Anxiety Disorders

What is anxiety?

All of us worry about things in our day-to-day life but people with anxiety disorder are extremely worried about these and many other things, even when there is little or no reason to worry about them. They are very anxious about just getting through the day. They think things will always go badly. At times, worrying keeps people with anxiety from doing everyday tasks. Researchers have found that several parts of the brain are involved in fear and anxiety. Anxiety sometimes runs in families, but no one knows for sure why some people have it while others don’t.

Scientists believe that biological, psycho-social and environmental factors are involved in development of anxiety. Alterations in the gabaergic and seratoninergic systems or anomalies in the limbic system are the most affected biological factors. Stressful situations, family environment, threatening life experiences, and excessive worry about common subjects are among the well known psychological risk factors of anxiety. learning more about fear and anxiety in the brain, scientists may be able to create better treatments. Researchers are also looking for ways in which stress and environmental factors may play a role.

Who Is at risk?

  • Generalized anxiety disorders affect about 3.1% American adults age 18 years and older (about 18%) in a given year, causing them to be filled with fearfulness and uncertainty.
  • GAD affects about 6.8 million American adults, including twice as many women as men. The disorder develops gradually and can begin at any point in the life cycle, although the years of highest risk are between childhood and middle age.
  • Combined anxiety disorders affect approximately 12% of Canadians: about 9% of men and 16% of women during a one-year period and anxiety disorders represent the most common of all mental illnesses.

What causes anxiety disorders?

The development of anxiety disorders appears to result from a complex interplay of genetic, biological, developmental and other factors such as socio-economic and workplace stress.

Some people may learn their fear from an initial experience, such as an embarrassing situation, physical or sexual abuse, or the witnessing of a violent act. Similar subsequent experiences serve to reinforce the fear.

Some people believe or predict that the result of a specific situation will be embarrassing or harmful. This may occur, for example, if parents are over-protective and continually warn against potential problems.

Research suggests that the amygdala, a structure deep within the brain, serves as a communication hub that signals the presence of a threat and triggers a fear response or anxiety. It also stores emotional memories and may play a role in the development of anxiety disorders. The children of adults with anxiety disorders are at much greater risk of an anxiety disorder than is the general population, which may imply a genetic factor, an effect of parenting practices, or both.

What are different types of anxiety disorders?

Generalized Anxiety Disorder

People with generalized anxiety disorder display excessive anxiety or worry for months and face several anxiety-related symptoms.

Generalized anxiety disorder symptoms include:

  • Restlessness or feeling wound-up or on edge
  • Being easily fatigued
  • Difficulty concentrating or having their minds go blank
  • Irritability
  • Muscle tension
  • Difficulty controlling the worry
  • Sleep problems (difficulty falling or staying asleep or restless, unsatisfying sleep)

Panic Disorder

People with panic disorder have recurrent unexpected panic attacks, which are sudden periods of intense fear that may include palpitations, pounding heart, or accelerated heart rate; sweating; trembling or shaking; sensations of shortness of breath, smothering, or choking; and feeling of impending doom.

Panic disorder symptoms include:

  • Sudden and repeated attacks of intense fear
  • Feelings of being out of control during a panic attack
  • Intense worries about when the next attack will happen
  • Fear or avoidance of places where panic attacks have occurred in the past

Social Anxiety Disorder

People with social anxiety disorder (sometimes called “social phobia”) have a marked fear of social or performance situations in which they expect to feel embarrassed, judged, rejected, or fearful of offending others.

Social anxiety disorder symptoms include:

  • Feeling highly anxious about being with other people and having a hard time talking to them
  • Feeling very self-conscious in front of other people and worried about feeling humiliated, embarrassed, or rejected, or fearful of offending others
  • Being very afraid that other people will judge them
  • Worrying for days or weeks before an event where other people will be
  • Staying away from places where there are other people
  • Having a hard time making friends and keeping friends
  • Blushing, sweating, or trembling around other people
  • Feeling nauseous or sick to your stomach when other people are around

Evaluation for an anxiety disorder often begins with a visit to a primary care provider. Some physical health conditions, such as an overactive thyroid or low blood sugar, as well as taking certain medications, can imitate or worsen an anxiety disorder. A thorough mental health evaluation is also helpful, because anxiety disorders often co-exist with other related conditions, such as depression or obsessive-compulsive disorder.

