Abstract
Most anxiety is quite good for you. It ‘psychs’ you up, it gets you going on tasks and it is part of your ‘fight or flight’ mechanism. Anxiety that is too severe or too prolonged becomes an illness: morbid anxiety. In the standard classification system (ICD-10), it comes as one of the phobic anxiety disorders, as ‘episodic paroxysmal anxiety’ (i.e. panic disorder), as generalized anxiety disorder and even as mixed anxiety and depressive disorder. These are unclear and diffuse categories, with many overlapping symptoms, and not especially helpful in terms of deciding treatment. In my role as a General Adult Psychiatrist, I do many liaison clinics with different general practitioner (GP) practices, dealing with GP questions and seeing the more complex primary care patients.
The real problem with anxiety is that it is often misdiagnosed. People actually complain of feeling stressed or depressed or of having headaches or palpitations; and search for meaning in terms of a personal life event (arguing with a partner, problems at work); or a potential physical illness which they fear to be serious. Anxiety, as illness, has no defining blood test or X-ray (as yet; research scans can show for example an activated amygdala), so it ends up as that baggage, a diagnosis of exclusion. But the process of exclusion, examinations, investigations, specialist referral and so forth tends to produce negative results. Being told there is nothing wrong or that it might be psychological (all in the mind) makes anxious people more anxious. The vicious cycle of medically unexplained symptoms can readily kick in. For these reasons, it represents a real challenge for the GP.
In terms of facts, the lifetime prevalence of obsessive—compulsive disorder and panic states is about 20%; heritability accounts for about 40% of illnesses and there is more than 80% co-morbidity. Some 20–30% of patients seeing a GP will have psychological issues/symptoms, mainly of the ‘mixed anxiety and depression’ category. It is a mess and, of course, alcohol and drug dependence are common responses to an unpleasant internal state of discomfort. There are social correlates such as unemployment, low income and education, being single and possibly violence in early life. In evolutionary terms, anxiety, as over-alertness, was probably a positive advantage when sabre-toothed tigers were hunting our ancestors.
Anxiety is easy to diagnose if you take a proper history. There are standard questionnaires (e.g. the Hospital Anxiety and Depressive Scale), but essentially the more positive answers you get on symptom enquiry, the more likely anxiety is the core factor. Headaches and dizziness, palpitations and/or difficulty breathing (inhaling rather than exhaling — thus the differentiation with asthma); nausea and ‘dyspepsia’, feeling on edge and tiredness are common symptoms among many.
Each symptom can provoke a formal investigation by an uncertain clinician. But there are usually no signs, so physical examination does not help. Nevertheless, take note of frowning, muscle tension, ready wincing and the sense of worry that pervades the clinical atmosphere. Many anxiety sufferers are very good at transmitting a sense of urgency to their doctor and want something done, quickly. Getting them to hyperventilate and thus panic, is helpfully illuminating.
What to do next? It is tempting to send off for a full blood count, liver function tests, thyroid function tests, electrocardiograms and so forth. Apart from a urine drug screen and asking about their alcohol intake, it is far better given the pattern of symptoms to start off the treatment programme. Unfortunately, fear of missing that unusual organic disorder dominates medical custom; hence the millions of negative investigations carried out by nervous clinicians, covering their backs for that 1 in a 1000 possibility. The damage done by unnecessary investigations and unnecessary treatments, which may continue for years, is sadly forgotten.
The Nice Guidelines are reasonably clear although they try to distinguish too fussily between panic disorder, agoraphobia and generalized anxiety disorder, when most patients hover around all three ‘states’. The need for shared decision making and information is vital but many patients are actively resistant to psychological interventions and will need ongoing support/advice, over several years to accept input. This is certainly best delivered in primary care. Patients should be told that antidepressants are not addictive: The Guideline phrase ‘not associated with tolerance and craving’ is too technical. The restrictions on benzodiazepines are unnecessarily puritan since most patients can use them very sensibly when educated as to their limits. There is no mention of monoamine oxidase inhibitors or pregabalin, which can be very effective for more entrenched conditions.
Most important of all, anxious people require insight. They need advice about lifestyle, methods of self-help, psychological approaches and, possibly, medication. Lifestyle is the usual mantra of avoiding stimulants (e.g. caffeine in the form of tea, coffee, diet cola), taking regular exercise (very good for calming the nerves), possibly keeping a mood diary and regulating alcohol intake. Self-help can include bibliotherapy, a computerized package such as Fearfighter (www.fearfighter.com), local support groups and any alternative therapy (e.g. yoga, aromatherapy, meditation) that simply helps people unwind.
More formal treatments include applied relaxation training, cognitive behaviour therapy, graded exposure (for example to feared things, like needles) or even problem solving. None of these will work of course unless the patient has been educated into their diagnosis (i.e. anxiety or, put rather more nicely, increased ‘sensitivity’) as opposed to thinking they have something seriously wrong with their heart, bowels or head. Some 80% of new neurology outpatients, 50% of new gastroenterology outpatients and 20% of new cardiology outpatients are primarily just worried.
Inevitably, there are some patients who will reject the most detailed explanations and reassurances simply demanding to have a computerized tomography head scan or another blood test. They will decline psychiatric referral and will be fixated on a physical disorder that you, as a useless clinician, have failed to diagnose. They are what specialists, such as liaison psychiatrists and tertiary referral units, are paid to do but the lack of psychological expertise even among many nationally acclaimed centres of excellence, can be frightening. Managing anxiety begins in primary care since the GP is the best placed clinician to grasp the diagnosis, work with it, educate appropriately and detoxify the demanding. You have nothing to fear but fear itself.