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Anxiety disorder       

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Anxiety disorder is a blanket term covering several different forms of abnormal and pathological fear and anxiety Conditions now considered anxiety disorders only came under the aegis of psychiatry at the end of the 19th century. Gelder, Mayou & Geddes (2005) explains that anxiety disorders are classified in two groups: continuous symptoms and episodic symptoms. Current psychiatric diagnostic criteria recognize a wide variety of anxiety disorders. Recent surveys have found that as many as 18% of Americans may be affected by one or more of them.

The term anxiety covers four aspects of experiences an individual may have: mental apprehension, physical tension, physical symptoms and dissociative anxiety (symptoms associated with hyperventilation). Anxiety disorder is divided into generalised anxiety disorder, phobic disorder, and panic disorder; each has its own characteristics and symptoms and they require different treatment (Gelder et al. 2005). The emotions present in anxiety disorders range from simple nervousness to bouts of terror (Barker 2003).

Standardized screening clinical questionnaires such as Zung Self-Rating Anxiety Scale can be used to detect anxiety symptoms, and suggest the need for a formal diagnostic assessment of anxiety disorder.

Classification

 Generalized anxiety disorder

Generalized anxiety disorder (GAD) is a common chronic disorder characterized by long-lasting anxiety that is not focused on any one object or situation. Those suffering from generalized anxiety experience non-specific persistent fear and worry and become overly concerned with everyday matters. Generalized anxiety disorder is the most common anxiety disorder to affect older adults.Anxiety can be a symptom of a medical or substance abuse problem, and medical professionals must be aware of this. A diagnosis of GAD is made when a person has been excessively worried about an everyday problem for six months or more. A person may find they have problems making daily decisions and remembering commitments as a result of lack of concentration/preoccupation with worry. Appearance looks strained, skin is pale with increased sweating from the hands, feet and axillae. May be tearful which can suggest depression.Before a diagnosis of anxiety disorder is made, nurses and physicians must rule out drug-induced anxiety and medical causes.

 Panic disorder

In panic disorder, a person suffers from brief attacks of intense terror and apprehension, often marked by trembling, shaking, confusion, dizziness, nausea, difficulty breathing. These panic attacks, defined by the APA as fear or discomfort that abruptly arises and peaks in less than ten minutes, can last for several hours and can be triggered by stress, fear, or even exercise; the specific cause is not always apparent.

In addition to recurrent unexpected panic attacks, a diagnosis of panic disorder requires that said attacks have chronic consequences: either worry over the attacks' potential implications, persistent fear of future attacks, or significant changes in behavior related to the attacks. Accordingly, those suffering from panic disorder experience symptoms even outside specific panic episodes. Often, normal changes in heartbeat are noticed by a panic sufferer, leading them to think something is wrong with their heart or they are about to have another panic attack. In some cases, a heightened awareness (hypervigilance) of body functioning occurs during panic attacks, wherein any perceived physiological change is interpreted as a possible life-threatening illness (i.e., extreme hypochondriasis).

Panic disorder with agoraphobia

A person experiences an unexpected panic attack, then has substantial anxiety over the possibility of having another attack. The person fears and avoids whatever situation might induce a panic attack. The person may never or rarely leave their home to prevent a panic attack they believe to be inescapable, extreme terror.

 Phobias

1. The single largest category of anxiety disorders is that of phobic disorders, which includes all cases in which fear and anxiety is triggered by a specific stimulus or situation. Between 5% and 12% of the population worldwide suffer from phobic disorders.Sufferers typically anticipate terrifying consequences from encountering the object of their fear, which can be anything from an animal to a location to a bodily fluid to a particular situation. Sufferers understand that their fear is not proportional to the actual potential danger but still are overwhelmed by the fear.
2.  Agoraphobia

Agoraphobia is the specific anxiety about being in a place or situation where escape is difficult or embarrassing or where help may be unavailable.^[11] Agoraphobia is strongly linked with panic disorder and is often precipitated by the fear of having a panic attack. A common manifestation involves needing to be in constant view of a door or other escape route. In addition to the fears themselves, the term agoraphobia is often used to refer to avoidance behaviors that sufferers often develop. For example, following a panic attack while driving, someone suffering from agoraphobia may develop anxiety over driving and will therefore avoid driving. These avoidance behaviors can often have serious consequences; in severe cases, one can be confined to one's home.

