Anxiety

Introduction

We've all experienced symptoms of anxiety at some point in our lives. A pounding heart, tense muscles, rapid breathing, perfuse sweating, or an upset stomach characterize a few of the many symptoms associated with the illness. Perhaps you've felt anxious when you've given a speech, taken a test, or driven in heavy traffic. While this kind of tension may have felt uncomfortable, it also helped you cope. You had a reason to be anxious, and the tension it caused kept you aware and ready to react. Now imagine feeling anxious for no apparent reason.

What is it?

Generally, anxiety is a complex but normal emotional state that occurs when an individual senses an unclear danger. When anxiety ceases being a protective response, the patient suffers from an anxiety disorder, which can have a debilitating effect on the patient?s lifestyle. Anxiety disorders arise from an individual?s brain chemistry, genetics, personality, and life events. Within the brain, cells communicate with one another through the intake and discharge of chemical substances known as neurotransmitters. Imbalances in neurotransmitter production produce the severe symptoms that accompany anxiety disorders. The neurotransmitters that are associated with anxiety disorders are norepinephrine, serotonin, and GABA.

There are five general types of anxiety:

Generalized Anxiety Disorder

Generalized Anxiety Disorder or GAD is characterized by excessive anxiety and worry, occurring more days than not for at least six months, about a number of events or activities (e.g. work, school, family, etc.). The person finds it difficult to control the anxiety or worry due to feelings that unidentified danger lurks. The anxiety and worry are usually associated with 3 or more of the following symptoms: restlessness or feeling on edge, fatigue, irritability, muscle tension, sleep disturbances, and difficulty concentrating.

GAD normally develops between the early teens and mid-fifties with the average age being 21 years old. GAD appears to be twice as common in females as in males. At least two-thirds of GAD patients have another psychiatric illness, most commonly depression or another anxiety disorder. There is some evidence that a family history of GAD increases the likelihood of developing GAD.

Alcohol abuse and dependence are common in GAD patients and are frequently a result of patients? attempts to self-medicate their anxiety disorder. Usually, a person who suffers from GAD is able to carry on with normal activities. He or she can function in social settings, or on the job, and does not usually have to avoid certain situations as a result of the disorder. However, severe GAD can be very debilitating and it can make daily life difficult, as well as having a negative impact on the sufferer's relationships with friends and family. Without treatment, less than half of GAD cases have their symptoms diminish over time.

Panic Disorder

Panic attacks occur suddenly and without warning. During a panic attack, a person may experience chest pain or a pounding heart, an intense feeling of terror, dizziness, sweating, tingling or numbness in the fingers or toes, difficulty breathing, and nausea. The sufferer may genuinely believe that he or she is having a heart attack or stroke, or is on the verge of death. The sufferer cannot predict when an attack will occur, and many develop intense anxiety between episodes, worrying when and where the next one will strike. In between times there is a persistent, lingering worry that another attack could come any minute. Most panic attacks last for just a few minutes, but they can last longer. In rare cases, they may last an hour or more.

About 2% of American adults will be affected by panic disorder at some point in their lives. Women are affected two or three times more often than men. It can appear at any age, but most often it begins in young adults. Not everyone who experiences panic attacks will develop panic disorder. Panic disorder is often accompanied by other conditions such as depression, alcoholism, or social anxiety disorder. In addition, panic disorder may give rise to phobias, which can develop in places or situations where panic attacks have occurred. For example, if a panic attack strikes while the sufferer is out shopping, he or she may develop a fear of stores, and start avoiding them. Sometimes, the panic disorder is accompanied by a fear of public or open places, which is known as agoraphobia. In severe cases of agoraphobia, the sufferer can become completely housebound.

Obsessive-Compulsive Disorder

Obsessions are recurrent thoughts, impulses, or images that provoke anxiety in the affected person; obsessions cannot be ignored or suppressed. Compulsions are the ritualistic behavior that is designed to reduce the anxiety that obsessions produce. Persons suffering from obsessive-compulsive disorder (OCD) realize that the obsessions and compulsions are excessive or unreasonable. However, OCD sufferers are forced to perform these rituals because it provides temporary relief from the anxiety and unease caused by the obsession.

The most common obsessions involve germs and contamination, order and neatness, and religious or sexual thoughts. Common compulsions include frequently washing hands, constantly checking zippers and buttons on clothing, repeatedly asking the same question, and hoarding objects. OCD is diagnosed when such activities consume at least an hour a day and when sufferers are compelled to perform rituals in order to feel relief from the intense feelings of discomfort and unease resulting from their obsession. In addition, the activities appear to be senseless, are very distressing, and interfere with daily life.

