Anxiety disorder
Encyclopedia
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. 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 symptom
s, and suggest the need for a formal diagnostic assessment of anxiety disorder.
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).
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.
(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.
s (distressing, persistent, and intrusive thoughts or images) and compulsions
(urges to perform specific acts or rituals). It affects roughly around 3% of the population worldwide. The OCD thought pattern may be likened to superstitions insofar as it involves a belief in a causative relationship where, in reality, one does not exist. Often the process is entirely illogical; for example, the compulsion of walking in a certain pattern may be employed to alleviate the obsession of impending harm. And in many cases, the compulsion is entirely inexplicable, simply an urge to complete a ritual
triggered by nervousness.
In a slight minority of cases, sufferers of OCD may only experience obsessions, with no overt compulsions; a much smaller number of sufferers experience only compulsions.
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.
in babies or children, and it is only when this feeling is excessive or inappropriate that it can be considered a disorder. 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.
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.
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. 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.
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. 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. 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.
, a neurotransmitter that reduces activity in the central nervous system, contribute to anxiety. A number of anxiolytic
s 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. Caffeine
, alcohol
and benzodiazepine
dependence can worsen or cause anxiety and panic attacks. In one study in 1988–1990, 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.
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.
is central to the processing of fear and anxiety, and its function may be disrupted in anxiety disorders. 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.
. 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.
conditions, which can be present from an early age or begin suddenly after a trigger
ing event. They are prone to flare up at times of high stress
and are frequently accompanied by physiological symptoms such as headache
, sweating
, muscle spasms, palpitations, and hypertension
, which in some cases lead to fatigue
or even exhaustion.
In casual discourse the words "anxiety" and "fear" are often used interchangeably; in clinical usage, they have distinct meanings: "anxiety
" is defined as an unpleasant emotional state for which the cause is either not readily identified or perceived to be uncontrollable or unavoidable, whereas "fear" is an emotional and physiological response to a recognized external threat. The term "anxiety disorder" includes fears (phobias) as well as anxieties.
Anxiety disorders are often comorbid with other mental disorders, particularly clinical depression
, which may occur in as many as 60% of people with anxiety disorders. The fact that there is considerable overlap between symptoms of anxiety and depression, and that the same environmental triggers can provoke symptoms in either condition, may help to explain this high rate of comorbidity.
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.
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. 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.
As such it serves as a logical extension of cognitive therapy, whereby people are shown proof in the real world that their dysfunctional thought processes are unrealistic. A key element of this component is gradual exposure, in which the patient is confronted by the things they fear in a structured, sensitive manner. Gradual exposure is an inherently unpleasant technique; ideally it involves exposure to a feared social situation that is anxiety provoking but bearable, for as long as possible, two to three times a week. Often, a hierarchy of feared steps is constructed and the patient is exposed to each step sequentially.
The aim is to learn from acting differently and observing reactions. This is intended to be done with support and guidance, and when the therapist and patient feel they are ready. Cognitive-behavioral therapy for social phobia also includes anxiety management training, which may include techniques such as deep breathing and muscle relaxation exercises, which may be practiced 'in-situ'. CBT can also be conducted partly in group sessions
, facilitating the sharing of experiences, a sense of acceptance by others and undertaking behavioral challenges in a trusted environment (Heimberg).
Some studies have suggested social skills training can help with social anxiety. However, it is not clear whether specific social skills techniques and training are required, rather than just support with general social functioning and exposure to social situations.
Additionally, a recent study has suggested that interpersonal therapy, a form of psychotherapy primarily used to treat depression, may also be effective in the treatment of social phobia.
Extensive research supports the neural plasticity of the brain in reaction to stressful experiences. A treatment and prevention method called Adaptive Behavioral therapy is based on understanding the adaptations which occur in developmental years due to stressful experiences and the brain's ability to create new reactions to the same stressor. In this treatment a time gap between when information is received by the brain (stress trigger) and the decision for behavior is widened to allow a re-evaluation to occur as a stressful experience is taking place. This new time to reprocess information is referred to as a Pivotal Moment when new behavior can be consciously created. The development of new adaptive behavior is promoted through the use of interruption techniques and specific tools.
Treatment is structured around a self report notebook which is used to collect historic and current stress patterns of response. Treatment is guided by the therapist in a direct manner in sessions and experiences between sessions are used to provide new experimental behavior. Adaptive behavioral therapy is also used as a preventive treatment. Practice with smaller stressors creates familiarity with healthy adaptive responses for future use.
(Effexor) are also effective. Benzodiazepines are also sometimes indicated for short-term or PRN
use. They are usually considered as a second-line treatment due to disadvantages such as cognitive impairment and due to their risks of dependence
and withdrawal
problems. MAOIs such as phenelzine
(Nardil) and tranylcypromine
(Parnate) are considered an effective treatment and are especially useful in treament-resistant cases, however, dietary restrictions and medical interactions may limit their use. There is evidence that certain newer medications including the GABA analogue
pregabalin
(Lyrica) and the novel antidepressant mirtazapine
(Remeron) are effective treatments for anxiety disorders. TCAs
such as imipramine
, as well as atypical antipsychotics such as quetiapine
, and piperazines such as hydroxyzine
are occasionally prescribed.
These medications need to be used with extreme care among older adults, who are more likely to suffer side effects because of coexisting physical disorders. Adherence problems are more likely among elderly patients, who may have difficulty understanding, seeing, or remembering instructions.
s (SSRIs), a class of antidepressants, are considered by many to be the first choice medication for generalised social phobia. These drugs elevate the level of the neurotransmitter serotonin, among other effects. The first drug formally approved by the Food and Drug Administration
was paroxetine
, sold as Paxil in the U.S. or Seroxat in the UK. Compared to older forms of medication, there is less risk of tolerability and drug dependency. However, their efficacy
and increased suicide risk has been subject to controversy.
In a 1995 double-blind
, placebo
-controlled trial, the SSRI paroxetine was shown to result in clinically meaningful improvement in 55% of patients with generalized social anxiety disorder, compared with 23.9% of those taking placebo. An October 2004 study yielded similar results. Patients were treated with either fluoxetine
, psychotherapy, fluoxetine and psychotherapy, placebo and psychotherapy, or a placebo. The first four sets saw improvement in 50.8% to 54.2% of the patients. Of those assigned to receive only a placebo, 31.7% achieved a rating of 1 or 2 on the Clinical Global Impression-Improvement scale. Those who sought both therapy and medication did not see a boost in improvement.
