anxiety disorders

Anxiety disorders د.وليد عزيز العميدي
Anxiety is a state associated with intense feelings of dread accompanied by somatic complaints that indicate a hyperactive autonomic nervous system such as palpitations and sweating. Anxiety is a state that has many effects . it influences the cognition and tends to produce distortion of perception . it is differentiated from fear which is an appropriate response to a known threat ; anxiety is a response to a threat that is unknown , vague or conflictual . most of effects of anxiety are dread accompanied by somatic complaints that indicate a hyperactive autonomic nervous asystem such as palpitation and sweating .
Classification of anxiety disorders :
- Generalized anxiety disorder.
- Panic disorder with or without agoraphobia.
- Agoraphobia without history of panic disorder.
- Specific phobia.
- Social phobia.
- Obsessive-compulsive disorder.
- Post-traumatic stress disorder and acute stress disorder.
- Substance-induced anxiety.
- Anxiety due to ageneral medical condition.
Biology of anxiety : the following neurotransmitter systems are involved in anxiety :
Noradrenaline : this neurotransmitter is closely related to the central and peripheral effects of anxiety .drugs that enhance its release (yohimbine) lead to an increase in anxiety , where as drugs which reduce its release (clonidine) decrease anxiety levels.
Serotonin (5HT) : a reduction in the levels of 5HT .
GABA : is extremely widely dispersed throughout the brain and it acts as an inhibitory neurotransmitter . when GABA receptors are blocked , symptoms of anxiety appear , whereas stimulation of the action of GABA leads to a reduction in anxiety .
It is unlikely that any one neurotransmitter is responsible for all the changes seen in the anxiety disorders , but a number of pathways interact to develop the symptoms.
Symptoms of anxiety :
1- Psychological arousal : fearful anticipation , irritability , sensitivity to noise , restlessness , poor concentration and worrying thoughts.
2- Autonomic arousal : GIT ( dry mouth , difficulty in swallowing , epigastric discomfort , frequent or loose motions ) , respiratory (constriction in the chest , difficulty inhaling ) , CVS ( palpitations ) , GUS ( frequent or urgent micturition , failure of erection , menestural discomfort , amenorrhoea ).
3- Muscle tension : tremor , headache , aching muscles.
4- Hyperventilation : dizziness , tingling in the extremities , feeling of breathlessness.
5- Sleep disturbance : insomnia , night terror.
Generalized anxiety disorder : the symptoms of GAD are persistent and are not restricted to , or markedly increased in , any particular set of circumstances (in contrast to phobic anxiety disorders ).
Symptoms of GAD : worry and apprehension , muscle tension , autonomic overactivity , psychological arousal , sleep disturbance , depression , obsessions , depersonalization.
Excessive anxiety and worry (apprehensive expectation ) occurring for at least 6 months.
Clinical signs : the face appears strained , the brow is furrowed , and the posture is tense . the person is restless and may tremble . the skin is pale and sweating is common , especially from hands , feet and axillae .
Epidmeology : life time prevalence 3 – 8 % of population , M/F = 1/2 , age of onset variable but usually early adulthood.
Treatment : psychological : counseling , relaxation training , CBT.
Pharmacological treatment : - short term treatment : longer acting benzodiazepines is appropriate for short term treatment of GAD .e.g. diazepam in a dose from 5mg twice daily in mild cases to 10mg three times a day in the most severe . anxioloytic drugs should seldom prescribed for more than 3 weeeks because of the risk of dependence when given for longer .buspirone is similarly effective for short term management of GAD and less likely to cause dependence , but has slower onset of action . Beta adrenergic antagonist are sometimes used to control anxiety associated with severe palpitations that have not reponded to other treatment .
- Long term treatment : both tricyclic and specific serotonin reuptake inhibitors can be used for this purpose . antipsychotics given in low doses can also be employed but their use is usually restricted to anxiety in people with aggressive personalities or people who have become dependant on other drugs.
Medical disorders , drugs and anxiety : anxiety may be a response to being told about any diagnosis , but some medical disorders include anxiety as part of their symptomatology :
Medical causes of anxiety : hyperthyroidism , phaeochromocytoma (noradrenaline-producing tumor ), cardiac dysrhythmia and failure , insulinomas(hypoglycemia) and respiratory dysfunction (COAD) , asthma.
In addition to medical disorders causing anxiety symptoms , drugs may also produce similar types of symptoms :
Intoxication : amphetamine , cocaine , alcohol and PCP (phencyclidine).
Therapeutic concentration : thyroid replacement therapy , SSRI , insulin , sympathomimetics(in cold remedies) , bronchodilators , analgesics (especially opiod-based types) , caffeine.
Withdrawal symptoms : alcohol , opiates and benzodiazepines.

