ANXIETY

DISORDERS
• DEFINITION OF ANXIETY
• SYMPTOMS OF ANXIETY
• 5 BASIC QUESTIONS FOR PATIENT ASSESSMENT
• PATHOLOGICAL ANXIETY
• DIAGNOSING ANXIETY
• CONDITIONS FOR EXCLUSION
• PATIENT MANAGEMENT
• TREATMENT POINTERS
• CONDITIONS FOR REFERRAL
• CONSIDERATIONS WHEN USING
BENZODIAZPINES IN GENERAL PRACTICE

Contributors
Dr Kwan Pek Yee
Dr Margaret Ling
Dr Winnie Soon

Advisor
Dr Nelson Lee

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 Anxiety Disorders
ANXIETY DISORDERS
DEFINITION OF ANXIETY 5 BASIC QUESTIONS FOR PATIENT ASSESSMENT
Anxiety is a tense emotional state associated with a These are the questions that a doctor should ask
feeling of impending danger, often accompanied by himself or herself when a patient presents with anxiety
somatic symptoms. It is used to describe the mental and symptoms.
physical response to a feared situation – Flight or Fight.
• Is what my patient experiencing Pathological?
• What is the Pattern of the symptoms described?
Anxiety is normal and serves as a built-in warning
• What are the present stressors and Problems faced by
device. Moderate levels of anxiety can enhance
him/her?
performance. Even high levels of anxiety are normal if
consistent with the demands of the situation. • What can I do for him/her Practically in a
busy practice?
• Is Psychiatric referral needed?
SYMPTOMS OF ANXIETY
• Psychological
PATHOLOGICAL ANXIETY
- Irritability
Anxiety is pathological when:
- Poor concentration and memory
• It is greatly disproportionate to the risks and
- Restlessness
severity of the stimulus/stressors
- Worrying thoughts
• It continues even when the danger is no
- Sexual Dysfunction longer present
- Insomnia / Nightmares • Interferes with social, vocational or physical
• Physical aspects of daily life
- Bowel disturbance • Leads to avoidance
- Tremor
- Indigestion
- Dizziness
- Chest discomfort
- Headache
- Difficulty inhaling
- Muscle ache
- Palpitations

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Anxiety Disorders
ANXIETY DISORDERS
DIAGNOSING ANXIETY
1. Type of Anxiety Disorder

TYPE SYMPTOMS

Panic disorder without agoraphobia Recurrent unexpected panic attacks

Panic disorder with agoraphobia Panic attacks with avoidance of situations where escape is
difficult / embarrassing

Specific phobia Persistent, unreasonable fear, and avoidance of feared

object or situation

Social anxiety disorder (SAD) / Fear and avoidance of situations involving potential negative
Social phobia evaluation and scrutiny by others

Generalized anxiety disorder (GAD) Excessive worry about a number of events or activities on
most days for at least 6 months

Obsessive compulsive disorder (OCD) Repeated, intrusive thoughts / images or actions which are
recognized as excessive

Post traumatic stress disorder (PTSD) Trauma causing intense fear and re-experiencing of trauma
lasting longer than 1 month

Acute stress disorder Trauma causing intense fear lasting less than 1 month

Adjustment disorder with anxiety Stressor or life-event temporally related to onset of anxiety
symptoms

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 Anxiety Disorders
ANXIETY DISORDERS

2. Flowchart for Diagnosis of Anxiety

Diagnosis
Acute Stress Reaction
1. Is the anxiety related to
a specific stressful event? Post Traumatic Stress Disorder

No
Adjustment Disorder

2. Is the anxiety constant

(free-floating) or episodic?
Episodic
3. Does the anxiety occur
Generalised Anxiety Disorder
Organic Anxiety Disorder
(hyperthyroidism, CNS / extracranial
neoplasia, subarachnoid haemorrhage,
seizure disorders, hypoglycaemia,
drug inotoxication / withdrawal,
phaeochromocytoma, hypercalcaemia)

at random or only in Panic Disorder

specific situations?

Specific
Situations

The anxiety is associated

with going shopping, crowds,
leaving the house Agoraphobia

The anxiety is caused by

being in small social groups
Social phobia
of people

The anxiety is caused by

Specific phobia
some other specific stimulus

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Anxiety Disorders
ANXIETY DISORDERS
CONDITIONS FOR EXCLUSION
The following conditions may aggravate or mimic anxiety symptoms and should be excluded.