OCD affects men and women equally though men tend to develop OCD earlier in life. OCD afflicts between 2% and 3% of the worldwide population. It can appear in childhood, adolescence, or adulthood, but on average it first shows up in the teens or early adulthood. The course and severity of OCD are highly variable and unpredictable, with some persons only mildly or irregularly suffering and others suffering severely and constantly throughout life. There is some evidence that OCD might run in families.

OCD can lead to clinical depression over time. Some OCD patients may avoid situations in which they might have to confront their obsessions, or they may try to use alcohol or drugs to escape their compulsion. Severe OCD can keep someone from holding down a job or from carrying out normal responsibilities at home.

Exaggerated Fears (Phobias)

Phobias are the most common form of anxiety disorders. Between 8.7% and 18.1% of Americans suffer from phobias. Among women in all age groups, phobias were the most common mental illness, while, among men older than 25 phobias, were the second most common mental illness. Specific phobias can be classified into different subtypes. There are animal type (e.g. snakes, dogs, spiders, etc.) and situational type (e.g. flying, bridges, elevators, etc.) phobias. Another phobia type is the blood-injection type (e.g. blood, injury, medical procedures, etc.) while there are phobic sufferers whose fears are the natural environment type (e.g. heights, water, storms, etc.). One specific phobia, agoraphobia, is often associated with panic disorder. Agoraphobia is a fear of being in public or open places. In patients with agoraphobia and panic disorder the phobia is usually due to a fear that any situation might provoke a panic attack, or that escape from the area may be difficult if one occurred.

Around 5% to 12% of Americans suffer from phobias. An adult with a phobia can be aware that his or her fears are excessive or unreasonable but still be unable to overcome those fears. The exact cause of phobias is unknown, but most phobias appear to be related to a traumatic event or a learned reaction to a situation. Only about 20% of specific phobias in adults resolve without treatment.

Phobias appear to run in families and are a little more prevalent in women. Phobias usually first appear in adolescence or adulthood, but can occur in any person regardless of age. Childhood phobias, like a fear of animals, usually disappear over time. But in some cases, for unknown reasons, they may continue into adulthood. Symptoms of specific phobias include excessive fear of a specific object or situation, nausea, sweating, pounding heart, anticipatory anxiety of certain upcoming situations, shortness of breath, numbness or tingling, and avoidance of the specific object or situation.

Patients with specific phobias are generally symptom free unless faced with their fears. These patients adjust their lives and activities in order to avoid the feared objects.

Social phobias are fears involving other people or social situations such as performance anxiety or fears of embarrassment by scrutiny of others, such as eating in public. Although this disorder is often thought of as shyness, the two are not the same. A shy person can be uneasy around others, but does not experience extreme anxiety when they think about a social situation. A person with a social phobia may not be shy at all. Only in a particular situation, like giving a speech, do they experience intense anxiety. Social phobia can disrupt normal life and interfere with a person's career or social relationships. The dread of a social event can begin weeks in advance, and symptoms can be quite debilitating.

Post-Traumatic Stress Disorder

Post-Traumatic Stress Disorder (PTSD) is a specific type of anxiety disorder that results from experiencing or witnessing a traumatic event, especially if the sufferer felt that their life or someone else?s was in danger. Originally, PTSD was called shell-shock or battle fatigue. It was first diagnosed in war veterans, notably the soldiers who survived the horrifying trench warfare of World War I and more recently in veterans of the Vietnam and Iraq Wars. However, PTSD is not confined only to soldiers as PTSD has been diagnosed in victims of violent crimes (e.g. mugging or rape) and survivors of an accident, natural disaster, or terrorist attack.

PTSD cannot be diagnosed unless symptoms last for at least one month, cause great emotional distress, and interfere significantly with the sufferer?s life. A typical PTSD symptom is reliving the traumatic event thru nightmares and disturbing recollections of the event. Often, these ?flashbacks? are accompanied by intense feelings of fear, helplessness, and horror as the PTSD sufferer ?relives? the event. PTSD sufferers often experience sleep problems and depression while also being prone to outbursts of anger or irritability. They may lose interest in activities they used to enjoy and have trouble feeling affectionate.

PTSD can occur at any age, including childhood. Depression, substance abuse, or anxiety can accompany the disorder. While many people experience a traumatic event in their lifetime, PTSD does not afflict every person who experiences a trauma. Those who are affected usually have symptoms within three months of the event, but there have been cases where the condition has only appeared years later.