Panic disorder : The central feature is the occurrence of spontaneous panic attacks i.e. sudden attacks of anxiety in which physical symptoms predominate and are accompanied by fear of serious medical consequences such as a heart attack.
Symptoms of panic attack : DSM-IV requires the presence of only four or more of the following symptoms developed abruptly and reached a peak within 10 min. : shortness of breath , chocking , palpitation , chest pain , sweating , dizziness , nausia or abdominal distress , depersonalization or derealization ,numbness or tingling sensation , fear of dying , fear of going crazy or doing something uncontrolled.
Important features of panic attacks :
- Anxiety builds up quickly.
- The symptoms are severe .
- The person fears a catastrophic outcome.
In DSM-IV the diagnosis of panic disorder is made when :
1- Panic attacks occur unexpectedly(i.e. not in response to a known phobic stimulus .
2- More than four attacks have occurred in 4weeks , or one attack has been followed by 4 weeks of persistent fear of another and worry about its implications.
About 20% of patients with panic attacks may also display agoraphobia.
Panic disorder is about twice as frequent among women as among men.
Aetiological theories : - genetic : first degree relatives of those with panic disorder have a 5 times greater likelihood than members of general population of developing the disorder.
- Biochemical : panic attacks can be easily induced in this group by yohimbine , and this suggests an abnormality of noradreneric receptors ,also it can be induced by sodium lactate , flumazenil and cholecystokinin while panic attacks can be reduced by imipramine which affects both 5HT and noradrenergic systems.
- Hyperventilation : some people can induce panic attacks by hyperventilation . spontaneous attacks are believed to arise from involuntary hyperventilation.
- Cognitive : concerns about physical illness are more common in anxious patients who experience panic attacks than in those who do not . this suggests are spiraling effect in which anxiety leads to physical symptoms , which lead to anxiety , which leads to physical symptoms , which lead to anxiety…..
Treatment : Drug treatment : treatment with benzodiazepines ( Alprazolam) is the most rapid form of short term relief for panic disorder , but over a longer peroid tricyclic antidepressants especially imipramine , are more effective and do not cause the problem of dependence .
Several SSRIs have been reported to be effective in panic disorder and they do not have the cardiac side effects of imipramine , they include : fluvoxamine , paroxetine , sertraline and fluoxetine.
Cognitive behavioral treatment : breaking the spiralling thought patterns of the person is the aim here , by learning to control the symptoms and reattribute them so that the panic does not develop .
Phobic anxiety disorders : The symptoms of phobic anxiety disorder are the same as those of generalized anxiety disorders , but there are three distinguishing features :
1- Anxiety in particular circumstances only .
2- Avoidance of circumstances that provoke anxiety.
3- Anticipatory anxiety when there is the prospect of encountering such circumstances.
The circumstances that provoke anxiety include situations such as crowded places , living things such as spiders and natural phenomena such as thunder.
Phobic disorders are classified in three groups : simple phobia , social phobia and agoraphobia.
Agoraphobia : The symptoms of agoraphobia :
- A fear of being in situations from which escape might be difficult or embarrassing.
- A fear of being in situations where help might not be available in the event of calamity or embarrassment.
- Avoidance of these places.
When away from home or in crowds the person develops anxiety symptoms , often with a fear that something awful will happen to them . This fear can develop following an episode of anxiety in a public place. Afterwards , the possibility that the attacks might occur is sufficient to develop the anxiety (anticipatory anxiety). Many situations provoke anxiety and avoidance , but there are three common themes of distance from home , crowding and confinement . the situations include buses and trains , shops and supermarkets.
The symptoms usually develop in the person`s twenties or thirties and frequently do not come to the attention of professionals . the disorder is more common in women than men.
Aetiology : The development of anticipatory anxiety and avoidance after the first panic attack can be understood in terms of conditioning. The agoraphobia is maintained by avoidance ,which prevents deconditioning , and by apprehensive thoughts such as fear of fainting or social embarrassment which set up vicious circles of anxiety.
Treatment : - exposure to the situation with anxiety management .
- Anxiolytics used in the short term for specific events.
- Tricyclics : useful if there are high levels of depressive symptoms.
- MAOI .
Simple phobia (specific phobia) : Simple phobias are common. These are fears that are above and beyond the perceived threat , and are believed to be irrational by the person experiencing them. In DSM-IV four types of specific phobia are recognized concerned with : animals , aspects of natural environment , blood ,injection and injury , situations and other provoking agents . this group includes fears of dental and medical situations and fears of choking.
Phobia of blood, injection and injury differ from other types of simple phobia is that there is a strong vasovagal response instead of the usual sympathetic reaction. Fainting is common.
Most of the simple phobias of adult life begin in childhood .
Treatment : learning relaxation technique to control the anxiety is the core of treatment. Once these have been mastered , exposure to the feared situation can begin. This exposure is graded until the person can tolerate the feared situation .
Patients sometimes ask for immediate relief of symptoms when a longstanding phobia makes it difficult to fulfill a forthcoming important engagement. In such circumstances, a benzodiazepine can be used , but in the short term only.

