ANXIETY DISORDERS

Anxiety is a normal reaction to stress and can be beneficial in some situations. It can alert us to
dangers and help us prepare and pay attention. Anxiety disorders differ from normal feelings of
nervousness or anxiousness, and involve excessive fear or anxiety. Anxiety disorders are the
most common of mental disorders and affect nearly 30% of adults at some point in their lives.
But anxiety disorders are treatable and a number of effective treatments are available. Treatment
helps most people lead normal productive lives. Anxiety refers to anticipation of a future concern
and is more associated with muscle tension and avoidance behavior. Anxiety disorders can cause
people to try to avoid situations that trigger or worsen their symptoms. Job performance, school
work and personal relationships can be affected. In general, for a person to be diagnosed with an
anxiety disorder, the fear or anxiety must:1.Be out of proportion to the situation or age
inappropriate 2.Hinder ability to function normally

Changes to Anxiety Disorders in DSM V

1. Place obsessive-compulsive disorder and PTSD into separate categories

2. In keeping with the life-span, developmental approach two disorders, which were
formerly classified as childhood disorders, are now part of the anxiety disorders group.
These are separation anxiety and selective mutism. Both children and adults may receive
these diagnoses.

3. Agoraphobia and Panic Disorder have been decoupled and now form two distinct
disorders.

4. Additionally, a panic attack specifier is now applicable to any diagnostic category: e.g.,
depressive disorder with panic attacks, PTDS with panic attacks.

ANXIETY DISORDER SYMPTOMS The main symptom of anxiety disorders is excessive

fear or worry. Anxiety disorders can also make it hard to breathe, sleep, stay still, and
concentrate. Your specific symptoms depend on the type of anxiety disorder you have. Common
symptoms are:

 Panic, fear, and uneasiness

  Feelings of panic, doom, or danger

 Sleep problems

 Not being able to stay calm and still

 Cold, sweaty, numb, or tingling hands or feet

 Shortness of breath

 Breathing faster and more quickly than normal (hyperventilation)

 Heart palpitations

 Dry mouth

 Nausea

 Tense muscles

 Dizziness

 Thinking about a problem over and over again and unable to stop (rumination)

 Inability to concentrate

 Intensely or obsessively avoiding feared objects or places

TYPES OF ANXIETY DISORDERS Based on the current DSM-5 following 9 mental

disorders under anxiety category:

1. Generalized Anxiety DisorderGeneralized anxiety disorder involves persistent and

excessive worry that interferes with daily activities. This ongoing worry and tension may
be accompanied by physical symptoms, such as restlessness, feeling on edge or easily
fatigued, difficulty concentrating, muscle tension or problems sleeping. Often the worries
focus on everyday things such as job responsibilities, family health or minor matters such
as chores, car repairs, or appointments. Generalized anxiety disorder (GAD) is a common
disorder, characterized by long-lasting anxiety which is not focused on any one object or
situation. Those suffering from generalized anxiety disorder experience non-specific
 persistent fear and worry, and become overly concerned with everyday matters.
DIAGNOSIS: Generalized anxiety disorder is "characterized by chronic excessive worry
accompanied by three or more of the following symptoms: restlessness, fatigue,
concentration problems, irritability, muscle tension, and sleep disturbance (In children,
only one of these symptoms is necessary for a diagnosis of GAD)".Generalized anxiety
disorder is the most common anxiety disorder to affect older adults. In children GAD
may be associated with headaches, restlessness, abdominal pain, and heart palpitations.
Typically it begins around 8 to 9 years of age.
2. Panic DisorderThe individual experiences recurrent unexpected panic attacks and is
persistently concerned or worried about having more panic attacks or changes his or her
behavior in maladaptive ways because of the panic attacks (e.g. avoidance of exercise or
of unfamiliar locations). Panic attacks are abrupt surges of intense fear or intense
discomfort that reach a peak within minutes, accompanied by physical and/or cognitive
symptoms. The core symptom of panic disorder is recurrent panic attacks, an
overwhelming combination of physical and psychological distress. DIAGNOSIS: DSM-
5 criteria for panic disorder include the experiencing of recurrent panic attacks, with 1 or
more attacks followed by at least 1 month of fear of another panic attack or significant
maladaptive behavior related to the attacks. A panic attack is an abrupt period of intense
fear or discomfort accompanied by 4 or more of the following 13 systemic symptoms:

 Palpitations, pounding heart or rapid heart rate

 Sweating

 Trembling or shaking

 Feeling of shortness of breath or smothering sensations

 Chest pain

 Feeling dizzy, light-headed or faint

 Feeling of choking

 Numbness or tingling
  Chills or hot flashes

 Nausea or abdominal pains

 Feeling detached

 Fear of losing control

 Fear of dying

Because symptoms are so severe, many people who experience a panic attack may believe they
are having a heart attack or other life-threatening illness and may go to a hospital ER. Panic
attacks may be expected, such as a response to a feared object, or unexpected, apparently
occurring for no reason. The mean age for onset of panic disorder is 22-23. Panic attacks may
occur with other mental disorders such as depression or PTSD. They commonly report a sudden
unexpected and spontaneous onset of fear or discomfort, typically reaching a peak within 10
minute

3. Specific PhobiaA specific phobia is excessive and persistent fear of a specific object,
situation or activity that is generally not harmful. Patients know their fear is excessive,
but they can’t overcome it. These fears cause such distress that some people go to
extreme lengths to avoid what they fear. Examples are fear of flying or fear of spiders.
Individuals with specific phobia are fearful or anxious about or avoidant of circumscribed
objects or situations. A specific cognitive ideation is not featured in this disorder, as it is
in other anxiety disorders. The fear, anxiety, or avoidance is almost always immediately
induced by the phobic situation, to the degree that is persistent an out of proportion to the
actual risk posed. There are various types of specific phobias: animal, natural
environment, blood-injection-injury, situational, and other situations. DIAGNOSIS: In
children and adults, the duration of symptoms must last for at least six months. Specific
phobias can first appear in childhood, usually by age 10, but can occur later in life.

Types of specific phobias

1. Natural/environment type: These are phobias of nature, weather, and environmental events or
situations. These can include the fear of thunder and lightning (astraphobia) or water
(aquaphobia).
2. Injury type: This type of fear is related to a fear of physical harm or injury. These include a
fear of the dentist (dentophobia) or injections (trypanophobia).
3. Animal type: These fears are centered on animals or insects. This can include the fear of dogs
(cynophobia), snakes (ophidiophobia), and insects (entomophobia).
4. Situational type: This type of phobia centers on fears triggered by specific situations. These
include the fear of washing (ablutophobia) and enclosed spaces (claustrophobia).
5. Other types: Fears that don't fit into the other four types are included in this category. This
can include things such as a fear of dolls, vomiting, or loud sounds.

4. AgoraphobiaAgoraphobia is the fear of being in situations where escape may be difficult

or embarrassing, or help might not be available in the event of panic symptoms. The fear
is out of proportion to the actual situation and lasts generally six months or more and
causes problems in functioning. Individuals with agoraphobia are fearful and anxious
about two or more of the following situations:

 Using public transportation

 Being in open spaces

 Being in enclosed places

 Standing in line or being in a crowd

 Being outside the home alone

A person with agoraphobia experiences this fear in two or more of the above situations. The
individual actively avoids the situation, requires a companion or endures with intense fear or
anxiety. Untreated agoraphobia can become so serious that a person may be unable to leave the
house. A person can only be diagnosed with agoraphobia if the fear is intensely upsetting, or if it
significantly interferes with normal daily activities.
 5. Social Anxiety Disorder (previously called social phobia)A person with social anxiety
disorder has significant anxiety and discomfort about being embarrassed, humiliated,
rejected or looked down on in social interactions. People with this disorder will try to
avoid the situation or endure it with great anxiety. Common examples are extreme fear of
public speaking, meeting new people or eating/drinking in public. The fear or anxiety
causes problems with daily functioning and lasts at least six months. The individual is
fearful or anxious about or avoidant of social interactions and situations that involve the
possibility of being scrutinized. These include social interactions such as meeting
unfamiliar people, situations in which the individual may be observed eating or drinking,
and situations in which the individual performs in front of others. The cognitive ideation
is being negatively evaluated by others, by being embarrassed, humiliated, or rejected, or
offending others.

Onset: Symptoms of this disorder may start around the age of 13.

