Anxiety-Related Conditions (Generalized Anxiety; Panic attacks; Phobia; Social Phobia/Social Anxiety; OCD; PTSD)
Anxiety-Related Conditions
(Generalized Anxiety; Panic attacks;
Phobia; Social Phobia/Social Anxiety; OCD; PTSD)
Everyone
periodically experiences fear and anxiety. Fear is an emotional, physical, and
behavioural response to an immediately recognizable external threat. Anxiety is
a distressing, unpleasant emotional state of nervousness and uneasiness; its
causes are less clear. Anxiety is less tied to the exact timing of a threat; it
can be anticipatory before a threat, persist after a threat has passed, or
occur without an identifiable threat. Anxiety is often accompanied by physical
changes and behaviours similar to those caused by fear. Some degree of anxiety is
adaptive; it can help people prepare, practice, and rehearse so that their
functioning is improved and can help them be appropriately cautious in
potentially dangerous situations. However, beyond a certain level, anxiety
causes dysfunction and undue distress. At this point, it is maladaptive and
considered a disorder.
Anxiety occurs in a wide range of
physical and mental disorders, but it is the predominant symptom of several.
Anxiety disorders are more common than any other class of psychiatric disorder.
However, they often are not recognized and consequently not treated. Left
untreated, chronic, maladaptive anxiety can contribute to or interfere with
treatment of some physical disorders.
Anxiety disorders constitute being ‘the
apprehensive anticipation of future danger or misfortune accompanied by a
feeling of dysphoria or somatic symptoms of tension are the most common forms of psychiatric disorder (APA,
1994; Kessler et al., 2005). Anxiety
may be defined as a state of neurological arousal characterized by both
physical and psychological signs. Anxiety may be a normal reaction that acts as
a signal to the body that aspects of its systems are under stress or out of
equilibrium. Anxiety disorders include the phobias, panic disorder, obsessive-compulsive disorder
(OCD), and posttraumatic stress disorder. Symptoms may be so severe as to be
disabling, but these illnesses seldom involve psychosis. Panic attacks come '“out
of the blue” when there is no reason to be afraid. Symptoms include sweating,
shortness of breath, heart palpitations, choking, and faintness. With OCD, the
individual may have only obsessions or only compulsions, but most have both.
Obsessions are repeated, intrusive, unwanted thoughts that cause extreme
anxiety. Compulsions are ritual behaviours that a person uses to diminish
anxiety. Examples are hand washing, counting, repeated checking, and repeating
a word or action.
Research in the West has shown that anxiety disorders appear to be more
highly prevalent in the public mental health system than might be expected
given the lack of attention in research and program policy statements to
anxiety disorders, and the corresponding emphasis given to what are generally considered
the serious mental disorders (schizophrenia, bipolar disorder, and major
depressive disorder). They also have higher rates of outpatient mental health services
utilisation. Anxiety disorders rival depression in terms of risk, co morbidity
and outcome and as such should not be treated lightly.
Aetiology of Anxiety
Related Conditions
The causes of anxiety disorders are not
fully known, but both mental and physical factors are involved. Many people
develop anxiety disorders without any identifiable antecedent triggers. Anxiety
can be a response to environmental stressors, such as the ending of a
significant relationship or exposure to a life-threatening disaster. Some
physical disorders can directly produce anxiety; they include the following:
1.
See mood
disorders.
3. Pheochromocytoma
4. Hyperadrenocorticism
5. Heart
failure
6. Arrhythmias
7. Asthma
8. Chronic Obstructive
Pulmonary Disease
Other
physical causes include use of drugs; effects of corticosteroids, cocaine,
amphetamines, and even caffeine can mimic anxiety disorders. Withdrawal from
alcohol, sedatives, and some illicit drugs can also cause anxiety.
Symptoms and
Signs of Anxiety Disorders
Anxiety can
arise suddenly, as in panic, or gradually over many minutes, hours, or even
days. Anxiety may last from a few seconds to years; longer duration is more
characteristic of anxiety disorders. Anxiety ranges from barely noticeable
qualms to complete panic. The ability to tolerate a given level of anxiety
varies from person to person.
