Anxiety, fear and panic

Introduction

• Fear is an immediate emotional response to a real, external threat.

• Anxiety is excessive worry or apprehension about future or uncertain events.

• Panic is an intense surge of fear or discomfort, often occurring suddenly and without clear danger, usually accompanied by strong physical symptoms.

These experiences can be protective (alerting us to danger) but become problematic when excessive, persistent, or disproportionate, leading to functional impairment.

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Types of Anxiety and Panic Disorders

1. Generalized Anxiety Disorder (GAD) – chronic, excessive worry about daily issues.

2. Panic Disorder – recurrent, unexpected panic attacks with ongoing fear of recurrence.

3. Phobias – intense fear of specific objects/situations (heights, spiders, flying).

4. Social Anxiety Disorder – fear of scrutiny or embarrassment in social settings.

5. Obsessive-Compulsive Disorder (OCD) – intrusive thoughts (obsessions) and repetitive behaviors (compulsions).

6. Post-Traumatic Stress Disorder (PTSD) – anxiety after traumatic experiences.

7. Health Anxiety / Illness Anxiety Disorder.

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Causes and Risk Factors

1. Biological

• Genetic predisposition (family history of anxiety, depression).

• Imbalance of neurotransmitters: serotonin, norepinephrine, GABA.

• Overactive amygdala (fear processing center in the brain).

2. Psychological

• Stressful life events (loss, trauma, abuse).

• Personality traits (perfectionism, neuroticism).

• Learned fear responses (conditioning).

3. Medical / Substance-Related

• Hyperthyroidism, hypoglycemia, asthma, COPD, heart disease.

• Caffeine, nicotine, alcohol withdrawal.

• Medications (steroids, stimulants).

4. Environmental / Social

• Chronic stress (work, financial, relationship problems).

• Lack of social support.

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Clinical Features

Anxiety

• Excessive worry, tension, restlessness.

• Difficulty concentrating.

• Muscle tension, headaches.

• Sleep disturbances.

Panic Attack (Diagnostic criteria: sudden onset, peaks within 10 min, ≥4 symptoms):

• Palpitations, tachycardia.

• Shortness of breath, chest pain.

• Sweating, trembling.

• Dizziness, faintness.

• Feeling of choking.

• Fear of losing control or dying.

• Numbness, tingling, chills, or hot flushes.

Fear

• Immediate fight-or-flight response.

• Avoidance of feared situations.

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Diagnostic Approach

1. History

• Onset, frequency, triggers of symptoms.

• Impact on daily life, school/work, relationships.

• Past trauma, medical illness, substance use.

• Family history of psychiatric disorders.

2. Examination

• Rule out medical causes (thyroid disease, heart disease, asthma).

• Assess mental state: mood, thought process, insight.

3. Investigations

• Basic labs: CBC, thyroid function, glucose, electrolytes.

• ECG: rule out arrhythmias in palpitations.

• Psychological questionnaires: GAD-7, PHQ-9, Panic Disorder Severity Scale.

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Management and Treatment

Treatment involves a combination of psychological therapy, lifestyle modification, and pharmacological treatment when needed.

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A. Psychological and Behavioral Interventions

1. Cognitive-Behavioral Therapy (CBT)

   • Gold standard.

   • Helps patients recognize and change negative thought patterns and avoidance behaviors.

2. Exposure Therapy

   • Gradual exposure to feared objects/situations.

   • Used in phobias, social anxiety, PTSD.

3. Relaxation Techniques

   • Deep breathing, progressive muscle relaxation, mindfulness meditation.

   • Yoga, guided imagery.

4. Lifestyle Measures

   • Regular exercise (30 min/day).

   • Sleep hygiene (7–8 hours/night).

   • Limit caffeine, nicotine, alcohol.

   • Balanced diet and hydration.

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B. Pharmacological Treatment

1. Antidepressants (first-line for long-term management)

• Selective Serotonin Reuptake Inhibitors (SSRIs):

  • Sertraline 50 mg orally daily (range 50–200 mg).

  • Escitalopram 10 mg orally daily (range 10–20 mg).

  • Paroxetine 20 mg orally daily.

• Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs):

  • Venlafaxine XR 75 mg orally daily (range 75–225 mg).

  • Duloxetine 30–60 mg orally daily.

2. Anxiolytics (short-term, for acute severe symptoms)

• Benzodiazepines:

  • Lorazepam 0.5–2 mg orally every 6–8 h as needed.

  • Diazepam 2–10 mg orally every 6–12 h as needed.
    ⚠️ Use short-term only (risk of dependence).

3. Other Medications

• Buspirone 5–10 mg orally two to three times daily (non-sedating anxiolytic, for GAD).

• Pregabalin 150–600 mg orally daily in divided doses (effective in GAD).

• Beta-blockers (for physical symptoms like palpitations, tremors):

  • Propranolol 10–40 mg orally before anxiety-inducing events (e.g., public speaking).

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C. Emergency Management of Panic Attack

• Reassurance, calm environment.

• Breathing exercises (slow, deep breathing).

• If severe: Lorazepam 1–2 mg orally/IV or Diazepam 5–10 mg IV.

• Rule out life-threatening conditions (MI, asthma, seizure).

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Complications

• Poor quality of life, impaired relationships.

• Occupational and academic dysfunction.

• Substance abuse (self-medication).

• Depression, increased suicide risk.

• Physical health problems from chronic stress (hypertension, heart disease).

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Prognosis

• With proper treatment, prognosis is excellent.

• CBT + medication combination is most effective.

• Early intervention prevents chronicity.

• Some patients may need long-term maintenance therapy.

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Patient Education

• Anxiety and panic are common and treatable.

• Learn and practice relaxation techniques daily.

• Avoid stimulants (caffeine, nicotine, recreational drugs).

• Exercise regularly and maintain a healthy lifestyle.

• Seek professional help if symptoms interfere with work, school, or relationships.

• Emergency: seek help immediately if chest pain, fainting, or suicidal thoughts occur.