Anxiety

Anxiety disorders are a group of mental health conditions characterized by excessive and persistent worry, fear, or nervousness. In the clinical setting, they include disorders such as generalized anxiety disorder (GAD), panic disorder, social anxiety disorder, and others.

Diagnosis:

The diagnosis of an anxiety disorder typically involves the following steps:

  • Clinical Interview: Detailed discussion of the patient’s symptoms, including their nature, timing, and impact on daily functioning. The DSM-5 criteria are often used to determine the specific type of anxiety disorder.
    • Adjustment disorder with anxious mood
    • Specific Phobias: ie spiders, social
    • Global Anxiety Disorder: Phobias to many things
    • Panic Disorder
    • OCD
  • Medical History: Assessment of personal and family medical history, as anxiety can be associated with various medical conditions or can be a side effect of certain medications.
  • Physical Examination: While there is no lab test to diagnose anxiety, a physical exam might be conducted to rule out physical conditions that could be causing symptoms.
  • Psychological Questionnaires: Tools such as the Generalized Anxiety Disorder 7-item (GAD-7) scale or the Hamilton Anxiety Rating Scale (HAM-A) can be helpful in assessing the severity of anxiety.
  • Rule Out Other Conditions: It’s important to distinguish anxiety from other psychiatric conditions like depression, which often co-occurs, or to identify any substance abuse that may contribute to or exacerbate anxiety symptoms.
  • Duration and Impact: For a diagnosis of GAD, for example, symptoms must be present for more days than not for at least six months and must cause significant impairment in daily life.

Management:

The management of anxiety disorders typically involves a combination of psychotherapy, pharmacotherapy, and lifestyle modifications.

  1. Psychotherapy:
    1. Cognitive Behavioral Therapy (CBT): This is one of the most effective forms of psychotherapy for anxiety. CBT focuses on identifying, understanding, and changing thinking and behavior patterns.
    2. Exposure Therapy: Particularly useful for phobias and social anxiety disorder, this involves gradual exposure to the feared object or context without any danger, in order to overcome anxiety.
    3. Other Therapies: Depending on the type of anxiety and individual preferences, other therapeutic approaches like psychodynamic therapy, mindfulness, and acceptance and commitment therapy (ACT) can be beneficial.
  2. Pharmacotherapy:
    1. Selective Serotonin Reuptake Inhibitors (SSRIs) are typically the first-line medications for chronic anxiety disorders.
    2. Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs): are second line
    3. Benzodiazepines: These may be used for short-term relief of acute anxiety symptoms but are generally avoided for long-term use due to the risk of dependence and withdrawal.
    4. Buspirone: Can be an effective anxiolytic without the potential for misuse associated with benzodiazepines.
    5. Prazosin: Can be useful in some cases
    6. Other Medications: In some cases, other antidepressants, beta-blockers, or antipsychotics may be used off-label for anxiety.
    7. Specific Treatments:
      1. Adjustment disorder with anxious mood
        • Diazepam 2-5mg oral BD for up to 2/52
      2. GAD – Generalised Anxiety Disorder
        • Escitalopram 10-20mg oral OD (increase by 5mg every 2/52)
        • Sertraline not TGA approved and Escitalopram has the best evidence
        • Duloxetine 30-120mg OD (good for anxious thoughts)
        • Buspirone 5-20mg oral TDS
      3. Panic
        • Sertraline 25mg oral OD (start with low dose due to activating effect risk)
      4. OCD Obsessions (thoughts) and Compulsions (rituals)
        • Respond best to combined CBT + Pharmacotherapy
        • Sertraline 50-200mg oral OD
        • Clomipramine 50-300mg oral nocte (may be uniquely effective)
  3. Lifestyle Modifications:
    1. Stress Management: Techniques such as deep breathing, meditation, and yoga can help manage stress.
    2. Regular Exercise: Physical activity is known to reduce symptoms of anxiety and depression.
    3. Sleep Hygiene: Improving sleep can reduce anxiety symptoms.
    4. Nutrition: A balanced diet may help manage anxiety.
    5. Avoiding Alcohol and Drugs: These substances can increase anxiety and interfere with the effectiveness of treatment.
  4. Support Groups and Education:
    1. Support Groups: Can provide a space for sharing experiences and coping strategies.
    2. Educational Resources: Understanding anxiety is empowering for many patients and can assist in the management.
      1. This Way Up
      2. Get.gg

Regular follow-up is important to monitor treatment progress, make adjustments as necessary, and provide support. The specific course of treatment will depend on the severity and type of anxiety disorder, as well as the patient’s individual needs and preferences. In Australia, mental health care plans can be developed by general practitioners, which may provide Medicare-subsidized sessions with psychologists or psychiatrists for assessment and treatment.