University of Oxford

Anxiety Disorders

Anxiety Disorders

Introduction

Medicine, psychiatry, and dualism:

In the past, psychiatric diagnoses have been regarded as ‘mental’ in nature, in contrast to the ‘physical’ nature of medical diagnoses. This distinction reflects the absence of gross pathology in most psychiatric disorders, and the fact that these conditions usually present with disturbed mental states or behaviour rather than physical symptoms.

Underling this division of illnesses into physical and mental, is the assumption that a parallel distinction can be made in healthy people ‘body-mind dualism’. This has and continues to exert a profound influence on medical thinking.

Co-morbidity means the occurrence of two disorders. The term has been extended to describe the co-occurrence of prominent mental symptoms and bodily pathology since these patients are usually given a psychiatric and a physical diagnosis. In particular neither of these diagnoses may lead to effective treatment because a focus on either may lead to neglect of the other. An example is the widespread neglect of depression in patients with medical disease.

Somatization some patients have somatic symptoms but no evidence of bodily pathology. It is then unclear whether their illness should be categorized as medical or as psychiatric. In the past these conditions were generally given the medical diagnosis of functional illness (function is abnormal but there is no pathology). Now these conditions are usually given the psychiatric diagnosis of somatoform disorder. Such patients receive both a medical diagnosis (organic disorder) and a psychiatric diagnosis such as somatoform disorder (functional disorder) and the resulting confusion and controversy is well illustrated by literature about the condition called Chronic Fatigue Syndrome (CSF) or Myalgic Encephalomyelitis (ME).

Modern (integrated) approach:

New scientific knowledge, such as the demonstration of the neural basis to many psychiatric disorders (esp. with the functional imaging and genetics) has shown that crude dualistic thinking is untenable. Evidence for the effect of psychiatric disorder on the outcome of medical conditions such as MI (Frasure-Smith et al 1993) has pointed to the same conclusions.

Mind and brain are now increasingly regarded as two side of the same coin. This shift implies that psychiatric disorders are no more distinct from medical conditions than the higher nervous system is from the rest of the body. As Eisenberg (i986a) put it, psychiatry has to become less ‘brain-less’ and medicine less ‘mind-less’. Correspondingly medical and psychiatric care need to be more integrated.

The ‘biopsychosocial’ approach which can be further divided into predisposing, precipitating and perpetuating causes can go a long way to bridge the gap and most importantly, serve the patient.

Anxiety Disorders

Abnormal state in which the most striking features are mental and physical symptoms of anxiety, occurring in the absence of organic brain disease or another psychiatric disorder

Symptoms of anxiety:

Psychological arousal

  • Fearful anticipation
  • Irritability
  • Sensitivity to noise
  • Restlessness
  • Poor concentration
  • Worrying thoughts

Autonomic arousal

  • Gastrointestinal: dry mouth, difficulty swallowing, epigastric discomfort, excessive wind, frequent loose motions
  • Respiratory: constriction in the chest, difficulty inhaling
  • Cardiovascular: palpitations, discomfort in the chest, awareness of missed heart beats.
  • Genitourinary: Frequent or urgent micturation, failure of erection, menstrual discomfort, amenorrhoea

 Muscle tension

  • Tremor
  • Headache
  • Aching muscles

 Hyperventilation

  • Dizziness
  • Tingling in the extremities
  • Feeling of breathlessness

 Sleep Disturbance

  • Insomnia
  • Night terror

 Although all the symptoms can occur in any of the anxiety disorders, there is a characteristic pattern in each disorder which will be described later. The disorders share many features of their clinical picture and aetiology but there are also differences:

  • In generalized anxiety disorders, anxiety is continuous-though it may fluctuate in intensity.
  • In phobic anxiety disorders, anxiety is intermittent, arising in particular circumstances.
  • In panic disorder, anxiety is intermittent but its occurrence is unrelated to any particular circumstances.

 The Classification of anxiety disorders (ICD-10):

  •  Phobic anxiety disorder:

 Agoraphobia (with or without panic disorder)

Social phobia

Specific phobias

  •  Panic Disorder
  • Generalized anxiety disorder
  • Mixed anxiety and depression disorder.

 (OCD in ICD-10 is diagnosed separately, in the DSM-IV it is under anxiety disorder)

Generalized Anxiety Disorders

Clinical Picture

The symptoms in GAD are persistent and are not restricted to, or markedly increased in, any particular set of circumstances. All the previously mentioned symptoms can occur, but there are characteristic pattern comprised of the following features:

  • Worry and apprehension that are more prolonged than those oh healthy people. The worries are widespread and not focused on a specific issue as they are in panic disorder (on having a panic attack) or social phobia (on being embarrassed). The person feels that theses widespread worries are difficult to control.
  • Psychological arousal which may be evident as irritability, poor concentration, and sensitivity to noise. Some patients complain of poor memory.
  • Autonomic overactivity experienced most often as sweating, palpitation, dry mouth, epigastric discomfort, and dizziness. Some patients ask for help without mentioning the psychological symptoms of anxiety.
  • Muscle tension often as restlessness, trembling, inability to relax, headache (usually bilateral and frontal or occipital) and aching in shoulders and neck.
  • Hyperventilation which may lead to dizziness, tingling in the extremities and, paradoxically, a feeling of shortness of breath.
  • Sleep disturbance include difficulty falling asleep and persistent worrying thoughts. Sleep often intermittent, unrefreshing, and accompanied by unpleasant dreams. Some patients have night terrors in which they awake suddenly feeling intensely anxious. Early morning waking is not a feature of GAD and its presence strongly suggests a depressive disorder.
  • Other features include tiredness, depressive symptoms, obsession symptoms, and depersonalization. These never prominent. If so, another diagnosis should be considered.

