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ESSENTIALS OF DIAGNOSIS

  • Persistent excessive anxiety or chronic fear and associated behavioral disturbances.

  • Somatic symptoms referable to the autonomic nervous system or to a specific organ system (eg, dyspnea, palpitations, paresthesias).

  • Not limited to an adjustment disorder.

  • Not a result of physical disorders, other psychiatric conditions (eg, schizophrenia), or drug abuse (eg, cocaine).

GENERAL CONSIDERATIONS

Stress, fear, and anxiety all tend to be interactive. The principal components of anxiety are psychological (tension, fears, difficulty in concentration, apprehension) and somatic (tachycardia, hyperventilation, shortness of breath, palpitations, tremor, sweating). Other organ systems (eg, gastrointestinal) may be involved in multiple-system complaints. Fatigue and sleep disturbances are common. Sympathomimetic symptoms of anxiety are both a response to a central nervous system state and a reinforcement of further anxiety. Anxiety can become self-generating, since the symptoms reinforce the reaction, causing it to spiral. Additionally, avoidance of triggers of anxiety leads to reinforcement of the anxiety. The person continues to associate the trigger with anxiety and never relearns through experience that the trigger need not always result in fear, or that anxiety will naturally improve with prolonged exposure to an objectively neutral stressor.

Anxiety may be free-floating, resulting in acute anxiety attacks, occasionally becoming chronic. Lack of structure is frequently a contributing factor, as noted in those people who have “Sunday neuroses.” They do well during the week with a planned work schedule but cannot tolerate the unstructured weekend. Planned-time activities tend to bind anxiety, and many people have increased difficulties when this is lost, as in retirement.

CLINICAL FINDINGS

A. Generalized Anxiety Disorder

Anxiety disorders are the most prevalent psychiatric disorders. About 7% of women and 4% of men will meet criteria for GAD over a lifetime. GAD becomes chronic in many patients with over half of patients having the disorder for longer than 2 years. Anxiety disorder in the elderly is twice as common as dementia and four to six times more common than major depression, and it is associated with poorer quality of life and contributes to the onset of disability. The anxiety symptoms of apprehension, worry, irritability, difficulty in concentrating, insomnia, or somatic complaints are present more days than not for at least 6 months. Manifestations can include cardiac (eg, tachycardia, increased blood pressure), gastrointestinal (eg, increased acidity, nausea, epigastric pain), and neurologic (eg, headache, near-syncope) systems. The focus of the anxiety may be a number of everyday activities.

B. Panic Disorder

Panic attacks are recurrent, unpredictable episodes of intense surges of anxiety accompanied by marked physiologic manifestations. Agoraphobia, fear of being in places where escape is difficult, such as open spaces or public places where one cannot easily hide, may be present and may lead the individual to confine his or her life to home. Distressing symptoms and signs such as dyspnea, tachycardia, palpitations, dizziness, paresthesias, choking, smothering feelings, ...

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