SECTION 9: ANXIETY DISORDER

ANXIETY DISORDER:

Anxiety is a wide spread phenomenon in which the subject experiences a feeling of tension and
apprehension and fear with or without any obvious cause usually accompanied by autonomic
disturbances manifested by sympathetic over activity.

TYPES OF ANXIETY:

Anxiety may be a transient abnormal manifestation when:

It is a feeling of discomfort arising from a sense of inadequacy.

It may be a healthy anxiety if it can be used to enhance performance under conditions of stress,
e.g.,when appearing for examination and interviews.

Anxiety as a pathological manifestation may accompany:

Depression

Obsessive compulsive disorder

Schizophrenia
Dementia

Anxiety may accompany or occur as a reaction to somatic illness such as:

Thyrotoxicosis

Hypertension

Pheochromocytoma

Drug induced anxiety

Stimulants : tea, coffee, cocoa used in excess can produce anxiety.

Ephedrine and other stimulant drugs eg. Amphetamine.

Anxiety as an illness (anxiety disorders)

It is a maladjustment response to stress which does not serve any useful purpose as does
healthy anxiety.

Interrupting vital mental functioning such as attention and concentration;, memory and
judgement.

In severe cases it can lead to social problems or complete isolation.

VARIATIONS OF PATHOLOGICAL ANXIETY

PHOBIAS

This is marked by irrational fears of an object or situation and the need to avoid it.

Agoraphobia:

Fear of crowds, entering shops, public places, travelling alone in trains or planes.

Social phobia:

Fear of social situations which include fear of being unable, due to nervousness, to continue
talking while eating in public or choking on food when eating in front of others or trembling
when writing in the presence of others.

Specific phobia:
These are fears restricted to highly specific situations e.g., heights, darkness, injections, illness,
particular animals or places etc.

PANIC ATTACKS

Recurrent attacks of severe anxiety which are not restricted to any particular situation hence
being unpredictable and often followed by a persistent fear of having another attack.

Panic attacks manifest by a sudden onset of palpitations, chest pain, feeling of choking or
suffocation and a feeling of dread that something disastrous is about to happen. Such patients
sometimes present in the hospital emergency department and may mimic myocardial infarction
especially when presenting with chest pain. They may start to hyper ventilate and have carpo-
pedal spasms due to respiratory alkalosis.

GENERALISED ANXIETY

Excessive anxiety and worry about life circumstances and future events with contineous feelings
of nervousness, fears and tension.

MIXED ANXIETY DEPRESSION

Symptoms of both anxiety and depression are present.

RISK FACTORS:
Any age group can be affected. Anxiety is more common in the older age group.

Females are more affected than males.

CLINICAL PIUTURE:

Emotional symptoms:

Distressing feelings of apprehension, tension, restlessness and helplessness

Difficulty in concentration.

Autonomic features: (mainly sympathetic over activity)

Skin pallor (pale), sweaty and cold hands

Dryness of mouth and difficulty swallowing

Palpitation and tachycardia.

Slight to moderate rise in blood pressure and blood sugar

Shallow breathing, hyperventilation and shortness of breath

Parasympathetic phenomena may be seen as frequency of micturation and diarrhoea.

Psychomotor Features:

Worried appearance

Tremors, trembling and feeling shaky

Agitation or retardation

Aggressive outbursts

Somatic fratures:

Sleep disturbances- insomnia, nightmares, waking with cold sweats.

Appetite- mostly decreased but sometimes unusually increased

Epigastric discomfort and abdominal gases.

Exhaustion and tiredness.

Loss of weight (or increase if appetite is unusually increased)

Tension headaches: usually throbbing or stabbing in quality, distributed usually in the parieto-
occipital region or behind the eyes, sometimes band like or like a tight cap over the head.

Pains : whole body or neck due to skeletal muscle spasm.

Hypochondriasis (irrational fear of having physical illness). Patient may be preoccupied with his
own bodily sensations.

DIAGNOSIS:

Physical Conditions:

Medical or neurological illness (if any) manifested mainly by anxiety symptoms

Hyperthyroidism (check for increased sleeping pulse rate)

Temporal lobe epilepsy (may be confirmed by BEG)

Hypoglycaemia (confirmed by Random Blood Sugar)

Hypertension

Pheochromocytoma

Psychiatric Condition
All psychiatric disorders may have anxiety as part of their manifestations.

The primary psychiatric condition will need to be treated. The anxiety will be relieved when the
primary condition improves.

TREATMENT OF ANXIETY DISORDERS:

DRUG TREA TMENT:

Beta Blockers :Propranolol (Inderal® ) 30-80 mg /daily . Does not produce drowsiness and can
help patients with more autonomic manifestations such as tremors, palpitations and sweating.

Low doses of antidepressant. Especially in cases of anxiety mixed with some depression. Tablet
Maprotiline (Ludiomil ®) 25- 50 mg /day.

If not controlled then refer to regional psychiatrists.

PSYCHOTHERAPY;

Listen to the patient and let the patient ventilate his feelings and arrive at the solution of the
problem himself.

Suggest ways in which the patient would be able to manage stress.

Suggest relaxation exercises and meditation to relax the mind and body.
Discuss the patient’s problem with his family or spouse and involve them in the management
and reassuring the patient.

