Anxiety disorders

The anxiety disorders are a group of mental disturbances characterized by anxiety as the main symptom. Although anxiety is common, not everyone who experiences it has an anxiety disorder. Anxiety is associated with a wide range ofphysical illnesses, medication side effects, and other psychiatric disorders.

Anxiety disorders are the most common form of mental disturbance in the United States population. It is estimated that 28 million persons suffer from an anxiety disorder every year. These disorders are a serious problem for the entire society because of their interference with patients' work, schooling, andfamily life. They also contribute to the high rates of alcohol and substanceabuse in the United States. Anxiety disorders are an additional problem forhealth professionals because the physical symptoms of anxiety frequently bring people to primary care doctors or emergency rooms.

The revisions of the Diagnostic and Statistical Manual of Mental Disorders(DSM) that took place after 1980 brought major changes in the classification of the anxiety disorders. Prior to 1980, psychiatrists classified patients on the basis of a theory of causality that defined anxiety as the outcomeof unconscious conflicts in the patient's mind. DSM-III (1980), DSM-III-R (1987), and DSM-IV (1994) introduced and refined a new classification that took into consideration recent discoveries about the biochemical and post-traumatic origins of some types of anxiety. The present definitions are based on the external and reported symptom patterns of the disordersrather than on theories about their origins.

DSM-IV defines twelve types of anxiety disorders in the adult population. They can be grouped under seven headings:

  • Panic disorders with orwithout agoraphobia. The chief characteristic of panic disorder is the occurrence of panic attacks coupled with fear of their recurrence. Patients with agoraphobia are afraid of places or situations in which they might have a panicattack and be unable to leave or to find help.
  • Phobias. These include specific phobias and social phobia. A phobia is an intense irrational fearof a specific object or situation that compels the patient to avoid it. Somephobias concern activities or objects that involve some risk (for example, flying or driving) but many are focused on harmless animals or other objects. Social phobia involves a fear of being humiliated, judged, or scrutinized. Itmanifests itself as a fear of performing certain functions in the presence ofothers, such as public speaking or using public lavatories.
  • Obsessive-compulsive disorder (OCD). This disorder is marked by unwanted, intrusive,persistent thoughts or repetitive behaviors that reflect the patient's anxiety or attempts to control it. It affects between 2-3% of the population and ismuch more common than was previously thought.
  • Stress disorders. These include post-traumatic stress disorder (PTSD) and acute stress disorder. Stress disorders are symptomatic reactions to traumatic events in the patient'slife.
  • Generalized anxiety disorder (GAD). GAD is the most commonly diagnosed anxiety disorder and occurs most frequently in young adults.
  • Anxiety disorders due to known physical causes. These include general medical conditions or substance abuse.
  • Anxiety disorder not otherwise specified. This last category is not a separate type of disorder, but is includedto cover symptoms that do not meet the specific DSM-IV criteria for other anxiety disorders.

DSM-IV defines one anxiety disorder as specific to children, namely, separation anxiety disorder. This disorder is defined as anxiety regarding separation from home or family that is excessive or inappropriate for the child's age. In some children, separation anxiety takes the form of school avoidance. Children and adolescents can also be diagnosed with panic disorder, phobias, generalized anxiety disorder, and the post- traumatic stress syndromes.

The causes of anxiety include a variety of individual and general social factors, and may produce physical, cognitive, emotional, or behavioral symptoms.The patient's ethnic or cultural background may also influence his or her vulnerability to certain forms of anxiety. Genetic factors that lead to biochemical abnormalities may also play a role. Anxiety in children may be caused bysuffering from abuse, as well as by the factors that cause anxiety in adults.

The diagnosis of anxiety disorders is complicated by the variety of causes ofanxiety and the range of disorders that may include anxiety as a symptom. Many patients who suffer from anxiety disorders have features or symptoms of more than one disorder. Patients whose anxiety is accounted for by another psychic disorder, such as schizophrenia or major depression, are not diagnosed with an anxiety disorder. A doctor examining an anxious patient will usually begin by ruling out diseases that are known to cause anxiety and then proceed to take the patient's medication history, in order to exclude side effects ofprescription drugs. Most doctors will ask about caffeine consumption to see if the patient's dietary habits are a factor. The patient's work and family situation will also be discussed. Laboratory tests for blood sugar and thyroidfunction are also common.

There are no laboratory tests that can diagnose anxiety, although the doctormay order some specific tests to rule out disease conditions. Although thereis no psychiatric test that can provide definite diagnoses of anxiety disorders, there are several short-answer interviews or symptom inventories that doctors can use to evaluate the intensity of a patient's anxiety and some of itsassociated features. These measures include the Hamilton Anxiety Scale and the Anxiety Disorders Interview Schedule (ADIS).

For relatively mild anxiety disorders, psychotherapy alone may suffice. In general, doctors prefer to use a combination of medications and psychotherapy with more severely anxious patients. Most patients respond better to a combination of treatment methods than to either medications or psychotherapy in isolation. In many cases the doctor will need to try a new medication or treatment over a six- to eight-week period in order to assess its effectiveness.

Although anxiety disorders are not always easy to diagnose, there are severalreasons why it is important for patients with severe anxiety symptoms to gethelp. Anxiety doesn't always go away by itself; it often progresses to panicattacks, phobias, and episodes of depression. Untreated anxiety disorders may eventually lead to a diagnosis of major depression, or interfere with the patient's education or ability to keep a job. In addition, many anxious patients develop addictions to drugs or alcohol when they try to "medicate" their symptoms. Moreover, since children learn ways of coping with anxiety from their parents, adults who get help for anxiety disorders are in a better positionto help their families cope with factors that lead to anxiety than those whoremain untreated.

Alternative treatments for anxiety cover a variety of approaches. Meditationand mindfulness training are thought beneficial to patients with phobias andpanic disorder. Hydrotherapy is useful to some anxious patients because it promotes general relaxation of the nervous system. Yoga, aikido, tai chi, and dance therapy help patients work with the physical, as well as the emotional,tensions that either promote anxiety or are created by the anxiety.

The prognosis for recovery depends on the specific disorder, the severity ofthe patient's symptoms, the specific causes of the anxiety, and the patient'sdegree of control over these causes. Anxiety is an unavoidable feature of human existence. However, humans do have some power over their reactions to anxiety-provoking events and situations. Cognitive therapy and meditation or mindfulness training appear to be beneficial in helping people lower their long-term anxiety levels.

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