10 Dimensions Of Anxiety Disorders
Anxiety disorders are common psychiatric disorders. Many patients with anxiety disorders experience physical symptoms related to anxiety and subsequently visit their primary care providers. Despite the high prevalence rates of these anxiety disorders, they often are underrecognized and undertreated clinical problems.
Anxiety disorders appear to be caused by an interaction of biopsychosocial factors, including genetic vulnerability, which interact with situations, stress, or trauma to produce clinically significant syndromes.
Symptoms vary depending on the specific anxiety disorder.
Treatment usually consists of a combination of pharmacotherapy and/or psychotherapy.
The brain circuits and regions associated with anxiety disorders are the amygdala and other limbic system structures, which are connected to prefrontal cortex regions. Hyperresponsiveness of the amygdala may relate to reduced activation thresholds when responding to perceived social threat. Prefrontal-limbic activation abnormalities have been shown to reverse with clinical response to psychologic or pharmacologic interventions.
3. Abnormal Function:
In the central nervous system (CNS), the major mediators of the symptoms of anxiety disorders appear to be norepinephrine, serotonin, dopamine, and gamma-aminobutyric acid (GABA). Peripherally, the autonomic nervous system, especially the sympathetic nervous system, mediates many of the symptoms.
4. Types Of Anxiety Disorders :
Following is the description of different types of anxiety disorders:
Generalized anxiety disorder
This disorder is characterized by excessive anxiety and worry. Worrying is difficult to control. Anxiety and worry are associated with at least 3 of the following symptoms:
- Restlessness or feeling keyed-up or on edge
- Being easily fatigued
- Difficulty concentrating or mind going blank
- Muscle tension
- Sleep disturbance
- Although not a diagnostic feature, suicidal ideation and completed suicide have been associated with generalized anxiety disorder
Mental status examination of the patient with generalized anxiety disorder involves asking about suicidal/homicidal ideation or plan and formal testing of orientation/recall. Common physical signs of generalized anxiety disorder include tremor, fast heart beat, rapid breathing, sweaty palms, and restlessness.
The first consideration in determining the underlying cause of anxiety is the possibility of a known or unrecognized medical condition. Substance-induced anxiety disorder (over-the-counter medications, herbal medications, substances of abuse) is a diagnosis that often is missed. Recently, interaction between genes and environment has been implicated in the development of anxiety disorders because genetic factors significantly influence risk for many anxiety disorders and environmental factors such as early childhood trauma can also contribute to risk for later anxiety disorders. Patients with anxiety disorder tend to imagine the worst possible scenario and avoid situations they think are dangerous, such as crowds, heights, or social interaction.
Patients with panic disorder report a spontaneous sudden onset of fear or discomfort, typically reaching a peak within 10 minutes. Attacks are associated with a constellation of systemic symptoms, including the following (4 or more of these are needed forDSM-IV-TR criteria):
- Palpitations, pounding heart, or accelerated heart rate
- Trembling or shaking
- Shortness of breath or feeling of smothering
- Choking sensation
- Chest pain or discomfort
- Nausea or abdominal distress
- Feeling dizzy, unsteady, lightheaded, or faint
- Derealization (ie, feeling of unreality) or depersonalization (ie, being detached from oneself)
- Fear of losing control or going crazy
- Fear of dying
- Paresthesias (ie, numbness or tingling sensations)
- Chills or hot flashes
During the episode, patients have the urge to flee or escape and have a sense of impending doom (as though they are dying from a heart attack or suffocation). Other symptoms may include headache, cold hands, diarrhea, insomnia, fatigue, intrusive thoughts, and ruminations.
Patients with panic disorder have recurring episodes of panic, with the fear of recurrent attack resulting in significant behavioral changes (eg, avoiding situations or locations) and worry about the implications of the attack or its consequences (eg, losing control, going crazy, dying).
Panic disorder may result in changes in personality traits, characterized by the patient becoming more passive, dependent, or withdrawn. DSM-IV-TR criteria include 4 or more attacks in a 4-week period or 1 or more attacks followed by at least 1 month of fear of another.
Assess precipitating events, suicidal ideation or plan, phobias, agoraphobia, and obsessive-compulsive behavior. No signs on physical examination are specific for panic disorder. The diagnosis is made primarily by history. Exclude involvement of alcohol, illicit drugs (eg, cocaine, amphetamine, phencyclidine, amyl nitrate, lysergic acid diethylamide [LSD], yohimbine, 3,4-methylenedioxymethamphetamine [MDMA, or ecstasy]), cannabis, and medications (eg, caffeine, theophylline, sympathomimetics, anticholinergics). Mental status screening includes cognitive performance, memory, serial-7, and proverb interpretation.
