Disorder Clinical History Clinical Examination Features
Phobia Specifi c fear of object Behavioral observation Can precipitate fear by useful talking about specifi c
phobia
Hyperventilation syndrome Precipitated by hyper- May represent secondary ventilation and relieved complication of anxiety by increased CO2 attacks
Posttraumatic neurosis Recurrent dreams, Mixed features of Diagnostic interviews with nightmares, and day depression sodium amytal or recollections Reluctance to discuss hypnosis
Specifi c precipitating traumatic events Treatment with anti-
event depressant helpful
More constant and
unremitting
Secondary alcoholism
and drugs
Chronic anxiety state Chronic, unremitting, Mixed features of Anxiety neurosis may and often with no depression evolve into chronic precipitating event Obsessive ruminations anxiety state Usually no discrete
anxiety attacks
Early schizophrenia Typical age of onset Thought disorders Favorable response to Family history Delusions, hallucinations neuroleptic drugs Reports of weird
experiences
Mania Previous episode of Euphoria or irritability Atypical forms of mania affective illness paramount may resemble anxiety Family history Flight of ideas attack
Grandiosity Favorable response to
lithium
Agitated depression Depressive symptoma- Poverty of ideas Favorable response to tology paramount Delusions of sin, poverty, antidepressants or ECT Biological signs of nihilism, and bizarre
depression somatic complaints
Hyperthyroidism Intolerance to heat Palpable thyroid May also respond to Profound weakness Exopthalmos propranolol Cardiac arrhythmias Often precipitated by Pulse rate refl ects EKG corroboration
caffeine or nicotine arrhythmia or PAT
Angina Characteristic pain EKG corroboration. Relief
distribution and by nitroglycerine
duration
Mitral valve prolapse Symptoms referable to Extrasystolies, tachycardia Prolapse of mitral valve syndrome cardiovascular system Midsystolic click during systole
but also mimics classic Diagnostic echocardiogram
anxiety attacks shows abnormal mitral
valve movement
(Table continues)
ANXIETY-RELATED CONDITIONS (continued)
Disorder Clinical History Clinical Examination Features
Hypoparathyroidism Often previous thyroid Chvostek and Taussig Decrease of serum calcium operation signs Hyperrefl exia Poor response to anti-
anxiety agents
Pheochromocytoma Episodic or sustained Marked elevations in Increased urinary blood pressure, fl ushing catechola mines Severe headaches Induced by phentolamine
and relieved by mecholyl Insulinoma (hypoglycemia) Faintness, nausea Low blood sugar during
Seizures attack
Abnormal glucose
tolerance
Carcinoid syndrome Itching Skin blotches Increased 5-HIAA in urine Flushing of skin
Acute intermittent porphyria Acute intermittent Sinus tachycardia Increased urinary attacks of colicky Decreased deep tendon porphobilinogens abdominal pain refl exes
Positive family history Occasional cranial nerve
Personality change involvement
Reddish urine
Stimulant drugs Drug use Paranoid ideation or Drugs in urine
delusions
Caffeinism Ingestion of large Panic attacks
amounts of coffee,
tea, etc.
Hypnotic-sedative drug Ingestion of barbiturates, Postural hypotension Heightened tolerance to withdrawal alcohol, or related Clouding of consciousness pentobarbital test dose
agents Transient hallucinations
Presenile dementia Older onset with other Memory and abstraction Other features of dementia
cognitive and defi cits Emotional lability
behavioral Little insight into illness
disturbances
Cerebral neoplasm Unremitting headache Increased intracranial vague neurological pressure and papilledema
complaints Soft or specifi c neurological
signs
Auras of migraine, temporal Precede headache, May be induced by hyper- lobe lesions, or grand amnesic period, altered ventilation or special mal epilepsy mental states or seizures provocative procedures
No sustained anxiety
between attacks EEG changes with
Characteristic clinical temporal lobe or grand
history for migraine mal epilepsy
or epilepsy
Following are several of the major categories described in the DIAGNOSTICAND STATISTICAL MANUAL OF MENTAL DISORDERS, FOURTH EDITION:
• GENERALIZEDANXIETYDISORDER
• phobias: specific phobia (formerly simple pho- bia), social phobia
• AGORAPHOBIA
• PANICDISORDER
• OBSESSIVE-COMPULSIVEDISORDER • POST-TRAUMATICSTRESSDISORDER
Primary care physicians have indicated that anxiety disorders are among the most common mental health problems seen in their practice. Yet in primary care settings, anxiety disorders often are underrecognized because anxious individuals fre- quently present with physical symptoms rather than psychological concerns. Individuals suffering from anxiety disorders are often apprehensive and they are worried, ruminative, and expecting something very bad to happen to themselves or loved ones in the future. They often feel on edge, impatient, and irritable and are easily distracted. Some individuals have anxiety symptoms that are so severe that they are almost totally disabled.
Prevalence of Anxiety Disorders in the United States
The most common form of anxiety disorder is spe- cific phobia and according to the NIMH, about 19.2 million American adults, or about 8.7 percent of individuals 18 and older, have some type of spe- cific phobia in any given year. Often these phobias have their onset in childhood and the median age of onset is age seven.
Social phobia is a problem for an estimated 15 million Americans, and women and men are equally likely to suffer from this disorder. Social phobias generally begin in late childhood or early adolescence. There may be only one particular social situation that elicits anxiety in an individual or, in the case of many people with social phobias, they may feel anxiety in several social situations.
