Anxiety

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List of terms related to Anxiety

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

Anxiety is a physiological state characterized by cognitive, somatic, emotional, and behavioral components (Seligman, Walker & Rosenhan, 2001). These components combine to create the feelings that we typically recognize as fear, apprehension, or worry. Anxiety is often accompanied by physical sensations such as heart palpitations, nausea, chest pain, shortness of breath, or headache.

The cognitive component entails expectation of a diffuse and uncertain danger. Somatically the body prepares the organism to deal with threat (known as an emergency reaction): blood pressure and heart rate are increased, sweating is increased, bloodflow to the major muscle groups is increased, and immune and digestive system functions are inhibited. Externally, somatic signs of anxiety may include pale skin, sweating, trembling, and pupillary dilation. Emotionally, anxiety causes a sense of dread or panic and physically causes nausea, and chills. Behaviorally, both voluntary and involuntary behaviors may arise directed at escaping or avoiding the source of anxiety and often maladaptive, being most extreme in anxiety disorders. However, anxiety is not always pathological or maladaptive: it is a common emotion along with fear, anger, sadness, and happiness, and it has a very important function in relation to survival.

Neural circuitry involving the amygdala and hippocampus is thought to underlie anxiety (Rosen & Schulkin, 1998). When confronted with unpleasant and potentially harmful stimuli such as foul odors or tastes, PET-scans show increased bloodflow in the amygdala (Zald & Pardo, 1997; Zald, Hagen & Pardo, 2002). In these studies, the participants also reported moderate anxiety. This might indicate that anxiety is a protective mechanism designed to prevent the organism from engaging in potentially harmful behaviors.

Anxiety disorders

Complete List of Differential Diagnoses

Agoraphobia
Anxiety disorder due to general medical conditions
- Cardiovascular
- Respiratory
- Endocrine
- Neurological
- Cancer
Bipolar Disorder
Depression
Generalized anxiety disorder
Medications
Obsessive-Complusive Disorder
Panic disorder
Parkinson's Disease
Pheochromocytoma
Post-traumatic or acute stress disorder
Social anxiety disorder
Specific phobia
Substance use

Diagnosis

The Generalized Anxiety Disorder [GAD]-2 scale can screen for the four most common anxiety disorders (posttraumatic stress disorder, generalized anxiety disorder, panic disorder, and social anxiety disorder) and the Generalized Anxiety Disorder [GAD]-7 scale can add certainty.^[1]

GAD-2

The Generalized Anxiety Disorder (GAD) - 2 scale is^[1]:

"During the past month, have you been bothered a lot by:"

1. 'nerves' or feeling anxious or on edge?

'Not at all' = 0pts; 'Several days' = 1 pt; 'More than half of the days' =2 pts; 'Nearly every day' =3 pts

2. worrying about a lot of different things?

'Not at all' = 0pts; 'Several days' = 1 pt; 'More than half of the days' =2 pts; 'Nearly every day' =3 pts

The performance of the GAD-2 in diagnosing any anxiety disorder is^[1]:

2 or more points:

sensitivity 86%
specificity 70%

3 or more points:

sensitivity 65%
specificity 88%

GAD-7

The Generalized Anxiety Disorder (GAD) - 7 scale is copyrighted. Its full text is available at http://annals.org/cgi/content/full/146/5/317/FA1 ^[1]:

The performance of the GAD-7 in diagnosing any anxiety disorder is^[1]:

8 or more points:

sensitivity 77%
specificity 82%

History and Symptoms

Detailed history
- Duration
- Onset
- Type of anxiety
Events causing anxiety
- Stressors
- Medical illnesses
Drug and medication history

Physical Examination

Physical exam important to rule out organic medical diseases

Anxiety in palliative care

Some research has strongly suggested that treating anxiety in cancer patients improves their quality of life. The treatment generally consists of counseling, relaxation techniques or pharmacologically with benzodiazepines.

Theories

Two factor theory of anxiety

Sigmund Freud recognized anxiety as a "signal of danger" and a cause of "defensive behavior". He believed we acquire anxious feelings through classical conditioning and traumatic experiences.

