Anxiety disorders are common psychiatric disorders. Many patients with anxiety disorders experience physical symptoms related to anxiety and subsequently visit their primary care physicians. Despite the high prevalence rates of these anxiety disorders, they often are underrecognized and undertreated clinical problems. Anxiety disorders are classified into the following categories:
- Ø Anxiety due to a general medical condition
- Ø Substance-induced anxiety disorder
- Ø Generalized anxiety
- Ø Panic disorder
- Ø Acute stress disorder
- Ø Posttraumatic stress disorder (PTSD)
- Ø Adjustment disorder with anxious features
- Ø Social phobia
- Ø Obsessive-compulsive disorder (OCD)
- Ø Specific phobias
Pathophysiology
Anxiety disorders appear to be caused by an interaction of biopsychosocial factors, including genetic vulnerability, which interact with situations, stress, or trauma to produce clinically significant syndromes. In the central nervous system, the major mediators of the symptoms of anxiety disorders appear to be norepinephrine and serotonin. Other neurotransmitters and peptides, such as corticotropin-releasing factor, may be involved. Peripherally, the autonomic nervous system, especially the sympathetic nervous system, mediates many of the symptoms.
Frequency
The prevalence of specific anxiety disorders appears to vary between countries and cultures.
Mortality/Morbidity
Anxiety disorders may contribute to morbidity and mortality through neuroendocrine and neuroimmune mechanisms or by direct neural stimulation, eg, hypertension or cardiac arrhythmia. Severe anxiety disorders may be complicated by suicide, with or without secondary mood disorders (eg, depression). Anxiety disorders have high rates of comorbidity with major depression and alcohol and drug abuse. Some of the increased morbidity and mortality associated with anxiety disorders may be related to this high rate of comorbidity. The ECA study found that panic disorder was associated with suicide attempts. How much of the association of panic disorder with suicide is mediated through the association of panic disorder with mood and substance abuse disorders is unclear. Acute stress may play a role in producing suicidal behavior. Suicide attempts can be precipitated by adverse life events such as divorce or financial disaster. The effects of acute stress in producing suicidal behavior are increased in those with underlying mood, anxiety, and substance abuse problems.
Chronic anxiety may be associated with increased risk for cardiovascular morbidity and mortality.
Sex
The female-to-male ratio for any lifetime anxiety disorder is 3:2.
Age
Most anxiety disorders begin in childhood, adolescence, and early adulthood. Separation anxiety is an anxiety disorder of childhood that often includes anxiety related to going to school. This disorder may be a precursor for adult anxiety disorders. Panic disorder demonstrates a bimodal age of onset in the NCS study in the age groups of 15-24 years and 45-54 years. The median age of onset of social phobia in the NCS study was 16 years. The age of onset for OCD appears to be in the mid 20s to early 30s. New-onset anxiety symptoms in older adults should prompt a search for an unrecognized general medical condition, a substance abuse disorder, or major depression with secondary anxiety symptoms.
CLINICAL FEATURES
Symptoms vary depending on the specific anxiety disorder. To rule out anxiety disorders secondary to general medical or substance abuse conditions, a detailed history and review of symptoms is essential. Review use of caffeine-containing beverages (coffee, tea, colas, Mountain Dew), over-the-counter medications (aspirin with caffeine, sympathomimetics), herbal "medications," or street drugs. Ask the patient's sleep partner about apneic episodes or myoclonic limb jerks. Concurrent depressive symptoms are common in all of the anxiety disorders. Severe anxiety disorders may produce agitation, suicidal ideation, and increased risk of completed suicide. Always ask about suicidal ideation or suicidal intent.
Panic disorder is characterized by recurrent panic attacks (ie, periods of intense fear of abrupt onset peaking in intensity within 10 min). Four of the following must be present for a panic attack:
- Ø Palpitations, pounding heart, or accelerated heart rate
- Ø Sweating
- Ø Trembling or shaking
- Ø Shortness of breath or dyspnea
- Ø Sensation of choking
- Ø Chest pain or discomfort
- Ø Nausea or abdominal distress
- Ø Feeling dizzy, unsteady, lightheaded, or faint
- Ø Derealization or depersonalization
- Ø Fear of losing control or going crazy
- Ø Fear of dying
- Ø Paresthesias
- Ø Chills or hot flashes
- Ø Although not a diagnostic feature, suicidal ideation and completed suicide have been associated with panic disorder.