Post-traumatic stress disorder (PTSD) is the next most common form of anxiety disorder and 7.7 mil- lion American adults in any given year, or about 3.5
percent of adults 18 and older, suffer from PTSD. PTSD can occur at any age, but the median age of onset is 23 years. It is believed that 30 percent of returning Vietnam veterans suffered from PTSD, and estimates are that an equivalent percentage of the many servicepeople serving in Iraq will return with PTSD. PTSD may also develop in individuals who have been sexually assaulted or terrorized or who have experienced severe accidents, domestic violence, or natural disasters.
Generalized anxiety disorder (GAD) is the next most common form of anxiety disorder, and accord- ing to the NIMH, about 6.8 million American adults ages 18 and older, or 3.1 percent of adults 18 and older, suffer from GAD, and this form of anxiety disorder is about twice as common in females as in males. The median age of onset for GAD is 31 years old. GAD is characterized by chronic worry and moderate anxiety as a result.
Fourth in the prevalence of anxiety disorders is panic disorder and about 6 million American adults (2.7 percent of adults ages 18 and older) have panic disorder. Panic disorder is about twice as common among women than men. The median age of onset is 24 years. About a third of those with panic disor- der will develop agoraphobia, a disorder in which the person fears being away from a safe place or being trapped (such as being trapped in a left-turn lane). Some people with agoraphobia become housebound, their fear is so intense.
Obsessive-compulsive disorder (OCD) is the least common form of anxiety disorder in the United States, and 2.2 million adults ages 18 and older, or about 1 percent of adults, suffer from OCD. In most cases, the first symptoms occur in childhood or ado- lescence, but the median age of onset is 19 years.
Types of Anxiety Disorders
Each type of anxiety disorder has its own symp- toms, signs, and treatment.
Phobias. People who suffer from phobias feel
terror, dread, or panic when confronted with the feared object, situation, or activity. Many have such an overwhelming desire to avoid the source of the fear that it interferes with their jobs, family life, and social relationships. For example, they may lose their job because they fear traveling or eating in front of others. Some become fearful of leaving anxiety disorders 55
their homes, and they live hermitlike existences with their window shades pulled down, afraid of light or darkness, insects or birds. They may also fear being assaulted.
Within the category of phobias are specific pho- bias, social phobias (also known as social anxiety disorder), and agoraphobia. Specific phobias are fears of specific objects or situations; examples of such phobias are the fear of snakes, the fear of fly- ing, or the fear of closed spaces.
Social phobias are fears of situations in which the individual can be watched by others, such as public speaking, or in which individual behavior might prove embarrassing, such as eating in pub- lic, using public restrooms, or signing their name in public. Some experts report that genetic factors may be involved with social phobia, so that if a par- ent or other close relative has the disorder, others in the family are more likely to suffer as well.
Individuals with social phobia often have depres- sion and other forms of anxiety disorders, and substance abuse is a problem among those who medicate themselves with alcohol or drugs. Social phobia is treated with psychotherapy and with medications such as selective serotonin reuptake inhibitors (SSRIs), like fluoxetine (Prozac), sertra- line (Zoloft), or citalopram (Celexa). Antianxiety drugs, also known as benzodiazepines, are also used to treat social phobia; for example, clonazepam (Klonopin) is commonly used for social phobia. In addition, beta blockers such as propranolol (Inderal) are sometimes used to treat social phobia.
Agoraphobia, the fear of being away from a safe place, being in a public place, being in a place with no escape, such as a train or plane, or being alone, is the most disabling because sufferers can become housebound. Early treatment is the most effective solution and includes exposure therapies and medi- cations.
Panic Disorder. Individuals who have panic dis-
order have intense, overwhelming terror and feel- ings of doom for no apparent reason. These attacks are known as panic attacks. Some people suffer from one or two panic attacks but do not develop panic disorder, which is a condition of chronic panic attacks.
Often people suffering a panic attack for the first time rush to the hospital emergency room, con-
vinced they are having a heart attack because their heart is racing and they may experience chest pain. They may also experience chills and/or nausea. Panic attacks are usually brief and peak within about 10 minutes, although some attacks last longer.
When it is determined that a patient’s heart is normal, the physician may suggest that panic disor- der is the problem. Sufferers cannot predict when the attacks will occur, although certain situations such as driving a car can become associated with them if it was in those situations that the first attack occurred.
People with panic disorder may develop depres- sion and substance abuse. Some experts estimate that about one-third of those with ALCOHOLISM have a panic disorder. Panic disorder is considered highly treatable with cognitive-behavioral therapy and medications. Medications such as lorazepam (Ativan) are used to treat panic disorder, as is alpra- zolam (Xanax).
Generalized Anxiety Disorder Individuals with GAD are constantly tense and worried, even though most know their worries are irrational and unwar- ranted. Such individuals may worry constantly about their own health or the health of others or they may worry about money (when finances are not a problem), work, or other issues. Individuals with GAD often have problems with insomnia and may have physical symptoms such as fatigue, mus- cle pain, nausea, irritability, a frequent need to use the bathroom, breathlessness, etc.
Individuals with GAD are at risk for depres- sion, other anxiety disorders, and substance abuse. GAD is treated with cognitive behavioral therapy and antidepressant medications such as venlafax- ine (Effexor), a serotonin norepinephrine reuptake inhibitor (SNRI). Antianxiety medications such as clonazepam (Klonopin) are used to treat GAD, as is alprazolam (Xanax).
Obsessive-Compulsive Disorders Some individuals attempt to cope with their anxiety by associating it with obsessions, which are defined as repeated, unwanted thoughts, or with compulsive behaviors, which are defined as rituals that may spin out of con- trol. Individuals who suffer from obsessive disorders do not automatically have compulsive behaviors. However, most people who have compulsive, ritual- istic behaviors also suffer from obsessions. Obessions 56 anxiety disorders