Anxiety Attacks

How individuals respond to stresses in their environment varies enormously. Some people never seem to worry about anything, some people worry about everything, and most people are somewhere in between.

          Only when normal concern becomes overwhelming and troublesome do people seek medical attention for it. The language used is important. 'Anxiety' has a clear medical meaning — curiously people seem happier describing themselves as 'suffering from anxiety than being described as 'anxious'. 'Worry' suggests an exaggerated and unreasonable response to circumstances, a mental weakness, whereas 'concern' is a more legitimate reaction. 'Stress' refers to the things in the environment that cause anxiety. 'Suffering from stress' is associated with a high-powered lifestyle and is almost a desirable illness to have.

The ability to withstand stress can vary in the same person on different occasions. The effects of stress are cumulative, so that an extra, seemingly minor, worry may tip the balance into illness. It is the perception of stress that is important.
DEFINITIONS AND PREVALENCE

A number of anxiety disorders have been defined, of which the most common is generalised anxiety disorder (GAD). This is probably a group of conditions rather than a single entity, all accompanied by mild depression. GAD is defined as excessive worry and tension about everyday events and problems, on most days, for at least 6 months, to the point where the person experiences distress or has marked difficulty in performing day-to-day tasks. The point prevalence of GAD is 1.5-3% in adults, with 3-5% having had GAD in the previous year, and 4-7% having had GAD at some time in their life.¹ Around one in four patients with GAD will have consulted their GP.

Acute episodes or worsenings of anxiety are termed 'panic', and these can be a feature of all anxiety disorders. A panic attack is a period in which there is a sudden onset of intense apprehension, fearfulness or terror, often associated with feelings of impending doom. In addition, a 'panic disorder' has been defined where episodes occur without a background of anxiety or other mental disorder. Panic disorder occurs when there are recurrent, unpredictable attacks followed by at least 1 month of persistent concern about having another attack, worry about the possible implications or consequences of the panic attacks, or significant behavioural changes related to the attacks.

The term panic disorder excludes panic attacks attributable to the direct physiological effects of a general medical condition, substance, or another mental disorder.

The lifetime chance of developing panic disorder is between 1% and 3%, and it is more common in women. Half of sufferers will consult their GP.

Definitions of GAD and panic disorder facilitate research and assist clinicians, but cases seen in primary care may not completely match the definitions.

PRESENTATION

In GAD there will be anxiety symptoms which often have been present for some months or even years. The patient will usually be aware that their symptoms are due to anxiety, and will have made attempts to rationalise the problem by reference to life stresses. There appears to be a progressive increase in the number of things that people find stressful.

The symptoms of a panic attack are the same as for anxiety, the difference being that they are very severe and come on suddenly. A first episode of panic is invariably alarming, and may prompt attendance at an A&E department rather than a trip to see a GP. This is particularly likely if autonomic symptoms predominate.

DIAGNOSIS

Where typical anxiety symptoms are present, you should have little difficulty making a diagnosis. Episodes of panic may be accompanied by symptoms such as dyspnoea, dizziness, palpitations, tingling and chest pain.² These symptoms may be misinterpreted as being serious and possibly life-threatening. In patients suffering panic, it may be difficult to obtain a full history as opposed to an alarmed description of frightening physical symptoms.

GAD should be present for 6 months before a formal diagnosis is made. Many patients present with a much longer history than this, but a few attend at the first sign of problems. Below contains series of standard questions to establish a diagnosis of anxiety. A description of the symptoms will give a good idea about the diagnosis, and will usually reveal whether or not there are phobic, obsessional or panic elements to the anxiety.

People with anxiety are also more prone to bouts of depression. Anxiety and depression commonly coexist.

It is necessary to spend sufficient time at the first consultation to establish the diagnosis, and to lay the foundations of a management plan. Most patients with anxiety do not consult a doctor at all, and so it could be supposed (but it is not proven) that those who do present have more debilitating symptoms. Many will have had their problem for a number of years.

You should ask about consumption of drugs, caffeine and alcohol. A thyroid function test is usually a good idea. Any other tests and investigations should only be ordered if there is a good chance of a helpful result. Since many anxious patients are already worried about their physical health, the fact that you are ordering tests can cause further worry.

It is useful to find out what is on the patient's agenda. Many will suspect that their symptoms result from anxiety, but at the same time do not want a physical diagnosis to be missed. To most people, pain suggests some tissue damage. It is important for patients to understand that emotional illness can cause physical symptoms without physical damage. Specific concerns should be discussed.

Medication is of limited use in treating anxiety disorders, and where it is useful there may be several weeks' delay before improvement is seen.

The prognosis of chronic anxiety is not very good. A small study from general practice of nonpsychotic psychiatric illness (mainly anxiety and depression) followed up over 11 years found that:

    * sufferers are twice as likely to die;
    * sufferers consult around 10 times a year;
    * 50% have physical or mental illness;
    * most are treated only with medication.

MANAGEMENT OF ANXIETY

One of the first aims will be to exclude physical disease. You should then explain the basis of the symptoms. A discussion of the role of adrenaline and the 'fight or flight' reflex is usually helpful. For hyperventilation, a discussion of the physiological effects of over-breathing may help. For some, a leaflet will prove useful. Many people who are anxious want someone they can 'lean on' psychologically. This may be one of the few appropriate uses of medical authority.

Pharmacological therapy

Buspirone (Buspar) has proven effectiveness in GAD at least in the short term (9 weeks). Some (but not all) antidepressants are effective — imipramine (Tofranil), paroxetine (Seroxat), trazadone (Molipaxin), venlafaxine (Efexor): they have roughly equal efficacy after 8 weeks' use.

