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Anxiety Disorders

Definition

The anxiety disorders are a group of mental disturbances characterized by anxiety as a central or core symptom. Although anxiety is a commonplace experience, not everyone who experiences it has an anxiety disorder. Anxiety is associated with a wide range of physical illnesses, medication side effects, and other psychiatric disorders.

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 outcome of 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 disorders rather than on theories about their origins.

Description

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, and family life. They also contribute to the high rates of alcohol and substance abuse in the United States. Anxiety disorders are an additional problem for health professionals because the physical symptoms of anxiety frequently bring people to primary care doctors or emergency rooms.

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

  • Panic disorders with or without agoraphobia. The chief characteristic of panic disorder is the occurrence of panic attacks coupled with fear of their recurrence. In clinical settings, agoraphobia is usually not a disorder by itself, but is typically associated with some form of panic disorder. Patients with agoraphobia are afraid of places or situations in which they might have a panic attack and be unable to leave or to find help. About 25% of patients with panic disorder develop obsessive-compulsive disorder (OCD).
  • Phobias. These include specific phobias and social phobia. A phobia is an intense irrational fear of a specific object or situation that compels the patient to avoid it. Some phobias 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. It manifests itself as a fear of performing certain functions in the presence of others, 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 is much 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's life.
  • 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 included to cover symptoms that do not meet the specific DSM-IV criteria for other anxiety disorders.

All DSM-IV anxiety disorder diagnoses include a criterion of severity. The anxiety must be severe enough to interfere significantly with the patient's occupational or educational functioning, social activities or close relationships, and other customary activities.

The anxiety disorders vary widely in their frequency of occurrence in the general population, age of onset, family patterns, and gender distribution. The stress disorders and anxiety disorders caused by medical conditions or substance abuse are less age-and gender-specific. Whereas OCD affects males and females equally, GAD, panic disorder, and specific phobias all affect women more frequently than men. GAD and panic disorders are more likely to develop in young adults, while phobias and OCD can begin in childhood.

Anxiety disorders in children and adolescents

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.

Causes and symptoms

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 by suffering from abuse, as well as by the factors that cause anxiety in adults.

Diagnosis

The diagnosis of anxiety disorders is complicated by the variety of causes of anxiety 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 of prescription 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 thyroid function are also common

Diagnostic testing for anxiety

There are no laboratory tests that can diagnose anxiety, although the doctor may order some specific tests to rule out disease conditions. Although there is 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 its associated features. These measures include the Hamilton Anxiety Scale and the Anxiety Disorders Interview Schedule (ADIS).

Treatment

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. Because of the variety of medications and treatment approaches that are used to treat anxiety disorders, the doctor cannot predict in advance which combination will be most helpful to a specific patient. 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. Treatment trials do not necessarily mean that the patient cannot be helped or that the doctor is incompetent.

Although anxiety disorders are not always easy to diagnose, there are several reasons why it is important for patients with severe anxiety symptoms to get help. Anxiety doesn't always go away by itself; it often progresses to panic attacks, 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 position to help their families cope with factors that lead to anxiety than those who remain untreated.

Alternative treatment

Alternative treatments for anxiety cover a variety of approaches. Meditation and mindfulness training are thought beneficial to patients with phobias and panic disorder. Hydrotherapy is useful to some anxious patients because it promotes general relaxation of the nervous system. Yoga, aikido, t'ai 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.

Homeopathy and traditional Chinese medicine approach anxiety as a symptom of a systemic disorder. Homeopathic practitioners select a remedy based on other associated symptoms and the patient's general constitution. Chinese medicine regards anxiety as a blockage of qi,or vital force, inside the patient's body that is most likely to affect the lung and large intestine meridian flow. The practitioner of Chinese medicine chooses acupuncture point locations and/or herbal therapy to move the qi and rebalance the entire system in relation to the lung and large intestine.

Aromatherapy using essential oils can also be beneficial in treating patients with anxiety. The oils go directly to the brain via the olfactory nerve (which controls smell) and can have direct affect on calming the nervous system.

Prognosis

The prognosis for recovery depends on the specific disorder, the severity of the patient's symptoms, the specific causes of the anxiety, and the patient's degree of control over these causes.

Prevention

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.

BOOKS

"Anxiety Disorders." In Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: The American Psychiatric Association, 1994.

Clark, R. Barkley. "Psychosocial Aspects of Pediatrics & Psychiatric Disorders." In Current Pediatric Diagnosis & Treatment, ed. William W. Hay Jr., et al. Stamford: Appleton & Lange, 1997.

Corbman, Gene R. "Anxiety Disorders." In Current Diagnosis. Vol. 9. Ed. Rex B. Conn, et al. Philadelphia: W. B. Saunders Co., 1997.

Doctor, Ronald M., and Ada P. Kahn. The Encyclopedia of Phobias, Fears, and Anxieties. New York: Facts On File, 1989.

Gaylin, Willard. Feelings: Our Vital Signs. New York: Ballantine Books, 1979.

Nemiah, John C. "Psychoneurotic Disorders." In The New Harvard Guide to Psychiatry, ed. Armand M. Nicholi Jr. Cambridge, MA: The Belknap Press of Harvard University Press, 1988.

"Psychiatric Disorders: Anxiety Neurosis." In The Merck Manual of Diagnosis and Therapy. 16th ed. Ed. Robert Berkow. Rahway, NJ: Merck Research Laboratories, 1992.

Rebecca J. FreyM

KEY TERMS


Agoraphobia—Abnormal anxiety regarding public places or situations from which the patient may wish to flee or in which he or she would be helpless in the event of a panic attack.

Compulsion—A repetitive or ritualistic behavior that a person performs to reduce anxiety. Compulsions often develop as a way of controlling or "undoing" obsessive thoughts.

Obsession—A repetitive or persistent thought, idea, or impulse that is perceived as inappropriate and distressing.

Panic attack—A time-limited period of intense fear accompanied by physical and cognitive symptoms. Panic attacks may be unexpected or triggered by specific cues.

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