Anxiety Disorders

There are a number of different types of anxiety disorders. They include:

• Generalized anxiety disorder
• Separation anxiety disorder
•  Social anxiety disorder
•  Panic disorder
•  Agoraphobia
•  Substance/medication-induced anxiety disorder
•  Selective mutism
•  Specific phobia
•  Anxiety disorder due to another medical condition
•  Other specified anxiety disorder 
• Unspecified anxiety disorder

Anxiety disorders make up one of the most common groups of psychiatric disorders. According to the National Comorbidity Study: 

• One in four people in the United States meets the diagnosis for an anxiety disorder.
• Approximately 18 percent of people will have an anxiety disorder that lasts for 12 months.
• Women are more likely to have an anxiety disorder than men.
• Approximately 30 percent of women experience an anxiety disorder during their lifetime, compared to 19 percent of men.
• The prevalence of anxiety disorders decreases with higher socioeconomic status.

There is solid evidence that heredity is a predisposing factor in the development of anxiety disorders. Nearly half of all patients with panic disorder have at least one relative with the same condition. Data from studies of twins also indicate that anxiety disorders are at least partially genetically determined.

From a psychodynamic perspective, the goal of therapy is not necessarily to eliminate all anxiety a person feels but to increase anxiety tolerance and use it as a signal to investigate the underlying conflict that has created it. Anxiety appears in response to various situations during a lifespan, and though medications may improve symptoms, they may do nothing to address one’s life situation or internal responses that lead to anxiety.

Generalized anxiety disorder is diagnosed when a person has excessive anxiety and worry concerning events or activities, such as work or school performance, occurring more days than not for at least 6 months. The individual has difficulty controlling the worry, and has three or more of the following symptoms:

• Restlessness or feeling keyed up or on edge 
• Easily fatigued 
• Difficulty concentrating, or mind going blank 
• Irritability 
• Muscle tension
• Sleep disturbance, such as difficulty falling or staying asleep, or restless, unsatisfying sleep
  In addition, the anxiety causes significant distress or impairment in social, occupational or other important areas of functioning. A diagnosis of generalized anxiety disorder is possible when the anxiety is not attributable to the physiological effects of a substance (drug of abuse or medication) or another medical condition, such as hyperthyroidism. Neither can the condition be explained by another anxiety disorder.

Generalized Anxiety Disorder Epidemiology

• Generalized anxiety disorder is a common condition. Estimates for its prevalence lasting 1 year or longer range from 3 to 8 percent.
• About twice as many women have anxiety disorder as men.
• The disorder usually starts in late adolescence or early adulthood but is also commonly seen in older adults.

Generalized Anxiety Comorbidity

•  It’s estimated that 50 to 90 percent of individuals with generalized anxiety disorder have another mental disorder.
•  As many as 25 percent of patients eventually experience panic disorder.
•  An additional high percentage of patients are likely to have major depressive disorder.
•  Other common conditions associated with generalized anxiety disorder are dysthymic depressive disorder and substance-related disorders.

Psychosocial Factors of Generalized Anxiety Disorder

•  The cognitive-behavioral school of psychology believes that patients with generalized anxiety disorders respond to incorrectly perceived dangers. The inaccuracy comes from focusing on negative details in the environment, by distortions in information processing, and by an overly negative view of one’s ability to cope.
•  The psychoanalytic school hypothesizes that anxiety is a symptom of unresolved, unconscious conflicts.

The most effective treatment of generalized anxiety disorder is probably one that combines psychotherapy, pharmacotherapy, and supportive approaches.

In terms of psychotherapy, cognitive approaches address an individual’s distorted thoughts, while behavioral approaches address somatic symptoms. The major techniques of used in behavioral approaches are relaxation and biofeedback. Supportive therapy offers patients reassurance and comfort. Insight-oriented psychotherapy focuses on uncovering unconscious conflicts and identifying ego strengths. Most patients experience a marked reduction in anxiety when given the opportunity to discuss their difficulties with a concerned and sympathetic physician or therapist.

The most effective prescription drugs for the treatment of generalized anxiety disorder are benzodiazepines, SSRIs (Zoloft, Prozac, Paxil, etc.), SNRIs (Effexor, Cymbalta, etc.), and buspirone (BuSpar). Other drugs that may be useful are tricyclic drugs (Nortriptyline, Amytriptyline, etc.) and beta-adrenergic antagonists or blockers (Propranolol).

