Understanding Anxiety Disorders

• Anxiety disorders are characterized by excessive and persistent feelings of worry, uneasiness and apprehension that interfere with daily life.
• Anxiety is a state of tension and apprehension in response to a perceived threat.
• Clinical diagnosis of anxiety disorders uses the Diagnostic Statistical Manual of Mental Disorders (DSM-5) or International Classification of Diseases (ICD-11).

Objectives of the Lecture

• Understand anxiety and anxiety disorders.
• Identify the clinical features of anxiety disorders.
• Know the risk factors of developing anxiety disorders.
• Know the treatment and management of anxiety disorders.

Definition of Anxiety

• The persistent uneasiness stems from anticipation of danger (internal/external) or response to stress.
• Anxiety is extreme apprehension (worry) about a future threat/event.
• Anxiety is persistent and excessive worry about everyday things like work, school, relationships, and exams.
• Characterized by excessive worry, nervousness, and restlessness.
• Moderate levels of anxiety improve performance.
• High levels of anxiety are detrimental to performance.
• Absence of anxiety interferes with performance.
• Anxiety can interfere with a person's daily life.

Anxiety vs Fear

• Fear is a strong emotional response to an exact and immediate existing danger.
• Fear is usually an emotional reaction to a specific, real threat.
• Both involve physiological arousal via the Sympathetic nervous system.
• Both result in emotional and physical reactions such as feeling tensed or sweating.
• Both can be adaptive; fear triggers fight or flight to save one from danger, and anxiety increases preparedness.
• Fear is a response to a specific, immediate, intense, and short-lived threat, like seeing a snake.
• Anxiety is an excessive and unfocused response that may be triggered by a variety of stimuli.
• Anxiety includes worrying about potential danger that may be lingering.
• Anxiety includes worry over things that may or may not occur, like worrying about seeing a snake in a bushy area.

Anxiety Disorders Definition

• Anxiety disorders are a group of disorders characterized by excessive and irrational fear responses that leave a person clinically distressed and dysfunctional.
• The frequency, rationale, and intensity of anxiety responses are usually out of proportion to the situation that triggered them.

Characteristics of Anxiety Disorders

• Anxiety responses are characterized by emotional, cognitive, physiological, and behavioral symptoms.
• Emotional symptoms include feeling tense and irritable.
• Cognitive symptoms include worry or thoughts of inability to cope.
• Physiological symptoms include increased heart rate, nausea, and sweating.
• Behavioral symptoms include restlessness and avoidance of a feared situation or object.

Additional Facts about Anxiety Disorders

• Anxiety disorders are among the most common mental health disorders.
• Anxiety disorders are more common in females than males.
• Most anxiety disorders start in childhood and can stay on till adulthood.
• The WHO estimates that about 2.9% of the population in Ghana experienced anxiety disorders between 1990 and 2017.
• A 2021 community-based cross-sectional study in the Volta region (N=2456) showed that 53.3% of participants had an anxiety disorder.

General Indicators for Identifying Anxiety Disorders

• Excessive and persistent worry or fear is unreasonable, persistent, and intense, and it persists for an extended period and is usually difficult to control.
• Interference with daily life; worry or fear interferes with social, occupational, or other areas of life.
• Distress or impairment: Significant distress or impairment in social, occupational, or other areas of life.
• Fear of loss of control indicates a fear of losing control or going crazy.
• Physical symptoms include rapid heartbeat, sweating, trembling, or shortness of breath.
• Avoidance behaviors include avoiding situations or places that trigger anxiety.
• Rumination includes recurrent and persistent thoughts or worries that are difficult to control.
• Hypervigilance is excessive alertness or watchfulness.
• Symptoms persist for at least 6 months, except for some specific disorders like phobias.

Clinical Assessment of Anxiety and Stress Related Disorders

• Psychological tools that can be used to clinically assess and diagnose anxiety disorders include:
• Beck Anxiety Inventory (BAI).
• Social Phobia and Anxiety Inventory.
• Hospital Anxiety and Depression scale.
• Generalized Anxiety Disorder Scale (GAD-7).
• Panic and Agoraphobia Scale (PAS).
• Hamilton Anxiety Rating Scale (HAM-A).
• Zung Self-Rating Anxiety Scale (SAS).
• Depression Anxiety Stress Scale (DASS-21 and DASS-42).
• Revised Children’s Anxiety and Depress Scale (RCADS and RCADS-P).
• Screen for Child Anxiety Related Disorders-Parent (SCARED).

Physical Symptoms of Anxiety Disorders

• Choking sensation.
• Breathlessness.
• Dilated pupils.
• Muscle tension.
• Tightness of chest.
• Excessive thirst.
• Dry mouth.
• Difficulty in swallowing.
• Palpitations.
• Shaking.
• Shortness of breath.
• Nausea.
• Sweating.
• Gastrointestinal discomfort.
• Headache.

Psychological/Emotional Symptoms of Anxiety Disorders

• Worry.
• Irritability.
• Restlessness.
• Insomnia.
• Lack of interest or apathy.
• Feeling of worthlessness.
• Apprehension.
• Helplessness.
• Fear of losing control.

Cognitive Symptoms of Anxiety Disorders

• Inability to concentrate.
• Memory problem.
• Intrusive negative thoughts.

Behavioral Symptoms of Anxiety Disorders

• Withdrawal/avoidance behaviors.
• Escape behaviors.
• Compulsive behaviors.

