Introduction

Anxiety is a common disorder that can present in multiple ways. NICE define the central feature as an 'excessive worry about a number of different events associated with heightened tension.'

Epidemiology

  • Incidence: 2000.00 cases per 100,000 person-years
  • Peak incidence: 40-50 years
  • Sex ratio: more common in females 2:1
<1 1-5 6+ 16+ 30+ 40+ 50+ 60+ 70+ 80+

Clinical features

Differential diagnosis

Always look for a potential physical cause when considering a psychiatric diagnosis. In anxiety disorders, important alternative causes include hyperthyroidism, cardiac disease and medication-induced anxiety (NICE). Medications that may trigger anxiety include salbutamol, theophylline, corticosteroids, antidepressants and caffeine

Management


NICE suggest a step-wise approach:
  • step 1: education about GAD + active monitoring
  • step 2: low intensity psychological interventions (individual non-facilitated self-help or individual guided self-help or psychoeducational groups)
  • step 3: high intensity psychological interventions (cognitive behavioural therapy or applied relaxation) or drug treatment. See drug treatment below for more information
  • step 4: highly specialist input e.g. Multi agency teams

Drug treatment
  • NICE suggest sertraline should be considered the first-line SSRI
  • interestingly for patients under the age of 30 years NICE recommend you warn patients of the increased risk of suicidal thinking and self-harm. Weekly follow-up is recommended for the first month

Management of panic disorder

Again a stepwise approach:
  • step 1: recognition and diagnosis
  • step 2: treatment in primary care - see below
  • step 3: review and consideration of alternative treatments
  • step 4: review and referral to specialist mental health services
  • step 5: care in specialist mental health services

Treatment in primary care
  • NICE recommend either cognitive behavioural therapy or drug treatment
  • SSRIs are first-line. If contraindicated or no response after 12 weeks then imipramine or clomipramine should be offered