• Clinical science

Anxiety disorders

Abstract

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).

Etiology

Risk and prognostic factors

  • Female sex: Higher rates of anxiety disorders are seen in women.
  • Neurobiological factors
    • Disorders of the serotonin system; → treatment with SSRIs
    • Disorders of GABAergic inhibitory transmission
  • Substance use (= substance/medication-induced anxiety disorder)
  • Environmental and developmental factors
    • Stress
    • Smoking (risk factor for panic disorder and panic attacks)
    • Psychological trauma, esp. during childhood
  • Temperamental factors
    • 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)
    • Conditions that may cause anxiety and/or panic include endocrine disease (e.g., hyperthyroidism), cardiovascular disorders (e.g., congestive heart failure), respiratory illness (e.g., asthma), metabolic disorders (e.g., porphyria), and neurological diseases (e.g., encephalitis).

Psychological theories

  • 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)

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
    • First-line: psychotherapy, pharmacotherapy, or both
      • CBT
      • SNRI/SSRIs
      • Buspirone
        • Buspirone requires consistent, daily intake for at least two weeks due to a delayed onset of action
    • 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.
    • 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.
    • Social anxiety disorder: Patients with GAD are usually comfortable in social situations and not particularly disturbed by the evaluation by others.

References:[1][2][3][4][5]

Panic disorder

  • Definition: recurrent spontaneous panic attacks without a known trigger
  • Epidemiology
    • Lifetime prevalence: approx. 5%
    • Most common in patients of age 20–30
    • > (2:1)
  • Associations
  • Symptoms
    • Episodes of intense fear and discomfort
    • Fear of dying
    • Sympathetic overstimulation (sweating, palpitations)
    • Panic attacks that last for several minutes
    • Also: paraesthesias, abdominal pain, nausea, light-headedness, chest pain, shortness of breath, choking sensation
  • Treatment

In children, diagnosis of panic disorder requires that anxiety occurs in peer settings and not just in interaction with adults!

References:[6][7]

Social anxiety disorder

  • Definition: pronounced anxiety of social situations that may involve scrutiny by others and lasts ≥ 6 months
  • Epidemiology:
    • One of the most common mental disorders
    • Lifetime prevalence: approx. 5–10%
    • Peak incidence: adolescence and early adulthood
    • > (2:1)
  • Sub-types
    • 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
    • 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
  • Treatment

References:[1][8][9][10]

Specific phobias

References:[11][12][13]

Agoraphobia

  • 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
  • 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 a comorbid panic disorder
  • Treatment

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

References:[14][15][16][16][16]