Anxiety Spectrum Disorders
Introduction
Anxiety is an emotional state that is part of the general condition. It can be useful in focusing attention during times of perceived threats (internal or external), stimulating appropriate and adaptive responses and ultimately improving function. If the anxiety becomes prolonged, excessive or out of proportion to the stimulus, it can become maladaptive and impair function.
Anxiety disorders can occur in isolation, be co-morbid with other psychiatric disorders (particularly depression), be a consequence of physical illness such as thyrotoxicosis or be drug-induced (e.g. by caffeine). Co-morbidity with other psychiatric disorders is very common.
These disorders tend to be chronic, and treatment is often partially successful. People with anxiety disorders may be especially prone to adverse effects. High initial doses of SSRIs in particular may be poorly tolerated, for example.
Psychological Approaches
There is good evidence to support the efficacy of psychological interventions in anxiety spectrum disorders. Examples include exposure therapy in OCD and social phobia. Initial drug therapy may be required to help the patient become more receptive to psychological input, although evidence to support this assumption is slim. Some studies suggest that optimal outcome is achieved by combining psychological and drug therapies, but negative studies also exist.
It is recognised that for many patients, psychological therapies are the appropriate first-line treatment, and indeed this is supported by NICE.
Benzodiazepines
Benzodiazepines provide rapid symptomatic relief from acute anxiety states. All guidelines and consensus statements recommend that this group of drugs should be used only to treat anxiety that is severe, disabling, or subjecting the individual to extreme distress. Because of their potential to cause physical dependence and withdrawal symptoms, these drugs should be used at the lowest effective dose for the shortest period of time (maximum 4 weeks), while longer-term treatment strategies are put in place and with caution in patients with substance misuse. For the majority of patients these recommendations are sensible and should be followed. A very small number of patients with severely disabling anxiety may benefit from long-term treatment with a benzodiazepine, and these patients should not be denied treatment.
NICE recommends that benzodiazepines should not be used to treat panic disorder.
SSRIs
When treating generalised anxiety disorder (GAD), panic disorder, post -traumatic stress disorder (PTSD), obsessive compulsive disorder (OCD), an SSRI should be used as first-line treatment.
SSRIs should not be stopped abruptly, as patients with anxiety spectrum disorders are particularly sensitive to discontinuation symptoms. The dose should be reduced as slowly as tolerated over several months.
The Maudsley Prescribing Guidelines in Psychiatry, 2021
Generalised anxiety disorder
Panic disorder
Post-traumatic stress disorder
Obsessive compulsive disorder
Social phobia (Social anxiety disorder)
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