Anxiety

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Shankar Kumar, M.B.B.S. [2]

Overview

Anxiety is a physiological state characterized by cognitive, somatic, emotional, and behavioral components (Seligman, Walker & Rosenhan, 2001). These components combine to create the feelings that we typically recognize as fear, apprehension, or worry. Anxiety is often accompanied by physical sensations such as heart palpitations, nausea, chest pain, shortness of breath, or headache.

The cognitive component entails expectation of a diffuse and uncertain danger. Somatically the body prepares the organism to deal with threat (known as an emergency reaction): blood pressure and heart rate are increased, sweating is increased, bloodflow to the major muscle groups is increased, and immune and digestive system functions are inhibited. Externally, somatic signs of anxiety may include pale skin, sweating, trembling, and pupillary dilation. Emotionally, anxiety causes a sense of dread or panic and physically causes nausea, and chills. Behaviorally, both voluntary and involuntary behaviors may arise directed at escaping or avoiding the source of anxiety and often maladaptive, being most extreme in anxiety disorders. However, anxiety is not always pathological or maladaptive: it is a common emotion along with fear, anger, sadness, and happiness, and it has a very important function in relation to survival.

Neural circuitry involving the amygdala and hippocampus is thought to underlie anxiety (Rosen & Schulkin, 1998). When confronted with unpleasant and potentially harmful stimuli such as foul odors or tastes, PET-scans show increased bloodflow in the amygdala (Zald & Pardo, 1997; Zald, Hagen & Pardo, 2002). In these studies, the participants also reported moderate anxiety. This might indicate that anxiety is a protective mechanism designed to prevent the organism from engaging in potentially harmful behaviors.

Anxiety disorders

Anxiety disorders

Complete Differential Diagnosis of the Causes of Anxiety

(By organ system)

