Suddenly your heart is racing, palms are sweaty, stomach’s

churning. Your muscles are tense and your senses alert. Your

mind is flooded with worries and fears that something bad will

happen. This is anxiety; and we have all had it. When faced with

a threatening event such as a physical attack or a natural disaster,

most people feel anxiety or fear. Our bodies give us a surge of

adrenaline and our instincts take over. This gives us the strength

we need to get out of the situation and survive. Anxiety is our

body’s response to stress and danger, but in today’s world most

of the ‘dangers’ we face day to day are not ones we can fight with

our fists or run away from easily. These modern ‘dangers’ are

many and can be anything from a heavy work load at your job

to family conflicts, aggressive drivers or money troubles. Some

anxiety from time to time is normal and healthy; it can help

motivate us and help get us out of tough situations. But when

anxiety lasts for weeks or months, develops into a constant sense

of dread or begins to affect your everyday life, you may have an

anxiety disorder.

Anxiety becomes

troubling when

it lasts weeks or

months, develops

into a constant

sense of dread and

begins to affect your

everyday life.

WHAT IS ANXIETY DISORDER ?

 Anxiety disorders are a group of mental disorders characterized by significant feelings of anxiety and fear.[2] Anxiety is a worry about future events and fear is a reaction to current events.[2] These feelings may cause physical symptoms, such as a fast heart rate and shakiness.[2] There are a number of anxiety disorders: including generalized anxiety disorder, specific phobia, social anxiety disorder, separation anxiety disorder, agoraphobia, panic disorder, and selective mutism.[2] The disorder differs by what results in the symptoms.[2] People often have more than one anxiety disorder.[2]

The cause of anxiety disorders is a combination of genetic and environmental factors.[4] Risk factors include a history of child abuse, family history of mental disorders, and poverty.[3] Anxiety disorders often occur with other mental disorders, particularly major depressive disorder, personality disorder, and substance use disorder.[3] To be diagnosed symptoms typically need to be present for at least six months, be more than would be expected for the situation, and decrease functioning.[2][3] Other problems that may result in similar symptoms including hyperthyroidism; heart disease; caffeine, alcohol, or cannabis use; and withdrawal from certain drugs, among others.[3][5]

Without treatment, anxiety disorders tend to remain.[2][4] Treatment may include lifestyle changes, counselling, and medications.[3] Counselling is typically with a type of cognitive behavioral therapy.[3] Medications, such as antidepressants, benzodiazepines, or beta blockers, may improve symptoms.[4]

About 12% of people are affected by an anxiety disorder in a given year and between 5-30% are affected at some point in their life.[3][6] They occur about twice as often in females as males, and generally begin before the age of 25.[2][3] The most common are specific phobia which affects nearly 12% and social anxiety disorder which affects 10% at some point in their life.[3] They affect those between the ages of 15 and 35 the most and become less common after the age of 55.[3] Rates appear to be higher in the United States and Europe.[3]

Who does it affect?

Anxiety is the most common type of

mental disorder affecting 12% of BC’s

population, or one in eight people, in

any given year. There are a number of

things about who you are that can put

you at greater risk of developing an

anxiety disorder:

•  Gender: Women are twice as

likely as men to be diagnosed with

an anxiety disorder. There are a

number of reasons for this including

women’s hormonal changes,

caregiving stress, and greater

comfort seeking help than men.

•  Age: Anxiety disorders most often

appear in youth, with phobias

and OCD showing up in early

childhood and panic disorders and

social phobias in the teen years. An

estimated 6.5% of BC youth have an

anxiety disorder.

•  Personality factors: Children who

are shy and worrisome are more

likely than other children to suffer

from an anxiety disorder later in life.

People who tend to be perfectionists

are also more prone to anxiety

disorders.

•  Family history: Anxiety disorders

run in families. In addition to

possible genetic influences, the role a

child may play within their families

can also be a factor in developing an

anxiety disorder in the future.

•  Social factors: People with a lack

of social support are more likely to

develop anxiety disorders.

•  Occupational risks: One kind of

anxiety disorder, post-traumatic

stress, can be linked to people’s

jobs. For example, emergency

personnel and military personnel

are at high risk.

•  Chronic illness: People who have

chronic mental or physical illnesses

often worry about their illness, their

treatments and the effect the illness

has on their lives and the lives of

those around them. This constant

worry can sometimes lead to the

development of an anxiety disorder. 

types

Generalized anxiety disorder (GAD) is an anxiety disorder characterized by excessive, uncontrollable and often irrational worry, that is, apprehensive expectation about events or activities.[2] This excessive worry often interferes with daily functioning, as individuals with GAD typically anticipate disaster, and are overly concerned about everyday matters such as health issues, money, death, family problems, friendship problems, interpersonal relationship problems, or work difficulties.[3][4] Individuals may exhibit a variety of physical symptoms, including feeling tired, fidgeting, headaches, numbness in hands and feet, muscle tension, difficulty swallowing, upset stomach, vomiting, diarrhea, breathing difficulty, difficulty concentrating, trembling, irritability, sweating, restlessness, sleeping difficulties, hot flashes, rashes, and inability to fully control the anxiety.[5] These symptoms must be consistent and ongoing, persisting at least six months, for a formal diagnosis of GAD.[2][3]

