ANXIETY & RELATED DISORDERS

DIOGNOSTIC CRITETRIA

Definition : Generalised Anxiety Disorder (GAD) with excessive worry and tension on most days, / for at least 6 months, together with somatic symptoms and signs.

1. Subtypes include acute situational anxiety, phobias (excessive and persistent fear of certain objects and situations), obsessive compulsive features (recurrent thoughts and behaviour around certain obsessions), post-traumatic stress disorder (after major trauma with upsetting thoughts and nightmare), and panic disorder (sudden attacks of fear or apprehension with attendant sense of doom).
2. Needs careful work up by psychiatrist to identify nature and aetiology of the state, but general treatment modalities apply.
3. Somatic symptoms like sweating, palpitation, Insomnia, hyperventilation, tremors, syncope, and chest tightness (Pseudo-angina), tremors, dry mouth etc.
4. Somatisation with headache, syncope, epigastric pain, muscle pain, etc.
5. Diagnosis should exclude anxiety arising from other Psychiatric Illness, or Organic physical Illness or Drug abuse.

Prognosis : GAD is a long term condition, beginning at an young age, is life long and spontaneous remission is rare. Short term anxiety disorders including panic disorders can be very adequately controlled with active treatment. But obsessive, compulsive and post-traumatic stress disorders are more difficult to control and might need prolonged therapy.

MANAGEMENT

General Principles:

Comprehensive management calls for behavioral, social, psychologic and medical approaches.

Drugs should be given for a limited time and as part of an overall treatment plan. For GAD benzdiazepines seem best for long term symptom control and buspirone has the least adverse effects. Antidepressantsare best used if an element of comorbid depression exists, but sedation, confusion and falls tend to occur.

1. Chronic Anxiety states - Long acting drugs like Diazepam 5-10 mgs 8 hourly, Chlordiazepoxide -mgs 8 hourly, or Oxazepam 10-20 mgs 8 hourly, or Short acting drugs like Lorazepam I -2 mgs 8 hourly, or Alprazolam 0.5 -1.0 mg 8 hourly or, Buspirone 5-20 mg 8 hourly, or Phenobarbitone 10-30mg 8 hourly as the last choice Buspirone takes 1-3 weeks to get effective and has potential for minimal problems in the group.
2. With co-morbid depression Antidepressants are effective. Imipramine, trazadone, venlafaxine, and paroxetine are all effective, but could cause sedation (See chapter on Depression).
3. For Insomnia Flurazepam 15-30 mgs or Hydroxyzine 15-30 mgs
4. Panic Disorder - Alprazolam-0.5-1 .0 mg or Lorazepam 2.0 mg for emergency therapy. Then start on Antidepressants starting in smaller doses. (See chapter on ‘Depression’ for dosage Schedule). Alprazolam in higher doses, up to 6.0mg daily. Clonazepam 1-6mg daily may also be tried, but the propensity for dependency is marked, unlike with antidepressants.SSRls produce good response.
5. Phobic disorder - Clomipramine (25-200 mg a day), and Fluoxetine( 10-40 mg a day) have been found useful.
6. Obsessive compulsive states - Selective Serotonin reuptake inhibitors (SSRI ) have been found quite effective, and better than antidepressants or clomipramine with less side effects. Fluoxetine (20-60 mg/daily), Sertaline (50-200mg/daily), orfiuvoxamine (100-300 mg/day, but has multiple drug interactions), Always start on the lowest dose and increase if required, after some weeks. Withdrawal symptoms can occur with SSRls.
7. Post-traumatic stress disorder Psychologic support, relaxation therapy and antidepressants to reduce symptoms

General Measure

1. Psychological therapy in collaboration with psychiatrist. Cognitive behavioural therapy reduces the frequency and symptoms, and improves sleep and social interactions.
2. Stress reduction by Relaxation techniques, bio-feed back, Yoga, Meditation, etc. (see unit on ‘stress reduction’).
3. Regular exercise programme. Aerobic forms of exercise appear to be more helpful, and daily exercise for at least 20 minutes would appear necessary. It takes 10 weeks before significant reduction in anxiety occurs.
4. Identify any coexistent substance abuse, and remedial measures, if any.
5. Personal and family counselling.
6. Judicious reassurance th other serious medical disorders have been ruled out.

Patient - Teaching

1. Follow General Measures, as applicable.
2. Maintain an optimistic outlook.
3. When on sedating drugs, avoid driving vehicles or operating machinery.