Separation anxiety disorder is developmentally inappropriate and excessive fear or anxiety concerning separation from loved ones. The anxiety lasts at least 4 weeks in children and adolescents, and typically 6 months or more in adults. The diagnosis requires at least three of the following symptoms:

• Recurrent excessive distress when anticipating or experiencing separation from home or from loved ones.
• Persistent and excessive worry about losing loved ones or about possible harm to them, such as illness, injury, disasters, or death.
• Persistent and excessive worry about experiencing a negative event, such as getting lost, being kidnapped, having an accident, or becoming ill, that causes separation from the loved one.
• Persistent reluctance or refusal to go out, away from home, to school, to work, or elsewhere due to fear of separation.
• Persistent fear or reluctance about being alone at home or in other settings.
• Persistent reluctance or refusal to sleep away from home or to go to sleep without being near a loved one. 
• Repeated nightmares involving the theme of separation. 
• Repeated complaints of physical symptoms (such as headache, stomachache, nausea, vomiting) when separation from loved ones occurs or is anticipated.
  The anxiety causes significant distress or impairment in social, academic, occupational, or other important areas of functioning.

Social anxiety disorder is diagnosed when a person has excessive fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others. Examples include social interactions, such as having a conversation, meeting new people, being observed while eating or drinking, and performing in front of others (e.g., giving a speech). In children, the anxiety must occur in peer settings and not just during interactions with adults.

The fear, anxiety or social avoidance typically lasts for 6 months or more, and causes significant distress or impairment in social, occupational, or other important areas of functioning. A diagnosis of social anxiety disorder cannot be explained by the physiological effects of a substance (e.g., a drug of abuse or medication) or another medical condition. If another medical condition (e.g., Parkinson’s disease, obesity, disfigurement from burns or injury is present) the fear, anxiety or avoidance is clearly unrelated or is excessive. Social anxiety disorder may be diagnosed as “performance only” if the fear is restricted to speaking or performing in public.

Social Anxiety Disorder Epidemiology & Genetics

• Studies have reported a lifetime prevalence of social anxiety disorder ranging from 3 to 13 percent.
• The peak onset for social anxiety disorder is in the teens, although it can start at ages as young as 5 years and as old as 35 years.
• People who have relatives with social anxiety disorder are about 3 times more likely to be affected by the condition.

Both psychotherapy and pharmacotherapy are useful in treating social anxiety disorder. Some studies indicate that the use of both pharmacotherapy and psychotherapy is more effective than either therapy alone.

The most effective prescription drugs for the treatment of social anxiety disorder are benzodiazepines, SSRIs (Zoloft, Prozac, Paxil, etc.), SNRIs (Effexor, Cymbalta, etc.), and buspirone (BuSpar). Other drugs that may be useful are tricyclic drugs (Nortriptyline, Amytriptyline, etc.) and beta-adrenergic antagonists or blockers (Propranolol).

Psychotherapy for social anxiety disorder usually involves behavioral and cognitive approaches, including cognitive retraining, desensitization, rehearsal during sessions, and a range of homework assignments.

A panic disorder diagnosis is given to a person who has recurrent unexpected panic attacks. A panic attack is a sudden surge of intense fear or discomfort that reaches a peak within minutes. During this time, four or more of the following symptoms occur:

• Palpitations, pounding heart, or accelerated heart rate
• Sweating
• Trembling or shaking
• Shortness of breath or feeling smothered
• Feeling choked
• Chest pain or discomfort 
• Nausea or abdominal distress
• Dizziness, light-headedness or feeling faint 
• Chills or heat sensations
• Numbness or tingling sensations
• Feelings of unreality or of being detached from oneself
• Fear of losing control or “going crazy”
• Fear of dying

A diagnosis of panic disorder request that at least one of the attacks be followed by 1 month or more of one or both of the following:

• Persistent concern or worry about additional panic attacks or their consequences
• A significant maladaptive change in behavior related to the attacks, such as avoiding exercise or unfamiliar situations

Moreover, the disturbance cannot be explained by the physiological effects of a substance (e.g., drug of abuse or medication), another mental condition (e.g., hyperthyroidism or cardiopulmonary disorders), or another mental disorder, such as post-traumatic stress disorder (PTSD) or obsessive-compulsive disorder (OCD).

Panic Attack / Panic Disorder Epidemiology

• The lifetime prevalence of panic disorder is in the 1 to 4 percent range.
• Women are two to three times more likely to be affected by panic attacks than men, although the underdiagnosis of panic disorder in men may contribute to this difference.
• The only social factor identified as contributing to panic disorder is a recent history of divorce or separation.
•  The panic disorder most commonly develops in young adulthood at the mean age of 25. However, panic disorder and agoraphobia can develop at any age.

