Anxiety
Anxiety disorders can be viewed as a family of related but distinct mental disorders, which include (1) Generalized Anxiety Disorder, (2) Social Anxiety Disorder or Phobia, (3) Panic Disorder, (4) Phobias
(1) Generalized Anxiety Disorder (GAD)
Generalized anxiety disorder is defined as excessive anxiety and worry about several events or activities for most days during at least a 6-month period. Individuals with GAD experience persistent anxiety and worry that is out of proportion to actual events or circumstances. Typically, the anxiety and worry involve minor or everyday matters, such as work, finances, relationships, the health or safety of loved ones, and routine tasks. Often, the focus of worry shifts from one concern to another. Although people with GAD do not always consider their worries to be unrealistic or excessive, they do find them difficult to control. Consequently, the worries often interfere with concentration and performance. Associated with the anxiety and worry, individuals with GAD have a variety of cognitive and somatic symptoms, including trembling, feeling shaky, aching in the back and shoulders, tension headaches, chest tightness, restlessness, exaggerated startle, irritability, insomnia, fatigue, dry mouth, sweating, urinary frequency, trouble swallowing, nausea, and diarrhoea. In addition, GAD may be accompanied by other conditions typically associated with stress, such as irritable bowel syndrome or atypical chest pain.
(2) Panic Disorder
A panic attack is an abrupt surge of intense fear that reaches a peak within minutes accompanied by palpitations, sweating, trembling or shaking, sensations of shortness of breath/choking, chest pain/discomfort, nausea/abdominal distress, feeling of dizziness/light headedness/fainting, chills/heat sensations, numbness, feelings of losing control or dying. In Panic disorder, there will be recurrent unexpected panic attacks, accompanied by persistent concern or worry of having another panic attack and or a maladaptive behavioural change designed to avoid another panic attack like avoiding exercises or unfamiliar situations.
(3) Phobias
The term phobia refers to an excessive fear even to the point of panic when exposed to the
feared object, circumstance, or situation. Even the mere thought of the feared object or
situation may be enough to evoke fear or cause a panic attack. So, they will avoid facing those situations or objects or thoughts. Some of the common phobias are –
- Social Phobia (Social Anxiety disorder) – fear of scrutiny by other people in small groups, fear of speaking/writing/eating/encounters with opposite sex in public. Social phobias are usually associated with low self esteem and fear of criticism. They may present as a complaint of blushing, hand tremor, nausea, or urgency of micturition. Symptoms may progress to panic attacks. Avoidance is often marked, and in extreme cases may result in almost complete social isolation.
- Agoraphobia – fear of being alone at places from where escape to familiar safe place may be difficult. The term includes a cluster of phobias like fears of leaving home, fear of entering shops, crowds, and public places, or of travelling alone in trains, buses, or planes. Some sufferers become completely housebound; many are terrified by the thought of collapsing and being left helpless in public.
- Specific (isolated) phobias – These are phobias restricted to highly specific situations such as proximity to particular animals, heights, thunder, darkness, flying, closed spaces, urinating or defecating in public toilets, eating certain foods, dentistry, the sight of blood or injury, and the fear of exposure to specific diseases. Although the triggering situation is discrete, contact with it can evoke panic as in agoraphobia or social phobias.
Causes/ risk factors of Anxiety Disorders
Biological factors
1. Neurotransmitters : Neurotransmitters are chemicals in the brain found between neurons & they help in the transmission of signals from one neuron to another. Main neurotransmitters which are implicated in Anxiety disorders are- GABA, serotonin, norepinephrine, glutamate, and Cholecystokinin – the balance of which are found disturbed in mood disorders, thus altering the signal transmission & thereby the connectivity between different brain regions.
2. Receptors : Different Neurotransmitters bind to specific receptors on the neurons to
transmit the signals. In Anxiety disorders, these receptors may be upregulated or downregulated or hypo-functional or hyper-functional for specific neurotransmitters
in specific brain regions.
3. Second Messengers and Intracellular Cascades : Each Neurotransmitter after binding to its specific receptor on the neuron, triggers the G Proteins & some enzymes causing the production of 2nd messengers such as cAMP & cGMP, which in turn regulate the function of neuronal membrane ion channels; thereby regulating the transmission of signals across neurons. In Anxiety disorders, this complex machinery is found to be deranged.