Generalized anxiety disorder is characterized by excessive anxiety and worry. Worrying is difficult to control. Anxiety and worry are associated with at least 3 of the following symptoms:
- Ø Restlessness or feeling keyed-up or on edge
- Ø Being easily fatigued
- Ø Difficulty concentrating or mind going blank
- Ø Irritability
- Ø Muscle tension
- Ø Sleep disturbance
- Ø Although not a diagnostic feature, suicidal ideation and completed suicide have been associated with generalized anxiety disorder.
OCD(Obsessive-compulsive disorder) is characterized by obsessions or compulsions. Obsessions or compulsions must be recognized as unreasonable or excessive and must cause marked distress.
Obsessions include all of the following:
- Ø Recurrent and persistent thoughts, impulses, or images that are intrusive and knowingly inappropriate andcause anxiety or distress
- Ø Thoughts, impulses, or images that are not simply excessive worries about real-life problems
- Ø Attempts are made to ignore or suppress thoughts.
- Ø Thoughts, impulses, or images are recognized as being the product of the mind and not imposed from an outside force.
Compulsions include the following:
- Ø Repetitive behaviors, such as handwashing, ordering, and checking, that people feel are driven and must be carried out and occur to such an extreme that a person's ability to function is impaired.
- Ø Behaviors or mental acts are done to reduce distress or anxiety.
Social phobia: Marked and persistent fear of social or performance situations to the extent that a person's ability to function at work or in school is impaired.
- Ø Exposure to social or performance situation always produces anxiety.
- Ø Fear/anxiety recognized as excessive
- Ø Social or performance situations are avoided or endured with intense anxiety.
- Ø Avoidance behavior, anticipation, or distress in the feared social or performance setting produces significant impairment in functioning.
PTSD( Posttraumatic stress disorder ) is a severe trauma that is experienced that includes
(1) actual or threatened death or serious injury or threat to personal integrity of self or others and
(2) responses that include intense fear, helplessness, or horror. (Life-threatening experiences and the attendant loss of control are key elements.)
Persistent reexperience of the event occurs by at least 1 of the following:
- Ø Recurrent and intrusive recollections
- Ø Recurrent distressing dreams/nightmares
- Ø Feelings of reliving traumatic event, ie, flashbacks
- Ø Intense psychologic distress with internal or external cues to the trauma
- Ø Physiological reactivity on exposure to trauma cues
Persistent avoidance of stimuli of trauma and numbing/avoidance behavior demonstrated by at least 3 of the following:
- Ø Avoidance of thoughts or conversation related to the trauma
- Ø Avoidance of activities, places, or people related to the trauma
- Ø Amnesia for important trauma-related events
- Ø Decreased participation in significant activities
- Ø Feeling detached or estranged from others
- Ø Restricted affect
- Ø Foreshortened sense of the future
Persistent symptoms of increased arousal demonstrated by 2 or more of the following:
- Ø Difficulty staying or falling asleep
- Ø Irritability or anger outbursts
- Ø Difficulty concentrating
- Ø Hypervigilance
- Ø Exaggerated startle response
Although not a diagnostic feature, suicidal and homicidal ideation have been associated with PTSD.
Physical Features
- Ø Tremor
- Ø Tachycardia
- Ø Tachypnea
- Ø Sweaty palms
- Ø Restlessness
Lab Studies
When the index of suspicion for anxiety being produced by a medical disorder is low (lack of physical findings, younger age, typical anxiety disorder presentation), initial lab studies might be limited to the following:
- Ø CBC count
- Ø Chemistry profile
- Ø Thyroid function tests
- Ø Urinalysis
- Ø Urine drug screen
For presentations with a higher index of suspicion for other medical causes of anxiety (ie, atypical anxiety disorder presentation, older age, specific physical examination abnormalities), more detailed evaluations may be indicated as follows:
- Ø Rule out CNS disorder using electroencephalogram, lumbar puncture, or brain CT scan, as indicated by history and associated clinical findings.
- Ø Rule out cardiac disorder using ECG or treadmill ECG.
- Ø Rule out infectious causes using rapid plasma reagent test, lumbar puncture (CNS infections), or HIV testing.