Standardized rating scales such as GAD-7 can be used to assess severity of GAD symptoms.[6] GAD is the most common cause of disability in the workplace in the United States.[7]

In a given year, approximately two percent of American adults and European adults experience GAD.[8][9] Globally about 4% are affected at some point in their life.[1] GAD is seen in women twice as much as men.[10] GAD is also common in individuals with a history of substance abuse and a family history of the disorder.[11] Once GAD develops, it may become chronic, but can be managed or eliminated with proper treatment.

Causes

Genetics

Substance-induced

Diagnosis

DSM-5 criteria

⦁ Too much anxiety or worry over more than six months. This is present most of the time in regards to many activities.

⦁ Inability to manage these symptoms

⦁ At least three of the following occur:

Note: Only one item is required in children.

Restlessness

Tires easily

Problems concentrating

Irritability

Muscle tension.

Problems with sleep

⦁ Symptoms result in problems with functioning.

⦁ Symptoms are not due to medications, drugs, other physical health problems

⦁ Symptoms do not fit better with another psychiatric problem such as panic disorder

SPECIFIC PHOBIA

A specific phobia is any kind of anxiety disorder that amounts to an unreasonable or irrational fear related to exposure to specific objects or situations. As a result, the affected person tends to avoid contact with the objects or situations and, in severe cases, any mention or depiction of them. The fear can, in fact, be disabling to their daily lives.[1]

The fear or anxiety may be triggered both by the presence and the anticipation of the specific object or situation. A person who encounters that of which they are phobic will often show signs of fear or express discomfort. In some cases, it can result in a panic attack. In most adults, the person may logically know the fear is unreasonable but still find it difficult to control the anxiety. Thus, this condition may significantly impair the person's functioning and even physical health.

Specific phobia affects up to 12% of people at some point in their life.

Specific Phobia – DSM 5 Criteria[3]

Diagnosis

Fear or anxiety about a specific object or situation (In children fear/anxiety can be expressed by crying, tantrums, freezing, or clinging)

The phobic object or situation almost always provokes immediate fear or anxiety

The phobic object or situation is avoided or endured with intense fear or anxiety

The fear or anxiety is out of proportion to the actual danger posed by the specific object or situation and to the sociocultural context

The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more

The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning

The disturbance is not better explained by symptoms of another mental disorder, including fear, anxiety, and avoidance of situations associated with panic-like symptoms or other incapacitating symptoms; objects or situations related to obsessions; reminders of traumatic events; separation from home or attachment figures; or social situations.

Treatment

Cognitive behavioral therapy (CBT), a short term, skills-focused therapy that aims to help people diffuse unhelpful emotional responses by helping people consider them differently or change their behavior, is effective in treating specific phobias.[6] Exposure therapy is a particularly effective form of CBT for specific phobias.

PANIC DISORDER

Panic disorder is an anxiety disorder characterized by reoccurring unexpected panic attacks.[1] Panic attacks are sudden periods of intense fear that may include palpitations, sweating, shaking, shortness of breath, numbness, or a feeling that something really bad is going to happen.[1][2] The maximum degree of symptoms occurs within minutes.[2] There may be ongoing worries about having further attacks and avoidance of places where attacks have occurred in the past.[1]

The cause of panic disorder is unknown.[3] Panic disorder often runs in families.[3] Risk factors include smoking, psychological stress, and a history of child abuse.[2] Diagnosis involves ruling out other potential causes of anxiety including other mental disorders, medical conditions such as heart disease or hyperthyroidism, and drug use.[2][3] Screening for the condition may be done using a questionnaire.[5]

Panic disorder is usually treated with counselling and medications.[3] The type of counselling used is typically cognitive behavioral therapy (CBT) which is effective in more than half of people.[3][4] Medications used include antidepressants and occasionally benzodiazepines or beta blockers.[1][3] Following stopping treatment up to 30% of people have a recurrence.[4]

Panic disorder affects about 2.5% of people at some point in their life.[4] It usually begins during adolescence or early adulthood but any age can be affected.[3] It is less common in children and older people.[2] Women are more often affected than men.

Symptoms Sudden periods of intense fear, palpitations, sweating, shaking, shortness of breath, numbness[1][2]

Usual onset Sudden and recurrent[1]

Causes Unknown[3]

Risk factors Family history, smoking, psychological stress, history of child abuse[2]

Diagnostic method Based on symptoms after ruling out other potential causes[2][3]

Differential diagnosis Heart disease, hyperthyroidism, drug use[2][3]

Treatment Counselling, medications[3]

Medication Antidepressants, benzodiazepines beta blockers[1][3]

Frequency 2.5% of people at some point

Symptom inductions generally occur for one minute and may include:

Intentional hyperventilation – creates lightheadedness, derealization, blurred vision, dizziness

Spinning in a chair – creates dizziness, disorientation

Straw breathing – creates dyspnea, airway constriction

Breath holding – creates sensation of being out of breath

Running in place – creates increased heart rate, respiration, perspiration

Body tensing – creates feelings of being tense and vigilant

dignosis

DSM-5 simplifies it into two very clear categories: expected and unexpected panic attacks.

