Understanding Anxiety Disorders: A helpful guide for health professionals

We all experience feelings of nervousness, worry, fear, or anxiety to the point of discomfort and distress at various points in our lives. Anxiety is a normal response to fear-provoking situations. However, for people who live with an anxiety disorder, these feelings are excessive, persistent, and disrupt the flow of daily activities such as relationships, work, and school. The symptoms that accompany an anxiety disorder are frequently out of proportion to the trigger, or there’s no identifiable trigger present. It’s important to note that these anxiety symptoms should not be due to any underlying medical condition, substance use, or other mental health condition for a patient to be diagnosed with an anxiety disorder.

Having an understanding of the various anxiety disorders is vital not only for mental health professionals but for all health professionals. Anxiety disorders are one of the most prevalent mental health conditions, with about 19.1% of U.S. adults being affected each year. Aside from how common these disorders are, some of the anxiety symptoms can overlap with other conditions, leading patients to a primary care physician, for example, rather than a psychologist or psychiatrist. As you can see, gaining an understanding of the symptoms, diagnostic criteria of anxiety disorders, and the best anxiety treatment options available will ensure patients receive optimal care.

Types of Anxiety Disorders

What do Generalized Anxiety Disorder (GAD), Panic Disorder, Social Anxiety Disorder (SAD), Specific Phobia, Agoraphobia, Selective Mutism, and Separation Anxiety Disorder all have in common? They’re all different types of anxiety disorders that you should acquaint yourself with and be prepared to educate your patients about.

Generalized Anxiety Disorder

Let’s kick off our discussion of anxiety disorders by learning about Generalized Anxiety Disorder. GAD is more common in women, and 5.7% of adults in the U.S. will experience it during their lifetime. In this condition, patients feel intense and persistent anxiety about many different aspects of their lives.

GAD manifests with symptoms such as:

Difficulty concentrating
Difficulty controlling worry
Restlessness
Fatigue
Muscle tension
Difficulty sleeping
Headaches
Stomachaches
Nausea
Diarrhea

To be diagnosed with Generalized Anxiety Disorder, this excessive worry about elements of daily life should be present for six or more months, with the presence of three or more of the symptoms.

So, how is GAD treated? It’s often with a combination of psychotherapy and medications. Often recommended for GAD, Cognitive Behavioral Therapy (CBT) is a form of psychotherapy that focuses on changing thinking patterns that are negative or unhelpful, introduces relaxation techniques, and reduces unproductive behaviors.

In terms of medications, antidepressants such as serotonin reuptake inhibitors (SSRIs) and serotonin and norepinephrine reuptake inhibitors (SNRIs) are helpful. Buspirone, which is an anti-anxiety medication, can also be used to augment the effects of antidepressants if necessary. Benzodiazepines can also be considered for use as long as it is only on a short-term basis due to the risk of addiction.

Panic Disorder

Next, let’s learn more about Panic Disorder. Similar to Generalized Anxiety Disorder, this condition is more prevalent in women than in men. Overall, 4.7% of U.S. adults will deal with panic disorder at some point in their lifetime. The main feature is panic attacks, which are episodes of profound terror, fear, or anxiety that tend to reach their peak after a few minutes. These panic attacks may occur several times a day or a few times a month.

Other key symptoms include:

Sweating
Feeling of heart racing
Shortness of breath
Chest pain
Dizziness or lightheadedness
Hot flashes or chills
Feelings of losing control
Sensation of choking
Afraid of losing control
Fear of dying
Nausea or stomach discomfort
Shaking or trembling

Aside from these symptoms, important diagnostic criteria for panic disorder include recurrent panic attacks without a clearly identifiable trigger, as well as one or more months of persistent worry of having another panic attack or the consequences associated with them.

An ideal treatment strategy is a combination of psychotherapy and medication. CBT and SSRIs or SNRIs are generally the primary therapeutic approach. Tricyclic antidepressants (TCAs) can also be used if the first-line medications are not effective. However, they should be used with caution due to their multitude of side effects. Benzodiazepines may also used for short periods when treatment for panic disorder is present, as they provide relief from panic attacks.

