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Anxiety disorders: Understanding and managing anxiety

Behaviour, Depression, Mental Health | February 27, 2015 | Author: The Super Pharmacist

behaviour, depression, mental

Anxiety disorders: Understanding and managing anxiety

The main function of fear and anxiety is to act as a signal of danger, threat, or motivational conflict, and to trigger appropriate adaptive responses. Some experts see fear and anxiety as indistinguishable, whereas others believe they are distinct phenomena. Investigators who view them as distinct entities see fear as a response provoked by a real or perceived immediate threat whereas anxiety is the expectation of future threat.

Anxiety is a feeling of uneasiness, usually generalised and unfocused, as an overreaction to a situation that is only subjectively seen as menacing. Dr. David Barlow, Director of the Center for Anxiety and Related Disorders at Boston University, defines anxiety as "a future-oriented mood state in which one is ready or prepared to attempt to cope with upcoming negative events," and that it is a distinction between future and present dangers which divides anxiety and fear.

The "fight-or-flight" response

The body has an innate, automatic reaction that is triggered when a person perceives harm or threat. In the late 1930's, Walter Cannon described this complex, coordinated physical and chemical process and termed it the "fight-or-flight" response.

Fear and anxiety are emotional components of this response. The fight-or-flight response allows us to do what is necessary to protect ourselves whenever we encounter danger. This response involves a series of changes in our bodies that prepare us to take immediate action to deal with a threat or crisis.

The fight-or-flight response activates the sympathetic nervous system which sends out impulses to glands and smooth muscles and tells the adrenal medulla to release adrenaline and noradrenaline into the bloodstream. These "acute stress hormones" cause an increase in heart rate, blood pressure and respiration, and shunt blood away from the nonessential organs of digestion to the brain and muscles thus preparing the body for fight or flight. The origins of the fight-or-flight response go back to ancient times when people lived closer to natural predators. At that time, daily life was filled with very real and immediate threats that called for quick responses.

Today, our bodies still respond in the same way to perceived threats. However, rather than saber-toothed tigers, the stresses of modern life come in different forms (looming work deadlines, letters from the tax bureau, financial issues and interpersonal conflict) and are less amenable to solutions that invoke the fight-or-flight response. Since so many of the perceived threats that we encounter in modern life do not call for either fight or flight, we are often left in a state of persistent arousal with limited opportunities to release the built-up tension. This built-up tension takes the form of anxiety.

Is Anxiety Normal?

Is Anxiety Normal?Anxiety can be a normal response to stress, such as an exam, an upcoming interview, a fight with a friend or a new job.

It is not accurate to speak of stress only in negative terms, because, to a point, stress can actually be good for you. It provides a burst of energy, a boost to your immune system and allows you to accomplish more "Eustress" is a term coined by endocrinologist, Hans Selye and refers to manageable stress which can lead to growth and enhanced competence. Eustress occurs when the gap between what one has and what one wants is slightly pushed, but not overwhelmed.

The goal is not too far out of reach but is still slightly more than one can handle. This fosters challenge and motivation.

Eustress is primarily based on subjective perceptions and is related to self-efficacy. If a person has low self-efficacy, they will see the demand as more distressful than eustressful. When a person has high self-efficacy, they can set goals higher and be motivated to achieve them. Selye argued that persistent stress that is not resolved through coping or adaptation should be known as distress, and may lead to excessive anxiety, withdrawal, and depressive behavior. 

When Is Anxiety Considered Abnormal?

When anxiety is persistent, seemingly uncontrollable, and overwhelming, it is abnormal. This type of anxiety comes when we repeatedly face stressors that take a heavy toll and feel inescapable. A stressful job or an unhappy home life can bring chronic stress. Because our bodies are not designed for chronic stress, we can face negative health effects (both physical and emotional) if we deal with chronic stress for an extended period of time. When anxiety becomes disruptive to one's well-being and daily function, it becomes an anxiety disorder. The anxiety response is often not triggered by a real threat, but it can still paralyse the individual into inaction or withdrawal. Anxiety disorders are the most common mental disorders in Australia, with 1/7 people (14% of the population) reporting having had an anxiety disorder in the last 12 months. Women are more likely to have an anxiety disorder than men, 18% vs 11%.

Anxiety disorders are usually caused by a combination of psychological, physical, and genetic factors.

What Are the Most Common Anxiety Disorders?

The most common forms of anxiety disorder include:

Generalised Anxiety Disorder (GAD)

This type of disorder affects about one in 20 Australians at some stage of their lives. GAD is diagnosed when a person worries excessively about a variety of everyday problems for at least 6 months. 

