Anxiety Disorder and Fear(Phobia)

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Anxiety disorder are mainly collection of mental abnormalities that’s characterized by significant perception of phobia and anxiety.

Hello world ,  As we all know today people are anxious because of COVID19  and  world is under lockdown  because of it .Now  lots of things is running in our mind . Today I am going to write about Anxiety disorder and fear . Let’s begin it 

Anxiety is a normal human physiological response that helps us respond to potential threats or dangers. We cannot get by without it. With an increase in anxiety, our performance should increase accordingly (e.g. preparing for exams).

Anxiety becomes a problem when the stressor overwhelms us, resulting in poor performance, or if the unwanted consequences of the anxiety response give us undesirable physiological consequences.

anxiety-disorder

The stressor causes limbic activation, which in turn leads to autonomic and neuro-endocrine activity (down-regulation) that causes various physiological responses, including activation of the hypothalamic–pituitary axis. Blood flows from the gut to the skeletal muscles, there is activation of smooth muscle contraction in the bowels and an increase in nausea, muscle tension increases, the pupils dilate, the heart rate increases and blood pressure rises.

The various somatic symptoms commonly seen in anxiety disorders can be explained by this (e.g. headache  , tension) The physiological role of anxiety and the way in which excess anxiety can cause these physical symptoms can be explained to patients suffering from anxiety disorders—and the GP is very well placed to conduct such psycho-education.

Patients suffering from somatic symptoms are often unaware of the physiological consequences of anxiety and usually find this clarification comforting. It can help motivate patients to pursue strategies to reduce them.

Prevalence and classification of anxiety

 Anxiety disorders affect 14% of the population,  1with many people fulfilling the criteria for multiple anxiety disorders, also a common co-diagnosis of depression.  2   Specific phobias are the most common anxiety-related diagnosis (1 in 5 women and 1 in 10 men), and PTSD is the most common disorder (over 6%).    Anxiety disorders listed in the  diagnostic and statistical  manual are:  

• separation anxiety disorder    

 • selective mutism     

• specific phobia    

• social anxiety disorder (social phobia)    

 • panic disorder                                                                                             

• panic attack (specifier)     

• agoraphobia   

• generalized anxiety disorder    

• substance/medication-induced anxiety disorder     

• anxiety due to another medical condition   

• other specified anxiety disorder    

• unspecified anxiety disorder     Other conditions discussed in this chapter include:  

• obsessive–compulsive disorder     

• body dysmorphic disorder     

• post-traumatic stress disorder     

• acute stress disorder    

• adjustment disorder with anxious mood     

• somatic symptom disorder

Generalised anxiety disorder 

  Generalised anxiety comprises excessive anxiety and worry about various life circumstances and is not related to a specific activity, time or event such as trauma, obsessions or phobias. There is an overlap between generalised anxiety disorder (GAD) and other anxiety disorders.  General features:   

 • persistent unrealistic and excessive anxiety   

  • worry about a number of life circumstances for 6 months or longer

Diagnostic criteria for generalised anxiety disorder  

Three or more of:  

  • restless, ‘keyed up’ or ‘on edge’   

 • easily fatigued     

• difficulty concentrating or ‘mind going blank’     

• irritability     

• muscle tension    

• sleep disturbance

Clinical features 

  Psychological     

• Apprehension/fearful anticipation     

• Irritability     

• Exaggerated startle response     

• Sleep disturbance and nightmares     

• Impatience     

• Panic     

• Sensitivity to noise    

• Difficulty concentrating or ‘mind going blank’      Physical     

• Motor tension:    — muscle tension/aching     — tension headache     — trembling/shaky/twitching     — restlessness     — tiredness/fatigue       

• Autonomic over activity:    — dry mouth     — palpitations/tachycardia     — sweating/cold, clammy hands     — flushes/chills     — difficulty swallowing or ‘lump in throat’     — diarrhea/abdominal distress     — frequency of micturition     — difficulty breathing/smothering feeling     — dizziness or lightheadedness

Symptoms and signs according to systems     

•  Neurological:  dizziness, headache, trembling, twitching, shaking, paraesthesia     

•  Cardiovascular:  palpitations, tachycardia, flushing, chest discomfort    

•  Gastrointestinal:  nausea, indigestion, diarrhoea, abdominal distress    

•  Respiratory:  hyperventilation, breathing difficulty, air hunger     

•  Cognitive:  fear of dying, difficulty concentrating, ‘mind going blank’, hypervigilance      

Diagnosis of generalised anxiety disorder 

 The diagnosis is based on:  

  • history—it is vital to listen carefully to what the patient is saying    

 • exclusion of organic disorders simulating anxiety by history, examination and appropriate investigation   

  • exclusion of other psychiatric disorders, especially depression     Main differential diagnoses (note that this conforms to the seven masquerades list):   

 • depression    

 • drug and alcohol dependence/withdrawal     

• benzodiazepine dependence/withdrawal   

  • hyperthyroidism     

• angina and cardiac arrhythmias    

 • iatrogenic drugs    

 • caffeine intoxication

  Important checkpoints  

Five self-posed questions should be considered by the family doctor before treating an anxious patient:    

• Is this hyperthyroidism?   