Social anxiety disorder

Social anxiety disorder (SAD; also known as social phobia) describes an intense fear and avoidance of negative public scrutiny, public embarrassment, humiliation, or social interaction. This fear can be specific to particular social situations (such as public speaking) or, more typically, is experienced in most (or all) social interactions. Social anxiety often manifests specific physical symptoms, including blushing, sweating, and difficulty speaking. Like with all phobic disorders, those suffering from social anxiety often will attempt to avoid the source of their anxiety; in the case of social anxiety this is particularly problematic, and in severe cases can lead to complete social isolation.

 Post-traumatic stress disorder

Post-traumatic stress disorder (PTSD) is an anxiety disorder which results from a traumatic experience. Post-traumatic stress can result from an extreme situation, such as combat, natural disaster, rape, hostage situations, child abuse, bullying or even a serious accident. It can also result from long term (chronic) exposure to a severe stressor,for example soldiers who endure individual battles but cannot cope with continuous combat. Common symptoms include hypervigilance, flashbacks, avoidant behaviors, anxiety, anger and depression. There are a number of treatments which form the basis of the care plan for those suffering with PTSD. Such treatments include cognitive behavioral therapy (CBT), psychotherapy and support from family and friends. These are all examples of treatments used to help people suffering from PTSD.

Separation anxiety

Separation anxiety disorder (SepAD) is the feeling of excessive and inappropriate levels of anxiety over being separated from a person or place. Separation anxiety is a normal part of development in babies or children, and it is only when this feeling is excessive or inappropriate that it can be considered a disorder.^[14] Separation anxiety disorder affects roughly 7% of adults and 4% of children, but the childhood cases tend to be more severe, in some instances even a brief separation can produce panic.

 Childhood anxiety disorders

Children as well as adults experience feelings of anxiousness, worry and fear when facing different situations, especially those involving a new experience. However, if anxiety is no longer temporary and begins to interfere with the child's normal functioning or do harm to their learning, the problem may be more than just an ordinary anxiousness and fear common to the age.^[17]

When children suffer from a severe anxiety disorder their thinking, decision-making ability, perceptions of the environment, learning and concentration get affected. They not only experience fear, nervousness, and shyness but also start avoiding places and activities. Anxiety also raises blood pressure and heart rate and can cause nausea, vomiting, stomach pain, ulcers, diarrhea, tingling, weakness, and shortness of breath.^[18] Some other symptoms are frequent self-doubt and self-criticism, irritability, sleep problems and, in extreme cases, thoughts of not wanting to be alive.

If these children are left untreated, they face risks such as poor results at school, avoidance of important social activities, and substance abuse. Children who suffer from an anxiety disorder are likely to suffer other disorders such as depression, eating disorders, and attention deficit disorders, both hyperactive and inattentive.^[19]

About 13 of every 100 children and adolescents between 9 to 17 years experience some kind of anxiety disorder, and girls are more affected than boys.^{[citation needed]} The basic temperament of children may be key in some of their childhood and adolescent disorders.

Research in this area is very difficult to perform because as children grow their fears change, making it difficult for researchers to obtain enough data and thus more reliable results.^{[citation needed]} For instance, between the ages of 6 and 8, children's fear of the dark and imaginary creatures decreases, but they become more anxious about school performance and social relationships. If children experience an excessive amount of anxiety during this stage, this could lead to development of anxiety disorders later in life.

