Anxiety


Article Author:
Suma Chand


Article Editor:
Raman Marwaha


Editors In Chief:
Patricia Maani-Fogelman
Julianne Oates


Managing Editors:
Frank Smeeks
Scott Dulebohn
Erin Hughes
Pritesh Sheth
Mark Pellegrini
James Hughes
Richard Ciresi
Phillip Hynes


Updated:
11/23/2018 10:32:55 AM

Introduction

Fear is an automatic neurophysiological state of alarm characterized by a fight or flight response to a cognitive appraisal of present or imminent danger (real or perceived). 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.[1][2][3]

Etiology

Anxiety disorders appear to be caused by an interaction of biopsychosocial factors. Genetic vulnerability interacts with situations that are stressful or traumatic to produce clinically significant syndromes.

Epidemiology

Anxiety is one of the most common psychiatric disorders in the general population. Specific phobia is the most common with a 12-month prevalence rate of 12.1%. Social anxiety disorder is the next most common, with a 12-month prevalence rate of 7.4%. The least common anxiety disorder is agoraphobia with a 12-month prevalence rate of 2.5%. Anxiety disorders occur more frequently in females than in males with an approximate 2:1 ratio.[4]

Pathophysiology

The significant mediators of anxiety in the central nervous system are thought to be norepinephrine, serotonin, dopamine, and gamma-aminobutyric acid (GABA). The autonomic nervous system, especially the sympathetic nervous system, mediates most of the symptoms.

The amygdala plays an important role in tempering fear and anxiety. Patients with anxiety disorders have been found to show heightened amygdala response to anxiety cues. The amygdala and limbic system structures are connected to prefrontal cortex regions, and prefrontal-limbic activation abnormalities may be reversed with psychological or pharmacologic interventions.

History and Physical

Characteristic Symptoms Pathological Anxiety

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.
  • Agoraphobia: Individuals 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 Disorder: The 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 Conditions: Anxiety 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.

Evaluation

When the history and examination do not suggest the symptoms as arising from any other medical disorder, the initial laboratory studies may be limited to the following: complete blood cell count (CBC) chemistry profile, thyroid function tests, urinalysis, and urine drug screen.[5][6][7]

If the anxiety symptoms are atypical or there are some abnormalities noted in the physical examination more detailed evaluations may be indicated to identify or exclude underlying medical conditions. This would include the following: electroencephalography, brain computed tomography (CT) scan, electrocardiography, tests for infection, arterial blood gas analysis, chest radiography, and thyroid function tests.

Treatment / Management

Treatment consists of psychotherapy, pharmacotherapy, or a combination of both.

Pharmacotherapy: selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), benzodiazepines, tricyclic antidepressants, mild tranquilizers, and beta-blockers treat anxiety disorders. [3][8][9]

  • 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 form of therapy focuses on building behavioral skills so that patients can behave and react more adaptively to anxiety-producing situations. Exposure therapy is utilized to move individuals towards facing the anxiety-provoking situations and stimuli which they typically avoid. This exposure results in a reduction in anxiety symptoms as they learn that their anxiety is causing them to experience false alarms and they do not need to fear the situation or stimuli and can cope effectively with such a situation.

Pearls and Other Issues

Characteristic features noted in individuals with clinical anxiety:

  1. False alarms: The presence of intense fear in the absence of threat cues or very minimal threat provocation.
  2. 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.
  3. 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.
  4. 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.
  5. Dysfunctional cognition and cognitive symptoms: Thinking characterized by overestimation of threat or danger appraisal of a situation that is not confirmed in any way.

Enhancing Healthcare Team Outcomes

Anxiety disorders are very common and can present in diverse ways. When a person has chronic anxiety, the condition can be very debilitating and hence it is best managed by a multidisciplinary team consisting of a mental health nurse, psychiatrist, psychotherapist, social worker, and a primary care provider. The outlook for patients with anxiety is guarded. Data indicate that the high rates of mortality are associated with adverse cardiac events. In those with social phobia, the condition leads to significant functional impairment and a very poor quality of life. The risk of suicides is also high in this population. Patients with anxiety need lifelong follow up because, despite drug therapy, relapse rates are high. [2][10][11](Level V)


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Anxiety - Questions

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What is the first step in the management of a patient with mild levels of anxiety?



