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Anxiety Disorders

Key Points ⚡

  • Anxiety: psychological and physiological response to potential/uncertain threats; essential CNS function to avoid harm.
  • Prevalence: lifetime 5-29%, significant disability burden.
  • Aetiology: positive feedback loops of thought/behavior; trait anxiety (genetic/environmental), state anxiety (acute feelings).
  • Symptoms: psychological (worry, suspense), behavioral (avoidance, restlessness), physiological (palpitations, dyspnoea, muscle tension).
  • Types: Generalized Anxiety Disorder (GAD), phobic disorders, panic disorder, PTSD, OCD.
  • Diagnosis: clinical, based on symptom persistence and functional impairment.
  • Management: psychological therapies (CBT, exposure), pharmacological (SSRIs, SNRIs); avoid chronic benzodiazepine use.
  • Complications: co-morbid depression, poor sleep, anxiety exacerbation by avoidance/rumination.
  • Medical students: high prevalence (~33%), importance of sleep hygiene, self-guided CBT, professional support.

Introduction

  • Anxiety is an unpleasant experience that motivates avoidance of harm, similar to pain.
  • Anxiety disorders are common globally, debilitating, with a stigma often misattributing them to weakness.

Aetiology

Trait Anxiety

  • Stable characteristic of tendency to experience anxiety when stressed, shaped by genetics and early life environment (e.g., trauma, attachment).
  • High trait anxiety may confer evolutionary survival advantage.

State Anxiety

  • Acute feelings of anxiety involving psychological (worry), behavioral (avoidance), and physiological symptoms (palpitations, tremor).

Anxiety Disorder

  • Excessive and persistent anxiety caused by interplay of high trait anxiety and stressors, forming positive feedback loops.
  • Avoidance behaviors maintain and worsen anxiety.
  • Attentional bias: heightened threat perception increases anxiety range.
  • Rumination: repetitive worry perpetuates anxiety.
  • Low self-worth: comorbid with depression, exacerbating anxiety.
  • Poor sleep: contributes to and worsens anxiety.

Neurobiology

  • Reduced connectivity between prefrontal cortex and limbic system (amygdala, anterior cingulate).
  • Variations in serotonin transporter genes (5-HT) reduce serotonin signalling, basis for SSRI treatment.
  • Dysregulation of HPA axis involved in stress response.
  • Neuroimaging changes may reverse with treatment.

Types of Anxiety Disorder

  • Symptoms overlap across types; diagnostic criteria include:
  • Symptoms persistent for months
  • Significant distress or impairment
  • Not due to other health conditions or substances

Generalized Anxiety Disorder (GAD)

  • Persistent worry about multiple events.
  • Features: nervousness, muscle tension, irritability, sleep disturbance.
  • Lifetime prevalence 5-12%, female > male.

Phobic Disorders

  • Anxiety triggered by specific stimuli, leading to avoidance.
  • Types: agoraphobia, social phobia, specific phobias.
  • Somatic symptoms common during exposure.
  • Lifetime prevalence up to 12%.

Panic Disorder

  • Recurrent, unpredictable acute anxiety attacks.
  • Somatic symptoms peak rapidly, often cause fear of dying/losing control.
  • Lifetime prevalence ~4.7%, female > male.

Management

  • Combine psychological (CBT, exposure, relaxation) and pharmacological (SSRIs, SNRIs, mirtazapine) approaches.
  • Psychoeducation, sleep hygiene, self-guided CBT as first step for mild/moderate cases.
  • Avoid chronic benzodiazepine use due to addiction and tolerance risks; use short-term only for transient anxiety.

Post-Traumatic Stress Disorder (PTSD)

  • Develops after traumatic exposure; features hyperarousal, avoidance, re-experiencing, distress (mnemonic HARD).
  • Treatment: trauma-focused CBT, EMDR, SSRIs/venlafaxine.
  • Lifetime prevalence 2-6%, female > male.

Complex PTSD (C-PTSD)

  • Results from prolonged trauma, includes PTSD symptoms plus emotional regulation, self-worth, relational problems.
  • Treatment similar to PTSD, may require long-term therapy.
  • Characterized by intrusive thoughts and compulsive behaviors: OCD, BDD, trichotillomania, health anxiety, hoarding.
  • Anxiety is a core feature; treatment involves SSRIs and psychotherapy.
  • Alternative meds: clomipramine, adjunct antipsychotics if resistant.

Anxiety in Medical Students

  • Prevalence high (~33% globally).
  • Anxiety is adaptive at moderate levels but can become debilitating.
  • Sleep hygiene and self-guided CBT crucial; professional support encouraged when needed.
  • Stigma and misunderstanding of anxiety may worsen condition; balanced perspective important.

References

  • NICE CG113, CG159, QS53
  • BMJ Best Practice
  • Various epidemiological and neurobiological studies cited on geekymedics.com
  • Bipolar Disorder
  • Bulimia Nervosa
  • Depression
  • Medically Unexplained Symptoms
  • Personality Disorder