Anxiety

What is Anxiety?

Anxiety disorder is a mental ailment that leads to unnecessary anxiety over different activities and events.

Who experiences Anxiety?

Anxiety is a common condition which often runs in families and maybe triggered by stress.

Even children may develop anxiety disorders but women are more prone to the condition than men.

Symptoms of Anxiety

Anxiety disorder is characterized by constant unrealistic worry or tension even if there is little or no cause.

The worries flit from one problem to another like family, work problems, health, finances etc.

The worries are often difficult to control and may leave a patient severely distressed.

There may be accompanying difficulty in concentration, tiredness, irritability, sleep problems, jumpiness or restlessness and palpitations.

Physical symptom of headaches, muscle weakness, palpitations, stomach upsets, nausea etc. may also be seen. (1, 2)

Causes of Anxiety

Sometimes the worry may stem from certain objects or rituals.

Anxiety disorders encompass various subtypes of mental disorders. Anxiety alone may be a symptom of each of these conditions. These include (3, 4, 5) –

  • Generalized anxiety disorders – Characterized by unnecessary and non-specific worries and tension.
  • Simple phobias – Here the excessive anxiety is caused by certain objects (for example fear of closed spaces like lifts etc. called Claustrophobia).
  • Obsessive-compulsive disorder (OCD) – Patients have an obsession which may be a recurrent, intrusive idea, thought or sensation that leads to a compulsion or a daily ritual For example repeated hand washing for fear of germs.
  • Panic disorders – Patients get sudden attacks of fear and anxiety without cause or prior warning.
  • Post-traumatic stress disorders (PTSD) – This is an anxiety that is caused long after the person has been through a particularly harrowing experience. This is common among survivors of a natural calamity or war. Past history of sexual or physical abuse may also result in a higher risk of PTSD.
  • Social anxiety disorder – Also known as social phobia this includes worries about facing daily social situations.

Frequency of Anxiety

Anxiety disorders are the commonest of all psychiatric ailments.

At least one in 20 in Britain suffer from anxiety disorders.

  • Clinically diagnosed simple phobias affect up to 25% of people.
  • Social anxiety disorder affects nearly 13% of people.
  • PTSD affects approximately 7.8% of the population and 12% of women.
  • Generalized anxiety disorders Panic disorder has a lifetime risk of 5% and 3.5%, respectively.
  • OCD is found in 2.5% of the population. (6)

Edited by April Cashin-Garbutt, BA Hons (Cantab)

Causes of Anxiety

Anxiety disorders are a common condition.

The most common cause of this condition is thought to be genetic. Thus the condition often runs in the families.

Stress factors tend to aggravate and precipitate the condition in some patients.

Triggers of Anxiety

The exact cause of anxiety disorders is unknown. However, research has pinpointed certain possible triggers.

Causes of anxiety disorders may be summarized as follows (1, 2, 3, 4) –

  • Genes – Inherited genes may determine the propensity to get anxiety disorders.
  • Sex – Women are more prone to anxiety disorders than men.
  • Anxiety disorders may also be triggered by a particularly stressful event.

This is seen in patients with Post-traumatic stress disorder (PTSD). A traumatic experience (e.g. sexual or physical injury or harm in the past) may lead to fears and anxiety later in life.

  • Some drugs of abuse like amphetamines, LSD or ecstasy and even coffee may lead to attacks of anxiety.
  • A significant experience like loss of job, pregnancy or moving house may lead to anxiety precipitation.

Underlying pathophysiology (3, 4, 5)

Anxiety disorders are caused due to an imbalance of certain chemicals in the brain. These are actually chemical messengers that carry information within the brain and are called neurotransmitters.

Two neurotransmitters that relate to anxiety disorders are serotonin and noradrenaline.

The misbalance of these neurotransmitters leads to certain physical and mood changes and manifestations.

The most common problem is low serotonin and high noradrenaline.

Disruption of the gamma-aminobutyric acid (GABA) system in the brain is another underlying cause of anxiety disorders.

