obsessions are varied and may be words, phrases or thoughts, such as whether the front door is locked.

Compulsive behaviour, such as hand-washing or counting, is conducted in order to relieve anxiety. Neither the obsessions nor the compulsions can be resisted.

The condition may affect a patient's everyday life such that their functioning is significantly impaired.

Differential diagnosis
When managing patients with anxiety, it is important to consider underlying conditions that may either mimic anxiety or include anxiety as part of the symptomatology.

Medical conditions that may mimic anxiety include hyperthyroidism, calcium disorders, phaeochromocytoma, mitral valve prolapse (although some researchers suggest this may be a consequence of anxiety), coronary artery disease and arrhythmia.

Alcohol and drug abuse or withdrawal may also present as anxiety. Cerebral pathology such as dementia, multiple sclerosis, HIV and tumours should also be considered in these patients.

In addition, psychiatric conditions may have anxiety as part of their symptom complex. Paranoid thoughts or even delusions may manifest as anxiety in schizophrenia. Mania or hypomania may manifest as anxiety and agitation. Depression often has a large anxiety component and patients with severe depression may become paranoid and delusional.

Management
Once a diagnosis has been made and alternative conditions have been excluded, a number of management options may be considered. Of course, if a patient is suicidal or presents with another medical or psychiatric emergency, appropriate and swift actions should be taken.

The treatment of anxiety disorders has been discussed by NICE.1 Educating the patient is important and this may be reinforced by self-help books and leaflets. The management strategy should be discussed with the patient, empowering them to choose a course of treatment that best suits them.

A number of counselling techniques are available to help patients with anxiety, many of which are successful. Cognitive behavioural therapy is the mainstay of psychological treatment. Phobias may require a 'flooding' or 'graded' (as part of systematic desensitisation) introduction to the anxiety-provoking situation.

Exposure and response prevention techniques are used in OCD. The mainstays of pharmacological treatment are SSRIs or tricyclics. NICE advised an SSRI as first choice

Benzodiazepines can be highly effective in the acute situation. However, long-term use should be balanced against their risk in overdose and addictive properties.

Beta-blockers may be used to reduce the somatic symptoms of anxiety. Patients should feel supported and be followed up regularly.

  • Dr Thakkar is a GP in Wooburn Green, Buckinghamshire

Reference

1. NICE Clinical Guideline CG22. Management of anxiety (panic disorder with or without agoraphobia, and generalised anxiety disorder) in adults in primary, secondary and community care. London: NICE, 2004.

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