Anxiety; Types, Causes, Symptom, Diagnosis, Treatment

Anxiety disorders
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Anxiety is what we feel when we are worried, tense or afraid – particularly about things that are about to happen, or which we think could happen in the future. Anxiety is a natural human response when we perceive that we are under threat. It can be experienced through our thoughts, feelings and physical sensations.

Anxiety is linked to fear and manifests as a future-oriented mood state that consists of a complex cognitive, affective, physiological, and behavioral response system associated with preparation for the anticipated events or circumstances perceived as threatening. Pathological anxiety is triggered when there is an overestimation of perceived threat or an erroneous danger appraisal of a situation which leads to excessive and inappropriate responses.

Types of Anxiety

Anxiety disorders can be classified into six main types. These include:

  • Generalized anxiety disorder (GAD) This is a chronic disorder involving excessive, long-lasting anxiety and worries about nonspecific life events, objects, and situations. It is the most common anxiety disorder. People with GAD are not always able to identify the cause of their anxiety.
  • Panic disorder – Brief or sudden attacks of intense terror and apprehension characterize the panic disorder. These attacks can lead to shaking, confusion, dizziness, nausea, and breathing difficulties. Panic attacks tend to occur and escalate rapidly and peak after 10 minutes. However, they may last for hours. Panic disorders usually occur after frightening experiences or prolonged stress but can also occur without a trigger. An individual experiencing a panic attack may misinterpret it as a life-threatening illness. Panic attacks can also lead to drastic changes in behavior to avoid future attacks.
  • Specific phobias  – You feel intense fear of a specific object or situation, such as heights or flying. The fear goes beyond what’s appropriate and may cause you to avoid ordinary situations.
  • Phobia –This is an irrational fear and avoidance of an object or situation. Phobias differ from other anxiety disorders, as they relate to a specific cause. The fear may be acknowledged as irrational or unnecessary, but the person is still unable to control the anxiety. Triggers for a phobia may be as varied as situations, animals, or everyday objects.
  • Social anxiety disorder – This is a fear of being negatively judged by others in social situations or a fear of public embarrassment. This includes a range of feelings, such as stage fright, a fear of intimacy, and a fear of humiliation. This disorder can cause people to avoid public situations and human contact to the point that everyday living is rendered extremely difficult.
  • Obsessive-compulsive disorder (OCD) – This is an anxiety disorder characterized by thoughts or actions that are repetitive, distressing, and intrusive. OCD suffers usually know that their compulsions are unreasonable or irrational, but they serve to alleviate their anxiety. People with OCD may obsessively clean personal items or hands or constantly check locks, stoves, or light switches.
  • Post-traumatic stress disorder (PTSD) – This is anxiety that results from previous trauma such as military combat, sexual assault, a hostage situation, or a serious accident. PTSD often leads to flashbacks, and the person may make behavioral changes to avoid triggers.
  • Separation anxiety disorder – This is characterized by high levels of anxiety when separated from a person or place that provides feelings of security or safety. Separation sometimes results in panic symptoms. It is considered a disorder when the response is excessive or inappropriate after separation.

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Causes of Anxiety

Anxiety disorders have a complicated network of causes, including:

  • Environmental factors, such as stress from a personal relationship, job, school, finances, traumatic event, or even a shortage of oxygen in high-altitude areas
  • Genetics
  • Medical factors, such as the side effects of medicine, symptoms of a condition, or stress from a serious underlying medical condition
  • Brain chemistry
  • Use of or withdrawal from an illicit substance

Symptoms of Anxiety

All anxiety disorders share some general symptoms

  • Cognitive symptoms fear of losing control; fear of physical injury or death; fear of “going crazy”; fear of negative evaluation by others; frightening thoughts, mental images, or memories; perception of unreality or detachment; poor concentration, confusion, distractible; narrowing of attention, hypervigilance for threat; poor memory; and difficulty speaking.
  • Physiological symptoms – increased heart rate, palpitations; shortness of breath, rapid breathing; chest pain or pressure; choking sensation; dizzy, light-headed; sweaty, hot flashes, chills; nausea, upset stomach, diarrhea; trembling, shaking; tingling or numbness in arms and legs; weakness, unsteadiness, faintness; tense muscles, rigidity; and dry mouth.
  • Behavioral symptoms  avoidance of threat cues or situations; escape, flight; pursuit of safety, reassurance; restlessness, agitation, pacing; hyperventilation; freezing, motionless; and difficulty speaking.
  • Affective symptoms  nervous, tense, wound up; frightened, fearful, terrified; edgy, jumpy, jittery; and impatient, frustrated.

