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• The anxiety disorders are common and disabling mental disorders.
  
• The doctor's first task is to delineate these disorders from anxiety secondary to threat or crisis, and then manage accordingly.
  
• For all the five major anxiety disorders -- panic/agoraphobia, social phobia, obsessive-compulsive disorder, generalised anxiety disorder and post-traumatic stress disorder -- psychological treatments are the treatments of choice.
  
• Three psychological techniques are described that can be applied in general practice: hyperventilation control to allow people to limit their anxiety and panic, structured problem solving to allow them to deal with problem situations and worries, and graded exposure to allow them to enter and master previously feared situations.
  
• Despite the challenges offered by these often chronic and disabling disorders, much can be done in general practice to aid recovery.

Box 1:
Prevalence of mental disorders in Australia, 1997

The answer is, in part, related to the normality of being anxious and, on occasions, too anxious. Anxiety is a normal emotion and a powerful motivator. Mild to moderate levels of anxiety improve the ability to cope, reactions become faster, understanding is better and responses are more appropriate. This sense of increased mastery is usually pleasurable. It is good to be aroused, tense, and anxious before important events, but care should be taken to see that the anxiety does not become so severe that it impairs performance. Just as moderate levels of anxiety facilitate coping, high levels reduce the capacity to plan, to make accurate judgements or to carry out skilled tasks, or even to comprehend useful information.

Patients who are stressed complain of being disabled by anxiety, yet some level of anxiety is required to make them keen to work on their problems. This facilitating effect of moderate anxiety and the debilitating effect of high anxiety makes the prescribing of anxiolytics difficult. Sufficient medication to produce the calm that patients seek will usually result in impaired performance. There is now considerable concern about the dependency-producing potential of the benzodiazepines and many doctors are looking to alternative treatments.²

In this article, alternative and useful drug therapies will be mentioned because they tend to be the treatments used most often in general practice (details of drug therapies can be found in chapters 4 and 6),^2,5 but, like Tyrer,^3,4 we would encourage doctors "to introduce patients to psychological treatment whenever possible". The results of the national survey reinforce this advice. Of people with any mental disorder (and anxiety disorders were the most common diagnoses), three quarters expressed a need for counselling or other "talking therapy", significantly more than the number who expressed a need for medication. In this respect, the public are right. In the anxiety disorders, the cognitive behavioural range of treatments are mostly superior to therapy with drugs, both in short term effectiveness and in the long term, after treatment has concluded.^6,7 These psychological treatments can restore the mental health of anxious people and overcome the debilitating effects of excessive anxiety.

Doctors must divide their time between attending to crises, caring for the chronically ill, and putting energy into people who they can cure and need never see again. The anxiety disorders are in the last category, potentially curable by psychological techniques, given a skilful practitioner and a hard-working patient.

Most disorders have signs as well as symptoms. Anxiety is different. The experience of being chronically anxious is a private one and there is little to observe, except perhaps some tremor and an occasional burst of unexpected panicky behaviour. One central feature of all anxiety disorders is that patients complain of the physical symptoms of the "flight or fight" response -- rapid heart rate, need to overbreathe, tremor and shaking, nausea, sweating and focusing of attention -- that would be normal if there was a significant physical exertion required to deal with a danger. Because hyperventilation is part of this response most patients also complain of dizziness and light-headedness, tingling and numbness.

Complaints of anxiety that differ from the stereotypes -- especially in patients over 40 with no previous history of anxiety -- should alert the physician to the need for skilful interviewing to discover the nature of the underlying condition. Of all such conditions, a depressive disorder with secondary anxiety is the most common, and the symptoms of depression will have to be specifically elicited -- depression, loss of interest, loss of energy, loss of self esteem, being prey to morbid thoughts, disturbed sleep, and weight loss. Antidepressant drugs, especially the selective serotonin reuptake inhibitors (SSRIs), are the treatment of choice.

Physical conditions such as hyperthyroidism and other mental disorders such as schizophrenia, delirium or dementia can also present with untoward anxiety. In such cases, management of the underlying disorder is the top priority and first step towards controlling anxiety.

