We have now completed our first three themes (Psychotic, Depressive, and Bipolar disorders). Now we will begin our theme of anxiety disorders which will include generalized anxiety disorder (GAD), phobias, social anxiety disorder (SAD), panic disorder (PD), and more. Over the next few weeks we will cover this topic in depth, but today will be an introduction to the clinical features and diagnostic criteria of anxiety disorders.
Today's Content Level: Beginner; Intermediate (Review)
WHAT IS ANXIETY?
•Anxiety is a feeling of worry, nervousness, or unease. It is often regarding an uncertain outcome, something in the future, or fear of embarrassment/rejection.
•Anxiety taps into our natural emotional and physical fear response that evolved to respond to perceived threats (hint: think of our hunter-gatherer ancestors).
•Anxiety is a common experience for all of us, but can be classified as a disorder when it becomes persistent, excessive, and impairing. Pathologic anxiety also occurs when the symptoms are irrational, out of proportion to the trigger, or are without an identifiable trigger.
•Like every DSM-V diagnosis, symptoms must cause significant distress or impairment and not be caused by another substance or medical condition.
EPIDEMIOLOGY / PATHOGENESIS
•We will discuss the epidemiology and pathogenesis of each anxiety disorder in following posts, but here we will provide an overview of anxiety disorders as a whole.
Pathogenesis
Caused by a combination of genetic, biological, environmental, and psychosocial factors.
Psychologically, anxiety is thought to be related to a hypersensitivity and overgeneralization of fear.
Major neurotransmitter systems implicated include norepinephrine, serotonin, and GABA.
Epidemiology
Collectively, anxiety disorders are the most common form of psychopathology.
Prevalence: 12-month prevalence = ~22%. Lifetime prevalence = ~34%.
Gender: overall occurs in women more than men in a 3:2 ratio.
Age: can present at any age and varies significantly by diagnosis. Median age of onset is 11 years old and 95% onset by age 51.
Please see disorder-specific posts for details of epidemiology and pathogenesis.
CLINICAL FEATURES OF SPECIFIC ANXIETY DISORDERS
•We will now provide a brief overview of the anxiety disorders in the DSMV. During later posts we will cover each of these disorders in depth to include their diagnostic criteria, epidemiology, work-up, differential diagnose, and treatment.
Generalized Anxiety Disorder (GAD)
Excessive chronic almost daily worry about various issues that is hard to control.
At least three physical symptoms also present such as fatigue, irritability, tense muscles, insomnia, etc...
Symptom duration ≥ 6 months although often a lifelong condition.
Specific Phobia
Anxiety bound to specific triggers. The object or situation almost always provokes immediate fear or anxiety.
Common triggers include animals/spiders, heights, needles, airplanes, elevators, etc...
Fear or avoidance typically lasts ≥ 6 months.
Social Anxiety Disorder (SAD)
Prominent fear of embarrassment or scrutiny or humiliation. Essentially they fear they will be negatively evaluated by others.
Must have significant anxiety in ≥ 1 social situations such as starting conversations, meeting new people, public speaking, dating, eating in front of people, etc...
The anxiety or avoidance is persistent, typically lasting ≥ 6 months.
Panic Disorder (PD)
Recurrent, unexpected panic attacks. Panic attack is described as an abrupt surge of intense anxiety and include both physical and cognitive symptoms.
Physical symptoms include sweating, palpitations, trembling, shortness of breath, chest pain, etc...
Cognitive symptoms include sense of impending doom, fear of dying, or feel like they are "going crazy".
At least one attack has been followed by ≥ 1 month of persistent worry of future attacks or avoidance behaviors.
Agoraphobia
Anxiety about having a panic attack or losing control in a place where escape is not possible.
Often comorbid with panic disorder.
Situations commonly include public transportation, being in open spaces such as a marketplace, being in enclosed places such as movie theaters, standing in lines/crowds, or being outside of the home alone.
Symptoms typically last ≥ 6 months.
Separation Anxiety Disorder
Excessive anxiety concerning separating from major attachment figures.
Demonstrated by recurrent and excessive distress when going to work or school, worrying about losing attachment figures or possible harm coming upon them, etc...
Must last ≥4 weeks in children/adolescents and ≥6 months in adults.
Selective Mutism
Consistent failure to speak in specific social situations (ex: school) despite speaking in other situations.
Not attributed to lack of knowledge or by a communication disorder.
Must occur for ≥1 month and not limited to the first month of school.
Other
Temporally related to substances/medications such as starting a new medication, intoxication, or withdrawal -> Substance/Medication-Induced Anxiety Disorder.
Associated with a medical illness -> Anxiety Disorder Due to Another Medical Condition.
Does not meet full criteria for other anxiety disorder but still clinically relevant anxiety -> Unspecified Anxiety Disorder or Other Specified Anxiety Disorder.
Anxiety symptoms that are related to a specific event or trauma are characterized as adjustment disorder, acute stress disorder, or postraumatic stress disorder which will be discussed in a different theme (Trauma and Adjustment Disorders).
CONCLUSIONS
There is a lot of information in this post, however it should mostly be a review for intermediate learners. Hopefully this provided a helpful overview and introduction to anxiety disorders. Next post we will discuss clinical pearls for anxiety disorders which will include tips on the clinical interview and general treatment considerations.
Resources used today include Pocket Psychiatry, Pocket DSM-V (I use the pocket version on a daily basis as a desk reference), and First Aid for the Psychiatry Clerkship.
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