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Dr Tanvir Jamil discusses causes and management

Dr Tanvir Jamil discusses causes and management

Case History

Fiona, a 32-year-old secretary, has been seeing one of your partners for stress. She has had problems for years but managed to cope so far.

She has been trying some relaxation tapes at home but they have not helped. Fiona presents with worse symptoms after an argument at work – feelings of panic, palpitations and tingling in her hands. She asks for something to help keep her calm.

What is the difference between stress and anxiety?

Anxiety is bad stress. We all suffer from a degree of stress almost on a daily basis. It helps motivate us and helps improve our performance and self-esteem. But increasing stress can only improve performance so much. Greater levels will eventually become detrimental to our health – both physical and psychological. That is when you start calling it anxiety.

The problem is that anxiety has many negative connotations – stress on the other hand is acceptable. So the terms are often used synonymously. We might ask a patient: 'Do you think this problem may be caused by stress?' Once they consider this we can bring into the consultation the relationship between stress and anxiety.

What are the main symptoms of anxiety?

  • Impending doom
  • Tension and agitation
  • Excessive worrying
  • Poor concentration
  • Difficulty getting to sleep
  • Poor appetite (occasionally greater appetite)
  • Autonomic symptoms such as palpitations, diarrhoea, sweating, tremor, urinary frequency, dry mouth

What is the differential diagnosis?

It is always worth doing thyroid function tests to exclude hyperthyroidism. The presence of lots of autonomic symptoms might make you consider respiratory, cardiovascular and neurological problems. Phaeochromocytoma is rare but can cause identical symptoms to acute anxiety. Alcohol and benzodiazepine withdrawal can also cause similar symptoms as can too much alcohol and other stimulants such as caffeine or drugs.

Fiona is typical of a patient who presents with acute anxiety – she is already known to her doctor.

What is the best way to manage this acute phase?

One of the most important treatments is the doctor. An air of calm composure while examining the patient is essential and reassuring. There is certainly a place for short-term use of tranquillisers, eg diazepam or chlordiazepoxide. Make it clear that these are for short-term use only (seven to 10 days) and are to alleviate the main symptoms of her anxiety, not treat the cause. ß-blockers (eg propranolol 10 to 40mg up to tds) are also useful for autonomic symptoms such as palpitations, sweating and tremor.

Some patients find it useful to take sleeping tablets (eg zopliclone 3.75 to 7.5mg nocte) for about a week to re-establish a sleep pattern. Many patients suffer from depression that presents with anxiety. Antidepressants will relieve anxiety symptoms once the depression starts to lift. Try SSRIs such as citalopram 10 to 20mg or sertraline 50- 100mg once daily. The tricyclic antidepressant imipramine (75 to 200mg od) was traditionally used in the treatment of anxiety but its side-effects and the arrival of SSRIs has seen its use significantly reduced. Amitriptylline in low dose (10-20mg nocte) is useful in lifting anxiety and helping sleep disturbance. It is also relatively safe long-term.

How can we help her chronic anxiety?

Many patients will need a dual approach with long-term antidepressants (SSRI) and a 'talking therapy'. Evidence indicates that almost 50 per cent of patients with anxiety disorders regain a normal level of functioning after psychological therapies.

Can you tell me more about counselling?

Many practices employ a practitioner on the premises. Some community psychiatric nurses are also trained in counselling. Counselling involves assisting awareness of how familiar attitudes, prejudices and ways of responding might influence emotional, mental, physical and spiritual well-being.

The recommended course of treatment is six sessions but some patients may need more. The occasional problems with counselling occur when the patient becomes dependent on the therapist and has trouble weaning herself off them.

What about behavioural therapy?

This type of psychotherapy emphasises the current conditions that maintain a behaviour and keep it going. It focuses on the problem, not on the person.

Graduated-exposure therapy is particularly useful for patients with chronic anxiety. It is a form of desensitisation that is done gradually. So a woman with agoraphobia might first imagine she is in a crowd, then look outside the window, then walk out of the front door, then down the street, then to a shop and finally to a large shopping mall. There is a gradual move to the eventual goal of going outside regularly and inter-acting normally with large numbers of people but not until there has been a lot of preparation.

I've heard that cognitive behaviour therapy (CBT) works well also.

CBT is popular and is, unfortunately, not easily available on the NHS. It emphasises the power of 'stinking thinking' – anxious people have anxious thoughts that prolong their symptoms. This faulty thinking originates in maladaptive assumptions and attitudes acquired in early life. When a critical life event challenges these thought processes patients may develop irrationally negative thought patterns.

During therapy these conclusions are analysed and examined by logical refutation, questioning, challenging and testing. So CBT attempts to make the patient a better thinker and break the habit of poor information processing.

Tanvir Jamil is a GP trainer in Burnham, Buckinghamshire

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