General side-effects
are common during the first weeks while the body adjusts to the drug. Symptoms may include headache
s, nausea
, insomnia
and changes in sexual behavior. Treatment safety during pregnancy has not been established. In late 2004 much media attention was given to a proposed link between SSRI use and juvenile suicide
. For this reason, the use of SSRIs in pediatric cases of depression is now recognized by the Food and Drug Administration as warranting a cautionary statement to the parents of children who may be prescribed SSRIs by a family doctor. Recent studies have shown no increase in rates of suicide. These tests, however, represent those diagnosed with depression, not necessarily with social anxiety disorder. However, due to the nature of the conditions, those taking SSRIs for social phobias are far less likely to have suicidal ideation than those with depression.
In 1985, before the introduction of SSRIs, anti-depressants such as monoamine oxidase inhibitor
s (MAOIs) were frequently used in the treatment of social anxiety. Their efficacy appears to be comparable or sometimes superior to SSRIs or benzodiazepines. However, because of the dietary
restrictions required, high toxicity in overdose, and incompatibilities with other drugs, its usefulness as a treatment for social phobics is now limited. Some argue for their continued use, however, or that a special diet does not need to be strictly adhered to. A newer type of this medication, Reversible inhibitors of monoamine oxidase subtype A
(RIMAs) inhibit the MAO enzyme
only temporarily, improving the adverse-effect profile but possibly reducing their efficacy.
Benzodiazepine
s such as alprazolam
and clonazepam
are an alternative to SSRIs. These drugs are often used for short-term relief of severe, disabling anxiety. Although benzodiazepines are still sometimes prescribed for long-term everyday use in some countries, there is much concern over the development of drug tolerance, dependency and recreational abuse
. It has been recommended that benzodiazepines are only considered for individuals who fail to respond to safer medications. Benzodiazepines augment the action of GABA
, the major inhibitory neurotransmitter in the brain; effects usually begin to appear within minutes or hours.
The novel antidepressant mirtazapine
has been proven effective in treatment of social anxiety disorder. This is especially significant due to mirtazapine's fast onset and lack of many unpleasant side-effects associated with SSRIs (particularly, sexual dysfunction
).
In Japan
, the serotonin-norepinephrine reuptake inhibitor
(SNRI) Milnacipran is used in the treatment of Taijin kyofusho
a Japanese variant of social anxiety disorder.
Some people with a form of social phobia called performance phobia have been helped by beta-blockers, which are more commonly used to control high blood pressure. Taken in low doses, they control the physical manifestation of anxiety and can be taken before a public performance.
A novel treatment approach has recently been developed as a result of translational research. It has been shown that a combination of acute dosing of d-cycloserine (DCS) with exposure therapy facilitates the effects of exposure therapy of social phobia (Hofmann, Meuret, Smits, et al., 2006). DCS is an old antibiotic
medication used for treating tuberculosis and does not have any anxiolytic properties per se. However, it acts as an agonist at the glutamatergic N-methyl-D-aspartate (NMDA) receptor site, which is important for learning and memory (Hofmann, Pollack, & Otto, 2006). It has been shown that administering a small dose acutely 1 hour before exposure therapy can facilitate extinction learning that occurs during therapy.
Treatment controversy arises because while some studies indicate that a combination of medication and psychotherapy can be more effective than either one alone, others suggest pharmacological interventions are largely palliative, and can actually interfere with the mechanisms of successful therapy. Meta-analysis
indicates that psychotherapeutic interventions have better long-term efficacy compared to pharmacotherapy. However, the right treatment may very much depend on the individual patient's genetics and environmental factors.
and reducing caffeine 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. 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 wort and Sympathyl have also been used to treat anxiety, but with little scientific evidence as to their effectiveness.
Fear
Fear is a distressing negative sensation induced by a perceived threat. It is a basic survival mechanism occurring in response to a specific stimulus, such as pain or the threat of danger...
and anxiety
Anxiety
Anxiety is a psychological and physiological state characterized by somatic, emotional, cognitive, and behavioral components. The root meaning of the word anxiety is 'to vex or trouble'; in either presence or absence of psychological stress, anxiety can create feelings of fear, worry, uneasiness,...
. 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
Anxiety
Anxiety is a psychological and physiological state characterized by somatic, emotional, cognitive, and behavioral components. The root meaning of the word anxiety is 'to vex or trouble'; in either presence or absence of psychological stress, anxiety can create feelings of fear, worry, uneasiness,...
covers four aspects of experiences an individual may have: mental apprehension, physical tension, physical symptoms and dissociative anxiety. Anxiety disorder is divided into generalised anxiety disorder, phobic disorder, and panic disorder
Panic disorder
Panic disorder is an anxiety disorder characterized by recurring severe panic attacks. It may also include significant behavioral change lasting at least a month and of ongoing worry about the implications or concern about having other attacks. The latter are called anticipatory attacks...
; 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
Zung Self-Rating Anxiety Scale
The Zung Self-Rating Anxiety Scale was designed by William W. K. Zung, a psychiatrist from Duke University, to quantify a patient's level of anxiety....
can be used to detect anxiety symptom
Symptom
A symptom is a departure from normal function or feeling which is noticed by a patient, indicating the presence of disease or abnormality...
s, and suggest the need for a formal diagnostic assessment of anxiety disorder.
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 APAAmerican Psychiatric Association
The American Psychiatric Association is the main professional organization of psychiatrists and trainee psychiatrists in the United States, and the most influential worldwide. Its some 38,000 members are mainly American but some are international...
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
Hypervigilance
Hypervigilance is an enhanced state of sensory sensitivity accompanied by an exaggerated intensity of behaviors whose purpose is to detect threats. Hypervigilance is also accompanied by a state of increased anxiety which can cause exhaustion. Other symptoms include: abnormally increased arousal, a...
) 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
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.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. Agoraphobia is strongly linked with panic disorderPanic disorder
Panic disorder is an anxiety disorder characterized by recurring severe panic attacks. It may also include significant behavioral change lasting at least a month and of ongoing worry about the implications or concern about having other attacks. The latter are called anticipatory attacks...
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
Agoraphobia
Agoraphobia is an anxiety disorder defined as a morbid fear of having a panic attack or panic-like symptoms in a situation from which it is perceived to be difficult to escape. These situations can include, but are not limited to, wide-open spaces, crowds, or uncontrolled social conditions...
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 disorderSocial anxiety disorder
Social anxiety disorder , also known as social phobia, is an anxiety disorder characterized by intense fear in social situations causing considerable distress and impaired ability to function in at least some parts of daily life...