Panic disorder appears to be a genetically inherited neurochemical dysfunction that may involve autonomic imbalance; decreased GABA-ergic tone; allelic polymorphism of the catechol-O-methyltransferase (COMT) gene; increased adenosine receptor function; increased cortisol ; diminished benzodiazepine receptor function; and disturbances in serotonin, serotonin transporter (5-HTTLPR) and promoter (SLC6A4) genes, norepinephrine, dopamine, cholecystokinin, and interleukin-1-beta.
A panic attack generally lasts 20-30 minutes from onset—rarely more than an hour. Somatic concerns of death from cardiac or respiratory problems may be a major focus of patients during an attack. Patients may end up in the emergency department.
Posttraumatic stress disorder
Diagnosis is based on criteria from the DSM-IV-TR. The first criterion has 2 components: (1) experiencing, witnessing, or being confronted with an event involving serious injury, death, or a threat to a person’s physical integrity and (2) a response involving helplessness, intense fear, or horror (sometimes expressed in children as agitation or disorganized behavior).
The second major criterion involves the persistent reexperiencing of the event in one of several ways. This may involve thoughts or perception, images, dreams, illusions, hallucinations, dissociative flashback episodes, or intense psychological distress or reactivity to cues that symbolize some aspect of the event. However, children reexperience the event through repetitive play, not through perception like adults.
The third diagnostic criterion involves avoidance of stimuli that are associated with the trauma and numbing of general responsiveness; this is determined by the presence of 3 or more of the following:
- Avoidance of thoughts, feelings, or conversations that are associated with the event
- Avoidance of people, places, or activities that may trigger recollections of the event
- Inability to recall important aspects of the event
- Significantly diminished interest or participation in important activities
- Feeling of detachment from others
- Narrowed range of affect
- Sense of having a foreshortened future
The fourth criterion is symptoms of hyperarousal, and 2 or more of the following symptoms are required to fulfill this criterion:
- Difficulty sleeping or falling asleep
- Decreased concentration
- Hyper vigilance
- Outbursts of anger or irritable mood
- Exaggerated startle response
Fifth, the duration of the relevant criteria symptoms should be more than 1 month, as opposed to acute stress disorder, for which the criterion is a duration of less than 1 month.
Finally, the disturbance is a cause of clinically significant distress or impairment in functioning.
Children may have different reactions to trauma than adults. For children aged 5 years or younger, typical reactions can include a fear of being separated from a parent, crying, whimpering, screaming, immobility and/or aimless motion, trembling, frightened facial expressions, and excessive clinging. Parents may also notice regressive behaviors. Children of this age tend to be strongly affected by their parents’ reactions to the traumatic event.
Children aged 6-11 years may show extreme withdrawal, disruptive behavior, and/or an inability to pay attention. Regressive behaviors, nightmares, sleep problems, irrational fears, irritability, refusal to attend school, outbursts of anger, and fighting are also common. The child may have somatic complaints with no medical basis. Schoolwork often suffers. Also, depression, anxiety, feelings of guilt, and emotional numbing are often present. Adolescents aged 12-17 years may have responses similar to adults.
General appearance may be affected in patients with PTSD. Patients may appear disheveled and have poor personal hygiene. Behavior may be altered. Patients may appear agitated, and their startle reaction may be extreme.
Orientation is sometimes affected. The patient may report episodes of not knowing the current place or time, even though this may not have been evident during the interview. Memory is likely to be affected. Patients may report forgetfulness, especially concerning the specific details of the traumatic event. A pilot study suggests memory abnormalities may not be limited to the traumatic event itself. Concentration is poor, as is impulse control. Speech rate and flow may be altered.
Mood and affect may be changed. Patients may have feelings of depression, anxiety, guilt, and/or fear. Thoughts and perception may be affected. Patients may be more concerned with the content of hallucinations, delusions, suicidal ideation, phobias, and reliving the experience; certain patients may become homicidal. Potential for suicide and homicide must be noted as part of the mental status.
Special attention should be paid to the patient’s sleep hygiene. Recent studies suggest that even a single cognitive-behavioral treatment (CBT) for sleep abnormalities can significantly improve daytime PTSD symptoms, as can pharmacological treatments for sleep abnormalities.
PTSD is caused by experiencing, witnessing, or being confronted with an event involving serious injury, death, or threat to the physical integrity of an individual, along with a response involving helplessness and/or intense fear or horror. The more severe the trauma and the more intense the acute stress symptoms, the higher the risk for PTSD. When these events involve an individual with a physiologic vulnerability based on genetic (inherited) contributions and other personal characteristics, PTSD results.
