Anxiety: Causes, Symptoms, and Treatment

What is Anxiety?

It is the distress caused and associated impairment or interference in the normal functioning of our body.

There are three systems of anxiety namely

1. cognitive system (what people think either before, during or after
   a situation where they feel anxious)
2. behavioral system (what people do when they
   are anxious)
3. physiological system (what happens in people’s bodies when they
   are anxious)

Type of Anxiety Disorders:

There are several DSM-5 anxiety disorders namely

1) Separation Anxiety Disorder

2)Selective Mutism

3) Specific Phobia

4)Social Anxiety Disorder (Social Phobia)

5)Panic Disorder

6)Agoraphobia

7)Generalized Anxiety Disorder

8)Substance/Medication-Induced Anxiety Disorder

9)Anxiety Disorder Due to Another Medical Condition,

10)Other Specified Anxiety Disorder

11) Unspecified Anxiety Disorder.

Specific Phobia

In specific phobia, people demonstrate a high level of fear, anxiety or avoidance concerning very specific, circumscribed situations or objects.
i.e. specific fears that are out of all proportion to any actual danger.

This is a disorder that usually develops in early childhood, with most cases beginning before the age of 10.

Types of phobic stimuli

The most common types of phobic stimuli are:

1. animals, for example, snakes
2. the natural environment, for example, storms
3. Blood-injection-injury, for example, injections
4. Situational, for example, enclosed spaces
5. other situations, for example, situations that a person associates with choking or vomiting.

Diagnostic Criteria

1. the fear, anxiety or avoidance must have been experienced for 6 months or longer.
2. the fear must cause clinically significant distress or interference, and must not be better explained by symptoms of any other mental illness.
3. a person must demonstrate extreme fear or anxiety about a specific situation or object almost always when confronted with the phobic object or situation.

Social Anxiety Disorder

Do you ever feel awkward in social situations?

Social Anxiety Disorder, often referred to as Social Phobia, is fear or anxiety about or avoidance of social situations and interactions in which there is the possibility of being scrutinized or judged by others.

Common social interactions that might be very anxiety-provoking for someone with this disorder include:

1. eating in front of others
2. performing in front of others
3. having to meet someone new.

This disorder is more common in females. Onset is between the ages of 8 and 15 years for about 75% of people with this disorder, with onset in adulthood being reasonably rare.

Diagnostic criteria

1. The anxiety must have been present for at least 6 months.
2. the fear must be out of proportion to the actual threat posed by the social interaction or situation
3. It must result in either intense distress and/or significant impairment in functioning.
4. the symptoms should not be explained by either another mental
   illness or the physiological effects of either substance use or a medical condition.

Generalized anxiety disorder

We all worry, right?

Generalized anxiety disorder or GAD, is essentially defined by excessive worrying. This disorder epitomizes the difficulty with the anxiety disorders in terms of drawing that line between what is within the broad parameters of normal anxiety and what is clinically significant anxiety.
Some of the differences with a GAD and non-clinical worrying would be that people who have a GAD may tell you that they experience their worry as totally uncontrollable.

Diagnostic criteria

1. The anxiety must have been present for at least 6 months.
2. a person must experience 3 out of 6 physiological symptoms associated with their anxiety or worry. e.g muscle tension, restlessness, distress.
3. a sense of hypervigilance, a sense that the world is a very dangerous place and that you need to be constantly on the lookout for danger to prevent bad things from happening to you.

Panic disorder

Panic disorder is characterized by recurrent, unexpected panic attacks.
Panic attacks, which are the building blocks of panic disorder, are defined in the DSM-5 as ‘an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes’.

Panic disorder is not commonly seen in children and is diagnosed about twice as often in females as in males.

What is a Panic attack?

It relates to the tendency of people with Panic Disorder to misinterpret
the physical symptoms like sweaty palms, a racing heart, trembling or a sense of nausea; they are experiencing.

Here the problem is in how the person is making sense of the physical symptoms. e.g. pounding heart can is misunderstood for a heart attack.

A panic attack involves four or more of the following symptoms, which are mainly physiological sensations:

1. Palpitations
2. pounding heart or accelerated heart rate.
3. Sweating.
4. Trembling or shaking.
5. Sensations of shortness of breath or smothering.
6. Feelings of choking.
7. Chest pain or discomfort
8. Nausea or abdominal distress.
9. Feeling dizzy, unsteady, lightheaded, or faint.
10. Chills or heat sensations.
11. Paresthesias which is numbness or tingling sensations.
12. Derealization — which is feelings of unreality
13. depersonalization — being detached from oneself.
14. Fear of losing control or “going crazy.”
15. Fear of dying.

Diagnostic criteria

To meet the criteria for Panic Disorder, at least one panic attack must have been followed by at least a month of either or both of the following:

1. Persistent anticipatory anxiety or concern about having another attack or the consequences of having an attack.
2. A significant and problematic behavioral change related to the attack, for example, avoiding any form of exercise because the person believes that exercise might induce a panic attack.

Causal models of anxiety disorders

1. heritability accounts for upwards of 30–40% of the variance in the development of anxiety disorders (Hettema et al., 2001).
2. Temperamental quality of behavioral inhibition — characterized
   by shyness, fear of unfamiliar situations and withdrawal — has been identified as an important risk factor.
   (REF: Svihra & Katzman, 2004; Behavioural inhibition: A predictor of anxiety. Paediatr Child Health. 2004 Oct; 9(8): 547–550.)
3. Important environmental factors include exposure to potentially traumatic events, an accumulation of stressful life events, and parenting behaviors, such as modeling and overprotection. (Ref: Rapee (2012).
4. Family factors in the development and management of anxiety disorders.
   (ref Clin Child Fam Psychol Rev. 2012 Mar;15(1):69–80.
   DOI: 10.1007/s10567–011–0106–3.; Ref: Last et al., (1984).
   Precipitants of Agoraphobia: Role of Stressful Life Events.
   DOI: 10.2466/pr0.1984.54.2.567 Psychol Rep April 1984 vol. 54 no.
   2 567–570)

Nowadays there is a consensus that the best way of understanding how anxiety disorders develop is by considering how biological risks may interact with environmental triggers.

Cognitive Behavioural models of anxiety

Rachman proposed three pathways through which people might develop fear.

The first is through their own direct experience, which may become generalized through conditioning.

for example, if you have experienced a dog biting you, you might acquire a fear of dogs, which might then generalise to various other animals or not.

The second pathway is instructional learning, which involves the transmission of information relating to danger.

For example, when a parent repeatedly warns a child to stay away from pools because people drown in pools all the time, the child might develop a fear of pools.

The third pathway that Rachman proposed was vicarious learning.
This is when you repeatedly see someone else, usually an important person in your life such as a parent, behave fearfully when confronted by a particular stimulus, and then you develop that fear yourself.

Treatment for anxiety disorders

1. The frontline intervention for treating anxiety disorders is cognitive-behavioral therapy or CBT.
   CBT is an efficacious treatment across diagnoses, resulting in superior outcomes compared to waitlist control conditions and expectancy control treatments. A systematic review of studies evaluating CBT in the treatment of anxiety disorders in children and adolescents reported an average remission rate (defined as participants being free of their primary anxiety diagnosis at post-treatment) of 56.5%.

A significant proportion of people don’t respond to CBT in the first instance. In addition, of those who do respond, a significant minority appear to experience a recurrence in their symptoms over time.

Other methods of treatment

1. medication
2. psychoeducation about anxiety
3. cognitive restructuring and exposure.