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Anxiety disorders

Last updated: January 24, 2020

Summary

Anxiety disorders cover a broad spectrum of conditions characterized by excessive and persistent fear (an emotional response to imminent threats), anxiety (the anticipation of a future threat), worry (apprehensive expectation), and/or avoidance behavior. The etiology of anxiety disorders is multifactorial and may involve genetic, developmental, environmental, neurobiological, cognitive, and psychosocial factors. Therapy typically consists of a combination of pharmacotherapy, especially selective serotonin reuptake inhibitors (SSRIs), and psychotherapy, especially cognitive-behavioral therapy (CBT).

For separation anxiety disorder and selective mutism, see the article on emotional and behavioral disorders in children and adolescents.

Overview

Generalized anxiety disorder (GAD) Panic disorder Social anxiety disorder (SAD) Specific phobias Agoraphobia Substance/medication-induced anxiety disorder

Clinical features

  • Prolonged and excessive anxiety not focused on a single specific fear
  • Pronounced anxiety of social situations that involve scrutiny from others
  • Persistent and intense fears of particular situations or objects
  • Pronounced fear or anxiety of situations that are perceived as difficult to escape from
  • Prominent anxiety or panic attacks after using or stopping a substance/medication
Triggers
  • No definitive trigger or source
  • May not have an obvious trigger
  • Social interaction and/or performance of any actions in public
  • One or more specific situations or objects
  • Being in enclosed spaces or open public spaces
  • Crowds
  • Being alone
Duration of symptoms required for diagnosis
  • ≥ 6 months
  • Panic attacks: several minutes
  • Fear of subsequent attacks: ≥ 1 month
  • ≥ 6 months
  • ≥ 6 months
  • ≥ 6 months in ≥ 2 different situations
  • Within 1 month of using or stopping the substance/medication
Treatment

Etiology

Risk and prognostic factors

  • Higher rates of anxiety disorders are reported in women.
  • Neurobiological factors
  • Substance use (leading to substance/medication-induced anxiety disorder)
  • Environmental and developmental factors
  • Other medical conditions

Generalized anxiety disorder

  • Definition: prolonged and excessive anxiety that is either unspecific or revolves around certain themes (e.g., health, work); not focused on a single specific fear
  • Epidemiology
    • Most common anxiety disorder among the elderly population
    • Lifetime prevalence: 5–10%
    • > (2:1)
  • Symptoms
    • Prolonged (≥ 6 months, occurring more days than not) and excessive anxiety
    • Anxiety causes clinically significant distress
    • Not caused by substance use, medication, or underlying medical condition
    • Fatigue and muscle tension
    • Restlessness and irritability
    • Sleep disturbances and difficulty concentrating
  • Treatment [1][2]
  • Differential diagnosis

References:[1][3][4][5][6]

Panic disorder

To remember the symptoms of a panic attack, think of “STUDENTS FEAR the 3Cs”: Sweating, Trembling, Unsteadiness (dizziness), Derealization, Elevated heart rate (palpitations), Nausea, Tingling, and Shortness of breath; FEAR of dying or going crazy; Chest pain, Choking, and Chills.

References:[8][9]

Social anxiety disorder

References:[3][10][11][12]

Specific phobias

  • Definition: persistent and intense fears of one or more specific situations or objects (phobic stimuli); always occurs during encounters with the phobic stimulus but may already surge in anticipation of an encounter
  • Epidemiology
    • Lifetime prevalence: approx. 5–10% of the population
    • The average age of onset depends on the specific phobia (e.g., animal phobias more commonly develop in early childhood).
    • > (2:1)
  • Common phobias
    • Animal: spiders (arachnophobia), insects (entomophobia), dogs (cynophobia)
    • Natural environment: heights (acrophobia), storms (astraphobia)
    • Blood-injection-injury: blood (hematophobia), needles (blenophobia), dental procedures (odontophobia), fear of injury (traumatophobia)
    • Situational: enclosed places (claustrophobia), flying (aviophobia)
    • Other: fear of vomiting (emetophobia), the number 13 (triskaidekaphobia), costumed characters (masklophobia), fear of clowns (coulrophobia)
  • Treatment

References:[13][14][15]