 • Is this depression?    

 • Is this normal anxiety?    

 • Is this mild anxiety or simple phobia?    

 • Is this moderate or severe anxiety?    

Management

 The management applies mainly to generalised anxiety, as specific psychotherapy is required in other types of anxiety. Much of the management can be carried out successfully by the family doctor using brief counselling and support. Cognitive behaviour therapy (CBT), in which maladaptive thinking, feelings, perceptions and related behaviours are identified, assessed, challenged and modified, can be

Significant differential diagnoses of anxiety

Psychiatric disorders

Depression

Drug and alcohol dependence/withdrawal

Benzodiazepine dependence/withdrawal

Schizophrenia

Acute or chronic organic brain disorder

Early dementia 

Organic disorders

Drug-related:

• amphetamines

• bronchodilators

• caffeine excess

• ephedrine

• levodopa

• thyroxine

Cardiovascular:

• angina

• cardiac arrhythmias

• mitral valve prolapse

Endocrine:

• hyperthyroidism

• phaeochromocytoma

• carcinoid syndrome

• hypoglycaemia

• insulinoma

Neurological:

• epilepsy, especially complex partial seizures

• acute brain syndrome Respiratory:

• asthma

• acute respiratory distress

• pulmonary embolism  

psychological therapy and non-drug strategies are first-line therapy for most anxiety disorders.   Principles of management     

• Non-pharmacological approaches (e.g. ‘life coaching’ and CBT) are first line.     

• Give careful explanation and reassurance:    —  explain the reasons for the symptoms     —  be aware that patients often ‘worry about worrying’ (e.g. that anxiety is dangerous, that they are going crazy or ‘losing it’)  —  reassure the patient about the absence of organic disease (can only be based on a thorough examination and appropriate investigations)     —  direct the patient to appropriate resources to give insight and support (see box: Further information)      

 • Provide practical advice on ways of dealing with the problems.    

• Advise on the avoidance of aggravating substances such as caffeine, nicotine and other drugs.    

 • Advise on general measures such as stress management techniques, relaxation programs and regular exercise and if possible organize these for the patient (don’t leave it to the patient).     

• Advise on coping skills, including personal and interpersonal strategies, to manage difficult circumstances and people (in relation to that patient).     

• Provide ongoing supportive psychotherapy.  

  Pharmacological treatment  

 The key principles of using medication for anxiety disorders are:   

• SSRIs and other antidepressants have shown to benefit some anxiety disorders  but their benefits are not as long lasting as psychological and behavioral approaches     

• assess efficacy of antidepressants after at least 12 weeks (in contrast to 6–8 weeks when treating major depression) and treat for at least 6 months    

 • propranolol is of benefit in social anxiety disorder, particularly with anticipated stressful events (e.g. public speaking, presenting at work events)     

• benzodiazepines have a limited role in anxiety disorders. If used, they should be reserved for people who have not responded to at least 2 therapies (e.g. psychological therapy and antidepressant) and used only in the short term (stop within 6 weeks). They can also be used for specific phobias (e.g. fear of flying, agoraphobia and MRI machines)

Agoraphobia

 Avoidance includes staying away from many situations where there are issues of distance from home, crowding or confinement. Typical examples are travel on public transport, crowded shops and confined places. Patients fear they may lose control, faint and suffer embarrassment.

Panic attack

   A panic attack is defined    as a discrete period of intense fear or discomfort in which four (or more) of the following symptoms develop abruptly and reach a peak within 10 minutes:   

 • shortness of breath or smothering sensations     

• dizziness, unsteady feelings, lightheadedness or faintness    

• palpitations or accelerated heart rate    

• trembling or shaking    

• sweating     

• feeling of choking    

• nausea or abdominal distress     

• depersonalisation or derealisation     

• numbness or tingling sensations (paraesthesia)     

• flushes (hot flashes) or chills     

• chest pain or discomfort  

• fear of dying     

• fear of going crazy or of doing something uncontrolled     

Organic disorders that simulate a panic attack are hyperthyroidism, phaeochromocytoma and hypoglycaemia.

     Note:  A single panic attack is not synonymous with panic disorder. Some 40% of young people have had at least one spontaneous panic attack. 

Panic disorder is when there are recurrent attacks that are followed by at least a month of worrying about future attacks and/or the consequences of them. Panic disorder can occur with or without associated agoraphobia, though >90% of people with agoraphobia develop it as a result of recurrent panic attacks.    