Diagnosis: The fear, anxiety, or avoidance is persistent, lasting at least 4 weeks in children and
adolescents and typically 6 months or more in adults

It might be cause due to bullying

 family conflict
 humiliation
 sexual abuse

6. Separation Anxiety Disorder A person with separation anxiety disorder is excessively

fearful or anxious about separation from those with whom he or she is attached. The
feeling is beyond what is appropriate for the person’s age, persists (at least four weeks in
children and six months in adults) and causes problems functioning. A person with
separation anxiety disorder may be persistently worried about losing the person closest
to him or her, may be reluctant or refuse to go out or sleep away from home or without
that person, or may experience nightmares about separation. Physical symptoms of
distress often develop in childhood, but symptoms can carry though adulthood.Separation
 anxiety is a normal stage of development for infants and toddlers. Young children often
experience a period of separation anxiety, but most children outgrow separation anxiety
by about 3 years of age. Symptoms of Separation and Anxiety Disorder

 Unusual distress at the discussion or experience of being parted from their attachment
figure.
 Excessive fears that harm will befall their attachment person.
 Persistent worry of an unexpected event that could lead to separation from the attachment
figure.
 Refusal to leave the attachment figure.
 Excessive fear of being alone.
 Nightmares about separation.
 Anxiety about sleeping and being separated from the attachment figure.
 Physical complaints when separation is immanent.

7. Selective Mutism Is characterized by a consistent failure to speak in social situations in

which there is an expectation to speak (e.g. school) even though the individual speaks in
other situations. The failure to speak has significant consequences on achievement in
academic or occupational settings or otherwise interferes with normal social
communication.
8. Substance/Medication-Induced Anxiety Disorder This disorder involves anxiety due to
substance intoxication or withdrawal or to a medication treatment.
9. Anxiety Disorder Due to Another Medical Condition Anxiety symptoms are the
physiological consequence of another medical condition: Examples:

a) Endocrine disease: hyperthyroidism, hypoglycemia, hyperadrenalcorticolism.

b) Cardiovascular disorders: congestive heart failure, arrhythmia, pulmonary
embolism.
c) Respiratory illness: asthma, pneumonia.
d) Metabolic disturbances: B12 df, porphyria
e) Neurological illnesses: neoplasms, encephalitis, seizure disorder.
CAUSES OF ANXIETY DISORDERS

Some causes of anxiety disorders are:

1. Genetics. Anxiety disorders can run in families.

2. Brain chemistry. Some research suggests anxiety disorders may be linked to faulty
circuits in the brain that control fear and emotions.
3. Environmental stress. This refers to stressful events you have seen or lived through.
Life events often linked to anxiety disorders include childhood abuse and neglect, a death
of a loved one, or being attacked or seeing violence.
4. Drug withdrawal or misuse. Certain drugs may be used to hide or decrease certain
anxiety symptoms. Anxiety disorder often goes hand in hand with alcohol and substance
use.
5. Medical conditions. Some heart, lung, and thyroid conditions can cause symptoms
similar to anxiety disorders or make anxiety symptoms worse. It’s important to get a full
physical exam to rule out other medical conditions when talking to your doctor about
anxiety.

RISK FACTORS FOR ANXIETY DISORDER Some things also make you more likely to
develop an anxiety disorder. These are called risk factors. Some risk factors you can’t change,
but others you can. Risk factors for anxiety disorders include:

1. History of mental health disorder. Having another mental health disorder, like
depression, raises your risk for anxiety disorder.
2. Childhood sexual abuse. Emotional, physical, and sexual abuse or neglect during
childhood is linked to anxiety disorders later in life.
3. Trauma. Living through a traumatic event increases the risk of posttraumatic stress
disorder (PTSD), which can cause panic attacks.
4. Negative life events. Stressful or negative life events, like losing a parent in early
childhood, increase your risk for anxiety disorder.
 5. Severe illness or chronic health condition. Constant worry about your health or the
health of a loved one, or caring for someone who is sick, can cause you to feel
overwhelmed and anxious.
6. Substance abuse. The use of alcohol and illegal drugs makes you more likely to get an
anxiety disorder. Some people also use these substances to hide or ease anxiety
symptoms.
7. Being shy as a child. Shyness and withdrawal from unfamiliar people and places during
childhood is linked to social anxiety in teens and adults.
8. Low self-esteem. Negative perceptions about yourself may lead to social anxiety
disorder.

