14th February 2025

Anxiety disorders

Overview of anxiety disorders

Anxiety forms part of our fear response, a normal emotional experience and crucial for survival. We all experience anxiety symptoms on a regular basis, such as worrying about passing MRCP Part II or having intrusive thoughts about having left the stove on. However, these symptoms form part of a “disorder” when they cause significant distress and/or are severe enough to interfere with daily functioning.

Panic disorder

A panic attack is an acute episode of intense fear which develops quickly and reaches its peak in approximately 10 minutes. It rarely lasts more than an hour. It may be out of the blue, triggered by specific situations, or occur during sleep. It is characterised by both physical and cognitive symptoms of anxiety.

Panic disorder describes when panic attacks occur repeatedly and are not due to psychiatric or medical conditions or substance misuse.

Epidemiology and aetiology of panic disorder

Panic attacks are common, with a lifetime prevalence of 5-10%. Fewer meet the criteria for panic disorder. There are two incidence peaks, at 15-24 and 45-54 years.

Risk factors include family history, female gender, Caucasian ethnicity, being widowed, divorced or separated, urban living, lower educational attainment, early loss of a parent, and being a victim of physical or sexual abuse.

Presentation and diagnosis of panic disorder

Common features of a panic attack are palpitations, tachycardia, dyspnoea, trembling, chest pain, gastrointestinal upset, presyncope, paraesthesia, fear of losing control, and fear of impending harm or death. Patients may repeatedly present to medical services. There is a risk of impulsive suicide or self harm as a coping mechanism.

For panic disorder to be diagnosed, attacks must recur over a period of at least 1 month. There may be avoidance behaviours to evade triggering situations.

Usually, the history is sufficient to make a diagnosis. Organic causes may need to be ruled out with ECG, blood glucose, thyroid function tests and drug testing.

Management of panic disorder

Cognitive behavioural therapy (CBT) is first line, with the potential addition of a selective serotonin reuptake inhibitors (SSRI) (e.g. sertraline) or serotonin noradrenaline reuptake inhibitors (SNRI) (e.g. venlafaxine) for longer-term management. Second line is an alternate antidepressant such as a tricyclic antidepressant (TCA), monoamine oxidase inhibitor (MAOI) or bupropion, although these are rarely used.

Benzodiazepines are not recommended by NICE but can be used as an acute treatment or as an interim measure whilst an antidepressant is taking effect.

Generalised anxiety disorder (GAD)

Generalised anxiety disorder is characterised by a global sense of worry and fear regarding everyday events, disproportionate to any inherent risk. It presents with both cognitive and somatic symptoms and causes significant distress and functional impairment.

Epidemiology and aetiology of GAD

GAD is also common, with a lifetime prevalence of roughly 5%. Incidence peaks in middle age.

Risk factors include female gender (especially for early onset), stressful events, being single, dysfunctional relationships and unemployment. It has a genetic component, sharing heritability with depression. Patients may have psychological vulnerabilities such as insecure attachment to primary caregivers, intolerance of uncertainty, or have received parenting which is overprotective or lacking warmth.

Presentation and diagnosis of GAD

In GAD, significant anxiety symptoms are present most days for at least 6 months. There may be either generalised apprehension (“free-floating” anxiety) or excessive worry related to daily events. This is accompanied by somatic symptoms such as muscle tension, restlessness, sympathetic overdrive (e.g. dry mouth, palpitations, sweating), or gastrointestinal upset. Sleep and concentration are often impaired.

Commonly used screening tools include the Hamilton Anxiety Rating Scale (HAM-A) and the Generalised Anxiety Disorder 7 (GAD-7) self-scoring tool.

Symptoms must not be caused by another condition, such as hyperthyroidism, phaeochromocytoma, lung disease, caffeine or cocaine use, or alcohol or benzodiazepine withdrawal. As such, thyroid function tests, urine drug screen, 24-hour urine metanephrines, pulmonary function tests and ECG may be needed. Medications can also cause anxiety symptoms such as commonly used salbutamol and thyroxine.

Management of GAD

NICE recommends patient education and low-intensity psychological interventions such as guided self help as first-line treatment. If response is inadequate or there is marked functional impairment, high-intensity psychological intervention such as CBT or drug treatment is indicated.

An SSRI would be the first-line medication, followed by an SNRI if ineffective, or pregabalin as a third-line option. Benzodiazepines are only to be used as a short-term measure in a crisis.

Beta blockers such as propranolol are commonly used for somatic symptoms.

Obsessive-compulsive disorder (OCD)

Obsessive-compulsive disorder is a common, chronic condition characterised by obsessions and compulsions.

An obsession is an unwanted, unpleasant and intrusive thought, mental image or impulse which the patient recognises as abnormal. Obsessions lead to a compulsion, which is a stereotyped behaviour that neutralises the obsession and provides relief.

Epidemiology and aetiology of OCD

OCD affects up to 3% of the population. Men and women are equally affected. It affects younger people more commonly, with an average age of 20 years at diagnosis.

Risk factors include family history, comorbid depressive or anxiety disorders, alcohol or substance misuse, and certain personality traits, e.g. avoidant, dependent, or histrionic. OCD is also associated with schizophrenia, Sydenham’s chorea, and Tourette’s syndrome.

Presentation and diagnosis of OCD

Obsessions and compulsions must be time consuming (taking more than an hour per day) or result in significant distress or functional impairment.

Common obsessions include contamination, symmetry, safety and sexual or violent thoughts. Common compulsions include checking (e.g. doors), cleaning, counting, and hoarding.

Management of OCD

If functional impairment is mild, first-line treatment is low-intensity psychological treatments such as CBT. If not suitable or ineffective, an SSRI and/or intensive CBT should be offered. Clomipramine (a TCA) is an alternative to SSRIs, although not commonly used.

Other antidepressants such as TCAs (except clomipramine), SNRIs or MAOIs should not be used unless there is a comorbid anxiety or depressive disorder.

References

• Semple D, Smyth R. Oxford handbook of psychiatry. Oxford; New York: Oxford University Press; 2019
• World Health Organization. ICD-11 for Mortality and Morbidity Statistics [Internet]. icd.who.int. World Health Organization; 2019 [cited 2022 Feb 23]. Available from: https://icd.who.int/browse11/l-m/en#/http://id.who.int/icd/entity/1707067746
• Sawchuck C, Veitengruber J. Panic disorders – Symptoms, diagnosis and treatment [Internet]. BMJ Best Practice; 2021 [cited 2022 Feb 23]. Available from: https://bestpractice.bmj.com/topics/en-gb/121
• The National Institute for Health and Care Excellence. Generalised anxiety disorder and panic disorder in adults [Internet]. NICE, 2019. [cited 2022 Feb 23] Available from: https://www.nice.org.uk/guidance/cg113
• Gale C. Generalised anxiety disorder [Internet]. BMJ Best Practice; 2021. [cited 2022 Feb 23] Available from: https://bestpractice.bmj.com/topics/en-gb/120
• Seibell P. Obsessive-compulsive disorder [Internet]. BMJ Best Practice; 2021 [cited 2022 Feb 24]. Available from: https://bestpractice.bmj.com/topics/en-gb/362
• The National Institute for Health and Care Excellence. Obsessive-compulsive disorder and body dysmorphic disorder [Internet]. NICE; 2005. [cited 2022 Feb 23] Available from: https://www.nice.org.uk/guidance/cg31