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REVIEW OF ANXIETY DISORDERS

OVERVIEW

Anxiety occurs as a symptom in many emotional illnesses, including depression, bipolar disorder, and adjustment reaction. It is also a part of normal life. The term anxiety disorder, however, refers to a spectrum of psychiatric problems in which anxiety or avoidance of anxiety-provoking situations are the key components. Anxiety disorders include generalized anxiety disorder, panic disorder, agoraphobia, posttraumatic stress disorder (PTSD), acute stress disorder, obsessive-compulsive disorder (OCD), specific phobia, social phobia, anxiety disorder due to a general medical condition, substance-induced anxiety disorder, and anxiety disorder NOS. The key symptoms vary widely across these disorders; however, they all generally have responded to therapy with selective serotonin reuptake inhibitors (SSRIs).

THE DIFFERENT TYPES OF ANXIETY DISORDER

Obsessive-compulsive disorder

The diagnosis of OCD requires the presence of either obsessions or compulsions. Obsessions are persistent and recurring thoughts, impulses, or images that are experienced as intrusive, inappropriate, and distressing. They are not simply excessive worries about realistic problems. A person with OCD realizes that such thoughts are products of his or her own mind.

Compulsions are repetitive behaviors (eg, hand-washing, ordering, checking) or mental acts (eg, praying, counting, repeating words silently) that a person feels driven to perform according to a rigidly applied rule in order to reduce distress or prevent a dreaded outcome. The behaviors or mental acts are clearly excessive. At some point during the course of the disorder, the person with OCD has recognized that the obsessions or compulsions are excessive or unreasonable (this level of awareness is not necessary to make a diagnosis of OCD in children).

The lifetime prevalence of OCD is 2.5%. Obsessive and compulsive symptoms that do not rise to the level of OCD probably occur in more than one third of people. At times, the nearly delusional attachment of individuals with OCD to their fears, and the deterioration in their adaptive functioning, can make them appear almost psychotic.

Cognitive behavior therapy (CBT) is the psychotherapeutic treatment of choice for core obsessive-compulsive symptoms. Treatment consists of information-gathering, therapist-assisted exposure with response prevention, and homework assignments. Stimulus exposure with response prevention entails exposing the patient to a situation that generally leads to compulsive behavior and then blocking the compulsion. For example, someone with a hand-washing compulsion could touch a doorknob but then be blocked from hand-washing. Providing accurate information about OCD, providing positive reinforcement for desired behavior, working to change false OCD beliefs, and fostering psychological distance from the symptoms are also helpful. To enlist the cooperation of children (and adults), patients should be reassured that they will not be required to sustain unbearable anxiety, and they should be involved in selecting which symptoms to confront. Thought stopping (ie, visualizing a stop sign during repetitive thoughts) can also be helpful.

Non-CBT psychotherapy may be helpful with fostering coping skills, increasing confidence, treating anxiety and depression, treating comorbid conditions, and improving peer and family relations, but it has not been shown to be effective in treating OCD symptoms. Family treatment may be important in limiting expressed emotion (which can exacerbate symptoms), dealing with family stress that has arisen from the disorder, and disentangling other family members from the disorder.

SSRIs are the drug of choice for OCD. Higher doses may be needed than are used to treat depression, eg, up to 80 mg/d of fluoxetine (Prozac). Clonazepam (Klonopin) is sometimes a useful adjuvant. Clomipramine (Anafranil) causes more adverse effects than SSRIs but may be helpful in refractory cases.

Posttraumatic stress disorder

PTSD involves the development of a constellation of symptoms following exposure (either personal or vicarious through a close associate) to an event that threatened death, serious injury, or threat to personal integrity. The individual experienced intense fear, helplessness, or horror in response to exposure to the event. The symptoms of PTSD include persistent re-experiencing of the event, avoidance of stimuli associated with the event, numbing of general responsiveness, and persistent symptoms of increased arousal. The lifetime prevalence of PTSD in the United States is 8%.

PTSD involves a combination of a conditioned fear response to trauma-related stimuli, altered neurobiological processes leading to increased arousal, and altered cognitive schemata about the world and oneself. Individuals may experience difficulty being alone, survival guilt, dissociative symptoms, somatic complaints, learned helplessness, loss of affect control, hostility, personality change, change in belief system, self-destructive and impulsive behavior, substance abuse, social withdrawal, auditory hallucinations, or paranoid ideation. Individuals who do not meet the full set of diagnostic criteria may have considerable morbidity and need treatment.

SSRIs are the medication of choice in managing anxiety, depression, avoidance behavior, and intrusive recollections. Benzodiazepines or other sleep aids are helpful if used briefly. People need to sleep to process information, function, and recover. Chronic use of benzodiazepines, however, impairs recovery. Beta blockers, if given in the first few hours (especially to those who are tachycardic), may decrease hyperarousal symptoms in the long run but will not address the full syndrome. Severe dissociative symptoms may improve with divalproex sodium (Depakote).

