Anxiety Disorders

Anxiety is a normal emotion. It is allied to interest, passion, excitement but also to caution and vigilance.

An Anxiety Disorder occurs when there is a persistent and excessive level of anxiety which interferes with daily activity. It comes in four basic forms –

  • choppy water”   –   Generalised Anxiety
  • “tidal waves ”       –    Panic Disorder
  • too scared to go near the water for a swim” –  Phobias and Social Anxiety
  • scared to leave the house” – Agorophobia

About 15% of the population are genetically predisposed to anxiety.  If genetically predisposed people are given 5% carbon dioxide to breath they are likely to experience a panic attack.

Anxious people are also more prone to depression and substance abuse as well as a number of medical conditions such as irritable bowel, fibromyalgia, chronic fatigue.

Once anxiety disorder is triggered in predisposed persons the condition persists although it can be substantially controlled with proper treatment. Lifestyle management is very important.

Generalised Anxiety Disorder

Persons with generalised anxiety disorder comprise 5% of the general population. On MRI they show different activation patterns of dorsomedial prefrontal cortex, ventromedial prefrontal cortex, anterior cingulate cortex, and altered functional connectivity with the amygdala.   The amygdala is the flight fight organ of the brain. It is usually modulated by messages from the dorsomedial prefrontal cortex and anterior cingulate cortex. The ventromedial cortex plays a role in ruminating about anxieties.

The goals of treatment are:

  1. Lower arousal levels
  2. Reduce stressors
  3. Return to usual activities
  4. Relapse Prevention

Lowering of arousal levels can be done by:

  • Hypnosis
  • Training in progressive muscle relaxation or autogenic breathing
  • Biofeedback

Reducing Stressors involves:

  • Structuring the day
  • Getting rid of any obsessive control issues
  • Gentle Exercise Regime
  • Blocking Ruminative Thought Patterns
  • Stopping unhelpful habits such as substance abuse and excess caffeine consumption.

Return to Normal Activities:

  • This is done in a graded fashion tackling any apprehensions with cognitive therapy
  • Provision of if required medication such as Diazepam 2.5-5mg .

Relapse Prevention:

As mentioned anxiety disorders are recurring conditions. However once a person has learned how to deal with an initial episode , subsequent episodes tend to be hiccups rather than catastrophes.

Health foods helpful for anxious people are-  Inositol  800mg  twice daily  and  Nervatona (by Brauer) homeopathic spray.

Panic Disorder

Panic Attack is a common emergency department presentation. The person has had sudden onset chest pain and believes they are having a heart attack or have had a collapse episode and fears they have had a stroke.   Sometimes an episodic  hereditary heart irregularity mimics a panic attack -so a cardiology check is warranted.  Panic attacks last from 3-20minutes but often decay into generalised anxiety for the rest of the day.  Panic attacks are stereotyped and always present in the same way-so you know how its going to proceed.

Tips for managing panic disorder

  1. Pay particular attention to your breathing -make sure you are not hyperventilating. ( If you have tingling or numbness you are definitely hyperventilating)
  2. Go for a brisk walk
  3. Find a quite place where you feel safe – eg: library, newsagent, cafe . Don’t go home immediately. For recurring visits eg: shopping trips find your safe place in advance.
  4. Try to have something to eat carbohydrates and mild are best – a lamington and malted milk
  5. Take prn anti-anxiety medication which you should have with you.
  6. If you are still feeling anxious go home – but don’t self-criticise .Take the view that you win some and lose some with panic attacks.

Management of Panic Disorder

Usually an SSRI antidepressant in moderately high dose is prescribed.   Generally a patient stays on a high dose for 12 months than the dose is tapered to a low maintainence dose so that the medication can be quickly reinstituted in case of recurrence.

Cognitive Behaviour Therapy is also useful

An if required benzodiazepine is also usually needed

Relapse planning is also important




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