Understanding Anxiety Disorders
Anxiety is an emotion that we all experience and that presents as a diffuse and highly unpleasant feeling. Anxiety generally manifests as a pervading and persistent sense of apprehension that may be founded on a familiar situation but often occurs in the absence of an identifiable threat.
Anxiety disorders are the most prevalent mental health problem affecting Australians and one in four people are affected by anxiety at some point in life. Recent statistics reveal that 1.3 million adults, comprising 12% of women and 7.1% of men, were affected by anxiety disorders within a 12 month period.5 Anxiety disorders also negatively impact productivity and are a major cause of disability:
Many factors are believed to be involved in the onset of anxiety disorders including:
A core issue with anxiety disorders is that symptoms may occur without a potentially dangerous event precipitating. Common features of all anxiety disorders are:
Normal versus Abnormal Anxiety
Adaptive anxiety helps individuals practice and prepare such that their ability to function is enhanced, as well as allowing them to be sufficiently cautious in potentially dangerous situations. As anxiety increases the ability to perform increases proportionally until an optimal level is reached. Beyond this optimal point performance efficiency decreases with further increases in anxiety.
Anxiety becomes maladaptive in situations where there is no real threat or when anxiety persists long after the threat has passed. If maladaptive anxiety remains untreated it can become chronic, resulting in significant distress and disability and symptoms such as fatigue, poor concentration, insomnia and feeling stressed.
The progressive development of symptoms in an anxiety disorder is marked by increased frequency, duration and intensity of anxiety and worry which is significantly out of proportion to the actual probability or impact of the feared event. This progressive development is a consequence of a reinforcement cycle inherent in the symptoms themselves plus other factors impacting on an individual’s emotional, mental and physical wellbeing.
Maladaptive anxiety manifests as several anxiety disorders defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV):
Although an anxiety disorder can be debilitating the disorders themselves do not diminish a person’s intellectual capacity, level of insight or awareness of reality. Often people suffering from an anxiety disorder can present with concomitant depression, sleep disorders and physical complaints associated with stress. In some cases anxiety disorders may arise from the use of a legal or illicit drug.
Pathophysiology of Anxiety
Anxiety is made up of cognitive, emotional and physical elements. From a physiological point of view, all thoughts and feelings may be understood as resulting from electrochemical processes in the brain. Although there are over 200 neurotransmitters and neuromodulators in the brain with complex interactions, how these brain chemicals may produce maladaptive anxiety responses is poorly understood.
Altered monoamine function in the brain is thought to be associated with the onset of anxiety disorders. The major monoamine neurotransmitters include serotonin and the catecholamines dopamine, norepinephrine and epinephrine.3 Gamma-aminobutyric acid (GABA) may also be implicated in these disorders.8 Serotonin and GABA are both inhibitory neurotransmitters and are believed to control anxiety, depression and pain perception.
It is thought that an underactivation of the serotonergic system and an overactivation of the noradrenergic system in conjunction with a disruption of the GABA system are implicated in the development of anxiety disorders.
The thalamus essentially determines if sensory input is ‘safe’ or not. If the input is deemed ‘unsafe’, the sympathetic cascade is activated through the hypothalamic-pituitary-adrenal (HPA) axis, resulting in many of the basic symptoms common to all anxiety disorders.
Limited and inconsistent evidence supports the notion that alterations of the HPA axis pathway are responsible for all anxiety disorders. Altered HPA axis activity has been most consistently documented with PTSD whereas those with panic disorder do not appear to exhibit consistent alterations in HPA axis function.
The amygdala is the area of the brain that registers the emotional significance of environmental stimuli and stores emotional memories. It may also play a role in the pathophysiology of anxiety. Efferent pathways from the amygdala travel to several critical brain structures which then activate the parasympathetic and sympathetic nervous systems, resulting in many of the symptoms experienced by the individual. Reciprocal neuronal pathways connecting the amygdala to the prefrontal cortex allow cognitive experience which differs depending on the specific anxiety disorder, although fear symptoms may overlap. For example, in panic disorder there may be a fear of imminent death, with social phobia there may be a fear of embarrassment, and in OCD obsessional ideas recur and intrude.