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Which of the following is the first step in treating a patient with acutely increasing levels of anxiety?



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A patient complains of episodic dizziness of 3 months duration. There are also palpitations, tremulousness, and shortness of breath. She is afraid to leave the house. Which of the following cannot be diagnosed?



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What is the term thanatophobia?



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Which of the following mental disorders is most prevalent?



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Which is characterized by a general feeling of uneasiness?



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Which statement is false about anxiety?



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What would be the best way to decide which group members in a day program for adults are having anxiety during group sessions?



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An inpatient with severe anxiety has great difficulty leaving her room to go to OT group as she feels overwhelmed. Select the best intervention.



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Which of the following would be best to decrease muscle tension in patients with anxiety disorders?



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Which of the following is not an anxiety disorder?



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A patient who is living in a nursing home is having problems with concentration during occupational therapy sessions. She is having problems sleeping, complains of anxiety during group, and does not like to leave her room. What is the best intervention?



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Under what condition is anxiety pathological?



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A 59-year-old woman goes to a mental health practitioner for a 3-month history of what she describes as panic attacks. She has never had these attacks before. Her symptoms during these episodes include palpitations, shortness of breath, sweating, and fear of dying; they happen suddenly and last 10 to 15 minutes per attack. She denies any history of substance abuse. Which part of this scenario would make one suspect an underlying medical condition presenting as anxiety?



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Which of the following is not considered an anxiety disorder?



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Anxiety-like symptoms, such as nervousness, restlessness, and hyperventilation, can be associated with a medical illness. Which statement is false regarding anxiety-like symptoms associated with a medical illness?



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Which statement is false about anxiety?



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Which is true of cognitive-behavioral therapy?



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Which of the following responses is true about anxiety? Select all that apply.



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Norepinephrine (NE) is most likely elevated in what condition?



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Anxiety - References

References

Hawken T,Turner-Cobb J,Barnett J, Coping and adjustment in caregivers: A systematic review. Health psychology open. 2018 Jul-Dec     [PubMed]
Domhardt M,Geßlein H,von Rezori RE,Baumeister H, Internet- and mobile-based interventions for anxiety disorders: A meta-analytic review of intervention components. Depression and anxiety. 2018 Nov 19     [PubMed]
Lahousen T,Kapfhammer HP, [Anxiety disorders - clinical and neurobiological aspects]. Psychiatria Danubina. 2018 Dec     [PubMed]
Remes O,Wainwright N,Surtees P,Lafortune L,Khaw KT,Brayne C, Generalised anxiety disorder and hospital admissions: findings from a large, population cohort study. BMJ open. 2018 Oct 27     [PubMed]
Durazzo M,Gargiulo G,Pellicano R, Noncardiac chest pain: a 2018 update. Minerva cardioangiologica. 2018 Apr 11     [PubMed]
Jafferany M,Khalid Z,McDonald KA,Shelley AJ, Psychological Aspects of Factitious Disorder. The primary care companion for CNS disorders. 2018 Feb 22     [PubMed]
Cosci F,Fava GA,Sonino N, Mood and anxiety disorders as early manifestations of medical illness: a systematic review. Psychotherapy and psychosomatics. 2015     [PubMed]
Chapdelaine A,Carrier JD,Fournier L,Duhoux A,Roberge P, Treatment adequacy for social anxiety disorder in primary care patients. PloS one. 2018     [PubMed]
Rickels K,Moeller HJ, Benzodiazepines in anxiety disorders: Reassessment of usefulness and safety. The world journal of biological psychiatry : the official journal of the World Federation of Societies of Biological Psychiatry. 2018 Sep 25     [PubMed]
Kreuze LJ,Pijnenborg GHM,de Jonge YB,Nauta MH, Cognitive-behavior therapy for children and adolescents with anxiety disorders: A meta-analysis of secondary outcomes. Journal of anxiety disorders. 2018 Oct 30     [PubMed]
Pereira AS,Willhelm AR,Koller SH,Almeida RMM, Risk and protective factors for suicide attempt in emerging adulthood. Ciencia     [PubMed]

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