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Anxiety

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Vindhya BellamKonda, M.B.B.S [2], Shankar kumar,M.B.B.S. Synonyms and keywords: Angst, trouble, anxiety disorder.

Overview

Overview

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Vindhya BellamKonda, M.B.B.S [2]

Overview

Anxiety is a physiological state characterized by cognitive, somatic, emotional, and behavioral components. 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.

Historical Perspective

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.

Classification

According to DSM-5 diagnostic criteria, anxiety is classified as follows:

Pathophysiology

Various theories have been implicated in the pathogenesis of anxiety which are as follows: Biologic( increased sympathetic tone and decreased GABA), psychoanalytic component(Freud described that anxiety is developmentally related to childhood fears of disintegration that derive from the fear of actual or imagined loss of a love object or fear of bodily harm), learning theory ( where anxiety is attributed to continuous exposure to stress), about 5% individuals with anxiety have polymorphic variant of the gene associated with serotonin transporter metabolism.

Causes

Life threatening causes of anxiety include anaphylaxis, acute coronary syndromes, cardiogenic shock, and myocardial infarction. Other common causes of anxiety include anemia, caffeine, diabetes, and hyperthyroidism.

Differential diagnosis

Anxiety must be differentiated from: Major depressive disorder, bipolar disorder, atypical psychosis, schizophrenia, substance related disorder, cognitive disorder. Some of the medical conditions similar to anxiety are myocardial infarction/angina pectoris, hyperventilation syndrome, hypoglycemia, hyperthyroidism, carcinoid.

Epidemiology and demographics

The prevalence of anxiety is estimated to 28800 per 100,000 (28.8%) individuals. The female to male ratio is 3 to 2.

Risk factors

Common risk factors in the development of anxiety are: Depression, Alcohol, low socio-economic status, bipolar disorder, urbanization, stress, family history ofanxiety, unemployment,substance abuse

Natural history, complications and prognosis

If left untreated, anxiety may cause consequences such as depression, suicide, substance abuse, insomnia, compromised immune system.

Diagnosis

History and Symptoms | Physical Examination | Laboratory Findings | Imaging Findings

History and symptoms

The most common symptoms of anxiety is inappropriate worry about multiple factors, restlessness, fatigue, insomnia, and impairment in functioning of the individual. The symptoms must be persistent for at least a duration of six months.

Physical examination

The following are the some of the physical examination findings associated with anxiety :Tachycardia, tremors, sweating, restlessness, twitches, shortness of breath.

Lab tests

The diagnosis of anxiety is mostly clinical, based on a thorough history and physical exam. Lab tests are done to rule out other medical causes that cause anxiety. Some of the lab tests that could help differentiate anxiety causing conditions are as follows: CBC, BMP, urine analysis, urine drug screen, thyroid function tests, urine catecholamines

Electrocardiogram

The EKG in anxiety is characterized by sinus tachycardia.

Imaging studies

The diagnosis of anxiety is mostly clinical, based on a thorough history and physical exam. Imaging studies should not be routinely done, but rather be guided by pertinent findings in the history and physical exam and ruling out secondary causes.

Treatment

Medical Therapy | Primary Prevention | Secondary Prevention | Cost-Effectiveness of Therapy | Future or Investigational Therapies

Medical therapy

The mainstay of therapy for anxiety is the administration of pharmacotherapy and psychotherapy, pharmacotherapy includes treatment with benzodiazepine, buspirone, tricyclic antidepressant, SSRI . Cognitive behavioral therapy is the main stay of psychotherapy

Primary prevention

There is no established method for the prevention of anxiety. Although there is no proven way to prevent anxiety, early identification of stressors, getting help to cope with crisis situations and avoiding substances that can induce anxiety to some extent can minimize severity of symptoms.

Secondary prevention

The secondary prevention of anxiety is same as its primary prevention.

References

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Historical Perspective

Historical Perspective

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Vindhya BellamKonda, M.B.B.S [2]

Overview

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.

Historical perspective

References

  1. ↑ Bandelow B, Michaelis S (2015). “Epidemiology of anxiety disorders in the 21st century”. Dialogues Clin Neurosci. 17 (3): 327–35. PMC 4610617. PMID 26487813.

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Classification

Classification

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Vindhya BellamKonda, M.B.B.S [2]

Overview

Anxiety may be classified according to the DSM V criteria into the following subgroups: Generalized anxiety disorder, panic attack, separation anxiety disorder, social anxiety disorder, agoraphobia, substance/medication induced anxiety, selective mutism, specific phobia, anxiety due to another medical condition, unspecified anxiety disorder.