Anxiety Disorders as defined in the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM–5; American Psychiatric Association, 2013):

  • Separation Anxiety Disorder  An individual with separation anxiety disorder displays anxiety and fear atypical for his/her age and development level of separation from attachment figures. There is persistent and excessive fear or anxiety about harm to, loss of, or separation from attachment figures. The symptoms include nightmares and physical symptoms. Although the symptoms develop in childhood, they can be expressed throughout adulthood as well.
  • Selective Mutism This disorder is characterized by a consistent failure to speak in social situations where there is an expectation to speak even though the individual speaks in other circumstances, can speak, and comprehends the spoken language. The disorder is more likely to be seen in young children than in adolescents and adults.
  • Specific Phobia  Individuals with a specific phobia are fearful or anxious about specific objects or situations which they avoid or endure with intense fear or anxiety. The fear, anxiety, and avoidance is almost always immediate and tends to be persistently out of proportion to the actual danger posed by the specific object or situation. There are different types of phobias: animal, blood-injection-injury, and situational.
  • Social Anxiety Disorder – This disorder is characterized by marked or intense fear or anxiety of social situations in which one could be the subject of scrutiny. The individual fears that he/she will be negatively evaluated in such circumstances. He/she also fears being embarrassed, rejected, humiliated or offending others. These situations always provoke fear or anxiety and are avoided or endured with intense fear and anxiety.
  • Panic Disorder Individuals with this disorder experience recurrent, unexpected panic attacks and experience persistent concern and worry about having another panic attack. They also have changes in their behavior linked to the panic attacks which are maladaptive, such as avoidance of activities and situations to prevent the occurrence of panic attacks. Panic attacks are abrupt surges of intense fear or extreme discomfort that reach a peak within minutes, accompanied by physical and cognitive symptoms such as palpitations, sweating, shortness of breath, fear of going crazy, or fear of dying. Panic attacks can occur unexpectedly with no obvious trigger, or they may be expected, such as in response to a feared object or situation.
  • AgoraphobiaIndividuals with this disorder are fearful and anxious in two or more of the following circumstances: using public transportation, being in open spaces, being in enclosed spaces like shops and theaters, standing in line or being in a crowd, or being outside of the home alone. The individual fears and avoids these situations because he/she is concerned that escape may be difficult or help may not be available in the event of panic-like symptoms, or other incapacitating or embarrassing symptoms (e.g., falling or incontinence).
  • Generalized Anxiety DisorderThe key feature of this disorder is persistent and excessive worry about various domains, including work and school performance, that the individual finds hard to control. The person also may experience feeling restless, keyed up, or on edge; being easily fatigued; difficulty concentrating or mind going blank; irritability, muscle tension, and sleep disturbance.
  • Substance/Medication-Induced Anxiety Disorder  This disorder involves anxiety symptoms due to substance intoxication or withdrawal or to medical treatment.
  • Anxiety Disorder Due to Other Medical ConditionsAnxiety symptoms are the physiological consequence of another medical condition. Examples include endocrine disease: hypothyroidism, hypoglycemia, and hypercortisolism; cardiovascular disorders: congestive heart failure, arrhythmia, and pulmonary embolism; respiratory illness: asthma and pneumonia; metabolic disturbances: B12 or porphyria; neurological illnesses: neoplasms, encephalitis, and seizure disorder.
  • Not being able to stay calm and still
  • Cold, sweaty, numb or tingling hands or feet
  • Heart palpitations
  • Tense muscles

The physiological symptoms of anxiety may include

Diagnosis of Anxiety

The diagnosis of an anxiety disorder requires first ruling out an underlying medical cause. Diseases that may present similar to an anxiety disorder, including certain endocrine diseases (hypo- and hyperthyroidism, hyperprolactinemia),metabolic disorders (diabetes),deficiency states (low levels of vitamin D, B2, B12, folic acid), gastrointestinal diseases (celiac disease, non-celiac gluten sensitivity, inflammatory bowel disease), heart diseases,blood diseases (anemia), and brain degenerative diseases (Parkinson’s disease, dementia, multiple sclerosis, Huntington’s disease).