(SAD; also known as social phobia) describes an intense fear and avoidance of negative public scrutiny, public embarrassment, humiliation, or social interaction. This fear
Fear
Fear is a distressing negative sensation induced by a perceived threat. It is a basic survival mechanism occurring in response to a specific stimulus, such as pain or the threat of danger...
can be specific to particular social situations (such as public speaking) or, more typically, is experienced in most (or all) social interactions. Social anxiety
Social anxiety
Social anxiety is anxiety about social situations, interactions with others, and being evaluated or scrutinized by other people...
often manifests specific physical symptoms, including blushing, sweating, and difficulty speaking. Like with all phobic disorders, those suffering from social anxiety
Social anxiety
Social anxiety is anxiety about social situations, interactions with others, and being evaluated or scrutinized by other people...
often will attempt to avoid the source of their anxiety
Anxiety
Anxiety is a psychological and physiological state characterized by somatic, emotional, cognitive, and behavioral components. The root meaning of the word anxiety is 'to vex or trouble'; in either presence or absence of psychological stress, anxiety can create feelings of fear, worry, uneasiness,...
; in the case of social anxiety
Social anxiety
Social anxiety is anxiety about social situations, interactions with others, and being evaluated or scrutinized by other people...
this is particularly problematic, and in severe cases can lead to complete social isolation.
Obsessive–compulsive disorder
Obsessive–compulsive disorder (OCD) is a type of anxiety disorder primarily characterized by repetitive obsessionFixation (psychology)
Fixation: 'concept originated by Sigmund Freud to denote the persistence of anachronistic sexual traits'. Subsequently '"Fixation" acquired a broader connotation...
s (distressing, persistent, and intrusive thoughts or images) and compulsions
Compulsive behavior
Compulsive behavior is behavior which a person does compulsively—in other words, not because they want to behave that way, but because they feel they have to do so....
(urges to perform specific acts or rituals). It affects roughly around 3% of the population worldwide. The OCD thought pattern may be likened to superstitions insofar as it involves a belief in a causative relationship where, in reality, one does not exist. Often the process is entirely illogical; for example, the compulsion of walking in a certain pattern may be employed to alleviate the obsession of impending harm. And in many cases, the compulsion is entirely inexplicable, simply an urge to complete a ritual
Ritual
A ritual is a set of actions, performed mainly for their symbolic value. It may be prescribed by a religion or by the traditions of a community. The term usually excludes actions which are arbitrarily chosen by the performers....
triggered by nervousness.
In a slight minority of cases, sufferers of OCD may only experience obsessions, with no overt compulsions; a much smaller number of sufferers experience only compulsions.
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, hostageHostage
A hostage is a person or entity which is held by a captor. The original definition meant that this was handed over by one of two belligerent parties to the other or seized as security for the carrying out of an agreement, or as a preventive measure against certain acts of war...
situations, child abuse
Child abuse
Child abuse is the physical, sexual, emotional mistreatment, or neglect of a child. In the United States, the Centers for Disease Control and Prevention and the Department of Children And Families define child maltreatment as any act or series of acts of commission or omission by a parent or...
, 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
Coping (psychology)
Coping has been defined in psychological terms by Susan Folkman and Richard Lazarus as "constantly changing cognitive and behavioral efforts to manage specific external and/or internal demands that are appraised as taxing" or "exceeding the resources of the person".Coping is thus expending...
with continuous combat. Common symptoms include hypervigilance
Hypervigilance
Hypervigilance is an enhanced state of sensory sensitivity accompanied by an exaggerated intensity of behaviors whose purpose is to detect threats. Hypervigilance is also accompanied by a state of increased anxiety which can cause exhaustion. Other symptoms include: abnormally increased arousal, a...
, flashbacks
Flashback (psychological phenomenon)
A flashback, or involuntary recurrent memory, is a psychological phenomenon in which an individual has a sudden, usually powerful, re-experiencing of a past experience or elements of a past experience. These experiences can be happy, sad, exciting, or any other emotion one can consider...
, 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 developmentDevelopmental psychology
Developmental psychology, also known as human development, is the scientific study of systematic psychological changes, emotional changes, and perception changes that occur in human beings over the course of their life span. Originally concerned with infants and children, the field has expanded to...
in babies or children, and it is only when this feeling is excessive or inappropriate that it can be considered a disorder. 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, worryWorry
Worry is thoughts, images and emotions of a negative nature in whichmental attempts are made to avoid anticipated potential threats. As an emotion it is experienced as anxiety or concern about a real or imagined issue, usually personal issues such as health or finances or broader ones such as...
and fear
Fear
Fear is a distressing negative sensation induced by a perceived threat. It is a basic survival mechanism occurring in response to a specific stimulus, such as pain or the threat of danger...
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
Learning
Learning is acquiring new or modifying existing knowledge, behaviors, skills, values, or preferences and may involve synthesizing different types of information. The ability to learn is possessed by humans, animals and some machines. Progress over time tends to follow learning curves.Human learning...
, the problem may be more than just an ordinary anxiousness and fear common to the age.
When children suffer from a severe anxiety disorder their thinking, decision-making ability, perceptions of the environment, learning and concentration
Concentration
In chemistry, concentration is defined as the abundance of a constituent divided by the total volume of a mixture. Four types can be distinguished: mass concentration, molar concentration, number concentration, and volume concentration...
get affected. They not only experience fear, nervousness, and shyness
Shyness
In humans, shyness is a social psychology term used to describe the feeling of apprehension, lack of comfort, or awkwardness experienced when a person is in proximity to, approaching, or being approached by other people, especially in new situations or with unfamiliar people...
but also start avoiding places and activities. Anxiety also raises blood pressure
Blood pressure
Blood pressure is the pressure exerted by circulating blood upon the walls of blood vessels, and is one of the principal vital signs. When used without further specification, "blood pressure" usually refers to the arterial pressure of the systemic circulation. During each heartbeat, BP varies...
and heart rate
Heart rate
Heart rate is the number of heartbeats per unit of time, typically expressed as beats per minute . Heart rate can vary as the body's need to absorb oxygen and excrete carbon dioxide changes, such as during exercise or sleep....
and can cause nausea
Nausea
Nausea , is a sensation of unease and discomfort in the upper stomach with an involuntary urge to vomit. It often, but not always, precedes vomiting...
, vomiting
Vomiting
Vomiting is the forceful expulsion of the contents of one's stomach through the mouth and sometimes the nose...
, stomach pain, ulcers
Peptic ulcer
A peptic ulcer, also known as PUD or peptic ulcer disease, is the most common ulcer of an area of the gastrointestinal tract that is usually acidic and thus extremely painful. It is defined as mucosal erosions equal to or greater than 0.5 cm...