Clinical signs

The face appears strained, the brow is furrowed, and the posture is tense. The person is restless and may tremble. The skin is pale and sweating is common, especially from the hand, feet, and axillae. Readiness to tears, which may at first suggest depression, reflects the generally apprehensive state.

Note that there is no clear dividing line between GAD and normal anxiety. They differ both in the extent of the symptoms and the duration (in DSM-IV 6 month, in the ICD-10, more flexible; symptoms should have been present on most days at least several weeks at a time, and usually several month’

Comorbidity is common:

  • Anxiety and depression
  • Schizophrenia
  • Dementia
  • Substance misuse
  • Physical illness e.g. Thyroid disease, hypoglycaemia.

Epidemiology:

Life time rate 4-5 %

Incidence 3% per year

Aetiology:

Biopsychosocial, Interaction between stressful events, genetic causes, early experiences, personality and social circumstances.

Areas of the brain most likely involved: the amyygdala, the hippocampus.

Na, 5-HT, GABA and recently CRH (corticotrophin releasing hormone)

Prognosis

Duration is important and the longer the GAD the worse the prognosis.

Co-morbidity (physical or psychiatric) worsen the prognosis

However GAD has a very good prognosis if treated.

 Treatment

  • Counselling: involving clear plan, explanation, reassurance, problem solving, advice about life style (e.g  caffeine)
  • Relaxation training has to be regular to work
  • CBT (Cognitive -Behavioural Therap)
  • Medications:in the short term, long acting BDZ (not more than 3 weeks, risk of addiction). For the long term, antidepressant are effective, SSRI first line and Venelafaxine is 2nd line.

Phobic anxiety disorders:

1. Specific phobia

Same core symptoms as GAD, but occur in particular circumstances, there may be anticipatory anxiety. Grouped into:

  • Situation(e.g. crowded places)
  • Objects (e.g. spiders)
  • Natural phenomena (e.g. Thunder)

The following specific phobias will be described briefly:

Phobia of dental treatment: 5% of adults.

Phobia of flying: CBT or behavioural treatment (desensitization is effective)

Blood injury phobia: unique in that fainting does occur, tensing works effectively with behavioural treatment.

Phobia of choking: exaggerated gag reflex (usually past experience). Desensitization works.

Phobia of illness: though recognised as irrational and not resisted.

Epidemiology:

Incidence 4.4 %per year

Prevalence 4% in M and 13 % in F.

Most start in childhood.

2. Social phobia

 Clinical picture:

Inappropriate anxiety, experienced in social situations in which the person feels observed by others and could be criticized by them. Avoidance and escape are characteristic. Can be generalised or specific (e.g. public speaking). Associated with depression and substance misuse

Two discrete social phobias require separate consideration:

  1. Phobia of excretion: patient become anxious and unable to pass urine in public lavatories, or fear of incontinence, patient arrange their lives so as never to be far from a lavatory.
  2. Phobia of vomiting: fear of vomiting in public places, feeling of nausea and anxiety.

 Prevalence 7%. M=F (seeking treatment). F>M (community).

Treatment with psychotherapy or medication (SSRIs and ? blockers).

 3. Agoraphobia

Patients are anxious when they are away from home, in crowds, or in situations that they cannot leave easily. They avoid these situations, feel anxious when anticipating them, and experience other symptoms. Especially panic attacks and fear of fainting and loss of control. Anticipatory anxiety is common, also depression, depersonalization and substance misuse.

 Epidemiology:

Life time prevalence 6-10% F>M

Usually begins in mid twenties (later than social or specific phobias)

 Panic disorder:

Clinical features:

Symptoms (at least 4) , more than 4 attacks in 4 weeks, or one attack followed by 4 weeks of persistent fear. Symptoms are:

  •  Shortness of breath and smothering sensation
  • Choking
  • Palpitation and accelerated heart rate
  • Chest discomfort or pain
  • Sweating
  • Dizziness, unsteady feelings or faintness
  • Nausea or abdominal distress
  • Depersonalization or derealization
  • Numbness or tingling sensations
  • Flushes or chills
  • Trembling or shaking
  • Fear of dying
  • Fear of going crazy or doing something uncontrolled.

 Epidemiology:

 Life-time prevalence is 5%.

Herdedibility is high, up to 30-40%.

F>M 2:1

Amongst men mortality is higher from cardiovascular disorders.

 Mixed anxiety and depressive disorder

This diagnosis is reserved when the diagnostic criteria for depression or GAD are not severe enough to meet the criteria. Mild illness

Influence of culture on anxiety disorders:

In several cultures the presenting symptoms of anxiety disorders are more often somatic than psychological. e.g. Koro ,occur amongst Chinese men , there are episodes of acute anxiety, lasting 30 min to a day or two, the person complain of palpitation, sweating, pericardia discomfort and trembling. At the same time he is convinced that the penis will retract into the abdomen and that when this process is complete he will die.

References

•1.      Stevens L, Rodin I. Psychiatry: An illustrated colour text, Churchill Livingstone 2001

•2.      Steple D. Oxford Handbook of Psychiatry, Oxford University Press, 2006

•3.      World Health Organization (WHO). ICD-10 Classification of mental and behavioural disorders. Churchill Livingstone

•4.      American Psychiatric Association (APA). DSM-IV-TR. Fourth Edition Text Revision. APA Publication

  

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