Family doctor

OVERVIEW

• Anxiety is a normal response to stress but some suffer more severely than others. This results in anxiety disorders including phobias, obsessive compulsiveness and disorders induced by substance use or other medical conditions.
• 10-15% of adults suffer anxiety disorders in their lifetime, females more often than males. It may be a hereditary, from social conditioning rather than genetic inheritance.
• Physical symptoms such as shaking, palpitations, high blood pressure, loose bowels and the like are common. Medical conditions, substance use, depression and more severe mental illness may be the cause of anxiety symptoms.
• Diagnosis involves examining the reasons or situations that bring on anxiety, and ruling out other reasons for symptoms, such as medical conditions or substance use.
• Currently favoured theories support anxiety being caused by chemical problems in the brain.
• The types of anxiety disorders include panic disorders; specific or social phobias; obsessive compulsive disorders; post traumatic stress disorders; acute stress disorders; generalised anxiety disorder; and anxiety due to medical condition or substance use.
• Treatment generally includes recognition, reassurance, involving friends and family, and therapy and/or medication. The use of therapy and medication together can result in excellent long term improvements.
• Professionals involved in anxiety treatment include general practitioners,psychiatrists, psychologists, psychotherapists and counsellors.
• Those suffering minor anxiety disorders may find they can prevent the condition by learning a combination of relaxation type techniques. A combination of suitable medication and successful therapy usually results in significant long-term improvement for anxiety disorder sufferers.

What is anxiety?

Anxiety is a feeling of discomfort or fear that may show up as sweating, trembling, palpitations and the like. Anxiety in certain circumstances is normal, but some people suffer more frequently and severely than others. These people suffer anxiety disorders. These disorders include phobias, obsessive compulsiveness and disorders induced by substance use or other medical conditions.

Although these conditions begin slowly and early in life and may not be as disabling as some psychiatric conditions, they can make normal day to day functioning difficult. School, social situations, establishing relationships and work may be difficult for those suffering anxiety disorders.

How common are anxiety disorders?

Anxiety disorders are one of the most common psychological disorders - around 10-15% of adults suffer anxiety disorders in their lifetime. Generally disorders begin early - for instance phobias start in childhood, social phobias and obsessive compulsive disorders as an adolescent, and the remainder of disorders usually before the age of 30.

In general females seem to be more commonly affected by anxiety disorders than men.

Anxiety does seem to be inherited in some cases, although it is not known whether this is due to biological inheritance or social learning factors. Heritability is not particularly high and no single gene seems to be involved.

What are the symptoms?

General symptoms of anxiety are many and varied, including

• perspiration
• dizziness
• shakiness
• heart palpitations
• pins and needles in the hands and feet
• loose bowels
• high blood pressure
• frequent urination
• sense of discomfort in the abdomen
• loss of concentration
• over excited nervous system
• difficulty with recall
• confusion, distortion of perceptions
• decreased ability to make associations.

An anxiety disorder may be a result of a psychological or physical problem. While anxiety can be a symptom of an anxiety disorder, it can also be associated with other conditions such as:

• a medical condition
• associated substance use such as cannabis, coffee or alcohol
• depression
• a more severe mental illness
• a personality problem.

How would anxiety be defined as a disorder?

Everyone at some stage has anxious feelings and this is quite normal. However anxiety is different from fear - fear is a reaction to a known threat. More severe and frequent anxiety becomes incapacitating and may be described as a pathological disorder.

Anxiety disorders include the following sort of reactions:

• repeated panic attacks for no apparent reason with fear of another attack, and physical anxiety symptoms
• anxiety about being in places where escape may prove difficult or embarrassing, such as leaving home alone, crowds, travelling on a motorway
• excessive or unreasonable fear of situation or objects, such as flying, heights, injections, spiders
• marked fear of social situations, especially when performance is expected
• marked persistent inappropriate thoughts, impulses or images that are upsetting, for instance, concern about getting dirty, needing to clean compulsively or count things, concern for hurting others or sexual impulses
• ongoing and severe worrying for period of 6 months or more about a number of issues or activities.

A person suffering from any of the above should seek medical advice.

How is a anxiety disorder diagnosed?

Diagnosis of an anxiety order is generally confirmed using certain criteria matched against complaints or symptoms, and by excluding other possible causes such as a medical condition or substance use.

For instance, the reactions described above to would prompt further investigation by a medical professional. Physical examination would take place and questions about use of substances that may cause the reactions would be asked, such as use of alcohol, medications, cannabis, coffee, cigarettes.

General blood tests would be taken to exclude other medical reasons for reactions, such as thyroid or adrenal gland dysfunction.

How does the body produce feelings of anxiety?

Although there are several theories supporting the psychological causes for anxiety, the currently favoured theory claims physical problems with either the autonomic nervous system, or faulty neurotransmitter transmission to the brain causes anxiety.

Recent studies seem to show very deep centres in the brain are involved and that anxiety is a response to the natural "fight or flight" reaction. This reaction is displayed by most animals, prompting them to reaction swiftly in the face of danger.

What types of anxiety disorders are there?

Anxiety disorders may be grouped into the following types:

• panic disorders with or without agoraphobia (fear of small spaces)
• specific phobia (fear of spiders, flying or the like)
• social phobia
• OCD - obsessive compulsive disorder (compulsion to count things, clean or the like)
• PTSD - post traumatic stress disorder
• acute stress disorder
• generalised anxiety disorder
• anxiety disorder due to medical condition
• substance induced anxiety disorder

Can anxiety disorders be treated?