What other conditions could present with symptoms of anxiety?

Several physical and mental illnesses can present with anxiety or symptoms of anxiety disorders.

  • Mental illnesses
    • Major Depression
    • Anxiety Adjustment Disorder
    • Personality Disorder
    • Panic disorders
    • Social phobia
    • OCD
    • Anorexia nervosa
    • Separation anxiety disorders
    • PTSD
    • Adjustment disorder
    • Mood Disorder
    • Psychotic disorder
    • Substance use disorder
  • Secondary to Medications or Drug use
    • Cocaine Abuse
    • Amphetamine
    • Marijuana
    • Lysergic Acid (LSD)
    • Ephedrine and other Decongestants
    • Digoxin Toxicity
    • Theophylline toxicity
    • Methylphenidate
    • Anticholinergics
    • Caffeine
  • Secondary to withdrawal from:
    • Smoking cessation
    • Benzodiazepines
    • Beta-Blocker
    • Alcohol
    • Narcotic
    • Anticholinergic
    • Caffeine
  • Cardiopulmonary disease
    • Atrial flutter
    • Paroxysmal Supraventricular Tachycardia
    • Hypertension
    • Asthma
    • Pulmonary Embolus
  • Endocrine disease
    • Hyperthyroidism
    • Hypoparathyroidism
    • Cushing’s Disease
    • Carcinoid Syndrome
    • Pheochromocytoma
    • Hypoglycemia
    • Menopause

What are the symptoms and signs of anxiety disorders?

Individuals who suffer from anxiety disorders could present with impairments of one or more organ systems. Often, they report anxiety and worry more days than not for the past 6 months. Their anxiety is related to work, school, academic performance, family safety, health, financial status or other similar issues. They find it difficult to control their worry and their anxiety and worry are associated with (3 or more of) the restlessness or feeling keyed up or on edge; being easily fatigued; difficulty concentrating or mind going blank; irritability; muscle tension; and sleep disturbance. Anxiety and worry or the related physical symptoms cause clinically significant distress or impairment in social, occupational or other important areas of functioning.

 

Cognitive symptoms: 

  • Thoughts of imminent danger are commonly felt and reported.
  • Often, people are concerned over inability to cope with day-to-day life and work tasks.

Behavioral symptoms: 

  • Avoidance behavior is another cause of increased anxiety
  • Safety behavior:
    • Tries to eliminate the danger (unlike coping behavior)
    • May maintain or increase anxiety

Physical signs and symptoms:

  • Increased blood pressure
  • Shortness of breath
  • Rapid heartbeat
  • Dry mouth
  • Sweating
  • Muscle tension and muscle aches
  • Shakiness
  • Dizziness
  • Nausea
  • Hot flashes or chills
  • Frequent urination
  • Restlessness
  • Difficulty swallowing
  • Difficulty concentrating.
  • Trouble falling asleep or staying asleep.
  • Fatigue
  • Headaches
  • Dry mouth
  • Paresthesia
  • Palpitations
  • Chest pain
  • Dyspnea
  • Diarrhea
  • Constipation
  • Aerophagia
  • Sexual problems

Mood:

  • Nervousness
  • Panicky
  • On edge

What laboratory work ups are used in making the diagnosis of anxiety disorders?

Majority of the laboratory work up requested in anxiety disorders are used to rule out other health conditions that could present with symptoms of anxiety disorders.

  • CBC to rule out anemia
  • Electrolytes
  • Serum cortisol
  • Thyroid hormones
  • Urine Drug Screen

Are there any diagnostic tests for anxiety problems?

Although there is no specific diagnostic investigation for diagnosing anxiety disorders, clinicians might request specific tests just to rule our potential health problems that might present with symptoms of anxiety disorders. Type of the test would depend on the nature of the symptoms, findings of physical assessment, patients age, gender and ….