In Obsessive compulsive disorders another neurotransmitter dopamine might play a role.

Edited by April Cashin-Garbut, BA Hons (Cantab)

Symptoms of Anxiety

Anxiety disorders are mainly characterized by an unnecessary worry, distress and tension.

This may lead to disturbances in concentration, sleep and regular social and work related functioning.

Symptoms vary from person to person and generally develop slowly. The symptoms may be physical or psychological. (1, 2, 3, 4)

Primary symptoms

The primary symptom is usually related to physical health.

This is common in patients with panic attacks. These patients suffer from sudden bouts of anxiety with chest pain, dizziness, hot flushes or chills, choking, palpitation, nausea, abdominal pain, sense of “impending doom”, shortness of breath, trembling, sweating etc.

Patients with simple phobias may also present to the emergency department with these features.

Psychological symptoms

Psychological symptoms include difficulty in concentrating, tiredness and fatigue, irritability, trouble getting to and staying asleep, dizziness and vertigo and general restlessness and jumpiness.

There is a sensation of dread or “impending doom” and a feeling of being constantly on the “edge”.

Physical symptoms

Physical symptoms of anxiety disorders include palpitations, headaches, stomach upsets like nausea, diarrhoea, chest tightness, breathlessness, sweating, trembling, muscle weakness etc.

There may be drowsiness, pins and needles sensation, dry mouth, excessive thirst, frequent urinating, painful and missed periods.

Worrying or tension

Constant worry or tension that lasts for at least 6 months.

Social anxiety disorders are characterised by fear and anxiety in social surroundings and avoidance of interactions with people.

The worries may flit from one cause to another like family, relationships, work problems, finances, health or other problems. Most of the times they may be trivial.

Symptoms of OCD

OCD or obsessive compulsive disorders manifest as repeated actions to reduce the anxiety that stems from an obsession, which may be a recurrent or intrusive idea, worry or thought.

For example repeated cleaning or washing due to concerns about contamination.

Symptoms of PTSD

Those with Post-traumatic stress disorders may suffer from sudden panic attacks or constant generalized anxiety.

Edited by April Cashin-Garbutt, BA Hons (Cantab)

Diagnosis of Anxiety

Anxiety disorders have multiple subtypes each of which is characterized by unnecessary worry that can be distressing to the patient.

How is diagnosis of Anxiety made?

Diagnosis is made using the Diagnostic and Statistical Manual of Mental Disorders IV (Text Revision) also called DSM-IV-TR.

The manual lays down criteria for diagnosis of each of the types of anxiety disorders. If these criteria are fulfilled for at least 6 months, the diagnosis may be made.

Since anxiety disorders often coexist with other psychiatric disorders, diagnosis may be a challenge.

For example, nearly 60% of patients with generalized anxiety disorders have accompanying panic disorder or depressive disorders.

Further the condition may be accompanied with alcohol or drug abuse. (1, 2, 3, 4)

DSM IV-TR criteria for Generalized Anxiety Disorder

The DSM IV-TR Criteria for Generalized Anxiety Disorder include (1):

  • Presence of excessive anxiety about events or activities occurring on most days for at least 6 months
  • Losing control over the worry intensity
  • At least three of the symptoms including restless or jumpiness, fatigue, lack of concentration, irritability, muscle tension and sleep problems
  • Significant interference of symptoms with social and work related functioning or leading to significant distress
  • No other mood disorder or psychiatric problem

DSM IV-TR criteria for Panic Disorder

The DSM IV-TR criteria for Panic Disorder include (1):

Frequent panic attacks without cause or warning.

There may be presence of agoraphobia (fear of large open spaces). There are no other psychiatric or medial ailments that explain the attacks.

At least a single attack is followed by fear of:

  • Fear and concern regarding another attack
  • Worry regarding the consequences of an attack
  • Change in behavior with relation to the panic attacks

DSM IV-TR criteria for PTSD

The DSM IV-TR criteria for Post-traumatic stress Disorder include (1):

PTSD patients have a history of experiencing, witnessing or confronting an event that involved treat or actual risk of death or serious harm.