It is often useful to identify four steps in helping such patients cope with a crisis:¹¹

1. Ensure that they are certain the problem is theirs; many people get needlessly upset over distressing events that do not actually threaten their own well-being.
2. Have them write down the essence of the problem, including listing the outcome if everything were to go wrong. This task will illustrate the extent of their worrying thoughts.
3. Ask them to make a list of a number of ways of solving the problem, choose the one that seems most practical, and have them write down the steps involved in effecting that solution. Coping with the problem should always be divided into steps. The patient will see some steps as being manageable, while other steps may require further thought and perhaps help from others. If necessary, make formal use of the structured problem-solving technique described below.
4. Talk about how they will manage to stay reasonably calm until the problem is solved. Many patients can be helped to remain calm by seeking comfort and support from sensible friends, by putting energy into physical tasks, or by relaxing while reading or listening to music. Alcohol is not a suitable means of relaxation for people with anxiety disorders. Very occasionally, diazepam (5-10 mg daily for 1-4 days) may be of value for the patient who becomes distraught, agitated, or sleepless, while stress management programs are of value for people who are chronically under pressure because of their life circumstances or occupation.¹¹

Box 2:
Generalised anxiety disorder

Box 3:
Panic disorder and agoraphobia

Box 4:
Social phobia

Box 5:
Obsessive-compulsive disorder

Box 6:
Post-traumatic stress disorder

Generalised anxiety disorder (months of irrational worry accompanied by somatic symptoms of anxiety -- see Box 2) is the commonest anxiety disorder. It is an acute-on-chronic disorder that arises in a person who is by nature a worrier, the habitual oversensitivity and overconcern finally getting out of control. Cognitive behaviour therapy, with the goal of bringing the worry process under control, is the most efficacious treatment.^6,7 Benzodiazepines reduce the anxiety and worry symptoms but too often lead to dependence. Buspirone is equally effective but seldom used (it takes two weeks to work and is not on the Pharmaceutical Benefits Schedule), and low dose sedative tricyclic antidepressants are also of use.

However, as this disorder is often an extension of a worrying nature, the cognitive behaviour therapies that can teach new ways of coping are more appropriate.¹² General practitioners can educate their patients about the flight or fight response and teach them how to decrease their physical symptoms using techniques such as progressive muscle relaxation. Teaching structured problem solving (described later) is also helpful in allowing people to focus the worry constructively.

Panic disorder/agoraphobia (sudden brief attacks of incapacitating fear that commonly lead to avoidance of precipitating situations -- see Box 3) is also common, especially in young women, who present to doctors because they feel that the physical symptoms reflect cardiac or neurological conditions.

Tricyclic antidepressants, monoamine oxidase inhibitors, high potency benzodiazepines like alprazolam and the SSRIs have all been shown to reduce panic frequency, anxiety, and phobic avoidance.⁶ Introducing the antidepressant drugs is often difficult because these patients are sensitive to side effects, and the dependency-producing potential of the high potency anxiolytics is a real cause for concern. Most importantly, these drugs relieve symptoms but do not cure the disorder.

Many patients will find that hyperventilation control (described below), if sufficiently mastered, will be effective in controlling panic attacks. Once the panic attacks are controlled, the doctor will then have to encourage patients to enter previously feared situations using the principles of graded exposure, also described below. Cognitive behaviour therapy programs for panic disorder/agoraphobia are more effective than medication⁶ and the benefits have been shown to be stable for five years after treatment has concluded.

Social phobia (avoidance of social interactions, for fear of scrutiny by others -- see Box 4) begins in adolescence and affects both sexes equally. It can be totally incapacitating and lead to a miserable hermit-like existence when the condition shades into avoidant personality disorder. The diagnosis is best made, not from the situations avoided or from the anxiety in those situations, but from the key fear that others will think badly of them.

Again, cognitive behavioural programs are the treatments of choice.^6,12 Most such programs are conducted in specialised centres and doctors may have to encourage their patients to attend. It is important to realise that the benefits of such programs are considerable and long-lasting. Drugs from four groups (reversible inhibitors of monoamine oxidase [RIMAs], SSRIs, benzodiazepines and monoamine oxidase inhibitors [MAOIs]) have all been shown to relieve symptoms, but none lead to an enduring recovery from the disorder. Indeed, it is difficult to conceptualise that these anxiolytic and antidepressant drugs could do other than improve well-being, leaving the core issue in the disorder, "fear of scrutiny", untouched.

Obsessive-compulsive disorder (fears of harm following intrusive, repugnant thoughts of contamination, violence or blasphemy, controlled by ceaseless washing or checking -- see Box 5) is a rare, disabling condition that begins in adolescence and affects both sexes equally. The diagnosis, while often evident from the excessiveness of the compulsive behaviours, is confirmed by the content of the recurrent obsession.

Cognitive behaviour therapy involving exposure and response prevention can reduce or eliminate the obsessions and behavioural and mental rituals of this disorder.⁶ About 50% of patients respond to SSRIs, with an average drop of 20%-40% in obsessions and compulsions.⁶ Again, the issue is over the relative merits of a simple but non-curative drug therapy with the limited goal of partial relief of symptoms versus a more complex psychological intervention with some chance of effecting a cure.