Panic Attack / Panic Disorder Comorbidity

• Of patients with panic disorder, 91 percent have at least one other psychiatric disorder. About one-third of individuals with panic disorders have major depressive disorder before the panic disorder onset. About two-thirds first experience panic disorder during or after the onset of major depression.
• Of patients with panic disorder, 15 to 30 percent also have social anxiety disorder or social phobia, 15 to 30 percent have generalized anxiety disorder, 2 to 20 percent have specific phobia, 2 to 10 percent have post-traumatic stress disorder (PTSD), and up to 30 percent have obsessive-compulsive disorder (OCD). Other common comorbid conditions include hypochondriasis or illness anxiety disorder, personality disorders, and substance-related disorders.
• Various studies also indicate that 40 to 80 percent of all panic disorder patients suffer from depression.

Psychodynamic Themes in Panic Attacks / Panic Disorder

Psychodynamic theory considers the interplay of conscious and unconscious factors that may develop through interpersonal relationships and during childhood. Psychodynamic themes often seen in patients with panic disorder include:

• Difficulty tolerating anger
• Physical or emotional separation from significant persons both in
• childhood and adult life
• Situations of increased work responsibilities
• Perception of parents as controlling, frightening, critical and demanding
• Perception of relationships involving sexual or physical abuse
• A chronic sense of feeling trapped

Panic Attack Disorder vs. Medical Disorders

Panic disorder must be differentiated from a number of medical conditions that produce similar symptoms. These include cardiovascular diseases, pulmonary diseases, neurological diseases, and endocrine diseases.

The two most effective treatments for panic attacks / panic disorder are medications and cognitive behavioral therapy. Family and group therapy may also help patients and their families.

Pharmacotherapy
In general, selective serotonin reuptake inhibitors (SSRIs) and clomipramine (Anafranil) are shown to be more effective and better tolerated than benzodiazepines, monoamine oxidase inhibitors and tricyclic and tetracyclic drugs. Some reports suggest a role for venlafaxine (Effexor) and buspirone (BuSpar). Venlafaxine is approved for treatment of generalized anxiety disorder and may help in patients with both panic disorder and depression.

Cognitive & Behavior Therapies
Cognitive and behavior therapies are effective treatments for panic disorder. Several studies have found that the combination of cognitive or behavioral therapy with pharmacotherapy is more effective than either approach alone.

The most effective prescription drugs for the treatment of generalized anxiety disorder are benzodiazepines, SSRIs (Zoloft, Prozac, Paxil, etc.), SNRIs (Effexor, Cymbalta, etc.), and buspirone (BuSpar). Other drugs that may be useful are tricyclic drugs (Nortriptyline, Amytriptyline, etc.) and beta-adrenergic antagonists or blockers (Propranolol).

To treat panic disorders, selective serotonin reuptake inhibitors (SSRIs) and clomipramine (Anafranil) are shown to be more effective and better tolerated than benzodiazepines, monoamine oxidase inhibitors and tricyclic and tetracyclic drugs. Some reports suggest a role for venlafaxine (Effexor) and buspirone (BuSpar). Venlafaxine is approved for treatment of generalized anxiety disorder and may help in patients with both panic disorder and depression.

Agoraphobia is a marked fear or anxiety about two or more of the following situations:

• Being in open spaces (e.g., marketplaces, parking lots, streets)
• Being in enclosed places (e.g., shops, theaters)
• Using public transportation (e.g., cars, buses, trains, ships, planes)
• Standing in line or being in a crowd
• Being outside of the home alone

The individual fears or avoids these situations because of thoughts that escape might be difficult or help might not be available in the event of developing panic-like symptoms or other incapacitating or embarrassing symptoms (e.g., fear of incontinence or fear of falling in the elderly). The agoraphobic situations are actively avoided, require the presence of a companion, or are endured with intense fear or anxiety. The fear, anxiety or avoidance typically lasts for 6 months or more, and causes significant distress or impairment in social, occupational or other important areas of functioning.

Agoraphobia will be diagnosed irrespective of the presence of panic disorder.

Agoraphobia Epidemiology
The lifetime prevalence of agoraphobia varies between 2 to 6 percent across studies.

Agoraphobia vs. Other Disorders
Agoraphobia must be differentiated from a number of other medical conditions that produce similar symptoms. These include major depressive disorder, schizophrenia, paranoid personality disorder, avoidance personality disorder, and dependent personality disorder.

Pharmacotherapy

Benzodiazepines have the most rapid onset of action against panic. Xanax and Ativan are the most commonly prescribed benzodiazepines. Clonazepam has also been shown to be effective.
Benzodiazepines have the potential for dependency, cognitive impairment and abuse, especially with long-term use. However, when used appropriately under medical supervision benzodiazepines are effective and generally well-tolerated. Their most common side effects are mild dizziness and sedation, both of which are often reduced by time or by adjustment of dosing.

