Anxiety

Normally, anxiety works to set the body on high-alert during stressful times. In anxiety disorders, these normal feelings of anxiety go into overdrive, worsening performance on the job, at school, and in relationships. Anxiety disorders are extremely common affecting up to 30 percent of adults at some point in their lives. Anxiety disorders are caused by a combination of genetics, stress, environmental and social factors. For example, it may be due to having a low level of the neurotransmitter GABA - which is linked to anxiety, a tough job like police work, increased caffeine intake, and going through a divorce. There s also a strong correlation with trauma like humiliation,bullying, and sexual abuse, especially if it occurred during childhood. There s also evidence that individuals tend to mirror the anxiety of those around them. That s why threats to the community - like violence and global warming - are able to directly and indirectly raise anxiety. According to DSM-5, there are nine anxiety disorders: the archetype - generalized anxiety disorder, and the other eight illness that feature similar symptoms - separation anxiety disorder, selective mutism, specific phobia, social anxiety disorder, agoraphobia, panic disorder, substance or medication-induced anxiety disorder, and anxiety disorder due to another medical condition. The two key symptoms in anxiety disorders are fear and uncontrollable anxiety. Fear is the emotional response to a real or perceived imminent threat, whereas anxiety is the anticipation of a future threat. Fear causes a fight or flight response when your life is threatened, while anxiety is oftenassociated with feelings of imminent danger and causes avoidant behaviors. For example,fear is what you might feel during an exam, while anxiety is the dread you may feel the night before the exam. Fear and anxiety can easily get out of hand and turn into panic attacks. Panic attacks areshort uninterrupted periods of up to twenty minutes where individuals feel at least four of the following thirteen symptoms: palpitations, sweating, dyspnea, trembling, paresthesias, feeling throat tightness, chest pain, nausea, dizziness, hot flashes or chills, feeling of unreality of detachment from oneself, an intense fear of dying, and lastly, fear of losing control. Normal anxiety usually occurs in response to a real situation, isn t excessive, and doesn tcause physical symptoms - other than mild insomnia before an important event. In anxiety disorders, on the other hand, individuals worry even when there s no specificthreat present, and the anxiety interferes significantly with everyday tasks. So, the factors that distinguish normal anxiety from pathological anxiety are excessiveness, intensity, duration or chronicity, and impairment. Generalised Anxiety Disorder and other Anxiety Archetypes The most studied disorder is generalized anxiety disorder. According to DSM-5: Firstly, individuals must experience excessive anxiety and worry for the better part of at least six months - so at least 90 or more days out of 180. Second, these feelings must be hard to control but not reach the levels of severity found in panic attacks. Third, adults must have at least three of the following six symptoms: restlessness or edginess, fatigue, difficulty concentrating or feeling like the mind just goes blank, irritability, muscle tension, and trouble sleeping - usually falling asleep or staying asleep. For children, though, only one symptom must be present. Fourth, the anxiety must impair their life - like missing deadlines or skipping work due to symptoms. Fifth, the symptoms should not be due to drugs or medications, or a medical condition like hyperthyroidism. Finally, their anxiety shouldn t be better explained by another mental disorder. Now, for treatment, CBT, SSRIs and SNRIs are first line, whereas buspirone, TCAs, benzodiazepines are second line. A second disorder is separation anxiety disorder. That happens when separation from someone that the person is very attached to - like a parent or a friend - causes inappropriate and excessive fear and anxiety that may lead to factitious physical complaints so that individuals can miss school or work. It lasts more than six months for adults or more than four weeks for children and adolescents. Bear in mind, though, that it s considered normal behavior until the age of 3 or 4. This is distinguished from generalized anxiety disorder, by the fact that the symptoms are all related to the separation or anticipation of a separation. Treatment includes CBT, as well as play therapy, which uses play to help individuals deal with their anxiety, and family therapy, where parents and siblings can learn new ways to interact with the individual and help them when anxiety spikes. Third, there s selective mutism which is when individuals fail to speak when they re supposed to - for example, when giving a speech or presenting an award, despite speaking in other, presumably more comfortable situations. The problem should start before the age of 5, be recurrent, and last for at least one month, and should interfere with the person s work or education. The failure to speak shouldn t be attributable to a lack of preparation or a communication disorder. With selective mutism, the symptoms should occur only in those situations where speech is required. Treatment includes CBT, family and/or play therapy as well as SSRIs. Fourth, there s specific phobias - which are fears or anxiety about a specific animal, object or situation like raccoons, sharp needles, or swimming, that lasts for more than six months. The fear response is disproportionate to the actual danger caused