Anxiety Disease

BASICS

DESCRIPTION

A common acute or chronic, fearful emotion with associated physical symptoms. DSM-IV-R recognizes the following sub types:

Acute situational anxiety: Response to recent stressful event, usually transient symptoms
Adjustment disorder with anxious mood: Persistent, maladaptive reaction following psychosocial stress and lasting up to six months
Generalized anxiety disorder: Persistent underlying anxiety or adjustment disorder with anxious mood and significant symptoms of motor tension, autonomic hyperactivity and hypervigilance, lasting more than six months
Panic disorder: Recurrent unexpected attacks with at least one attack (or more) associated with persistent concern about additional attacks, worries about implications of the attack (losing control, having a heart attack) or a significant change in behavior related to the attack; often leads to agoraphobia
Post-traumatic stress disorder: Recurrent flashbacks or nightmares of catastrophic event by survivors, often associated with panic attacks and major depression
Specific phobias: Intense recurrent fear of, and avoidance of, an object or situation
Social phobia: Marked and persistent fear and avoidance of performance or social situations in which the person is exposed to unfamiliar people or scrutiny
Obsessive-compulsive disorder: Persistent unwanted and disturbing thoughts and recurrent behavioral patterns (i.e., hand washing) which interfere with daily life
System(s) affected: Nervous
Genetics: Panic disorder - increased concordance in monozygotic versus dizygotic twins
Incidence/Prevalence in USA: 40 million (the most common psychiatric disorder in US)
- 12 month prevalence rate
  - Panic disorder - female 3.2%, male 1.3%
  - Obsessive compulsive disorder - female 2.6-3.1%, male 1.1-2.6%
  - Agoraphobia - female 3.8%, male 1.7%
  - Generalized anxiety disorder - female 4.3%, male 2.0%
  - Social phobia - female 5.2%, male 3.8%
Predominant age: Mainly adults, highest prevalence in 20 to 45 year age group
Predominant sex: Female > Male (social phobia female 5.27:male 3.87)

SIGNS AND SYMPTOMS

Patterns vary with subtype of anxiety; not all present in each case

Unrealistic or excessive anxiety or worry
Sense of impending doom
Nervousness
Instability
Tachycardia; palpitations
Systolic click murmur
Hyperventilation, choking sensation
Labile hypertension
Sighing respiration
Nausea or abdominal distress
Paresthesias
Diaphoresis
Dizziness or syncope
Flushing
Muscle tension
Muscle tension
Restlessness
Chest tightness, pressure (pseudoangina)
Headache, backaches, muscle spasm

CAUSES

Panic disorder, social phobia and obsessive compulsive disorder are associated with genetic factors
Psychosocial stressors commonly trigger anxiety disorders and may provoke a genetic diathesis
Mediated by abnormalities of neurotransmitter systems (serotonin, norepinephrine and gamma-aminobutyric acid [GABA])

RISK FACTORS

Social and financial problems
Medical illness
Family history
Lack of social support

DIAGNOSIS

LABORATORY

Selective use of laboratory tests, (with minimal to more extensive workup depending on clinical picture). Laboratory tests often normal in anxiety disorders.
CBC and urinalysis
Sequential serial multiple analysis (SMA-12 panel)
Thyroid function studies

Drugs that may alter lab results: SSRIs may raise serum levels of other medications such as coumadin Disorders that may alter lab results: N/A

PATHOLOGICAL FINDINGS

N/A

SPECIAL TESTS

EEG, ECG, etc.

IMAGING

Usually none; chest x-ray possibly

DIAGNOSTIC PROCEDURES

Psychologic testing (e.g., Zung's anxiety self-assessment, Hamilton's anxiety scale)
DSM-IV based interview

TREATMENT

APPROPRIATE HEALTH CARE

Outpatient

GENERAL MEASURES

Should be based on careful workup and identification of etiology and subtype of anxiety disorders
Adequate workup
Identify co-existent substance abuse
Counseling or psychotherapy along with medications
Regular exercise program
Biofeedback in selected cases
Serial office visits
Judicious reassurance after other medical disorders ruled out

SURGICAL MEASURES

N/A

ACTIVITY

Fully active

DIET

No special diet

PATIENT EDUCATION

For a listing of sources for patient education materials favorably reviewed on this topic, physicians may contact: American Academy of Family Physicians Foundation, P.O. Box 8418, Kansas City, MO 64114, (800)274-2237, ext. 4400
National Institute of Mental Health (NIMH) - National Anxiety Awareness Program, 9000 Rockville Pike, Bethesda, MD 20892
Anxiety Disorders Association of America - www.adaa.org

FOLLOW UP

PREVENTION/AVOIDANCE

Management of stress, to extent possible, relaxation techniques, meditation

POSSIBLE COMPLICATIONS

Impaired social/occupational functioning
Drug dependence (benzodiazepines)
Cardiac arrhythmias (TCAs)

EXPECTED COURSE AND PROGNOSIS

With active treatment, excellent results can often be obtained, especially with short-term anxiety disorders, including panic disorder
Obsessive-compulsive disorder, and post-traumatic stress disorder are more difficult to treat, often requiring long-term psychotherapy and medication (combination treatment)

MISCELLANEOUS

ASSOCIATED CONDITIONS

Depression (commonly)
Agoraphobia
Alcohol or substance abuse
Somatoform disorders

AGE-RELATED FACTORS

Pediatric: Reduced dosage of medications in adolescent
Geriatric: Reduced dosage of medications
Others: N/A

PREGNANCY

Benzodiazepines - contraindicated in first-trimester of pregnancy, and with caution later in pregnancy and during lactation. May cause lethargy and weight loss in nursing infants; avoid breast feeding if mother taking benzodiazepines chronically or in high doses.
TCAs - some evidence of fetal risk, especially in first trimester
SSRIs - taper and discontinue, if possible, in first trimester; may be used later in pregnancy

OTHER NOTES

N/A

ABBREVIATIONS

DSM-IV-R = Diagnostic and Statistical Manual of Mental Disorders. 4th edition
TCA = tricyclic antidepressant
SSRI = selective serotonergic reuptake inhibitor

Clinical Investigations

ROLE OF HOMOEOPATHY

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