Social Anxiety Disorder

If a patient mentions that they’ve avoided social interactions due to a fear of being scrutinized or humiliated by others for a period of six or more months, what diagnosis pops into your mind? Hopefully, you confidently answered Social Anxiety Disorder (SAD), previously referred to as social phobia. For people who have it, the anxiety associated with social situations is so great that it impairs people academically, occupationally, and socially.

Symptoms to be on the lookout for are:

Difficulty making eye contact with others
Anxiousness
Stomach pains
Feeling of heart racing
Feelings of anxiety or embarrassment
Difficulty being around new people
Speaking with a very soft voice
Stiff posture
Fear of being judged by others
Feeling self-conscious

In terms of the diagnostic criteria, patients must present with a fear or anxiety that’s out of proportion to the situation, as well as avoidance of social settings and/or instant fear once they’re in a social setting. As previously mentioned, their feelings should also impair functioning, with symptoms persisting for six months or more. Treatment options include CBT, SSRIs, or SNRIs, as well as benzodiazepines, as needed. For those with anxiety surrounding public speaking or performance anxiety, a beta blocker can be prescribed to reduce shakiness and slow down the heart rate. However, be sure to watch for signs of emerging depression or anxiety, drowsiness, insomnia, hallucinations, or nightmares, which can be a side effect of use.

Specific Phobias

Have you ever heard of arachnophobia, the intense fear of spiders, or claustrophobia, a fear of tight, closed-in spaces? These types of anxieties and fears are known as Specific Phobias and involve the irrational fear of a situation or object. Interestingly, patients are typically aware their fear is irrational in proportion to what they’re facing, but they can’t overcome their feelings toward it.

Signs and symptoms of a Specific phobia include:

Immediate fear, anxiety, or panic
Sweating
Shortness of breath
Sense of heart racing
Chest tightness
Trembling
Strong avoidance of an object or situation

The diagnostic criteria for Specific Phobia and Social Anxiety Disorder are the same, but the treatments are different. Exposure therapy is a method of treatment in which a patient is gradually and continuously exposed to their phobia trigger to reduce the intense fear they experience, as well as learn helpful ways to manage the anxiety, feelings, and sensations associated with their phobia. Patients aren’t immediately confronted with their actual phobia. Instead, the process may begin with looking at photos of the phobia or simply thinking about it before fully immersing themselves in the situation or interacting with the object. CBT is also used to challenge their thoughts and find new ways to cope with their feelings towards their phobia.

Agoraphobia

Patients who present with an immense fear of public spaces, where escaping or getting help may be difficult, may be dealing with Agoraphobia. This condition frequently develops with Panic Disorder as well. In the most severe cases of Agoraphobia, patients may not leave their homes at all. Worldwide, there is a prevalence of 1-1.7%, including adolescents and adults.

In general, patients with Agoraphobia have a fear of two or more of these situations:

Lines or crowds
Enclosed spaces
Open spaces
Public transportation
Being outside of their homes alone

The immense anxiety and avoidance of certain environments, along with social and occupational dysfunction, must be present for six months or more to make a diagnosis. Agoraphobia can be managed with CBT along with SSRIs or SNRIs.

Selective Mutism

Have you ever met someone who refuses to speak in some environments but speaks freely in another? They may have Selective Mutism. Selective Mutism typically presents in childhood with a patient who has no issue using or comprehending language but, for one month or more, fails to speak in those environments, such as school. Patients may use gestures or other nonverbal forms of communication in environments where they fail to speak. As you can imagine, this condition can add to existing challenges with school, work, and social interactions. Selective Mutism typically presents prior to age five, with a prevalence of 1-2%, and may not be diagnosed until a child begins school.

Treatment options for Mutism include CBT, family therapy, and SSRIs for anxiety symptoms. Family therapy goals are to strengthen the relationships between family members, enhance communication, and address any underlying issues affecting the household. Some patients also develop speech delays or fluency issues, such as stuttering. In those cases, speech therapy can also be a helpful treatment tool.