Imaging Studies
Diagnostic imaging studies are not indicated in the diagnosis of primary anxiety disorders unless specific general medical conditions need to be ruled out. Imaging studies may be helpful, however, to rule out anxiety due to a general medical condition, eg, cephalic CT scan or MRI to evaluate for pathological intracranial processes.
Medical Care
Patients with panic disorder frequently present to the emergency department with chest pain or dyspnea, fearing that they are dying of myocardial infarction. Anxiety symptoms often accompany or can exacerbate respiratory conditions such as asthma and chronic obstructive pulmonary disease. If clinically indicated, obtain necessary studies to rule out myocardial infarction and pulmonary embolism (ECG, chest x-ray).
Consultations
Most often, psychiatrists are consulted.
In anxiety disorders secondary to a general medical condition, specialty consultation may be indicated.
Diet
Discontinue(or decrease to a low reasonable level) caffeine-containing products such as coffee, tea, colas, and Mountain Dew.
Over-the-counter preparations and herbal remedies should be reviewed with special caution because ephedrine and other herbal compounds may precipitate or exacerbate anxiety symptoms.
Activity
If no medical contraindication exists, recommend at least a mild-to-moderate daily exercise program.
Further Inpatient Care
Inpatient care rarely is needed for the management of anxiety disorders unless complicated by comorbid conditions such as affective or substance abuse disorders or general medical conditions.
Inpatient care should be considered if suicide is a risk or detoxification is needed for comorbid substance dependence.
Further Outpatient Care
Anxiety disorders often are chronic and require ongoing medical/psychiatric care, including psychosocial therapies and medication (pharmacotherapy).
Psychosocial interventions in anxiety disorder
Cognitive-behavioral therapy often is efficacious and is the treatment of choice for specific phobias. It often is used alone or in combination with pharmacotherapy in the treatment of OCD and panic disorder.
Other psychotherapeutic approaches, such as interpersonal therapy or psychodynamic therapy, also may be helpful in the treatment of anxiety disorders.
Marital therapy, family therapy, or group therapy may be helpful adjunct therapies in the long-term management of severe anxiety disorders. Educating families and friends enables them to cope with their loved one's disease.
Complications
- Ø Agoraphobia
- Ø Major depression
- Ø Suicide
- Ø Homicide (especially in patients with PTSD)
- Ø Alcohol abuse and dependence
- Ø Sedative abuse and dependence
- Ø Social dysfunction and withdrawal
- Ø Occupational impairment
- Ø Marital and familiar dysfunction, divorce
Prognosis
Anxiety disorders can range from mild and transient to severe and chronic.
Early treatment improves prognosis and limits social and occupational impairment.
MEDICATION
Homeopathic Remedies for Anxiety Disorders
The following remedies may be useful to you in treating symptoms of anxiety.
- Ø Aconite
- Ø Argentum nitricum
- Ø Arsenicum album
- Ø Calcarea carbonica
- Ø Gelsemium
- Ø Ignatia amara
- Ø Kali phosphoricum
- Ø Lycopodium
- Ø Natrum muriaticum
- Ø Phosphorus
- Ø Pulsatilla
- Ø Silicea
Aconite (Aconitum napellus)
A panic attack that comes on suddenly with very strong fear (even fear of death) may indicate this remedy. A state of immense anxiety may be accompanied by strong palpitations, shortness of breath, and flushing of the face.
Symptoms
- Ø Sudden, intense ailments from fright.
- Ø Anxiety and restlessness with complaints.
- Ø Fears that do not subside.
- Ø Faintness or dizziness upon waking up.
- Ø Sudden fever with one cheek red, the other pale
- Ø Intolerance of pain.
- Ø Painful urination with anxiety
- Ø Pains followed by numbness and tingling.
- Ø Eye pain and injuries
- Ø Throbbing headache.
- Ø Unquenchable thirst.
Argentum nitricum (Arg-n)
This remedy is indicated when anxiety develops before a big event. (Examples: an interview for job, an exam, a public speech, social engagement, marriage, etc.).
Symptoms
- Ø Emotional upset
- Ø Fear
- Ø Anxiety
- Ø Extended period of unusual or continued mental exertion
- Ø Dizziness
- Ø Diarrhea
- Ø Craving for sweets and salt. Craving for strong flavors.