Generalised Anxiety Disorder (GAD)People with GAD are unable to suppress their concerns, even though they usually realise that their anxiety is more intense than the situation warrants. They are unable to relax, startle easily, and have difficulty concentrating, have trouble falling asleep or staying asleep. Physical symptoms may include fatigue, headaches, muscle tension, muscle aches, difficulty swallowing, trembling, twitching, irritability, sweating, nausea, lightheadedness, frequent urination, feeling out of breath, and hot flashes. 

GAD develops slowly. It often starts during the teen years or young adulthood. Symptoms may get better or worse at different times, and often are worse during times of stress. When their anxiety level is mild, people with GAD can function socially and hold down a job. Although they do not avoid certain situations as a result of their disorder, people with GAD can have difficulty carrying out the simplest daily activities if their anxiety is severe. 

GAD frequently coexists with other conditions, including depression and somatic complaints. GAD sufferers with co-occurring disorders have increased psychologic and social impairment, request additional treatment, and have an extended course and poorer outcome than those with GAD alone.

Phobic Disorders

A phobia is an example of an anxiety disorder, defined as an irrational fear that produces a conscious avoidance of the feared subject, activity, or situation. The affected person usually recognises that the reaction is excessive. Common phobias include social phobia or social anxiety disorder which is characterised by overwhelming anxiety and excessive self-consciousness in everyday social situations. Social phobia can be limited to only one type of situation — such as a fear of speaking in formal or informal situations, or eating or drinking in front of others — or, in its most severe form, may be so broad that a person experiences symptoms almost anytime they are around other people.

Other phobias include agoraphobia (fear of being in large open spaces), specific phobia (an overwhelming, persisting fear of an object or situation), and acrophobia (fear of heights). Phobias are actually the most common type of anxiety disorder in Australia, affecting about one in 10 people at some stage of their lives.Severity can range from mild and unobtrusive to severe and can result in incapacity to work, travel, or interact with others.

Post Traumatic Stress Disorder (PTSD)

As the name suggests, PTSD occurs after a person has experienced some form of trauma which leaves them feeling anxious. Experiencing a traumatic event is not rare. About 60% of men and 50% of women experience this type of event in their lives. Women are more likely to experience sexual assault and child sexual abuse. Men are more likely to experience accidents, physical assault, combat, or disaster or to witness death or injury. PTSD affects about 1 in 12 people across their lives. Common symptoms include: flashbacks, difficulty sleeping (nightmares), loss of interest in usual activities, irritability, trouble concentrating, and memory difficulties.

Obsessive Compulsive Disorder (OCD)Obsessive Compulsive Disorder (OCD)

OCD is a disorder in which a person experiences repetitive, unwanted thoughts about something (obsession) which they then seek to dispel through some sort of behaviour (compulsion). Repetitive behaviors such as handwashing, counting, checking, or cleaning are often performed with the hope of preventing obsessive thoughts or making them go away. Performing these so-called "rituals," however, provides only temporary relief, and not performing them markedly increases anxiety.

Panic Disorder

Panic disorderis characterised by unexpected and repeated episodes of intense fear accompanied by physical symptoms that may include chest pain, heart palpitations, shortness of breath, dizziness, or abdominal distress. At some stage in their life, as many as 30% of the population will experience a 'panic attack.' When panic attacks become frequent, a diagnosis of panic disorder may be made.

How Are Anxiety Disorders Treated?

Anxiety disorders are treated with medications, psychotherapy or a combination of both. Research shows that counseling alone or the combination of medication and psychotherapy treatment are more effective than medication alone in overcoming anxiety. The most common type of therapy used to treat anxiety is cognitive behavioural therapy (CBT). This form of therapy seeks to help those with an anxiety disorder identify and decrease the irrational thoughts and behaviors that reinforce anxiety symptoms.

Treatment of Generalised anxiety disorder (GAD)

Therapy should alleviate both the psychic and somatic symptoms of GAD without negatively affecting the other conditions that often co-occur (are comorbid) with GAD. In the past, first-line treatment of GAD has consisted of benzodiazepines which produce rapid symptom relief. However, the use of benzodiazepines may be accompanied by undesirable side effects such as sedation and the possible development of physical dependence on those medications. In addition, benzodiazepines are generally ineffective in the treatment of comorbid depression that often presents with GAD, and may sometimes worsen it.

Treatment of Generalised anxiety disorder (GAD)As a result, more recent attention has focused on the use of antidepressants for the treatment of GAD with the hope that these agents may be effective for both the anxiety disorder and comorbid depression. In terms of medications, buspirone is known to be quite effective for treating GAD, but is less effective in managing co-occurring disorders.

The risks of developing dependance is markedly less than the comparative benzodiazepines.