Expected panic attacks are those associated with a specific fear like that of flying. Unexpected panic attacks have no apparent trigger or cue, and may appear to occur out of the blue.

According to DSM-5, a panic attack is characterized by four or more of the following symptoms:

Palpitations, pounding heart, or accelerated heart rate

Sweating

Trembling or shaking

Sensations of shortness of breath or smothering

A feeling of choking

Chest pain or discomfort

Nausea or abdominal distress

Feeling dizzy, unsteady, lightheaded, or faint

Feelings of unreality (derealization) or being detached from oneself (depersonalization)

Fear of losing control or going crazy

Fear of dying

Numbness or tingling sensations (paresthesias)

Chills or hot flushes

The presence of fewer than four of the above symptoms may be considered a limited-symptom panic attack.

AGORAPHOBIA

Agoraphobia is an anxiety disorder characterized by symptoms of anxiety in situations where the person perceives the environment to be unsafe with no easy way to get away.[1] These situations can include open spaces, public transit, shopping malls, or simply being outside their home.[1] Being in these situations may result in a panic attack.[2] The symptoms occur nearly every time the situation is encountered and last for more than six months.[1] Those affected will go to great lengths to avoid these situations.[1] In severe cases people may become completely unable to leave their homes due to the phobia.[2]

Agoraphobia is believed to be due to a combination of genetic and environmental factors.[1] The condition often runs in families, and stressful or traumatic events such as the death of a parent or being attacked may be a trigger.[1] In the DSM-5 agoraphobia is classified as a phobia along with specific phobias and social phobia.[1][3] Other conditions that can produce similar symptoms include separation anxiety, posttraumatic stress disorder, and major depressive disorder.[1] Those affected are at higher risk of depression and substance use disorder.[1]

Without treatment it is uncommon for agoraphobia to resolve.[1] Treatment is typically with a type of counselling called cognitive behavioral therapy (CBT).[3][5] CBT results in resolution for about half of people.[4] Agoraphobia affects about 1.7% of adults.[1] Women are affected about twice as often as men.[1] The condition often begins in early adulthood and becomes less common in old age.[1] It is rare in children.[1] The term "agoraphobia" is from Greek ἀγορά, agorá, meaning a "public square" and -φοβία, -phobia, meaning "fear".[6]

Symptoms Anxiety in situations perceived to be unsafe, panic attacks[1][2]

Complications Depression, substance use disorder[1]

Duration > 6 months[1]

Causes Genetic and environmental factors[1]

Risk factors Family history, stressful event[1]

Differential diagnosis Separation anxiety, posttraumatic stress disorder, major depressive disorder[1]

Treatment Cognitive behavioral therapy[3]

Prognosis Resolution in half with treatment[4]

Frequency 1.7% of adults[1]

Social anxiety disorder

Social anxiety disorder (SAD; also known as social phobia) describes an intense fear and avoidance of negative public scrutiny, public embarrassment, humiliation, or social interaction. This fear can be specific to particular social situations (such as public speaking) or, more typically, is experienced in most (or all) social interactions. Social anxiety often manifests specific physical symptoms, including blushing, sweating, and difficulty speaking. As with all phobic disorders, those suffering from social anxiety often will attempt to avoid the source of their anxiety; in the case of social anxiety this is particularly problematic, and in severe cases can lead to complete social isolation.

Social physique anxiety (SPA) is a subtype of social anxiety. It is concern over the evaluation of one's body by others.[20] SPA is common among adolescents, especially females.

Post-traumatic stress disorder

Post-traumatic stress disorder (PTSD) was once an anxiety disorder (now moved to trauma- and stressor-related disorders in DSM-V) that results from a traumatic experience. Post-traumatic stress can result from an extreme situation, such as combat, natural disaster, rape, hostage situations, child abuse, bullying, or even a serious accident. It can also result from long-term (chronic) exposure to a severe stressor--[21] for example, soldiers who endure individual battles but cannot cope with continuous combat. Common symptoms include hypervigilance, flashbacks, avoidant behaviors, anxiety, anger and depression.[22] In addition, individuals may experience sleep disturbances.[23] There are a number of treatments that form the basis of the care plan for those suffering with PTSD. Such treatments include cognitive behavioral therapy (CBT), psychotherapy and support from family and friends.[9]

Posttraumatic stress disorder (PTSD) research began with Vietnam veterans, as well as natural and non natural disaster victims. Studies have found the degree of exposure to a disaster has been found to be the best predictor of PTSD.[24]

