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Anxiety

Specialties > General practice

Background knowledge 🧠

Definition

  • Anxiety is a psychological and physiological state characterized by excessive, prolonged fear or worry.
  • It may be generalized or specific (e.g., social anxiety, panic disorder).
  • Distinguished from normal fear by its persistence and its impact on daily functioning.
  • Often associated with a range of physical symptoms, reflecting autonomic arousal.

Epidemiology

  • Anxiety disorders are among the most common psychiatric conditions globally.
  • Lifetime prevalence in the UK is approximately 13-20%.
  • More common in women than men, with a ratio of approximately 2:1.
  • Often begins in childhood or adolescence and can be chronic if untreated.

Aetiology and Pathophysiology

  • Genetic predisposition: family history increases risk.
  • Neurotransmitter imbalance: alterations in serotonin, noradrenaline, and GABA.
  • Environmental factors: stress, trauma, and early life experiences.
  • Neuroanatomical changes: hyperactivity in the amygdala and hypoactivity in the prefrontal cortex.
  • Cognitive-behavioral models: dysfunctional thought patterns and maladaptive coping mechanisms.

Types

  • Generalized Anxiety Disorder (GAD): persistent and excessive worry about various domains.
  • Panic Disorder: recurrent, unexpected panic attacks with ongoing concern about future attacks.
  • Social Anxiety Disorder (Social Phobia): fear of social situations where one may be judged.
  • Specific Phobias: intense fear of specific objects or situations (e.g., spiders, heights).
  • Agoraphobia: fear of places or situations where escape might be difficult.
  • Obsessive-Compulsive Disorder (OCD): characterized by intrusive thoughts and repetitive behaviors.
  • Post-Traumatic Stress Disorder (PTSD): anxiety following a traumatic event.

Clinical Features 🌡️

Symptoms

  • Excessive worry or fear that is difficult to control.
  • Restlessness or feeling keyed up/on edge.
  • Fatigue or being easily fatigued.
  • Difficulty concentrating or mind going blank.
  • Irritability.
  • Sleep disturbances, including difficulty falling asleep or staying asleep.

Signs

  • Tachycardia.
  • Hyperventilation.
  • Tremors.
  • Sweating.
  • Muscle tension.
  • Pale complexion.

Investigations 🧪

Tests

  • Primarily a clinical diagnosis based on history and mental state examination.
  • GAD-7: Screening tool for Generalized Anxiety Disorder.
  • Blood tests (e.g., FBC, TFTs) to exclude medical causes (e.g., hyperthyroidism).
  • ECG may be necessary to rule out cardiac causes of symptoms (e.g., palpitations).
  • Assessment for comorbid conditions (e.g., depression).

Management 🥼

Management

  • Psychoeducation: educating patients about anxiety and its management.
  • Cognitive Behavioral Therapy (CBT): first-line psychological treatment.
  • Medications: SSRIs (e.g., sertraline) are first-line pharmacotherapy.
  • Benzodiazepines: short-term use in acute settings.
  • Lifestyle modifications: regular exercise, sleep hygiene, and relaxation techniques.
  • Consider referral to secondary care if complex or refractory.

Complications

  • Chronic anxiety can lead to depression and other mood disorders.
  • Increased risk of substance abuse, particularly alcohol and sedatives.
  • Physical health complications such as hypertension and cardiovascular disease.
  • Impairment in social and occupational functioning.
  • Suicidal ideation or attempts in severe cases.

Prognosis

  • Variable depending on type and severity; GAD is often chronic with fluctuating severity.
  • Early intervention improves outcomes.
  • With appropriate treatment, many individuals experience significant symptom reduction.
  • Some may require long-term treatment to prevent relapse.

Key Points

  • Anxiety disorders are common and often coexist with other psychiatric conditions.
  • Diagnosis is clinical; history and mental state examination are crucial.
  • Management includes psychological therapies and medications, with SSRIs as first-line pharmacotherapy.
  • Prognosis varies; early and consistent treatment improves outcomes.

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General practice