Cardiovascular	Acute Coronary Syndromes, Hypertension, Myocardial infarction, Orthostatic intolerance, Postural orthostatic tachycardia syndrome, Supraventricular tachycardia
Chemical / poisoning	Barium nitrate, Irukandji syndrome
Dermatologic	No underlying causes
Drug Side Effect	Alpha-Methyltryptamine, Amantadine, Amineptine, Amphetamine, Aniracetam, Anorexia nervosa, Aripiprazole , Benzylpiperazine, Biperiden, Bortezomib , Buprenorphine, Buprenorphine Sublingual and Buprenorphine and Naloxone Sublingual , Bupropion, Buspirone, Butorphanol Injection , Caffeine, Carbamazepine , Clofarabine Injection , Cocaine, Dexamethasone Oral , Dextroamphetamine and Amphetamine , Dicyclomine , Diethylcathinone, Diethylpropion , Diphenhydramine, Doxylamine, ECA stack, Efavirenz , Enoxacin , Ethcathinone, Fentanyl Oral Transmucosal , Fentanyl Skin Patches , Fexofenadine and Pseudoephedrine , Fludrocortisone Acetate , Fluoxetine, Fluphenazine , Fluticasone Oral Inhalation , Gabapentin, Glatiramer acetate, Glycopyrrolate , Haloperidol, Heroin, Hydrocodone, Hydrocortisone Injection , Hydrocortisone Oral , Hydroxyzine, Imatinib , Interferon beta-1a Subcutaneous Injection , Interferon Beta-1b Injection , Leuprolide , Levetiracetam , Levodopa, Liothyronine , Lofepramine, Loratadine, MDPV, MeOPP, Mesalamine , Methamphetamine, Methylenedioxymethamphetamine, Methylphenidate Transdermal , Methylprednisolone Oral , Methylprednisolone Sodium Succinate Injection , Metrazol, Mirtazapine, Moclobemide, Modafinil, Monoamine oxidase inhibitor, Motofen, Nabilone , Naltrexone , Norfloxacin , Norplant, Nortriptyline , Orlistat , Oxaliplatin injection , Paroxetine, Pentostatin , PFPP, Phenylephrine, Pipradrol, Piracetam, Posaconazole , Promethazine , Pseudoephedrine, Psychiatric medication, Psychoactive drug, Pyrovalerone, Quetiapine, Reboxetine, Rilmenidine, Risperidone, Ropinirole , Selective serotonin reuptake inhibitor, Serotonin syndrome, Serotonin-norepinephrine reuptake inhibitor, Sertraline, Sibutramine , Temozolomide , Topiramate, Tramadol, Trazodone, Triamcinolone Oral , Triazolam, Trifluoperazine Oral , Trifluoromethylphenylpiperazine, Trimipramine , Yohimbine, Ziprasidone , Zopiclone, Oculogyric crisis
Ear Nose Throat	No underlying causes
Endocrine	Adrenal tumor, Hyperthyroidism, Insulinoma, Pheochromocytoma
Environmental	Nitrogen narcosis
Gastroenterologic	No underlying causes
Genetic	No underlying causes
Hematologic	Variegate porphyria
Iatrogenic	No underlying causes
Infectious Disease	Rabies
Musculoskeletal / Ortho	No underlying causes
Neurologic	Benign fasciculation syndrome, Deep water blackout, Post-concussion syndrome, Huntington's disease
Nutritional / Metabolic	No underlying causes
Obstetric/Gynecologic	Premenstrual syndrome
Oncologic	No underlying causes
Opthalmologic	Oculogyric crisis
Overdose / Toxicity	Bupropion, Dicyclomine , Efavirenz , Fexofenadine and Pseudoephedrine , Fluoxetine, Nabilone , Ziprasidone
Psychiatric	Acrophobia, Acute stress disorder, Addiction, Adjustment disorder, Adult attention-deficit disorder, Affective spectrum, Agoraphobia, Algophobia, Androphobia, Binge eating disorder, Bipolar disorder, Bruxism, Castration anxiety, Child abuse, Chronic stress, Claustrophobia, Combat stress reaction, Cyberchondria, Depression, Dermatillomania, Dhat syndrome, Drug addiction, Dual disorder, Eating disorder, Emotional conflict, Equinophobia, Existential anxiety, Fear, Fear of bees, Fear of childbirth, Fear of children, Female hysteria, Generalized anxiety disorder, Gerontophobia, Glossophobia, Gymnophobia, Holiday stress, Huntington's disease, Hypersomnia, Hypervigilance, Hypochondria, Hysterical contagion, Insomnia, Jerusalem syndrome, Medical students' disease, Mental breakdown, Night terror, Nyctophobia, Obsessive-compulsive disorder, Palinopsia, Panic disorder, Paranoia, Paranoid-schizoid position, Parkinson's disease, Penis panic, Post traumatic stress disorder , Posttraumatic stress disorder, Pseudodysphagia, Psychiatric Disorders, Psychological trauma, Ringxiety, Separation anxiety disorder, Serious Emotional Disturbance, Social anxiety, Social Anxiety Disorder, Social phobia, Sociophobia, Somniphobia, Stage fright, Stiff person syndrome, Stranger anxiety, Stress (medicine), Substance abuse, Sunday night blues, Tanorexia, Technostress, Test anxiety, Traumatic stress, Trichodynia, Trichotillomania, Trypanophobia, Workplace stress, Serotonin syndrome
Pulmonary	Hyperventilation, Hyperventilation syndrome, Pulmonary edema, Pulmonary Embolism, Respiratory alkalosis|-
Renal / Electrolyte	No underlying causes
Rheum / Immune / Allergy	No underlying causes
Sexual	No underlying causes
Trauma	No underlying causes
Urologic	No underlying causes
Dental	No underlying causes
Miscellaneous	Antipsychotic (withdrawal), Benzodiazepine withdrawal syndrome, Dosulepin hydrochloride (withdrawal), Phenibut (withdrawal)

Complete Differential Diagnosis of the Causes of Anxiety

(In alphabetical order)

Acrophobia Acute Coronary Syndromes Acute stress disorder Addiction Adjustment disorder Adrenal tumor Adult attention-deficit disorder Affective spectrum Agoraphobia Algophobia Alpha-Methyltryptamine Amantadine Amineptine Amphetamine Androphobia Aniracetam Anorexia nervosa Antipsychotic (withdrawal) Aripiprazole Barium nitrate Benign fasciculation syndrome Benzodiazepine withdrawal syndrome Benzylpiperazine Binge eating disorder Biperiden Bipolar disorder Bortezomib Bruxism Buprenorphine Buprenorphine Sublingual and Buprenorphine and Naloxone Sublingual Bupropion Buspirone Butorphanol Injection Caffeine Carbamazepine Castration anxiety Child abuse Chronic stress Claustrophobia Clofarabine Injection Cocaine Combat stress reaction Cyberchondria Deep water blackout Depression Dermatillomania Dexamethasone Oral Dextroamphetamine and Amphetamine Dhat syndrome Dicyclomine Diethylcathinone Diethylpropion Diphenhydramine Dosulepin hydrochloride (withdrawal) Doxylamine Drug addiction Dual disorder Eating disorder ECA stack Efavirenz Emotional conflict Enoxacin Equinophobia Ethcathinone Existential anxiety Fear Fear of bees Fear of childbirth Fear of children Female hysteria Fentanyl Oral Transmucosal Fentanyl Skin Patches Fexofenadine and Pseudoephedrine