Separation anxiety disorder

Main article: Separation anxiety disorder

Separation anxiety disorder (SepAD) is the feeling of excessive and inappropriate levels of anxiety over being separated from a person or place. Separation anxiety is a normal part of development in babies or children, and it is only when this feeling is excessive or inappropriate that it can be considered a disorder.[25] Separation anxiety disorder affects roughly 7% of adults and 4% of children, but the childhood cases tend to be more severe; in some instances, even a brief separation can produce panic.[26][27] Treating a child earlier may prevent problems. This may include training the parents and family on how to deal with it. Often, the parents will reinforce the anxiety because they do not know how to properly work through it with the child. In addition to parent training and family therapy, medication, such as SSRIs, can be used to treat separation anxiety.[28]

Situational anxiety

Situational anxiety is caused by new situations or changing events. It can also be caused by various events that make that particular individual uncomfortable. Its occurrence is very common. Often, an individual will experience panic attacks or extreme anxiety in specific situations. A situation that causes one individual to experience anxiety may not affect another individual at all. For example, some people become uneasy in crowds or tight spaces, so standing in a tightly packed line, say at the bank or a store register, may cause them to experience extreme anxiety, possibly a panic attack.[29] Others, however, may experience anxiety when major changes in life occur, such as entering college, getting married, having children, etc.

Obsessive–compulsive disorder

Obsessive–compulsive disorder (OCD) is not classified as an anxiety disorder by the DSM-5 but is by the ICD-10. It was previously classified as an anxiety disorder in the DSM-IV. It is a condition where the person has obsessions (distressing, persistent, and intrusive thoughts or images) and/or compulsions (urges to repeatedly perform specific acts or rituals), that are not caused by drugs or physical order, and which cause distress or social dysfunction.[30][31] The compulsive rituals are personal rules followed to relieve the anxiety.[31] OCD affects roughly 1-2% of adults (somewhat more women than men), and under 3% of children and adolescents.[30][31]

A person with OCD knows that the symptoms are unreasonable and struggles against both the thoughts and the behavior.[30][32] Their symptoms could be related to external events they fear (such as their home burning down because they forget to turn off the stove) or worry that they will behave inappropriately.[32]

It is not certain why some people have OCD, but behavioral, cognitive, genetic, and neurobiological factors may be involved.[31] Risk factors include family history, being single (although that may result from the disorder), and higher socioeconomic class or not being in paid employment.[31] Of those with OCD about 20% of people will overcome it, and symptoms will at least reduce over time for most people (a further 50%).[30]

Symptoms Feel the need to check things repeatedly, perform certain routines repeatedly, have certain thoughts repeatedly[1]

Complications Tics, anxiety disorder, suicide[2][3]

Usual onset Before 35 years[1][2]

Causes Unknown[1]

Risk factors Child abuse, stress[2]

Diagnostic method Based on the symptoms[2]

Differential diagnosis Anxiety disorder, major depressive disorder, eating disorders, obsessive–compulsive personality disorder[2]

Treatment Counseling, selective serotonin reuptake inhibitors, tricyclic antidepressants[4][5]

Frequency 2.3%

Selective mutism

Main article: Selective mutism

Selective mutism (SM) is a disorder in which a person who is normally capable of speech does not speak in specific situations or to specific people. Selective mutism usually co-exists with shyness or social anxiety.[33] People with selective mutism stay silent even when the consequences of their silence include shame, social ostracism or even punishment.[34] Selective mutism affects about 0.8% of people at some point in their life.

symptoms

Selective mutism is by definition characterized by the following:[5]

Consistent failure to speak in specific social situations (in which there is an expectation for speaking, e.g., at school) despite speaking in other situations.

The disturbance interferes with educational or occupational achievement or with social communication.

The duration of the disturbance is at least 1 month (not limited to the first month of school).

The failure to speak is not due to a lack of knowledge of, or comfort with, the spoken language required in the social situation.

The disturbance is not better accounted for by a communication disorder (e.g., childhood-onset fluency disorder) and does not occur exclusively during the course of autism spectrum disorder, schizophrenia, or another psychotic disorder.

Shyness, social anxiety, fear of social embarrassment, and/or social isolation and withdrawal

Difficulty maintaining eye contact

Blank expression and reluctance to smile

Difficulty expressing feelings, even to family members

Tendency to worry more than most people of the same age

Sensitivity to noise and crowds

On the positive side, many people with this condition have:

Above-average intelligence, perception, or inquisitiveness

Creativity and a love for art or music

Empathy and sensitivity to others' thoughts and feelings

A strong sense of right and wrong.