We maintain anxiety through operant conditioning; when we see or encounter something associated with a previous traumatic experience, anxious feelings resurface. We feel temporarily relieved when we avoid situations which make us anxious, but this only increases anxious feelings the next time we are in the same position, and we will want to escape the situation again and therefore will not make any progress against the anxiety.

Types of anxiety

Existential anxiety

See more under existential crisis.

Theologians like Paul Tillich and psychologists like Sigmund Freud have characterized anxiety as the reaction to what Tillich called, "The trauma of nonbeing." That is, the human comes to realize that there is a point at which he or she might cease to be (die), and their encounter with reality becomes characterized by anxiety. Religion, according to both Tillich and Freud, then becomes a carefully crafted coping mechanism in response to this anxiety since they redefine death as the end of only the corporal part of human personal existence, assuming an immortal soul. What then becomes of this soul and through what criteria is the cardinal difference of various religious faiths.

Philosophical ruminations are a part of this condition, and this is part of obsessive-compulsive disorder. They are typically about sex and religion or death.

According to Viktor Frankl, author of Man's Search for Meaning, when faced with extreme mortal dangers the very basic of all human wishes is to find a meaning of life to combat this "trauma of nonbeing" as death is near and to succumb to it (even by suicide) seems like a way out.

Test anxiety

Test anxiety is the uneasiness, apprehension, or nervousness felt by students who have a fear of failing an exam. Students suffering from test anxiety may experience any of the following: the association of grades with personal worth, embarrassment by a teacher, taking a class that is beyond their ability, fear of alienation from parents or friends, time pressures, or feeling a loss of control. Emotional, cognitive, behavioral, and physical components can all be present in test anxiety. Sweating, dizziness, headaches, racing heartbeats, nausea, fidgeting, and drumming on a desk are all common. An optimal level of arousal is necessary to best complete a task such as an exam; however, when the anxiety or level of arousal exceeds that optimum, it results in a decline in performance. Because test anxiety hinges on fear of negative evaluation, debate exists as to whether test anxiety is itself a unique anxiety disorder or whether it is a specific type of social phobia. In 2006, approximately 49% of high school students were reportedly suffering from this condition.

While the term test anxiety refers specifically to students, many adults share the same experience with regard to their career or profession. The fear of failing a task and being negatively evaluated for it can have a similarly negative effect on the adult.

Stranger anxiety

Anxiety when meeting or interacting with unknown people is a common stage of development in young people.

So-called "stranger anxiety" in younger people is not a phobia in the classic sense; rather it is a developmentally appropriate fear by young children of those who do not share a 'loved-one', caretaker or parenting role. In adults, an excessive fear of other people is not a developmentally common stage.

Treatment

Patient education
Biofeedback
Cognitive behavioral therapy

Pharmacotherapy

Acute Pharmacotherapies

For obsessive-compulsive disorder:
- SSRIs (selective serotonin reuptake inhibitors) in high doses
For general anxiety disorder, pharmacology proves to be beneficial:
- Antidepressants
- Benzodiazepines (some concern over dependency)
- Buspirone
For panic disorder:

References

↑ ^1.0 ^1.1 ^1.2 ^1.3 ^1.4 Kroenke K, Spitzer RL, Williams JB, Monahan PO, Löwe B (2007). "Anxiety disorders in primary care: prevalence, impairment, comorbidity, and detection". Ann. Intern. Med. 146 (5): 317–25. PMID 17339617.

Sources

Rosen, J.B. & Schulkin, J. (1998): "From normal fear to pathological anxiety". Psychological Review. 105(2); 325-350.
Seligman, M.E.P., Walker, E.F. & Rosenhan, D.L. (2001). Abnormal psychology, (4th ed.) New York: W.W. Norton & Company, Inc.
Zald, D.H., Hagen, M.C. & Pardo, J.V. (2002). "Neural correlates of tasting concentrated quinine and sugar solutions". J. Neurophysiol. 87(2), 1068-75.
Zald, D.H. & Pardo, J.V. (1997). "Emotion, olfaction, and the human amygdala: amygdala activation during aversive olfactory stimulation." Proc Nat'l Acad Sci USA. 94(8), 4119-24.