Selective serotonin reuptake inhibitors (SSRIs) are considered the first-line agents for treatment of panic disorders with or without agoraphobia, and they can help reduce or prevent relapse. The main advantage of SSRIs is their improved safety profile and more tolerable side effects.

Tricyclic and tetracyclic drugs are also effective treatments, although they require careful dosing and close monitoring of side effects, which can include jitteriness, possible seizures and potentially harmful cardiac effects.

Psychotherapy

A variety of different types of psychotherapy may be used to treat agoraphobia.

• Behavior therapy approaches include positive and negative reinforcement, systematic desensitization, relaxation techniques, stop thought, panic control therapy, self-monitoring, hypnosis, and others.
• Cognitive therapy focuses on correcting an individual’s distorted thoughts and perceptions. Treatment is short-term and interactive with assigned homework between sessions.
• Supportive psychotherapy focuses on strengthening an individual’s adaptive defenses while discouraging maladaptive behavior.
• Insight-oriented psychotherapy focuses on uncovering and resolving a person’s internal conflicts.
• Virtual therapy with computer programs allows patients to see themselves as avatars who are placed in open or crowded spaces. Identifying with the avatars in repeated sessions enables patients to master tehri anxiety through deconditioning.

Substance/medication-induced anxiety disorder can affect individuals during or after ingesting a number of different drugs or substances. These can include:

• Alcohol
• Amphetamine (or other stimulant)
• Caffeine
• Cannabis
• Cocaine
• Inhalants
• Opioids
• Phencyclidine (PCP)
• Sedative, hypnotic or anxiolytic drugs
• Or other unknown substance

A diagnosis of substance/medication induced anxiety is when an individual suffers from panic attacks or anxiety soon after substance intoxication or withdrawal, or after taking a medication. Moreover, the panic attacks or anxiety cannot be attributed to another anxiety disorder apart from the substance or medication use.

Selective mutism is a type of anxiety disorder that is diagnosed when an individual is afraid to speak in specific social situations where there is an expectation for speaking, such as at school or work, despite speaking in other situations.

• The anxiety interferes with educational or occupational performance and lasts at least 1 month.
• The failure to speak is not explained by a lack of knowledge of, or comfort with, the spoken language required in the social situation.
• The failure to speak is not better explained by a communication disorder and does not occur exclusively with autism spectrum disorder, schizophrenia, or another psychotic disorder.

An anxiety disorder diagnosed because of a specific phobia is based on an individual’s marked fear or anxiety about a specific object or situation. Examples include flying in planes, heights, animals, receiving an injection, or seeing blood. In children, the fear or anxiety may be expressed by crying, tantrums, freezing or clinging behavior. The diagnosis requires that:

• The fear, anxiety or avoidance lasts for 6 months or more.The phobic object or situation almost always provokes immediate fear or anxiety.
• The phobic object or situation is actively avoided or endures with intense fear or anxiety.
• The fear or anxiety is out of proportion to the actual danger posed by the specific object or situation.
• The fear, anxiety or avoidance causes significant distress or impairment in social, occupational, or other important areas of functioning.
• The anxiety is not better explained by the symptoms of another mental disorder, including panic disorder, agoraphobia, obsessive-compulsive disorder, posttraumatic stress disorder, separation anxiety disorder, or social anxiety disorder

A diagnosis for anxiety disorder due to another medical condition can be made when:

• An individual suffers largely from panic attacks or anxiety.
• There is evidence from the individual’s history, physical examination or laboratory findings that the anxiety is caused by another medical condition.
• The anxiety causes significant distress or impairment in social, occupational, or other important areas of functioning.
• The anxiety is not better explained by another mental disorder.
• The anxiety or panic attacks do not occur exclusively during episodes of delirium.

A diagnosis for unspecific anxiety disorder applies to situations in which anxiety symptoms do not meet the full criteria for any of the established anxiety disorders. The anxiety symptoms still cause significant distress or impairment in social, occupational, or other important areas of functioning. The clinician, however, lacks information to categorize the anxiety into one of the specific anxiety disorders. This may occur in emergency room situations.

No. Sometimes, individuals may be diagnosed with an anxiety disorder, even though their symptoms do not meet the normal diagnostic guidelines. This can happen with:

• Anxiety attacks with limited symptoms
• Generalized anxiety not occurring more days than not
• Fears related to a specific cultural belief system
• Ataque de nervios (“attack of nerves”) ¬– a syndrome among individuals of Latino descent characterized by intense emotional upset and a sense of being out of control, often occurring in response to a stressful family event
  In such cases, the clinician will diagnose the condition as “Other Specified Anxiety Disorder.”