The experience may be accompanied with feelings of fear, helplessness or horror. The feelings of distress persist for at least 1 month.

On presentation the patient may re-live the event by:

  • Recurrent recollections of the event with thoughts, perception or flashes of images
  • Recurrent dreams
  • Sense of reliving the incident with illusions, hallucinations and flashbacks
  • Severe psychological distress on exposure to cues to the event and a physiological reaction to the cues

Patient avoids or feels at least three of the following:

  • Thoughts, feelings and conversation associated with the event
  • Activities, places, or people associated with the event
  • Loss of recall of the event
  • Decreased interest in significant activities
  • Detachment or estrangement from others

There may be associated symptoms of anxiety like:

  • Sleep problems
  • Irritability and anger outbursts
  • Lack of concentration
  • Increased vigilance
  • Increased jumpiness or startle response
  • Interference with social and work functioning

DSM IV-TR criteria for Obsessive compulsive disorder

The DSM IV-TR Criteria for Obsessive compulsive Disorder include (1):

  • Obsessions include recurrent and intrusive thoughts, impulses or ideas. There are usually no excessive worries about real-life problems.

    Patient has attempted to ignore or suppress such thoughts and recognizes that the obsessional thoughts are a product of his or her own mind.

  • Compulsions are repeated behaviors and mental actions that the patient is driven to follow according to self-set rigid rules.

    The compulsions ease the anxiety and reduce distress. These are not realistic and are clearly excessive.

  • The compulsions may be recognised as excessive and may take over 1 hour a day.

Diagnosing children with Anxiety

Diagnosing children with an anxiety disorder is difficult. Anxiety in children may manifest as behavioral problems or as a disruptive or rebellious nature.

Exclusion of medical conditions

Exclusion of medical conditions (3) –

  • Heart disease – Since chest pain and shortness of breath are common symptoms, heart disease and heart attacks should be ruled out.

    Mitral valve prolapse is a disorder where the mitral valve that lies between two chambers of the heart does not close well. This leads to impaired blood flow from the heart and back flow into the left atrium.

    There may be symptoms like chest pain, difficulty breathing especially after exercise, fatigue, cough, palpitations etc. this needs to be ruled out.

  • Asthma – Panic attacks may mask asthma attacks
  • Over active thyroid may lead to palpitations and needs to be ruled out.
  • Low blood sugar or hypoglycaemia manifests as sweating and palpitations.
  • Substance abuse and caffeine over dose may lead to anxiety and similar symptoms.

Edited by April Cashin-Garbutt, BA Hons (Cantab)

Treatment of Anxiety

Anxiety disorders can be distressing and may often need therapy.

The most important part of treatment of this condition is patient education. The guidelines especially for panic disorders, where patient may suffer sudden attacks without warning, recommend education for the family as well.

The symptoms of an anxiety attack may appear similar to a heart attack or other medical ailments. Patients as well the family need to be educated regarding these symptoms.

If a medical condition like high blood pressure, irregular heart rates and rhythms or overactive thyroid is found then appropriate medical therapy may be needed.

Therapy includes psychotherapy and management with medications. The aim of therapy is to ensure that the patient functions adequately in their day-to-day life. (1, 2, 3, 4, 5)

Psychotherapy for Anxiety

Psychotherapy includes cognitive-behavioral therapy, anxiety management therapy and applied relaxation therapy.

Cognitive-behavioral therapy

Cognitive-behavioral therapy (CBT) is provided by a psychotherapist. Patient needs to be committed to therapy.

Patients treated with a combination of CBT and medicines have better response than those who are undergoing usual treatment.

Some 10 to 20 visits to the therapist are needed over a few weeks. For panic attacks 12 - 16 sessions over 3 - 4 months may be needed.

These focus towards recreating fear symptoms and help patients change their response to them.

In OCD for children CBT is the first choice of therapy.

The therapy teaches the patient to identify and handle stress factors better.

