8.

1 Nature of anxiety disorders

When a situation is identified as being a threat, the automatic response is arousal

that leads to the action. When action is not possible then the physiological action that
would have facilitated the action is experienced as symptom. The symptoms may be as
following:
• Increased circulation (experienced as palpitation), with shift of blood from
gut to muscle (experienced as dry mouth, nausea, abdominal distress)
• Increased respiratory drive (experienced as difficulty in breathing/
hyperventilation)
• Increased muscle tension (experienced as trembling, shaking, pain)
• Narrowing of attention

There are several types of anxiety disorders. But the symptoms will include
cognitive, physiological and behavioural dimensions, as discussed above. The cognitive
symptoms are mainly thoughts about impending danger. The physiological symptoms
may include increased heart rate, palpitations, and breathlessness, etc. while the
behavioural symptoms are always about escaping or fleeing away from the anxiety
provoking situation.

The symptoms may vary but all of them are associated with some perceived threat
and, avoidance of the threatening situation or some kind of voluntary actions which will
bring down the anxiety levels. The person is aware that the anxiety-related thoughts are
his or her own, and unpleasant or distressful in nature (This point is crucial to
differentiate anxiety disorder from psychosis). In severe form, anxiety disorders will
interfere with daily functioning.

8.2 Causes of Anxiety Disorders:

There are several causes identified with anxiety disorders. They could be broadly
divided into those related to biological and psychological factors.

8.2.1 Biological Factors: The biological factors implied in the etiology of anxiety
disorders are: structural and functional abnormalities of nervous system,
neurotransmitters, and genetics.

Nervous system: Several brain imaging studies have indicated that cerebral asymmetry
and specific structural changes, particularly involving the right hemisphere was
commonly seen in patients with anxiety. Though gross abnormalities are not detected,
some patients with anxiety may demonstrate some functional cerebral pathological
symptoms.
The autonomous nervous system is given lot of importance as the symptoms mimic the
activation of sympathetic nervous system such as cardiovascular (e.g. increased heart
beat), muscular (e.g. headache), gastrointestinal (e.g. abdominal discomfort) and
respiratory (e.g. breathlessness). These symptoms of anxiety may or may not be related to
the subjective perceptions of anxiety. But it is widely believed that the autonomic
nervous system is important in generating anxiety-like symptoms.

Neurotransmitters: Based on the animal studies and response to drug treatments in

humans, it is hypothesized that depletion of norepinephrin, serotonin and GABA are
correlated to the symptoms of anxiety. Out of these three, GABA has a strong support for
its involvement. That is the reason, the limbic system, which s rich in GABA and also
receives the seratonergic innervations, is implied in the modulation of anxiety. Further
evidence comes from the fact that ablation and stimulation of limbic system produced
anxiety responses.

Genetic studies: Though specific genes are not identified, it is widely believed that
genetic factors are involved in the occurrence of anxiety disorders. As most of the
patients with anxiety disorders have a family history for these disorders, with association
being strong for panic disorders.

8.2.2 Psychological Factors: The psychological theories could be broadly classified in to

psychoanalytical, behavioural and existential theories.

Psychoanalytical theory, for that matter, most of the psychodynamic theories indicate that
anxiety is a signal of the presence of danger in unconscious. Anxiety was viewed as the
conflict between unconscious sexual or aggressive wishes and the corresponding threats
from external threats or superego.

The behavioural theories, based on learning theories, postulate that anxiety is a

conditioned response to some environmental stimuli. And the related avoidance
behaviours are due to negative reinforcement. Behavioural theories have clubbed
cognitive theories to provide a holistic view of anxiety. Accordingly, it is viewed that it
is not the actual event that triggers anxiety but the way we evaluate or perceive the event.
In other words, our cognitions mediate our responses. It has been generally observed that
patients with anxiety disorders tend to overestimate the degree of danger and the
probability of harm in the given situation and led to underestimate their abilities to cope
with the situation. Patients with anxiety disorders usually have such thoughts of loss of
control following some inexplicable physiological symptoms but precede and accompany
panic attacks.

