FAQ For Anxiety Disorders
Who is this FAQ meant for?
This FAQ targets General Practitioners. It is not meant for the layperson. It is a simple FAQ and it is not meant to be a comprehensive chapter on anxiety disorders. It cannot replace drug information, medical journals or guidelines on anxiety disorders. Medical information provided here has to be combined with the clinical judgement of the doctor and considered in the unique context of the patient.
Are anxiety disorders common?
Yes they are. In the Singapore Mental Health study, the prevalence of Generalised Anxiety Disorder (GAD) is 1.6% in 2016. The other commonly encountered anxiety disorders in adults include:
- Panic disorder
- Social phobia
- Simple phobia
- Anxiety disorder due to another medical condition (e.g. hyperthyroidism)
In anxiety disorders and phobias, you will notice that the fear is out of proportion to the actual danger and there is avoidance behaviour.
What is GAD?
GAD is a condition in which the person worries excessively and finds it hard to stop. It would have occurred for > 6 months and there will be >3/6 of these associated symptoms (sleep problems, tiredness, irritability, restlessness, muscle tension and difficulty concentrating).
Tip! For other conditions, try googling "panic disorder", "DSM 5" then click "Images" for the DSM-5 criteria.
What is the difference between Social Anxiety Disorder and Agoraphobia?
Social anxiety disorder (as it is called in DSM-5) is anxiety during social situations where the person is afraid of being scrutinised and then getting a negative evaluation from others. An example is excessive fear during school or company presentations resulting in significant impairment.
Agoraphobia is fear in situations such as taking public transport; going out of the house; crowded spaces; enclosed spaces or open spaces. The commonality in all these situations is that the person perceives escape to be difficult eg, when they get a panic episode. They develop safety behaviours, such as getting others to accompany them. These safety behaviours help them to cope in the short-term, but reinforce and perpetuate the disorder in the long term.
(Interesting fact: Do you know that in Ancient Greek, "Agora" means the city centre or marketplace?)
What are the risk factors?
A stressor could have triggered the symptoms or the help-seeking behaviour (e.g. work, family, financial, health problems).
It may be difficult to take a comprehensive background history (which can take 1 hour) in your setting. But screen for risk factors like:
-Anxiety disorders in parents or siblings (family history)
-Challenging childhood eg. early parental divorce, abuse or neglect, severe bullying in school
-Pre-existing anxious personality
-Lower socioeconomic status
How does anxiety present?
Anxious patients will talk in a hurried way; ask a lot of questions and repeatedly seek reassurance. They may take down notes as you talk as they are afraid of forgetting what you have said. They may appear to be hesitant and indecisive.
On the other hand, depressed patients may have furrowed brows, poor eye contact and motor slowness. They report a low mood and may be tearful.
Is there a more objective way to quantify anxiety?
Try using the GAD-7 screening form. Patients can fill it up themselves or you can do it for them. A copy of the result will be mailed to you after you type in your email address. In general, higher scores reflect more severe anxiety.
You can also google for GAD-7 and print it out if you prefer hard copy forms.
Do you routinely diagnose panic disorder at the first consult?
While we can quite confidently make a diagnosis of GAD, Social Anxiety Disorder or phobias in the first presentation, this is less likely to be so in the case of Panic Disorder. This is because a range of medical conditions can present like a panic attack. These include angina, arrhythmias, transient ischemic attacks, asthma, hypoglycaemia and hyperthyroidism.
Medical problems which mimic panic episodes will have to be ruled out. Consider their cardiovascular risk profile, and then consider performing tests such as an ECG and blood tests (e.g. TFT, renal panel). This is even more important in elderly patients or those with pre-existing cardiovascular risks. If necessary, we may even refer the patient to a cardiologist.
Which medication do I start with?
Consider SSRI first.
As anxiety can get worse initially (first week) with SSRI (before it gets better), prescribe at half the usual starting dose. Then increase it a week later. For example, you can try one of these SSRIs:
Fluvoxamine - 25 mg ON (1st week) then 50 mg ON (2nd week)
Sertraline - 25 mg OM (1st week) then 50 mg ON (2nd week)
Fluoxetine - 10 mg OM (1st week) then 20 mg OM (2nd week)
Escitalopram - 5 mg OM (1st week) then 10 mg ON (2nd week)
What are the common side effects?
The common side effects are SING:
S - Sexual side effects (Reduced libido, delayed climax)
I - Insomnia (although fluvoxamine is sedative)
N - Nervousness in the initial week
G - Gastrointestinal like nausea, bloatedness, loss of appetite
What about benzodiazepines?
Only for short-term use eg. one week. If you do prescribe this, give it in limited supply (just a few tablets), and advise the patient that it is not for daily use, due to the risk for tolerance and dependence. In elderly patients, beware of the risks of sedation and falls.
What about the extremes of age groups?
If > 65 years old, there is higher risk of hyponatremia and GI bleed. You may want to check sodium level on next appointment.
If < 24 years old, there is a black box warning of increase suicidal thoughts although the risk is very, very small. I will inform parents and get their consent if the patient is <18. Consider referring to a specialist.
When not to give SSRI?
- On concurrent medications like Warfarin or Tamoxifen due to SSRI inhibiting Cytochrome P450
- Other medications that when combined with SSRI may trigger serotonin syndrome (e.g. other antidepressants, tramadol)
Are there counsellors in the community?
The Family Service Centre in your neighbourhood will have counsellors and social workers who will be able to provide counselling. You can locate one here:
You can also refer here for other counselling centres.
Is psychological therapy helpful?
Yes, very much so and there are various types of therapies which are helpful. For example, Acceptance and Commitment Therapy (ACT) and Cognitive Behavioural Therapy (CBT). These may be delivered by a psychologist or psychiatrist. During the sessions, patients will learn a combination of the following:
- Gaining awareness of their anxiety
- Learning to cope with anxiety (e.g. relaxation skills, acceptance)
- Exposure to situations that trigger anxiety in a stepwise fashion
In fact, therapy combined with medication is more effective than either medicine or therapy alone.