Social phobia : Social phobia is inappropriate anxiety in social situations. There are number of principle features :
1- Specific concerns (which they know to be irrational) about being observed critically by other people.
2- Situations that provoke anxiety include : restaurants , dinner parties , seminars , board meetings and other places where it is necessary to speak in public occasions when some action is open to scrutiny ( writing , eating or drinking in front of another person )
3- Anticipatory anxiety : people with social phobia also feel anxious when they anticipate entering such situation.
4- Avoidance of these situations : sometimes the avoidance is partial for example entering a social group but failing to make conversation or sitting in an inconspicuous place in the group.
5- Symptoms similar to those of other anxiety disorders although blushing and trembling are particularly frequent.
6- Use of alcohol : some people take alcohol to relieve anxiety and alcohol abuse is more common among social phobics than among people with other phobias.
Social phobia is about equally common in men and women.
Treatment :
Psychological treatment :
- Cognitive behavior therapy : is the psychological treatment of choice for social phobia, combines exposure to feared situations with procedures to reduce the patient`s anxiety provoking thoughts.
- Relaxation training : given alone appears to be ineffective for social phobia.
- Dynamic psychotherapy : may help some patients particularly those whose social phobia is associated with pre-existing problems in personal relationships.
Drug treatments : SSRIs are often the first choice ( paroxetine , fluvoxamine and sertraline ) the onset of action may take up 6 weeks , medication is usually continued for 9 months to a year.
Benzodiazepines can be used for short term relief of symptoms but should not be prescribed for long because of the risk of dependancy . Beta-adrenergic blockers such as atenolol may achieve short-term control of tremor and palpitations , which can be the most handicapping symptoms of specific social phobias such as performance anxiety.

