eMedicine Specialties > Psychiatry > Adult

Anxiety Disorders

Author: William R Yates, MD, MS, Research Psychiatrist, Laureate Institute for Brain Research; Professor of Research, Department of Psychiatry, University of Oklahoma College of Medicine at Tulsa
Contributor Information and Disclosures

Updated: Oct 26, 2009

Introduction

Background

Anxiety disorders are common psychiatric disorders. Many patients with anxiety disorders experience physical symptoms related to anxiety and subsequently visit their primary care providers. Despite the high prevalence rates of these anxiety disorders, they often are underrecognized and undertreated clinical problems. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) classifies the anxiety disorders into the following categories:¹

• Anxiety due to a general medical condition
• Substance-induced anxiety disorder
• Generalized anxiety
• Panic disorder
• Acute stress disorder
• Posttraumatic stress disorder (PTSD)
• Adjustment disorder with anxious features
• Social phobia
• Obsessive-compulsive disorder (OCD)
• Specific phobias

For related information, see Medscape's Anxiety Disorders Resource Center.

Case study
 
Ms J is a 22-year-old college student who is in her senior year in college. Over the past several months she has developed recurrent unexpected periods of chest pain accompanied by shortness of breath, trembling, numbness, tingling, and a feeling of doom. These spells began abruptly and lasted for 30-45 minutes. She began to worry more and anticipated future attacks. Her academic work began to suffer as she had increasing difficulty concentrating. 

After one episode, fearing a heart attack, Ms J went to the emergency room. Her ECG and physical examination were normal and there were no laboratory abnormalities. A follow-up visit to her family physician failed to support evidence of a heart or lung disorder. Her family physician diagnosed panic disorder and suggested she consider getting some counseling. She was placed on citalopram 10 mg, increasing to 20 mg. Following several weeks on the medication, her panic spells were reduced in frequency but not completely gone. She still has recurring spells that are less severe with fewer symptoms.

Ms J went to student health where she was assigned a therapist who started cognitive behavioral therapy. This therapy focused on relaxation and changing her exaggerated thoughts about the seriousness of her symptoms. Over 6 weeks, her symptoms continued to improve and were no longer considered serious or impairing her function.

Pathophysiology

Anxiety disorders appear to be caused by an interaction of biopsychosocial factors, including genetic vulnerability, which interact with situations, stress, or trauma to produce clinically significant syndromes. In the central nervous system, the major mediators of the symptoms of anxiety disorders appear to be norepinephrine and serotonin. Other neurotransmitters and peptides, such as corticotropin-releasing factor, may be involved. Peripherally, the autonomic nervous system, especially the sympathetic nervous system, mediates many of the symptoms.

Frequency

United States

Two major studies in the United States have estimated the prevalence rates for a variety of anxiety disorders. These 2 studies are the Epidemiological Catchment Area (ECA) study and the National Comorbidity Survey (NCS) study² . Using these and other studies, the estimated lifetime prevalence rates for individual anxiety disorders are panic disorder (2.3-2.7%), generalized anxiety disorder (4.1-6.6%), OCD (2.3-2.6%), PTSD (1-9.3%), and social phobia (2.6-13.3%).

International

The prevalence of specific anxiety disorders appears to vary between countries and cultures. A cross-national study of the prevalence of panic disorder found lifetime prevalence rates ranging from 0.4% in Taiwan to 2.9% in Italy. A cross-cultural study of the prevalence of OCD found lifetime prevalence rates ranging from 0.7% in Taiwan to 2.5% in Puerto Rico.

Mortality/Morbidity

• Anxiety disorders may contribute to morbidity and mortality through neuroendocrine and neuroimmune mechanisms or by direct neural stimulation, eg, hypertension or cardiac arrhythmia.
• Severe anxiety disorders may be complicated by suicide, with or without secondary mood disorders (eg, depression). Anxiety disorders have high rates of comorbidity with major depression and alcohol and drug abuse. Some of the increased morbidity and mortality associated with anxiety disorders may be related to this high rate of comorbidity. The ECA study found that panic disorder was associated with suicide attempts (odds ratio=18 compared to populations without psychiatric disorders). How much of the association of panic disorder with suicide is mediated through the association of panic disorder with mood and substance abuse disorders is unclear. Acute stress may play a role in producing suicidal behavior. Suicide attempts can be precipitated by adverse life events such as divorce or financial disaster. The effects of acute stress in producing suicidal behavior are increased in those with underlying mood, anxiety, and substance abuse problems.
• Chronic anxiety may be associated with increased risk for cardiovascular morbidity and mortality.

Race

• The ECA study found no difference in rates of panic disorder among white, African American, or Hispanic populations in the United States.
• Some studies have found higher rates of PTSD in minority populations. Some of this association may be due to higher rates of specific traumatic events (ie, assault) in minority populations.

Sex

The female-to-male ratio for any lifetime anxiety disorder is 3:2.

Age

• Most anxiety disorders begin in childhood, adolescence, and early adulthood. Separation anxiety is an anxiety disorder of childhood that often includes anxiety related to going to school. This disorder may be a precursor for adult anxiety disorders. Panic disorder demonstrates a bimodal age of onset in the NCS study in the age groups of 15-24 years and 45-54 years. The median age of onset of social phobia in the NCS study was 16 years. The age of onset for OCD appears to be in the mid 20s to early 30s.
• New-onset anxiety symptoms in older adults should prompt a search for an unrecognized general medical condition, a substance abuse disorder, or major depression with secondary anxiety symptoms.

