1. Anxiety- symptoms and management

2. What are palpations? Palpitations are an unpleasant awareness of the beating of the heart It does not always imply ‘racing’ of the heart (tachycardia) can be described as ‘pounding’, ‘flopping’, ‘skipping’, ‘jumping’, ‘thumping’ or ‘fluttering’ Concerning to the patient as heartbeat is regarded as synonymous with life may simply represent anxiety or it could be a prelude to a cardiac arrest

3. Probability Diagnosis for Palpitations Probability diagnosis Anxiety Premature beats (ectopics) Sinus tachycardia Drugs (e.g. stimulants)

4. What is Anxiety? Anxiety is an uncomfortable inner feeling of fear or imminent disaster. Anxiety is a normal human emotion and most of us experience some temporary degree of anxiety in our lives as a normal reaction to stress and misfortune. However, some people are constantly anxious to the extent that it is abnormal and interferes with their lives. Anxiety disorder, affect 5 - 10% of the population Diagnostic criteria from the DSM-IV for GAD – excessive anxiety and worry about a number of events or activities – occurring more days than not for at least six months – that are out of proportion to the likelihood or impact of feared events

5. Anxiety disorders recognised by the DMS include: Generalised Anxiety Disorders anxiety disorder due to a medical condition panic attack panic disorder, with or without agoraphobia agorophobia without history of panic disorder specific phobia social phobia obsessive compulsive disorder post-traumatic stress disorder acute stress disorder

6. Symptoms of Anxiety Neurological dizziness, headache, trembling, twitching, shaking, paraesthesia Cardiovascular palpitations, tachycardia, flushing, chest discomfort Gastrointestinal nausea, indigestion, diarrhoea, abdominal distress Respiratory hyperventilation, breathing difficulty, air hunger Cognitive fear of dying, difficulty concentrating, ‘mind going blank’, hypervigilance psychological and physical symptom Vary enormously from tiredness to panic attacks somatic symptoms, including fatigue, muscle tension, memory loss, and insomnia Sufferers often have little insight into the connection between reported worries, current life stress, and their physical symptoms

7. Diagnosis of Anxiety The diagnosis is based on: the history – listen to what the patient is saying, the initial interview should be open-ended and unhurried; family members should be involved when appropriate – Medical history should focus on possible contributions of current medical conditions, medication side effects, or substance abuse – The psychosocial history should screen for other psychiatric disorders particularly depression and agoraphobia, stressful life events, family hx of mental illness, current social history, substance abuse history, and past sexual, physical and emotional abuse Conduct a complete physical examination Investigations to exclude organic disorders – FBC – TSH – Urinalysis – ECG in patients >40 with palpitations – Urine or serum toxicology if medication or drugs suspected

8. These are all the things you need to have ruled out by the history, examination and investigation…….. Psychiatric disorders Depression Drug and alcohol dependence/withdrawal Benzodiazepine dependence/withdrawal Schizophrenia Acute or chronic organic brain disorder Presenile dementia Organic disorders Drug-related - amphetamines - bronchodilators - caffeine excess - ephedrine - levodopa - thyroxine Cardiovascular - angina - cardiac arrhythmias - mitral valve prolapse Endocrine - hyperthyroidism - phaeochromocytoma - carcinoid syndrome - hypoglycaemia - insulinoma Neurological - epilepsy, especially complex partial seizures - acute brain syndrome Respiratory - asthma - acute respiratory distress - pulmonary embolism Murtaghs- ‘Significant differential diagnoses of Anxiety’ Main differentials underlined

9. Management of anxiety- Self help Look at factors in your lifestyle that cause stress and anxiety and modify or remove them eg. changing jobs and keeping away from people or situations that cause anxiety Avoid aggravating substances such as caffeine, nicotine and other drugs. Employ stress management techniques, relaxation programs and regular exercise etc. Develop coping skills, including personal and interpersonal strategies, to manage difficult circumstances and people

10. Management of anxiety Much of the management can be carried out successfully by the family doctor using brief counselling and support. – Even providing handout material in less severe cases can be invaluable – Suggest relaxation or exercise programs in your local area Give careful explanation and reassurance – explain the reasons for the symptoms – reassure the patient about the absence of organic disease (can only be based on a thorough examination and appropriate investigations) Cognitive Behavioural Therapy, in which maladaptive thinking, feelings, perceptions and related behaviours are identified, assessed, challenged and modified, can be of considerable benefit. Specific psychotherapy is required other types of anxiety. The aim is to use non-pharmacological methods and avoid the use of drugs if possible.

11. Pharmacological treatment Only as a last resort Should only be used when anxiety is severe, cannot be controlled by other methods, and is interfering with life. Five Classes of Medications – SSRI- selective Serotonin Receptor Inhibitors, are first line treatment! – SNRI- selective serotonin and noradrenaline receptor inhibitors – Monoamine Oxidase inhibitors- side effects, diet and drug interactions – Tricyclic antidepressants- more side effects – Benzodiazepines: potential for abuse problems In patients with sympathetic activation, can consider beta-blockers to relieve palpitations, sweating etc. Herbal? : valerian is mild sedative All have possible side effects May need to taper up and down to minimise side effects Be aware of drug seekers

12. References Murtagh’s Up to Date