Anxiety disorder

Aetiology:

Genetic factors:

• Anxiety neurosis occurs in 15% of relatives of affected patients (compared to 3% of the general population)

Psychodynamic theory:

• Suggests that anxiety neurosis reflects overwhelming stress, anxiety and difficulties in the child-parent relationship in early childhood or even at birth

Learning theory:

• Regards anxiety as a fear response that has been attached to another stimulus through conditioning

Types of anxiety:

More or less continuous:

• Fluctuates to some extent in response to environmental circumstances

Panic attacks:

• Sudden and unpredictable attacks of anxiety
• Usually accompanied by severe physical symptoms

Phobic anxiety:

• Is anxiety triggered by a single stimulus of set of stimuli that are predictable and that normally cause no particular concern to others
• E.g. claustrophobia, agoraphobia

An anxious personality:

An individual who has a lifelong tendency to experience tension and anxiety

Usually have a worrisome attitude towards life and a constant anticipation of setback and stress

Physical symptoms of anxiety:

Gastrointestinal:

• Dry mouth
• Difficulty in swallowing
• Epigastric discomfort
• Flatulence
• Diarrhoea (usually frequency)

Respiratory:

• ‘Hyperventilation syndrome’
• Feeling of chest constriction
• Difficulty in inhaling

Cardiovascular:

• Palpitations
• Awareness of missed beats
• Feeling of pain over heart

Genitourinary:

• Increased frequency
• Failure of erection
• Lack of libido

Nervous system:

• Tinnitus
• Blurred vision
• Dizziness
• Headache
• Sleep disturbance

Hyperventilation syndrome:

Panic attacks (fear, terror and impending doom) accompanied by some or all of the following:

• Dyspnoea
• Palpitations
• Chest pain/discomfort
• Choking sensation
• Dizziness
• Paraesthesiae
• Sweating

Cause:

• Over-breathing leading to a decrease in P_aCO₂ and an increase in arterial pH

Diagnosis:

• A provocation test – voluntary over-breathing for 2-3 minutes provokes similar symptoms. Re-breathing from a paper bag relieves them

Management:

• Explanation and reassurance
• The patient is trained in relaxation techniques and slow breathing
• The patient is asked to breathe into a closed paper bag once the symptoms appear

Psychological symptoms of anxiety:

• Apprehension and fear
• Irritability
• Difficulty in concentrating
• Restlessness
• Sensitivity to noise
• Depression
• Depersonalization
• Obsessional symptoms

Differential diagnosis:

Psychiatric Physical

Depressive illness Hyperthyroidism

Schizophrenia Hypoglycaemia

Pre-senile dementia Phaeochromocytoma

Alcohol dependence

Drug dependence

Psychological treatment of anxiety neurosis:

• Reassurance
• Relaxation training
• Cognitive behavioural therapy (CBT)
• Individual and group psychotherapy

Drug treatment

Are 2 types of drugs – those that act on the CNS and those that block the ANS.

Centrally acting anxiolytic drugs:

Benzodiazepines

ANS blocking drugs:

E.g. propranolol