Patients will learn to decrease the sense of helplessness by shutting out or neutralizing panic-causing thoughts.

He or she will be taught to avoid speculating that minor worries may turn to bigger problems.

Relaxation techniques will be taught.

For OCD the techniques are exposure and response prevention (ERP).

For patients with PTSD the psychological treatment will focus on the trauma with exposure therapy, cognitive therapy, and eye movement desensitization and reprocessing.

Patient will be advised to lead a healthier lifestyle with regular exercise, adequate rest and sleep and healthy balanced nutrition.

They will be taught to avoid excessive caffeine and illicit drugs, alcohol and cigarettes. Family and social interactions to lessen the impact of the condition will be advised.

Anxiety management therapy

Anxiety management therapy involves education, relaxation training, and exposure to anxiety-provoking stimuli.

However, there is no positive reconstruction technique to fight anxiety.

Applied relaxation therapy

Applied relaxation therapy helps patient relax each part of the body.

The therapy takes 12 to 15 hour-long sessions in a number of sittings and has been found to be effective.

Medication therapy for Anxiety

Medication therapy includes antidepressants, Benzodiazepines, SNRIs and so forth.

Antidepressants

Antidepressant drugs like selective serotonin reuptake inhibitors (SSRIs) that include fluoxetine, fluvoxamine, escitalopram, paroxetine, sertraline etc. show good effectiveness in panic disorders, Obsessive compulsive disorders, Post-traumatic stress disorders, social anxiety disorder and generalized anxiety disorder.

Within 3 to 4 weeks in most cases, and 8 to 12 weeks in OCD cases, there may be improvement.

The drugs should be started at low doses and slowly their doses may be increased to higher levels,

Benzodiazepines

Benzodiazepines have been used in the past to treat anxiety disorders. The drugs include clonazepam, lorazepam alprazolam, diazepam etc.

They are useful in short term management and are often given alongside initiation of CBT or SSRIs.

SSRIs have better tolerability and lesser risk of addiction and dependence and so they are preferred therapy for the anxiety disorders in the long run over benzodiazepines.

Short acting benzodiazepines like alprazolam carry a risk of rebound anxiety when withdrawing from the drug and are thus not preferred.

Venlafaxine

Venlafaxine may also be prescribed. It belongs to a group of medicines known as selective serotonin and noradrenaline reuptake inhibitors (SNRIs).

This type of medicine increases the amount of the neurotransmitters serotonin and noradrenaline in the brain, helping restore the chemical imbalance that sometimes causes GAD.

Buspirone

Buspirone may also be prescribed for anxiety instead of benzodiazepines. It belongs to a group of medicines known as anxiolytics.

It has to be taken for two weeks before a response is seen.

There are no risks of dependence or abuse with this medication unlike benzodiazepines. However, it is only recommended as a short-term form of medication.

Beta blockers

Beta blockers like Propranolol. This drug is used to treat high blood pressure.

In the short term it may easy symptoms of anxiety like palpitations etc.

Antipsychotic medications

For patients of PTSD who do not respond to SSRIs along an atypical antipsychotic – Olanzapine, used to treat psychosis and other psychiatric ailments may be added.

Antiepileptic medications

Pregabalin is used for seizures. Sometimes it may be effective in treating anxiety disorders not responding to other therapies.

Treatment for specialist groups

Certain populations are more vulnerable to ill effects and complications of anxiety disorders. These people also commonly have coexisting mental disorders that need prompt diagnosis and therapy. These include drug addicts and those with chronic obstructive pulmonary disease (COPD) or other respiratory or heart illness.

Pregnant and the elderly are also at a heightened risk.

Benzodiazepines are considered generally unsafe during pregnancy and may be abused by patients who have a substance abuse problem.

These patients may need combined treatment of an SSRI with CBT therapy.

Anxiety disorders are not easy to cure. They may recur along with ups and downs of life. Most patients however respond to medication and behavioural therapy.

Edited by April Cashin-Garbutt, BA Hons (Cantab)