Agoraphobia

  • Definition: pronounced fear or anxiety of being in situations that are perceived as difficult to escape from or situations in which it might be difficult to seek help
  • Epidemiology
    • > (2:1)
    • Age of onset: < 35 years (60–70% of cases)
  • Clinical features
    • Fear, anxiety, or even panic attacks over a period of ≥ 6 months in ≥ 2 of the following 5 situations:
      • Using public transportation
      • Being in open spaces
      • Being in enclosed places
      • Standing in line or being in a crowd
      • Being outside of the home alone
    • Active avoidance of these settings unless a companion is present
    • Some patients can have comorbid panic disorder.
  • Treatment

If a patient meets the criteria for panic disorder and agoraphobia, both conditions should be diagnosed.

References:[16][17][18][18][18]

Substance/medication-induced anxiety disorder

References:[18][19][22]

References

  1. Vorspan F, Mehtelli W, Dupuy G, Bloch V, Lépine J-P. Anxiety and Substance Use Disorders: Co-occurrence and Clinical Issues. Curr Psychiatry Rep. 2015; 17 (2). doi: 10.1007/s11920-014-0544-y . | Open in Read by QxMD
  2. Kedzior KK, Laeber LT. A positive association between anxiety disorders and cannabis use or cannabis use disorders in the general population- a meta-analysis of 31 studies. BMC Psychiatry. 2014; 14 (1). doi: 10.1186/1471-244x-14-136 . | Open in Read by QxMD
  3. Bruce M. Anxiogenic Effects of Caffeine in Patients With Anxiety Disorders. Arch Gen Psychiatry. 1992; 49 (11): p.867. doi: 10.1001/archpsyc.1992.01820110031004 . | Open in Read by QxMD
  4. Kaplan K et al.. Substance-induced anxiety disorder after one dose of 3,4-methylenedioxymethamphetamine: a case report. J Med Case Reports. 2018; 12 (1). doi: 10.1186/s13256-018-1670-7 . | Open in Read by QxMD
  5. Diagnostic and Statistical Manual of Mental Disorders.
  6. Craske M, Bystritsky A, Stein MB, Hermann R. Approach to Treating Generalized Anxiety Disorder in Adults. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/approach-to-treating-generalized-anxiety-disorder-in-adults.Last updated: April 15, 2016. Accessed: July 26, 2017.
  7. Anxiety and Depression Association of America Clinical Practice Review for GAD. https://adaa.org/resources-professionals/practice-guidelines-gad. Updated: July 2, 2015. Accessed: October 1, 2019.
  8. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM–5). undefined. 2013 . doi: 10.1176/appi.books.9780890425596 . | Open in Read by QxMD
  9. Baldwin D, Stein MB, Hermann R. Generalized Anxiety Disorder in Adults: Epidemiology, Pathogenesis, Clinical Manifestations, Course, Assessment, and Diagnosis. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/generalized-anxiety-disorder-in-adults-epidemiology-pathogenesis-clinical-manifestations-course-assessment-and-diagnosis.Last updated: May 26, 2017. Accessed: July 26, 2017.
  10. Bystritsky A, Stein MB, Hermann R. Pharmacotherapy for Generalized Anxiety Disorder in Adults. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/pharmacotherapy-for-generalized-anxiety-disorder-in-adults.Last updated: April 25, 2016. Accessed: July 26, 2017.
  11. UpToDate. Buspirone: Drug Information. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/buspirone-drug-information.Last updated: January 1, 2018. Accessed: November 5, 2018.
  12. McCabe RE, Stein MB, Hermann R. Specific Phobia in Adults: Epidemiology, Clinical Manifestations, Course and Diagnosis. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/specific-phobia-in-adults-epidemiology-clinical-manifestations-course-and-diagnosis.Last updated: February 17, 2017. Accessed: July 26, 2017.
  13. Swinson R, McCabe RE, Stein MB, Hermann R. Pharmacotherapy for Specific Phobia in Adults. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/pharmacotherapy-for-specific-phobia-in-adults.Last updated: November 30, 2015. Accessed: October 12, 2017.
  14. McCabe RE, Swinson R, Stein MB, Hermann R. Psychotherapy for Specific Phobia in Adults. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/psychotherapy-for-specific-phobia-in-adults.Last updated: November 6, 2015. Accessed: October 12, 2017.
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