Fludrocortisone Acetate Fluoxetine Fluphenazine Fluticasone Oral Inhalation Gabapentin Generalized anxiety disorder Gerontophobia Glatiramer acetate Glossophobia Glycopyrrolate Gymnophobia Haloperidol Heroin Holiday stress Huntington's disease Hydrocodone Hydrocortisone Injection Hydrocortisone Oral Hydroxyzine Hypersomnia Hypertension Hyperthyroidism Hyperventilation Hyperventilation syndrome Hypervigilance Hypochondria Hysterical contagion Imatinib Insomnia Insulinoma Interferon beta-1a Subcutaneous Injection Interferon Beta-1b Injection Irukandji syndrome Jerusalem syndrome Leuprolide Levetiracetam Levodopa Liothyronine Lofepramine Loratadine MDPV Medical students' disease Mental breakdown MeOPP Mesalamine Methamphetamine Methylenedioxymethamphetamine Methylphenidate Transdermal Methylprednisolone Oral Methylprednisolone Sodium Succinate Injection Metrazol Mirtazapine Moclobemide Modafinil Monoamine oxidase inhibitor Motofen Myocardial infarction Nabilone Naltrexone Night terror Nitrogen narcosis Norfloxacin Norplant Nortriptyline Nyctophobia Obsessive-compulsive disorder Oculogyric crisis Orlistat Orthostatic intolerance Oxaliplatin injection Palinopsia Panic disorder Paranoia Paranoid-schizoid position

Parkinson's disease Paroxetine Penis panic Pentostatin PFPP Phenibut (withdrawal) Phenylephrine Pheochromocytoma Pipradrol Piracetam Posaconazole Post traumatic stress disorder Post-concussion syndrome Posttraumatic stress disorder Postural orthostatic tachycardia syndrome Premenstrual syndrome Promethazine Pseudodysphagia Pseudoephedrine Psychiatric Disorders Psychiatric medication Psychoactive drug Psychological trauma Pulmonary edema Pulmonary Embolism Pyrovalerone Quetiapine Rabies Reboxetine Respiratory alkalosis Rilmenidine Ringxiety Risperidone Ropinirole Selective serotonin reuptake inhibitor Separation anxiety disorder Serious Emotional Disturbance Serotonin syndrome Serotonin-norepinephrine reuptake inhibitor Sertraline Sibutramine Social anxiety Social Anxiety Disorder Social phobia Sociophobia Somniphobia Stage fright Stiff person syndrome Stranger anxiety Stress (medicine) Substance abuse Sunday night blues Supraventricular tachycardia Tanorexia Technostress Temozolomide Test anxiety Topiramate Tramadol Traumatic stress Trazodone Triamcinolone Oral Triazolam Trichodynia Trichotillomania Trifluoperazine Oral Trifluoromethylphenylpiperazine Trimipramine Trypanophobia Variegate porphyria Workplace stress Yohimbine Ziprasidone Zopiclone

Diagnosis

The Generalized Anxiety Disorder [GAD]-2 scale can screen for the four most common anxiety disorders (posttraumatic stress disorder, generalized anxiety disorder, panic disorder, and social anxiety disorder) and the Generalized Anxiety Disorder [GAD]-7 scale can add certainty.

GAD-2

The Generalized Anxiety Disorder (GAD) - 2 scale is:

"During the past month, have you been bothered a lot by:"

1. 'nerves' or feeling anxious or on edge?

'Not at all' = 0pts; 'Several days' = 1 pt; 'More than half of the days' =2 pts; 'Nearly every day' =3 pts

2. worrying about a lot of different things?

'Not at all' = 0pts; 'Several days' = 1 pt; 'More than half of the days' =2 pts; 'Nearly every day' =3 pts

The performance of the GAD-2 in diagnosing any anxiety disorder is:

2 or more points:

• sensitivity 86%
• specificity 70%

3 or more points:

• sensitivity 65%
• specificity 88%

GAD-7

The Generalized Anxiety Disorder (GAD) - 7 scale is copyrighted. Its full text is available at http://annals.org/cgi/content/full/146/5/317/FA1 :

The performance of the GAD-7 in diagnosing any anxiety disorder is:

8 or more points:

• sensitivity 77%
• specificity 82%

History and Symptoms

• Detailed history

  • Duration
  • Onset
  • Type of anxiety

• Events causing anxiety

  • Stressors
  • Medical illnesses

• Drug and medication history

Physical Examination

• Physical exam important to rule out organic medical diseases

Anxiety in palliative care

Some research has strongly suggested that treating anxiety in cancer patients improves their quality of life. The treatment generally consists of counseling, relaxation techniques or pharmacologically with benzodiazepines.