According to research, childhood anxiety disorders are caused by biological and psychological factors. Also, it is suggested that when children have a parent with anxiety disorders, they are more likely to have an anxiety disorder, too. Stress can trigger anxiety disorders, and children and adolescents with anxiety disorders seem to have an increased physical and psychological reaction to stress. Their reaction to danger, even if it is a small one, is quicker and stronger.

Causes

Biological

Low levels of GABA, a neurotransmitter that reduces activity in the central nervous system, contribute to anxiety. A number of anxiolytics achieve their effect by modulating the GABA receptors.

Selective serotonin reuptake inhibitors, the drugs most commonly used to treat depression, are frequently considered as a first line treatment for anxiety disorders. A 2004 study using functional brain imaging techniques suggests that the effects of SSRIs in alleviating anxiety may result from a direct action on GABA neurons rather than as a secondary consequence of mood improvement.

Severe anxiety and depression can be induced by sustained alcohol abuse which in most cases abates with prolonged abstinence. Even moderate, sustained alcohol use may increase anxiety and depression levels in some individuals.^[27]Caffeine, alcohol and benzodiazepine dependence can worsen or cause anxiety and panic attacks.In one study in 1988–1990,^[29] illness in approximately half of patients attending mental health services at one British hospital psychiatric clinic, for conditions including anxiety disorders such as panic disorder or social phobia, was determined to be the result of alcohol or benzodiazepine dependence. In these patients, an initial increase in anxiety occurred during the withdrawal period followed by a cessation of their anxiety symptoms.

Intoxication from stimulants is likely to be associated with repetitive panic attacks.^{[citation needed]}

There is evidence that chronic exposure to organic solvents in the work environment can be associated with anxiety disorders. Painting, varnishing and carpet-laying are some of the jobs in which significant exposure to organic solvents may occur.

People with obsessive-compulsive disorder (sometimes considered an anxiety disorder), evince increased grey matter volumes in bilateral lenticular nuclei, extending to the caudate nuclei, while decreased grey matter volumes in bilateral dorsal medial frontal/anterior cingulate gyri. These findings contrast with those in people with other anxiety disorders, who evince decreased (rather than increased) grey matter volumes in bilateral lenticular/caudate nuclei, while also decreased grey matter volumes in bilateral dorsal medial frontal/anterior cingulate gyri.

 Amygdala

The amygdala is central to the processing of fear and anxiety, and its function may be disrupted in anxiety disorders.^[33] Sensory information enters the amgydala through the nuclei of the basolateral complex (consisting of lateral, basal, and accessory basal nuclei). The basolateral complex processes sensory-related fear memories and communicates their threat importance to memory and sensory processing elsewhere in the brain, such as the medial prefrontal cortex and sensory cortices.

Another important area is the adjacent central nucleus of the amygdala, which controls species-specific fear responses, via connections to the brainstem, hypothalamus, and cerebellum areas. In those with general anxiety disorder, these connections functionally seem to be less distinct, with greater gray matter in the central nucleus. Another difference is that the amygdala areas have decreased connectivity with the insula and cingulate areas that control general stimulus salience, while having greater connectivity with the parietal cortex and prefrontal cortex circuits that underlie executive functions.

The latter suggests a compensation strategy for dysfunctional amygdala processing of anxiety. Researchers have noted "Amygdalofrontoparietal coupling in generalized anxiety disorder patients may ... reflect the habitual engagement of a cognitive control system to regulate excessive anxiety. This is consistent with cognitive theories that suggest the use in this disorder of attempts to reduce the involvement of emotions with compensatory cognitive strategies.

Clinical and animal studies suggest a correlation between anxiety disorders and difficulty in maintaining balance. A possible mechanism is malfunction in the parabrachial nucleus, a brain structure that, among other functions, coordinates signals from the amygdala with input concerning balance.

