Clinical Practice Guidelines for the Management of Generalised Anxiety Disorder (GAD) and Panic Disorder (PD).

Abstract

Short description of anxiety disorders Generalized Anxiety Disorder (GAD) Definition: One of the anxiety disorders, where the primary symptoms of anxiety are present at most days for at least several weeks at a time, and usually for several months. The symptoms should usually involve elements of: (a) Apprehension (worries about future misfortunes, feeling “ on edge”, etc) (b) Motor tension (restlessness, inability to relax, trembling) (c) Autonomic over activity (light-headedness, sweating, tachycardia, tachypnea, dry mouth etc) The transient appearance of depressive symptoms, does not rule out the diagnosis of GAD as main diagnosis. The sufferer must not meet the full criteria for depressive episode, phobic disorder, panic disorder or OCD. Patients with generalised anxiety disorder have high anxiety and are worried about intrapsychic conflicts or external environmental events. They have multiple somatic symptoms of anxiety, restlessness, difficulty in concentration, irritability, fatigue, muscular tensions and difficulty in sleeping particularly early insomnia. They have vague apprehension about future events and fear of unknown. Common features observed in anxiety disorders include: Panic Disorder- Episodes of intense fear or discomfort accompanied by severe autonomic activity, palpitations, sweating, dyspnoea, chocking sensation or other somatic symptoms like chest pain, trembling, nausea, discomfort or fluttering sensation in abdomen and impending fear of death. Patient perceives it as a serious medical condition and invariably reaches to a medical emergency setup where after thorough physical evaluation he is declared normal. Phobias- Many patients with GAD suffer from irrational, unrealistic fears and acute autonomic reactions to certain specific situations or extreme fear to certan inanimate objects. They include agarophobia (fear of open spaces) fear of crowds, being out side home alone or traveling in a bus train or car. Some may have fear in closed spaces (claustrophobia) fear of heights (acrophobia) fear of opposite sex (hetero-phobia) fear of sight of blood (erythrophobia) or fear of facing certain social situations (social anxiety disorder) the common feature among all phobias being intense fear, increased autonomic activity and avoidance behavior (avoiding the fearful object or situation). Obsessive compulsive disorder- (OCD) has been seperately dealt with in details in these guidelines however the patients suffering from OCD have recurrent repetitive unwanted intrinsic thoughts (obsessions) or actions (compulsions) or both which lead to extreme distress, loss of time and impairment of functioning of the individual. The obsessious include douts, ideas of contamination, sexual thoughts or religious preoccupations or negative thoughts towards gods/goddess, the compulsions include activities like counting, checking, repeating, washing hoarding and touching objects, some have to and fro movements of body parts. Patient is aware of the irrationality of thoughts/actions but cannot control them, which produces intense anxiety and autonomic arousal with feelings of helplessness and guilt. Post-traumatic stress disorder (PTSD) - Usually it occurs after a terrifying event that involving physical or psychological traumatic event. It may also occure because of witnessing or experiencing a serious harm to other significant persons in life. Patients have terrifying recollections of the event, or nightmares. Some patients have an experience of living the event in an illusionary or imaginary situation with hallucinations, or flashback episodes. The patients suffer from intense psychological or physical distress. Many patients develop loss of interest, estrangement from others, sleep disturbances, irritability, difficulty concentrating, hypervigilance, and exaggerated startle response. This phenomenon may persist for one month or more before it is diagnosed.