SECTION 10: DEPRESSIVE DISORDER

DEPRESSIVE DISORDER:

The Depressive Disorders are a group of disorders characterized by either a depressed mood or
a loss of interest or pleasure.

CLASSIFICATION OF DEPRESSIVE DISORDERS:

Major Depressive Episode — the criteria for the diagnosis are given below
Dysthymic Disorder — the criteria for the diagnosis are given below:

Bipolar Disorder (Depression) — there would be a past history of at least one Bipolar Disorder —
Manic episode (see Section 11) and a depressive illness in the current episode. The Depression
will be similar to that seen in a Major Depressive Episode. Suicidal ideation may be more severe.

DIAGNOSTIC CRITERIA FOR MAJOR DEPRESSIVE EPISODE:

The diagnosis of a Major Depressive Episode requires a history of a two-week period of five or
more of the following symptoms for most of the day and nearly every day. At least one or both
out of either depressed mood or loss of interest/pleasure should be amongst the minimum of
five or more of the following symptoms that are required to establish the diagnosis of
depression.

Depressed mood — patient feels or looks sad, empty or tearful.

Loss of interests/ pleasure — marked reduction in interest or pleasure in most activities.

Weight changes — a significant increase or decrease in weight or in appetite that is not related
to dieting. Failure to put on weight may be seen in children.

Change in sleep pattern — excessive, reduced or markedly disturbed sleep.

Changed activity levels — restlessness, psychomotor agitation or retardation that is observable

by others.

Feelings of fatigue, exhaustion or loss of energy.

Feelings of worthlessness or excessive or inappropriate guilt (these should be other than those
due to being sick.)

Reduced concentration or diminished ability to think or make decisions.

Recurrent thoughts of death or suicidal ideas with or without a specific plan of suicide or history
of suicide attempts.

Note: The symptoms should not be due to the effect of any medication, substance abuse or
illnesses; they should not be after the loss of a loved one (bereavement) and should cause
clinically significant social, operational, or other impairment.

Presence of only two or three of the above symptoms may suggest the presence of minor-to-
moderate depressionlanxiety. This degree of anxiety and depression will need to be managed
with support and psychotherapy and the patient may or may not need anti-depressant
medication.

CLINICAL FEATURES:

MOOD: Persistently sad mood, feeling empty or detached from family.

SOMATIC SYMPTOMS: Feeling low energy, persistent pain (not of organic origin), sleep and
appetite disturbance, sexual complaints, impaired work performance.

THOUGHTS: Negative thoughts and feelings of worthlessness, shame or guilt, thoughts of death
and suicide may be present.
DIAGNOSTIC CRITERIA FOR DYSTHYMIC DISORDER:

The diagnosis of a Dysthymic disorder requires a history of depressed mood, that is felt or
observed, for most of the day for more than 50% of the days, over a two-year period. (In
children and adolescents the duration must be at least one year.) The individual should never be
asymptomatic for more than 2 months at a time.

To establish the diagnosis of a Dysthymic disorder, while depressed, two or more of the
following should be present:

Poor appetite or overeating

Insomnia or hypersomnia

Low energy or fatigue

Low self-esteem

Poor concentration or difficulty making decisions

Feelings of hopelessness

Note: The patient should not have suffered any episodes of Major Depression or of any other
major psychiatric illness like Schizophrenia or other disorder with delusions. The symptoms
should also not be due to any substance abuse or other general medical condition, e.g.,
hypothyroidism, etc.

MANAGEMENT AND TREATMENT:

Mild to Moderate Depression or Dysthymia:

Discuss the diagnosis and treatment plan (including psychotherapy and medicines) with the
patient and involve the family, if possible, in supervising the regular administration of medicines.

Review patients regularly (initially every week and then every two weeks) and assess progress. If
there is inadequate response to medicines or if there are suicidal ideas or the patient feels he
would be better off dead then the patient should be referred to the psychiatrist.

Psychotherapy: Listen to the patient’s problems. Let the patient ventilate his feelings and guide
the patient towards possible ways to manage the problem. Reassure the patient and remain
considerate, supportive and non-judgmental. Suggest relaxation exercises, meditation and
family support.

Anti-Depressant Medication: Tablets Maprotiline (Ludiomil ®) 25 mg tablets; 2 5—75 mg per day

can be administered as a single dose at night or in two or three divided doses. In mild to
moderate cases it is better to start with 25 mg at night and increase the dose, if needed, upon
review.

The patient may feel lack of energy and poor will power due to the depression. It is advisable
not to force the patient to try to be cheerful since the patient will feel frustrated and worse.

Major Depressive Episode or Dysthymia:

All such cases, particularly those with suicidal risk or ideas, should be referred to the Specialist
for initial management till the patient is stabilized.

Periodic reviews and follow-up after the patient has shown good response can be done at the
Primary Health Care level.

If there is a past history of a Major Depressive Disorder or of Bipolar Affective Disorder (with
past history of a Hypomanic Episode) then there is a higher risk of another episode especially if
the patient has not been taking medicines regularly. Caution should be exercised in such cases
and the case referred to the Specialist.

One should not avoid exploring suicidal ideation but it should be done with sensitivity and in a
reassuring way. First explore how the person feels about life and if the person feels hopeless.
Next ask if the person sometimes wishes he would not wake up or if he would be better off
dead.

The patient should be advised to take regular treatment for at least 6 months after recovery
from depression as there is a high risk of relapse if the treatment is stopped too soon.