Anxiety

Anxiety

Nov 14, 2016 0
onthepods,psychiatry

James talks to Julian Nasti about anxiety symptoms.

Summary Writer:  Antonia Clarke

Editor:  James Edwards

Interviewee: Julian Nasti

About Dr Julian Nasti

Dr Julian Nasti is an Advanced Trainee in Consultation-Liaison Psychiatry currently based at Canterbury Hospital where the main focus of his clinical work is perinatal mental health.

Anxiety disorders

With Dr Julian Nasti, Advanced Trainee in Psychiatry at Canterbury Hospital, New South Wales, Australia

Introduction

Anxiety symptoms are on a spectrum of normality. It is important to exclude underlying causes that may present with anxiety as a symptom. Treatment modalities for anxiety include psychotherapy, cognitive behavioural therapy and pharmacotherapy.

Case

A middle-aged man with recurrent presentations to ED with chest pain that has been extensively investigated without a cause found presents again very concerned about his chest pain and shortness of breath. He agrees that he is anxious but does not see his physical symptoms to be related to his anxiety.

  • Anxiety disorders are characterised by:
    • Excessive or disproportionate fear of a particular object or situation; or
    • Fear or anxiety when not faced with a specific object or situation.
      • The person with anxiety usually recognises the fear as irrational, or excessive (compared to someone with a psychotic disorder where insight can be absent).
  • History:
    • Useful to divide symptoms between cognitive (anxious thoughts) and somatic (anxious bodily sensations related to sympathetic activation).
    • Assess the behavioural consequences of those responses i.e. how the person copes with those symptoms (usually related to avoidance, with the effect of short term relief but long term detriment).
    • Always consider an underlying organic cause as a differential (especially if patient presents with sudden onset anxiety for the first time).
      • Must exclude alcohol or benzodiazepine dependence.
    • Think about possible co-morbidities e.g. personality disorders, panic disorder.
  • Secondary medical causes of anxiety are rare.
  • Investigations should be targeted to exclude:
    • Thyroid disorder
    • Arrhythmia e.g. SVT
    • BSL (neuroglycopaenic effects of low BSLs can mimic anxiety)
    • Drug and alcohol use
    • Hyperventilation
    • Adrenal disorders e.g. phaeochromocytomas are very rare
  • Review the investigations that have already been done.
  • Acute:
    • Reassurance (this is a common ED presentation).
    • Deep breathing – breathe all the way in, hold for 10 seconds, then breath all the way out, pause and repeat – this provides a strong parasympathetic surge via vagal stimulation.
    • Stat dose of benzodiazepine or low dose anti-psychotic can be warranted if the anxiety is interfering with appropriate medical care or management.
    • In someone with recurrent presentations e.g. to the Emergency Department, it is important to establish the pattern of presentation.
  • Long term
    • Non-pharmacological: psychotherapy and cognitive behavioural therapy (can be used alone for mild to moderate anxiety).
    • Pharmacological: SSRIs
  • Referral pathways
    • GP may initiate referral to a psychologist.
    • Headspace for young people.
    • CRUfAD- Clinical Research Unit for Anxiety and Depression (crufad.org) – clinic attached to SVH.
  • Exclude drugs and alcohol as a cause.
  • Review the investigations that have already been done.
  • Anxiety and physical conditions are not necessarily mutually exclusive.

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Tags: #anxiety,#anxiety disorders,#health and wellbeing,#mental health,#mental health issues

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