Causes OF ANXIETY DISORDER

Drugs

Anxiety and depression can be caused by alcohol abuse, which in most cases improves with prolonged abstinence. Even moderate, sustained alcohol use may increase anxiety levels in some individuals.[35] Caffeine, alcohol, and benzodiazepine dependence can worsen or cause anxiety and panic attacks.[36] Anxiety commonly occurs during the acute withdrawal phase of alcohol and can persist for up to 2 years as part of a post-acute withdrawal syndrome, in about a quarter of people recovering from alcoholism.[37] In one study in 1988–1990, illness in approximately half of patients attending mental health services at one British hospital psychiatric clinic, for conditions including anxiety disorders such as panic disorder or social phobia, was determined to be the result of alcohol or benzodiazepine dependence. In these patients, an initial increase in anxiety occurred during the withdrawal period followed by a cessation of their anxiety symptoms.[38]

There is evidence that chronic exposure to organic solvents in the work environment can be associated with anxiety disorders. Painting, varnishing and carpet-laying are some of the jobs in which significant exposure to organic solvents may occur.[39]

Taking caffeine may cause or worsen anxiety disorders,[40][41] including panic disorder.[42][43][44] Those with anxiety disorders can have high caffeine sensitivity.[45][46] Caffeine-induced anxiety disorder is a subclass of the DSM-5 diagnosis of substance/medication-induced anxiety disorder. Substance/medication-induced anxiety disorder falls under the category of anxiety disorders, and not the category of substance-related and addictive disorders, even though the symptoms are due to the effects of a substance.[47]

Cannabis use is associated with anxiety disorders. However, the precise relationship between cannabis use and anxiety still needs to be established.[48][49]

Medical conditions

Occasionally, an anxiety disorder may be a side-effect of an underlying endocrine disease that causes nervous system hyperactivity, such as pheochromocytoma[50][51] or hyperthyroidism.[52]

Stress

Anxiety disorders can arise in response to life stresses such as financial worries or chronic physical illness. Anxiety among adolescents and young adults is common due to the stresses of social interaction, evaluation, and body image. Anxiety is also common among older people who have dementia. On the other hand, anxiety disorder is sometimes misdiagnosed among older adults when doctors misinterpret symptoms of a physical ailment (for instance, racing heartbeat due to cardiac arrhythmia) as signs of anxiety.[8]

Genetics

GAD runs in families and is six times more common in the children of someone with the condition.[53]

While anxiety arose as an adaptation, in modern times it is almost always thought of negatively in the context of anxiety disorders. People with these disorders have highly sensitive systems; hence, their systems tend to overreact to seemingly harmless stimuli. Sometimes anxiety disorders occur in those who have had traumatic youths, demonstrating an increased prevalence of anxiety when it appears a child will have a difficult future.[54] In these cases, the disorder arises as a way to predict that the individual’s environment will continue to pose threats.

Persistence of anxiety

At a low level, anxiety is not a bad thing. In fact, the hormonal response to anxiety has evolved as a benefit, as it helps humans react to dangers. Researchers in evolutionary medicine believe this adaptation allows humans to realize there is a potential threat and to act accordingly in order to ensure greatest possibility of protection. It has actually been shown that those with low levels of anxiety have a greater risk of death than those with average levels. This is because the absence of fear can lead to injury or death.[54] Additionally, patients with both anxiety and depression were found to have lower morbidity than those with depression alone.[55] The functional significance of the symptoms associated with anxiety includes: greater alertness, quicker preparation for action, and reduced probability of missing threats.[55] In the wild, vulnerable individuals, for example those who are hurt or pregnant, have a lower threshold for anxiety response, making them more alert.[55] This demonstrates a lengthy evolutionary history of the anxiety response.

Evolutionary mismatch

It has been theorized that high rates of anxiety are a reaction to how the social environment has changed from the Paleolithic era. For example, in the Stone Age there was greater skin-to-skin contact and more handling of babies by their mothers, both of which are strategies that reduce anxiety.[54] Additionally, there is greater interaction with strangers in present times as opposed to interactions solely between close-knit tribes. Researchers posit that the lack of constant social interaction, especially in the formative years, is a driving cause of high rates of anxiety.

Many current cases are likely to have resulted from an evolutionary mismatch, which has been specifically termed a "psychopathogical mismatch". In evolutionary terms, a mismatch occurs when an individual possesses traits that were adapted for an environment that differs from the individual’s current environment. For example, even though an anxiety reaction may have been evolved to help with life-threatening situations, for highly sensitized individuals in Westernized cultures simply hearing bad news can elicit a strong reaction.[56]

An evolutionary perspective may provide insight into alternatives to current clinical treatment methods for anxiety disorders. Simply knowing some anxiety is beneficial may alleviate some of the panic associated with mild conditions. Some researchers believe that, in theory, anxiety can be mediated by reducing a patient’s feeling of vulnerability and then changing their appraisal of the situation.