Separation Anxiety Disorder

Let’s discuss Separation Anxiety Disorder. Experiencing separation anxiety is a normal part of development. However, when the level of anxiety associated with separation becomes excessive and doesn’t coincide developmentally with the person’s age, it’s time to consider the possibility of Separation Anxiety Disorder. About 4% of children have this disorder, with it being diagnosed more frequently in girls.

This disorder typically presents in kids and adolescents but may continue into adulthood. Patients have an immense fear that their caregiver(s) will be harmed in some way if they’re away from them. To be diagnosed, at least three of the following must be present for four weeks or more in kids/ adolescents and six months or more in adults:

Excessive worry about harm or loss of a caregiver
Difficulty leaving the house
Difficulty sleeping alone or outside of the home
Reluctance to be alone
Nightmares regarding separation
Complaints about physical symptoms such as stomach pain or headaches when away from caregiver(s).

The best treatment approach is CBT, family therapy, and SSRIs.

Understanding the Etiology of Anxiety Disorders

There are a few different factors that contribute to the development of anxiety disorders. Different neurotransmitters within the central nervous system, including serotonin, gamma-aminobutyric acid (GABA), norepinephrine, and dopamine, are involved in mediating anxiety. The medications prescribed for anxiety disorders affect these neurotransmitters to produce a therapeutic effect on the patient.

The amygdala is a structure in the brain that’s key to regulating fear and anxiety. Patients with anxiety disorders have been found to have a heightened amygdala response in response to anxiety-provoking cues. Family history also plays a role in the development of certain conditions, such as Agoraphobia and Panic Disorder.

Psychosocial factors, like a history of childhood physical or sexual abuse, as well as a higher number of stressors preceding the onset of an anxiety disorder, can contribute to its development. Environmental factors can also cause anxiety disorders due to exposure to traumatic experiences such as illness, divorce, or death.

Diagnosis and Assessment of Anxiety Disorders

Symptoms of anxiety disorders can present in other conditions and may make proper diagnosis challenging. There are several differential diagnoses for anxiety disorders, ranging from heart issues like unstable angina to gastrointestinal issues such as acute gastritis.

Health professionals must gather a thorough clinical history and perform a physical exam to make an accurate diagnosis. Lab tests measure thyroid function, blood sugar levels, electrolytes, liver function, and kidney function, which are helpful to rule out an underlying medical condition causing anxiety.

Once the cause of the anxiety is established and attributed to a psychological reason, patients are often referred to a mental health professional for further assessment. There are quite a few assessment tools, including the Generalized Anxiety Disorder 7 (GAD-7), Beck Anxiety Inventory (BAI), and more.

Treatment Approaches

Aside from the anxiety medication management strategies and anxiety therapy techniques previously discussed, other helpful approaches include lifestyle modifications and alternative treatments. Meditation, mindfulness techniques, exercise, eating anti-inflammatory foods, reducing caffeine intake, and attending support groups can all help reduce anxiety symptoms. Combining these lifestyle changes with psychotherapy and medication can genuinely make a positive impact on those living with anxiety disorders.

Management Strategies for Health Professionals

Patients with anxiety disorders often see their primary care physician or other internal medicine specialist when experiencing anxiety disorders. Due to the way these disorders manifest with muscle tension, stomach issues, dizziness, and much more, health professionals need to understand and educate their patients about anxiety disorders and the importance of seeking treatment. Referring patients to a mental health professional who can perform psychological assessments, properly diagnose, and formulate an effective treatment plan is also important. The patient’s care team should actively participate in a collaborative approach, with a particular focus on medication management to avoid harmful interactions or side effects.

Conclusion

As the prevalence of anxiety conditions increases, it’s vital to have a clear understanding of the various anxiety disorders, methods for coping with anxiety, therapy techniques, and management strategies. There’s a lot to learn, but hopefully, this introduction/refresher has been helpful. Psychotherapy, medication, and the addition of lifestyle changes and holistic techniques can all support patient progress and treatment. Remember, just like every other organ in the body, the brain deserves to be cared for too!