What is anxiety

Anxiety is a universal and generally adaptive response to a threat, but in certain circumstances it can become maladaptive. Characteristics that distinguish abnormal from adaptive anxiety include

• Anxiety out of proportion to the level of threat

• Persistence or deterioration without intervention (> 3 weeks)

• Symptoms that are unacceptable regardless of the level of threat, including

Recurrent panic attacks Severe physical symptoms

Abnormal beliefs such as thoughts of sudden death

• Disruption of usual or desirable functioning.

One way to judge whether anxiety is abnormal is to assess whether it is having a negative effect on the patient's functioning.

Abnormal anxiety can present with various typical symptoms and signs, which include

• Autonomic overactivity

• Behaviours such as restlessness and reassurance seeking

• Changes in thinking, including intrusive catastrophic thoughts, worry, and poor concentration

• Physical symptoms such as muscle tension or fatigue.

Classification of abnormal anxiety

Abnormal anxiety can be classified according to its clinical features. In standardised diagnostic systems there are four main patterns of abnormal anxiety.

Anxious adjustment disorder—Anxiety is closely linked in time to the onset of a stressor.

Generalised anxiety disorder—Anxiety is more pervasive and persistent, occurring in many different settings.

Panic disorder—Anxiety comes in waves or attacks and is often associated with panicky thoughts (catastrophic thoughts) of impending disaster and can lead to repeated emergency medical presentations.

Phobic anxiety—Anxiety is provoked by exposure to a specific feared object or situation. Medically related phobic stimuli include blood, hospitals, needles, doctors and (especially) dentists, and painful or unpleasant procedures.

Additionally, anxiety often presents in association with depression. Mixed anxiety and depressive disorders are much more common than anxiety disorders alone. Treatment for the depression may resolve the anxiety. Anxiety can also be the presenting feature of other psychiatric illnesses common in physically ill people, such as delirium or drug and alcohol misuse.

William Cullen (1710-90) coined the term neurosis (though the term as he used it bears little resemblance to modern concepts of anxiety disorders)

Somatic and psychological symptoms of anxiety disorders

In all anxiety disorders

Palpitations, pounding heart, • Sweating accelerated heart rate • Dry mouth

• Trembling or shaking • Feeling of choking

• Difficulty in breathing • Nausea or abdominal discomfort

• Chest pain or discomfort • Feeling that objects are unreal or

• Feeling dizzy, unsteady, faint, that self is distant light headed • Fear of dying

• Fear of losing control, going • Numbness or tingling sensations crazy, passing out • Hot flushes or cold chills

In more severe or generalised anxiety disorders

• Muscle tension or aches and • Restlessness, inability to relax pains • Sensation of difficulty

• Feeling keyed up, on edge, or swallowing, lump in the throat mentally tense • Difficulty concentrating or

• Exaggerated response to "mind going blank" from minor surprises or being anxiety or worry startled • Difficulty in getting to sleep

• Persistent irritability because of worry

Distinguishing features of anxiety disorders

Anxious adjustment disorder

Prevalence in general population—Not known Cardinal features

• Onset of symptoms within 1 month of an identifiable stressor

• No specific situation or response

Generalised anxiety disorder

Prevalence in general population—31 cases/1000 adults Cardinal features

• Period of 6 months with prominent tension, worry, and feelings of apprehension about everyday problems

• Present in most situations and no specific response

Panic disorder

Prevalence in general population—8 cases/1000 adults Cardinal features

• Discrete episode of intense fear or discomfort with crescendo pattern; starts abruptly and reaches a maximum in a few minutes

• Occurs in many situations, with a hurried exit the typical response Phobia

Prevalence in general population—11 cases/1000 adults Cardinal features

• No specific symptom pattern

• Occurs in specific situations, with an avoidance response

William Cullen (1710-90) coined the term neurosis (though the term as he used it bears little resemblance to modern concepts of anxiety disorders)

Anxiety in medical patients

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