Anxiety disorders, phobias and stress-related disorders: Pathology Review

19 year old Anastasia comes to the emergency department convinced that she’s about to die from a heart attack. It all started as soon as she entered the lecture hall to take her final exam for college, when she began sweating and feeling light-headed. Within 5 minutes, this quickly progressed to being unable to breathe and experiencing a stabbing chest pain. She doesn’t use illicit substances or alcohol, and has no personal or family history of cardiovascular or pulmonary disease. Her mother, who’s by her side, mentions that Anastasia has had five similar episodes in the past six months, all while preparing for her exams. Anastasia adds that she wants to quit college, because she is afraid an attack will happen again and she won’t be able to make it. Upon examination, her ECG is normal, and on a blood test, D-dimer is negative, and cardiac enzymes remain normal after 6 hours.

The next day, you see 43 year old Olivia, who is brought to the office by her husband, who thinks she needs help. They constantly get into fights because Olivia wants everything in the house to be sparkling-clean and organized in a very specific way. She always blames him for leaving contaminated fingerprints around the house and moving items from their proper place. She then goes on to clean up for hours and even loses sleep over it. When you ask Olivia about these behaviors, she says that she understands they are irrational and wishes she could stop them, but she just can’t.

Okay, based on the initial presentation, both Anastasia and Olivia seem to have some form of anxiety or obsessive-compulsive disorder.

Many of us experience fear or anxiety during stressful times, which is perfectly normal and can actually be beneficial, since it helps set the body on high-alert. Now, fear is the emotional response to an imminent threat or danger, and can cause a fight or flight response when your life is threatened. For your exams, make sure you can differentiate fear from anxiety, which is the anticipation of a future threat or stressful situation with an uncertain outcome, and is often associated with feelings of worry and nervousness, which causes avoidant behaviors. Now, it’s important to keep in mind that fear and anxiety can be experienced at the same time. For example, you may fear a particularly tough exam, while feeling anxious about an uncertain outcome like passing it! So, normally, fear and anxiety occur in response to a real threat, but normally shouldn’t cause any excessive physical or psychological manifestations, other than perhaps, mild insomnia before an important event, like the night before your test!

In contrast, with anxiety disorders, these feelings of fear and anxiety go into overdrive, and are often disproportionate to the stressful situation. What’s worse is that these feelings may be accompanied by physical manifestations, such as tachycardia, sweating, and trembling, as well as psychological manifestations, such as trouble concentrating or behavioral changes. What’s important to note is that, with anxiety disorders, these manifestations may be so severe that they interfere with day-to-day activities like working, studying, eating, and sleeping. Now, the underlying cause of anxiety disorders is poorly understood; for your exams, what you need to remember is that there’s usually an imbalance of the neurotransmitter GABA, which is linked to anxiety. The main risk factors for anxiety disorders seem to include having a family history or experiencing a personal trauma. Another important thing to keep in mind is that other psychiatric disorders, medical conditions, like hyperthyroidism, and the use of medications or substances like cocaine may also cause anxiety, so they should be ruled out before diagnosing an anxiety disorder. For your exams, the most common anxiety disorders include generalized anxiety disorder, panic disorder, phobias, social anxiety disorder, selective mutism, and agoraphobia. Obsessive-compulsive disorders, including obsessive-compulsive disorder, body dysmorphic disorder, and trichotillomania, used to be grouped with the anxiety disorders, but now they have their own separate category.

Okay, let’s start with generalized anxiety disorder, or GAD for short. This is characterized by excessive, and unreasonable anxiety about everyday things, like money, work, and personal relationships. These individuals often find it difficult to control their anxiety, meaning that they have a hard time calming themselves or helping themselves regain control over their feelings. And bear in mind that this occurs for more days than not over the course of 6 months. In addition to having feelings of worries and anxiety, adults must have at least three of the following six symptoms: restlessness, fatigue, difficulty concentrating or feeling like the mind just goes blank, irritability or edginess, muscle tension, and sleep disturbances like falling asleep or staying asleep. For children, though, only one of these symptoms must be present. And that’s a high yield fact!

