High anxiety

Anxiety disorder is characterised by anxious feelings about a variety of issues and not being able to control worries.

ANXIETY is part and parcel of life. It is normal for everyone to experience anxiety at various times, e.g. prior to sitting for an examination, attending an interview for a job, consulting a doctor or retirement. These feelings have been described as uneasiness and can include worry or even fear. They can be mild or severe.

However, some people experience so much anxiety that it affects their daily lives. They are not able to control their worries and are anxious about a variety of issues and situations, and not specific ones. This condition is called generalised anxiety disorder (GAD).

Neverending worry: People with generalised anxiety disorder are so anxious about a variety of issues and situations that it affects their daily life

Those who have GAD are anxious almost all the time and usually have to try very hard to remember the last occasion they were relaxed. The stressful worries are uncontrollable and the person has a tendency to think of the worst. There is marked difficulty with the activities of daily living, whether it is work or social life. Some doctors have put a time line before diagnosing GAD, which is anxiety occurring continuously for about six months.

GAD is common. It has been reported to affect about 5% of the population in developed countries, with women slightly more affected than men. Many of those affected are in the third decade of life.

Causes

The causes of GAD are not well understood. Some people develop GAD after a stressful incident. Others develop it for no apparent reason. There is evidence to suggest that GAD is due to an imbalance of neurotransmitters in the brain, ie noradrenaline and serotonin. However, it is believed that GAD is more likely to be due to a combination of causes, which include a person’s genetic make-up, biological processes, life experiences, and the environment.

Clinical features

The clinical features of GAD include psychological and physical symptoms, which vary between individuals in number and severity.

The psychological symptoms include constant worries, restlessness, dreading something will happen, irritability, poor concentration, and easy distraction.

The physical symptoms are many and include irregular heart beat (palpitations), dizziness, difficulty breathing, excessive sweating, muscle aches, abdominal ache, frequent passing of urine, diarrhoea, tiredness and difficulty falling and staying asleep (insomnia). Women who have GAD may have missed or painful periods (dysmenorrhoea).

The symptoms may lead to a person with GAD going off work and avoiding contact with family and friends. This increases the loss of self esteem, which in turn may aggravate the worries and fears.

Although people who have conditions like phobias know the cause of their anxiety, people with GAD often do not know what causes their anxiety. This worsens their anxiety to the extent that they worry that a solution is not possible.

A consultation with a regular attending doctor will be helpful. It is essential that there is frankness and openness in the consultation as it will facilitate the making of a correct diagnosis. After hearing the patient out, the doctor will carry out a physical examination to exclude other conditions which may be causing the symptoms. If there is difficulty in making a diagnosis, the doctor may carry out laboratory and/or imaging investigations and/or refer the patient to a mental health team.

Management

GAD is managed with psychotherapy and/or medicines, depending on a patient’s individual needs. The doctor will discuss with the patient the management options prior to the commencement of treatment. It is important that a patient inform the doctor of his or her preferences and circumstances.

Psychotherapy is usually initiated prior to the prescription of medicines. A primary mode of psychotherapy is cognitive behavioural therapy (CBT). This involves helping a patient identify unrealistic beliefs and behavioural patterns, and then working together with the therapist to replace them with more realistic and balanced beliefs as well as alter behaviour. The patient is taught new skills and provided assistance in better understanding of situations that cause the anxiety.

It is important that a patient be patient and give sufficient time for CBT to take effect. CBT has been reported to be effective in treating about 50% of patients with GAD.

Another mode of psychotherapy is applied relaxation, which is as effective as CBT. It involves learning how to relax the muscles rapidly and practising the technique in situations that makes one anxious.

Medicines are also prescribed in the treatment of GAD. Depending on a patient’s circumstances, they are prescribed for the short term or the long term. The doctor will inform the patient about the side effects of the medicines and their interactions with other medicines that the patient may be taking. Short term medicines include antihistamines, benzodiazepines and other anxiolytics. The long term medicines include the selective serotonin reuptake inhibitors (SSRI) and venlafaxine.

Antihistamines are prescribed for the short term. They have a calming effect on the patient. The side effects include dizziness, blurring of vision, headache and dry mouth.

Benzodiazepines are very effective in treating anxiety, easing symptoms within an hour or so after consumption. However, they cannot be used for long periods because of their addictive potential if used for longer than four weeks and loss of effectiveness after this period. The side effects include loss of balance, drowsiness and confusion. It is important to avoid driving or operating machinery when taking benzodiazepines.

The SSRIs increases the level of brain serotonin. Their side effects include nausea, blurring of vision, dry mouth, poor appetite, poor libido and insomnia.

The consumption of SSRI requires medical supervision, which may include regular blood pressure and laboratory checks. It is important to follow the doctor’s instruction on how the SSRI is to be taken.

Venlafaxine is a selective serotonin and noradrenaline reuptake inhibitor (SNRI). It increases the amount of serotonin and noradrenaline in the brain. The side effects include nausea, dry mouth, constipation, insomnia and sweating.

It cannot be prescribed if there is untreated high blood pressure, a recent heart attack or when there is risk of irregular heartbeats. Regular monitoring of the blood pressure is necessary when taking this medicine.

Referral to a mental health team may be made by a patient’s regular attending doctor. The team includes psychiatrists, psychiatric nurses, clinical psychologists, occupational therapists and social workers.

After evaluation and assessment, a treatment plan will be formulated for the individual patient. This may include psychotherapies, treatment of other conditions that may have an effect on the anxiety, other medicines, and treatment by other specialists.

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High anxiety