, diarrhea
Diarrhea
Diarrhea , also spelled diarrhoea, is the condition of having three or more loose or liquid bowel movements per day. It is a common cause of death in developing countries and the second most common cause of infant deaths worldwide. The loss of fluids through diarrhea can cause dehydration and...
, tingling, weakness, and shortness of breath. Some other symptoms are frequent self-doubt and self-criticism
Self-criticism
Self-criticism refers to the pointing out of things critical/important to one's own beliefs, thoughts, actions, behaviour or results; it can form part of private, personal reflection or a group discussion.-Philosophy:...
, irritability
Irritability
Irritability is an excessive response to stimuli. The term is used for both the physiological reaction to stimuli and for the pathological, abnormal or excessive sensitivity to stimuli; It is usually used to refer to anger or frustration....
, 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
Substance abuse
A substance-related disorder is an umbrella term used to describe several different conditions associated with several different substances .A substance related disorder is a condition in which an individual uses or abuses a...
. Children who suffer from an anxiety disorder are likely to suffer other disorders such as depression, eating disorders, and attention deficit disorders
Attention-deficit hyperactivity disorder
Attention deficit hyperactivity disorder is a developmental disorder. It is primarily characterized by "the co-existence of attentional problems and hyperactivity, with each behavior occurring infrequently alone" and symptoms starting before seven years of age.ADHD is the most commonly studied and...
, both hyperactive and inattentive.
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. 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. 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
Interpersonal relationship
An interpersonal relationship is an association between two or more people that may range from fleeting to enduring. This association may be based on limerence, love, solidarity, regular business interactions, or some other type of social commitment. Interpersonal relationships are formed in the...
. 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
Stress (biology)
Stress is a term in psychology and biology, borrowed from physics and engineering and first used in the biological context in the 1930s, which has in more recent decades become commonly used in popular parlance...
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.
Biological
Low levels of GABAGamma-aminobutyric acid
γ-Aminobutyric acid is the chief inhibitory neurotransmitter in the mammalian central nervous system. It plays a role in regulating neuronal excitability throughout the nervous system...
, a neurotransmitter that reduces activity in the central nervous system, contribute to anxiety. A number of anxiolytic
Anxiolytic
An anxiolytic is a drug used for the treatment of anxiety, and its related psychological and physical symptoms...
s 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. Caffeine
Caffeine
Caffeine is a bitter, white crystalline xanthine alkaloid that acts as a stimulant drug. Caffeine is found in varying quantities in the seeds, leaves, and fruit of some plants, where it acts as a natural pesticide that paralyzes and kills certain insects feeding on the plants...
, alcohol
Ethanol
Ethanol, also called ethyl alcohol, pure alcohol, grain alcohol, or drinking alcohol, is a volatile, flammable, colorless liquid. It is a psychoactive drug and one of the oldest recreational drugs. Best known as the type of alcohol found in alcoholic beverages, it is also used in thermometers, as a...
and benzodiazepine
Benzodiazepine
A benzodiazepine is a psychoactive drug whose core chemical structure is the fusion of a benzene ring and a diazepine ring...
dependence can worsen or cause anxiety and panic attacks. In one study in 1988–1990, 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
Panic disorder
Panic disorder is an anxiety disorder characterized by recurring severe panic attacks. It may also include significant behavioral change lasting at least a month and of ongoing worry about the implications or concern about having other attacks. The latter are called anticipatory attacks...
or social phobia
Social anxiety
Social anxiety is anxiety about social situations, interactions with others, and being evaluated or scrutinized by other people...
, was determined to be the result of alcohol
Ethanol
Ethanol, also called ethyl alcohol, pure alcohol, grain alcohol, or drinking alcohol, is a volatile, flammable, colorless liquid. It is a psychoactive drug and one of the oldest recreational drugs. Best known as the type of alcohol found in alcoholic beverages, it is also used in thermometers, as a...
or benzodiazepine dependence
Benzodiazepine dependence
Benzodiazepine dependence or benzodiazepine addiction is a condition during which a person is dependent on benzodiazepine drugs. Dependence can be either a psychological dependence, physical dependence, or a combination of the two...
. 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.
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
Grey matter
Grey matter is a major component of the central nervous system, consisting of neuronal cell bodies, neuropil , glial cells and capillaries. Grey matter contains neural cell bodies, in contrast to white matter, which does not and mostly contains myelinated axon tracts...
volumes in bilateral lenticular nuclei, extending to the caudate nuclei
Caudate nucleus
The caudate nucleus is a nucleus located within the basal ganglia of the brains of many animal species. The caudate nucleus is an important part of the brain's learning and memory system.-Anatomy:...
, while decreased grey matter volumes in bilateral dorsal medial frontal
Medial frontal gyrus
The superior frontal gyrus is situated above the superior frontal sulcus and is continued on to the medial surface of the hemisphere, the medial frontal gyrus...
/anterior cingulate
Anterior cingulate cortex
The anterior cingulate cortex is the frontal part of the cingulate cortex, that resembles a "collar" form around the corpus callosum, the fibrous bundle that relays neural signals between the right and left cerebral hemispheres of the brain...
gyri. These findings contrast with those in people with other anxiety disorders, who evince decreased (rather than increased) grey matter
Grey matter
Grey matter is a major component of the central nervous system, consisting of neuronal cell bodies, neuropil , glial cells and capillaries. Grey matter contains neural cell bodies, in contrast to white matter, which does not and mostly contains myelinated axon tracts...
volumes in bilateral lenticular/caudate nuclei
Caudate nucleus
The caudate nucleus is a nucleus located within the basal ganglia of the brains of many animal species. The caudate nucleus is an important part of the brain's learning and memory system.-Anatomy:...
, while also decreased grey matter volumes in bilateral dorsal medial frontal
Medial frontal gyrus
The superior frontal gyrus is situated above the superior frontal sulcus and is continued on to the medial surface of the hemisphere, the medial frontal gyrus...
/anterior cingulate
Anterior cingulate cortex
The anterior cingulate cortex is the frontal part of the cingulate cortex, that resembles a "collar" form around the corpus callosum, the fibrous bundle that relays neural signals between the right and left cerebral hemispheres of the brain...
gyri.
Amygdala
The amygdalaAmygdala
The ' are almond-shaped groups of nuclei located deep within the medial temporal lobes of the brain in complex vertebrates, including humans. Shown in research to perform a primary role in the processing and memory of emotional reactions, the amygdalae are considered part of the limbic system.-...
is central to the processing of fear and anxiety, and its function may be disrupted in anxiety disorders. 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
Hypothalamus
The Hypothalamus is a portion of the brain that contains a number of small nuclei with a variety of functions...