Obsessive-compulsive disorder : OCD are characterized by obsessional thinking , compulsive behavior and varying degrees of anxiety , depression and depersonalization.
Obsessions : these are repeated ideas that come unbidden into the mind of a person , despite attempts to force them out .
Compulsions : these are actions a person feels compelled to undertake , often increasing their anxiety levels . such actions are often repeated a magical (ritual) number of times.
- Obsessional thoughts : are words , ideas and beliefs recognized patients as their own , that intrude forcibly into the mind . they are usually unpleasant , and attempts are made to exclude them . obsessional thoughts may take the form of single words , phrases or rhymes , and may be obscene or blasphemous.
- Obsessional images : vividly imagined scenes often of violence or of a kind that disgust the patient such as abnormal sexual practices.
- Obsessional ruminations : are internal debates in which arguments for and against even the simplest everyday actions are reviewed endlessly such as turning off a gas tap or securing a door.
- Obsessional impulses : are urges to perform acts , usually of a violent or embarrassing kind , e.g. leaping in front of a car.
- Obsessional rituals : include both mental activities , such as counting repeatedly in a special way or repeating a certain form of words , and repeated but senseless behaviors such as washing the hands 20 or more times a day.

DSM-IV criteria of OCD :
A. Either obsessions or compulsions:
Obsessions as defined by (1), (2), (3), and (4):
(1) recurrent and persistent thoughts, impulses, or images that are experienced at some time during the disturbance, as intrusive and inappropriate and that cause marked anxiety or distress
(2) the thoughts, impulses, or images are not simply excessive worries about real-life problems
(3) the person attempts to ignore or suppress such thoughts, impulses, or images, or to neutralize them with some other thought or action
(4) the person recognizes that the obsessional thoughts, impulses, or images are a product of his or her own mind (not imposed from without as in thought insertion)
Compulsions as defined by (1) and (2):
(1) repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the person feels driven to perform in response to an obsession, or according to rules that must be applied rigidly
(2) the behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation; however, these behaviors or mental acts either are not connected in a realistic way with what they are designed to neutralize or prevent or are clearly excessive
B. At some point during the course of the disorder, the person has recognized that the obsessions or compulsions are excessive or unreasonable. Note: This does not apply to children.
C. The obsessions or compulsions cause marked distress, are time consuming (take more than 1 hour a day), or significantly interfere with the person’s normal routine, occupational (or academic) functioning, or usual social activities or relationships.
D. If another Axis I disorder is present, the content of the obsessions or compulsions is not restricted to it (e.g., preoccupation with food in the presence of an Eating Disorder; hair pulling in the presence of Trichotillomania; concern with appearance in the presence of Body Dysmorphic Disorder; preoccupation with drugs in the presence of a Substance Use Disorder; preoccupation with having a serious illness in the presence of Hypochondriasis; preoccupation with sexual urges or fantasies in the presence of a Paraphilia; or guilty ruminations in the presence of Major Depressive Disorder).
E. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.

Prevalence : 2 – 3 % of population with men and women affected about equally.
Aetiology : it is difficult to identify the aetiological factors in this disorder. There is some genetic component to the illness. Obsessional mothers might be expected to transmit a tendency to obsessional symptoms to their children through social learning. Some people develop these symptoms following head injury or encephalitis.





Treatment :
Medication : clomipramine which is a TCA with potent 5-HT uptake blocking effects , a clinically useful effect may not be reached until about 6 weeks of treatment and further improvement may take another 6 weeks.
SSRIs : including fluoxetine ,fluvoxamine , paroxetine and sertraline are effective in reducing obsessional symptoms .
Anxiolytic drugs : are give some short term symptomatic relief but should not be prescribed for more than 3 weeks at a time .
Cognitive behavioral therapy : -exposure with response prevention : obsessional rituals usually improve with a combination of response prevention with exposure to any environmental cues that increase the symptoms .
Cognitive therapy : seeks to reduce attempts to suppress and avoid obsessional thoughts since these attempts have been shown to increase rather than decrease their frequency .
Neurosurgery : It should be only considered for the most chronic cases that have resisted intensive inpatient or day patient treatments including drug and behavioral methods , for at least a year. The immediate result of neurosurgery for severe OCD is often striking reduction in tension and distress. Several kinds of operative lesion were used, mainly involving the frontal white matter. Psychosurgery is now used very rarely.