What causes it?

There are several theories about what causes anxiety disorders. They include the following:

  • Family history
  • Drug use or withdrawal
  • Traumatic events
  • Severe or long-lasting stress
  • Medical or psychiatric illnesses

    Who has it?

    According to the National Institutes of Mental Health, 40 million American adults suffer from anxiety disorders every year. Of those 40 million, 6.8 million suffer from Generalized Anxiety Disorder, GAD, while 6 million American adults suffer from panic disorder. GAD and panic disorder affect twice as many women as men.

    Specific phobias, which are intense and irrational fears of things that pose little or no actual danger, affect 19.2 million adult Americans. Specific phobias are twice as common in women as men. Obsessive-compulsive disorder affects both genders equally and is seen in about 2.2 million American adults. Though it is seen in about 7.7 million American adults, Post-Traumatic Stress Disorder, PTSD, can occur at any age and affects more women than men.

    What are the risk factors?

    Risk factors are characteristics that increase the likelihood that you will develop a particular condition. Common risk factors for anxiety disorders are:

  • a family history of anxiety disorders
  • past negative experiences (e.g. family conflict or sexual abuse)
  • buildup of stress
  • medical illness, such as heart or respiratory ailments
  • psychiatric illness, such as depression or dementia
  • medication use or discontinuation
  • withdrawal after discontinuing certain substances, such as alcohol
  • drug abuse

    What are the symptoms?

    Physical symptoms include blushing, sweating, dizziness, abdominal discomfort, sleep disturbances, shortness of breath, heart palpitations, chest pain, and fatigue.

    Mental symptoms include poor concentration, feeling out of control, sense of fear or dread, and feelings of panic.

    Behavioral symptoms include inability to be still or calm, avoidance of stressful situations, and poor coping skills.

    How is it treated?

    A number of different medication classes are used to treat anxiety disorders. Certain drug classes have greater effectiveness on specific anxiety disorders than others. For an acute anxiety attack, short-term treatment with benzodiazepines is generally used first. To help prevent episodes of anxiety, selective serotonin reuptake inhibitors, serotonin norepinephrine reuptake inhibitors, or buspirone are generally tried first. Other choices may include tricyclic antidepressants, beta-blockers, and, rarely, monoamine oxidase inhibitors. Some of these drugs may be used together if needed to control anxiety.

    Each drug class has their benefits and risks. For instance, elderly patients may have to take different doses compared to younger patients due to changes in how the body metabolizes medications. Some medications may have dietary restrictions, while other medications may have important drug interactions that the patient needs to be aware of. In addition, there are sometimes side effects with the use of anti-anxiety medications. With all of these precautions, doctors must carefully evaluate the patient?s condition before prescribing an anti-anxiety medication. Additionally, because treatment may take several weeks to work best, the physician should closely monitor the patient?s condition and treatment strategy for effectiveness, side effects, and toxicity.

    Helping Yourself

    Anxiety disorders can affect you physically and psychologically. Therefore, treatment usually has physical and psychological components, like medications and psychotherapy. Your doctor is likely to tailor treatment options and the selection of medications to your specific anxiety disorder; treatment can be complicated if you have more than one type of anxiety disorder and you also are experiencing depression.

    Psychotherapy may involve:

    • Supportive Therapy - consists of listening to your symptoms, educating you about them and encouraging you to develop strategies for coping with future episodes of anxiety.

    • Behavioral Therapy - teaches you how to modify and gain control over an unwanted behavior. Deep breathing exercises are often used for a calming effect and to decrease the rapid heartbeat that often accompanies anxiety. You may also be taught how to control your fears by gradually confronting frightening situations with guidance from your healthcare professional.

    • Cognitive Therapy - teaches you how to react differently to anxiety but concentrates on understanding how your thought processes contribute to your symptoms. Once you learn to recognize an inappropriate or unrealistic thought, you may be better able to replace it with one more appropriate to the situation.


    In addition to medication and psychotherapy, there are certain things patients can do on their own to make treatment even more useful. Some patients may find it beneficial to join a self help or support group, or speak with a trusted friend or clergy member. Stress management, meditation techniques, or routine exercise can be very helpful in learning to cope with feelings of anxiety. Though these may be effective methods of coping with your anxiety, they should not replace the advice or care of a physician.

