Understanding AnxietyLeave a comment

What is anxiety?

Anxiety is a complex, multidimensional experience, not a simple unidimensional phenomenon. Anxiety can be understood as having three separate dimensions (Lang, 1970):

It is also described as follows:

"Apprehension, tension, or uneasiness that stems from the anticipation of danger, which may be internal or external...The manifestations of anxiety and fear are the same and include motor tension, autonomic hyperactivity, apprehensive expectation, and vigilance and scanning."

            i) Verbal reports of subjective experiences (eg: tension, apprehension, sense of impending danger, expectations of an inability to cope in the future).

            ii) Behavioral responses (eg: avoidance, impaired speech and motor coordination, performance deficits). iii) Physiological responses (eg: muscle tension, increased heart rate, elevated blood pressure, rapid respiration, dryness of the mouth, nausea).

When does anxiety become pathological?

Anxiety is abnormal when it is persistent and coupled with no objective danger or threat, leading to ineffective and self-defeating behavior. The sufferer must have primary symptoms of anxiety most days for at least several weeks at a time, and usually for several months. These symptoms should usually involve elements of:

1. Apprehension (worries about future misfortunes, feeling "on edge", difficulty in concentrating, etc.);
2. Motor tension (restless fidgeting, tension headaches, trembling, inability to relax); and
3. Autonomic overactivity (light-headedness, sweating, tachycardia or tachypnoea, epigastric discomfort, dizziness, dry mouth, etc.).

The transient appearance (for a few days at a time) of other symptoms, particularly depression, does not rule out generalized anxiety disorder as a main diagnosis, but the sufferer must not meet the full criteria for depressive episode, phobic anxiety disorder, panic disorder, or obsessive-compulsive disorder.

What is the relevance of Anxiety Disorders in Primary Health Care?

• Because it is a common condition.

            * Prevalence of mixed Anxiety and Depression in the general public are high.

            Eg: OPCS Survey of Psychiatric Morbidity Report 1. London: HMSO, 1995. revealed 70%

            * Symptoms of anxiety are experienced at various tiers.

• Because the awareness of this disorder amongst medical as well as non-medical people is low.
• Because it has varied presentations - disguised as - "heart attacks", depression, alcohol dependence, poor school work. We are sure that you must be coming across patients with anxiety or mixed anxiety and depression in your practice. It is common for such patients to present to family doctors/primary care physicians with somatic symptoms.
• Somatic symptoms may overshadow the underlying psychological problem thus affecting the diagnosis.

Clinical Features

Generalized Anxiety Disorder

All the features of the symptoms are "free floating" (felt throughout the day)

Episodic Anxiety

1. Situational anxiety disorders - Phobic Anxiety Disorder
2. Non situational anxiety disorder - Panic disorder

1) Phobic Anxiety Disorder

To say it is a phobia all of the following features are necessary.

        i) The anxiety (or fear) is involuntary.

        ii) The fear is experienced on specific situations.

        ii) The anxiety is overwhelming and inappropriate to the actual degree of threat.

        iv) The patient would avoid the situation where possible

        v) The avoidance would make the patient comfortable.

A) Simple phobia

        i) Fear in the presence of an object or situation.

        ii) Avoidance of such situation

        iii) Early in life, many dissipates away

B) Social phobia

        i) Fear of situations in which the person is observed or criticized.

        ii) Avoidance of such situations

        iii) Anticipatory anxiety

        iv) Preoccupied with the fear of being observed critically

C) Agoraphobia

        i) Fear in situation (at least in two situations) where they cannot leave easily or no help is available

        ii) Avoidance of such situations psychological/physical symptoms are primary.

        iii) Fear of loss of control other symptoms such as depression, obsessional thoughts are more common

2) Panic Disorder

Fear comes unexpectedly.

overwhelming and a sense of choking or death by a serious consequence such as a heart attack. Symptoms reach a peak within 10 minutes and subsides quickly (within 30 minutes max.) Fear of fear

Activity

Maintain a record of patients whom you have treated for anxiety within a one-week period in your practice by writing down the age, sex, occupation, presenting symptoms and management. This will give you an idea of the extent and profile of psychological illness in your practice.

Obsessive Compulsive Disorder (OCD)

What is an obsession?