Existential theories: They view that anxiety is result of our awareness to our profound
nothingness. In other words, anxiety is a response of the individual to the vast void in
existence and meaning.

8.3 Types of anxiety disorders

The Diagnostic and Statistical Manual for Mental Disorders, 4th edition (DSM-IV;
American Psychiatric Association, 1994) and the International Classification of Diseases,
10th version (ICD-10; World Health Organization, 1992) identify several anxiety
disorders. Following is the list of anxiety disorders as per both the systems:
DSM-IV
Panic disorder with and without agoraphobia
Agoraphobia with or without panic disorder
Specific and social phobias
Obsessive-compulsive disorder
Posttraumatic stress disorder
Acute stress disorder
Generalized anxiety disorder
Mixed anxiety and depressive disorders
Anxiety disorder due to general medical
conditions
Anxiety disorders not otherwise specified
ICD-10
Agoraphobia without panic disorder
Agoraphobia with panic disorder
Phobic anxiety disorders
Obsessive-compulsive disorder
Panic disorder
Acute stress reaction
Post-traumatic stress disorder
Generalized anxiety disorder
Adjustment disorders

It could be seen that both DSM-IV and ICD-10 more or less have the same list of anxiety
disorders.

Panic disorders

Panic attack is defined as a ‘discrete period of intense fear or discomfort’,

accompanied at least by four somatic or cognitive symptoms such as palpitations,
trembling, shortness of breath, sweating, and feelings of choking, among others. It
is characterized by spontaneous, unexpected occurrence of panic attacks, which
can vary from several attacks in a day to only few attacks during a year. Panic
disorder is usually accompanied by agoraphobia, the fear being alone in public
places. While panic disorders are extremely distressful, agoraphobia limits the
social functioning of the individual.

As discussed above, Agoraphobia can occur without panic disorder. Agoraphobia

without panic disorder is based on the fear of sudden incapacitating and
embarrassing symptom. Patients with agoraphobia rigidly avoid situations in
which it would be difficult to obtain help. They prefer to be accompanied by some
acquaintance in bys streets, crowded place, closed-in spaces and closed-in
vehicles.

Specific phobia and social phobia

Phobia is defined as an irrational, exaggerated fear that produces a conscious

avoidance of the feared subject. Either the presence or the anticipation of the
phobic stimulus elicits severe distress in the affected person. But the affected
person is ware that their reaction is exaggerated.

Phobias are two types- specific and social. Specific phobias are more common
than the social phobia. Specific phobias are related to either an object or situation
e.g. animals, heights, illness, injury, and death, etc. Social phobia are related to
 the social context such as meeting people, public address etc. Social phobias are
about the fear of being an intense scrutiny in social situations.
4.3. Obsessive compulsive disorder

Obsession is a recurrent and intrusive thought, feeling, idea, or sensation. A

compulsion is a conscious, standardized, recurring pattern of behaviour, such as
washing, counting, checking, or avoiding. The person feels driven to perform
compulsive acts in order to manage the anxiety aroused due to obsessions.
Obsessions increase anxiety, whereas compulsions decrease the anxiety. Majority
experience both obsessions and compulsions while few experience only either of
the two. However, both obsessions and compulsions are viewed unpleasant by the
individual. In most cases, they are disabling, time-consuming, and interfering with
daily functioning.

Generalized anxiety disorder

It refers to a general, vague worry and anxiety about several situations in life. In
this disorder anxiety and worry are about various events and activities, lasting for
more days for a minimum period of six months. This disorder may or may not be
accompanied by depression.

Posttraumatic Stress Disorder

This disorder develops after a person is involved in, or sees or hears of an extreme
traumatic stressor. The stressor could be any of the following: natural or man-
made disasters, combat , serious accident, witnessing the violent death of others;
being the victim of torture, terrorism, assault, abuse, rape, or other crime. Typical
reactions to such stressors will include, reliving the experience, avoidance of
reminders of trauma, hyperarousal and emotional numbing.

