3.9.4 Anxiety disorders
Anxiety Disorders
Anxiety disorders are a group of mental health conditions characterized by excessive or unreasonable fear, worry, and nervousness. Here is a brief overview of the clinical differences between some of the most common anxiety disorders:
| Anxiety Disorder: | Description: |
| Generalized anxiety disorder (GAD) | GAD is characterized by excessive, long-lasting worry and fears about a variety of everyday events and activities. People with GAD often worry about things such as health, money, or family for no apparent reason, and this worry is often out of proportion to the actual situation. Other symptoms may include restlessness, fatigue, difficulty concentrating, irritability, and muscle tension. |
| Social anxiety disorder (social phobia) | Social phobia is a fear of being scrutinized or judged by others in social or performance situations, causing significant distress and avoidance behaviour. The fear is often centred on specific situations such as public speaking, eating in public, or being around others in general. People with social anxiety disorder often worry for days or weeks before the event and experience physical symptoms such as shaking, sweating, and blushing. |
| Specific phobias | A specific phobia is an intense fear of a specific object or situation that is out of proportion to the actual threat. Common phobias include fear of flying, animals (such as spiders or snakes), and heights. People with phobias often go to great lengths to avoid the object or situation they fear, and the fear can interfere with daily activities and relationships. |
| Separation anxiety disorder | Separation anxiety disorder is a condition in which a person experiences excessive fear or anxiety when separated from someone to whom they are attached, such as a parent or caregiver. This can involve excessive worry about harm befalling the attachment figure, or about being away from home or from the attachment figure. Children with a separation anxiety disorder may have trouble sleeping away from home or separating from the attachment figure for even brief periods. |
| Disorder: | DSM-5: | ICD-11: |
|---|---|---|
| Generalized Anxiety Disorder (GAD) | ✓ | ✓ |
| Panic Disorder | ✓ | ✓ |
| Agoraphobia | ✓ | ✓ |
| Specific Phobia | ✓ | ✓ |
| Social Anxiety Disorder (Social Phobia) | ✓ | ✓ |
| Separation Anxiety Disorder | ✓ | – |
| Selective Mutism | ✓ | – |
| Substance/Medication-Induced Anxiety Disorder | ✓ | – |
| Anxiety Disorder Due to Another Medical Condition | ✓ | – |
| Other Specified Anxiety Disorder | ✓ | – |
| Unspecified Anxiety Disorder | ✓ | – |
It’s important to note that while the DSM-5 and ICD-11 both cover various types of anxiety disorders, the specific criteria for diagnosis may differ between the two systems. Additionally, the categorization of mental disorders can vary between different diagnostic systems, and a diagnosis should always be made by a mental health professional through a comprehensive evaluation.
Generalized Anxiety Disorders
It’s common to have anxiety every now and then. However, strong, excessive, and persistent worry and panic over commonplace circumstances are typically experienced by those with anxiety disorders. Anxiety disorders sometimes entail recurrent episodes of acute anxiety, fear, or terror that peak in a matter of minutes (panic attacks).
Generalized Anxiety Disorder (GAD) is a common psychiatric disorder, with estimates as high as 1 in 5 adults experiencing it in their lifetime (Angst, 2016).
GAD is characterized by:
- Excessive anxiety and worry about a number of events or activities
- Individuals find it challenging to control the emotion of anxiety
- Anxiety impairs multiple contexts (eg. work, home and social)
(Patriquin, 2017)
These uncomfortable, hard-to-regulate, out-of-proportion to the real threat and protracted sensations of worry and panic interfere with daily activities.
Symptoms:
The following list of symptoms and indicators of anxiety:
- Feeling anxious, irritable, or uptight
- A feeling of impending catastrophe, terror, or disaster
- Having a faster heartbeat
- Breaths quickly (hyperventilation)
- Sweating
- Trembling
- Feeling drained or feeble
- Difficulty focusing or thinking about anything but the current issue
- Having issues falling asleep
- Having digestive system (GI) issues
- Having trouble managing worry
- A desire to stay away from things that make you anxious
Genetics and Neurobiology:
Environmental factors such as stress and trauma likely contribute to the development of anxiety disorders through epigenetic mechanisms. These epigenetic mechanisms are thought to even begin in utero. For example, mothers with anxiety disorders who were not prescribed anti-anxiety medication have altered DNA methylation of the glucocorticoid receptor gene (NR3C1) promoter region in cord blood and the genome, which may raise their child’s risk of having an anxiety disorder.
