Anxiety Disorders

July 28, 2011

The term Anxiety Disorders refers to a category of psychiatric illnesses that are generally more chronic than substance use or affective (mood) disorders. It is estimated that 25% of the population have had some type of anxiety disorder in their lifetime. The fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) classifies 12 anxiety disorders: panic disorder without agoraphobia, panic disorder with agoraphobia, agoraphobia without history of panic disorder, specific phobia, social phobia, obsessive-compulsive disorder, posttraumatic stress disorder (PTSD), generalized anxiety disorder (GAD), acute stress disorder, anxiety disorder due to a general medical condition, substance-induced anxiety disorder, and anxiety disorder not otherwise specified.

The two most common anxiety disorders are social phobia (13% lifetime prevalence) and simple phobia (11% lifetime prevalence). Risk factors for anxiety disorders include lower socioeconomic status, female gender, and living in the Northeast region of the United States. Women are twice as likely to have any anxiety diagnosis, except social phobia, where the womento-men ratio is 3 : 2. Adults between the ages of 25 and 34 have the highest prevalence rates. There are no differences among races. Individuals with anxiety disorders are highly likely to have another coexisting mental disorder, but only a small number actually seek treatment.

Anxiety is a universal feeling that is normal and adaptive in the right circumstances; however, when the level of anxiety begins to interfere with functioning or cause considerable emotional distress, it is important to evaluate for the presence of an anxiety disorder. In most of the disorders outlined here, the level of anxiety experienced causes the suffering person to seek refuge by avoiding the source of anxiety, or by performing some neutralizing behavior until the lifestyle is drastically hampered, or to experience intense anxiety in the face of the source. Panic attacks are a central feature of several of the anxiety disorders. These are episodes of intense anxiety in which at least four of the following thirteen symptoms peak very quickly: increased heart rate, sweating, shakiness, short of breath, choking feelings, chest pain, abdominal distress, dizziness, feelings of unreality or detachment from self, fear of losing control or dying, tingling, chills, or hot flushes. Panic-like symptoms are fewer in number than is required for a full-fledged panic attack, but can also include other incapacitating symptoms (e.g., severe headache).

Panic attacks or panic-like symptoms can be either unexpected, situationally bound, or situationally predisposed. The first type occurs unpredictably whereas the situationally bound type occurs in the presence of a trigger. Situationally predisposed can be in response to some stimulus but at other times attacks do not occur with that stimulus at all (e.g., an attack may occur after entering a mall but at other times this may not happen).

A diagnosis of panic disorder with agoraphobia is given when agoraphobia occurs along with unexpected full-fledged panic attacks with a month of concern about one of the following: fears of another attack, the implications of the attack, or a marked change in behavior associated with the attacks. Panic disorder without agoraphobia has the same criteria for diagnosis except that it occurs in the absence of agoraphobia symptoms. On the other hand, a diagnosis of agoraphobia without history of panic disorder is made when agoraphobia symptoms are related to fears of developing the panic-like symptoms without a history of full-fledged panic attacks.

Specific phobia and social phobia are similar in that the increased anxiety is situationally bound to a specific trigger(s). In specific phobia, this can be anything from animals, to storms, to public transportation. When these triggers can be easily avoided, functioning is rarely impaired (e.g., fear of buses, but no need to travel by bus). However, when the specific phobia is something occurring in everyday life, the impairment can be considerable (e.g., fear of tunnels when living in New York City). In social phobia, the anxiety arousal is linked to social interactions and feared negative evaluations by others. Since anyone can speak to you at any time, individuals may experience more of a general anxiety arousal than those with other anxiety disorders. Individuals with this disorder will adopt a range of avoidance behaviors to manage their anxiety, at times with significant consequences (e.g., turning down a promotion that requires more social interaction).

Individuals with obsessive-compulsive disorder (OCD) experience recurrent intrusive thoughts or behaviors that are time consuming enough to impair functioning or cause significant distress. Obsessions are not worries about everyday problems, but instead can be about contamination (touching a public door handle), order (distress when objects are asymmetrical), or aggressive imagery (hurting a child). Attempts are made to ignore these thoughts or to neutralize them with some repeated action (e.g., hand washing). These repeated actions (compulsions) serve to lower the anxiety associated with the unwanted thoughts or impulses. At times this may also take the form of mental acts (e.g., repeating words to oneself or counting). Compulsions can be related to the obsession (e.g., checking that the iron is unplugged in response to fear that the iron was left on and may start a fire), but in other cases, may have nothing to do with them (e.g., counting backwards from 100 to neutralize fear of hitting someone while driving). Attempts to avoid provoking situations or objects can lead to even greater decrease in functioning.

PTSD develops after exposure to some extreme traumatic stressor that was either experienced directly, was witnessed, or learned about that involved either actual or threatened death or injury or threat to physical integrity of others or self. The person’s reaction to the event is one of intense horror. Triggers can be anything reminiscent of the original event including similar sounds, smells, dreams, or internal body sensations. Symptoms include a feeling that one is reexperiencing the event, avoidance of any cues that are related to the original trauma, and increased arousal (e.g., sleep difficulties, irritability) that persist for more than a month. Those who develop PTSD continue to experience a myriad of symptoms long after a typical recovery period. Acute stress disorder is similar to PTSD but it involves significant dissociative symptoms (e.g., dazed, numb) and the duration is shorter, a minimum of 2 days and a maximum of 4 weeks after the traumatic event occurs.

Individuals who worry excessively and are unable to control it may be experiencing GAD. Associated body symptoms include feeling restless, irritable, and easily fatigued. Sore muscles and sleep disturbance may also accompany the anxiety. The focus of worry is usually everyday things like work, school, or family finances but it is severe enough to cause impairment in functioning or cause significant distress.

Anxiety disorder due to a general medical condition and substance-induced anxiety disorder are diagnosed when anxiety symptoms from panic, GAD, or OCD occur in direct relation to a medical condition in the former or, in the latter, as a response to a medication or drug. A diagnosis of anxiety disorder not otherwise specified is given when anxiety symptoms are predominant but do not meet criteria for any of the specific disorders listed above.

Hypotheses regarding individual differences in vulnerability to anxiety include genetic, cultural, and personality factors, early childhood experiences, and other learned factors. Various interventions have been used to target specific anxiety symptoms. More common treatments include exposure-based therapies, behavioral therapy, cognitive restructuring, and relaxation training. Numerous medications are available to treat specific anxiety disorders, most notably the selective serotonin reuptake inhibitors, monoamine oxidase inhibitors, buspirone, tricyclics, beta-blockers, carbamazepine, venlafaxine, and benzodiazepines.

SEE ALSO: Depression, Panic attack, Phobia, Posttraumatic stress disorder

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