What treatments are available for treatment of anxiety disorders?

Early recognition and appropriate management are imperative in order to enhance the quality of life of individuals with anxiety disorders. Proper recognition and management also help to prevent common secondary disorders, such as depression and abuse of drugs and alcohol. The delay in seeking and receiving a diagnosis and treatment may be due to a number of factors, such as stigma, a lack of human resources, restrictive government funding systems and lack of knowledge.

Too often, the symptoms are not taken seriously and an individual with an anxiety disorder is labelled as being emotionally unstable. Many individuals might not seek help for management of their anxiety problems. Some, choose unhealthy approaches such as drinking alcohol, using drugs or taking medications that are not prescribed to them.

A combination of behavioral therapy, life style modification, risk factor removal and if indicated medications can be used for management of symptoms of anxiety disorders.

Cognitive Therapy

  • Self-instruction
    • detect negative self-verbalization (“I won’t be able to…”) and replace them with positive self-instruction
  • Training in handling anxiety symptoms:
    • Relaxation
    • Recognize, Reexamine and Replace anxious thoughts
  • Cognitive distraction and thought stopping
    • focus attention on non-threatening stimuli such as counting trees… etc.
  • Problem resolution techniques:
    • Reduces the intensity of the apprehension and increases the feeling of control
  • Cognitive Restructuring:
    • replaces irrational or distorted thoughts with other more rational ones
    • The work is structured around a skill-training model

 

Behavioral Techniques:

  • Relaxation techniques:
    • Progressive relaxation
    • Breathing control
  • Exposure techniques:
    • Systematic desensitization
    • Gradual exposure
  • Self-control techniques:
    • Self-observation
    • Self-reinforcement/self-punishment
    • Control of stimuli
  • Training in social skills:
    • after analyzing the problem behavior and retraining it

 

Medications:

  • Antidepressants
    • Paroxtetine
    • Velnlafaxine
    • Imipramine
    • Sertraline
    • Escitalopram
    • Duloxetine
  • Encourage healthy lifestyle as an adjunct to treatment
    • Physical activity
    • Avoid drugs and alcohol
  • Medications:
    • Buspirone (Buspar®)
      • Non-addictive anxiolytics
      • Less adverse effects compared with Benzodiazepines
    • SSRI:
      • Indicated for concurrent depression
      • Paroxetine (Paxil®)
      • Venlafaxine (Effexor®)
      • Nefazodone (Serzone®)
    • TCAs:
      • Imipramine (Tofranil®)
      • Desipramine (Norpramin®)
    • MAOi:
      • Indicated for concurrent phobia
      • Phenelzine (Nardil®)
      • Tranylcypromine (Parnate®)
    • Beta Blockers:
      • Indicated for excessive autonomic symptoms
      • Propranolol (Inderal®)
      • Atenolol (Tenormin®)
    • Benzodiazepines (Long Acting) only for acute phase and for short term:
      • BDZs are not recommended currently because of risk of physical dependence, tolerance, memory problem, and withdrawal
      • Preferred only in Generalized Anxiety Disorder and for short period of time
      • Clonazepam (Klonopin®)
    • Benzodiazepines (Short-acting) only for acute phase and for short term:
      • Indicated in the elderly or with decreased clearance
      • Alprazolam (Xanax®)
      • Lorazepam (Ativan®)
      • Oxazepam (Serax®)

Management of anxiety disorders

Psychotherapy:

  • A type of psychotherapy called cognitive behavior therapy is especially useful for treating GAD. It teaches a person different ways of thinking, behaving, and reacting to situations that help him or her feel less anxious and worried.
  • Avoiding stimulants such as cocaine, crack, crystal meth
  • Avoid drinking alcohol as a self-treatment for anxiety. It might work in low doses in short term but causes serious health problems such as depression, rebound anxiety …
  • Mindfulness:
  • Breathing:
  • Imagery: 
  • Progressive Muscle Relaxation: 
  • Anxiety Ladder:
    • Create a hierarchy of fearful events. Start with the least fearful at the bottom and the most fearful event on the top ladder.
  • Meditation: 
    • Stress management techniques and meditation can help people with anxiety disorders calm themselves and may enhance the effects of therapy.