Cognitive therapy dernonstrably improves the symptoms of GAD over 12 weeks (Box 3). Such 'talking treatment' may be more acceptable than the use of drugs. However, anyone undertaking cognitive therapy must:

    * believe that the treatment is worth trying;
    * be aware of what the treatment involves;
    * take appropriate responsibility for the illness;
    * be prepared to invest sufficient time and effort;
    * be aware that treatment may uncover things that have been deliberately forgotten;
    * sometimes be prepared to work in a group.

About half of those with anxiety disorders will regain a normal level of functioning after psychological treatment. The less severely affected do betters.

MANAGEMENT OF PANIC

A panic attack may occur out of the blue, or against a background of ongoing anxiety. The sufferer will be restless, agitated and wide-eyed.

Hyperventilation may occur. Over-breathing reduces blood levels of carbon dioxide, causing alkalosis. This causes spontaneous discharge of the peripheral nerves, resulting in tetany and paraesthesiae in the motor and sensory nerves respectively. The tetany leads to breathlessness and a crushing chest pain, and the sensory involvement causes the 'pins and needles' sensation.

Apart from the agitation and the sense of urgency that the patient imparts and possibly tachycardia there is little else to find on clinical examination. In a calm and unhurried manner, check the patient's pulse and listen to their heart and lungs. In the breathless, a peak flow reading is helpful.

An attack of panic or hyperventilation is physiologically very demanding and cannot be sustained for more than a few minutes. Treatments for the acute episode are therefore of limited use as even an intravenous injection of a tranquilliser will take several minutes to work. The air of cairn and confidence imparted by the GP is probably the most effective remedy.

Benzodiazepines are useful in acute anxiety, work quickly, have few somatic side-effects, and are relatively safe in overdosage. Diazepam 5-10 mg three times a day for 2-3 days is about right, although it is best to use the smallest effective dose.

Specific techniques can be taught to patients who experience repeated episodes of acute panic. Breathing into and out of a paper bag restores the blood levels of carbon dioxide and so reduces the symptoms of panic. Control of the breathing pattern to reduce overbreathing can also help, although controlled trials of respiration techniques have yielded disappointing results. A brief expenditure of physical energy can also be of benefit, probably employing the effects of distraction and endorphin release.

Another distraction technique is to encourage the patient to stand on one leg — the concentration on balance provides the distraction.

The re-attribution approach encourages patients to deliberately overbreath so that they can realise for themselves that overbreathing produces symptoms.

When the attack has passed, a more detailed diagnosis can be established. Since treatment will tend to be prolonged, and will require insight and co-operation by the patient, this may safely be left to an early follow-up appointment.

Where a diagnosis of panic disorder is made, SSRIs and the TCA imipramine are beneficial. The hazards of long term benzodiazepine use probably outweigh the benefits. Cognitive therapy helps.

NEW GMS CONTRACT

The management of anxiety is not included in either the Clinical Quality Indicators, or on the list of Enhanced Services in the new GMS contract. Accordingly it is likely that cognitive therapy — the best overall treatment for anxiety disorders — will remain the province of secondary care. Delays in securing cognitive therapy make it inevitable that drugs remain the only treatment option readily available.

"About half of those with anxiety disorders will regain a normal level of functioning after psychological treatment. The less severely affected do better"
ideas for audit anxiety

Review patients referred to the local psychiatric services in the last year ...

What proportion were referred because of anxiety? What treatments were recommended? What was the GP consultation rate before and after referral?

Identify a cohort of patients on repeat antidepressant medication ...

What proportion had primarily anxiety symptoms? How many have improved on treatment? Has any treatment other than medication been offered?

"The term panic disorder excludes panic attacks attributable to the direct physiological effects of a general medical condition, substance, or another mental disorder"
practical points

    * Anxiety and panic are very common. Most cases do not come to medical attention.
    * A panic attack can be very alarming, and may prompt attendance at an A&E department.
    * A panic attack may occur out of the blue, or against a background of ongoing anxiety.
    * Medication, especially some antidepressants, is of proven benefit in GAD and panic disorder, but is not acceptable to all patients.
    * Buspirone (Buspar) has proven effectiveness in GAD at least in the short term.
    * Talking treatments', and especially cognitive behavioural therapy, are the treatments of choice in anxiety disorders but they do not suit all patients.

Symptoms of anxiety
* inner tension
* A feeling of impending doom
* Worrying about trivial issues
* Difficulty falling asleep
* Loss of appetite — however, some sufferers eat more
* Difficulty concentrating due to distractibility
* Agitation
* Autonomic symptoms:
- palpitations
- sweating
- dyspepsia or diarrhoea
- urinary frequency or urgency
- dry mouth
- blurred vision
- tremor

Questionnaire to diagnose anxiety
SCORE ONE FOR EACH 'YES':
1 Have you felt keyed up, on edge?
2 Have you been worrying a lot?
3 Have you been irritable?
4 Have you had difficulty relaxing?
If 'yes' to three or more questions, go on to:
5 Have you been sleeping poorly?
6 Have you had headaches or neck ache?
7 Have you had any of the following: trembling, tingling, dizzy
spells, sweating, urinary frequency, diarrhoea?
8 Have you been worried about your health?
9 Have you had difficulty falling asleep?
A total score of 6 or more predicts a 50% chance of a clinically
important anxiety disorder.

Treatment of panic disorder
* 87% of patients improve after 15 weekly sessions of cognitive
therapy
* 50% improve on benzodiazepine
* 36% improve on placebo

Specialist referral
PATIENTS SHOULD BE REFERRED TO A SPECIALIST WHERE THERE ARE:
* severe symptoms
* complicating psychological, social or physical problems
* possible underlying physical cause
* no response to treatment
* treatment needed that is not available in the community