Specialist treatment with cognitive behaviour therapy that involves entering situations that evoke the thoughts but not carrying out the compulsions can provide superior results to medication, improvement that is usually maintained after treatment has concluded.^7,12 Patients treated with medication should, as the intensity of the obsessions diminishes, be encouraged to resist carrying out the compulsions when entering situations that evoke the thoughts. Reassurance from the doctor which addresses the patient's fears is contraindicated during treatment as the patient is encouraged to confront his or her fears and find them groundless.

Post-traumatic stress disorder (nightmares, flashbacks and emotional numbing that continue months or years after surviving a dreadful experience -- see Box 6) often presents as depression, the traumatic experience being concealed. Three classes of drugs (MAOIs, tricyclic antidepressants and SSRIs) all reduce the intrusive thoughts, the anxiety and depression, and the sleep problems. These are real gains, but, while the symptoms respond to medication, the core inability to trust and feel safe again does not.

The core problem will respond only to careful and repeated exposure to the details and emotions surrounding the original experience and to the cues in the current environment that evoke the traumatic memories¹³ until they lose their power to disturb. This type of therapy should only be carried out by experienced specialist therapists, but anxiety management strategies such as hyperventilation control or progressive muscle relaxation and the drug treatment of comorbid conditions is within the range of all general practitioners.

Box 7:
Slow breathing technique

Box 8:
Structured problem solving

Box 9:
Graded exposure

Box 10:
Patient support group

• hyperventilation control techniques to help patients lower the acute level of anxiety
• graded exposure to feared situations to eliminate the avoidance
• structured problem solving approach to facilitate crisis resolution.

The hyperventilation control technique^16,17 has two key elements: regular monitoring of respiration rates by the patient and practice of the slow breathing technique to inhibit hyperventilation when anxious. The essence of the technique is simple -- "Hold your breath for six seconds and then breathe in and out in a six second cycle" (Box 7), but, because it is to be used when stressed and anxious, it needs to be overlearned if patients are to be able to use it when they need it. Thus, general practitioners need to educate their patients about the rationale, and have them regularly practise counting the respiration rate and doing the slow breathing procedure, both at home and in the doctor's presence. Many patients will say that they already understand the technique, but if you have them rehearse during the consultation it is amazing how many think that deep breathing, which only worsens the hypocapnoea, is what is meant by slow breathing, which, of course, is aimed at reducing the hypocapnoea.

The structured problem solving approach is displayed in Box 8. At first glance it appears to be little more than applied common sense -- carefully identify what troubles you, work out how to deal with it, do what has to be done, then review progress. But acting in a common sense fashion is exactly what people who are anxious have difficulty doing. The procedure was derived from problem solving techniques used in industry^18,19 and is actually very sophisticated for, with the doctor's guidance, the patient learns to appraise situations accurately and then develop appropriate coping techniques. After one or two crises handled in this way patients seem to learn to carry out the technique for themselves. It is a most useful technique for general practice and doctors should photocopy figure 1, enlarge it to A4 size and use it routinely with patients who are anxious or distressed.

As Mitchell mentioned and others have shown,^5,20,21 it is effective in the management of people with depression and of value in managing people who have attempted suicide.

The first step is to get the patient to specify the key threat or problem. Overwhelming and complex problems can usually be broken down into a series of component parts, best specified as a list of discrete goals, one of which is identified as the target problem. The target problem is ideally single, specific and potentially solvable.

Next, have the patient quickly list a number of ways that this problem could be solved or modified. Also list impractical solutions because they may contain the germ of a good idea. Then have the patient discuss the main advantages and disadvantages of each solution and agree on the preferred one. Now have the patient plan the steps required to put this solution into effect. The details should be written down, including names, addresses and phone numbers, as, when anxious, patients will all too often forget or confuse the rational steps they planned. Do not offer advice during the problem solving unless something the patient proposes to do is clearly impractical. It is their problem and by learning how to solve it they will be learning a process that they will continue to use independently of the doctor. Nevertheless, one must arrange to review the results, applauding the outcome. Real problems are complex, and even if the first attempt proves to be ineffective something of use will have been learned that can be used when the process is repeated.

Structured problem solving with complex problems is an iterative procedure, a procedure infinitely more powerful than the usual advice from the doctor.

Graded exposure¹² was one of the first of the powerful behavioural techniques. It is of value in assisting patients to overcome phobic situations by gradually re-exposing themselves to the feared situation in a manner that allows them to habituate themselves to it.