, and cerebellum
Cerebellum
The cerebellum is a region of the brain that plays an important role in motor control. It may also be involved in some cognitive functions such as attention and language, and in regulating fear and pleasure responses, but its movement-related functions are the most solidly established...
areas. In those with general anxiety disorder, these connections functionally seem to be less distinct, with greater gray matter
Gray Matter
"Gray Matter" is a short story by Stephen King, first published in the October 1973 issue of Cavalier magazine, and later collected in King's 1978 collection Night Shift. It is set in the same area as King's novel Dreamcatcher.-Setting:...
in the central nucleus. Another difference is that the amygdala areas have decreased connectivity with the insula
Insular cortex
In each hemisphere of the mammalian brain the insular cortex is a portion of the cerebral cortex folded deep within the lateral sulcus between the temporal lobe and the frontal lobe. The cortical area overlying it towards the lateral surface of the brain is the operculum...
and cingulate areas that control general stimulus salience, while having greater connectivity with the parietal cortex and prefrontal cortex
Prefrontal cortex
The prefrontal cortex is the anterior part of the frontal lobes of the brain, lying in front of the motor and premotor areas.This brain region has been implicated in planning complex cognitive behaviors, personality expression, decision making and moderating correct social behavior...
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
Parabrachial nucleus
The parabrachial nucleus is a region in the pons human brain that is related to the ascending reticular activating system . It can be subdivided into the lateral parabrachial nucleus and the medial parabrachial nucleus...
, a brain structure that, among other functions, coordinates signals from the amygdala
Amygdala
The ' are almond-shaped groups of nuclei located deep within the medial temporal lobes of the brain in complex vertebrates, including humans. Shown in research to perform a primary role in the processing and memory of emotional reactions, the amygdalae are considered part of the limbic system.-...
with input concerning balance.
Anxiety processing in the basolateral amygdala has been implicated with dendritic arborization of the amygdaloid neurons. SK2
KCNN2
Potassium intermediate/small conductance calcium-activated channel, subfamily N, member 2, also known as KCNN2, is a protein which in humans is encoded by the KCNN2 gene...
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
Corticosterone
Corticosterone is a 21-carbon steroid hormone of the corticosteroid type produced in the cortex of the adrenal glands.-Roles:In many species, including amphibians, reptiles, rodents and birds, corticosterone is a main glucocorticoid, involved in regulation of fuel, immune reactions, and stress...
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. Anxiety is also common among older people who have dementiaDementia
Dementia is a serious loss of cognitive ability in a previously unimpaired person, beyond what might be expected from normal aging...
. 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.
Diagnosis
Anxiety disorders are often debilitating chronicChronic (medicine)
A chronic disease is a disease or other human health condition that is persistent or long-lasting in nature. The term chronic is usually applied when the course of the disease lasts for more than three months. Common chronic diseases include asthma, cancer, diabetes and HIV/AIDS.In medicine, the...
conditions, which can be present from an early age or begin suddenly after a trigger
Post-traumatic stress disorder
Posttraumaticstress disorder is a severe anxiety disorder that can develop after exposure to any event that results in psychological trauma. This event may involve the threat of death to oneself or to someone else, or to one's own or someone else's physical, sexual, or psychological integrity,...
ing event. They are prone to flare up at times of high stress
Stress (medicine)
Stress is a term in psychology and biology, borrowed from physics and engineering and first used in the biological context in the 1930s, which has in more recent decades become commonly used in popular parlance...
and are frequently accompanied by physiological symptoms such as headache
Headache
A headache or cephalalgia is pain anywhere in the region of the head or neck. It can be a symptom of a number of different conditions of the head and neck. The brain tissue itself is not sensitive to pain because it lacks pain receptors. Rather, the pain is caused by disturbance of the...
, sweating
Sweating
Perspiration is the production of a fluid consisting primarily of water as well as various dissolved solids , that is excreted by the sweat glands in the skin of mammals...
, muscle spasms, palpitations, and hypertension
Hypertension
Hypertension or high blood pressure is a cardiac chronic medical condition in which the systemic arterial blood pressure is elevated. What that means is that the heart is having to work harder than it should to pump the blood around the body. Blood pressure involves two measurements, systolic and...
, which in some cases lead to fatigue
Fatigue (physical)
Fatigue is a state of awareness describing a range of afflictions, usually associated with physical and/or mental weakness, though varying from a general state of lethargy to a specific work-induced burning sensation within one's muscles...
or even exhaustion.
In casual discourse the words "anxiety" and "fear" are often used interchangeably; in clinical usage, they have distinct meanings: "anxiety
Anxiety
Anxiety is a psychological and physiological state characterized by somatic, emotional, cognitive, and behavioral components. The root meaning of the word anxiety is 'to vex or trouble'; in either presence or absence of psychological stress, anxiety can create feelings of fear, worry, uneasiness,...
" is defined as an unpleasant emotional state for which the cause is either not readily identified or perceived to be uncontrollable or unavoidable, whereas "fear" is an emotional and physiological response to a recognized external threat. The term "anxiety disorder" includes fears (phobias) as well as anxieties.
Anxiety disorders are often comorbid with other mental disorders, particularly clinical depression
Clinical depression
Major depressive disorder is a mental disorder characterized by an all-encompassing low mood accompanied by low self-esteem, and by loss of interest or pleasure in normally enjoyable activities...
, which may occur in as many as 60% of people with anxiety disorders. The fact that there is considerable overlap between symptoms of anxiety and depression, and that the same environmental triggers can provoke symptoms in either condition, may help to explain this high rate of comorbidity.
Studies have also indicated that anxiety disorders are more likely among those with family history of anxiety disorders, especially certain types.
Sexual dysfunction
Sexual dysfunction
Sexual dysfunction or sexual malfunction refers to a difficulty experienced by an individual or a couple during any stage of a normal sexual activity, including desire, arousal or orgasm....
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 carePrimary care
Primary care is the term for the health services by providers who act as the principal point of consultation for patients within a health care system...
practice, with patients often presenting for treatment only after the onset of complications
Complication (medicine)
Complication, in medicine, is an unfavorable evolution of a disease, a health condition or a medical treatment. The disease can become worse in its severity or show a higher number of signs, symptoms or new pathological changes, become widespread throughout the body or affect other organ systems. A...
such as clinical depression
Clinical depression
Major depressive disorder is a mental disorder characterized by an all-encompassing low mood accompanied by low self-esteem, and by loss of interest or pleasure in normally enjoyable activities...
or substance abuse disorders.
Treatment options available include lifestyle changes; psychotherapy
Psychotherapy
Psychotherapy is a general term referring to any form of therapeutic interaction or treatment contracted between a trained professional and a client or patient; family, couple or group...