1.
Generalized Anxiety Disorder
2.
Panic and agoraphobia
3.
Phobia
4.
Social phobia/Social Anxiety Disorder
5.
Obsessive-compulsive Disorder
6.
Post-traumatic and Acute Stress
Disorders
Signs,
characteristics, and therapeutic interventions for these conditions are
outlined in the following section.
Signs/Characteristics
of Specific Conditions
Generalized Anxiety Disorder
The essential feature is anxiety, which is generalized and persistent
but not restricted to, or even strongly predominating in, any particular
environmental circumstances (i.e. it is "free-floating"). As in other
anxiety disorders the dominant symptoms are highly variable, but complaints of
continuous feelings of nervousness, trembling, muscular tension, sweating,
light-headedness, palpitations, dizziness, and epigastric discomfort are
common. Fears that the sufferer or a relative will shortly become ill or have
an accident are often expressed, together with a variety of other worries and
forebodings. This disorder is more common in women, and often related to chronic
environmental stress. Its course is variable but tends to be fluctuating and
chronic. This is defined as
chronic, constant anxiety that persists throughout the day consistently for at
least 1 month.
Essentials of Diagnosis
The sufferer must have primary symptoms of anxiety most days for at
least several weeks at a time, and usually for several months. These symptoms
should usually involve elements of:
a)
Apprehension
(worries about future misfortunes, feeling "on edge", difficulty in
concentrating, etc.);
b)
Motor tension
(restless fidgeting, tension headaches, trembling, inability to relax); and
c)
Autonomic over
activity (light-headedness, sweating, tachycardia or tachypnoea, epigastric
d)
Discomfort,
dizziness, dry mouth, etc.).
In children, frequent need for reassurance and recurrent somatic
complaints may be prominent. The transient appearance (for a few days at a
time) of other symptoms, particularly depression, does not rule out generalized
anxiety disorder as a main diagnosis, but the sufferer must not meet the full
criteria for depressive episode , phobic anxiety disorder , panic disorder or
obsessive-compulsive disorder.
Treatment
– supportive counselling (see Counselling Interventions in this chapter);
individual or group psychotherapy; anti-anxiety medication (see table in this
chapter).
Mixed Anxiety and
Depressive Disorder
This mixed category should be used when symptoms of both anxiety and
depression are present, but neither set of symptoms, considered separately, is
sufficiently severe to justify a diagnosis. If severe anxiety is present with a
lesser degree of depression, one of the other categories for anxiety or phobic
disorders should be used. When both depressive and anxiety syndromes are
present and severe enough to justify individual diagnoses, both disorders
should be recorded and this category should not be used; if, for practical
reasons of recording, only one diagnosis can be made, depression should be
given precedence. Some autonomic symptoms (tremor, palpitations, dry mouth,
stomach churning, etc.) must be present, even if only intermittently; if only
worry or over-concern is present, without autonomic symptoms, this category
should not be used. If symptoms that fulfil the criteria for this disorder
occur in close association with significant life changes or stressful life
events, criteria for adjustment disorders, should be used (These are states of
subjective distress and emotional disturbance, usually interfering with social
functioning and performance, and arising in the period of adaptation to a
significant life change or to the consequences of a stressful life event
(including the presence or possibility of serious physical illness). The
stressor may have affected the integrity of an individual's social network (through).
Individuals with this mixture of comparatively mild symptoms are
frequently seen in primary care, but many more cases exist among the population
at large which never come to medical or psychiatric attention.
Treatment
– supportive counselling (see Counselling
Interventions in this chapter); individual or group psychotherapy; anti-anxiety
medication (see table in this chapter).