Panic disorder is diagnosed if there is a history of repeated sudden attacks of overwhelming anxiety (fear, terror, and impending doom) accompanied by physical symptoms including:
The panic attacks occur frequently with at least four attacks per month and each attack develops over a short time frame of about 10 minutes. Between panic attacks the individual spends an excessive quantity of time worrying when the next attack may occur.
Sympathetic nervous system overactivity, increased muscle tension and hyperventilation are the common pathophysiological mechanisms associated with panic disorder. The amygdala and hippocampus brain regions and disruption of the GABA-benzodiazepine receptor system may be involved in the development of panic disorder. The risk of developing this disorder is increased among individuals with a family history of panic disorder, suggesting a genetic link.
Those with panic disorder may develop secondary phobias of places or situations in which panic attacks have occurred. About one third of individuals with panic disorder will develop agoraphobia which can become chronic regardless of the presence or absence of panic attacks.
Generalised Anxiety Disorder (GAD)
The essential feature of GAD is excessive anxiety and worry about several events or activities occurring more days than not, for a period of at least six months. This is accompanied by at least three additional symptoms (only one symptom is required in children)
The individual finds it difficult to control their level of unrealistic worry. They may also exhibit unrealistic assessment of problems, display avoidance strategies, procrastination and have poor problem-solving skills.
Abnormalities of serotonin and the GABA-benzodiazepine receptor system may contribute to the pathophysiology of GAD. Studies have demonstrated that people with GAD have increased sympathetic nervous system response and slower adaptation to stressful stimuli. The anxiety, worry or physical symptoms cause clinically significant distress or impairment in social, occupational or other important areas of functioning.
Social phobia is marked by persistent anxiety about being scrutinised or evaluated by unfamiliar people. This level of anxiety usually leads to avoidance of certain social situations such as eating, speaking or performing in public or being in any situation where they may blush or appear anxious. The person knows it is irrational but cannot control it. Social phobia usually starts in youth and can present as a panic-like attack in response to a feared situation. Those who commonly suffer from this disorder are aged 18-29 years and generally are less educated and have a lower socio-economic status. Most do not seek management for their condition and frequently present with additional illnesses such as agoraphobia, depression or alcohol abuse.
Specific phobia is marked by a persistent irrational fear and avoidance of a specific object or situation including heights, enclosed spaces, animals and blood. The phobia usually develops in childhood and generally does not persist into adulthood. Should this occur, only approximately 20% of cases are likely to spontaneously remit.
Obsessive Compulsive Disorder (OCD)
This disorder is marked by recurring obsessions, compulsions or both. The obsessions and compulsions are so persistent and intrusive they greatly hinder daily life and cause significant distress. OCD is particularly associated with depressive illness.
OCD may have a familial connection and neuroimaging also suggests that the condition may also result from abnormalities in the frontal lobe and basal ganglia. Serotonin function is probably abnormal in individuals with OCD.
Post-Traumatic Stress Disorder (PTSD)
The DSM-IV criteria for PTSD states that the person must have been exposed to a traumatic event that involved an actual or threatened death or serious injury or threat to the physical integrity of others; and that the individual’s response was that of intense fear, helplessness or horror.
The traumatic event is persistently re-experienced via dreams (nightmares), intrusive thoughts or images and the individual displays persistent avoidance of stimuli associated with the trauma. The individual may display the following symptoms:
Studies reveal a reduction in hippocampal volume and an increased blood flow in the amygdala in people with PTSD. Alterations in the HPA system have also been found in individuals with PTSD. Other results suggest that norepinephrine hyperactivity may contribute to the symptomatology underlying this disorder.
This disorder is generally diagnosed if the symptoms persist for more than one month, causing clinically significant distress and impairment in social, occupational or other important areas of functioning.
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