Moving on to panic disorder, this is when people have recurrent out-of-the-blue panic attacks that typically peak within 10 minutes and involve at least 4 of the following symptoms: palpitations, often associated with an increased heart rate and blood pressure, sweating, and trembling, as well as chest pain, dyspnea, and feeling like choking, nausea, dizziness or lightheadedness, chills or hot flashes, paresthesias or a “pins and needles” sensation, derealization or feelings of unreality, depersonalization or detachment from self, and an intense fear of dying or losing control.

People with panic disorder become preoccupied with when the next attack will happen and the consequences of it, and try to prevent future attacks by avoiding the people, places, situations, or behaviors that they think are triggers. So, diagnosis of a panic disorder requires a panic attack followed by at least one month of one or more of the following: persistent concern of future attacks, worrying about consequences of attack and change in behavior to avoid having panic attacks. It’s also important to know that panic disorder has a strong genetic component and carries an increased risk for suicide. In addition, remember that a panic attack could be triggered by a wide variety of things like finances and upcoming trips, but frequently no trigger can be identified. For your exams, keep in mind that panic attacks can be a symptom of other anxiety disorders, too, but in those settings they are related to a specific trigger and therefore don’t meet criteria for a panic disorder.

Next there’s specific phobias, which are fears or anxiety about a specific trigger, such as an animal or living creature like a racoon or insect, an object like a sharp needle, or a situation like flying. The fear response is disproportionate to the actual danger caused by the trigger, like freaking out when a raccoon scurries across the street. In fact, the individual often realizes that the fear is excessive. An important thing to keep in mind is that with phobias, symptoms occur only when the individual is faced with the trigger that causes anxiety, so the phobic object is actively avoided. And these feelings must last for more than six months to be diagnosed as phobia.

One of the most common types of phobias is social anxiety disorder or social phobia. Here, the anxiety is caused by social or performance situations like meeting groups of new people, going on dates, and job interviews, where people feel like they are under scrutiny or being judged. Individuals worry that what they do or say will be negatively evaluated by their colleagues, making them feel ashamed and embarrassed. A high yield subtype of social anxiety disorder is the performance type, where anxiety is only experienced during speaking or performing in public, but not in other types of social situations.

Now, in children before the age of 5, social anxiety is often accompanied by selective mutism which is when individuals fail to speak at specific social situations, such as at school. The problem should be recurrent, and last for at least one month. What’s important to remember here is that these individuals speak normally in other, presumably more comfortable situations, and the failure to speak isn’t due to a lack of teaching or a communication disorder.

Another common type of phobia is agoraphobia, which is when people have an intense fear of public spaces. This includes at least two of the following situations: leaving their home alone, using public transportation, being in open spaces like parks and rooftops, being in enclosed spaces like theaters, standing in line, and being in a crowd. People with agoraphobia often avoid these situations. In fact, severe cases might even refuse to go out, mostly because they fear having a panic reaction in a public space and that they may not be able to escape. In a test question, this can help you set agoraphobia apart from social anxiety disorder, which is more about a fear of being judged by others, rather than not being able to escape.

Okay, now, let’s switch gears and talk about obsessive-compulsive and related disorders. These used to be considered a specific group of anxiety disorders, although now, they’re classified separately. We all have unwanted thoughts at times that we can’t just shake off. And we also have things we want done only in a particular way, from organizing our closets to superstitions. But individuals with obsessive-compulsive or related disorders, experience this obsessive way of thinking and acting so extremely that it causes distress and negatively impacts their lives. Now, in terms of symptoms, the group is mainly characterized by obsessions and compulsions. Obsessions are recurrent, intrusive, and unwanted thoughts or urges, like a fear of being contaminated by germs or robbed, as well as religious or moral scrupulosity. These thoughts cause intense anxiety, are hard to get rid of, and usually disappear only after performing a certain action or series of actions called compulsions. These are ritualistic behaviors that the individual feels compelled to do, in order to try and reduce the anxiety associated with obsessions. Compulsions can be repetitive physical rituals like hand washing, cleaning, or checking to make sure that something’s definitely locked, as well as mental rituals such as praying, counting, or repeating words silently.