Confronting fears is common sense. However, few people with well established agoraphobia, social phobia or obsessive-compulsive disorder will be prepared to confront their principal fear and remain in the situation until the fear subsides. Hence the need for the graded approach.

The first step is a detailed analysis of the feared consequence. In agoraphobia the real fear is of the consequences of a panic attack -- so, for example, express trains are feared because escape will be impossible and medical help unavailable should a panic attack eventuate. Conversely, in social phobia, the real fear is of negative evaluation by others, and so an express train -- where everyone becomes immersed in the view or their reading -- is preferred to a commuter train, in which people get on and off all the time and are in a better position to notice others around them. The key question to ask about a fear is "In case what?" and most people will then usually describe the central fear. Once this central fear is understood, the doctor and patient can together generate a hierarchy of tasks -- starting with one that can be done with minor discomfort and finishing with one that is almost unthinkable because of the anxiety it would provoke (Box 9).

Once the hierarchy is constructed the patient should confront the first situation repeatedly, remaining in the situation until the anxiety is halved, and repeat the task until there is little anticipatory anxiety associated with the prospect of entering the situation. By mastering the less anxiety-provoking situations, the person learns that fears that are confronted lose their power to frighten.

Benzodiazepines should not be used to make the task easier, for new learning will not occur; instead, dependence on benzodiazepines will only be reinforced. Likewise, dependence on "safety" behaviours or devices, like carrying a mobile phone to summon help, should be avoided simply because the person has to learn to face their central fear of panic and heart attack, or embarrassment and shame, unprotected by any external aids. The doctor will need to see the person regularly to check on progress, to encourage when motivation flags and to reward when tasks are achieved. Once a number of stages in the hierarchy have been surmounted, the rewards of increasing mastery of a previously feared situation produce considerable motivation, but even so the doctor will need to continue to encourage regular and repeated practice until final mastery is achieved.

1. Australian Bureau of Statistics. Mental Health and Wellbeing: profile of Adults, Australia, 1997. (Cat. no. 4326.0), 1998.
2. Norman TR, Ellen SR, Burrows GD. Benzodiazepines in anxiety disorders: managing therapeutics and dependence. Med J Aust 1997; 167: 490-495.
3. Tyrer P. Prescribing psychotropic drugs in general practice. BMJ 1988; 296: 588-589.
4. Tyrer P. Treating panic. BMJ 1989; 298: 201.
5. Mitchell PB. Managing depression in a community setting. Med J Aust 1997; 167: 383-388.
6. Nathan PE, Gorman JM, editors. A guide to treatments that work. New York: Oxford University Press, 1998.
7. Andrews G. Talk that works: the rise of cognitive behaviour therapy. BMJ 1996; 313: 1501-1502.
8. Marks I. Living with fear. New York: McGraw-Hill, 1980.
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10. Page A. Don't panic. Sydney: Gore & Osment Publications, 1993.
11. Turner J, Raphael B. Stress management and counselling in primary care. Med J Aust 1998; 167: 547-551.
12. Andrews G, Crino R, Hunt C, et al. The treatment of anxiety disorders. New York: Cambridge University Press, 1994.
13. Foa EB, Rothbaum BO, Riggs DS, Murdock TB. Treatment of posttraumatic stress disorder in rape victims: a comparison between cognitive and behavioural procedures and counselling. J Consult Clin Psychol 1991; 59: 715-723.
14. Treatment Protocol Project. Management of mental disorders. Sydney: World Health Organization Collaborating Centre for Mental Health and Substance Abuse, 1997.
15. Andrews G, Hunt C. Counselling and management skills in clinical practice. Sydney: World Health Organization Collaborating Centre for Mental Health and Substance Abuse, 1998.
16. Rapee R. A case of panic disorder treated with breathing retraining. J Behav Ther Exper Psychiatry 1985; 16: 63-65.
17. Clark DM, Salkovskis PM, Chalkley AJ. Respiratory control as a treatment for panic attacks. J Behav Ther Exper Psychiatry 1985; 16: 23-30.
18. D'Zurilla TJ, Goldfried MR. Problem solving and behavior modification. J Abnorm Psychol 1971; 8: 107-126.
19. Falloon I, editor. Handbook of behavioral family therapy. New York: Guildford Press, 1988.
20. Mynors-Wallis LM, Gath DH, Lloyd-Thomas AT, Tomlinson D. Randomised controlled trial comparing problem solving treatment with amitriptyline and placebo for major depression for primary care. BMJ 1995; 310: 441-445.
21. Salkovskis PM, Atha C, Storer D. Cognitive-behavioural problem solving in the treatment of patients who repeatedly attempt suicide. Br J Psychiatry 1990; 157: 871-876.

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