Mechanisms

Biological

Low levels of GABA, a neurotransmitter that reduces activity in the central nervous system, contribute to anxiety. A number of anxiolytics achieve their effect by modulating the GABA receptors.[57][58][59]

Selective serotonin reuptake inhibitors, the drugs most commonly used to treat depression, are frequently considered as a first line treatment for anxiety disorders.[60]

Amygdala

The amygdala is central to the processing of fear and anxiety, and its function may be disrupted in anxiety disorders.[61] Sensory information enters the amygdala through the nuclei of the basolateral complex (consisting of lateral, basal, and accessory basal nuclei). The basolateral complex processes sensory-related fear memories and communicates their threat importance to memory and sensory processing elsewhere in the brain, such as the medial prefrontal cortex and sensory cortices.

Another important area is the adjacent central nucleus of the amygdala, which controls species-specific fear responses, via connections to the brainstem, hypothalamus, and cerebellum areas. In those with general anxiety disorder, these connections functionally seem to be less distinct, with greater gray matter in the central nucleus. Another difference is that the amygdala areas have decreased connectivity with the insula and cingulate areas that control general stimulus salience, while having greater connectivity with the parietal cortex and prefrontal cortex circuits that underlie executive functions.[61]

The latter suggests a compensation strategy for dysfunctional amygdala processing of anxiety. Researchers have noted "Amygdalofrontoparietal coupling in generalized anxiety disorder patients may ... reflect the habitual engagement of a cognitive control system to regulate excessive anxiety."[61] This is consistent with cognitive theories that suggest the use in this disorder of attempts to reduce the involvement of emotions with compensatory cognitive strategies.

Clinical and animal studies suggest a correlation between anxiety disorders and difficulty in maintaining balance.[62][63][64][65] A possible mechanism is malfunction in the parabrachial area, a brain structure that, among other functions, coordinates signals from the amygdala with input concerning balance.[66]

Anxiety processing in the basolateral amygdala has been implicated with dendritic arborization of the amygdaloid neurons. SK2 potassium channels mediate inhibitory influence on action potentials and reduce arborization. By overexpressing SK2 in the basolateral amygdala, anxiety in experimental animals can be reduced together with general levels of stress-induced corticosterone secretion.[67]

Diagnosis

Anxiety disorders are often severe chronic conditions, which can be present from an early age or begin suddenly after a triggering event. They are prone to flare up at times of high stress and are frequently accompanied by physiological symptoms such as headache, sweating, muscle spasms, tachycardia, palpitations, and hypertension, which in some cases lead to fatigue.

In casual discourse the words "anxiety" and "fear" are often used interchangeably; in clinical usage, they have distinct meanings: "anxiety" is defined as an unpleasant emotional state for which the cause is either not readily identified or perceived to be uncontrollable or unavoidable, whereas "fear" is an emotional and physiological response to a recognized external threat.[68] The term "anxiety disorder" includes fears (phobias) as well as anxieties.[medical citation needed]

The diagnosis of anxiety disorders is difficult because there are no objective biomarkers, it is based on symptoms,[69] which typically need to be present at least six months, be more than would be expected for the situation, and decrease functioning.[2][3] Several generic anxiety questionnaires can be used to detect anxiety symptoms, such as the State-Trait Anxiety Inventory (STAI), the Generalized Anxiety Disorder 7 (GAD-7), the Beck Anxiety Inventory (BAI), the Zung Self-Rating Anxiety Scale, and the Taylor Manifest Anxiety Scale.[70] Other questionnaires combine anxiety and depression measurement, such as the Hamilton Anxiety Rating Scale, the Hospital Anxiety and Depression Scale (HADS), the Patient Health Questionnaire (PHQ), and the Patient-Reported Outcomes Measurement Information System (PROMIS).[70] Examples of specific anxiety questionnaires include the Liebowitz Social Anxiety Scale (LSAS), the Social Interaction Anxiety Scale (SIAS), the Social Phobia Inventory (SPIN), the Social Phobia Scale (SPS), and the Social Anxiety Questionnaire (SAQ-A30).[71]

Anxiety disorders often occur along with other mental disorders, in particular depression, which may occur in as many as 60% of people with anxiety disorders. The fact that there is considerable overlap between symptoms of anxiety and depression, and that the same environmental triggers can provoke symptoms in either condition, may help to explain this high rate of comorbidity.[72]

Studies have also indicated that anxiety disorders are more likely among those with family history of anxiety disorders, especially certain types.[73]

Sexual dysfunction often accompanies anxiety disorders, although it is difficult to determine whether anxiety causes the sexual dysfunction or whether they arise from a common cause. The most common manifestations in individuals with anxiety disorder are avoidance of intercourse, premature ejaculation or erectile dysfunction among men and pain during intercourse among women. Sexual dysfunction is particularly common among people affected by panic disorder (who may fear that a panic attack will occur during sexual arousal) and posttraumatic stress disorder.[74]

TREATMENT

In general, anxiety disorders are treated with medication, specific types of psychotherapy, or both.

Treatment choices depend on the problem and the person’s preference.

People with anxiety disorders who have already received treatment should tell their current doctor

about that treatment in detail. If they received medication, they should tell their doctor what

medication was used, what the dosage was at the beginning of treatment, whether the dosage

was increased or decreased while they were under treatment, what side effects occurred, and

whether the treatment helped them become less anxious. If they received psychotherapy, they

should describe the type of therapy, how often they attended sessions, and whether the therapy

was useful.

