Anxiety disorders signs symptoms and Treatment

Anxiety disorders

Definitions 

Anxiety is a normal, protective, psychological response to an
unpleasant or threatening situation. Mild to moderate anxiety
can improve performance and ensure appropriate action
is taken. However, excessive or prolonged symptoms can be
disabling, lead to severe distress and cause much impairment
to social functioning.
increase performance/actions increase. However, as the anxiety
level increases beyond acceptable or tolerated levels, the
performance declines.
The term ‘anxiety disorder’ encompasses a variety of complaints
which can either exist on their own or in conjunction
with another psychiatric or physical illness. Symptoms of anxiety
vary but generally present with a combination of psychological,
physical and behavioural symptoms .Some
of these symptoms are common to many anxiety disorders
while others are distinctive to a particular disorder. Anxiety
disorders are broadly divided into generalised anxiety disorder
(GAD), panic disorder, social phobia, specific phobias, posttraumatic
stress disorder (PTSD) and obsessive-compulsive
disorder (OCD),. . Approximately two-thirds of sufferers of
an anxiety disorder will have another psychiatric illness. This is
most commonly depression and often successful treatment of prevalence
For all anxiety disorders together the overall female to male
ratio is 2:1. The age of onset of most anxiety disorders is in
young adulthood (20s and 30s), although the maximum prevalence
of generalised anxiety and agoraphobia in the general
population is in the 50–64 year age group.

signs and symptoms of anxiety 

It depends on the type of anxiety disorder, but general symptoms include:

Feelings of panic, fear, and uneasiness
Problems sleeping
Cold or sweaty hands or feet
Shortness of breath
Heart palpitations
Not being able to be still and calm
Dry mouth
Numbness or tingling in the hands or feet
Nausea
Muscle tension
Dizziness

Pathophysiology

Anxiety occurs when there is a disturbance of the arousal
systems in the brain. Arousal is maintained by at least three
interconnected systems: a general arousal system, an ‘emotional’
arousal system and an endocrine/autonomic arousal
system .The general arousal system, mediated
by the brainstem reticular formation, thalamic nuclei and
basal forebrain bundle, serves to link the cerebral cortex with
incoming sensory stimuli and provides a tonic influence on
cortical reactivity or alertness. Excessive activity in this system,
due to internal or external stresses, can lead to a state of
hyperarousal as seen in anxiety. Emotional aspects of arousal,
such as fear and anxiety, are contributed by the limbic system
which also serves to focus attention on selected aspects of
the environment. There is evidence that increased activity in
certain limbic pathways is associated with anxiety and panic
attacks.
These arousal systems activate somatic responses to arousal,
such as increased muscle tone, increased sympathetic activity
and increased output of anterior and posterior pituitary
hormones. Inappropriate increases in autonomic activity are
an underlying depression will significantly improve the symptoms
of anxiety. Many patients will also present with more
than one anxiety disorder at the same time which can further
complicate treatment. Anxiety disorders are the most commonly
reported mental illness and as a whole have a lifetime
often associated with anxiety states; the resulting symptoms
(palpitations, sweating, tremor, etc.) may initiate a vicious circle
that increases the anxiety.

Treatment

Treatment for anxiety disorders often requires multiple
approaches. The patient may need short-term treatment with
an anxiolytic, such as a benzodiazepine, to help reduce the
immediate symptoms combined with psychological therapies
and an antidepressant for longer term treatment and prevention
of symptoms returning.

Psychotherapy

Psychological therapies (talking therapies) are generally considered
first-line treatments in all anxiety disorders because
they may provide a longer lasting response and lower relapse
rates than pharmacotherapy. Psychotherapy, however, is less
available, more demanding and takes longer time to work
than pharmacotherapy. If the patient is unable to tolerate the
anxiety or associated distress, then medicines are often used
before psychotherapy or while awaiting psychotherapy. The
ideal treatment should be tailored to the individual and may
involve a combination of both psychotherapy and pharmacotherapy.
The type of treatment should depend on symptoms,
type of anxiety disorder, speed of response required, longterm
goals and patient preference.

Pharmacotherapy

Benzodiazepines

chemical structure 

Benzodiazepines are commonly prescribed to provide immediate
relief of the symptoms of severe anxiety. A number of
different benzodiazepines are available These
drugs differ considerably in potency (equivalent dosage) and
in rate of elimination but only slightly in clinical effects.
All benzodiazepines have sedative/hypnotic, anxiolytic, amnesic,
muscular relaxant and anticonvulsant actions with minor
differences in the relative potency of these effects.
Pharmacokinetics. Most benzodiazepines are well absorbed
and rapidly penetrate the brain, producing an effect within
half an hour after oral administration. Rates of elimination
vary; however, with elimination half-lives from 8 to 35 h
The drugs undergo hepatic metabolism via oxidation
or conjugation and some form pharmacologically active
metabolites with even longer elimination half-lives. Oxidation
of benzodiazepines
is decreased in the elderly, in patients
with hepatic impairment and in the presence of some drugs,
including alcohol. Benzodiazepines are metabolised through
the cytochrome
P450 3A4/3 enzyme system in the liver, so significant enzyme inducers (such as carbamazepine) may
reduce levels while enzyme inhibitors (e.g. erythromycin) may
increase levels

Choice of benzodiazepine in anxiety

Choice of benzodiazepine in anxiety. The choice of benzodiazepine
depends largely on pharmacokinetic characteristics.
Potent benzodiazepines such as lorazepam and alprazolam
 have been widely used for anxiety disorders but are
probably inappropriate. Both are rapidly eliminated and need
to be taken several times a day. Declining blood concentrations
may lead to interdose anxiety as the anxiolytic effect of each
tablet wears off. The high potency of lorazepam (~10 times
that of diazepam), and the fact that it is available only in
1 and 2.5 mg tablet strengths, has often led to excessive dosage.
Similarly, alprazolam (~20 times more potent than diazepam)
has often been used in excessive dosage, particularly in
the USA. Such doses lead to adverse effects, a high probability
of dependence and difficulties in withdrawal.
A slowly eliminated benzodiazepine such as diazepam is
more appropriate in most cases. Diazepam has a rapid onset
of action and its slow elimination ensures a steady blood
concentration. Clonazepam, although long acting, is more
potent than diazepam and in practice is often difficult to withdraw
from. It is only indicated for epilepsy in the UK, but is
commonly
used as an anxiolytic.
Parenteral administration of lorazepam or diazepam may
occasionally be indicated for severely agitated psychiatric
patients.

Adverse effects

. Adverse effects include drowsiness, lightheadedness,
confusion, ataxia, amnesia, a paradoxical increase
in aggression, an increased risk of falls and fractures in the
elderly and an increased risk of road traffic accidents. They
are also widely acknowledged as addictive and cause tolerance
after more than 2–4 weeks of continuous us Respiratory depression is rare, but possible following
high oral doses or parenteral use. Flumazenil, a benzodiazepine
receptor antagonist, can reverse the effects of severe
reactions but requires repeated dosing and close monitoring
because of its short half-life