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Anxiety & Stress Related Disorder
A GP may suspect anxiety disorder in a patient who complains of excessive worry,
nervousness, apprehension, fear, panic attacks, intrusive thoughts or images, or dramatization.(3)
There are several major types of anxiety disorders. Common types are:
1) Generalized Anxiety Disorder (GAD)
2) Panic Disorder (PA)
3) Phobia (Specific and Social phobia)
4) Posttraumatic Stress Disorder (PTSD)
5) Obsessive Compulsive Disorder (OCD).(1)
Generalized Anxiety Disorder
In GAD a patient complains of worrying about everything. The worry is excessive, is out of the patient’s
control, and has lasted more than 6 months. It takes a significant toll on the patient causing loss of
function and at least 3 complaints of: restlessness, irritability, fatigue, muscle tension, insomnia, and
difficulty concentrating. (1)
A. Common clinical symptoms and signs :
1. Psychological and cognitive:
- Worries and fear
- Inability to controlling worries
- Unrealistic assessment of problems
- Poor concentration
- Hyper vigilance
2. Physical and physiological
- Muscle tension
- Irritability
- Fatigue
- Restlessness
- Insomnia
3. Other symptoms
- Avoidance
- Postponing things
- Poor problem-solving skills
B. Differential Diagnosis:
If low or sad mood is prominent, see Depression.
If sudden attacks of unprovoked anxiety are present, see Panic disorder.
If fear and avoidance of specific situations are present, see Phobic disorders.
If heavy drug use is present, see Drug use disorders.
Certain physical conditions (especially endocrine or metabolic disorders e.g. thyrotoxicosis)
or medications (beta agonists) may cause anxiety symptoms.
A. Non Pharmacological interventions:
- Encourage the patient to practice daily relaxation methods to reduce physical symptoms of
Encourage the patient to engage in pleasurable activities and exercise, and to resume activities that have been helpful in the past.
Identifying and challenging exaggerated worries can reduce anxiety
Identify exaggerated worries or pessimistic thoughts (e. g., when daughter is five minutes late
from school, patient worries that she may have had an accident).
Discuss ways to challenge these exaggerated worries when they occur (e. g., when the patient
starts to worry about the daughter, the patient could tell him/her, “1 am starting to be caught
up in worry again. My daughter is only a few minutes late and should be home soon. I won’t
call the school to check unless she’s an hour late”).
Structured problem-solving methods can help patients to manage current life problems or
stresses which contribute to anxiety symptoms.
Identify events that trigger excessive worry (e. g., a young woman presents with worry,
tension, nausea and insomnia. These symptoms began after her son was diagnosed with
asthma. Her anxiety worsens when he has asthma episodes).
Discuss what the patient is doing to manage this situation. Identify and reinforce things that
are working.
Identify some specific actions the patient can take in the next few weeks, such as:
o Meet with nurse/doctor/health professionals to learn about the course and
management of asthma
o Discuss concerns with parents of other asthmatic children
o Write down a plan for management of asthma episodes.
o Regular physical exercise is often helpful.
B.Pharmachological treatment:
- Medication is a secondary treatment in the management of generalized anxiety.
It may be used, however, if significant anxiety symptoms persist despite counseling.
- Ant anxiety medication (e.g., diazepam 5—10mg at night) may 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.
- Beta-blockers may help control physical symptoms.
- Antidepressant drugs may be helpful (especially if symptoms of depression are present) and
do not lead to dependence or rebound symptoms. For details, see section on Depression.
 Referral:
Symptoms are increasing in severity
There is risk of suicide (if depression is present)
Physical illness is suspected
Counseling was not effective
Patient Instructions
A. General advise to the patient and family:
Feeling anxious is not patient’s fault
GAD is a treatable condition
This is not sign of weakness
Worries are related to daily life but unrealistic
Discuss treatment plan with patient
If one treatment doesn't work, another one will
Daily relaxation to reduce physical symptoms
Routine activities and exercise
B. Medication instructions:
Medication is used when psychosocial intervention is not helpful
Side effects are temporary and tolerable.
C. Follow-up instructions:
Follow up is similar to panic disorder: assessing compliance, symptoms
improvement, referral for counseling, improvement in coping, risk of suicide,
monitoring side effects, evaluation of psychosocial stresses and family support.
1. Mental Health in Primary Care based on the WHO PHC Guide lines pages 137 -140 WHO 2010
2. Professional package for medical doctors for mental health working in the BPHS in Afghanistan
pages 27-31 MoPH 2009