Stress and Anxiety Disorders Program
The Anxiety Disorders
Anxiety disorders only infrequently occur in isolated, pure form. They can vary in their presentation and are extensively co-morbid, with other anxiety disorders and with depression and substance abuse. All patients with depression and substance abuse should be screened for anxiety disorders. A significant portion of female alcoholism may be associated with panic and agoraphobia.
Patients will not present complaining of panic attacks, obsessions or compulsions, or social phobia. When anxiety, obsessional traits, any type of behavioral rituals, significant shyness, depressive symptoms, or substance abuse are detected or suspected, then specific questions, probing for the key features described below, should be asked.
Anxiety disorders cannot be "cured." Full, functional recovery is an achievable goal, but complete resolution of symptoms and invulnerability to relapse are not expected outcomes. Lingering symptoms, vulnerability to "normal" anxiety, and stress-related intensification of symptoms and anxiety contribute to a continuous risk of relapse. These factors are directly addressed in CBT, which is probably why it improves long-term outcomes.
Rapid onset, discrete, episodes of anxiety/distress/discomfort, accompanied by physical symptoms that are often suggestive of cardiac, endocrine or neurologic disorder. Panic patients become frightened of fear itself and its symptoms. Associated with fear/avoidance of crowds, driving, being closed in, being far from home alone, etc. (agoraphobia). Temporal course of symptoms (sudden onset, rapid progression to a peak, and recovery over 5 to 30 minutes) is as important as enumeration of specific symptoms in diagnosing panic attacks. Agoraphobic fears and avoidance help confirm the diagnosis. Must always be evaluated for depression, substance abuse, and suicidality.
First line treatment: CBT and/or medication (SSRIs). New data and APA guidelines now support CBT as a first line treatment for Panic Disorder.
Screening questions: Have you ever had a spell or attack when all of a sudden you felt frightened, anxious or very uneasy in situations when most people would not be afraid or anxious? In the past 6 months, have you had a spell or attack when for no reason your heart suddenly began to race, you felt faint, or you couldn't catch your breath? Some people have such an unreasonably strong fear of being in a crowd, leaving home alone, traveling on buses, cars or trains, crossing a bridge that they always get very upset in such situation or avoid it altogether. Did you ever go through a period when being in any of these situations frightened you?
Generalized: Excessive anxiety/distress in nearly all situations in which subject to attention, social scrutiny or evaluation
Specific: Anxiety and avoidance of a specific, social performance situation (public speaking, using public restrooms...)
Extremely common, can be severely debilitating, and is often minimized or ignored because social anxiety is "normal". Patients are also generally embarrassed and avoidant, so they often won't disclose their symptoms unless specifically asked. May have panic attacks but they are confined to situations in which the patient may be the center of attention.
First line treatment: CBT. Group CBT is our preferred treatment for those who are candidates for it. Medication is used for patients who are not likely to do well with CBT, such as those with extensively generalized or severe symptoms or co-morbid depression. Try standard SSRIs or Effexor first; MAOIs may be more effective. Beta-blockers have little direct impact on anxiety but can be helpful in performance situations where physical manifestations of anxiety (e.g., sweating, tremor) undermine the performance or become distractions. Some patients need social skills training.
Screening question: Some people have an unreasonably strong fear of doing things in front of other people - like speaking in public, using public rest rooms, eating in public, or even talking to people. Have you had any of these kinds of fears?
Obsessions are recurrent, intrusive thoughts, disturbing to the patient, but experienced as uncontrollable, often involving fears of harm coming to self or others. Typical examples include obsessive thoughts about germ contamination leading to illness, obsessive thoughts about making mistakes that will lead to harm. Violent, sexual, or blasphemous content is common. Compulsions are repetitive behaviors (e.g., washing, counting, repeating, checking...) that are performed according to certain rules or in a stereotyped fashion. Some patients may resist their compulsions, but usually cannot control them. OCD is the most hidden of the anxiety disorders. Patients must specifically be asked about counting, checking, washing rituals and intrusive, disturbing thoughts.
First line treatment: CBT and medication (SSRIs, often in high doses). Some patients do well without medication. Recovery is often incomplete, but substantial gains are usually possible.
Screening questions: Have you ever been bothered by thoughts that didn't make any sense, and kept coming back to you even when you tried not to have them? Was there ever anything you had to do over and over again and couldn't resist doing, like washing your hands again and again, counting up to a certain number, or checking something several times to make sure that you'd done it right?
Marked fear of specific, circumscribed objects or situations associated with severe distress upon exposure. Nearly all patients experience impairing avoidance. Impairment is often not evident to the patient, as they have incorporated accommodation to the phobia into their lives. Height phobias and claustrophobia are among our most commonly treated phobias. Snake and spider phobias are among the most common in the community but few people with these seek treatment. Blood, illness, and injury phobias are common, impede medical care, and should be treated, though they sometimes keep patients from even visiting the doctor's office.
Treatment - CBT for phobias is simple, quick, and extremely effective. These patients need help overcoming their reluctance to seek treatment.
Screening question: Are there things that you have been especially afraid of, like flying, seeing blood, getting a shot, heights, closed places, or certain kinds of insects or animals?
The hallmark of this disorder is chronic, excessive, uncontrollable worry about a broad range of events and activities, ranging from minor events, such as being late to more serious events such as having a serious disease. Patients often recognize that their worry is excessive and struggle with their inability to control it. Difficulty tolerating uncertainty appears to fuel the worry.
Additional symptoms include restlessness, insomnia, poor concentration, fatigue, muscle tension, and irritability. Though GAD can occur in isolation, it is far more common to see it in association with depressive symptoms, or other anxiety disorders. Many patients referred to us with suspected GAD turn out to have major depression with intense, ruminative anxiety.
If you are wondering if you have Generalized Anxiety Disorder, consider the following questions:
- Are you a particularly nervous or anxious person?
- Do you or people who know you well think of you a "worry wort?”
- Do you tend to worry about minor matters, such as being late for appointments?
- When you start worrying, do you jump from one worry to another and think of the worst possible outcomes?
- Do you worry about your worry?