Anxiety And Obsessive-Compulsive Disorders

Description

General measures

Medicine treatment

Referral

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ICD-10 code: F40.0-2/F40.8-9/F41.0-3/F41.8-9/F42.0-9 + (F10.0-F19.9/R45.0-8/Z65.0-5/Z65.8-9/Z81.0-4/Z81.8)

Description

Anxiety is an emotional response to a perceived or anticipated stress. It is diagnosed as a disorder when it is excessive or persistent and impacts daily functioning. Anxiety disorders often present with medically unexplained symptoms such as non-cardiac chest pain, abdominal discomfort and neck and back muscle tension. However, anxiety symptoms may be caused by various medical conditions. In addition, medical conditions are commonly comorbid with anxiety disorders; they may exacerbate the symptoms and the anxiety disorder may worsen the outcome of treatment of the medical condition.

Tobacco, alcohol, and other substance use are commonly associated with anxiety disorders. The substance use may be secondary to the disorder or causative or both. If caused by a substance, then an anxiety disorder due to the specific substance should be diagnosed.

Anxiety during pregnancy and the postnatal period may impact negatively on the mother’s well-being and use of services, and is associated with poor psychological and neurodevelopmental outcomes in the child (See PHC STGs and EML, Maternal mental health).

• Psychological manifestations of anxiety include panic symptoms, excessive worry, fear, mood changes, irritability, tearfulness, distress, and poor concentration.
• Physical symptoms include muscle tension, headache, abdominal cramps, nausea, palpitations, sweating, a choking feeling, shortness of breath, chest pain, dizziness, numbness, and tingling of the hands and feet.
• People with intellectual disability may present with aggression, agitation, and demanding behaviour instead of anxiety.
• Panic attacks are abrupt surges of intense anxiety with prominent physical symptoms. They may occur in anxiety, mood, and psychotic disorders, and with alcohol and other substance misuse. They are a marker of increased severity of the primary disorder and may indicate a heightened risk of suicide.
• Social phobia (social anxiety disorder) is the fear of social interactions and usually starts in adolescence. Distorted thoughts are of perceived negative evaluation by others. Self-medication with alcohol or other substances is common and substance intoxication may be the presenting feature.
• Obsessive thoughts and/or compulsive behaviour are a core feature of obsessive compulsive disorder but may also occur in other disorders, particularly tic disorders, autistic spectrum, and psychotic disorders. Themes of the distorted thoughts and compulsions include hygiene (cleaning), security, symmetry, sexual and taboo topics, fears of causing harm, perceived physical defects, hair-pulling, or hoarding.

General Measures

Most patients can be treated as outpatients, but some may need to be admitted for diagnostic clarification, containment in extreme distress, or if at high risk of suicide.

• Maintain patience and an empathic attitude.
• Screen for and manage:
  • causative and comorbid medical illness, e.g. thyroid disease, hyperparathyroidism, phaeochromocytoma, vestibular dysfunctions, epilepsy, and cardiac conditions, hypertension, COPD, asthma, inflammatory bowel disease, GORD.
  • substance misuse, e.g. caffeine, nicotine, alcohol, analgesics, amphetamines and cocaine.
  • psychosocial stressors, especially in people with intellectual and other disabilities.
• Psychoeducate the patient and family (with patient’s permission).
• Refer to registered counsellors and local support groups. Provide links to self-help literature, websites or groups, e.g. South African Depression and Anxiety Group (SADAG - www.sadag.org).

Medicine Treatment

Indicated where symptoms interfere with normal functions of daily living.

• Offer a choice of psychotherapy (if available) or medication and monitor response. Note: where there is concomitant drug/alcohol dependence or a comorbid major depressive episode, an antidepressant may be more appropriate than psychotherapy.
• Review every 2–4 weeks for 3 months, then 3–6 monthly.
• Partial response: combine medication with psychotherapy.
• If effective, continue for at least 12 months to prevent relapse.
• Selective serotonin reuptake inhibitor (SSRI), e.g.:
• Fluoxetine, oral.
  • Initiate at 20 mg alternate days for 2 weeks.
  • Increase to 20 mg daily after 2–4 weeks.
  • Delay dosage increase if increased agitation / panic symptoms occur.
  • If partial response, increase to 40 mg daily.

