Anxiety
Anxiety disorders are prevalent (estimated lifetime prevalence of 25% in the general population) and a frequent precipitant of visits to the non-psychiatric physician. Evaluation and management can be challenging because patients present with feelings of distress and concern about disease in the absence of objective evidence. Suffering no less from the subjective nature of their ailment, they fear something is amiss with their bodies and persistently seek an acceptable explanation and relief. The autonomic arousal accompanying anxiety may affect many organ systems and imitate physical disease. Moreover, anxiety and anxiety-like symptoms may be consequent to a variety of medical ailments and their treatments.
Anxiousness is a normal human affect. Distinguishing it from pathologic anxiety and anxiety disorders often requires systematic evaluation and a thorough understanding of the individual patient’s physical and psychological status. Unrecognized and untreated, anxiety disorders increase the cost of medical care and render patients vulnerable to further morbidity, including demoralization, hypochondriasis, depression, and varying degrees of disability. A comprehensive and empathic assessment of the anxious patient by the primary care physician permits a reasoned and often therapeutically effective approach to the difficult problems presented.
Definitions. Anxiety is the distressing experience of dread, foreboding, or panic accompanied by a variety of autonomic—primarily sympathetic—bodily symptoms. The distress, therefore, is both psychic and physical. Patients vary considerably in their tolerance to it. The new onset or exacerbation of anxiety often occurs in response to emotional or physiologic stimuli. Most persons meet the challenge of universally anxiety-provoking situations with their own personal strengths and styles of coping. When a patient’s capacity for coping is overwhelmed, excessive anxiety may emerge. Pathologic anxiety is distinguished from the normal by its occurrence in the absence of an appropriate stimulus and by its duration or intensity.
Neurotransmitter Mechanisms. Several monoamine and neuropeptide neurotransmitters are implicated in the neurobiology of anxiety. Norepinephrine plays a prominent role in mediating anxiety states centrally. The locus ceruleus of the pons serves as the chief noradrenergic nucleus. Abnormal firing patterns in the locus ceruleus have been implicated in the pathophysiology of some anxiety conditions, such as panic disorder. In contrast, the inhibitory neurotransmitter gamma-aminobutyric acid, ubiquitous throughout the brain, is implicated as serving an anxiolytic function within the limbic system. The resultant somatic manifestations of anxiety are principally mediated by the sympathetic nervous system.
Classification and Basic Components of the Clinical Presentation. The classification of anxiety disorders is largely based on clinical features. In both its normal and pathologic forms, anxiety’s manifestations consist of affective, cognitive, behavioral, and somatic components. The affective component is characterized by the experience of dread, foreboding, or panic countered by cognitions that make sense of or seek to neutralize the distress. A variety of behaviors reflect the anxious state or evolve in response to it (e.g., avoidance). Typical psychological presentations might include complaints of apprehension, motor tension or agitation (restlessness, edginess, jitteriness), and heightened arousal (including hypervigilance, distractibility, impaired concentration, and insomnia). The somatic complaints are mostly those of autonomic hyperactivity and include systemic, cardiopulmonary, gastrointestinal, urinary, and neurologic symptoms.
Adjustment Disorder with Anxious Mood. Most presentations of anxiety
within the medical setting are normal reactions to anxiety-provoking situations.
For a limited time period, a patient may suffer symptoms similar to those of a
generalized anxiety disorder (see below). When a patient’s capacity for coping
is overwhelmed, excessive anxiety may transiently emerge until the patient is
able to adjust. This state is termed adjustment disorder with anxious mood
and typically resolves in less than 6 months. Adjustment disorders may likewise
be heralded by other manifestations, including depressed mood and misconduct.
Generalized Anxiety Disorder. This common condition is characterized by anxiety lasting longer than 6 months and worry extending beyond a specific subject. Typically, the patient is ruminating with worries over a variety of concerns and may have been this way for several years with a waxing and waning course. Generalized anxiety disorder also includes an array of physical concomitants, including restlessness, fatigability, poor concentration, irritability, muscle tension, and insomnia. In addition to the persistent anxious state, the patient may describe more discrete episodes of acute anxiety.
When sudden spells of extreme anxiety occur with prominent symptoms of sympathetic activation, they may be accompanied by feelings of impending doom, fear of dying, the sensation of panic, and the impulse to flee. Such symptoms characterize panic attacks, which may occasionally be experienced by patients with generalized anxiety disorder, although they are a more prominent feature in panic disorder.
Panic Disorder. This anxiety disorder is characterized by recurrent unexpected panic attacks, with at least one attack followed by no less than a month of persistent concern about having additional attacks, worry about the implications of the attack or its consequences (e.g., losing control, having a heart attack), or a significant change in behavior related to the attacks. Panic disorder is more common in females and in those with a positive family history of panic. Emergence of anxiety symptoms early in life, including a history of separation difficulties during childhood, also represent risk factors for panic disorder.
Many patients become disabled by anticipatory fear of subsequent panic attacks and by phobic avoidant behavior patterns. They avoid places with restricted escape (e.g., crowds, theaters, tunnels, elevators), fearful of being trapped during an attack. In its most extreme form, agoraphobia (literally, “fear of the market place”), avoidant behavior may reach the point where a patient is afraid to leave the safety of the home or to be left alone. In rare situations, agoraphobia has also been reported to occur in the absence of panic disorder. (More commonly, the patient whose family describes them as “never leaving the house” has depression with loss of interest in doing their activities as a prominent symptom.)