Often people believe that they have “failed” at treatment or that the treatment didn’t work for them

when, in fact, it was not given for an adequate length of time or was administered incorrectly.

Sometimes people must try several different treatments or combinations of treatment before they

find the one that works for them.

Medication

Medication will not cure anxiety disorders, but it can keep them under control while the person

receives psychotherapy. Medication must be prescribed by physicians, usually psychiatrists, who

can either offer psychotherapy themselves or work as a team with psychologists, social workers,

or counselors who provide psychotherapy. The principal medications used for anxiety disorders

are antidepressants, anti­anxiety drugs, and beta­blockers to control some of the physical

symptoms. With proper treatment, many people with anxiety disorders can lead normal, fulfilling

lives.

Antidepressants

Antidepressants were developed to treat depression but are also effective for anxiety disorders.

Although these medications begin to alter brain chemistry after the very first dose, their full effect

requires a series of changes to occur; it is usually about 4 to 6 weeks before symptoms start to

fade. It is important to continue taking these medications long enough to let them work.

SSRIs

Some of the newest antidepressants are called selective serotonin reuptake inhibitors, or SSRIs.

SSRIs alter the levels of the neurotransmitter serotonin in the brain, which, like other

neurotransmitters, helps brain cells communicate with one another.

12/2/2014 NIMH · Anxiety Disorders

http://www.nimh.nih.gov/health/topics/anxiety­disorders/index.shtml 4/17

Fluoxetine (Prozac®), sertraline (Zoloft®), escitalopram (Lexapro®), paroxetine (Paxil®), and

citalopram (Celexa®) are some of the SSRIs commonly prescribed for panic disorder, OCD,

PTSD, and social phobia. SSRIs are also used to treat panic disorder when it occurs in

combination with OCD, social phobia, or depression. Venlafaxine (Effexor®), a drug closely

related to the SSRIs, is used to treat GAD. These medications are started at low doses and

gradually increased until they have a beneficial effect.

SSRIs have fewer side effects than older antidepressants, but they sometimes produce slight

nausea or jitters when people first start to take them. These symptoms fade with time. Some

people also experience sexual dysfunction with SSRIs, which may be helped by adjusting the

dosage or switching to another SSRI.

Tricyclics

Tricyclics are older than SSRIs and work as well as SSRIs for anxiety disorders other than OCD.

They are also started at low doses that are gradually increased. They sometimes cause dizziness,

drowsiness, dry mouth, and weight gain, which can usually be corrected by changing the dosage

or switching to another tricyclic medication.

Tricyclics include imipramine (Tofranil®), which is prescribed for panic disorder and GAD, and

clomipramine (Anafranil®), which is the only tricyclic antidep

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inadequate doses.

Buspirone (Buspar®), an azapirone, is a newer anti­anxiety medication used to treat GAD.

Possible side effects include dizziness, headaches, and nausea. Unlike benzodiazepines,

buspirone must be taken consistently for at least 2 weeks to achieve an anti­anxiety effect.

Beta­Blockers

Beta­blockers, such as propranolol (Inderal®), which is used to treat heart conditions, can prevent

the physical symptoms that accompany certain anxiety disorders, particularly social phobia. When

a feared situation can be predicted (such as giving a speech), a doctor may prescribe a betablocker

to keep physical symptoms of anxiety under control.

Taking Medications

Before taking medication for an anxiety disorder:

Ask your doctor to tell you about the effects and side effects of the drug.

Tell your doctor about any alternative therapies or over­the­counter medications you are

using.

Ask your doctor when and how the medication should be stopped. Some drugs can’t be

stopped abruptly but must be tapered off slowly under a doctor’s supervision.

Work with your doctor to determine which medication is right for you and what dosage is

best.

Be aware that some medications are effective only if they are taken regularly and that

symptoms may recur if the medication is stopped.

Psychotherapy

Psychotherapy involves talking with a trained mental health professional, such as a psychiatrist,

psychologist, social worker, or counselor, to discover what caused an anxiety disorder and how to

deal with its symptoms.

Cognitive­Behavioral Therapy

Cognitive­behavioral therapy (CBT) is very useful in treating anxiety disorders. The cognitive part

helps people change the thinking patterns that support their fears, and the behavioral part helps

people change the way they react to anxiety­provoking situations.

For example, CBT can help people with panic disorder learn that their panic attacks are not really

heart attacks and help people with social phobia learn how to overcome the belief that others are

always watching and judging them. When people are ready to confront their fears, they are shown

how to use exposure techniques to desensitize themselves to situations that trigger their anxieties.