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If fluoxetine is poorly tolerated:

• Alternative SSRI e.g.:
• Citalopram, oral.
  • Initiate at 10 mg daily for the 1st week.
  • Then increase to 20 mg daily.
  • If partial response, increase to 40 mg daily (except in cardiac disease or if >65 years of age).

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CAUTION - SSRIs
SSRIs (e.g. fluoxetine, citalopram) may cause agitation initially.
This typically resolves within 2-4 weeks.
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Ask about suicidal ideation in all patients, particularly adolescents and young adults (PHC STGs and EML, Suicide risk assessment).
If suicidal ideation present, refer before initiating SSRI. Once started, monitor closely for clinical worsening, suicidality, or unusual changes in behaviour. Advise families and caregivers of the need for close observation and refer as required.

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Note:
Continue treatment for a minimum of 12 months. Consider slowly tapering and stopping treatment only if patient has had no/minimal symptoms and has been able to carry out routine daily activities.

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Prolong treatment if any of the following are present:

• Previous episode/s of anxiety (extend treatment to at least 3 years).
• Any of the following: onset in adolescence, severe anxiety, suicidal attempt, sudden onset of symptoms, family history of bipolar disorder (extend treatment to at least 3 years).
• ≥3 previous episodes of anxiety (advise lifelong treatment).

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For short term use only in severe acute distress:

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• Benzodiazepines, e.g.:
• Diazepam, oral, 2.5–5 mg as a single dose.
  • Repeat 8 hourly, if required to a maximum of 30 mg daily (in divided doses).
  • Half the dose in the elderly or debilitated.
  • Duration of therapy: up to 2 weeks, taper off to zero within 6 weeks.
  • Commence definitive treatment with psychotherapy/SSRI treatment.

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CAUTION - BENZODIAZEPINES
- Associated with cognitive impairment – reversible with short-term use and irreversible with long-term use.
- Elderly are at risk of over-sedation, falls and hip fractures.
- Dependence may occur after only a few weeks of treatment.
- Prescribe for as short a period of time as possible to achieve desired effect.
- Warn patient not to drive or operate machinery when used short-term.
- Avoid use in people at high risk of addiction, e.g. personality disorders and those with previous or other substance misuse.

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PREGNANCY AND BREASTFEEDING
- SSRI treatment of depression in pregnancy is associated with improved symptoms in the mother and better emotional and psychological development of the child. Benefit is greater with increasing illness severity. Effect of SSRIs on anxiety in pregnancy is less clear.
- Lack of matched case-control studies mean harms of treatment are unclear.
- If stable on an SSRI, do not stop – discuss risk/benefit with mother.
- Index presentations: offer counselling, psychotherapy; discuss risk/benefit of SSRIs.
- Refer social worker to explore social and financial support systems.
- Avoid fluoxetine due to long half-life and relatively high concentration in breastmilk. Consider citalopram as alternative.
- All antidepressants: possible increased risk of miscarriage, transient neonatal symptoms (jitteriness, irritability), and persistent pulmonary hypertension of the newborn.
- Avoid benzodiazepines – some association with neurodevelopmental delay in the child; neonatal sedation if used late in pregnancy.

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Referral

• High suicide risk
• Severe symptoms with marked functional impairment
• Co-morbid severe psychiatric or medical conditions
• Poor response to treatment.

Figure 15.2: Antidepressant treatment algorithm for depression and anxiety in pregnancy and breastfeeding. Adapted from the MCPAP for Moms Perinatal Depression Toolkit funded by the Massachusetts Department of Mental Health. Original Authors: Byatt N., Biebel K., Mittal L., Lundquist R., Freeman M., & Cohen L., Moore Simas T.

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Standard Treatment Guidelines and Essential Medicines List for South Africa, Hospital Level, Adults_Chapter 15: Mental Health Conditions and Substance Misuse_NEMLC Recommendations for Medicine Amendments 2020-2023