Different types of antidepressants have proven effective for the treatment of GAD, including the selective serotonin reuptake inhibitors (SSRIs), the serotonin-norepinephrine reuptake inhibitors (SNRIs), and the tricyclic antidepressants. The SSRIs, paroxetine and escitalopram, and the SNRI, venlafaxine, have received approval from the Food and Drug Administration for the treatment of GAD. Antidepressants are effective for the comorbid depressive symptoms that often accompany GAD, as well as other comorbid conditions, including panic disorder and posttraumatic stress disorder, and in the case of the SSRIs and SNRIs, social anxiety disorder and obsessive-compulsive disorder, as well.

Examples of SSRI medications include fluoxetine, sertraline, paroxetine, citalopram, and escitalopram. Examples of SNRI medications are duloxetine, venlafaxine, and desvenlafaxine. One of the most common and well supported styles of psychotherapy for GAD is cognitive-behavioural therapy (CBT). The hallmark of CBT is an intense focus on thought processes and belief systems. The overall goals of the approach are to help people identify problematic beliefs and thought patterns, which are often irrational or unrealistic, and replace them with a more rational and realistic views.

Treatment of phobic disorders

If treatment is required, this usually consists of pharmacotherapy, psychotherapy, or some combination thereof. Controlled studies have found behavioural therapy and CBT to be effective in treating phobic disorders. Computerised CBT (FearFighter) has been recommended for panic and phobia by the National Institute for Health and Clinical Excellence guidelines (NICE). To date, no controlled studies have demonstrated the efficacy of psychopharmacologic intervention for specific phobias. Administration of a short-acting benzodiazepine might be useful for temporary anxiety relief in specific situations (e.g. right before boarding a plane for patients with a fear of flying).

Treating Agoraphobia: Randomised, double-blind, placebo-controlled trials have shown that agoraphobia, specifically the panic symptoms, responds to treatment with SSRIs (eg, escitalopram, citalopram, fluoxetine, fluvoxamine, paroxetine, and sertraline), venlafaxine and reboxetine, some tricyclic antidepressants (e.g. clomipramine and imipramine), and some benzodiazepines (e.g. alprazolam, lorazepam, diazepam, and clonazepam).

Treatment of Social anxiety disorder

At present, three drugs are approved by the Food and Drug Administration (FDA) for the treatment of social anxiety disorder: paroxetine and sertraline (SSRIs) and venlafaxine (SNRI). SSRIs and venlafaxine are generally considered first-line agents, whereas benzodiazepines, tricyclic antidepressants (TCAs), and MAOIs are considered second-line agents. Antihypertensive beta-blocker therapy (propranolol) may be useful for the treatment of situational/performance anxiety on an as-needed basis.

Treatment of Post traumatic stress disorder

Treatment of Post traumatic stress disorderIn children and adolescents, trauma focused–cognitive behavioral therapy (TF-CBT) is the most widely accepted treatment for PTSD. It has been consistently proven to be effective and has the largest controlled evidence base. In adults, "prolonged exposure therapy," also known as PE therapy, has been shown to be highly effective in treating the symptoms of PTSD. This form of psychotherapy purposefully exposes the individual to situations that trigger debilitating or dysfunctional stress reactions.

This exposure is intended to help a person overcome damaging reactions and develop a new ability to cope with the effects of stress. People affected by PTSD commonly benefit from the therapy, even when they have other serious, coexisting mental health problems.

Treating Obsessive compulsive disorders (OCD)

Combined selective serotonin reuptake inhibitors (SSRIs) and cognitive behavioural therapy (CBT) represent the first-line treatment for OCD and related disorders. Clomipramine (a tricyclic antidepressant) is reserved as a second line treatment for those who cannot tolerate SSRIs or who do not respond to them. CBT is an established treatment for OCD, equal or perhaps superior to pharmacotherapy. In CBT, the patient faces a feared object or activity without performing the compulsive ritual. The key element of this intervention is the exposure and prevention of the response or ritual. CBT can be used instead of or in addition to SSRIs, depending on the willingness of the patient to participate in therapy or to take medication, and the presence of comorbid diagnoses. In addition to CBT, group therapy can potentially benefit patients with OCD.

Treating Panic disorder

Cognitive-behavioural psychotherapy remains the treatment of choice for panic disorder. Recent studies confirm selective serotonin reuptake inhibitors as the first-choice drugs in treating panic disorder. Benzodiazepines act rapidly and are well tolerated, but their use presents clinical issues such as dependence, rebound anxiety, memory impairment, and discontinuation syndrome. Psychoeducation and combined pharmacotherapy/psychotherapy improve treatment response. Optimal long-term treatment of panic disorder involves adequate medication and duration of treatment, since relapse is frequent.

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