Anxiety is uncontrolled fear, nervousness and/or worry about trivial or non-existent things. It is an unpleasant fear of future events that are unlikely to occur. Some patients have insight and realize that their uneasiness is illogical, but that does not alleviate symptoms. A certain level of anxiety is considered normal in many situations, but frequent anxiety or anxiety that inhibits function is pathologic. During anxiety sympathetic nervous system activation can result in physical symptoms such as:
- Shortness of breath
- Muscle tension
- Lack of focus
- Sweating or chills
- Changes in sleeping pattern
In order to make a diagnosis of anxiety, one must rule out other potential causes of these symptoms. The differential diagnosis for anxiety includes other psychiatric disorders, cardiac abnormalities (such as myocardial infarction or valvular disease), endocrine disorders (like hyperthyroidism) and respiratory disease (such as asthma or Pulmonary Embolism). Substances such as street drugs and prescribed medications must also be ruled out as a potential cause of the symptoms.
Generalized Anxiety Disorder (GAD) = prolonged period of near constant anxiety. Their anxiety is not linked to a specific item, person, or situation (AKA it isn’t a phobia). They usually worry about a wide variety of things including school/work performance, finances, health, friends and/or family members. Their anxiety is “generalized” across many situations. Their anxiety frequently presents with “physical” symptoms and may be severe enough to impair function.
Panic Attack – sudden onset period of extremely intense anxiety accompanied by numerous signs and symptoms of anxiety. The attack is often associated with a sense of impending doom. These “episodes” usually last 10 to 30 minutes and are disabling. They may be brought on by an identifiable trigger or be completely unprovoked.
Panic Disorder = recurrent panic attacks that are unprovoked and have no identifiable trigger. The onset of these anxiety episodes is unpredictable. Patients may be relatively asymptomatic between attacks, but often have anxiety about having more attacks. Their fear is related to the panic attacks themselves rather than a particular external stimuli.
Agoraphobia is anxiety related to open spaces and/or crowded places. These people are afraid of being helpless or embarrassed in a situation that is difficult to “escape” from. This often leads to avoidance of such experiences and in severe cases these people never leave their homes. Agoraphobia is most closely related to Panic Disorder. In this situation patients fear having an unexpected panic attack in a place where they may be embarrassed in front of other or help may not be available. However, agoraphobia can be the result of other psychiatric disorders such as specific phobia.
(Specific) Phobia = an excessive amount of anxiety related to a specific situation or item that interferes with function. Common examples include fear of heights, spiders or medical injections. These individuals can be relatively asymptomatic in the absence of exposure to what they fear. Some individuals will adapt quite well and you won’t even know they have a phobia because they are good at avoiding the exposure. For example, somebody afraid of heights may move to an area with no mountains or high rise buildings.
Specific phobia can lead to a panic attack. However, these attacks only occur as a result of exposure to what they fear. They will not have panic attacks in the absence of external stimuli. This differentiates it from Panic Disorder where the individual will have unprovoked panic attacks. In extreme cases specific phobia can lead to Agoraphobia. For example, if somebody is deathly afraid of spiders they may never want to leave their house.
Treatment can include Exposure Therapy. Here the patient creates a hierarchy of fears and is exposed to them in order of increasing level of fear. So a person who is afraid of heights will start with standing on a step stool and then slowly work their way up to using an elevator and going to the top of a sky scraper. By taking “baby steps” patients are often able to do things they would have never been able to without the process. In certain situations benzos may be used if the feared stimuli is infrequent and unavoidable. For example, somebody who is afraid of flying but only takes a few flights a year may be well controlled with benzos on an as needed basis.
Social Anxiety Disorder (AKA Social Phobia) = anxiety in social situations such as public speaking, eating in public or using public restrooms. This usually includes an intense fear of scrutiny and judgment from others. These patients may be relatively asymptomatic if they can avoid being the center of attention. In extreme cases it can lead to panic attacks. Social Phobia can be thought of as a Specific Phobia where the fear is related to social situations. However, despite the similarities the two disorders are separate diagnoses in the DSM.
Beta blockers are sometimes used on an as needed basis for “performance anxiety” of “stage freight”. For example, if a person has to give a big presentation you can give a beta blocker about 30 minutes before the meeting in order to block some of the sympathetic signals. They will still have the anxiety, but because the physical symptoms of anxiety are blunted they won’t realize they are anxious.
Obsessive-Compulsive Disorder (OCD) = anxiety and intrusive thoughts that drive the patient to unusual repetitive actions called Compulsions. The compulsions temporarily relieve the anxiety in some patients while others feel like they “just have to” do their rituals. Common compulsions include counting their steps, repetitively washing hands, preoccupation with certain numbers and rituals such as opening and closing doors repetitively. The patient often realizes that their fears and compulsions are irrational, but there remains a lack of control.
OCD should not be confused with the similar sounding Obsessive Compulsive Personality Disorder (OCPD). There are some similarities between the two as both can include a preoccupation with things like order, cleanliness and organization. However, OCPD patients usually lack the “classic” compulsions found in OCD. OCD patients also have insight, while OCPD patients do not. In OCD they view their thoughts and behaviors as abnormal, unwanted and distressing. In OCPD they view their way of thinking as normal and beneficial. They don’t realize they have a disorder.
Post-traumatic Stress Disorder (PTSD) = anxiety related to a traumatic experience that may include flashbacks, nightmares and avoidance of certain triggers that remind them of the experience. These patients may also have hyperarousal where they have an amplified response to external stimuli such as loud noises. Classically the trauma is experiencing or witnessing a life threatening event or sexual assault. Symptoms must be present for more than a month in order to make a diagnosis of PTSD. If these same symptoms last for less than a month the patient would more correctly be diagnosed with Acute Stress Disorder.