Social Phobia/Social Anxiety Disorder
Social phobias often start in adolescence and are centred on a fear of
scrutiny by other people in comparatively small groups (as opposed to crowds),
usually leading to avoidance of social situations. Unlike most other phobias,
social phobias are equally common in men and women. They may be discrete (i.e.
restricted to eating in public, to public speaking, or to encounters with the
opposite sex) or diffuse, involving almost all social situations outside the family
circle. A fear of vomiting in public may be important. Direct eye-to-eye confrontation
may be particularly stressful in some cultures. Social phobias are usually associated
with low self-esteem and fear of criticism. They may present as a complaint of blushing,
hand tremor, nausea, or urgency of micturition, the individual sometimes being convinced
that one of these secondary manifestations of anxiety is the primary problem; symptoms
may progress to panic attacks. Avoidance is often marked, and in extreme cases may
result in almost complete social isolation.
All of the following criteria should be fulfilled for a definite
diagnosis:
a)
The
psychological, behavioural, or autonomic symptoms must be primarily
manifestations of anxiety and not secondary to other symptoms such as delusions
or obsessional thoughts;
b)
The anxiety
must be restricted to or predominate in particular social situations; and
c)
The phobic situation is avoided whenever possible.
Treatment - individual or group psychotherapy; supportive counselling
(see Counselling Interventions in this chapter); anti-anxiety medication (see
table in this chapter).
Obsessive-Compulsive
Disorder
The essential feature of this disorder is recurrent obsessional thoughts
or compulsive acts. (For brevity, "obsessional" will be used
subsequently in place of "obsessive-compulsive" when referring to
symptoms.) Obsessional thoughts are ideas, images or impulses that enter the individual's
mind again and again in a stereotyped form. They are almost invariably distressing
(because they are violent or obscene, or simply because they are perceived as senseless)
and the sufferer often tries, unsuccessfully, to resist them. They are,
however, recognized as the individual's own thoughts, even though they are
involuntary and often repugnant. Compulsive acts or rituals are stereotyped
behaviours that are repeated again and again. They are not inherently
enjoyable, nor do they result in the completion of inherently useful tasks. The
individual often views them as preventing some objectively unlikely event, often
involving harm to or caused by him or herself. Usually, though not invariably,
this behaviour is recognized by the individual as pointless or ineffectual and
repeated attempts are made to resist it; in very long-standing cases,
resistance may be minimal. Autonomic anxiety symptoms are often present, but
distressing feelings of internal or psychic tension without obvious autonomic
arousal are also common. There is a close relationship between obsessional
symptoms, particularly obsessional thoughts, and depression. Individuals with obsessive-compulsive
disorder often have depressive symptoms, and patients suffering from recurrent
depressive disorder may develop obsessional thoughts during their episodes of
depression. In either situation, increases or decreases in the severity of the
depressive symptoms are generally accompanied by parallel changes in the
severity of the obsessional symptoms.
Obsessive-compulsive disorder is equally common in men and women, and
there are often prominent anankastic features in the underlying personality.
Onset is usually in childhood or early adult life. The course is variable and
more likely to be chronic in the absence of significant depressive symptoms.
11.3.1 Essentials of Diagnosis
For a definite diagnosis, obsessional symptoms or compulsive acts, or
both, must be present on most days for at least 2 successive weeks and be a
source of distress or interference with activities.
The obsessional symptoms should have the following characteristics:
a)
They must be
recognized as the individual's own thoughts or impulses;
b)
There must be
at least one thought or act that is still resisted unsuccessfully, even though
others may be present which the sufferer no longer resists;
c)
)the thought
of carrying out the act must not in itself be pleasurable (simple relief of
tension or anxiety is not regarded as pleasure in this sense);
d)
The thoughts,
images, or impulses must be unpleasantly repetitive.
Post-Traumatic Stress
Disorder
This arises as a delayed and/or protracted response to a stressful event
or situation (either short- or long-lasting) of an exceptionally threatening or
catastrophic nature, which is likely to cause pervasive distress in almost
anyone (e.g. natural or man-made disaster, combat, serious accident, witnessing
the violent death of others, or being the victim of torture, terrorism, rape, or
other crime). Predisposing factors such as personality traits (e.g. compulsive,
asthenic) or previous history of neurotic illness may lower the threshold for
the development of the syndrome or aggravate its course, but they are neither
necessary nor sufficient to explain its occurrence.