Classification

According to DSM-5 diagnostic criteria, anxiety is classified as follows:[1][2]

Classification Features
Generalized anxiety disorders
  • Excessive wory about multiple life events for a period of atleast six months. The worry is disproportionate compared to the actual stressor.
Separation anxiety disorder
  • More common in children.
  • Recurrent excessive worry when anticipating or experiencing separation from home or major attachment figures.
Panic disorder.
  • Recurrent unexpected panic attacks. Excessive worry about additional panic attack.
Social anxiety disorder.
  • Excessive anxiety about social situations where the individual is worried about scrutiny by others.
Agoraphobia
  • Fear of places or (specific) circumstances, where an individual perceives as difficult to escape.
Substance/medication induced anxiety disorder
Selective mutism
  • Failure to speak in certain situations in which there is an expectation for speaking(e.g., school) but is able to speak at home.
Specific phobia
  • Persistent fear of a certain object or situation (e.g., fear of heights, fear of animals).
Anxiety due to another medical condition
  • Fear is due to direct result of a medical condition.
Unspecified anxiety disorder
  • This classification applies to conditions in which anxiety is predominant but do not meet full criteria for any of the disorders in the DSM-5 classification of anxiety disorders.

References

  1. ↑ Kampman O, Viikki M, Leinonen E (2017). “Anxiety Disorders and Temperament-an Update Review”. Curr Psychiatry Rep. 19 (5): 27. doi:10.1007/s11920-017-0779-5. PMID 28417269.
  2. ↑ Craske MG, Stein MB (2016). “Anxiety”. Lancet. 388 (10063): 3048–3059. doi:10.1016/S0140-6736(16)30381-6. PMID 27349358.

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Causes

Causes

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Vindhya BellamKonda, M.B.B.S [2]

Overview

Life threatening causes of anxiety include anaphylaxis, acute coronary syndromes, cardiogenic shock, and myocardial infarction. Other common causes include anemia, caffeine, diabetes, and hyperthyroidism.

Causes

Life Threatening Causes

Common Causes

Causes by Organ System

[1][2][3][4][5]

