Anxiety

• Neurotransmitters involved in anxiety disorders

  • GABA
  • Serotonin
  • Noradrenaline
• Types of anxiety disorders

  • Generalised Anxiety disorder (GAD)
  • Mixed anxiety and depressive disorder (MADD)
  • Social anxiety disorder (SAD)
  • Panic disorder (PD)
  • Obsessive compulsive disorder (OCD)
  • Post-traumatic stress disorder (PTSD)

  
• Mixed anxiety and depressive disorder: 8 in 100 people

  
• Generalised anxiety disorder (GAD): 6 in 100 people

  
• Post-traumatic stress disorder (PTSD): 4 in 100 people
• Phobias: 2 in 100 people
• Obsessive-compulsive disorder (OCD): 1 in 100 people
• Panic disorder: fewer than 1 in 100 people
• GAD


  • Diagnosis: ICD-10
  • More common in women
  • Related to chronic environmental stress
  • Non specific anxiety
  • Excessive and uncontrollable worry
  • Clinical Presentation: Motor tension, restlessness and irritability
  • Somatic symptoms: Hyperventilation, tachycardia and sweating
  • GAD often co-exists with major depression, panic disorder and OCD
  • Rating scales: GAD-7 and HAM-A

  
• GAD: General treatment principles

  1. First line: SSRI (sertraline and fluoxetine)

  2. Benzodiazepine – for crisis management

  3. SNRIs (venlafaxine)

  4. Pregabalin – licenced (150-600mg a day in divided dose)

  5. 2nd line options
• MADD


  • When symptoms of both anxiety and depression are present, neither set considered separately
  • Symptoms: similar with GAD
  • Autonomic symptom(s): tremor, palpitations, dry mouth stomach, churning etc MUST be present
  • Treatment similar to GAD
  • Diagnosis: ICD-10

  
• SAD (Social anxiety disorder)

  • Occurs more in adolescents
  • Affects 3—7% of adults
  • Avoid social and performance situations
  • The phobic situation is avoided when possible
  • Diagnosis: ICD-10
  • Avoidance behaviours – because of fear in what will happen , embarrassed about situation
  • Anxious anticipation e.g. feeling sick , sweaty, tremor, hot palpitation
  • Treatment: Similar to GAD

  
• Panic disorder


  • Diagnosis: Severe attacks over one month- no associated phobia
  • With or without Agoraphobia
  • Around 2/3rd of people will develop agoraphobia
  • Clinical presentation: Sudden and rapid
  • Symptoms: Shortness of breath, Autonomic symptoms such as tachycardia ( increased heart rate)
  • 30/45 mins in duration – cant calm down
  • Fear not rationalised etc dying, suffocation
• Panic disorder: Treatment


  1. First line: SSRI and venlafaxine MR

  2. Benzodiazepine- not recommended by NICE

  3. 2nd line- Mirtazapine 15-60mg (BNF max is 45mg)
• PTSD


  • Cause: Occurs after exposure to traumatic event
  • Onset: May be recent or years after the traumatic event
  • Anxiety and depressive symptoms common
  • Treatment: First line: Sertraline (paroxetine, fluoxetine), Venlafaxine
  • 2nd line: antipsychotics like olanzapine, risperidone (usually secondary care), Mirtazapine
• OCD


  • Obsessional thoughts followed by the compulsive behaviour
  • Anxiety is always present
  • Treatment: SSRI (sertraline), Then clomipramine (up to 250mg OD)
  • 2nd line: Antipsychotic like aripiprazole, risperidone
  • Not recommend : TCA like amitriptyline, mirtazapine, SNRI, MAOIs, anxiolytics

  
• General principles for anxiety disorders

  1. Optimise dose

  2. 12 weeks

  3. 6 months minimum

  4. Gradual reduction

  5. GP

  6. Substance misuse can be a contributing factor

  
• Sertraline


  • Licenced indication depression, OCD, panic disorder, PTSD,SAD
  • Dose range 25mg – 200mg
  • Side effects: common Anxiety, abnormal appetite, arrhythmia, drowsiness, concentration impaired sexual dysfunction
  • SSRI safety information - pregnancy
  • Other SSRIs: Fluoxetine, citalopram, escitalopram, paroxetine
• Withdrawal side effects of SSRIs

  • Gastro-intestinal disturbances
  • Headache
  • Anxiety
  • Dizziness,
  • Paraesthesia
  • Electric shock sensation in the head, neck, and spine,
  • Tinnitus
  • Sleep disturbances
  • Fatigue
  • Influenza-like symptoms
  • Sweating
• Non-pharmacological treatment


  • CBT (Cognitive behavioural therapy)
  • Graded exposure: SAD or phobia
  • Education groups (psycho-educational)
  • Individual guided Self-help
  • Individual Non-facilitated self-help
  • Mindfulness
  • Applied relaxation
• Self-help organisations


  • Anxiety UK : Anxiety.org.uk
  • British Association for behavioural and cognitive psychotherapies (BABCP)
  • No panic- National organisation for phobias, anxiety, neurosis, information and care
  • Living life to full: free course
  • Fearfighter ( access prescribed by doctor)
  • Free online CBT course
• Red flags


  • Failure of 2 medications
  • Deteriorating symptoms despite treatment
  • Suicidal thoughts
  • Physical threat
• Role of pharmacist


  1. Initiation

  2. Side effects

  3. Withdrawal side effects

  4. Monitor symptoms

  5. Pregnancy

  6. Sign post