Management

  Reassurance, explanation and support (as for generalised anxiety). This is the mainstay of treatment. A patient who is experiencing a panic attack should be taught breathing techniques to help control hyperventilation (e.g. timing breaths, breathing through nose, slow inspiration, measured medium-sized breaths).

Relaxation techniques can also be employed, such as progressive muscle relaxation, and patients can teach themselves these techniques via online resources. Rebreathing into a paper bag is rarely indicated in a general practice setting   as the hyperventilation has usually settled by the time the patient presents.

The above breathing techniques can be used by the patient anywhere and are more socially acceptable than breathing noisily into a paper bag when an attack is feared.

Cognitive behavior therapy (CBT)

     CBT aims to reduce anxiety by teaching patients how to identify, evaluate, control and modify their negative, fearful thoughts and behavior. If simple psychotherapy and stress management fail then patients should be referred for CBT.  Patients’ fears, especially if irrational, need to be clearly explained by the therapist, examined rationally and challenged, then replaced by positive calming thoughts.  

Pharmacological treatment 

 Pharmacological treatment is rarely of benefit in the acute attack, as the attacks occur too quickly for their effect to be of use. Antidepressants can be useful in reducing panic attacks and agoraphobia  with the response rate being 60–90%.  Dosage recommendations for SSRIs in anxiety disorders.  

Drug Initial dose Maximum dosecitalopram10 mg.  Maximum 40 mg escitalopram5 mg. Maximum 20 

mgfluoxetine10 mg.  Maximum  80 mg 

fluvoxamine50 mg maxim 300 mg (split dose to bd over 150 mg)

paroxetine10 mg maximum  60 mg

sertraline25 mg maximum  200 mg

Some principles of using BDZs in anxiety disorders   are:  

  • always check for a history of problem alcohol or drug use   

 • be wary of prescribing to unfamiliar patients, especially if asking for a particular drug by name (may indicate drug-seeking behaviour)   

 • carefully discuss the potential for addiction with the patient   

 • avoid using short-acting drugs as they are the most highly addictive  

• prescribe only small quantities of medication at a time     

• use only as short-term treatment    

• ensure regular review of the patient and continuity of care     If already being used, BDZs should be tapered very slowly (this may take 6–12 months or longer). A benzodiazepine withdrawal syndrome, which can include rebound anxiety, depression, confusion, insomnia and seizures, may occur. Specialist drug and alcohol advice should be sought in such situations.

Phobic disorders   

In phobic states, the anxiety is related to specific situations or objects. Phobic disorders include agoraphobia, social anxiety disorder (otherwise known as social phobia) and specific phobias. Patients avoid these objects or situations, become anxious when they anticipate having to meet them and/or endure them with intense distress. A list of specific phobias is presented below  .

Name of phobia.                                                             Fear of aversion to 

Acrophobia.                                                                Heights

Aerophobia.                                                                Draughts

Agoraphobia.                                                              Open spaces.           

Aichmophobia.                                                            Sharp objects

 Ailurophobia.                                                              Cats

Algophobia.                                                                 Pain

Androphobia.                                                               Men 

Anthophobia.                                                               Flowers

Anthropophobia.                                                          People

Apiphobia.                                                                   Bees

Aquaphobia.                                                             Water

Arachnophobia.                                                        Spiders

Astraphobia.                                                             Lightning 

Aviatophobia.                                                           Flying

Bacteriophobia.                                                       Bacteria

Bathophobia.                                                           Depth

Belonephobia.                                                         Needles

Brontophobia.                                                         Thunder

Cancerophobia.                                                      Cancer

Cardiophobia.                                                        Heart disease

Claustrophobia.              .                                      Closed spaces

Cynophobia.                                                          Dogs

Demonophobia.                                                     Demons

Dromophobia.                                                        Crossing Streets

Equinophobia.                                                        Horses

Genophobia                                                          Sex

Gynophobia.                                                        Women

Haptephobia.                                                       Being touched

Herpetophobia.                                                    Creeping, crawling things

Homophobia.                                                       Homosexuals

Hypsophobia.                                                      Falling

Hypnophobia.                                                     Going to sleep

Iatrophobia.                                                         Doctors

Musophobia.                                                        Mice

Mysophobia.                                                        Dirt, germs, contamination

Necrophobia.                                                       Death

Neophobia.                                                        Anything new

Noctiphobia.                                                       Night

Numerophobia.                                                  Numbers

Nyctophobia.                                                     Darkness

Ochlophobia.                                                    Crowds

Ophidiphobia.                                                   Snakes

Pyrophobia.                                                      Fire

Scotophobia.                                                    Blindness

Sociophobia.                                                    Social situations

Taphophobia.                                                  Being buried alive

Theophobia.                                                    God

Trypanophobia.                                               Injections

Xenophobia.                                                    Strangers

Zoophobia.                                                      Animals

No matter what you are going through there is light at the end of tunnel

Author (Dr. Umesh Kumar Yadav MD) , contact [email protected]

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