Obsessive-compulsive disorder (OCD)
OCD is diagnosed primarily by presentation and history. Common obsessions include contamination, safety, doubting one’s memory or perception, scrupulosity (need to do the right thing, fear of committing a transgression, often religious), need for order or symmetry, and unwanted and intrusive sexual/aggressive thought. Common compulsions include cleaning/washing, checking (checking locks, stove, iron, safety of children), counting/repeating actions a certain number of times or until it “feels right,” arranging objects, touching/tapping objects, hoarding, confessing/seeking reassurance, and list making.
The following elements should be covered when obtaining the history; some suggestions for typical interview questions are included.
The first element concerns the nature and severity of obsessive symptoms. The following questions may be asked:
- Have you ever been bothered by thoughts that do not make any sense and keep coming back to you even when you try not to have them?
- When you had these thoughts, did you try to get them out of your head? What would you try to do?
- Where do you think these thoughts were coming from?
The second element concerns the nature and severity of compulsive symptoms. The following questions may be asked:
- Has there ever been anything that you had to do over and over again and could not resist doing, such as repeatedly washing your hands, counting up to a certain number, or checking something several times to make sure you have done it right?
- What behavior did you have to do?
- Why did you have to do the repetitive behavior?
- How many times would you do it and how long would it take?
- Do these thoughts or actions take more time than you think makes sense?
- What effect do they have on your life?
The information appropriate for a full evaluation includes age of onset; a history of tics, either current or past; and a psychiatric review of systems and comorbidities.
A complete mental status examination includes evaluation for orientation, memory, disturbances of mood and affect, presence of hallucinations, delusions, suicidal and homicidal risk, and judgment (including whether insight into the irrational nature of their symptoms is still present).
Evaluate all patients with OCD for the presence of Tourette disorder or other tic disorders, as these comorbid diagnoses may influence treatment strategy.
Skin findings in OCD may include eczematous eruptions related to excessive washing, hair loss related to trichotillomania or compulsive hair pulling, and excoriations related to neurodermatitis or compulsive skin picking.
The cause of OCD is not known; however, genetic factors, infections, other neurologic conditions, stress, and interpersonal relationships have all been shown to be relevant.
OCD symptoms can interact negatively with interpersonal relationships, and families can become involved with the illness in a counterproductive way (eg, a patient with severe doubting obsessions may constantly ask reassurance for irrational fears from family members or significant others; constantly providing this can inhibit the patient from making attempts to work on their behavioral disturbances). Parenting style or upbringing does not appear to be a causative factor in OCD.
Social phobia (social anxiety disorder)
A person with social phobia will typically report a marked and persistent fear of social or performance situations, to the extent that his or her ability to function at work or in school is impaired.
Ask the patient about any difficulties in social situations, such as speaking in public, eating in a restaurant, or using public washrooms. Fear of scrutiny by others or of being embarrassed or humiliated is described commonly by people with social phobia.
The patient’s mental status examination is significant for an anxious affect with a restricted range during a situation where the patient is acutely confronted with the object of his or her phobia.
At any other time, a patient with phobic disorder has a mental status within normal limits, with the exception of thought content positive for phobic ideation.
Genetic factors seem to play a role in social phobia. Based on family and twin studies, the risk for social phobia appears to be moderately heritable. Social phobia can be initiated by traumatic social experience (eg, embarrassment) or by social skills deficits that produce recurring negative experiences. Hence social phobia appears to be an interaction between biological and genetic factors and environmental events.
Inquire about any intense anxiety reactions that occur when the patient is exposed to specific situations such as heights, animals, small spaces, or storms. Other areas of inquiry should include fear of being trapped without escape (eg, being outside the home and alone; in a crowd of unfamiliar people; on a bridge, in a tunnel, in a moving vehicle).
Specific (simple) phobia
If specific phobias are suspected, specific questions need to be asked about irrational and out of proportion fear to specific situations (eg, animals, insects, blood, needles, flying, heights). Phobias can be disabling and cause severe emotional distress, leading to other anxiety disorders, depression, suicidal ideation, and substance-related disorders, especially alcohol abuse or dependence. The physician must inquire about these areas as well.
Specific phobias have been further broken down to include animal type, such as fear of dogs (cynophobia), cats (ailurophobia), bees (apiphobia), spiders (arachnophobia), snakes (ophidiophobia); natural environment type, such as fear of heights (acrophobia), water (hydrophobia), or thunderstorms (astraphobia); blood injection/injury type, such as fear of pain (algophobia) or of being beaten (rhabdophobia); situational type, such as fear of flying (pteromerhanophobia), elevators, or enclosed spaces; and other type.
