ANXIETY DISORDERS

Mainly 3 types of anxiety we deal with:

· GENERALIZED ANXIETY DISORDER (GAD)
· PANIC DISORDER
· SOCIAL ANXIETY DISORDER (SAD)- 2 types: a) Generalized subtype
b) Non-generalized subtype/ Performance type


SYMPTOMS OF ANXIETY DISORDERS:

Depressive symptoms commonly co-exist especially in patients with severe anxiety.

A) GAD
§ Multiple unexplained bodily symptoms;
§ Excessive anxiety;
§ Person finds it difficult to control the worry;
§ Insomnia;
§ Restlessness, irritability, muscle spasm;
§ Easily tired, difficulty in concentrating.

B) Panic Disorder
§ Dizziness;
§ Chest pain or discomfort, shortness of breath
§ Palpitations or tachycardia;
§ Nausea, GI upset
§ Trembling, sweating, hot flushes and chills.

C) SAD
§ Blushing and sweating;
§ Palpitations;
§ Persistent & marked fear of being scrutinized & evaluated negatively by the people when in social gatherings and/or performance situations;
§ Fear is so great that it interferes w/ normal functioning, relationships, social activities or there is excessive distress concerning the phobia.

DIAGNOSIS

A) GAD
1) It is mostly a clinical diagnosis;.
2) Important to elicit history of difficult-to-control worry w/ psychic & somatic symptoms;
3) Inappropriate & persistent worrying lasting for >/= 6 months.

B) Panic Disorder
1) Eliciting the presence of unexpected pain attacks & behavioral changes due to anticipated risk of further attacks is important in establishing diagnosis;
2) Unable to tolerate physical symptoms of anxiety;
3) Agoraphobia (fear of being in a large open space) may or may not be present.

C) SAD
1) Diagnosis is made when fear or anxiety of a social situation results to considerable distress or functional impairment;
2) Basis for diagnosis is clinical presentation.
3) Generalized subtype – Fear & phobias in most social situations;
Usually patient is more functionally disabled.
4) Performance type – Limited to a number of social or performance situations (e.g. Public
Speaking.)
Associated w/ increased autonomic nervous system reactivity in feared
situations.
DIFFERENTIAL / ALTERNATIVE DIAGNOSIS:

A) Medical Illness: Thyroid disorders (Hyper or Hypothyroidism), Cushing’s disease, CVS, Respiratory
Diseases, Mitral Valve Prolapse (MVP) etc can cause symptoms of anxiety.

B) Substance Abuse/ Medication Use:
1. Inquire about withdrawal or use of addictive substances e.g. caffeine, Nicotine, Alcohol, Illegal substance use etc.
2. Obtain history of medications use that may cause anxiety e.g. Steroids, SSRIs, Thyroxine, Theophylline, some Herbal products etc.
3. Assess for substance abuse.

C) Other Psychiatric Disorders: like Major depression, mixed anxiety-depressive disorder.




NON-PHARMACOLOGICAL THERAPY OF ANXIETY DISORDERS:

1) Patient Education:

· Should be provided to all patients regardless of anxiety disorder or treatment type;
· Help the patient & family understand that the disorder is a real illness which requires treatment and support;
· Address patient’s concerns;
· Reassurance and instill hope;
· Interact with patient -- Explain that these are NOT life threatening,
--- Teach family that the attacks can be disabling to the patient;
· Discuss treatment options & risks Vs benefits of both pharmacotherapy & psychosocial treatment with the patient and family members.

2) Relaxation Techniques & Biofeedback
· May be used to treat mild GAD;
· Used to decrease arousal & control somatic manifestations;
· Studies have found that these techniques are more effective if combined with Cognitive therapy; may be combined with Cognitive-behavioral Therapy (CBT) in GAD treatment.

3) Lifestyle Changes
· Stress reduction - by Yoga, meditation etc.
· Reduction of caffeine & alcohol consumption;
· Avoidance of Nicotine & Drug/ Medication abuse;
· Regular exercise.


IMPLICATIONS OF COGNITIVE-BEHAVIORAL THERAPY (CBT) IN ANXIETY DISORDER TREATMENT

· Symptom oriented approach;
· Psychoeducation – identify patient’s symptoms, explain basis of symptoms and outline techniques for dealing with symptoms;
· Continuous panic monitoring;
· Relaxation breathing – e.g. abdominal breathing helps to control psychological overactivity;
· Cognitive restructuring – investigate and reverse fears that arise from misinterpretation of body sensations, to teach patient about different outcomes of situations other than only negative ones i.e. Stopping automatic negative thinking (ANTs);
· In vivo Exposure – Last component of CBT care, involves the actual exposure of patients to their fear cues.
· The vast majority of the controlled research is devoted to cognitive behavior therapy (CBT) and shows its efficiency and effectiveness in all the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) anxiety disorders in meta-analyses. Relaxation, psychoanalytic therapies, Rogerian nondirective therapy, hypnotherapy, and supportive therapy were examined in a few controlled studies, which preclude any definite conclusion about their effectiveness in specific phobias, agoraphobia, panic disorder, obsessive-compulsive disorder (OCD), and posttraumatic stress disorder (PTSD). CBT was clearly better than psychoanalytic therapy in generalized anxiety disorder (GAD) and performance anxiety. Psychological debriefing for PTSD appeared detrimental to the patients in one high-quality meta-analysis.