Generally, the earlier treatment can be applied, the better the outcome and quicker the response to treatment, but in some cases not all the symptoms will disappear.

Either or both psychological and medical treatments may be used successfully to treat anxiety disorders. Some conditions are more easily treated than others. For instance, specific phobias, generalised anxiety disorder and panic disorder are usually more easily treated than post traumatic stress disorder, social or agoraphobia and obsessive compulsive disorders.

If allowed to progress a disorder can become difficult to treat, for instance for a person who will not leave the house, or spends all day counting things or washing their hands, life is severely impacted.

General anxiety can sometimes be treated simply by identifying how the patient is becoming stressed and showing how to deal with stress using relaxation techniques and avoid situations causing stress. However, more severe anxiety may need more formal treatment.

Treatment generally includes the following:

• personal recognition of the problem
• reassurance
• bringing the problem out in the open
• involving friends or family to recognise and help
• therapy and/or medications

What therapy treatments are used?  

Behavioural, group and cognitive (examination of perception, thinking, and learning) therapies are used, as well as education and relaxation techniques.

Therapy aims to develop lifelong skills to deal with anxiety. They take time and effort on the patient's part to achieve results but can be very valuable and long lasting.

• Behavioural therapy - performed with a mental health professional to help gain control over unwanted behaviour. Can include control exposure to situations usually avoided.
• Cognitive therapy - similar to behavioural therapy but dealing with unhelpful and unproductive thoughts patterns. Feelings and thoughts are examined and the patient learns to identify which thoughts are unreasonable, unrealistic or overvalued.
• Group therapy - with one or two specialised therapists, particularly helpfully for certain conditions such as difficultly relating to others or being scrutinised by others. Allows exposure to feared situations and recognition and understanding by peers.
• Psychoeducation - recognition by the patient that they have a treatable medical condition, and self-education through books and websites, and mental health professionals.
• Relaxation techniques - these can be helpful to deal with particular stresses leading to anxiety. Skills include breathing retraining, relaxation exercises.

What medications are used?  

Medications can be very helpful to resolve anxiety symptoms very quickly by altering the brain chemistry causing symptoms. If used in conjunction with therapies, the lifelong skills developed in therapy mean medications can usually eventually be withdrawn. As with all medications, there are side effects and benefits that all need to be considered.

Medications can be particularly useful for those unable to undergo therapy because their anxiety is too great. Medication may relax them sufficiently to allow therapy to begin to develop long-term skills.

Many medications used for depression are also used for anxiety, as there are a lot of chemical similarities between these conditions.

The medical practitioner prescribing these types of medications will be able to explain how they work and their side effects. The following is a brief summary of general types of medications currently used:

• SSRIs (Specific Serotonin Re-uptake Inhibitors) - including the well publised Prozac. They may be used for generalised anxiety disorders, panic and social disorders, OCD, PTSD. They increase the brain chemical Serotonin. These medications are generally not habit forming but some have a slight withdrawal reaction, and may take some weeks to act.
• TCAs (Tricyclic Antidepressants) - may be effective for OCD, PTSD, panic disorder, generalised anxiety disorder in some cases. They increase Serotonin and Noradrenaline - brain neurotransmitters. These are not habit forming medications, and may take 10 days to a month to take effect.
• Beta Blockers - these are used particularly for controlling physical symptoms of anxiety such as shaking and trembling. They are often used for stressful situations rather than as regular dosage. It is not an addictive medication but may not be suitable when certain other medical conditions are present.
• Buspirone/Buspar - may be useful for many anxiety related conditions, particularly for generalised anxiety disorder. They increase the activity of Serotonin. They are an excellent alternative to Benziadiazepines for those suffering substance abuse and at risk of addiction. These are not addictive medications and do not usually cause sedation.
• Benzodiazepines - effective for many symptoms of anxiety disorders and can work very quickly, within hours or days. They can be addictive and would not usually be the first medication tried. They can cause drowsiness, sexual problems and confusion, and are not curative, acting only on symptoms.
• MAOIs (Monoamine Oxidase Inhibitors) - Effective for panic disorder, PTSD and social phobia. They work on the MAOI enzyme system in the brain. Some of these medications are not reversible, making them potentially dangerous in terms of side effects. As well as interactions with other medications, there are several dietary restrictions and side effects. They take several weeks to be effective and are often used as secondary treatment.

In most cases, medications is used in conjunction with therapy to gain best long term results.

Which mental health professionals deal with anxiety disorders?

The first point of help will usually be with a mental health professional with experience dealing with anxiety disorders.

Depending on the severity of the condition, one or a team of physicians and psychological professionals may be involved in treatment. Because anxiety disorders are common, general practitioners are usually the first to diagnose and suggest possible treatment, especially in less severe cases.

In general, the more severe conditions have a physician and psychologists working as a team.

The types of professionals a patient could expect to work with include:

• general practitioners
• psychiatrists
• psychologists
• psychotherapists
• counsellors.

If medication is prescribed, it is usually combined with some therapy to promote long term successful treatment.

Can anxiety disorders be prevented?

For minor anxiety disorders, self education and recognition, relaxation training, yoga and self-help groups can prove very useful.

What is the long term outcome for sufferers?

With good mental health professional advice and a good treatment regime, significant improvement should be seen between 2-6 weeks and 2-4 months, depending on the particular condition and treatment method.

A combination of suitable medication and successful therapy usually results in significant improvement for the sufferer long-term.

If improvement is not seen by 4-6 months following treatments, a second opinion may be necessary.