Cardiovascular Accelerated hypertension , Acute Coronary Syndromes, Angina pectoris, Aortic aneurysm, Bacterial pericarditis, Cardiac arrhythmia, Cardiac tamponade, Cardiogenic shock, Cerebrovascular disease, Chest pain, chronic orthostatic hypotension, Congenital heart disease, Congestive cardiac failure, Constrictive pericarditis , constrictive tuberculous pericarditis , decreased cardiac output, Heart disease, Hypertension, Mitral valve prolapse, Myocardial infarction, Orthostatic intolerance, Postural orthostatic tachycardia syndrome, Sinus arrhythmia, Sinus node disease, Sinus tachycardia Supraventricular tachycardia
Chemical / poisoning Amines, Barium nitrate, Carbamate insecticide poisoning, Carbon disulfide,Lead poisoning, Manganese, Mercury, Organophosphate poisoning
Dermatologic Acne, insect bite allergy, lupus, Pellagra, Vitiligo
Drug Side Effect Acamprosate calcium, Acetaminophen, alpha-methyltryptamine, amantadine, amobarbital sodium, amphetamine, antidepressants, anorexia nervosa, aripiprazole, armodafinil, bortezomib, buprenorphine, bupropion, buspirone, butorphanol, caffeine, cannabis, carbamazepine, cimetidine, clobazam, clofarabine Injection, cocaine, caspofungin acetate, cyclosporine, dexamethasone Oral, dextroamphetamine and Amphetamine, dicyclomine, diphenhydramine, doxylamine, ECA stack, efavirenz, enoxacin, epinephrine (aerosol), ethcathinone, ethynodiol diacetate and ethinyl estradiol, Fentanyl fludrocortisone acetate, fluticasone Oral Inhalation , fluoxetine, fluphenazine, fluticasone Oral Inhalation, gabapentin, ginseng, paroxetine, pergolide, phencyclidine, phenylephrine
Ear Nose Throat Burning mouth syndrome, cholesteatoma, infectious mononucleosis, middle ear infection
Endocrine Addison’s disease, adrenal cortex diseases, adrenal gland hypofunction, autoimmune thyroid diseases, Graves disease, adrenal hypertension, adrenal tumor, anorexia nervosa, autoimmune thyroid diseases, carcinoid syndrome, congenital adrenal hyperplasia, conn syndrome-induced hypertension, cushing’s disease, cushing syndrome, diabetes, eating disorder, Ectopic ACTH Syndrome, Graves disease, high t4 syndrome, hyperthyroidism, hyperparathyroidism hypoadrenalism, hypoglycaemia, hypoparathyroidism, hypothyroidism, insulinoma, multiple endocrine neoplasia type 1, pheochromocytoma, pituitary dysfunction, postpartum thyroiditis, subacute thyroiditis
Environmental Nitrogen narcosis
Gastroenterologic Anorexia nervosa, carcinoid syndrome, celiac disease, chest pain, congenital hepatic porphyria, Crohn’s disease, eating disorder, hepatic encephalopathy syndrome, hiatus hernia, irritable bowel syndrome, pellagra, ulcerative colitis, Wilson’s disease
Genetic 22q11.2 deletion syndrome, acute intermittent porphyria, Asperger syndrome, celiac disease, chromosome 22q deletion, congenital heart disease, Crohn’s disease, early-onset Alzheimer’s disease, familial dysautonomia, Gulf War syndrome, heritable connective tissue disorders, velocardiofacial syndrome, WAGR syndrome
Hematologic Anemia
Iatrogenic Akathisia
Infectious Disease Brucellosis, cystitis, encephalitis, infectious mononucleosis, neurosyphilis, rabies, tetanus, toxic shock syndrome, variant Creutzfeldt-Jakob disease
Musculoskeletal / Ortho Tension myositis
Neurologic Aging brain syndrome, akathisia, Alzheimer disease, Asperger syndrome, autism, autoimmune limbic encephalitis, autonomic dysreflexia autonomic hyperreflexia, brain tumor, delirium, delirium tremens, dementia, early-onset Alzheimer’s, encephalitis, familial dysautonomia, head injury, hepatic encephalopathy syndrome, Huntington’s disease, hypersomnia, limbic encephalitis, multiple sclerosis, pellagra, post-concussion syndrome, Right parietal lobe syndrome, subarachnoid hemorrhage, temporal arteritis, temporal lobe epilepsy, vascular malformations of the brain, Wernicke-Korsakoff syndrome, Wilson’s disease
Nutritional / Metabolic Acute intermittent porphyria, celiac disease, food additives, glycogen storage disease type 6, hyperglycemia, hypoglycaemia, inborn amino acid metabolism disorder, pellagra, Wernicke-Korsakoff syndrome, Wilson’s disease
Obstetric/Gynecologic Menopause, postpartum depression, postpartum thyroiditis, premenstrual dysphoric disorder, premenstrual syndrome
Oncologic Adrenal tumor, brain tumor, carcinoid syndrome, insulinoma, paraneoplastic limbic encephalitis
Opthalmologic Oculogyric crisis, progressive external ophthalmoplegia, temporal arteritis
Overdose / Toxicity Alcohol intoxication, amphetamine abuse, barbiturate abuse, benzodiazepine abuse, caffeine addiction , chemical addiction, cocaine addiction, crack addiction, cyclosporine toxicity, ecstasy addiction, ginseng overdose, lidocaine toxicity, marijuana addiction, methamphetamine overdose, narcotic addiction
Psychiatric Abuse, Phonophobia, acrophobia, acute stress disorder, addiction, adjustment disorder, agoraphobia, alcohol withdrawal, anglophobia, anorexia nervosa, anthropophobia, antipsychotic (withdrawal), Asperger syndrome, attention deficit hyperactivity disorder, behavioral disorders, belonephobia, benzodiazepine withdrawal syndrome, bibliophobia, binge eating disorder, bipolar disorder, borderline personality disorder, bromidrosiphobia, bruxism, bulimia nervosa, cainophobia, cancerophobia, cardiophobia, cheimatophobia, cherophobia, child abuse, chrematophobia, chronic stress, claustrophobia, cocaine withdrawal, coitophobia, combat stress reaction, coulrophobia(fear of clowns), delirium tremens, dementia, demophobia
Pulmonary Airway obstruction, anaphylaxis, aspiration pneumonia, asthma, chest pain, chronic obstructive pulmonary disease, chronic respiratory failure, decreased oxygen saturation, diaphragmatic paralysis, emphysema, hyperoxia, hyperventilation syndrome, hyperventilation, pulmonary edema, pulmonary embolism, pneumonia, pneumothorax, respiratory alkalosis, stridor
Renal / Electrolyte Cystitis, Electrolyte disturbance, hematuria syndrome, lupus, Uremia
Rheum / Immune / Allergy 22q11.2 deletion syndrome, anaphylaxis, fibromyalgia, Graves disease, Gulf War syndrome, hypersensitivity to food, insect bite allergy, rheumatoid arthritis, lupus, paraneoplastic limbic encephalitis, polyarteritis nodosa, temporal arteritis, velocardiofacial syndrome, vitiligo, Wilson’s disease
Sexual Female hysteria, neurosyphilis, puberty
Trauma Concussion, head injury,
Urologic hematuria syndrome, subarachnoid hemorrhage
Dental No underlying causes