Typical symptoms include episodes of repeated reliving of the trauma in
intrusive memories
("flashbacks") or dreams, occurring against the persisting
background of a sense of "numbness" and emotional blunting,
detachment from other people, unresponsiveness to surroundings, anhedonia, and
avoidance of activities and situations reminiscent of the trauma. Commonly
there is fear and avoidance of cues that remind the sufferer of the original trauma.
Rarely, there may be dramatic, acute bursts of fear, panic or aggression, triggered
by stimuli arousing a sudden recollection and/or re-enactment of the trauma or
of
the original reaction to it. There is usually a state of autonomic
hyperarousal with hyper vigilance, an enhanced startle reaction, and insomnia.
Anxiety and depression are commonly associated with the above symptoms and
signs, and suicidal ideation is not infrequent. Excessive use of alcohol or
drugs may be a complicating factor. The onset follows the trauma with a latency
period which may range from a few weeks to months (but rarely exceeds 6
months). The course is fluctuating but recovery can be expected in the majority
of cases. In a small proportion of patients the condition may show a chronic
course over many years and a transition to an enduring personality change.
Essentials of Diagnosis
This disorder should not generally be diagnosed unless there is evidence
that it arose within 6 months of a traumatic event of exceptional severity. A
"probable" diagnosis might still be possible if the delay between the
event and the onset was longer than 6 months, provided that the clinical
manifestations are typical and no alternative identification of the disorder
(e.g. as an anxiety or obsessive-compulsive disorder or depressive episode) is
plausible. In addition to evidence of trauma, there must be a repetitive,
intrusive recollection or re-enactment of the event in memories, daytime
imagery, or dreams. Conspicuous emotional detachment, numbing of feeling and
avoidance of stimuli that might arouse recollection of the trauma are often
present but are not essential for the diagnosis. The autonomic disturbances,
mood disorder, and behavioural abnormalities all contribute to the diagnosis but
are not of prime importance.
Treatment of Anxiety Related Conditions
Counselling
Interventions for Anxiety-Related
Conditions
Managing
any type of anxiety involves first an awareness of factors that may underlie
the anxiety and an ability to recognize signs of anxiety. Specific techniques
can then be used to reduce the anxiety. Techniques will vary depending on the
type of anxiety disorder one experiences – that is, some techniques may be
better for certain types of anxiety (e.g. graded exposure is particularly
helpful for phobias). In addition, one does not necessarily have to have a
disorder to benefit from using an intervention (e.g. the breathing and
relaxation exercises can be useful for calming nor-mal anxiety).
Step 1 – Understanding factors that
underlie anxiety
Understanding
where anxiety may stem from may help some individuals put their reactions to
stress in perspective. Having a perspective about stress is important to
control subsequent anxiety feelings. Factors underlying anxiety may include:
a)
The structure and composition of an
individual‘s nervous system (e.g. family genetics).
b)
Environmental influences (e.g. the expression of emotion encouraged in the
family, school, or social settings).
Step 2 – Identifying specific anxiety
symptoms
Patients
should be encouraged to identify their anxiety by making a list of the people,
places and situations that make them uncomfortable (i.e. feel increased stress)
or avoidant. The patient should also indicate the specific anxiety feelings
that are experienced in these circumstances.
Step 3 – Reducing anxiety using
specific techniques
To
reduce anxiety, one may apply techniques including muscle relaxation, breathing
exercises, problem-solving, managing negative thinking, and graded exposure.
Details for each of these techniques have been outlined in the following pages.
Different techniques may be effective for different types of anxiety disorders.
Breathing Exercise
(May
be especially useful for panic/agoraphobia; generalized anxiety; phobias;
social phobia/anxiety; post-traumatic and acute stress). Shortness of breath is
a common feeling that many people get when anxious. When one feels out of
breath the natural tendency is to breathe in more or faster. This can lead to hyperventilation
which can make anxiety worse. An effective way to manage abnormal breathing
when anxious is to do the following:
Breathe in slowly to the count of
three.
Breathe using your abdomen instead of
the chest.
When you get to three, slowly breathe
out to the count of three seconds.
Pause for three seconds then breathe in
again for 3 seconds.
Continue this exercise for five
minutes.