, especially cognitive behavioral therapy; and pharmaceutical therapy. Education, reassurance and some form of cognitive-behavioral therapy should almost always be used in treatment. Research has provided evidence for the efficacy
Efficacy
Efficacy is the capacity to produce an effect. It has different specific meanings in different fields. In medicine, it is the ability of an intervention or drug to reproduce a desired effect in expert hands and under ideal circumstances.- Healthcare :...
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.
Psychotherapy
Research has shown that cognitive-behavioral therapy (CBT) can be highly effective for several anxiety disorders, particularly panic disorder and social phobia. CBT, as its name suggests, has two main components: cognitive and behavioral. In cases of social anxiety, the cognitive component can help the patient question how they can be so sure that others are continually watching and harshly judging him or her. The behavioral component seeks to change people's reactions to anxiety-provoking situations.As such it serves as a logical extension of cognitive therapy, whereby people are shown proof in the real world that their dysfunctional thought processes are unrealistic. A key element of this component is gradual exposure, in which the patient is confronted by the things they fear in a structured, sensitive manner. Gradual exposure is an inherently unpleasant technique; ideally it involves exposure to a feared social situation that is anxiety provoking but bearable, for as long as possible, two to three times a week. Often, a hierarchy of feared steps is constructed and the patient is exposed to each step sequentially.
The aim is to learn from acting differently and observing reactions. This is intended to be done with support and guidance, and when the therapist and patient feel they are ready. Cognitive-behavioral therapy for social phobia also includes anxiety management training, which may include techniques such as deep breathing and muscle relaxation exercises, which may be practiced 'in-situ'. CBT can also be conducted partly in group sessions
Group therapy
Group psychotherapy or group therapy is a form of psychotherapy in which one or more therapists treat a small group of clients together as a group...
, facilitating the sharing of experiences, a sense of acceptance by others and undertaking behavioral challenges in a trusted environment (Heimberg).
Some studies have suggested social skills training can help with social anxiety. However, it is not clear whether specific social skills techniques and training are required, rather than just support with general social functioning and exposure to social situations.
Additionally, a recent study has suggested that interpersonal therapy, a form of psychotherapy primarily used to treat depression, may also be effective in the treatment of social phobia.
Extensive research supports the neural plasticity of the brain in reaction to stressful experiences. A treatment and prevention method called Adaptive Behavioral therapy is based on understanding the adaptations which occur in developmental years due to stressful experiences and the brain's ability to create new reactions to the same stressor. In this treatment a time gap between when information is received by the brain (stress trigger) and the decision for behavior is widened to allow a re-evaluation to occur as a stressful experience is taking place. This new time to reprocess information is referred to as a Pivotal Moment when new behavior can be consciously created. The development of new adaptive behavior is promoted through the use of interruption techniques and specific tools.
Treatment is structured around a self report notebook which is used to collect historic and current stress patterns of response. Treatment is guided by the therapist in a direct manner in sessions and experiences between sessions are used to provide new experimental behavior. Adaptive behavioral therapy is also used as a preventive treatment. Practice with smaller stressors creates familiarity with healthy adaptive responses for future use.
Medications
When medication is indicated, SSRIs are generally recommended as first line agents. SNRIs such as venlafaxineVenlafaxine
Venlafaxine is an antidepressant of the serotonin-norepinephrine reuptake inhibitor class. First introduced by Wyeth in 1993, now marketed by Pfizer, it is licensed for the treatment of major depressive disorder , as a treatment for generalized anxiety disorder, and comorbid indications in...
(Effexor) are also effective. Benzodiazepines are also sometimes indicated for short-term or PRN
Pro re nata
Pro re nata is a Latin phrase meaning "in the circumstances" or "as the circumstance arises". It is commonly used in medicine to mean "as needed" or "as the situation arises." It is generally abbreviated to p.r.n. in reference to dosage of prescribed medication that is not scheduled; instead...
use. They are usually considered as a second-line treatment due to disadvantages such as cognitive impairment and due to their risks of dependence
Substance use disorder
Substance use disorders include substance abuse and substance dependence. In DSM-IV, the conditions are formally diagnosed as one or the other, but it has been proposed that DSM-5 combine the two into a single condition called "Substance-use disorder"....
and withdrawal
Withdrawal
Withdrawal can refer to any sort of separation, but is most commonly used to describe the group of symptoms that occurs upon the abrupt discontinuation/separation or a decrease in dosage of the intake of medications, recreational drugs, and alcohol...
problems. MAOIs such as phenelzine
Phenelzine
Phenelzine is a non-selective and irreversible monoamine oxidase inhibitor of the hydrazine class which is used as an antidepressant and anxiolytic...
(Nardil) and tranylcypromine
Tranylcypromine
Tranylcypromine is a drug of the substituted phenethylamine and amphetamine classes which acts as a monoamine oxidase inhibitor —it is a non-selective and irreversible inhibitor of the enzyme monoamine oxidase...
(Parnate) are considered an effective treatment and are especially useful in treament-resistant cases, however, dietary restrictions and medical interactions may limit their use. There is evidence that certain newer medications including the GABA analogue
Gabâ
Gabâ or gabaa, for the people in many parts of the Philippines), is the concept of a non-human and non-divine, imminent retribution. A sort of negative karma, it is generally seen as an evil effect on a person because of their wrongdoings or transgressions...
pregabalin
Pregabalin
Pregabalin is an anticonvulsant drug used for neuropathic pain and as an adjunct therapy for partial seizures with or without secondary generalization in adults. It has also been found effective for generalized anxiety disorder and is approved for this use in the European Union. It was designed...
(Lyrica) and the novel antidepressant mirtazapine
Mirtazapine
Mirtazapine is a tetracyclic antidepressant used primarily in the treatment of depression. It is also sometimes used as a hypnotic, antiemetic, and appetite stimulant, and for the treatment of anxiety, among other indications...
(Remeron) are effective treatments for anxiety disorders. TCAs
Tricyclic antidepressant
Tricyclic antidepressants are heterocyclic chemical compounds used primarily as antidepressants. The TCAs were first discovered in the early 1950s and were subsequently introduced later in the decade; they are named after their chemical structure, which contains three rings of atoms...
such as imipramine
Imipramine
Imipramine , also known as melipramine, is an antidepressant medication, a tricyclic antidepressant of the dibenzazepine group...
, as well as atypical antipsychotics such as quetiapine
Quetiapine
Quetiapine , is an atypical antipsychotic approved for the treatment of schizophrenia, and bipolar disorder....