- Ø Enthusiastic and suggestible, with a tendency toward peculiar thoughts and impulses.
Arsenicum album (Arsenicum, Ars)
This remedy is recommended for people who are deeply anxious about their health, and extremely concerned with order and security. Panic attacks often occur around midnight or the very early hours of the morning. The person may feel exhausted yet still be restless-fidgeting, pacing, and anxiously moving from place to place. These people may also have digestive problems or asthma attacks accompanied by anxiety. They are typically obsessive about small details and very neat. They may feel a desperate need to be in control of everything.
Symptoms
- Ø Anxious
- Ø Anxiety associated with later stages of head cold, with sneezing
- Ø Asthma worse after midnight, fears suffocation while lying down
- Ø Fearful
- Ø Irritable
- Ø Restless
- Ø Sleepiness but insomnia
- Ø Thirsty for frequent small drinks
- Ø Weak and exhausted
- Ø Desires air but sensitive to cold
- Ø Vomiting with or without diarrhea after eating and drinking
Calcarea carbonica (Calc)
People who benefit most from this remedy have a chilly constitution. The slightest cold "goes right through them." They have trouble keeping themselves warm. They have a craving for sweets, and are easily fatigued. They are dependable, solid people who become overwhelmed from physical illness or too much work and start to fear a breakdown. Their thoughts can be muddled and confused when tired, which adds to the anxiety. Worry and bad news may agitate them, and a nagging dread of disaster (to themselves or others) may develop. Fear of heights and claustrophobia are also common.
Symptoms
- Ø Increased perspiration
- Ø Night sweats
- Ø Cold hands and feet
- Ø Dizziness
- Ø Nausea
- Ø Ravenous hunger
- Ø Aversion to fats
- Ø Craving for eggs
- Ø Eyes sensitive to light
- Ø Pale face
- Ø Large appetite with slow digestion
Gelsemium (Gels)
This remedy is indicated when you have feelings of weakness, trembling, and mental dullness (being "paralyzed by fear"). It is also useful when a person experiences anxiety about an upcoming event such as stage-fright about a public performance or interview, or anxiety before a test, impending visit to the dentist, or other stressful events. Chills, perspiration, diarrhea, and headaches will often occur with nervousness. Fear of crowds, a fear of falling, and even a fear that the heart might stop are other indications for Gelsemium.
Symptoms
- Ø Nervousness
- Ø Apprehension
- Ø Anxiety prior to an examination or public performance
- Ø Fatigue and aching of whole body
- Ø Limbs, head, eyelids heavy
- Ø Headache
- Ø Scalp sore to touch
- Ø Sore throat
- Ø Lack of thirst
- Ø Dizziness, trembling, fatigue, dullness
Ignatia amara (Ignatia, Ign)
A sensitive person who is anxious because of grief, loss, disappointment, criticism, loneliness (or any stressful emotional experience) may benefit from this remedy. The primary factor for this remedy is emotional stress, especially disappointment or grief. Other indications are a defensive attitude, frequent sighing, and mood swings. The person may burst unexpectedly into either tears or laughter.
Symptoms
- Ø Vomiting
- Ø Sensation of a lump in the throat
- Ø Chills with fever
- Ø Thirst during chills
- Ø Chills relieved by warmth
- Ø Cramping pains in the abdomen or back
- Ø Headaches that feel like a nail driven into the side of the head
- Ø Skin very sensitive to drafts
- Ø Introspective
- Ø Sad
- Ø Brooding
- Ø Tearful
- Ø Rejects company
- Ø Disappointed
- Ø Grieving
- Ø Insomnia from emotional distress
- Ø Nausea relieved by eating
- Ø Eating intensifies hunger
Kali phosphoricum
Indicated when a person has been exhausted by overwork or illness. Feels a deep anxiety and inability to cope. Jumpy and oversensitive. May be startled by ordinary sounds. Hearing unpleasant news or thinking of world events can aggravate the problems. Insomnia and an inability to concentrate may develop, increasing the sense of nervous dread. Eating, warmth, and rest often bring relief.