    For patients with anxiety, it is important to first talk with your doctor or pharmacist before starting any new medications or using any over-the-counter medications. Things like caffeine, illicit drug use, and over-the-counter cold medications can potentially aggravate or worsen the symptoms of anxiety.

    What is on the horizon?

    A new study funded by the National Institute for Mental Health is investigating the cost and benefits of excluding benzodiazepines, a common class of drugs used in anxiety, from the new Medicare Part D plans. When Medicare Part D formularies were developed, benzodiazepines were excluded from coverage because it was felt that they contributed to worsening overall health in the elderly by increasing falls and fractures and worsening conditions such as emphysema and depression. This research aims to uncover how the exclusion of benzodiazepines has affected overall health, as well as the treatment of anxiety disorders, in older adults. It is not clear at this time whether the results of this study could change the formulary decisions for Medicare Part D.

    Today, SSRIs are usually the 1st line medications for most anxiety disorders. Current research focuses on developing new drugs that will correct imbalances in the chemistry of the brain causing anxiety disorders. Around 50% of persons with anxiety can be treated with an SSRI. The question remains, how should the others be treated? Many drugs are being tested for their use in anxiety. Strattera is a drug that has been used for Attention Deficit Hyperactivity Disorder (ADHD), and is currently being studied for the possible treatment of anxiety. Another new drug, duloxetine (Cymbalta), commonly used for depression and diabetic neuropathy, is also being studied for its potential use in anxiety. For alcoholics who suffer from anxiety, levetiracetam (Keppra), an anti-seizure medication, is also being tested.

    References

    1. Efficacy and Tolerability of Atomoxetine (Strattera) in Adult Patients with Generalized Anxiety Disorder. ClinicalTrials.gov. http://clinicaltrials.gov/ct/show/NCT00260533?order=47. (Accessed July 2006)

    2. Duloxetine Compared with Placebo in the Prevention of Relapse in Generalized Anxiety Disorder. ClinicalTrials.gov. http://clinicaltrials.gov/ct/show/NCT00122863?order=25. (Accessed July 2006)

    3. Levetiracetam for the Treatment of Alcohol Dependence and Anxiety. ClinicalTrials.gov. http://clinicaltrials.gov/ct/show/NCT00141115?order=2. (Accessed July 2006)

    4. McIntosh A, Cohen A, Turnbull N, et. al. Clinical guidelines for the management of anxiety. Guideline.gov. http://www.guideline.gov/summary/summary.aspx?doc_id=6248&nbr=004008&string=anxiety. (Accessed July 2006).

    5. Kirkwood CK, Melton ST. Anxiety Disorders. In: Dipiro JT, et al. Pharmacotherapy: A Pathophysiologic Approach. 6th ed., 1289-1310.

    6. Anxiety Disorders of America: Statistics and Facts About Anxiety Disorders. http://www.adaa.org/mediaroom/index.cfm. (Accessed January 2008).

    7. American Psychiatric Association: Anxiety Disorders. http://www.psych.org/public_info/anxiety.cfm. (Accessed January 2008).

    8. National Institutes of Mental Health. Anxiety disorders. National Institutes of Health. Publication No. 02-3879. 2006; http://www.nimh.nih.gov/healthinformation/anxietymenu.cfm. (Accessed March 2007).

    9. Rapee R. Craske M. Barlow D. The causes of anxiety and panic attacks. http://www.algy.com/anxiety/files/barlow.html

    10. Augustin SG. Anxiety Disorders. In: Koda-Kimble MA, et al. Applied Therapeutics: The Clinical Use of Drugs. 8th ed., 76-1 to 76-47.

    11. HealthyMinds.org. American Psychiatric Association. http://healthyminds.org/factsheets/LTF-Anxiety.pdf (Accessed January 2008).

    12. National Institute of Mental Health. Science News. http://www.nimh.nih.gov/science-news/2007/new-study-will-examine-effects-of-excluding-anti-anxiety-medications-in-medicare-part-d-coverage.shtml (Accessed January 2008).

    13. National Institute of Mental Health. Anxiety Disorders. http://www.nimh.nih.gov/health/publications/anxiety-disorders/how-to-get-help-for-anxiety-disorders.shtml (Accessed January 2008).

      Anxiety Health Condition Last Updated: January 2008

      Note: The above information is intended to supplement, not substitute for, the expertise and judgment of your physician, pharmacist, or other healthcare professional. It is not intended to diagnose a health condition, but it can be used as a guide to help you decide if you should seek professional treatment or to help you learn more about your condition once it has been diagnosed.

      Back