People with OCD who fear dirt and germs are encouraged to get their hands dirty and wait

increasing amounts of time before washing them. The therapist helps the person cope with the

anxiety that waiting produces; after the exercise has been repeated a number of times, the anxiety

diminishes. People with social phobia may be encouraged to spend time in feared social situations

without giving in to the temptation to flee and to make small social blunders and observe how

people respond to them. Since the response is usually far less harsh than the person fears, these

anxieties are lessened. People with PTSD may be supported through recalling their traumatic

event in a safe situation, which helps reduce the fear it produces. CBT therapists also teach deep

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breathing and other types of exercises to relieve anxiety and encourage relaxation.

Exposure­based behavioral therapy has been used for many years to treat specific phobias. The

person gradually encounters the object or situation that is feared, perhaps at first only through

pictures or tapes, then later face­to­face. Often the therapist will accompany the person to a

feared situation to provide support and guidance.

CBT is undertaken when people decide they are ready for it and with their permission and

cooperation. To be effective, the therapy must be directed at the person’s specific anxieties and

must be tailored to his or her needs. There are no side effects other than the discomfort of

temporarily increased anxiety.

CBT or behavioral therapy often lasts about 12 weeks. It may be conducted individually or with a

group of people who have similar problems. Group therapy is particularly effective for social

phobia. Often “homework” is assigned for participants to complete between sessions. There is

some evidence that the benefits of CBT last longer than those of medication for people with panic

disorder, and the same may be true for OCD, PTSD, and social phobia. If a disorder recurs at a

later date, the same therapy can be used to treat it successfully a second time.

Medication can be combined with psychotherapy for specific anxiety disorders, and this is the best

treatment approach for many people.

Ways to Make Treatment More Effective

Many people with anxiety disorders benefit from joining a self­help or support group and sharing

their problems and achievements with others. Internet chat rooms can also be useful in this

regard, but any advice received over the Internet should be used with caution, as Internet

acquaintances have usually never seen each other and false identities are common. Talking with

a trusted friend or member of the clergy can also provide support, but it is not a substitute for care

from a mental health professional.

Stress management techniques and meditation can help people with anxiety disorders calm

themselves and may enhance the effects of therapy. There is preliminary evidence that aerobic

exercise may have a calming effect. Since caffeine, certain illicit drugs, and even some over­thecounter

cold medications can aggravate the symptoms of anxiety disorders, they should be

avoided. Check with your physician or pharmacist before taking any additional medications.

The family is very important in the recovery of a person with an anxiety disorder. Ideally, the family

should be supportive but not help perpetuate their loved one’s symptoms. Family members should

not trivialize the disorder or demand improvement without treatment.

DIET 

Foods That Help Anxiety

There are many foods that can aid in controlling anxiety levels. By adding or increasing these “foods that calm” to your diet, you can help manage your generalized anxiety disorder symptoms:

Complex carbs (brown rice, *whole grain breads and pastas)

*Seaweed and kelp is a good alternative for those who are gluten sensitive

Provide balanced serotonin levels: keeps you happy and calm

Supply magnesium: a magnesium deficiency can contribute to anxiety

Peaches, blueberries, acai berries

Rich in vitamins, phytonutrients, and antioxidants: provide calming nutrients

Vegetables and legumes

Strengthen your immune system

Healthy fats such as those found in nuts and seeds

Contain zinc and iron to ward off brain fatigue and increase energy

Water

Circulates anxiety-reducing hormones through your body

Dehydration can result in mood changes

Chocolate: pure, dark chocolate without milks and sugars

Reduces the stress hormone, cortisol, and improves your mood

B vitamins, zinc, magnesium, antioxidants

Certain herbs such as passionflower and kava

Foods to Avoid or Minimize

Certain foods might provide you with a boost of energy or give you a temporary sense of calm, but the effects wear off quickly and often leave you feeling worse:

Simple carbs, high-glycemic carbs (white bread, white flour, cookies, cakes, anything with a high sugar content)

Give you an energy boost, followed by a “crash” that can produce anxiety

Fast food, fried food, processed food, foods with a high salt content

Makes your body more acidic, leading to more anxiety

Alcohol

Initial sense of relaxation, but disrupts sleep patterns, leading to anxiety

Caffeine, especially if you are prone to panic attacks

Small amounts can be soothing, but caffeine increases your heart rate, leading to nervousness and raising your anxiety levels.

PASTE THE QUESTIONNAIRE

THE GAD-7 score is calculated by assigning scores of 0, 1, 2, and 3, to the response categories of 'not at all', 'several days', 'more than half the days', and 'nearly every day', respectively, and adding together the scores for the seven questions.

Scores of 5, 10, and 15 are taken as the cut-off points for mild, moderate and severe anxiety, respectively. When used as a screening tool, further evaluation is recommended when the score is 10 or greater.

Using the threshold score of 10, the GAD-7 has a sensitivity of 89% and a specificity of 82% for GAD. It is moderately good at screening three other common anxiety disorders - panic disorder (sensitivity 74%, specificity 81%), social anxiety disorder (sensitivity 72%, specificity 80%) and post-traumatic stress disorder (sensitivity 66%, specificity 81%)