Anxiety Disorders

KEY FEATURES

Essentials of Diagnosis

• Persistent excessive anxiety or chronic fear and associated behavioral disturbances

• Physical symptoms such as muscle tension, restlessness, and becoming easily fatigued

• 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

  • 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 and lasts 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, and difficulty controlling the worry

    • Present more days than not for at least 6 months

    • Further manifestations can include cardiac restlessness, muscle tension, difficulty concentrating, sleep disturbance, and irritability

  • Panic disorder

    • Panic attacks are recurrent, unpredictable episodes of intense surges of anxiety accompanied by marked physiologic manifestations

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

    • 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

    • Persistent worry about future panic attacks develops in patients with panic disorder and further constricts their daily lives

    • Onset usually under age 25

    • Patients frequently undergo evaluations for emergent medical conditions (eg, heart attack or hypoglycemia), which are then ruled out before the correct diagnosis is made

    • Gastrointestinal symptoms (eg, stomach pain, heartburn, diarrhea, constipation, nausea, and vomiting) are common, occurring in about one-third of cases

    • Patients who have panic disorder ...