by the trigger - like freaking out when a raccoon scurries across the street. In fact, the individual often realizes that the fear is excessive. The phobic object is actively avoided, and the fear, anxiety and avoidance causes impairment in functioning. With phobias, the symptoms occur only when the individual is faced with the trigger that causes anxiety. Treatment includes CBT with exposure therapy, where individuals are exposed to things they fear and avoid in a safe and controlled environment. This is based on the theory behind flooding that a phobia is a learned fear, and can be unlearned by exposure to the thing that is feared. Now, exposure therapy can be placed in different ways, including graded exposure, in which feared objects, activities or situations are ranked according to difficulty and individuals move from mildly or moderately difficult exposures, to harder ones. There s also flooding, where exposure begins directly with the most difficult tasks, and systematic desensitization, where exposure is combined with relaxation exercises to make them feel more comfortable and to learn to associate the feared objects, activities or situations with relaxation. Fifth, is social anxiety disorder or social phobia. Here, the fear and anxiety are caused by social or performance situations like meeting groups of new people, going on dates, and job interviews - where people feel like they are under scrutiny or being judged. Individuals worry that what they do or say will be negatively evaluated by their colleagues, making them feel ashamed and embarrassed. A subtype of social anxiety disorder is the performance type, where fear and anxiety are only experienced during speaking or performing in public, but not in other types of social situations. This fear is disproportionate to the situation and needs to be persistent, typically over 6 months, with avoidance behaviors and impaired functioning. Treatment involves CBT, SSRIs and/or SNRIs. For the performance subtype, beta blockers or benzodiazepines may also be useful. Sixth, is agoraphobia, and it s when people have an intense fear of at least two of the following five situations: using public transportation in all forms including boats and planes, being in open spaces like parks and rooftops, being in enclosed spaces like theaters, standing in line or being in a crowd, and being outside of their home alone. People with agoraphobia often avoid these situations, mostly because they fear having a panic-reaction in a public space and that escape might be difficult. The symptoms also need to be persistent and interfere with functioning. In contrast to agoraphobia, generalized anxiety disorder doesn t include fears of having a panic-reaction and there are more types of triggers, beyond these five situations. Also in contrast to agoraphobia, social anxiety disorder is more about the fear of being judged by others, rather than a fear of having a public panic-attack. Treatment is based on CBT and SSRIs. Seventh, is panic disorder and it s when people have recurrent out-of-the-blue panic attacks with intense fear and discomfort, that could be triggered by a wide variety of things like finances and upcoming trips - but never a single trigger, and frequently no identifiable trigger. These attacks typically peak within 10 minutes and involve at least 4 of the following symptoms: palpitations, sweating, trembling, dyspnea, feelings of choking, chest pain, nausea, dizziness or lightheadedness, chills or hot flashes, paresthesias, feelings of unreality or detachment from self, fear of dying and fear of losing control. So, diagnosis requires an attack followed by at least one month of one or more of the nd the consequences of it, and try to prevent future attacks by avoiding the people, places, situations, or behaviors that they think are triggers. So, diagnosis requires an attack followed by at least one month of one or more of thefollowing: persistent concern of future attacks, worrying about consequences of attack and change in behavior to avoid having panic attacks. It s also important to know that panic disorder has a strong genetic component and carries an increased risk for suicide. Now, panic attacks can be a symptom of other anxiety disorders like agoraphobia, but in those settings they are related to a specific trigger and therefore don t meet criteria for a panic disorder. Treatment involves CBT, SSRIs and SNRIs as well as beta blockers in an acute setting. Eighth is a substance or medication-induced anxiety disorder, and it s when the symptoms of generalized anxiety disorder are due to the effects of a substance such as cocaine or withdrawal of a medication such as lorazepam. The symptoms develop during or right after using a substance or medication, and stop within a month of stopping that substance or medication. Some common substances or medications include cocaine, amphetamines and other sympathomimetics including methylphenidate, albuterol and other stimulants, decongestants like pseudoephedrine, caffeine and other methylxanthines like theophylline, taurine which is contained in energy drinks, anticholinergics, digitalis, cannabis, PCP, LSD and ecstasy, steroids like glucocorticoids thyroid hormone replacement and levodopa. Now, symptoms of anxiety disorders can also occur as a result of alcohol withdrawal, benzodiazepine or barbiturate withdrawal or abrupt cessation of SSRIs, but also serotonin toxicity as a result of overdose of serotonergic agents. Ninth is an anxiety disorder due to another medical condition like hyperthyroidism or pheochromocytoma. In that situation, the anxiety symptoms begin after the disease begins, worsen as the disease worsens, and resolve once the disease resolves. Cardiovascular disorders include congestive heart failure, arrhythmia, mitral valve arathyroidism, hypercortisolism, pheochromocytoma, diabetes and hypoglycemia, neurological disorders, like neoplasms, encephalitis, seizure disorders and especially complex partial seizures, arteriovenous malformation, cerebrovascular accidents, traumatic brain injury, multiple sclerosis, Huntington disease, Parkinson s disease, Alzheimer`s disease, Guillain Barr syndrome and myasthenia gravis. Cardiovascular disorders include congestive heart failure, arrhythmia, mitral valveprolapse and myocardial infarction or angina. Respiratory disorders include COPD and asthma. Toxic or metabolic disorders include porphyria, vitamin B12 deficiency, Wilson s disease and hypercalcemia. Finally, Lyme disease and systemic lupus erythematosus can also cause anxiety symptoms. Treatment of Anxiety DisordersSo, now that you know what anxiety disorders are, is it treatable? Yes, yes it is. Most anxiety disorders respond well to psychotherapy, medications, and lifestyle changes, which can be given alone or in combination. Support groups, both in-person and online can help individuals identify other coping strategies as well. CBT is similar to medications in short-term effectiveness, but it has major long-term f talk therapy that allows a person to learn a different way of thinking and reacting to stress and to acknowledge anxious patterns of thinking. CBT is similar to medications in short-term effectiveness, but it has major long-term advantages, as it does not have the unwanted effects of medications like tolerance, dependence, withdrawal and side effects. In terms of medications, selective serotonin reuptake inhibitors or SSRIs for short like fluoxetine, paroxetine, sertraline, citalopram, escitalopram and fluvoxamine and selective norepinephrine reuptake inhibitors or SNRIs for short like venlafaxine, duloxetine and desvenlafaxine are often first-line medications They can be used alone, but they re more effective when used along with CBT. Now, SSRIs and SNRIs are known to cause early activating side effects such as anxiety and insomnia that tend to improve with time. However, since individuals with anxiety disorders are more sensitive to these side effects,they may benefit from a temporary dose reduction or starting at a low dose. Tricyclic antidepressants or TCAs for short like doxepin and amitriptyline are second-line choices. Now, sometimes beta-blockers can be used to lower blood pressure and heart rate, to control the physical symptoms of anxiety like trembling and palpitations. Benzodiazepines act very rapidly but are given as a last resort due to their high potentialfor dependence and abuse, withdrawal syndromes and other side effects such as sedation, ataxia, and cognitive impairment. In individuals with high risk of abuse, buspirone, which is a non-benzodiazepine anxiolytic, is slightly weaker and with a slower onset of action than benzodiazepines. Important lifestyle changes include stress management techniques, such as mindfulness-based stress reduction, meditation, and staying physically active. Preliminary studies show that having a regular sleep schedule and doing yoga are specifically helpful at managing anxiety symptoms. In addition, creating a regular daily routine can be a powerful stress and anxiety reducer, increase serotonin levels, and also act as a positive distraction. There s emerging evidence that a healthy diet rich in foods with high levels of magnesium, probiotics, and zinc may also help reduce anxiety. For example, that could be done with leafy green vegetables, pickled foods, and nuts. Care should also be taken to avoid substances that worsen anxiety such as caffeine, alcohol and tobacco. Broadly speaking, it s essential for individuals to self-monitor their symptoms through scales and journals so that they can reach out for help proactively whenever symptoms reappear.Summary In anxiety disorders - fear and anxiety, combined with physical symptoms like trembling and palpitations become overwhelming and disruptive for a period of over six months. Generalized anxiety disorder is when individuals experience excessive anxiety for the better part of at least six months, without it turning into panic attacks. In separation anxiety disorder people feel anxiety for at least six months when they are separated from someone that they are very attached to whereas those with selective mutism fail to speak when they are supposed to on more than one occasion. There are also specific phobias where a specific animal, object or situation triggers symptoms over a period of more than six months. In social phobia, the fear and anxiety are caused by social situations where people feel like they are under scrutiny, whereas in agoraphobia, people have an intense fear of having a panic attack or not being able to escape from at least two out of five very particular, mostly public situations. Substance or medication-induced anxiety disorder is when the symptoms of generalizedanxiety disorder are due to a substance or medication, and anxiety disorder due to another medical condition is when the anxiety is related to a specific disease. Treatment options typically comprise psychotherapy such as cognitive behavioral therapy, and medications such as SSRIs, SNRIs and less commonly benzodiazepines, or both of these in combination. Other helpful adjunctive strategies include lifestyle changes and stress reduction techniques such as mindfulness-based stress reduction, meditation and yoga, dietary modification, staying physically active and having better sleep hygiene.