1. A NXIETY DISORDERS

2. Anxiety disorders include very specific anxiety such as phobias to generalised anxiety disorder Others include panic disorder, agorophobia (avoidance of places that may result in panic), social phobia, acute stress disorder and substance induced anxiety disorder Extreme anxiety results in physical and emotional exhaustion

3. L EVELS OF ANXIETY Mild anxiety: Motivate someone positively to perform at a high level by focusing on the situation at hand Moderate anxiety: Trouble attending to the surroundings but can follow directions / commands Severe anxiety: Physical symptoms such as sweating, palpitations may develop Panic anxiety: The only concern is to escape. Communication impossible

4. A SSESSMENT OF ANXIETY IN DRUG USERS Is there a temporal relationship between drug use and anxiety? Is there a physical illness that explains the anxiety? When did the anxiety appear first? Is there any evidence of a psychiatric disorder such as generalised anxiety disorder or panic disorder?

5. C AUSES OF ANXIETY Substance withdrawalAlcohol Sedative/hypnotic–benzodiazepines Nicotine ToxicCaffeine Cannabis Hallucinogens Cocaine Theophylline Sympathomimetic drugs Metabolic and EndocrineHypoglycaemia Hyperventilation Hyperthyroidism OthersTemporal lobe epilepsy Angina Pulmonary embolus Parkinson disease Traumatic brain injury Chronic obstructive pulmonary disease

6. C OMMON CAUSES OF ANXIETY Persistent Anxiety Alcohol withdrawal benzodiazepine withdrawal Generalised anxiety disorder Acute anxiety attacks (Panic episodes) Substance-induced panic episodes Panic disorder Hypoglycaemia Hyperventilation

7. C LINICAL FEATURES OF GENERALISED ANXIETY DISORDER Anxiety symptomPresentation WorryExcessive worrying and apprehension Difficulty in controlling worry SleepDifficulty in sleep – initiation or maintenance SomaticPalpitations Trembling Sweating Dizziness Light headaches Muscle tension Discomfort in the abdomen EnergyDecreased (fatigue) ConcentrationDifficulty in concentration Psychomotor activityRestlessness, nervousness EmotionIrritability, tension

8. T REATMENT OF GENERALISED ANXIETY DISORDER Relaxation techniques Supportive psychotherapy (reassurance, explanation, expert advice, suggestions, guidance, support and facilitating emotional support from key people) Pharmacotherapy Selective serotonin reuptake inhibitors (SSRIs) and venlafaxine are the first line of therapy Beta blockers - useful for somatic symptoms Benzodiazepines prescribed only for a short period of time

9. C LINICAL FEATURES OF PANIC DISORDER Panic symptomPresentation Episodic attacks of intense fear Discrete and intense period of anxiety, apprehension and distress SomaticPalpitations Trembling Sweating Dizziness or light-headedness Dyspnoea or choking sensation Chest pain or discomfort Paraesthesia or altered sensations Gastrointestinal upset Chills or hot flushes Thoughts and feelingsFear of becoming insane Fear of dying Content of thoughtDepersonalisation or derealisation AvoidanceUrgent desire to flee (agoraphobia may occur with or without panic and vice versa)

10. D IFFERENCE BETWEEN GENERALISED ANXIETY AND PANIC DISORDERS Generalised anxiety disorder Panic disorder Clinical featuresIrrational worries Motor tension Hypervigilance Somatic symptoms Sudden, unpredictable episodes of severe anxiety Shortness of breath Fear of suffocation and dying Urgent desire to flee First line treatmentSSRIs Venlafaxine SSRIs Acute managementShort term treatment with benzodiazepines

11. T REATMENT FOR PANIC DISORDER Antidepressants: SSRIs are the first-line drug treatment Other drugs: Mirtazapine, venlafaxine, sodium valproate, imipramine and clomipramine Benzodiazepines: The target dose of clonazepam for panic disorder is 1 mg per day; doses up to 4 mg per day may be required

12. P ATIENT / FAMILY EDUCATION Families must understand about levels of anxiety and the need for early diagnosis and treatment Family therapy may be needed to agree on living arrangements that respects the needs of clients and family members Ongoing treatment with psychological therapies and /or medication may be necessary Patience, persistence and multimodal approach is required for several patients

13. C ONCLUSION Anxiety disorders are common Many of the symptoms of anxiety are physical symptoms Anxiety can be treated effectively with SSRIs, relaxation and supportive psychotherapy Caution should be exercised in prescribing benzodiazepines for anxiety