One of the most effective treatment methods is prolonged exposure, which is a combination of in vivo exposure to things which have become frightening as a result of their association with the trauma and repeated imaginal exposure. Cognitive processing therapy, ie, exploring the meaning of the event and reworking cognitive perspectives that are likely to lead to problems, is also important. Problematic thought patterns may include self-blame for the incident, believing that no safe place exists in the world, survivor guilt, and themes of revenge and retaliation. Uncovering and reworking such ideas helps to deal with depression and various behavior problems the trauma can cause.

Generalized anxiety disorder

Generalized anxiety disorder entails a tendency to be anxious and worry about various events to such an extent that the individual suffers physical symptoms. Possible symptoms include restlessness, being easily fatigued, difficulty concentrating, irritability, muscle tension, and sleep disturbance.

Panic disorder

Panic disorder is diagnosed when an individual has recurrent, unexpected panic attacks and changes in behavior or persistent concern about having additional attacks. These attacks are characterized by discrete periods of intense fear or discomfort that occur when the patient is not facing real danger; they are accompanied by 4 out of 13 somatic or cognitive symptoms, including palpitations, sweating, trembling, shortness of breath or smothering, feeling of choking, chest discomfort, abdominal distress or nausea, lightheadedness, derealization or depersonalization, fear of losing control, fear of dying, paresthesias, and chills or hot flashes.

Panic attacks develop suddenly and reach a peak within 10 minutes. They can be unexpected or triggered by particular situations. Panic attacks can manifest in several of the anxiety disorders.

Agoraphobia

Agoraphobia entails anxiety about being in places or situations from which escape might be difficult or embarrassing, or in which help may not be available in the event of a panic attack. The events are either avoided or endured with considerable distress or demand for the presence of a companion. Agoraphobia is not diagnosed per se; rather, one diagnoses panic disorder with agoraphobia or agoraphobia without history of panic disorder. Agoraphobia can last for years and can cause considerable impairment.

Specific phobia

Specific phobias consist of intense and continuing fear of a specific object or situation. Adults and teenagers generally realize that such fear is exaggerated. Examples include fears of specific animals, environmental factors such as heights or storms, and particular means of transportation. People with specific phobias generally try to avoid the situation that causes their anxiety.

Social phobia

A social phobia is a marked and persistent fear of one or more social or performance situations. The individual fears that he or she will be humiliated or embarrassed.

TREATMENT

Cognitive behavior therapy

The treatment for anxiety disorders generally entails the use of CBT with desensitization and progressive exposure to the anxiety-provoking situation or object. Imaginal exposure is often used in advance of exposure in vivo. For PTSD, this entails exposure to traumatic triggers and to being able to talk about the traumatic experience. For OCD, CBT treatment entails exposure to the anxiety-provoking situation or object and subsequent blocking of the individual’s usual response (compulsive ritual). CBT treatment should also address the emotional impact of suffering from an anxiety disorder, ie, damage to the patient’s self-esteem.

Medication

SSRI medications (eg, fluoxetine, sertraline, paroxetine, fluvoxamine, citalopram, escitalopram) can be helpful in decreasing the intensity of all of the disorders described above. However, they generally take several weeks to begin working. Benzodiazepines can be useful in providing short-term relief or as a bridge over a period of 4-12 weeks until SSRI medications begin to be effective. The potential for dependence on benzodiazepines makes them problematic for long-term treatment, but certain agents such as clonazepam may be considered in refractory patients.

Venlafaxine is a newer generation dual-action (serotonin and norepinephrine) reuptake inhibitor and appears to be an effective alternative for the treatment of a broad spectrum of anxiety disorders. Venlafaxine is approved by the US Food and Drug Administration for the treatment of generalized anxiety disorder, social phobia, and panic disorder.

After diagnosis and initiation of pharmacologic therapy, initial follow-up care should occur within 2 weeks. This is especially important if SSRI medications are started, as they can cause an exacerbation of anxiety and panic symptoms in some patients. Providing a few doses of a benzodiazepine for use as needed can also enhance patient compliance.

CONCLUSION

A brief review can only begin to scratch the surface of what clinicians need to know about anxiety disorders. Clinicians should keep in mind that various medical disorders can present with the symptoms of anxiety, including (but not limited to) respiratory and metabolic problems. Therefore, assessment and screening for these conditions is imperative when a patient presents with an undifferentiated complaint of anxiety.

In addition, depression and anxiety are often comorbid conditions, and careful consideration should be given to the selection of pharmacologic and non-pharmacologic interventions.

Anxiety disorders frequently have a lifelong course, and patients may experience exacerbations and remissions. Appropriate close follow-up and treatment can decrease the risk of future exacerbations, and prompt treatment can limit the impact on the patient’s life when an exacerbation occurs.

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