Genetic factors seem to play a role in specific phobia as well (eg, in blood-injury phobia), and the risk for such phobias also seems to be moderately heritable. In addition, specific phobia can be acquired by conditioning, modeling, or traumatic experience.
The prevalence of specific anxiety disorders appears to vary between countries and cultures. A cross-national study of the prevalence of panic disorder found lifetime prevalence rates ranging from 0.4% in Taiwan to 2.9% in Italy. A cross-cultural study of the prevalence of OCD found lifetime prevalence rates ranging from 0.7% in Taiwan to 2.5% in Puerto Rico.
In some Far East cultures, individuals with social phobia may develop fears of being offensive to others rather than fears of being embarrassed.
The female-to-male ratio for any lifetime anxiety disorder is 3:2 (see the image below).
Most anxiety disorders begin in childhood, adolescence, and early adulthood (see the image below).
Selective serotonin reuptake inhibitors (SSRIs) are generally used as first-line agents, followed remotely by tricyclic antidepressants (TCAs).
Fluoxetine (Prozac) can be used (especially if panic disorder occurs with depression).
Paroxetine (Paxil) represents a partially sedating SSRI option.
Citalopram is also effective but is contraindicated in individuals with congenital long QT syndrome and the dose should not exceed 40 mg/day.
Escitalopram (Lexapro) appears to be particularly well tolerated.
Sertraline (Zoloft) represents a similar SSRI option.
Sedating antidepressants such as paroxetine, mirtazapine, and other TCAs/TeCAs are usually prescribed only at night before bed to help improve sleep but should include a warning not to operate a motor vehicle or machinery if feeling sedated or directly after the dose.
Initiation of antidepressant agents are thought to cause early worsening of anxiety, agitation, and irritability, particularly when used to treat anxiety.
Intravenous or oral acute sedation with benzodiazepines may be used. Alprazolam (Xanax) has been widely used for panic disorder, but it is currently discouraged because of its higher dependence potential; alprazolam has a short half-life, which makes it particularly prone to rebound anxiety and psychological dependence. Clonazepam (Klonopin) has become a favored replacement because it has a longer half-life and empirically elicits fewer withdrawal reactions upon discontinuation.
Benzodiazepines can ease the uncomfortable anxiety associated with the attack and can provide the patient with definitive confidence that treatment can control the symptoms. Benzodiazepines act quickly but carry the liability of physiologic and psychologic dependence. They can be reasonably used as an initial adjunct while SSRIs are titrated to an effective dose, and they can then be tapered over 4-12 weeks while the SSRI is continued. Long-term benzodiazepines use should be reserved for patients with refractory panic disorder.
7. Psychotherapy For Anxiety Disorders:
Cognitive and behavioral psychotherapy can be used alone or in combination with pharmacotherapy. This approach yields superior results for most patients compared to either single modality.
Cognitive therapy helps patients understand how automatic thoughts and false beliefs/distortions lead to exaggerated emotional responses, such as anxiety, and can lead to secondary behavioral consequences.
Behavioral therapy involves sequentially greater exposure of the patient to anxiety-provoking stimuli; over time, the patient becomes desensitized to the experience.
Relaxation techniques also help control patients’ levels of anxiety. Respiratory training can help control hyperventilation during panic attacks and help patients control anxiety with controlled breathing.
Anxiety disorders have high rates of comorbidity with major depression and alcohol and drug abuse. Chronic anxiety may be associated with increased risk for cardiovascular morbidity and mortality.
Considerable evidence shows that social phobia (social anxiety disorder) results in significant functional impairment and decreased quality of life.
Severe anxiety disorders may be complicated by suicide, with or without secondary mood disorders (eg, depression). The effects of acute stress in producing suicidal behavior are increased in those with underlying mood, anxiety, and substance abuse problems.
However prognosis is good with multipronged treatment strategies under professional supervision.
9. Patient Education:
Family members should receive information about the effect of anxiety disorders on mood, behavior, and relationships. Family members can assist in care by reinforcing the need for medical treatment and supervision. Family members may also assist by providing a collaborative resource for monitoring the severity of the patient’s anxiety symptoms and response to treatment interventions.
10. Dietary Measures:
Caffeine-containing products such as coffee, tea and colas should be discontinued (or decreased to a low reasonable level). Over-the-counter preparations and herbal remedies should be reviewed with special caution because ephedrine and other herbal compounds may precipitate or exacerbate anxiety symptoms. The use of some gentle herbal preparations may be considered in persons who do not have allergies or sensitivities to those agents.