An obsession should have all (1-4) of the following features

1. Recurrent and persistent thoughts, impulses, or images that are experienced, at some time during the disturbance, as intrusive and inappropriate and that cause marked anxiety or distress
2. The thoughts, impulses, or images are not simply excessive worries about real-life problems
3. The person attempts to ignore or suppress such thoughts, impulses, or images, or to neutralize them with some other thought or action
4. The person recognizes that the obsessional thoughts, impulses, or images are a product of his or her own mind (not imposed from without as in thought insertion)

The compulsions are repetitive behaviors (e.g., handwashing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the person feels driven to perform in response to an obsession, or according to rules that must be applied rigidly or an act to counteract the distress caused by the obsession.

To diagnose OCD the patient must have:

        i) Obsessions and or compulsions

        ii) an Obsession or Compulsion lasting more than 1 hour per day

        iii) symptoms affecting the patients day-to-day functioning

        iv) intense distress and suffering due to the symptoms

In addition to these, the disorder is generally,

        i) Waxing and waning

        ii) Associated with Depression (1/3 pts are depressed)

        iii) Presents with anxiety

From the above description you will realize that you often find a variety of symptoms, which are shared by different kinds of clinical conditions in patients with psychiatric disorders.

Management

This includes arriving at a diagnosis and treatment

It is of paramount importance to come to a diagnosis where possible after taking a psychiatric history, mental state examination and completing necessary laboratory investigations that are feasible at the primary health care. If in doubt it is always prudent to refer the patient to a secondary or tertiary care. If you suspect a possible diagnosis of phobia or OCD it is advisable you refer the patient to a psychiatrist. Patients with generalized anxiety disorder may be treated by the primary health care physician even when presented for the first time.

Treatment of Anxiety Disorders

The treatment is comprised of three aspects.

1. Psychological treatment
2. Physical (pharmacological) treatment
3. Social treatment

                  Listening, Explanation/Advice, Reassurance, Suggestion.

Psychological

• Brief supportive Psychotherapy
• Behavior therapy
• Anxiety management

This includes teaching breathing exercises coupled with progressive relaxation of body muscles.

• Other forms of psychotherapies such as cognitive behavior therapy could be used but providing such care in the primary health care setting in Sri Lanka is far from reality. Therefore, will not be discussed here.

Physical

Anxiolytics -

Benzodiazepines: as an acute intervention or on short-term use. The dosage has to be titrated against the intensity of symptoms. Not to be used on long term basis

        Diazepam 5mg b.d.

        Lorazepam 1mg b.d

        Clobazam 10mg b.d.

Antidepressants: Some antidepressants have anxiolytic effect in addition to the antidepressant action. Such medication also effectively used to treat anxiety.

Eg:   Imipramine 12.5 mg daily and titrated the dosage depending on response each week, up to 75mg day

        Venlafaxine 37.5 mgs b.d

        Paroxetine Sertraline and Fluoxetine : could be effectively used to treat patients with phobic anxiety, panic disorder and OCD

        Dosage 20 mgs daily.

Buspirone

Buspirone acts as an agonist of the serotonin 5-HT 1 receptor with high affinity. It is a preferential full agonist of presynaptic 5-HT1A receptors, which are inhibitory autoreceptors, and a partial agonist of postsynaptic 5-HTAreceptors. Buspirone could be used as a long term medication for anxiety as it has no addiction

        Eg: buspirone 10 mg b.d

Beta - adrenoreceptor blockers:

These are useful to negate the autonomic arousal that is found with patients with anxiety.

        Eg: Propranolol 10 mgs tds

Hypnotics

Useful to initiate the sleep as many patients with anxiety have initial insomnia. Benzodiazepines could be used at night for this purpose eg: nitrazepam 5mg note). However, there are non-benzodiazepine hypnotics currently available (zolpidem melatonin and agomelatine) that claim a less potential for addiction. There are other choices as well. For an example you may use a sedative anti-depressant mirtazapine, dothiepin or an antipsychotic-chlorpromazine, quetiapine) to combat the insomnia in anxiety.

Social Treatment

This includes assessing current social functioning and understanding the contribution of social factors in the causation and maintenance of the illness. It is the responsibility of the primary health care physician to explore this aspect and take remedial action where possible. The actions may include:

                ⁃ Meetings with the family members who are concerned: eg: alcoholic husband,

                ⁃ Liaison with school teachers, AGA, Gramasevaka

                ⁃ Making a home visit