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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