4. Alterations of Hormonal Regulation : Various hormones like CRH, Cortisol, Thyroid hormone, Growth hormone are found to be dysregulated in Anxiety disorders.
5. Alterations of Sleep Neurophysiology : increased sleep discontinuity, decreased delta sleep, decreased stage 1 sleep, and reduced rapid eye movement sleep.
6. Immunological Disturbance : Impaired cellular immunity – decreased ability of the body to fight against germs, pathogens & diseases.
7. Structural and Functional Brain Imaging :
• CT & MRI Scans have shown that mood disorders damage different parts of the Brain, causing Neurodegenerative changes – Ventricular enlargement, cortical atrophy, sulcal widening & reduced hippocampal or caudate nucleus volumes.
• PET Scans have shown lower metabolic rate in basal ganglia and white matter. Evidence suggests that medications normalize these changes.
Genetic Factors
1. Family Studies : About 25% of first-degree relatives of patients with generalized anxiety disorder are also affected.
2. Twin Studies : If one Monozygotic (identical) twin has a mood disorder, there is 50% risk that the other twin will develop the same disorder. In the case of Dizygotic (fraternal) twins, the risk is 15%.
Psychosocial Factors
1. Life Events and Environmental Stress : Stressful life events more often precede the development of anxiety disorders. Stress results in long-lasting changes in the brain’s biology- alter the Neurotransmitter balance, intraneuronal signalling systems & even loss of neurons and synaptic contacts.
2. Personality Factors : Persons with certain personality disorders : OCD, histrionic, and anxious avoidant— may be at greater risk for anxiety disorders.
Diagnosing Anxiety disorders
Depression is diagnosed by conducting a –
1. Psychiatric interview – of the client (patient) & informants (relatives). A detailed history of the complaints & the present illness, past history of psychiatric illness, family history to see if there are any genetic predisposing causes, personal history to see if any marital/relationship problems or any substance use like alcohol or if there are any external stressors like job loss contributing to the present illness, general medical history to rule out any possibility of any physical illness causing a secondary anxiety syndrome (like hypothyroidism/ Diabetes /parkinsonism), assessment of personality to see if any personality traits or personality disorder is contributing to the current episode of illness.
2. Mental Status examination – General appearance & behaviour, Psychomotor activity, Talk, Thought, Mood, Affect, Perception, Cognitive functions- attention & concentration, memory, intelligence, abstractability, judgment & insight are assessed.
3. Physical Examination – to see if the patient has any undiagnosed medical condition like hypothyroidism, parkinsonism or any other neurological condition causing or contributing to the present psychiatric illness.
4. Neuro-Psychiatric assessment scales – Anxiety rating scales to have an objective measurement of anxiety.
Investigations
Blood levels of Thyroid hormones, Blood vitamin D3 levels, Blood sugar levels etc to see if any physical illness is contributing or causing the anxiety
Treatment of Anxiety Disorders
A. Pharmacotherapy- It’s the treatment by using medicines- Anti-anxiety medications. Medicines correct the neurochemical imbalances, the receptor dysregulations, 2nd messenger & intracellular disarray, stops neuronal loss, increases neuronal dendritic spines and re-establishes neuronal synaptic connections and thus improves and normalises connectivity of different brain regions, thus improving the anxiety & worries. CT, MRI, PET & FMRI studies have shown that treatment with drugs have a positive rebuilding effect on the brain. Anti-anxiety medications are safe, efficacious and are not addictive. Most of the medicines have no to minimal side effects. The duration of treatment depends on the duration of the illness, its severity, level of functional impairment etc. It’s important to complete the full course of treatment and not to stop treatment after mere resolution of symptoms as premature termination of treatment can lead to illness recurrence.
B. Psychotherapy- Psychotherapy is the treatment by psychological means to overcome the patient’s problem. There are 3 types of psychotherapy which are useful in Anxiety disorders
1. Cognitive Therapy- Correcting cognitive distortions (-ve thoughts)
2. Behaviour Therapy- Focusses on maladaptive behaviour patterns.
3. Insight-oriented Therapy- focuses on uncovering unconscious conflicts and identifying ego strengths.
Reference:
1. Oxford Textbook of Psychiatry
2. Kaplan & Sadock’s Comprehensive Textbook of Psychiatry
3. The ICD-10: Classification of Mental and Behavioural Disorders
4. Diagnostic and Statistical Manual of Mental Disorders (DSM–5)
5. https://www.ncbi.nlm.nih.gov/pmc/
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