Download Anxiety disorders

Anxiety disorders
(Panic disorder, generalised anxiety disorder, post traumatic stress disorder, obsessive
compulsive disorder, social phobia, specific phobia)
Recommend
 Explain to the patient how the body’s arousal reaction produces tremor, hyperventilation, tachycardia,
muscle tension etc, and how worrying about such symptoms can create a vicious cycle
Background
 Anxiety is a normal reaction to threat. Anxiety disorders are characterised by irrational anxiety when a
threat does not exist or has passed. Behaviour designed to avoid the onset of anxiety is often an
important aspect of the clinical presentation
1. May present with:

Panic disorder [4]

is often exacerbated by the physiological sequelae of hyperventilation

patients recurrent attacks of severe anxiety that appear to come out of the blue, without obvious
precipitant

panic attacks have a sudden onset, with symptoms including palpitations, chest pain, choking
sensations, and dizziness

patients often fear that their symptoms are the result of a heart attack or stroke, and that they
may lose consciousness

may be accompanied by agoraphobia. Patients often fear that they will have a panic attack in a
place from which escape might be difficult (or embarrassing), or in which help might not be
available

Generalised anxiety disorder (at least 6 months duration)

anxiety is generalised and prolonged

physical symptoms such as: increased heart rate, dry mouth, muscle tension, dizziness or lightheadedness, nausea or stomach upsets, increased sweating, restlessness (“the fight / flight
reaction”)

apprehension - worry about the future, feeling ‘on edge', difficulty concentrating, inability to relax

Post traumatic stress disorder (PTSD) [4]

history of experiencing a traumatic event in which a person witnessed or experienced serious
injury or threat of death and during the event had intense feelings of fear, helplessness or horror

patients re-experience the traumatic event with flashbacks, nightmares or intrusive recollections

persistent symptoms of increased arousal, such as insomnia, anger, poor concentration, and
exaggerated startle response

avoidance of stimuli associated with trauma.

Obsessive compulsive disorder [4]

recurrent obsessional thoughts which cause marked anxiety or distress

obsessions are usually recognised as the individual’s own thoughts or impulses (ie not coming
from outside the patient as may occur in psychosis)

compulsive acts (e.g. hand washing, checking the stove is turned off and doors are locked),
which usually serve to reduce anxiety about a danger (e.g. contamination).

Social phobia [4]

a fear of scrutiny by other people leading to avoidance of social situations

often associated with low self esteem and hypersensitivity to criticism

Specific phobia

an excessive or unreasonable fear of an object or a situation (e.g. seeing blood, flying, animals)

avoidance of situations that trigger the anxiety
2.
Immediate management:

Ensure safety of consumer, self and others

Consult MO
3.
Clinical assessment:

Take comprehensive history including

mental health history – past episodes, admissions, suicide or self harm attempts. Include family
and carers to support history

medication history, ATODS history

Perform standard clinical observations + BGL, Oxygen saturation, conscious state – Glasgow coma
scale , AVPU

Perform general health assessment and physical examination

Perform MSE / risk assessment

Also consider diagnoses of depression, alcohol abuse, thyrotoxicosis
4.
Management:

Consult MO or Psychiatrist and describe findings of assessment

MO or Psychiatrist may order:

medication

blood tests





evacuation / hospitalisation for mental health assessment and treatment
Provide information about anxiety and panic attacks – explain how the body’s arousal reaction
produces tremor, hyperventilation, tachycardia, muscle tension etc, and how worrying about such
symptoms can create a vicious cycle
Encourage the patient to:

use relaxation methods daily to reduce physical symptoms of tension

reduce use of stimulants e.g. coffee and cigarettes

increase physical activity – often successful strategy

increased pleasant activity - encourage the patient to engage in pleasurable activities and to
resume activities that have been helpful in the past

avoid self-medicating with alcohol
Specific management strategies

cognitive behavioural therapy is the prime treatment for anxiety disorders Treatment may
include components of patient education, graded exposure to the source of anxiety, training in
anxiety management techniques, cognitive therapy techniques, and specific skills training (e.g.
assertiveness)

Panic disorder
o
During a panic attack a patient should (1) remain where they are until the panic attack
passes (2) breath slowly and gently through their nose, counting three seconds for each
breath in and three seconds for each breath out (3) remind themselves that it is just a panic
attack, they have survived numerous before, they are not having a stroke or heart attack,
and that the symptoms will pass
o
When patients become confident that they can cope with panic attacks, the frequency of
panic attacks usually diminishes
Medication management

the MO may consider medication if significant anxiety symptoms persist despite the measures
suggested above

benzodiazepines (e.g. diazepam) are an effective short term treatment for severe anxiety, but
should be used for no longer than two weeks
Longer-term use may lead to dependence and is likely to result in the return
of symptoms
when discontinued

antidepressant drugs may be helpful

beta-blockers may help control physical symptoms such as tremor
5.
Follow-up:
 According to MO instructions
 Offer ongoing support and encouragement
 Encourage use of psychological therapies
6.
Referral / Consultation.
 Consult MO as above
 Non-urgent referral to Mental Health Services is advised if the patient’s symptoms are sufficiently
severe as to interfere with daily functioning