DIFFERENTIAL DIAGNOSIS

1. Generalized anxiety disorder: Separation anxiety disorder is distinguished from

generalized anxiety disorder in that the anxiety predominantly concerns separation from
attachment figures, and if other worries occur, they do not predominate the clinical
picture.
2. Panic disorder: Threats of separation may lead to extreme anxiety and even a panic
attack. In separation anxiety disorder, in contrast to panic disorder, the anxiety concerns
the possibility of being away from attachment figures and worry about untoward events
befalling them, rather than being incapacitated by an unexpected panic attack.
3. Agoraphobia: Unlike individuals with agoraphobia, those with separation anxiety
disorder are not anxious about being trapped or incapacitated in situations from which
escape is perceived as difficult in the event of panic-like symptoms or other
incapacitating symptoms.
4. Conduct disorder: School avoidance (truancy) is common in conduct disorder, but
anxiety about separation is not responsible for school absences, and the child or
adolescent usually stays away from, rather than returns to, the home.
5. Social anxiety disorder: School refusal may be due to social anxiety disorder (social
phobia). In such instances, the school avoidance is due to fear of being judged negatively
by others rather than to worries about being separated from the attachment figures.
6. Posttraumatic stress disorder: Fear of separation from loved ones is common after
traumatic events, such as disasters, particularly when periods of separation from loved
ones were experienced during the traumatic event. In posttraumatic stress disorder
(PTSD), the central symptoms concern intrusions about, and avoidance of, memories
associated with the traumatic event itself, whereas in separation anxiety disorder, the
worries and avoidance concern the well-being of attachment figures and separation from
them.
7. Illness anxiety disorder: Individuals with illness anxiety disorder worry about specific
illnesses they may have, but the main concern is about the medical diagnosis itself, not
about being separated from attachment figures.
8. Bereavement: Intense yearning or longing for the deceased, intense sorrow and emotional
pain, and preoccupation with the deceased or the circumstances of the death are expected
responses occurring in bereavement, whereas fear of separation from other attachment
figures is central in separation anxiety disorder.
9. Depressive and bipolar disorders: These disorders may be associated with reluctance to
leave home, but the main concern is not worry or fear of untoward events befalling
attachment figures, but rather low motivation for engaging with the outside world.
However, individuals with separation anxiety disorder may become depressed while
being separated or in anticipation of separation.
10. Oppositional defiant disorder: Children and adolescents with separation anxiety
disorder may be oppositional in the context of being forced to separate from attachment
figures. Oppositional defiant disorder should be considered only when there is persistent
oppositional behavior unrelated to the anticipation or occurrence of separation from
attachment figures.
11. Psychotic disorders: Unlike the hallucinations in psychotic disorders, the unusual
perceptual experiences that may occur in separation anxiety disorder are usually based on
a misperception of an actual stimulus, occur only in certain situations (e.g., nighttime),
and are reversed by the presence of an attachment figure.
12. Personality disorders: Dependent personality disorder is characterized by an
indiscriminate tendency to rely on others, whereas separation anxiety disorder involves
concern about the proximity and safety of main attachment figures. Borderline
 personality disorder is characterized by fear of abandonment by loved ones, but problems
in identity, self-direction, interpersonal functioning, and impulsivity are additionally
central to that disorder, whereas they are not central to separation anxiety disorder.

COMORBIDITY In children, separation anxiety disorder is highly comorbid with generalized

anxiety disorder and specific phobia. In adults, common comorbidities include specific phobia,
PTSD, panic disorder, generalized anxiety disorder, social anxiety disorder, agoraphobia,
obsessive-compulsive disorder, and personality disorders. Depressive and bipolar disorders are
also comorbid with separation anxiety disorder in adults.

CHANGES TO ANXIETY DISORDERS. Aside from the removal of obsessive-compulsive

disorder and PTSD into separate categories (see above), not much has changed. In keeping with
the life-span, developmental approach (see newsletter #1), two disorders, which were formerly
classified as childhood disorders, are now part of the anxiety disorders group. These are
separation anxiety and selective mutism. Both children and adults may receive these diagnoses.
Agoraphobia and Panic Disorder have been decoupled and now form two distinct disorders.
Additionally, a panic attack specifier is now applicable to any diagnostic category: e.g.,
depressive disorder with panic attacks, PTDS with panic attacks.

ANXIETY DISORDER DIAGNOSIS If you have symptoms, your doctor will examine you
and ask questions about your medical history. She may run tests to rule out other health
conditions that might be causing your symptoms. No lab tests can specifically diagnose anxiety
disorders. If your doctor doesn’t find any physical reason for how you’re feeling, she may send
you to a psychiatrist, psychologist, or another mental health specialist. Those doctors will ask
you questions and use tools and testing to find out if you may have an anxiety disorder.Your
doctors will consider how long you’ve had symptoms and how intense they are when diagnosing
you. It’s important to let your doctors or counselors know if your anxiety makes it hard to enjoy
or complete everyday tasks at home, work, or school.