   DIOGNOSTIC CRITETRIA

   Definition : Generalised Anxiety Disorder (GAD) with excessive worry and tension on most days, / for at least 6 months, together with somatic symptoms and signs.

4. Subtypes include acute situational anxiety, phobias (excessive and persistent fear of certain objects and situations), obsessive compulsive features (recurrent thoughts and behaviour around certain obsessions), post-traumatic stress disorder (after major trauma with upsetting thoughts and nightmare), and panic disorder (sudden attacks of fear or apprehension with attendant sense of doom).
5. Needs careful work up by psychiatrist to identify nature and aetiology of the state, but general treatment modalities apply.
6. Somatic symptoms like sweating, palpitation, Insomnia, hyperventilation, tremors, syncope, and chest tightness (Pseudo-angina), tremors, dry mouth etc.
7. Somatisation with headache, syncope, epigastric pain, muscle pain, etc.
8. Diagnosis should exclude anxiety arising from other Psychiatric Illness, or Organic physical Illness or Drug abuse.

9. Prognosis : GAD is a long term condition, beginning at an young age, is life long and spontaneous remission is rare. Short term anxiety disorders including panic disorders can be very adequately controlled with active treatment. But obsessive, compulsive and post-traumatic stress disorders are more difficult to control and might need prolonged therapy.

   MANAGEMENT

   General Principles:

   Comprehensive management calls for behavioral, social, psychologic and medical approaches.

   Drugs should be given for a limited time and as part of an overall treatment plan. For GAD benzdiazepines seem best for long term symptom control and buspirone has the least adverse effects. Antidepressantsare best used if an element of comorbid depression exists, but sedation, confusion and falls tend to occur.

10. Chronic Anxiety states - Long acting drugs like Diazepam 5-10 mgs 8 hourly, Chlordiazepoxide -mgs 8 hourly, or Oxazepam 10-20 mgs 8 hourly, or Short acting drugs like Lorazepam I -2 mgs 8 hourly, or Alprazolam 0.5 -1.0 mg 8 hourly or, Buspirone 5-20 mg 8 hourly, or Phenobarbitone 10-30mg 8 hourly as the last choice Buspirone takes 1-3 weeks to get effective and has potential for minimal problems in the group.
11. With co-morbid depression Antidepressants are effective. Imipramine, trazadone, venlafaxine, and paroxetine are all effective, but could cause sedation (See chapter on Depression).
12. For Insomnia Flurazepam 15-30 mgs or Hydroxyzine 15-30 mgs
13. Panic Disorder - Alprazolam-0.5-1 .0 mg or Lorazepam 2.0 mg for emergency therapy. Then start on Antidepressants starting in smaller doses. (See chapter on ‘Depression’ for dosage Schedule). Alprazolam in higher doses, up to 6.0mg daily. Clonazepam 1-6mg daily may also be tried, but the propensity for dependency is marked, unlike with antidepressants.SSRls produce good response.
14. Phobic disorder - Clomipramine (25-200 mg a day), and Fluoxetine( 10-40 mg a day) have been found useful.
15. Obsessive compulsive states - Selective Serotonin reuptake inhibitors (SSRI ) have been found quite effective, and better than antidepressants or clomipramine with less side effects. Fluoxetine (20-60 mg/daily), Sertaline (50-200mg/daily), orfiuvoxamine (100-300 mg/day, but has multiple drug interactions), Always start on the lowest dose and increase if required, after some weeks. Withdrawal symptoms can occur with SSRls.
16. Post-traumatic stress disorder Psychologic support, relaxation therapy and antidepressants to reduce symptoms

17. General Measure

18. Psychological therapy in collaboration with psychiatrist. Cognitive behavioural therapy reduces the frequency and symptoms, and improves sleep and social interactions.
19. Stress reduction by Relaxation techniques, bio-feed back, Yoga, Meditation, etc. (see unit on ‘stress reduction’).
20. Regular exercise programme. Aerobic forms of exercise appear to be more helpful, and daily exercise for at least 20 minutes would appear necessary. It takes 10 weeks before significant reduction in anxiety occurs.
21. Identify any coexistent substance abuse, and remedial measures, if any.
22. Personal and family counselling.
23. Judicious reassurance th other serious medical disorders have been ruled out.

24. Patient - Teaching

25. Follow General Measures, as applicable.
26. Maintain an optimistic outlook.
27. When on sedating drugs, avoid driving vehicles or operating machinery.