DISEASE SYSTEM EXAMPLES

Endocrine Hyperthyroidism, hypoglycaemia, phaeochromocytoma,

adrenal insufficiency, hyperadrenocorticism

Cardiovascular Congestive heart failure, pulmonary embolism, arrhythmia,

mitral valve prolapse

Respiratory Asthma, chronic obstructive lung disease, pneumonia

Metabolic Diabetes mellitus

Neurologic Vestibular dysfunction, migraine, neoplasm, temporal lobe epilepsy

Gastrointestinal Irritable bowel syndrome

Haematologic Anaemia, Vitamin B12 deficiency

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 Anxiety Disorders
ANXIETY DISORDERS
PATIENT MANAGEMENT
1. Non Pharmacological Therapy
• Educate the patient about the nature and origin of his anxiety symptoms
• Stress reduction strategies:
- Deal with negative thoughts
- Diaphragmatic breathing
- Progressive muscle relaxation
• Encourage exercise
• Reduce alcohol and caffeine intake. Stop smoking.
• Involve family members. Utilize community / social resources.
• Supportive counseling
• Cognitive- behavioural therapy (CBT) if doctor is trained in this area
• Symptomatic relief with medication on a short-term basis
• Monitoring over time and deal with early signs of relapse

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Anxiety Disorders
ANXIETY DISORDERS

2. Pharmacological Therapy
a) Medication for Various Types of Anxiety

TYPE OF ANXIETY EXAMPLES OF NON-

DISORDER PHARMACOLOGICAL THERAPIES MEDICATION

Panic Disorder Behavioural therapy (graded exposure) SSRIs, TCAs, benzodiazepines

Agoraphobia Behavioural therapy (graded exposure to SSRIs, TCAs, benzodiazepines

feared situation)

SSRIs, TCAs, benzodiazepines,

Social Phobia Behavioural therapy (exposure to feared Moclobemide (for performance
social situation) anxiety), Beta-blockers

Specific Phobia Behavioural therapy (exposure to feared Drugs alone are not helpful.
situation or object) Require behavioural therapy

Obsessive-compulsive Behavioural therapy (exposure to provoking SSRIs, Clomipramine

Disorder stimuli), cognitive therapy

Multiple modalities e.g. CBT, stress

Post-traumatic Stress inoculation training, treatment of SSRIs, TCAs, Benzodiazepines
Disorder co-morbid conditions (depression)

Generalized Anxiety Behavioural therapy (relaxation therapy), SSRIs, TCAs, Benzodiazepines,

Disorder stress management Beta-blockers

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 Anxiety Disorders
ANXIETY DISORDERS

b) Adverse Reactions of Different Drug Classes

COMMON DOSE CONTRAINDICATIONS /

DRUGS MAXIMUM DOSE COMMON ADR
PRECAUTIONS

Benzodiazepines
Alprazolam Initiate at 0.25mg to 0.5mg Usual maximum dose of 4mg/ • Sedation • Contraindicated in pregnancy;
(0.25mg tablet) BD / TDS day • Drowsiness concomitant use with
• Muscle ketoconazole/ itraconazole;
Maintenance dose at 0.25mg to Up to 10mg/day may be required weakness narrow-angle glaucoma;
4mg/day for panic disorder • Ataxia pregnancy
• Headache
Doses > 4mg/day should be • Vertigo • Avoid in patients with history
increased cautiously (Periodic • Confusion of drug dependence.
reassessment and consideration
of dosage reduction is • Paradoxical excitement can
recommended occur

Clonazepam Initiate at 0.25mg BD 4mg/day in divided doses

(0.5mg tablet) Maintenance dose at 1mg/day

Diazepam Initiate at 1mg to 2mg OD / BD 30mg/day in divided doses

(2mg / 5mg
tablets) Maintenance : 4 - 20 mg/day in
divided doses

Lorazepam Initiate at 0.5mg to 2mg/day in 10mg/day in divided doses

(0.5mg / 1mg divided doses
tablet)
Maintenance at 2mg to 6mg/day

Selective Serotonin Reuptake Inhibitors (SSRIs)

Fluoxetine Initiate at 20mg/day 80mg/day • Insomnia • Contraindicated in patients
(20mg capsule) • Headache taking pimozide, or
May increase after several • Somnolence thioridazine, cisapride
weeks by 20mg/day • Nervousness concomitantly; use of MAO
• Sexual inhibitors within 14 days
Dose >20mg/day may be given dysfunction • May worsen psychosis in some
as once to twice daily • Nausea patients or precipitate a shift to
mania or hypomania in
patients with bipolar disorder
Fluvoxamine Initiate at 50mg/day 300mg/day in 2 divided doses • Use with caution in patients
(50mg tablet) with hepatic or renal
May increase after 4 to 7 days dysfunction, pregnancy and in
by 50mg/day
the elderly
• May cause hyponatremia/
Maintenance dose is 100mg to
300mg/day in 2 divided doses SIADH (elderly at increased
risk)