8.4 Psychological management

There are several psychological management therapies to manage anxiety but the
behavioral and cognitive therapies are very useful. They have been found to produce
long-lasting remission of symptoms. It is also informed that even if a real time anxiety
attack occurs, it is going to be time limited. Similarly, behavioural techniques would
focus on enhancing adaptive behaviours (e.g. controlling avoidance behaviours, intrusive
thoughts, maintaining productive life, etc.). Some of the basic techniques are as follows:

Cognitive Therapies
Cognitive therapy works on the premise that patient’s false beliefs and knowledge about
the anxiety attack perpetuate the problem. Based on this, appropriate instructions are
given not to read ordinary bodily sensations as impending doom. Specific techniques are
as follows:
Cognitive reappraisal: Since anxiety symptoms correspond with the threat appraisal than
the actual threat itself, this technique helps the individual to relook at the threat, and
change the faulty thinking and beliefs related to the threat.

Thought stopping: In any of the anxiety disorder, particularly the obsessive compulsive
disorders, intrusive thoughts are stopped with the help of cues. Sometimes distraction
techniques are used to divert the attention off the anxiety provoking events.

Invitro graded exposure/ Implosive therapy: All the anxiety disorders involve avoidance
of anxiety provoking stimulus, which in turn reinforces avoidance behaviours and
interferes with daily functioning. Therefore, to reduce anxiety the persons should be
taught to tolerate anxiety and avoid indulging in compulsive rituals. Accordingly,
depending the patient’s tolerance level, the persons it exposed to anxiety provoking
stimulus either in graded fashion (i.e. graded exposure) or as a whole (i.e. implosive
therapy) though mental imagery.

Behavioral Therapies: This would include various activities that counter anxiety
responses, based on the principle of classical conditioning and operant conditioning.

Relaxation: Patients will be taught to feel relaxed at will, even in the face of a threatening
situation. For this both behavioural and cognitive techniques could be used. Jacobson’s
Progressive Muscular Relaxation is a behavioural technique. Sometimes, biofeedback
apparatus are used to aid relaxation.

Systematic Desensitization: It is based on the principle of Reciprocal Inhibition. That is,

two antagonistic responses do not occur simultaneously. Anxiety and relaxation, two
antagonistic emotions, do not occur together. A person in relaxed state is gradually
exposed to anxiety provoking stimuli so that person learns to overcome the fear of that
stimuli.

In vivo exposure: In this method, the patient is exposed to the feared stimulus gradually
so that he/she gets desensitized. The feared stimulus could be both internal as well as
external. For example, if a person is scared of spiders, he/she will be exposed various,
graded stimuli ranging from watching pictures of spiders, watching a real spider from a
distance and to watching a spider from very close distance, etc. But the number of
exposure will vary from person to person.

Respiratory training: Hyperventilation is associated with panic attacks, and is probably

related to some symptoms such as dizziness and faintness. Breathing exercises are taught
to regularize breathing rate so that autonomic symptoms (e.g. giddiness, increased heart
beat, palpitations, etc.) are brought under control. In panic disorder, breathing into a
paper bag is used specifically to optimize carbon dioxide levels in the lungs, which is
necessary for keeping physiological arousal under control.

Other Therapies: There is also considerable support for the efficacy of insight oriented
therapy, dynamic therapy, which look into the unconscious impulses etc. even sometime,
support therapy will help the individual to function adequately when the therapist is non-
judgmental and accepting. Support therapy may or may not reduce the symptoms, but it
will help the individual to lead life even in presence of anxiety.

Apart from the above, family therapy is very important as the family functioning
might get affected by the individual’s disorder. The therapy primarily aims to education
about the nature and management of the illness and support to the family. Family
members are also taught not to reinforce maladaptive behaviours of the individual (for
example, allowing the individual to carry out compulsive rituals or allowing the person to
avoid anxiety-proving situations, etc.). Among all the psychological therapies, cognitive-
behavioural techniques are highly used. Research studies indicate that in fact the effect of
behaviour therapy is long lasting than the pharmacotherapy.