Clinical

History

Symptoms vary depending on the specific anxiety disorder. To rule out anxiety disorders secondary to general medical or substance abuse conditions, a detailed history and review of symptoms is essential. Review use of caffeine-containing beverages (coffee, tea, colas, Mountain Dew), over-the-counter medications (aspirin with caffeine, sympathomimetics), herbal "medications," or street drugs. Ask the patient's sleep partner about apneic episodes or myoclonic limb jerks. Concurrent depressive symptoms are common in all of the anxiety disorders. Severe anxiety disorders may produce agitation, suicidal ideation, and increased risk of completed suicide. Always ask about suicidal ideation or suicidal intent.  

• Obtain a complete Mental Status Examination for each patient with anxiety symptoms. Patients may exhibit physical signs of anxiety such as sweaty palms, restlessness, and distractibility. Patients are generally oriented times 3 and cooperative. Mood may be normal or depressed. Affect is often preserved. Psychotic symptoms are not typical of uncomplicated anxiety disorders. Suicidal ideation should be assessed by asking about passive thoughts of death, desires to be dead, thoughts of harming self, or plans or acts to harm self. Homicidal ideation is uncommon. Cognition is typically intact with no impairment in memory, language, or speech. Insight and judgment are typically intact.
• Panic disorder is characterized by recurrent panic attacks (ie, periods of intense fear of abrupt onset peaking in intensity within 10 min). Four of the following must be present for a panic attack:
  • Palpitations, pounding heart, or accelerated heart rate
  • Sweating
  • Trembling or shaking
  • Shortness of breath or dyspnea
  • Sensation of choking
  • Chest pain or discomfort
  • Nausea or abdominal distress
  • Feeling dizzy, unsteady, lightheaded, or faint
  • Derealization or depersonalization
  • Fear of losing control or going crazy
  • Fear of dying
  • Paresthesias
  • Chills or hot flashes
  • Although not a diagnostic feature, suicidal ideation and completed suicide have been associated with panic disorder.
• Generalized anxiety disorder is characterized by excessive anxiety and worry. Worrying is difficult to control. Anxiety and worry are associated with at least 3 of the following symptoms:
  • Restlessness or feeling keyed-up or on edge
  • Being easily fatigued
  • Difficulty concentrating or mind going blank
  • Irritability
  • Muscle tension
  • Sleep disturbance
  • Although not a diagnostic feature, suicidal ideation and completed suicide have been associated with generalized anxiety disorder.
• OCD is characterized by obsessions or compulsions. Obsessions or compulsions must be recognized as unreasonable or excessive and must cause marked distress.
  • Obsessions include all of the following:
    • Recurrent and persistent thoughts, impulses, or images that are intrusive and knowingly inappropriate and cause anxiety or distress
    • Obsessions are very discomforting and can include fear of losing control and harming someone close to the patient, such as his or her child.
    • Patient commonly knows he or show won't act on the obsessions, but it will still cause significant distress.
    • Obsessions may be hidden by the patient for fear of being called "crazy."
    • Thoughts, impulses, or images that are not simply excessive worries about real-life problems
    • Attempts are made to ignore or suppress thoughts.
    • Thoughts, impulses, or images are recognized as being the product of the mind and not imposed from an outside force.
  • Compulsions include the following:
    • Repetitive behaviors, such as handwashing, ordering, and checking, that people feel are driven and must be carried out and occur to such an extreme that a person's ability to function is impaired.
    • Behaviors or mental acts are done to reduce distress or anxiety.
• Social phobia
  • Marked and persistent fear of social or performance situations to the extent that a person's ability to function at work or in school is impaired.
  • Exposure to social or performance situation always produces anxiety.
  • Fear/anxiety recognized as excessive
  • Social or performance situations are avoided or endured with intense anxiety.
  • Avoidance behavior, anticipation, or distress in the feared social or performance setting produces significant impairment in functioning.
• PTSD is a severe trauma that is experienced that includes (1) actual or threatened death or serious injury or threat to personal integrity of self or others and (2) responses that include intense fear, helplessness, or horror. (Life-threatening experiences and the attendant loss of control are key elements.)
  • Persistent reexperience of the event occurs by at least 1 of the following:
    • Recurrent and intrusive recollections
    • Recurrent distressing dreams/nightmares
    • Feelings of reliving traumatic event, ie, flashbacks
    • Intense psychologic distress with internal or external cues to the trauma
    • Physiological reactivity on exposure to trauma cues
  • Persistent avoidance of stimuli of trauma and numbing/avoidance behavior demonstrated by at least 3 of the following:
    • Avoidance of thoughts or conversation related to the trauma
    • Avoidance of activities, places, or people related to the trauma
    • Amnesia for important trauma-related events
    • Decreased participation in significant activities
    • Feeling detached or estranged from others
    • Restricted affect
    • Foreshortened sense of the future
  • Persistent symptoms of increased arousal demonstrated by 2 or more of the following:
    • Difficulty staying or falling asleep
    • Irritability or anger outbursts
    • Difficulty concentrating
    • Hypervigilance
    • Exaggerated startle response
  • Although not a diagnostic feature, suicidal and homicidal ideation have been associated with PTSD.

Physical

• Tremor
• Tachycardia
• Tachypnea
• Sweaty palms
• Restlessness

Causes

• First, evaluate for anxiety due to a known or unrecognized medical condition.
• Most presenting anxiety disorders are functional psychiatric disorders.
• The psychodynamic theory has explained anxiety as a conflict between the id and ego. Aggressive and impulsive drives may be experienced as unacceptable resulting in repression. These repressed drives may break through repression, producing automatic anxiety.
• Cognitive theory has explained anxiety as the tendency, to overestimate the potential for danger. Patients with anxiety disorder patients tend to imagine the worst possible scenario and avoid situations they think are dangerous such as crowds, heights, or social interaction.
• Substance-induced anxiety disorder (over-the-counter medications, herbal medications, substances of abuse) is a diagnosis that often is missed.

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