Classification of Anxiety Disorders (DSM-5)

• Panic disorder involves sudden uncontrolled fear or anxiety related to a perceived threat or danger and recurring, unexpected, intense fear that brings on a panic attack.
• Generalized anxiety disorder (GAD) involves chronic, persistent, unrealistic and excessive worry or anxiety about everyday things that interferes with daily activities, has impaired concentration and insomnia, affects adolescents, widows, divorcees, and unemployed.
• Social anxiety disorder involves persistent, unrealistically intense fear of social situations that might involve being examined by, or even just exposed to, unfamiliar people or a situation.
• Specific phobias involve an excessive, unreasonable, persistent fear triggered by a specific object or situation. Examples include fear of flying (aerophobia), fear of snakes (ophidiophobia), fear of heights (acrophobia), fear of needles/injection (trypanophobia), and fear of enclosed/small space (claustrophobia).
• Agoraphobia is the fear of being in places or situations that are crowded, enclosed, and where rapid exit is difficult or impossible and a fear of losing control and not getting help e.g., being in an elevator, bridge, or airplane.
• Separate anxiety disorder involves unusual fear and anxiety about separation from parents or attachment figures to a degree that is developmentally inappropriate.
• Obsessive-Compulsive Disorder (OCD) involves recurring, intrusive thoughts (obsessions) and repetitive behaviors (compulsions).
• Selective mutism is a childhood disorder characterized by an inability to speak in certain social situations where there is an expectation to speak but the individual speaks in other situations.
• Substance/medication induced anxiety disorder involves the use of certain medications or illegal drugs, or withdrawal from certain drugs, potentially triggering some symptoms of anxiety disorder.
• Anxiety disorder due to medical conditions involves intense worry and panic due to the presence of a physical health problem such as heart problems, and thyroid issues.

Risk Factors of Anxiety Disorders

• Genetic vulnerability: Family history/inherited traits.
• Neuroticism: Decreased functioning of GABA and serotonin; increased norepinephrine activity.
• Personal traits/behaviors: Perfectionism, low self-esteem, and sensitivity to stress, shyness, introvert, etc.
• Cognitive distortion: factors including sustained negative beliefs, perceived lack of control, and attention to cues of threat.
• Environmental factors: Stressful life events, experiencing or witnessing a traumatic event.
• Medical conditions: Conditions such as heart conditions, chronic pain, and thyroid issues.

Treatment and Management of Anxiety

• Psychotherapy:
  • Cognitive Behavioral Therapy (CBT) is used to change thoughts about feared object/situations.
  • Behavioral Techniques include systematic desensitization, which is effective in phobias, and flooding.
  • Relaxation techniques include progressive muscle relaxation techniques, meditation, deep breathing exercises, and yoga.
• Medication (psychiatry):
  • Antidepressants: Modern antidepressants (SSRIs and SNRIs) are typically the first-line treatments for anxiety disorder.
  • SSRIs include escitalopram (Lexapro) and fluoxetine (Prozac).
  • SNRIs include duloxetine (Cymbalta), venlafaxine (Effexor), and bupropion (commonly used to treat chronic anxiety).
  • Anti-anxiety drugs: Benzodiazepines are sedatives that can help relax muscles and calm your mind by increasing the effects of certain neurotransmitters.
  • Examples of anti-anxiety drugs are alprazolam (Xanax), clonazepam (Klonopin) and buspirone (BuSpar), used to treat both short-term and chronic anxiety.
  • Beta-blockers treat physical symptoms of anxiety, such as a racing heart, severe palpitations, trembling, or shaking.
• Management:
  • Lifestyle Change: Regular exercise, healthy diet, stress management, mindfulness and relaxation techniques, and meditation.
  • Social support: Family support, friends, and social help groups.

Effect of Untreated Anxiety Disorders

• Physical health risks include contributing to high blood pressure, heart disease, and digestive issues.
• Mental health risks include increased risk of other mental health conditions like depression, substance abuse, and other mood disorders.
• Social impacts include difficulty maintaining relationships and performing well at work or school.

Case Study: Mary

• Mary is a 32-year-old female who is a successful project manager with an NGO in Tamale.
• She has been experiencing a chronic worry for the past two years, reporting feeling tense and worrying excessively about various aspects of her life, including work, relationships, health, and finances, even when there is no immediate threat
• Despite being divorced, having a stable job, and a supportive relationship with family and friends, Mary feels overwhelmed by her constant worrying.

Mary's Symptoms Include

• Persistent and uncontrollable worry about work deadlines, family matters, and personal health and difficulty relaxing or calming down, feeling restless or on edge.
• She experiences muscle tension and trouble sleeping due to racing thoughts and is irritable and has difficulty concentrating during daily activities.

Mary's Diagnosis and Treatment

• Mary has Generalized Anxiety Disorder (GAD) because her anxiety is excessive, prolonged (more than six months), affects several aspects of her life, and impacts her daily functioning.
• Treatment Approach:
  • Cognitive Behavioral Therapy (CBT) will focus on addressing negative thought patterns, such as catastrophic thinking, and learning strategies for relaxation and stress management.
  • Medication: Mary was prescribed a selective serotonin reuptake inhibitor (SSRI) to help manage her anxiety symptoms.
  • Lifestyle Changes: Mary will incorporate regular exercise into her routine, practice mindfulness meditation, and work on improving sleep hygiene.