, and piperazines such as hydroxyzine
Hydroxyzine
Hydroxyzine is a first-generation antihistamine of the diphenylmethane and piperazine classes. It was first synthesized by Union Chimique Belge in 1956 and was marketed by Pfizer in the United States later the same year, and is still in widespread use today....
are occasionally prescribed.
These medications need to be used with extreme care among older adults, who are more likely to suffer side effects because of coexisting physical disorders. Adherence problems are more likely among elderly patients, who may have difficulty understanding, seeing, or remembering instructions.
SSRIs
Selective serotonin reuptake inhibitorSelective serotonin reuptake inhibitor
Selective serotonin re-uptake inhibitors or serotonin-specific reuptake inhibitor are a class of compounds typically used as antidepressants in the treatment of depression, anxiety disorders, and some personality disorders. The efficacy of SSRIs is disputed...
s (SSRIs), a class of antidepressants, are considered by many to be the first choice medication for generalised social phobia. These drugs elevate the level of the neurotransmitter serotonin, among other effects. The first drug formally approved by the Food and Drug Administration
Food and Drug Administration
The Food and Drug Administration is an agency of the United States Department of Health and Human Services, one of the United States federal executive departments...
was paroxetine
Paroxetine
Paroxetine is an SSRI antidepressant. Marketing of the drug began in 1992 by the pharmaceutical company SmithKline Beecham, now GlaxoSmithKline...
, sold as Paxil in the U.S. or Seroxat in the UK. Compared to older forms of medication, there is less risk of tolerability and drug dependency. However, their efficacy
Efficacy
Efficacy is the capacity to produce an effect. It has different specific meanings in different fields. In medicine, it is the ability of an intervention or drug to reproduce a desired effect in expert hands and under ideal circumstances.- Healthcare :...
and increased suicide risk has been subject to controversy.
In a 1995 double-blind
Double-blind
A blind or blinded experiment is a scientific experiment where some of the people involved are prevented from knowing certain information that might lead to conscious or subconscious bias on their part, invalidating the results....
, placebo
Placebo
A placebo is a simulated or otherwise medically ineffectual treatment for a disease or other medical condition intended to deceive the recipient...
-controlled trial, the SSRI paroxetine was shown to result in clinically meaningful improvement in 55% of patients with generalized social anxiety disorder, compared with 23.9% of those taking placebo. An October 2004 study yielded similar results. Patients were treated with either fluoxetine
Fluoxetine
Fluoxetine is an antidepressant of the selective serotonin reuptake inhibitor class. It is manufactured and marketed by Eli Lilly and Company...
, psychotherapy, fluoxetine and psychotherapy, placebo and psychotherapy, or a placebo. The first four sets saw improvement in 50.8% to 54.2% of the patients. Of those assigned to receive only a placebo, 31.7% achieved a rating of 1 or 2 on the Clinical Global Impression-Improvement scale. Those who sought both therapy and medication did not see a boost in improvement.
General side-effects
Adverse effect (medicine)
In medicine, an adverse effect is a harmful and undesired effect resulting from a medication or other intervention such as surgery.An adverse effect may be termed a "side effect", when judged to be secondary to a main or therapeutic effect. If it results from an unsuitable or incorrect dosage or...
are common during the first weeks while the body adjusts to the drug. Symptoms may include headache
Headache
A headache or cephalalgia is pain anywhere in the region of the head or neck. It can be a symptom of a number of different conditions of the head and neck. The brain tissue itself is not sensitive to pain because it lacks pain receptors. Rather, the pain is caused by disturbance of the...
s, nausea
Nausea
Nausea , is a sensation of unease and discomfort in the upper stomach with an involuntary urge to vomit. It often, but not always, precedes vomiting...
, insomnia
Insomnia
Insomnia is most often defined by an individual's report of sleeping difficulties. While the term is sometimes used in sleep literature to describe a disorder demonstrated by polysomnographic evidence of disturbed sleep, insomnia is often defined as a positive response to either of two questions:...
and changes in sexual behavior. Treatment safety during pregnancy has not been established. In late 2004 much media attention was given to a proposed link between SSRI use and juvenile suicide
Teenage suicide
Teenage suicide in the United States remains comparatively high in the 15 to 24 age group with 4,000 suicides in this age range in 2004, making it the third leading cause of death for those aged 15 to 24...
. For this reason, the use of SSRIs in pediatric cases of depression is now recognized by the Food and Drug Administration as warranting a cautionary statement to the parents of children who may be prescribed SSRIs by a family doctor. Recent studies have shown no increase in rates of suicide. These tests, however, represent those diagnosed with depression, not necessarily with social anxiety disorder. However, due to the nature of the conditions, those taking SSRIs for social phobias are far less likely to have suicidal ideation than those with depression.
Other drugs
Although SSRIs are often the first choice for treatment, other prescription drugs are used, sometimes only if SSRIs fail to produce any clinically significant improvement.In 1985, before the introduction of SSRIs, anti-depressants such as monoamine oxidase inhibitor
Monoamine oxidase inhibitor
Monoamine oxidase inhibitors are a class of antidepressant drugs prescribed for the treatment of depression. They are particularly effective in treating atypical depression....
s (MAOIs) were frequently used in the treatment of social anxiety. Their efficacy appears to be comparable or sometimes superior to SSRIs or benzodiazepines. However, because of the dietary
Diet (nutrition)
In nutrition, diet is the sum of food consumed by a person or other organism. Dietary habits are the habitual decisions an individual or culture makes when choosing what foods to eat. With the word diet, it is often implied the use of specific intake of nutrition for health or weight-management...
restrictions required, high toxicity in overdose, and incompatibilities with other drugs, its usefulness as a treatment for social phobics is now limited. Some argue for their continued use, however, or that a special diet does not need to be strictly adhered to. A newer type of this medication, Reversible inhibitors of monoamine oxidase subtype A
Rima
Rima, also known as Rima the Jungle Girl, is the fictional heroine of W. H. Hudson's 1904 novel Green Mansions: A Romance of the Tropical Forest. In 1974, she was adapted into a comic book character and featured in the short-lived monthly series Rima the Jungle Girl, published by DC Comics...
(RIMAs) inhibit the MAO enzyme
Enzyme
Enzymes are proteins that catalyze chemical reactions. In enzymatic reactions, the molecules at the beginning of the process, called substrates, are converted into different molecules, called products. Almost all chemical reactions in a biological cell need enzymes in order to occur at rates...
only temporarily, improving the adverse-effect profile but possibly reducing their efficacy.