Anxiety processing in the basolateral amygdala has been implicated with dendritic arborization of the amygdaloid neurons. SK2 potassium channels mediate inhibitory influence on action potentials and reduce arborization. By overexpressing SK2 in the basolateral amygdala, anxiety in experimental animals can be reduced together with general levels of stress-induced corticosterone secretion.

Stress

Anxiety disorders can arise in response to life stresses such as financial worries or chronic physical illness. Somewhere between 4% and 10% of older adults are diagnosed with anxiety disorder, a figure that is probably an underestimate due to the tendency of adults to minimize psychiatric problems or to focus on their physical manifestations.^{[citation needed]} Anxiety is also common among older people who have dementia. On the other hand, anxiety disorder is sometimes misdiagnosed among older adults when doctors misinterpret symptoms of a physical ailment (for instance, racing heartbeat due to cardiac arrhythmia) as signs of anxiety.^[5]

 Studies have also indicated that anxiety disorders are more likely among those with family history of anxiety disorders, especially certain types.

Sexual dysfunction often accompanies anxiety disorders, although it is difficult to determine whether anxiety causes the sexual dysfunction or whether they arise from a common cause. The most common manifestations in individuals with anxiety disorder are avoidance of intercourse, premature ejaculation or erectile dysfunction among men and pain during intercourse among women. Sexual dysfunction is particularly common among people affected by panic disorder (who may fear that a panic attack will occur during sexual arousal) and posttraumatic stress disorder.

 Treatment

The most important clinical point to emerge from studies of social anxiety disorder is the benefit of early diagnosis and treatment. Social anxiety disorder remains under-recognized in primary care practice, with patients often presenting for treatment only after the onset of complications such as clinical depression or substance abuse disorders.

Treatment options available include lifestyle changes; psychotherapy, especially cognitive behavioral therapy; and pharmaceutical therapy. Education, reassurance and some form of cognitive-behavioral therapy should almost always be used in treatment.^{[citation needed]} Research has provided evidence for the efficacy of two forms of treatment available for social phobia: certain medications and a specific form of short-term psychotherapy called cognitive-behavioral therapy (CBT), the central component being gradual exposure therapy.

Alternative medicine

Regular aerobic exercise,^[66] improving sleep hygiene^{[citation needed]} and reducing caffeine^[67] are often useful in treating anxiety.

Herbal drugs are often used in patients with somatoform disorders. In one clinical trial, butterbur in a fixed herbal drug combination (Ze 185 = 4-combination versus 3-combination without butterbur and placebo) was used in patients with somatoform disorders.^[68] For a 2-week treatment in patients with somatization disorder (F45.0) and undifferentiated somatoform disorder (F45.1), 182 patients were randomized for a 3-arm trial (butterbur root, valerian root, passionflower herb, lemon balm leaf versus valerian root, passionflower herb, lemon balm leaf versus placebo). Anxiety (visual analogue scale – VAS) and depression (Beck's Depression Inventory – BDI) were used as primary parameters, and Clinical Global Impression (CGI) was used a secondary parameter. The 4-combination was significantly superior to the 3-combination and placebo in all the primary and secondary parameters (PP-population), without serious adverse events.

Many other natural remedies have been used for anxiety disorder. These include kava, where the potential for benefit seems greater than that for harm with short-term use in patients with mild to moderate anxiety. Based on Cochrane's systematic review of seven RCTs (n = 380), with findings supported by five lower-quality trials (n = 320), the American Academy of Family Physicians (AAFP) recommends use of kava for patients with mild to moderate anxiety disorders who are not using alcohol or taking other medicines metabolized by the liver, but who wish to use “natural” remedies.Side effects of kava in the clinical trials were rare and mild.

Inositol has been found to have modest effects in patients with panic disorder or obsessive-compulsive disorder. St. John's workand Sympathy have also been used to treat anxiety, but with little scientific evidence as to their effectiveness.

Clinical manifestation:

Experience takot .which are too small, unexplained duration of intense fear or discomfort. how

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