Theories

Two factor theory of anxiety

Sigmund Freud recognized anxiety as a "signal of danger" and a cause of "defensive behavior". He believed we acquire anxious feelings through classical conditioning and traumatic experiences.

We maintain anxiety through operant conditioning; when we see or encounter something associated with a previous traumatic experience, anxious feelings resurface. We feel temporarily relieved when we avoid situations which make us anxious, but this only increases anxious feelings the next time we are in the same position, and we will want to escape the situation again and therefore will not make any progress against the anxiety.

Types of anxiety

Existential anxiety

See more under existential crisis.

Theologians like Paul Tillich and psychologists like Sigmund Freud have characterized anxiety as the reaction to what Tillich called, "The trauma of nonbeing." That is, the human comes to realize that there is a point at which he or she might cease to be (die), and their encounter with reality becomes characterized by anxiety. Religion, according to both Tillich and Freud, then becomes a carefully crafted coping mechanism in response to this anxiety since they redefine death as the end of only the corporal part of human personal existence, assuming an immortal soul. What then becomes of this soul and through what criteria is the cardinal difference of various religious faiths.

Philosophical ruminations are a part of this condition, and this is part of obsessive-compulsive disorder. They are typically about sex and religion or death.

According to Viktor Frankl, author of Man's Search for Meaning, when faced with extreme mortal dangers the very basic of all human wishes is to find a meaning of life to combat this "trauma of nonbeing" as death is near and to succumb to it (even by suicide) seems like a way out.

Test anxiety

Test anxiety is the uneasiness, apprehension, or nervousness felt by students who have a fear of failing an exam. Students suffering from test anxiety may experience any of the following: the association of grades with personal worth, embarrassment by a teacher, taking a class that is beyond their ability, fear of alienation from parents or friends, time pressures, or feeling a loss of control. Emotional, cognitive, behavioral, and physical components can all be present in test anxiety. Sweating, dizziness, headaches, racing heartbeats, nausea, fidgeting, and drumming on a desk are all common. An optimal level of arousal is necessary to best complete a task such as an exam; however, when the anxiety or level of arousal exceeds that optimum, it results in a decline in performance. Because test anxiety hinges on fear of negative evaluation, debate exists as to whether test anxiety is itself a unique anxiety disorder or whether it is a specific type of social phobia. In 2006, approximately 49% of high school students were reportedly suffering from this condition.

While the term test anxiety refers specifically to students, many adults share the same experience with regard to their career or profession. The fear of failing a task and being negatively evaluated for it can have a similarly negative effect on the adult.

Stranger anxiety

Main articles: Stranger anxiety and socialization

Anxiety when meeting or interacting with unknown people is a common stage of development in young people.

So-called "stranger anxiety" in younger people is not a phobia in the classic sense; rather it is a developmentally appropriate fear by young children of those who do not share a 'loved-one', caretaker or parenting role. In adults, an excessive fear of other people is not a developmentally common stage.

Treatment

• Patient education
• Biofeedback
• Cognitive behavioral therapy

Pharmacotherapy

Acute Pharmacotherapies

• For obsessive-compulsive disorder:

  • SSRIs (selective serotonin reuptake inhibitors) in high doses

• For general anxiety disorder, pharmacology proves to be beneficial:

  • Antidepressants
  • Benzodiazepines (some concern over dependency)
  • Buspirone

• For panic disorder:

  • Tricyclic antidepressants
  • SSRIs (selective serotonin reuptake inhibitors)
  • Benzodiazepines

Sources

• Rosen, J.B. & Schulkin, J. (1998): "From normal fear to pathological anxiety". Psychological Review. 105(2); 325-350.
• Seligman, M.E.P., Walker, E.F. & Rosenhan, D.L. (2001). Abnormal psychology, (4th ed.) New York: W.W. Norton & Company, Inc.
• Zald, D.H., Hagen, M.C. & Pardo, J.V. (2002). "Neural correlates of tasting concentrated quinine and sugar solutions". J. Neurophysiol. 87(2), 1068-75.
• Zald, D.H. & Pardo, J.V. (1997). "Emotion, olfaction, and the human amygdala: amygdala activation during aversive olfactory stimulation." Proc Nat'l Acad Sci USA. 94(8), 4119-24.

See also

• Anxiety disorder
• Anxiolytic
• Anxiety Disorders Association of America
• Beck Anxiety Inventory
• Generalized anxiety disorder
• Panic attack
• Panic disorder

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