Anxiety Disorders Overview

Anxiety Disorders

• Anxiety is a universal human characteristic, serving as an adaptive mechanism to warn about external threats by activating the sympathetic nervous system, triggering the "fight or flight" response.
• Anxiety becomes pathological when:
  • Fear is disproportionate to the risk or severity of the threat.
  • The anxious response persists after the threat has ceased.
  • Attention is focused on the person's response to the threat, hindering normal functioning.
  • Social or occupational functioning is impaired.

Common Neurotic Disorders

• Anxiety/phobic disorders include:
  • Panic disorder
  • Generalized anxiety disorder (GAD)
  • Phobias
  • Hypochondriasis
• Stress-related disorders include:
  • Acute stress reactions
  • Adjustment disorder
  • Post-traumatic stress disorder (PTSD)
• Obsessive-compulsive disorder (OCD)

Features of Anxiety

• Psychological:
  • Apprehension
  • Fear anticipation
  • Feeling of dread
  • Hypervigilance
  • Restlessness
  • Sensitivity to noise
  • Difficulty concentrating
  • Insomnia or disturbing dreams
• Physical:
  • Chest tightness
  • Cardiovascular issues
  • Neurological symptoms
  • Gastrointestinal problems
  • Genitourinary symptoms
  • Musculoskeletal symptoms
  • Skin issues

Panic Disorder

• Characterized by recurrent, sudden, and unexpected panic attacks.
• At least one attack is followed by a month of ongoing concern about additional attacks, worry about consequences, or significant changes in behavior related to the attacks.
• Not a result of substance misuse, medical condition, or another psychiatric disorder.

Panic Disorder Symptoms

• Palpitations, pounding heart
• Sweating
• Trembling or shaking
• Shortness of breath
• Feeling of choking or difficulty swallowing
• Chest pain or discomfort
• Nausea or abdominal distress
• Feeling dizzy or faint
• Derealization or depersonalization
• Fear of losing control or going crazy
• Fear of dying
• Numbness or tingling sensations
• Chills or hot flashes

Epidemiology of Panic Disorder

• Lifetime prevalence: 4.2% for panic disorder, 8% for panic attacks.
• Women are 2-3 times more likely to be affected than men.
• Highest peak incidence: 15-24 years old.
• Second peak incidence: 45-54 years old.
• Rare after age 65.

Etiology of Anxiety Disorders

• Genetics
• Neurotransmitter imbalances
• Poor regulation of the autonomic nervous system response to stressors
• Locus ceruleus plays a critical role in anxiety expression

Differential Diagnosis of Anxiety

• Medical: Myocardial infarction, angina, chronic obstructive pulmonary disease (COPD), congestive heart failure, pheochromocytoma, other cardiac, pulmonary, or endocrine disorders.
• Psychiatric: Depressive disorders, phobic disorders, obsessive-compulsive disorder (OCD), post-traumatic stress disorder (PTSD).
• Substance-related: Cocaine, nicotine, caffeine, alcohol, or opiate withdrawal.

Course and Prognosis of Anxiety

• Chronic and waxing/waning course.
• Some patients recover within weeks.
• Prognosis is excellent with therapy.
• Relapse rate: 30-90%.

Management of Anxiety

• Pharmacological:
  • Selective serotonin reuptake inhibitors (SSRIs): (e.g., paroxetine, fluoxetine, fluvoxamine, citalopram, sertraline) for 8–12 months.
  • Tricyclic antidepressants (TCAs): (e.g., imipramine or clomipramine).
  • Benzodiazepines (short-term use) 2-4 weeks.
  • Beta-blockers
  • Buspirone
• Psychological:
  • Behavioral methods for phobias, exposure therapy, relaxation techniques, controlling hyperventilation.
  • Cognitive methods educating about bodily responses, modifying irrational thoughts and beliefs,cognitive behavioral therapy (CBT).

Phobic Disorder

• Intense, irrational fear & avoidance, impairing functioning.
• Agoraphobia: Anxiety symptoms restricted to places or situations where escape is difficult.
• Common phobias: panic disorder (60%), social phobia (55%),
• prevalence dependant.

Specific Phobias (Simple Phobias)

• Recurring excessive & unreasonable psychological/autonomic anxiety.
• Specific feared object or situation, leading to avoidance (e.g., animals, environment, blood/injection/injury, situational).
• Equally common in both sexes.
• Good prognosis often with late onset.

Social Phobia

• Anxiety restricted to social situations, leading to avoidance.
• Avoidance significantly interfering with daily routine.
• Commonest in South Africa (SA).
• Prevalence 3-13%.

Generalized Anxiety Disorder (GAD)

• Excessive worry, persistent anxiety, and feelings of apprehension regarding everyday events.
• Symptoms include muscle and psychic tension that causes distress and functional impairment.
• Lifetime prevalence 5%.
• More common in women.
• Commonly presented in primary care.

Stress-Related Disorders

• Acute stress disorder: Severe psychological disturbance following traumatic event, characterized by re-experiencing of elements of the event, hyper-arousal, avoidance, and emotional numbing.
• Adjustment disorders: Emotional or behavioral symptoms in reaction to identifiable stressors.
• Post-traumatic stress disorder (PTSD): Extended psychological distress following exposure to or witnessing of traumatic event.

Obsessive-Compulsive Disorder (OCD)

• Common, chronic condition often associated with marked anxiety and depression.
• Characterized by obsessions (recurrent thoughts, impulses, or images) and compulsions (repetitive behaviors or mental acts).
• Obsessions/compulsions cause distress or interfere with functioning.
• Not due to GMC or substance use.
• 2-3% of population globally.

OCD Epidemiology

• Mean age: 20 years
• 70% onset before age 25 years, 15% after age 35
• Equal sex distribution.

OCD Comorbidity

• Depressive disorder (50-70%)
• Alcohol and drug-related disorders
• Social phobia
• Specific phobia.
• Panic disorder
• Eating disorder

OCD Management

• Psychological:
  • Supportive psychotherapy (including family members, group therapy).
  • Psychoanalytic psychotherapy
  • Behavioral therapy: Response prevention, thought stopping
• Pharmacological:
  • Antidepressants (SSRIs, higher doses and longer treatment needed).
  • Electroconvulsive therapy (ECT) in some cases
  • Psychosurgery(in extreme cases)

Case Studies

These provide detailed examples of anxiety cases. Specific diagnoses, and potential approaches are presented in each case.