• Clinical science

Anxiety disorders

Summary

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).

For separation anxiety disorder and selective mutism, see the learning card on emotional and behavioral disorders in children and adolescents.

Overview

Generalized anxiety disorder (GAD) Panic disorder Social anxiety disorder (SAD) Specific phobias Agoraphobia Substance/medication-induced anxiety disorder

Clinical features

  • Prolonged and excessive anxiety not focused on a single specific fear
  • Pronounced anxiety of social situations that involve scrutiny from others
  • Persistent and intense fears of particular situations or objects
  • Pronounced fear or anxiety of situations that are perceived as difficult to escape from
  • Prominent anxiety or panic attacks after using or stopping a substance/medication
Triggers
  • No definitive trigger or source
  • May not have an obvious trigger
  • Social interaction and/or performance of any actions in public
  • One or more specific situations or objects
  • Being in enclosed spaces or open public spaces
  • Crowds
  • Being alone
Duration of symptoms required for diagnosis
  • ≥ 6 months
  • Panic attacks: several minutes
  • Fear of subsequent attacks: ≥ 1 month
  • ≥ 6 months
  • ≥ 6 months
  • ≥ 6 months in ≥ 2 different situations
  • Within 1 month of using or stopping the substance/medication
Treatment

Etiology

Risk and prognostic factors

  • Higher rates of anxiety disorders are reported in women.
  • Neurobiological factors
    • Disruption of the serotonin system
    • Dysfunction of GABAergic inhibitory transmission
  • Substance use (leading to substance/medication-induced anxiety disorder)
  • Environmental and developmental factors
  • Other medical conditions

Generalized anxiety disorder

  • 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
  • Epidemiology
    • Most common anxiety disorder among the elderly population
    • Lifetime prevalence: 5–10%
    • > (2:1)
  • Symptoms
    • 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
  • Treatment [1][2]
    • First-line: psychotherapy, pharmacotherapy, or both
    • Second-line
      • Benzodiazepines can be used until SSRIs take effect but should never be used for long-term management, as they increase the risk of benzodiazepine dependence.
      • Buspirone: requires consistent, daily intake for at least two weeks because of its delayed onset of action
      • Antipsychotics only for refractory cases
  • Differential diagnosis
    • 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.
    • SAD: Patients with GAD are usually comfortable in social situations and not particularly disturbed by the evaluation by others.

References:[3][4][1][5][6]

Panic disorder

  • Definition: recurrent spontaneous and unexpected panic attacks that often occur without a known trigger
  • Epidemiology [7]
    • Lifetime prevalence: approx. 5% of the population
    • Most common in patients aged 26–34 years
    • > (2:1)
  • Associations
  • Symptoms
    • Recurrent panic attacks
      • Episodes of intense fear and discomfort that last for several minutes
      • Fear of dying
      • Overstimulation of the sympathetic system
        • Sweating, palpitations
        • Paresthesias, abdominal pain, nausea, light-headedness, chest pain, shortness of breath, choking sensation
    • There is a concern about future attacks and their consequences, and/or a significant change in behavior related to the attacks, for at least one month.
  • Treatment

To remember the symptoms of a panic attack, think of “STUDENTS FEAR the 3Cs”: Sweating, Trembling, Unsteadiness (dizziness), Derealization, Elevated heart rate (palpitations), Nausea, Tingling, and Shortness of breath; FEAR of dying or going crazy; Chest pain, Choking, and Chills.

References:[8][9]

Social anxiety disorder

  • Definition: pronounced anxiety lasting ≥ 6 months of social situations that might involve scrutiny by others
  • Epidemiology
    • One of the most common mental disorders
    • Lifetime prevalence: approx. 5–10% of the population
    • Peak incidence: adolescence and early adulthood
    • > (2:1)
  • Types
    • Social anxiety disorder (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
  • Symptoms
    • Blushing, palpitations, sweating during a social interaction
    • Anticipatory anxiety (e.g., worrying weeks in advance about attending a social event)
    • Anxiety driven by fear of embarrassment and others noticing the reaction
    • Avoidance of the aforementioned triggers (e.g., not attending parties, refusing to attend school)
    • In children: refusing to speak at social events, crying/throwing a tantrum, clinging to their caregiver
  • Treatment

References:[3][10][11][12]

Specific phobias

References:[13][14][15]

Agoraphobia

  • Definition: pronounced 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
  • Epidemiology
    • > (2:1)
    • Age of onset: < 35 years (60–70% of cases)
  • Clinical features
    • 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 comorbid panic disorder.
  • Treatment

If a patient meets the criteria for panic disorder and agoraphobia, both conditions should be diagnosed.

References:[16][17][18][18][18]

Substance/medication-induced anxiety disorder

References:[22][19][18]