ANXIETY DISORDER TREATMENTS There are many treatments to reduce and manage
symptoms of anxiety disorder. Usually, people with anxiety disorder take medicine and go to
counseling. Treatments for anxiety disorder include:
1. Medication Several types of drugs are used to treat anxiety disorders. Talk to your doctor
or psychiatrist about the pros and cons of each medicine to decide which one is best for
you.

a) Antidepressants. Modern antidepressants (SSRIs and SNRIs) are typically the first drugs
prescribed to someone with an anxiety disorder. Examples of SSRIs are escitalopram
(Lexapro) and fluoxetine (Prozac). SNRIs include duloxetine (Cymbalta)and venlafaxine
(Effexor).
b) Bupropion. This is another type of antidepressant commonly used to treat chronic
anxiety. It works differently than SSRIs and SNRIs.
c) Other antidepressants. These include tricyclics and monoamine oxidase inhibitors
(MAOIs). They are less commonly used because side effects, like drops in blood
pressure, dry mouth, blurry vision, and urinary retention, can be unpleasant or unsafe for
some people.
d) Benzodiazepines. Your doctor may prescribe one of these drugs if you’re having
persistent panicky feelings or anxiety. They help lower anxiety. Examples are alprazolam
(Xanax) and clonazepam (Klonopin). They work quickly, but you can become dependent
on them. Usually, they’re meant to be an add-on to your anxiety disorder treatment and
you shouldn’t take them for a long time.
e) Beta-blockers. This type of high blood pressure drug can help you feel better if you’re
having physical symptoms of anxiety, such as a racing heart, trembling, or shaking. A
beta-blocker may help you relax during an acute anxiety attack.
f) Anticonvulsants. Used to prevent seizures in people with epilepsy, these drugs also can
relieve certain anxiety disorder symptoms.
g) Antipsychotics. Low doses of these drugs can be added to help make other treatments
work better.
h) Buspirone (BuSpar). This anti-anxiety drug is sometimes used to treat chronic anxiety.
You’ll need to take it for a few weeks before seeing full symptom relief.

2. Psychotherapy This is a type of counseling that helps you learn how your emotions
affect your behaviors. It’s sometimes called talk therapy. A trained mental health
 specialist listens and talks to you about your thoughts and feelings and suggests ways to
understand and manage them and your anxiety disorder.

a) Cognitive behavioral therapy (CBT): This common type of psychotherapy teaches you
how to turn negative, or panic-causing, thoughts and behaviors into positive ones. You’ll
learn ways to carefully approach and manage fearful or worrisome situations without
anxiety. Some places offer family CBT sessions.

MANAGING ANXIETY DISORDER SYMPTOMS These tips may help you control or
lessen your symptoms:

1. Learn about your disorder. The more you know, the better prepared you will be to
manage symptoms and roadblocks along the way. Don’t be afraid to ask your doctor any
questions you might have. Remember, you are a key part of your health care team.
2. Stick to your treatment plan. Suddenly stopping your meds can cause unpleasant side
effects and can even trigger anxiety symptoms.
3. Cut down on foods and drinks that have caffeine , such as coffee, tea, cola, energy
drinks, and chocolate. Caffeine is a mood-altering drug, and it may make symptoms of
anxiety disorders worse.
4. Don’t use alcohol and recreational street drugs. Substance abuse increases your risk of
anxiety disorders.
5. Eat right and exercise brisk aerobic exercises like jogging and biking help release brain
chemicals that cut stress and improve your mood.
6. Get better sleep. Sleep problems and anxiety disorder often go hand in hand. Make
getting good rest a priority. Follow a relaxing bedtime routine. Talk to your doctor if you
still have trouble sleeping.
7. Learn to relax. Stress management is an important part of your anxiety disorder
treatment plan. Things like meditation, or mindfulness, can help you unwind after a
stressful day and may make your treatment work better.
8. Keep a journal. Writing down your thoughts before the day is down may help you relax
so you’re not tossing and turning with anxious thoughts all night.
9. Manage your negative thoughts. Thinking positive thoughts instead of worrisome ones
can help reduce anxiety. This can be challenging if you have certain types of anxiety,
however. Cognitive behavioral therapy can teach you how to redirect your thoughts.
10. Get together with friends. Whether it’s in person, on the phone, or the computer, social
connections help people thrive and stay healthy. People who have a close group of
friends that support and chat with them have lower levels of social anxiety.
11. Seek support. Some people find it helpful and uplifting to talk to others who are
experiencing the same symptoms and emotions. Self-help or support groups let you share
your concerns and achievements with others who are or who have been there.
12. Ask your doctor or pharmacist before taking any over-the-counter meds or herbal
remedies. Many have chemicals that can make anxiety symptoms worse.