Benzodiazepine
Benzodiazepine
A benzodiazepine is a psychoactive drug whose core chemical structure is the fusion of a benzene ring and a diazepine ring...
s such as alprazolam
Alprazolam
Alprazolam is a short-acting anxiolytic of the benzodiazepine class of psychoactive drugs. Alprazolam, like other benzodiazepines, binds to specific sites on the GABAA gamma-amino-butyric acid receptor...
and clonazepam
Clonazepam
Clonazepamis a benzodiazepine drug having anxiolytic, anticonvulsant, muscle relaxant, and hypnotic properties. It is marketed by Roche under the trade name Klonopin in the United States and Rivotril in Australia, Brazil, Canada and Europe...
are an alternative to SSRIs. These drugs are often used for short-term relief of severe, disabling anxiety. Although benzodiazepines are still sometimes prescribed for long-term everyday use in some countries, there is much concern over the development of drug tolerance, dependency and recreational abuse
Recreational drug use
Recreational drug use is the use of a drug, usually psychoactive, with the intention of creating or enhancing recreational experience. Such use is controversial, however, often being considered to be also drug abuse, and it is often illegal...
. It has been recommended that benzodiazepines are only considered for individuals who fail to respond to safer medications. Benzodiazepines augment the action of GABA
Gabâ
Gabâ or gabaa, for the people in many parts of the Philippines), is the concept of a non-human and non-divine, imminent retribution. A sort of negative karma, it is generally seen as an evil effect on a person because of their wrongdoings or transgressions...
, the major inhibitory neurotransmitter in the brain; effects usually begin to appear within minutes or hours.
The novel antidepressant mirtazapine
Mirtazapine
Mirtazapine is a tetracyclic antidepressant used primarily in the treatment of depression. It is also sometimes used as a hypnotic, antiemetic, and appetite stimulant, and for the treatment of anxiety, among other indications...
has been proven effective in treatment of social anxiety disorder. This is especially significant due to mirtazapine's fast onset and lack of many unpleasant side-effects associated with SSRIs (particularly, sexual dysfunction
Sexual dysfunction
Sexual dysfunction or sexual malfunction refers to a difficulty experienced by an individual or a couple during any stage of a normal sexual activity, including desire, arousal or orgasm....
).
In Japan
Japan
Japan is an island nation in East Asia. Located in the Pacific Ocean, it lies to the east of the Sea of Japan, China, North Korea, South Korea and Russia, stretching from the Sea of Okhotsk in the north to the East China Sea and Taiwan in the south...
, the serotonin-norepinephrine reuptake inhibitor
Serotonin-norepinephrine reuptake inhibitor
Serotonin–norepinephrine reuptake inhibitors are a class of antidepressant drugs used in the treatment of major depression and other mood disorders...
(SNRI) Milnacipran is used in the treatment of Taijin kyofusho
Taijin kyofusho
Taijin kyofusho , is a Japanese culture-specific syndrome. The term taijin kyofusho literally means the disorder of fear of interpersonal relations . Dr...
a Japanese variant of social anxiety disorder.
Some people with a form of social phobia called performance phobia have been helped by beta-blockers, which are more commonly used to control high blood pressure. Taken in low doses, they control the physical manifestation of anxiety and can be taken before a public performance.
A novel treatment approach has recently been developed as a result of translational research. It has been shown that a combination of acute dosing of d-cycloserine (DCS) with exposure therapy facilitates the effects of exposure therapy of social phobia (Hofmann, Meuret, Smits, et al., 2006). DCS is an old antibiotic
Antibiotic
An antibacterial is a compound or substance that kills or slows down the growth of bacteria.The term is often used synonymously with the term antibiotic; today, however, with increased knowledge of the causative agents of various infectious diseases, antibiotic has come to denote a broader range of...
medication used for treating tuberculosis and does not have any anxiolytic properties per se. However, it acts as an agonist at the glutamatergic N-methyl-D-aspartate (NMDA) receptor site, which is important for learning and memory (Hofmann, Pollack, & Otto, 2006). It has been shown that administering a small dose acutely 1 hour before exposure therapy can facilitate extinction learning that occurs during therapy.
Treatment controversy arises because while some studies indicate that a combination of medication and psychotherapy can be more effective than either one alone, others suggest pharmacological interventions are largely palliative, and can actually interfere with the mechanisms of successful therapy. Meta-analysis
Meta-analysis
In statistics, a meta-analysis combines the results of several studies that address a set of related research hypotheses. In its simplest form, this is normally by identification of a common measure of effect size, for which a weighted average might be the output of a meta-analyses. Here the...
indicates that psychotherapeutic interventions have better long-term efficacy compared to pharmacotherapy. However, the right treatment may very much depend on the individual patient's genetics and environmental factors.
Alternative medicine
Regular aerobic exercise, improving sleep hygieneSleep hygiene
Sleep hygiene can be defined as the controlling of "all behavioural and environmental factors that precede sleep and may interfere with sleep." It is the practice of following guidelines in an attempt to ensure more restful, effective sleep which can promote daytime alertness and help treat or...
and reducing caffeine are often useful in treating anxiety.
Herbal
Herbal
AThe use of a or an depends on whether or not herbal is pronounced with a silent h. herbal is "a collection of descriptions of plants put together for medicinal purposes." Expressed more elaborately — it is a book containing the names and descriptions of plants, usually with information on their...
drugs are often used in patients with somatoform disorders. In one clinical trial, butterbur
Butterbur
The plants commonly referred to as Butterbur are found in the daisy family Asteraceae in the genus Petasites. They are mostly quite robust plants with thick, creeping underground rhizomes and large Rhubarb-like leaves during the growing season...
in a fixed herbal drug combination (Ze 185 = 4-combination versus 3-combination without butterbur and placebo) was used in patients with somatoform disorders. 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
Lemon balm
Lemon balm , not to be confused with bee balm, Monarda species, is a perennial herb in the mint family Lamiaceae, native to southern Europe and the Mediterranean region....
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
Kava
Kava or kava-kava is a crop of the western Pacific....
, 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
American Academy of Family Physicians
The American Academy of Family Physicians was founded in 1947 to promote the science and art of family medicine. It is one of the largest medical organizations in the United States, with over 100,000 members...
(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
Inositol
Inositol or cyclohexane-1,2,3,4,5,6-hexol is a chemical compound with formula 6126 or 6, a sixfold alcohol of cyclohexane. It exists in nine possible stereoisomers, of which the most prominent form, widely occurring in nature, is cis-1,2,3,5-trans-4,6-cyclohexanehexol, or myo-inositol...
has been found to have modest effects in patients with panic disorder or obsessive-compulsive disorder. St. John's wort and Sympathyl have also been used to treat anxiety, but with little scientific evidence as to their effectiveness.