Anxiety Disorders

Anxiety disorders are a group of psychiatric conditions characterised by excessive, persistent fear or anxiety with associated behavioural disturbance, causing clinically significant distress or functional impairment. They are among the commonest mental health conditions in clinical practice.

They are frequently underdiagnosed and undertreated. Affected individuals often present with predominantly physical symptoms, or attribute their symptoms to a personality trait rather than a treatable psychiatric condition. Active, direct enquiry and screening are warranted in appropriate clinical contexts.

The group includes:

• Generalised anxiety disorder: persistent, excessive worry across multiple domains of life
• Panic disorder: recurrent, unexpected panic attacks with persistent concern about further attacks or their consequences
• Specific phobia
• Social anxiety disorder
• Agoraphobia
• Separation anxiety disorder

Classification and pathophysiology

• Generalised anxiety disorder is persistent, excessive, difficult to control worry across multiple life domains, present for a minimum of six months. Associated physical symptoms include muscle tension, restlessness, fatigue, irritability, sleep disturbance and impaired concentration. It is the most common specific anxiety disorder subtype in general clinical practice.
• Panic disorder is recurrent, unexpected panic attacks: discrete episodes of intense fear or discomfort peaking within minutes. Symptoms include palpitations, sweating, trembling, dyspnoea, chest discomfort, and a sense of impending doom or loss of control. There is persistent concern about further attacks or significant behavioural change related to the attacks.
• Panic attacks frequently, though not exclusively, mimic acute cardiac or other significant medical presentations. Medical exclusion of relevant organic causes is therefore an essential component of assessment.
• The underlying pathophysiology across the spectrum is a complex interplay of genetic predisposition, neurobiological factors, and psychosocial and learning based factors. Neurobiological factors include dysregulation of neural circuitry involving the amygdala and related fear processing pathways, and of neurotransmitter systems including serotonin, noradrenaline and gamma-aminobutyric acid. The relative contribution varies between individuals and between subtypes.

• Generalised anxiety disorder presents with persistent, excessive worry that is difficult to control, with associated physical and cognitive symptoms. Significant somatic symptoms are frequent (including gastrointestinal disturbance, headache, and muscle tension) and may lead to presentation to general medical rather than mental health services.
• Generalised anxiety disorder is frequently under-recognised. Patients and clinicians tend to attribute the presentation to "just worry" or a personality trait rather than a specific, treatable psychiatric condition.
• Panic attacks present acutely, with rapid onset of intense physical and psychological symptoms. They frequently prompt emergency medical presentation, given understandable concern about a potential acute cardiac or other serious medical event.
• Panic disorder is characterised by recurrent attacks, persistent anticipatory anxiety and, frequently, significant avoidance behaviour developing in response.
• Agoraphobia frequently, though not invariably, occurs with panic disorder. It is marked fear or anxiety about situations from which escape might be difficult or help unavailable in the event of panic like symptoms (including public transport, open or enclosed spaces, crowds, or being outside the home alone). The resulting avoidance can become substantially functionally limiting in more severe presentations.
• Social anxiety disorder presents with marked, persistent fear of social or performance situations involving potential scrutiny by others, with associated fear of negative evaluation.
• Specific phobia presents with marked, persistent fear of a specific object or situation (common examples include specific animals, heights, or medical procedures including injections or blood).
• Both social anxiety disorder and specific phobia produce significant avoidance behaviour and functional impairment where the feared situation or stimulus cannot be entirely avoided in daily life.

• Diagnosis is established through full clinical psychiatric assessment against the established diagnostic criteria for the specific anxiety disorder subtype. Validated screening tools (including the Generalised Anxiety Disorder 7-item scale and other similar instruments) support structured initial screening and ongoing monitoring of treatment response.
• Careful medical assessment must exclude organic causes that can mimic or contribute to anxiety symptoms. This is particularly important given the significant symptomatic overlap between panic attacks and several genuine acute medical emergencies. Causes include:
• Hyperthyroidism
• Cardiac arrhythmia (particularly relevant given the frequent presentation of panic attacks with prominent cardiac symptoms)
• Certain substances, including excessive caffeine intake, and both acute intoxication and withdrawal from various substances including alcohol and stimulants
• Screen for coexisting psychiatric conditions, particularly depressive disorders, which frequently and substantially coexist with anxiety disorders. Screen also for coexisting substance use, which bears directly on treatment planning.
• Take a full history of the pattern, triggers, and functional impact of the anxiety symptoms, and explore any avoidance behaviour that has developed. This supports accurate subtype classification and targeted treatment planning.

• Cognitive behavioural therapy is the first line, most strongly evidence supported psychological treatment across the anxiety disorder spectrum. Tailored protocols address the features of each subtype. For panic disorder, interoceptive exposure techniques address the characteristic fear of the physical sensations themselves. For specific phobia and agoraphobia, graded exposure approaches address the feared situation or stimulus directly.
• Selective serotonin reuptake inhibitor antidepressants are first line pharmacological treatment across the spectrum. Serotonin-noradrenaline reuptake inhibitors are an effective alternative. Continue treatment typically for a minimum of six to twelve months after adequate symptomatic response, given the substantial relapse risk with premature discontinuation.
• Benzodiazepines are effective for rapid, short term symptomatic relief of acute anxiety. Generally avoid them for longer term management, because of the substantial risk of tolerance and dependency with sustained use.
• Limit benzodiazepines to short term, time limited use during initial titration of a standard antidepressant (given its delayed onset of therapeutic benefit), or to infrequent, acute situational anxiety, such as a specific phobia related to a discrete situation such as flying. They are not a standard, ongoing treatment for chronic anxiety disorders.
• Pregabalin is an additional, effective pharmacological option specifically for generalised anxiety disorder. It offers an alternative mechanism of action to the standard antidepressant classes. Consider its own adverse effect profile and, in some contexts, its misuse potential.
• Beta blockade may give useful adjunctive relief for prominent physical, autonomic symptoms of anxiety (particularly palpitations and tremor). It is particularly relevant for discrete situational anxiety such as performance related social anxiety.
• Beta blockade does not address the underlying psychological components. Use it as a targeted adjunct rather than a primary, standalone treatment.
• Effective long term management is full, structured and ongoing. It includes regular monitoring of treatment response and functional improvement, and psychoeducation about the condition and its generally favourable prognosis with evidence based treatment. These conditions are common and frequently significantly impairing, but generally highly treatable.