Anxiety

Presented with an anxious patient:

A good way of taking a history is using SEDATE:

• Symptoms
  • Physical (increased autonomic response, hyperventilation, sweating, palpitations, loss of sleep/memory/concentration)
  • Psychological (Agitation, irritable)
  • Fear
• Episodic/continuous
• Depression, drinking, drugs (including caffeine and smoking)
• Avoidance/Escape
• Triggers and timing
• Effect on life

To Differentiate between:

• GAD– persisten, no phobic stimulus, must be present for at least 6 months
• PTSD– symptoms >1 month after traumatic incident, at least lasting 1 month
  • Trauma
  • Re-experiencing: flashbacks, nightmares
  • Avoidance
  • Hyperarousal e.g. hypervigilance
  • Blunting of affect
• OCD– unwanted obsessions, compulsions, INSIGHT
  • Compulsion should interfere with life for >1hr /day
  • Takes an average of 9 years from onset to Dx and a further 9 years on average to successfully treat
• Phobias- create fear -> result in avoidance
  • Agoraphobia, simple phobia, social phobia
  • specific stimulus, panic only lasts during that time
  • cannot be reasoned away
• Panic disorder- discrete episodes, extreme, symptoms for >1 month
  • Often described as ‘fear of fear’
  • Avoidance, drug abuse

Good questions:

• Are you troubling by any recurrent worrying thoughts?
• Has something happened to you recently to trigger these thoughts?(PTSD)
• Do these thoughts cause you troubling sleeping?
• Do you have recurrent or unexpected panic attacks?
• Are you worries about a significant change in behaviour duringthese attacks?
• Do you avoid certain activities (e.g. meeting people,eating/speaking in public?)
• Have you had the feeling that things around you were not real(derealisation)?
• Have you yourself felt unreal/ not living in the world?(depersonalisation)

Consider also asking about suicide if appropriate.

 

Mental State Examination

• Appearance
  • May be a bit unorganised/dishevelled
• Behaviour
  • May seem irritable, may be fidgeting
  • Hypervigilance, hyperalert
• Speech
  • May have increased rate of speech, reduced volume
• Mood
  • May be low, may be irritable
• Affect
  • May be blunted (PTSD) or expansive (during a panic attack). 
• Thought process
  • May have a racing thought process (possibly flight of ideas)
  • May have obsessions (OCD)
• Insight
  • Almost always preserved unless associated with psychosis

NB Anxiety as a primary disorder rarely presents with disorders of perception (hallucinations/illusions/delusions).  However, anxiety may present secondary to a psychosis or delirium in which these features may be present.

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