Causes in Alphabetical Order

References

  1. ↑ Thobois S, Prange S, Sgambato-Faure V, Tremblay L, Broussolle E (2017). “Imaging the Etiology of Apathy, Anxiety, and Depression in Parkinson’s Disease: Implication for Treatment”. Curr Neurol Neurosci Rep. 17 (10): 76. doi:10.1007/s11910-017-0788-0. PMID 28822071.
  2. ↑ Tseng CC, Hu LY, Liu ME, Yang AC, Shen CC, Tsai SJ (2017). “Bidirectional association between Bell’s palsy and anxiety disorders: A nationwide population-based retrospective cohort study”. J Affect Disord. 215: 269–273. doi:10.1016/j.jad.2017.03.051. PMID 28359982.
  3. ↑ Pham T, Sauro KM, Patten SB, Wiebe S, Fiest KM, Bulloch A, Jetté N (2017). “The prevalence of anxiety and associated factors in persons with epilepsy”. Epilepsia. 58 (8): e107–e110. doi:10.1111/epi.13817. PMID 28597927. Vancouver style error: initials (help)
  4. ↑ Mitsikostas DD, Ljubisavljevic S, Deligianni CI (2017). “Refractory burning mouth syndrome: clinical and paraclinical evaluation, comorbiities, treatment and outcome”. J Headache Pain. 18 (1): 40. doi:10.1186/s10194-017-0745-y. PMC 5371535. PMID 28357703.
  5. ↑ Empty citation (help)

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Differentiating Anxiety from other Diseases

Differentiating Anxiety from other Diseases

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Vindhya BellamKonda, M.B.B.S [2]

Overview

Anxiety must be differentiated from other diseases that cause anxiety such as major depressive disorder, bipolar disorder, atypical psychosis, schizophrenia, other medical and neurologic conditions.

Differential diagnosis

Anxiety must be differentiated from the causes listed below:

Psychiatric Cardinal features
Major depressive disorder

DSM major depressive disorder (MDD) diagnostic criteria require the occurrence of one or more major depressive episodes. Symptoms of a major depressive episode include the following:

  • Depressed mood
  • Anhedonia (diminished loss of interest or pleasure in almost all activities)
  • Significant weight or appetite disturbance
  • Sleep disturbance
  • Psychomotor agitation or retardation (a speeding or slowing of muscle movement)
  • Loss of energy or fatigue
  • Feelings of worthlessness
  • Diminished ability to think, concentrate and make decisions
  • Recurrent thoughts of death, dying or suicide
  • Longstanding interpersonal rejection ideation (ie. others would be better off without me); specific suicide plan; suicide attempt.
  • The DSM states either a depressed mood or anhedonia must be present. In addition to the above DSM criteria for a major depressive episode, the episode must:
  • Be at least two weeks long
  • Cause significant distress or severely impact social, occupational or other important life areas
  • Not be precipitated by drug use
  • Not meet the criteria for another mental disorder like schizophrenia or bipolar disorder
  • Not be better explained by bereavement (such as the loss experienced after a death)
Bipolar I disorder

Bipolar I disorder– A person affected by bipolar I disorder has had at least one manic episode in his/her life, and also suffer from episodes of depression, there is an alternating pattern of mania and depression. Manic episode is characterized by:

  • A period of abnormally elevated or irritable mood and increased goal directed activity,lasting atleast one week and present most of the day, nearly every day.
  • During the period of mood disturbance and increased energy /activity, three (or more) of the following symptoms ( four if the mood is only irritable) are present to a significant degree and represent a noticeable change from usual behavior:
    • Grandiosity
    • Decreased need for sleep
    • More talkative than usual or pressure to keep talking
    • Flight of ideas
    • Distractability
    • Increase in goal directed activity
    • Excessive involvement in activities that have dire consequences(e.g. engaging in excessive buying, sexual activity)
    • The mood disturbance is sufficiently severe to cause marked impairment in social or occupational functioning
    • the episode is not attributable to the physiological effects of a substance
    • Depressive episodes of bipolar disorder are similar to clinical depression
Atypical psychosis