    Exercice: 

    • There is preliminary evidence that aerobic exercise may have a calming effect. Since caffeine, certain illicit drugs, and even some over-the-counter cold medications can aggravate the symptoms of anxiety disorders, they should be avoided.
  • CBT: 
    • Changing your thoughts of perception of danger
    • Increasing your confidence

 

Medications:

  • The use of anti-depressants is recommended as one of the pharmacological treatments of choice for GAD.
  • When the response to the optimal dosage of one of the SSRIs is inadequate or if they are not well tolerated, the patient should switch to another SSRI. If there is no improvement after 8-12 weeks, consider using another drug with a different mechanism of action (SNSRI, TAD)

Ways to make treatment effective:

  • If you think you have an anxiety disorder, the first person you should see is your family doctor. A physician can determine whether the symptoms that alarm you are due to an anxiety disorder, another medical condition, or both.
  • If an anxiety disorder is diagnosed, the next step is usually seeing a mental health professional. The practitioners who are most helpful with anxiety disorders are those who have training in cognitive-behavioral therapy and/or behavioral therapy, and who are open to using medication if it is needed.
  • You should feel comfortable talking with the mental health professional you choose. If you do not, you should seek help elsewhere. Once you find a mental health professional with whom you are comfortable, the two of you should work as a team and make a plan to treat your anxiety disorder together.
  • Remember that once you start on medication, it is important not to stop taking it abruptly. Certain drugs must be tapered off under the supervision of a doctor or bad reactions can occur. Make sure you talk to the doctor who prescribed your medication before you stop taking it. If you are having trouble with side effects, it’s possible that they can be eliminated by adjusting how much medication you take and when you take it.
  • Most insurance plans, including health maintenance organizations (HMOs), will cover treatment for anxiety disorders. Check with your insurance company and find out. If you don’t have insurance, the Health and Human Services division of your county government may offer mental health care at a public mental health center that charges people according to how much they are able to pay. If you are on public assistance, you may be able to get care through your state Medicaid plan.
  • Many people with anxiety disorders benefit from joining a self-help or support group and sharing their problems and achievements with others.
  • Internet chat rooms can also be useful in this regard, but any advice received over the Internet should be used with caution, as Internet acquaintances have usually never seen each other and false identities are common.
  • Talking with a trusted friend or member of the clergy can also provide support, but it is not a substitute for care from a mental health professional.
  • The family is very important in the recovery of a person with an anxiety disorder. Ideally, the family should be supportive but not help perpetuate their loved one’s symptoms. Family members should not trivialize the disorder or demand improvement without treatment.

 

Are there any adverse effects related to anxiety medications?

  • The adverse effects of anti-depressants described include sedation, dizziness, nausea, dry mouth, constipation, falls, and sexual dysfunction (with the exception of dizziness and sexual dysfunction) decrease after 6 months in patients who continue with the medication.
  • The prescription of venlafaxine is not recommended to patients at high risk of cardiac arrhythmia or recent myocardial infarct, and will only be used in patients with hypertension when the hypertension is controlled.
  • When the response to the optimal dosage of one of the SSRIs is inadequate or if they are not well tolerated, the patient should switch to another SSRI. If there is no improvement after 8-12 weeks, consider using another drug with a different mechanism of action (SNSRI, TAD).
  • During pregnancy, the choice of the treatment must consider whether the potential advantages for the mother of the prescribed SSRIs outweigh the possible risks to the embryo.
  • BDZs provide fast initial relief of anxiety symptoms, but the evidence suggests that their effects do not differ significantly from those obtained with a placebo after 4 to 6 weeks of treatment.
  • The use of BDZs is associated with higher risk of dependence, tolerance, sedation, traffic accidents, and withdrawal effects (rebound anxiety).

 

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