Anxiety

Last updated: November 2021

A patient suffering from anxiety has:

• psychological symptoms: pervasive worries, e.g. fear of having a serious illness, fear with no clearly-defined object or phobias;
• behavioural changes: nervousness, avoidance behaviour, self-isolating tendency, irritability;
• physical symptoms: e.g. dry mouth, “lump in the throat”; sometimes medically unexplained symptoms (e.g. feeling of malaise, hot flashes or chills, diffuse pain);
• concentration difficulties, sleep problems (difficulty getting to sleep, recurrent nightmares).

Anxiety is a common feature in depression, post-traumatic stress disorder and psychosis. It can also occur in isolation, not associated with any other mental disorders. Anxiety symptoms often occur immediately after a difficult life event. Medically unexplained symptoms are frequent in refugees and people exposed to adversity; in certain cultures they may be the only expression of psychological distress. 

Management

Try to determine the source of the anxiety and reassure the patient (without minimising the distress or symptoms). If necessary, use simple relaxation techniques to alleviate the symptoms a Citation a. For example, in case of hyperventilation, use a technique that controls the respiratory rate: get the patient in a comfortable position with his eyes closed. Help him focus on his breathing so that it becomes calmer and more regular, with three-phase breathing cycles: inhalation (count to three), exhalation (count to three), pause (count to three), etc. .

If symptoms are exacerbated (e.g., tachycardia, feeling of suffocation, fear of dying or “going crazy,” agitation, or conversely, prostration), it may be necessary to administer diazepam: 5 to 10 mg PO or 10 mg IM, to be repeated after one hour if required.

Acute severe anxiety may justify a short course (max. 2 or 3 weeks) of:
diazepam PO: 2.5 to 5 mg 2 times daily; reducing the dose by half in the last few days of treatment

Moderate anxiety lasting more than 2 weeks, administer as first-line treatment: 
hydroxyzine PO: 25 to 50 mg 2 times daily (max. 100 mg daily)
or, only if there is no improvement after 1 week, diazepam PO: 2.5 to 5 mg 2 times daily for max. 2 weeks.

If symptoms recur after treatment discontinuation, do not resume diazepam or hydroxyzine. Re-evaluate for possible depression or post-traumatic stress disorder.

For generalised anxiety that lasts more than 2 months, and does not improve with psychosocial interventions, an antidepressant should be prescribed (fluoxetine or paroxetine PO: 20 mg once daily), to be continued for 2 to 3 months after symptoms resolve then, stop gradually over 2 weeks.