Disrupted coordination of brain activity and communication is thought to be the neurobiological reason for GAD:
- Reduced resting-state functional connectivity between the amygdala and prefrontal cortex.
- Decreased connectivity between the amygdala and prefrontal cortex.
- Remember the prefrontal cortex is critical for the regulation of emotion, specifically in the ventromedial regions that appear to control negative emotion (Diekhof, 2011).
- Structural and functional changes in the amygdala.
Management:
| Approach: | Summary: |
| Psychological | Cognitive behavioural therapy: Through relaxation and biofeedback, cognitive behavioural therapy directly tackles both skewed negative mental processes and some bodily symptoms. Psychodynamic psychotherapy: mediates its effects by increasing the patient’s anxiety tolerance. |
| Pharmacotherapy | Benzodiazepines: useful in the short term to allow patients to cope with the psychotherapeutic approaches. Antidepressants: Imipramine and SSRIs are often of some benefit if there is effective overlay. Buspirone: 5-HT1a agonists can be effective specifically on cognitive symptoms rather than somatic symptoms. |
Phobias
Social phobia:
Anxiety is solely restricted to particular social situations. Marked fear of being the focus of attention, or fear of behaving in a way that will be embarrassing or humiliating. Avoidance of phobic situations must be a prominent feature.
Specific phobia:
| Phobia: | Summary: |
| Animal phobia | 95% of people presenting for treatment are women. Boys tend to grow out of their phobias in adolescence. |
| Blood/injury phobia | More likely to have a family history compared to any other phobia, suspected to have a genetic component. |
| Space phobia | Characterized by fear of absent visuospatial support and of falling. Generally associated with a stable personality. |
| Illness phobia | Equal sex incidence. Previous illness in a relative or individual may be a precipitating factor. |
| Dental treatment phobia | Prevalence of 5%. |
Phobia treatment: Exposure therapy via flooding or systematic desensitization.
Panic Disorder
A panic attack is defined as a sudden onset of discrete anxiety for a defined time period. Symptoms experienced include palpitations, sweating, trembling or shaking, the sensation of shortness of breath, feeling of choking, chest pain, nausea, dizziness/lightheadedness, derealization/depersonalization, fear of losing control, fear of dying, paraesthesia, and chills or hot flushes. There is a female-to-male ratio of 2:1.
To diagnose a panic disorder a patient needs to have experienced three panic attacks within a three-week period.
PET scanning shows the following increases in the right para-hippocampal area:
- Increased blood flow
- Increased blood volume
- Increased O2 metabolism
Treatment: Cognitive behavioural therapy mixes exposure to the stimulus with relaxation and therapeutic work around the patient’s false cognition. Antidepressants and benzodiazepines will often be used as adjuncts.
Adjustment Disorder
A maladaptive reaction to a psychosocial stressor. It is often described as maladaptive since it interferes with the person’s social or occupational functioning. When the stressor passes, the disorder is expected to disappear.
Clinical features: Onset is usually within 1 month of the stressor. Duration of no longer than 6 months.
Young single women are a high percentage of patients suffering from the disorder.
| Treatment modality: | Summary: |
| Psychological | Group therapy: reinforce positive coping strategies. Individual therapy: must be time limited to avoid dependence. |
| Pharmacotherapy | Short courses of prescriptions may provide benefits for symptom relief ie. insomnia. |
References:
(1) Angst J, Paksarian D, Cui L, et al. The epidemiology of common mental disorders from age 20 to 50: results from the prospective Zurich cohort study. Epidemiol Psychiatr Sci 2016; 25(1): 24–32.
(2) Diekhof EK, Geier K, Falkai P, et al. Fear is only as deep as the mind allows: a coordinate-based meta-analysis of neuroimaging studies on the regulation of negative affect. Neuroimage 2011; 58(1): 275–285.
(3) Patriquin, M.A. and Mathew, S.J. (2017). The Neurobiological Mechanisms of Generalized Anxiety Disorder and Chronic Stress. Chronic Stress, 1(1), p.247054701770399. doi:10.1177/2470547017703993.