The term atypical psychosis has not been included in DSM-V, but was listed in DSM-III-R under the heading psychosis Not otherwise specified( examples include: postpartum psychosis, psychosis with unusual features, psychosis with confusing clinical features that make a more definite diagnosis impossible

Schizophrenia
  • Two (or more) of the following , each present for a significant portion of time during a 1-month period(or less if successfully treated). Atleast one of these must be delusions, hallucinations, disorganized speech. Apart from these symptoms, grossly disorganized or catatonic behavior and negative symptoms (e.g.Avolition) are present
  • Significant functional impairment in all aspects of life
  • Continuous signs of the disturbance persist at least 6 months
  • Schizoaffective, depressive and bipolar disorder with psychotic features have been ruled out
  • The disturbance is not attributable to the physiological effects of a substance or another medical condition
Substance abuse

Substance abuse, including alcohol and prescription drugs, can induce symptomatology which resembles mental illness. This can occur both in the intoxicated state and also during the withdrawal state. Signs and symptoms depend on the substance being used

Cognitive disorders

Cognitive disorders predominantly affect cognitive skills, such as learning, memory, thinking, executive functioning, problem solving. It includes delirium and mild and major neurocognitive disorder ( formerly called as dementia)

Mediacl condition Cardinal features
Myocardial infarction
Angina pectoris
Hyperthyroidism
Carcinoid
Hypoglycemia
Hyperventilation

References

  1. ↑ Horcicka V, Lindusková M, Vykydal M (1990). “Injury to gastric mucosa due to cortisonoid therapy”. Acta Univ Palacki Olomuc Fac Med. 126: 151–5. PMID 2151080.
  2. ↑ Cryer PE, Axelrod L, Grossman AB, Heller SR, Montori VM, Seaquist ER, Service FJ (2009). “Evaluation and management of adult hypoglycemic disorders: an Endocrine Society Clinical Practice Guideline”. J. Clin. Endocrinol. Metab. 94 (3): 709–28. doi:10.1210/jc.2008-1410. PMID 19088155.
  3. ↑ Rapee R (1986). “Differential response to hyperventilation in panic disorder and generalized anxiety disorder”. J Abnorm Psychol. 95 (1): 24–8. PMID 3084604.

LastName, FirstName (2013). Desk reference to the diagnostic criteria from DSM-5. Washington, DC: American Psychiatric Publishing. ISBN 978-0-89042-556-5.

Epidemiology and Demographics

Epidemiology and Demographics

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Vindhya BellamKonda, M.B.B.S [2]

Overview

The prevalence of anxiety disorders is estimated to be 28800 per 100,000 individuals (28.8%). The female to male ratio is 3 to 2.

Epidemiology and Demographics

Prevalence

Age

Race

  • Anxiety usually more commonly affects individuals of the non-Hispanic Whites. [non Hispanic blacks] individuals are 20% less likely to develop anxiety, Hispanics are 30% less likely to experience an anxiety disorder during their life time.

Gender

References

  1. ↑ Wang PS, Lane M, Olfson M, Pincus HA, Wells KB, Kessler RC (2005). “Twelve-month use of mental health services in the United States: results from the National Comorbidity Survey Replication”. Arch. Gen. Psychiatry. 62 (6): 629–40. doi:10.1001/archpsyc.62.6.629. PMID 15939840.
  2. ↑ Kessler RC, Chiu WT, Demler O, Merikangas KR, Walters EE (2005). “Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication”. Arch. Gen. Psychiatry. 62 (6): 617–27. doi:10.1001/archpsyc.62.6.617. PMC 2847357. PMID 15939839.

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Risk Factors

Risk Factors

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Vindhya BellamKonda, M.B.B.S [2]

Overview

Common risk factors in the development of anxiety are: depression, alcohol, low socioeconomic status, bipolar disorder, urbanization, stress, family history of anxiety, unemployment, and substance abuse.

Risk factors

Close interaction between genetic and environmental factors is attributed for increased risk of anxiety:[1]

References

  1. ↑ Muris P, Mannens J, Peters L, Meesters C (2017). “The Youth Anxiety Measure for DSM-5 (YAM-5): Correlations with anxiety, fear, and depression scales in non-clinical children”. J Anxiety Disord. doi:10.1016/j.janxdis.2017.06.001. PMID 28668214.
Diagnosis

Diagnosis

History and Symptoms | Physical Examination | Laboratory Findings | ECG | Other Diagnostic Studies

Treatment

Treatment

Medical Therapy | Non-medical Therapy | Surgery | Primary Prevention | Secondary Prevention | Cost-Effectiveness of Therapy | Future or Investigational Therapies

Case Studies

Case Studies

Case #1

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