Practice
twice a day.
Medication Therapy for Anxiety-Related Conditions
General
Treatments
vary for the different anxiety disorders, but typically involve a combination
of psychotherapy and drug treatment.
a)
The benzodiazepine class of medication is commonly used for anxiety but caution
should be used in prescribing since tolerance, dependence, and serious
withdrawal may occur. Use of the benzodiazepines in short-term is usually
recommended.
b) For chronic anxiety conditions (e.g. panic disorder, obsessive-compulsive disorder, generalized anxiety disorder, post-traumatic stress, and social anxiety disorder) other agents such as the tricyclic imipramine may be used.
A panic attack is the sudden onset of a
discrete, brief period of intense discomfort, anxiety, or fear accompanied by
somatic or cognitive symptoms. Panic
disorder is occurrence of repeated panic attacks typically accompanied
by fears about future attacks or changes in behaviour to avoid situations that
might predispose to attacks. Diagnosis is clinical. Isolated panic attacks may
not require treatment. Panic disorder is treated with drug therapy,
psychotherapy (eg, exposure therapy, cognitive-behavioural therapy), or both.
Panic attacks are common, affecting as
many as 10% of the population in a single year. Most people recover without
treatment; a few develop panic disorder. Panic disorder is uncommon, affecting
2 to 3% of the population in a 12-mo period. Panic disorder usually begins in
late adolescence or early adulthood and affects women 2 to 3 times more often
than men.
11.6.1 Symptoms and Signs
Symptoms
usually peak within 10 min and dissipate within minutes thereafter, leaving
little for a physician to observe. Although uncomfortable—at times extremely
so—panic attacks are not medically dangerous. Panic attacks may occur in any anxiety disorder, usually
in situations tied to the core features of the disorder (eg, a person with a
phobia of snakes may panic at seeing a snake). In pure panic disorder, however,
some of the attacks occur spontaneously.
Most people with panic disorder anticipate and
worry about another attack (anticipatory anxiety) and avoid places or
situations where they have previously panicked. People with panic disorder
often worry that they have a dangerous heart, lung, or brain disorder and
repeatedly visit their family physician or an emergency department seeking
help. Unfortunately, in these settings, attention is focused on physical
symptoms, and the correct diagnosis often is not made. Many people with panic
disorder also have symptoms of major depression.
Some people recover without treatment, particularly
if they continue to confront situations in which attacks have occurred. For
others, especially without treatment, panic disorder follows a chronic waxing
and waning course.
Patients should be told that treatment usually
helps control symptoms. If avoidance behaviors have not developed, reassurance,
education about anxiety, and encouragement to continue to return to and remain
in places where panic attacks have occurred may be all that is needed. However,
with a long-standing disorder that involves frequent attacks and avoidance
behaviors, treatment is likely to require drug therapy combined with more
intensive psychotherapy.
Many drugs can prevent or greatly reduce
anticipatory anxiety, phobic avoidance, and the number and intensity of panic
attacks:
- Benzodiazepines: These anxiolytics
work more rapidly than antidepressants but are more likely to cause
physical dependence and such adverse effects as somnolence, ataxia, and
memory problems.
- Antidepressants plus benzodiazepines: These
drugs are sometimes used in combination initially; the benzodiazepine
slowly tapered after the antidepressant becomes effective.
Panic attacks often recur when drugs are stopped.
Different forms of psychotherapy are effective.
Exposure therapy, in which patients confront their fears, helps diminish the
fear and complications caused by fearful avoidance. For example, patients who
fear that they will faint during a panic attack are asked to spin in a chair or
to hyperventilate until they feel faint, thereby learning that they will not
faint during an attack. Cognitive-behavioral therapy involves teaching patients
to recognize and control their distorted thinking and false beliefs and to
modify their behavior so that it is more adaptive. For example, if patients
describe acceleration of their heart rate or shortness of breath in certain
situations or places and fear that they are having a heart attack, they could
be taught the following:
- Not to avoid those situations.
- To understand that their worries are unfounded.
- To respond instead with slow, controlled breathing or other methods that promote relaxation.
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