Symptoms
- Ø Exhaustion
- Ø Deep anxiety and inability to cope
- Ø Headaches
- Ø Jumpy and oversensitive
- Ø Startled by ordinary sounds
- Ø Backaches
- Ø Nervous digestive upsets
Lycopodium (Lyc)
Lycopodium patients attempt to cover an inner sense of inadequacy by putting up fronts, by pretending to be something they are not. They feel anxiety from mental stress and suffer from a lack of confidence. They can be self-conscious and feel intimidated by people they perceive as powerful. They can feel a deep anxiety and fear of failure, when they take on responsibility. They usually do well, once started on a task.
Symptoms
- Ø Shakes head without any apparent cause
- Ø Facial contortions
- Ø Gassy, constipation or diarrhea
- Ø Sour belching
- Ø Claustrophobia
- Ø Irritability
- Ø Digestive upsets with gas and bloating
- Ø Craves sweets, warm food and drink
- Ø Night cough
- Ø Wants to be alone
- Ø Cranky on waking
- Ø Bullying tendency
- Ø Fear of failure
- Ø Breaking down under stress
Natrum muriaticum (Nat mur)
The primary candidates for this remedy are personally aloof but have a social conscience and a desire to help others. Deep emotions and a self-protective shyness can make these people seem reserved, aloof, and private. Even when feeling lonely, they tend to stay away from social situations, not knowing what to say or do. Easily hurt and offended, they can brood, bear grudges, dwell on unhappy feelings, and isolate themselves. They refuse consolation even when they want it. They are often sympathetic listeners to other people's problems. Claustrophobia, anxiety at night (with fears of robbers or intruders), migraines, and insomnia are often seen when this remedy is needed.
Symptoms
- Ø Tongue feels dry
- Ø Mucous membranes dry
- Ø Nausea
- Ø Insomnia
- Ø Claustrophobia
- Ø Migraine headache
- Ø Vomiting
- Ø Pains around eyes
- Ø Craves salt and dry foods
- Ø Weepy but won't let others see it. (Wants to be alone to cry.)
- Ø Consolation aggravates them
- Ø Angry from isolation
- Ø Fright, grief, anger
- Ø Nervous, discouraged, broken down
- Ø Depressed
Phosphorus
Indicated when the victims are openhearted, imaginative, excitable, easily startled, and full of intense and vivid fears. Strong anxiety can be easily triggered just by thinking of almost anything. They are nervous and sensitive to others. They can overextend themselves with sympathy to the point of feeling exhausted and "spaced out" or even getting ill. They need a lot of company and reassurance. They often feel better from conversation or a back-rub. Easy flushing of the face, palpitations, thirst, and a strong desire for cold, refreshing foods are other indications for Phosphorus.
Symptoms
- Ø Anxious
- Ø Fearful
- Ø Weak
- Ø Associated with hoarseness
- Ø Tight heavy chest
- Ø Dry rasping cough
- Ø Burning pains in stomach, abdomen, between shoulder blades
- Ø Thirst for cold drinks that are vomited
- Ø Nausea
- Ø Night sweats
Pulsatilla (Puls)
People who need this remedy often express anxiety as insecurity and clinginess, with a need for constant support and comforting. They fear being alone. They are easily discouraged, moody, tearful, whiny, even emotionally childish. Getting too warm or being in a stuffy room often increases anxiety. Anxiety around the time of hormonal changes (puberty, menstrual periods, or menopause) often is helped with Pulsatilla.
Symptoms
- Ø Sensitive
- Ø Weepy
- Ø Wants attention and sympathy
- Ø Changeable symptoms and moods
- Ø Craves open air
- Ø Sensitive to heat
- Ø Dry mouth with lack of thirst
- Ø Rich food upsets stomach
- Ø Insomnia from recurring thought
- Ø Head colds
- Ø Loose cough, worse at night
- Ø Delayed menstrual period with scanty flow
Silicea (Silica)
Indicated for those who are capable and serious, yet are also nervous, shy, and subject to bouts of temporary loss of confidence. Anxiety can be extreme when they are faced with a public appearance, interview, examination, or any new job or task. Worry and overwork can bring on headaches, difficulty concentrating, and states of exhaustion, oversensitivity, and dread.
Symptoms
- Ø Worry
- Ø Overwork
- Ø Headaches
- Ø Difficulty concentrating
- Ø Exhaustion,
- Ø Oversensitivity
- Ø Overreact and devote attention to tiny details
- Ø Low stamina
- Ø Frequently catch colds, sore throats, or other illnesses.
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