- Clinical science
Anxiety disorders cover a broad spectrum of conditions characterized by excessive and persistent fear (an emotional response to imminent threats), anxiety (the anticipation of a future threat), worry (apprehensive expectation), and/or avoidance behavior. The etiology of anxiety disorders is multifactorial and may involve genetic, developmental, environmental, neurobiological, cognitive, and psychosocial factors. Therapy typically consists of a combination of pharmacotherapy, especially selective serotonin reuptake inhibitors (SSRIs), and psychotherapy, especially cognitive-behavioral therapy (CBT).
Risk and prognostic factors
- Female sex: Higher rates of anxiety disorders are seen in women.
- Neurobiological factors
- Substance use (= substance/medication-induced anxiety disorder)
Environmental and developmental factors
- Smoking (risk factor for panic disorder and panic attacks)
- Psychological trauma, esp. during childhood
- Negative affectivity (neuroticism)
- Vulnerability to stress
- Susceptibility to anxiety
- Hypersensitivity to (perceiving) threatening stimuli
- Behavioral inhibition
- Other medical conditions (= anxiety disorder due to another medical condition)
- Psychodynamic: displacement of intrapsychic conflict
- Cognitive: overestimation and heightened perception of potential threats; worrying to avoid fear response; worrying as problem-solving strategy
- Behavioral: operant conditioning/learning paradigms (negative reinforcement promotes maladaptive behavior)
- Definition: prolonged and excessive anxiety that is either unspecific or revolves around certain themes (e.g., health, work); not focused on a single specific fear
- Most common anxiety disorder among the elderly population
- Lifetime prevalence: 5–10%
- ♀ > ♂ (2:1)
- Prolonged (≥ 6 months, occurring more days than not) and excessive anxiety
- Anxiety causes clinically significant distress
- Not caused by substance use, medication, or underlying medical condition
- Fatigue and muscle tension
- Restlessness and irritability
- Sleep disturbances and difficulty concentrating
- First-line: psychotherapy, pharmacotherapy, or both
- Benzodiazepines can be used until SSRIs take effect but should never be used for long-term management, as they increase the risk of .
- Antipsychotics only for refractory cases
Panic disorder: Panic attacks may also occur in GAD.
- Panic symptoms in GAD are generally precipitated by the uncontrolled escalation of anxiety/worry rather than occurring spontaneously or acutely in specific situations as in panic disorder.
- Depressive disorders
- Individuals with GAD tend to be more concerned with the future; individuals with depressive disorders are more past-oriented.
- Mood swings and suicidal ideation are uncommon in GAD.
- Social anxiety disorder: Patients with GAD are usually comfortable in social situations and not particularly disturbed by the evaluation by others.
- Panic disorder: Panic attacks may also occur in GAD.
- Definition: recurrent spontaneous panic attacks without a known trigger
- Lifetime prevalence: approx. 5%
- Most common in patients of age 20–30
- ♀ > ♂ (2:1)
In children, diagnosis of panic disorder requires that anxiety occurs in peer settings and not just in interaction with adults!
- Definition: pronounced anxiety of social situations that may involve scrutiny by others and lasts ≥ 6 months
- One of the most common mental disorders
- Lifetime prevalence: approx. 5–10%
- Peak incidence: adolescence and early adulthood
- ♀ > ♂ (2:1)
- SAD: Fear/anxiety out of proportion to a social situation where one may be scrutinized by others (e.g., meeting new people at a party, eating in public, using public restrooms)
- Performance-only SAD: symptoms of fear/anxiety restricted only to public speaking or performing in front of crowds
- Blushing, palpitations, sweating during a social interaction
- Anticipatory anxiety
- Anxiety driven by fear of embarrassment and others noticing the reaction
- Avoidance of the aforementioned triggers
- In children: refusing to speak at a social event, crying/throwing a tantrum, clinging to the care giver
- Cognitive behavioral therapy: for SAD and performance-only SAD
- Pharmacotherapy for SAD
- Pharmacotherapy for performance-only SAD: (beta blockers) or on an as-needed basis; taken 30–60 minutes before an anxiety-causing event
- Definition: persistent and intense fears of one or more specific situations or objects (phobic stimuli); always occur during encounters with the phobic stimulus, but may already surge in its anticipation
- Animal: spiders (arachnophobia), insects (entomophobia), dogs (cynophobia)
- Natural environment: heights (acrophobia), storms (astraphobia)
- Blood-injection-injury: blood (), needles (blenophobia), dental procedures (odontophobia), fear of injury (traumatophobia)
- Situational: enclosed places (claustrophobia); , flying (aviophobia)
- Other: fear of vomiting (emetophobia), the number 13 (triskaidekaphobia), costumed characters (masklophobia), fear of clowns (coulrophobia)
- Definition: inordinate fear or anxiety of being in situations that are perceived as difficult to escape from, or situations in which it might be difficult to seek help
- ♀ > ♂ (2:1)
- Age of onset: < 35 years (60–70% of cases)
Fear, anxiety, or even panic attacks over a period of ≥ 6 months in ≥ 2 of the following 5 situations:
- Using public transportation
- Being in open spaces
- Being in enclosed places
- Standing in line or being in a crowd
- Being outside of the home alone
- Active avoidance of these settings unless a companion is present
- Some patients can have a comorbid panic disorder
- Fear, anxiety, or even panic attacks over a period of ≥ 6 months in ≥ 2 of the following 5 situations: