DR MOHAMED EL HEFNAWEY

Consultant-psychiatrist

Anxiety is a normal human feeling of apprehension in certain threatening situations. Mild degree of anxiety is unavoidable and is not considered abnormal. Table 111 shows the main differences between normal and abnormal anxiety.

NORMAL ANXIETY Proportional apprehension to the external stimulus. Features of anxiety are few. Anxiety is not severe and not prolonged. Attention is focused on the external threat rather than on the persons feelings.

ABNORMAL ANXIETY Apprehension is out of proportion to the external stimulus. Features are multiple. Anxiety is prolonged or severe or both. Attention is focused also on the persons response to the threat (e.g. palpitation).

Anxiety can be: Trait anxiety: (part of personality character) in which a person has a habitual tendency to be anxious in a wide range of different circumstances (longitudinal view).

State anxiety: in which anxiety is experienced as a response to external stimuli (cross sectional view).

What Kinds of Anxiety Disorders are There?

Panic disorder (with and without a history of agoraphobia) Agoraphobia (with and without a history of panic disorder) Generalized anxiety disorder Specific phobia Social phobia Obsessive-compulsive disorder Acute stress disorder post-traumatic stress disorder y In addition, y there are adjustment disorders with anxious features, anxiety disorders due to general medical conditions, substance-induced anxiety disorders, and the residual category of anxiety disorder not otherwise specified (DSM-IV).
y y y y y y y

Anxiety disorders are abnormal states in which the most striking features are worry, dread and physical symptoms of anxiety that indicate a hyperactive autonomic nervous system and are not caused by an organic brain disease, medical illness nor psychiatric disorder.

Psychological Excessive apprehension Fearful anticipation Feeling of dread Worrying thoughts Hypervigilance Feeling of restlessness Sensitivity to noise Difficulty concentrating

Physical
Gastrointestinal: Chest: - disturbed appetite - chest discomfort - dysphagia - difficulty in inhalation - epigastric discomfort Cardiovascular: - disturbed bowel habits - palpitation Genitourinary: - awareness of missed beats - urine frequency and urgency - cold extremities -  libido Neurological: - impotence - headache - dysmenorrheoea - dizziness Musculoskeletal: - tinnitus - muscle and joint pain - numbness Sleep: - tremor - insomnia - blurred vision - bad dreams Skin: - sweating itching hot /cold skin.

GENERALIZED ANXIETY DISORDER (GAD)

Excessive worry about number of events and circumstances for at least 6 months duration. The person finds it difficult to control the worry, which is accompanied by other features of anxiety physical and psychological. Features cause clinically significant distress or functional impairment (social, occupational). Sleep is often intermittent and accompanied by unpleasant dreams or night terrors. Patient may wake unrefreshed, or may have difficulty in falling asleep. If early morning waking is present, it should suggest the possibility of major depression which may be associated with anxiety symptoms.

Mental State Examination (MSE): Strained face with furrowed brow and frequent blinking. Tense posture, tremulous and restless. Sweating (forehead, hands, feet). Difficulty in inhalation.

Symptoms that may be associated with generalized anxiety disorder: Panic attacks (see later). Mild depressive symptoms. Hypochondrical thoughts (see later). Depersonalization and derealization.

Epidemiology: One year prevalence rate: 3 %. Life time prevalence rate: 5 %. Women > men. Often begins in early adult life, but may occur for the first time in middle age. There is a considerable cultural variation in the expression of anxiety. Frequent in primary care and other medical specialties.

Aetiology: Generalized anxiety disorder appears to be caused by stressors acting on a personality predisposed by a combination of genetic and environmental influences in childhood. Maladaptive patterns of thinking may act as maintaining factors. Anxiety as a trait has a familial association.

Differential Diagnosis: 1. Anxiety disorder due to medical conditions: - Hyperthyroidism - Hypoglycemia - Hypocalcaemia - Phaeochromocytoma - Paroxysmal tachycardia - Hypoxaemia /anaemia.

2. Depressive Disorder: - When anxiety and depressive symptoms coexist, the diagnostic criteria may be met for both depressive disorder and generalized anxiety disorder. Anxiety is a common symptom in depressive disorder. It is conventional to make the diagnosis on the basis of the severity of symptoms and by the order in which they appeared. Ask any anxious patient routinely about symptoms of depression including depressive thinking, and when appropriate, suicidal ideation.

3. Substance-Induced Anxiety Disorder: - Intoxication with CNS stimulants (e.g. amphetamine). - Withdrawal from CNS depressants (e.g. alcohol). 4. Panic Disorder (see later). 5. Adjustment Disorders. 6. Psychotic Disorders (e.g. mania).

Course and Prognosis: The course is often chronic, fluctuating and worsen during times of stress. - Symptoms may diminish as patient gets older. - Over time, patient may develop secondary depression (not uncommon if left untreated). When patient complains mainly of physical symptoms of anxiety and attributes these symptoms to physical causes, he generally seems more difficult to help. Poorer prognosis is associated with severe symptoms and with derealization, syncopal episodes, agitation and hysterical

Management: Ruling out possible organic causes. Reassurance that symptoms are not due to a serious physical disease. Explanation of the nature of the illness. Assisting the patient to deal with, or adjust to, any ongoing problem. Reduction of caffeine intake (coffee, tea, cola )

Management: (cont.)

Cognitive behaviour therapy: - Relaxation training. - Anxiety management training : relaxation with cognitive therapy to control worrying thoughts, through identifying and changing the automatic faulty thoughts.

Drug Treatment: Benzodiazepines for a short period (2 4 weeks) to avoid the risk of dependence. Buspirone: as effective as benzodiazepines and is much less likely to cause dependence. No crosstolerance with benzodiazepines. Antidepressants have been used to treat anxiety. No risk of dependence. They act more slowly than benzodiazepines but with equivalent effect. Beta-adrenergic antagonists are used to treat some physical features of anxiety (palpitation, tremor)

MIXED ANXIETY AND DEPRESSIVE DISORDER

Anxiety and depressive features are both present but neither set of features, considered separately, is severe enough to make a diagnosis of depressive disorder or anxiety disorder as a primary diagnosis. Seen commonly in clinical practice. Features of anxiety and depression may arise together because : - many stressful events combine elements of loss (associated with depression) and danger (associate with anxiety).

What are the Risk Factors for Anxiety Disorder?

risk factors and socio-demographic variables y associated with anxiety disorders include surviving severe abuse, parental mental disorder, low income, and being on public assistance. These were also risk factors for other mental y disorders listed in the report, including mood disorders, substance abuse, and antisocial behaviour.

More on Risk Factors:

Family history of anxiety places individuals at risk for y developing an anxiety disorder. A number of studies have shown that each of the anxiety disorders tends to run in families . Parental behaviour (e.g., a tendency to be y overprotective, less affectionate, and more controlling) appears to be associated with the development of anxiety disorders.