The course of panic disorder includes times of frequent panic attacks interspersed with periods of less frequent episodes, complicated by phobic avoidance and anticipatory anxiety. The paroxysmal nature of panic attacks and the prominence of autonomic symptoms may mimic cardiac or neurologic disease, causing some patients to become hypervigilant, convinced of a serious underlying medical disorder, and “doctor shoppers” in search of such a diagnosis. Such persons may become demoralized, depressed, and debilitated. Suicide risk appears to be increased in panic disorder, especially in patients with concurrent depression.
Specific Phobias. A phobia is an irrational fear related to a specific stimulus. On exposure to that stimulus, the patient almost invariably manifests an anxiety response. A patient may suffer from a specific phobia of any specific stimulus. Although specific phobias commonly generate circumscribed symptoms, they may interfere with some aspect of a patient’s functioning due to avoidance of the phobic stimulus or perseverance in the face of great discomfort (e.g., fear of flying leading to difficulty with travel).
Social Phobia (Social Anxiety Disorder). Patients with social phobia develop anxiety in situations where they are the focus of attention or might be scrutinized publicly. The individual fears they will act in a way (or show anxiety symptoms) that will be humiliating or embarrassing. Such patients may experience performance anxiety or “stage fright” but also exhibit distress in more ordinary social settings. In the generalized type, the fear includes most social situations (participating in small groups, dating, initiating or maintaining conversations, speaking to authority figures, attending parties, etc.). Social phobia is to be distinguished from the more limited form of normal performance anxiety, which occurs in universally acknowledged anxiety-provoking situational settings (e.g., performing in front of a very large audience or as part of a very important event).
Obsessive-Compulsive Disorder. More common than previously recognized, obsessive-compulsive disorder (OCD) affects up to 3% of the population. It is characterized by obsessions and/or compulsions that are sufficiently severe to cause patients substantial distress or impair their ability to function.
Obsessions are unwanted intrusive thoughts of a bizarre, senseless, or extreme nature. The subject of obsessions typically includes sexual or violent themes that are very distressing to patients and may lead them to fear that they are “going crazy.” The recurrent and persistent thoughts, impulses, or images themselves become a source of anxiety.
Compulsions refer to repetitive behaviors that are performed in a stereotypical or ritualized fashion, usually in response to obsessions, sometimes in an effort to neutralize them. Resisting the drive to perform compulsions causes escalating anxiety, whereas succumbing and performing them is accompanied by feelings of transient relief, followed by feelings of shame. Characteristic compulsions include hand washing (to neutralize contamination obsessions), checking behaviors (e.g., doorlocks and stove burners to counteract obsessions of uncertainty), and counting (to neutralize anxiety associated with other obsessions).
The relationship between the compulsions and obsessions may also be nonsensical or irrational. Usually patients retain insight regarding the nonsensical or extreme nature of their thoughts and behaviors, distinguishing them from psychotic persons.
Because of the shame associated with the symptoms of OCD, it is not uncommon for patients to hide the disorder from friends, family, and doctors. OCD may come to the attention of primary care physicians when patients’ obsessions involve preoccupations with their bodily functions (e.g., urinary or bowel obsessions) or susceptibility to disease (e.g., obsessions with contamination or fear of AIDS). Rarely, the compulsions may be performed to such extreme as to pose medical risk or sequellae (e.g., dermatologic complications of hand washing).
The onset of OCD is variable, with a bimodal distribution of age at onset, a peak in the preteen years, and another peak in the third decade of life. There is a disproportionate representation of males in the early peak and a disproportionate representation of females in the later peak. The clinical course is similarly variable; symptoms may arise at any age, wax and wane, and become exacerbated in times of stress.
The etiology and underlying pathophysiology of OCD are poorly understood. It has been related genetically to Tourette’s disorder and commonly occurs with depression. Associated disorders include body dysmorphic disorder (i.e., preoccupation with a defective body image) and trichotillomania (compulsive hair pulling).
Posttraumatic Stress Disorder. Hours to months after a traumatic exposure (e.g., combat experience, natural disaster, physical assault, rape), the posttraumatic stress disorder (PTSD) patient reports persistent reexperiencing of the traumatic event, via intrusive thoughts, vivid dreams, or “flashbacks.” Other requisite characteristics include avoidance of stimuli associated with the trauma, hyperarousal (e.g., increased startle response), and persistence of symptoms for more than 1 month. In many cases, the symptoms may continue for years. Rarely, the syndrome emerges more than 6 months after the traumatic exposure and in such cases is designated “PTSD with delayed onset.”
Patients may present for medical assistance with primary complaints of anxiety or with concerns and questions regarding the neurologic underpinnings of their symptoms. Alternatively, PTSD may develop as a consequence of medical illness or procedures (e.g., amputation), which by their nature represent profound trauma. Medical settings may serve to trigger reexperiencing phenomena. It is important to be aware of the entity and sensitive to the needs of its sufferers.
Substance Abuse. Anxiety is often poorly tolerated, leading some patients to seek relief through use or abuse of anxiolytic substances. A patient’s reliance on alcohol, benzodiazepines (BZDs), or any other sedating medication may reflect an unrecognized underlying anxiety disorder. Chronic use of sedating substances can lead to neural irritability and can cause or exacerbate anxiety after withdrawal. It often becomes difficult to differentiate the cause and effect relationship between substance abuse and anxiety. Patients with anxiety disorders are 50% more likely to be alcoholic, and similarly, the prevalence of anxiety disorders is 50% higher in alcoholics.
In traditional Chinese medicine, anxiety is defined as "jiao lu" or "jing zhang" that is due to Heart, Spleen or Kidney dysfunction. For more information please call:
The central Practice Clinic 01992 711 772.