Also, several drugs can cause or worsen anxiety, whether in intoxication, withdrawal or chronic use. These include alcohol, tobacco, cannabis, sedatives(including prescription benzodiazepines), opioids (including prescription painkillers and illicit drugs like heroin), stimulants (such as caffeine, cocaine, and amphetamines), hallucinogens, and inhalants.

Treatment of Anxiety

Pharmacotherapy: selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), benzodiazepines, tricyclic antidepressants, mild tranquilizers, and beta-blockers treat anxiety disorders. 

  • SSRIs (fluoxetine, sertraline, paroxetine, escitalopram, and citalopram) – are an effective treatment for all anxiety disorders and considered first-line treatment.
  • SNRIs (venlafaxine and duloxetine) – are considered as effective as SSRIs and also are considered first-line treatment, particularly for generalized anxiety disorder (GAD).
  • Tricyclic antidepressants (amitriptyline, imipramine, and nortriptyline) – are useful in the treatment of anxiety disorders but cause significant adverse effects.
  • Benzodiazepines (alprazolam, clonazepam, diazepam, and lorazepam) – are used for short-term management of anxiety. They are fast acting and bring relief within 30 minutes to an hour. They are effective in promoting relaxation and reducing muscular tension and other symptoms of anxiety. Because they work quickly, they are effective when taken for panic attacks or overwhelming episodes. Long-term use may require increased doses to achieve the same effect, which may result in problems related to tolerance and dependence.
  • Buspirone – is a mild tranquilizer that is slow acting as compared to benzodiazepines and takes about 2 weeks to start working. It has the advantage of being less sedating and also not being addicting with minimal withdrawal effects. It works for GAD.
  • Beta-blockers (propranolol and atenolol) – control the physical symptoms of anxiety such as rapid heart rate, a trembling voice, sweating, dizziness, and shaky hands. They are most helpful for phobias, particularly social phobia.
  • Psychotherapy – One of the most effective forms of psychotherapy is cognitive-behavioral therapy. It is a structured, goal-oriented, and didactic form of therapy that focuses on helping individuals identify and modify characteristic maladaptive thinking patterns and beliefs that trigger and maintain symptoms. This is a type of counseling that addresses the emotional response to mental illness. A mental health specialist helps you by talking about how to understand and deal with your anxiety disorder.
  • Cognitive behavioral therapy This is a certain type of psychotherapy that teaches you how to recognize and change thought patterns and behaviors that trigger deep anxiety or panic.

Managing Symptoms

These tips may help you control or lessen your symptoms:

  • Cut down on foods and drinks that have caffeine, such as coffee, tea, cola, energy drinks, and chocolate. Caffeine is a mood-altering drug, and it may make symptoms of anxiety disorders worse.
  • Eat right, exercise, and get better sleep. Brisk aerobic exercises like jogging and biking help release brain chemicals that cut stress and improve your mood.
  • Sleep problems and anxiety disorder often go hand in hand. Make getting good rest a priority. Follow a relaxing bedtime routine. Talk to your doctor if you still have trouble sleeping.
  • Ask your doctor or pharmacist before taking any over-the-counter meds or herbal remedies. Many contain chemicals that can make anxiety symptoms worse.

Characteristic features noted in individuals with clinical anxiety:

  • False alarms – The presence of intense fear in the absence of threat cues or very minimal threat provocation.
  • Persistence – There is a future-oriented perspective that involves the anticipation of threat or danger which causes the patient to experience a heightened level of apprehension and thoughts about impending potential threat, regardless of whether it materializes.
  • Impaired Functioning – The anxiety interferes with effective and adaptive coping in the face of a perceived threat and the person’s daily social or occupational life.
  • Stimulus hypersensitivity – In clinical states, fear is elicited by a wider range of stimuli or situations of relatively mild intensity that would be innocuous to a person who does not have clinical anxiety.
  • Dysfunctional cognition and cognitive symptoms – Thinking characterized by overestimation of threat or danger appraisal of a situation that is not confirmed in any way.

References

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