Anxiety Disorders

KEY FEATURES

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

• Anxiety can become self-generating, since the symptoms reinforce the reaction, causing it to spiral

• Additionally, avoidance of triggers of anxiety reinforces the anxiety, because 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 improve with prolonged exposure to an objectively neutral stressor

• Anxiety disorders include

  • Generalized anxiety disorder (GAD)

  • Panic disorder

  • Phobic disorder

• GAD

  • Everyday activities trigger symptoms

  • Symptoms present on most days for at least 6 months

• Panic disorder

  • Somatic symptoms are often marked; however, the key to diagnosis is the psychic pain and suffering the individual expresses

• Phobic disorder

  • Symptoms occur predictably

  • Follows exposure to certain objects or situations

  • Fears out of proportion to the danger posed, which tend to be chronic

Demographics

• About 7% of women and 4% of men will meet criteria for GAD over a lifetime

• GAD becomes chronic in many patients, lasting longer than 2 years in > 50%

• Anxiety disorder in older adults is twice as common as dementia and 4–6 times more common than major depression

• Prevalence of panic disorder: 3–5%, 25% with coincident obsessive-compulsive disorder; the female-to-male ratio is 2:1

CLINICAL FINDINGS

Symptoms and Signs

• The principal components of anxiety are psychological and somatic

  • GAD

    • Psychological symptoms include apprehension, worry, irritability, difficulty in concentrating, insomnia, or somatic complaints

    • Present more days than not for at least 6 months

    • Somatic manifestations include cardiac (eg, tachycardia, increased blood pressure), gastrointestinal (eg, increased acidity, nausea, epigastric pain), and neurologic (eg, headache, near-syncope) systems

  • 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 keep the individual confined at home

    • Dyspnea, tachycardia, palpitations, dizziness, paresthesia, choking, smothering feelings, and nausea can be associated with feelings of impending doom (alarm response)

    • Panic disorder; diagnosed when panic attacks are accompanied by a chronic fear of the recurrence of an attack or a maladaptive change in behavior to try to avoid potential triggers of the panic attack

    • Recurrent sleep panic attacks (not nightmares) occur in about 30% of panic disorders

    • Anticipatory anxiety develops

    • Onset usually under age 25

    • Patients with panic disorder are at increased risk for ...