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Anxiety Disorders
ANXIETY DISORDERS

COMMON DOSE CONTRAINDICATIONS /

DRUGS MAXIMUM DOSE COMMON ADR
PRECAUTIONS
Escitalopram Initiate at 10mg/day 20mg/day If to be discontinued after long
(10mg tablet) term use, taper dose over
several weeks
Tricyclic Antidepressants
Clomipramine 25mg/day, may increase to 250mg/day in divided doses • Dizziness • Contraindicated if MAO
(25mg tablet) 100mg/day in divided doses • Somnolence inhibitors are being used
over the first 2 weeks • Drowsiness/ within past 14 days; use in
headache patient during acute
• Fatigue recovery phase following
• Dry mouth myocardial infarction;
• Constipation concurrent use of cisapride
• Nausea • May worsen psychosis in some
Imipramine Initiate at 25mg OM/BD 200mg/day in single or divided • Blurred vision patients or precipitate a shift to
(25mg tablet) doses • Increased mania or hypomania in
intraocular patients with bipolar disorder
Elderly : 100mg/day pressure • May lower seizure threshold
• Palpitations • Use with caution in patients
• Tachycardia with hepatic or renal
dysfunction and in elderly
patients
• Toxic cardiac effects if overdose
– to monitor pulse rate, BP
prior and during therapy;
ECG/cardiac status in older
adults and patients with
cardiac disease

Antihistamine

Hydroxyzine May initiate at 30mg to 100mg/ 100mg QDS • Dizziness • Contraindicated during early
(10mg / 25mg day in divided doses • Drowsiness pregnancy
Tablets) • Headache • Anticholinergic effects are not
• Dry mouth well tolerated in the elderly.
• Blurred vision Not recommended for use as a
• Constipation sedative or anxiolytic in the
• Urinary elderly.
retention

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 Anxiety Disorders
ANXIETY DISORDERS
TREATMENT POINTERS
1. Management Guidelines 4. Dosages and Treatment Phases
• Adequate dose of antidepressant therapy should • Dosages typically similar for adult primary
be used (See depression flipchart) care and psychiatric patients
• An adequate duration: 8-12 months should be • Acute treatment: 8 to 12 weeks
given
• Maintenance treatment: 6-12 months
2. Most cases of anxiety present first to primary care symptom-free
physicians
• “The dose that makes them well is the dose that
• Most cases can be managed in primary care keeps them well”
• Take a good history
- Symptoms, severity, duration CONDITIONS FOR REFERRAL
- Psychosocial stressors Patients should be referred when:
- Suicidality • symptoms are severe/complex
• Exclude organic illness • symptoms fail to improve on initial treatment
and follow-up
3. Some Treatment Pointers
• co-occuring drug/alcohol problems exist
• Start with an SSRI
• there are psychotic symptoms
• It is OK to prescribe BZPs but watch for
abuse/dependency • there is serious risk of suicide
• Give common sense problem-solving advice
• Listen actively
• Encourage relaxation, stress reduction
• Review regularly
- Weekly to 2-weekly for first 2 to 3 sessions
- Monthly to 2-monthly subsequently

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Anxiety Disorders
ANXIETY DISORDERS
CONSIDERATIONS WHEN USING BENZODIAZEPINES
(BZD) IN GENERAL PRACTICE1
• Do not prescribe highly addictive BZD such as
midazolam and nimetazepam
• The dosage of BZD should be the lowest effective
dose necessary to achieve symptomatic relief
• Repeat prescriptions for BZD should not be provided
without a clinical review
• When there are doubts about dosage prescription or
tapering of BZD, a psychiatrist should be consulted

Specialist Referral should be initiated for:

• Patients who require or have been prescribed BZD
beyond a cumulative period of 8 weeks
• Patients who are already on high dose and or long
term BZD from specialist or hospitals should be
referred back to their specialist for review
• Patients who are non compliant with professional
advice or warning to reduce the intake of BZD

Note: Patients who refuse to be referred to a specialist

should be counselled appropriately and documented in the
case sheet. If the patient turns aggressive, they should be
reported to the police.

References
1. MOH Clinical Practice Guidelines 2/2008: Prescribing of Benzodiazepines
2. Drug Information Handbook, 17th Edition 2008-2009

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