Understanding and managing anxiety disorders presentations

Understanding anxiety

Anxiety is something we all experience from time to time - it is normal to feel anxious sometimes. Anxiety affects your whole being, consisting of behavioural, physical, emotional and psychological responses occurring all at once.

Anxiety has many functions, and not all are negative; it alerts us to danger and helps us perform, for instance at a job interview. We expect to feel a level of anxiety that prepares us for our performance, however if anxiety goes beyond the threshold, the performance starts to decline. Below is an illustration of how anxiety affects performance.

Yerkes-Dodson law: Performance improves as a function of anxiety up to a threshold beyond which there is a falloff in performance.

1. Anxiety as a threat-detection system:

• Anxiety is part of our body's natural response to perceived danger, alerting us to potential threats and activating our protective mechanisms. 
• This system is designed to help us survive by preparing us to either fight or flight/flee from dangerous situations. 
• When we feel anxious, our bodies and minds are primed to react quickly, ensuring our safety, and so many physiological sensations are experienced in the body.

2. Anxiety and self-protection:

• Anxiety can motivate us to take proactive steps to protect ourselves, such as avoiding potentially dangerous situations or making us more aware of our surroundings and potential threats. 

While self-protection behaviours can be helpful in the right situations, excessive anxiety can lead to fear and avoidance, where one is feeling more anxious than a situation may warrant.

An overestimation of the likelihood and severity of harm is experienced when excessive anxiety is present, and one underestimates their ability to cope in the situation.

Anxiety disorders vs symptomatic anxiety 

Anxiety disorders can be difficult to diagnose as excessive anxiety can be a prominent symptom of many other mental health difficulties, and even a response to everyday stressors. It is important to differentiate between symptomatic anxiety and specific anxiety disorders. Other presentations that can cause excessive anxiety include: 

• Depression: Depression can affect a person’s sleep, energy levels, motivation, concentration and ability to enjoy activities. As a result, a person with depression may feel anxious when dealing with situations they normally cope well with.
  
  
• Bipolar affective disorder: A person with bipolar affective disorder may experience anxiety when depressed or during a manic episode due to increased stress; increased risk-taking or impulsive behaviour; paranoia; and impact on relationships. They may also experience agitation and restlessness that they can misinterpret as being anxious. Agitation can present as physiologically similar to anxiety but occurring in the absence of any specific anxious cognitions or worries.
  
  
• Personality disorders: People with Axis-II disorders such as emotionally unstable personality disorder, avoidant personality disorder or obsessive-compulsive personality disorder (OCPD) may experience anxiety as a primary symptom. It is particularly important to differentiate between obsessive compulsive disorder (OCD) and OCPD. The main difference between the two is how the person experiences their thoughts and behaviours. A person with OCD will generally experience obsessions as intrusive and unwanted, and their behaviours as excessive and unreasonable. The person with OCPD will often experience their ideas as correct and appropriate and see their behaviours as beneficial, right and/or necessary.
  
  
• Perfectionism: While not a separate diagnosis in the DSM-V (perfectionism is identified as an OCPD personality trait), perfectionism can lead to significant anxiety and stress, whereby the person’s unrealistic standards lead them to feeling anxious about things well within their capability or can lead to procrastination which then results in anxiety.
  
  
• Substance misuse: Increased anxiety can be a significant symptoms of substance withdrawal. People can interpret this short-term increase as an indication that their main issue is anxiety and that they are managing chronic anxiety by using substances. While co-morbidity between anxiety disorders and substance misuse does occur, it is difficult to get a baseline of anxiety while a person is withdrawing from substances or adjusting to abstinence.
  
  
• Real life stressors: Excessive anxiety may be occurring in the context of chronic biopsychosocial stressors or acute stress-inducing situations, whereby a person’s inaccurate cognitions about situations are not what is making them stressful but rather the situation itself needs to be addressed. Adjustment disorder following a significant life event may also lead to an increase in anxiety.

Anxiety disorders and diagnosis challenges

Some people experience anxiety and worries that become distressing and chronic and interfere with their daily functioning. These difficulties arise when the response is out of proportion to the actual danger of the situation, or indeed is generated when there is no danger present. As GPs you may find patients attend frequently to seek help or seek reassurance, or alternatively family members attend looking for help for a loved one.

Anxiety disorders are the most common of mental health difficulties. They will affect nearly 30% of adults at some point in their lives (American Psychiatric Association). There is usually a long time between the onset of the disorder and the commencement of treatment (up to 10 years according to studies).

Anxiety disorders are categorised into general areas where each anxiety disorder has its own distinct features. They are all bound together by the common theme of excessive, irrational fear and avoidant behaviours. These behaviours, such as avoidance and checking, are believed to either help achieve a sense of safety, feel less threatened or control the anxiety related to the threat.

Anxiety disorder presentations

Shared features of anxiety disorders are that the symptoms are experienced as ego-dystonic (distressing); the disorders are enduring or recurrent; there is an absence of organic factors present; and reality testing is intact.

It is important to establish a shared understanding of the problem and identify what lies at the root of the anxiety. This will help inform the diagnosis, as each individual disorder has key features and cognitive processes unique to the disorder:

• Panic - fear of body letting one down
• Social – fear of humiliation, embarrassment, scrutiny
• GAD – worry something going wrong/intolerance to uncertainty/fear of failure
• OCD – depends on the subtype (fear of causing harm & inflated responsibility)

Panic disorder

Panic disorder is diagnosed by recurrent unexplained panic attacks and at least one of the attacks has been followed by one month (or more) of one (or more) of the following:

• Persistent concern about having future attacks
• Worry about consequences of the attack (such as dying or losing control)
• Behavioural changes because of the attack (avoidance)
• Not related to a medical condition or substance induced
• Presence/absence of agoraphobia
• Sudden in onset
• Not predictable or confined to a given situation
• Concern about future attacks and secondary avoidance.

Panic attacks are extremely frightening. They may appear to come out of the blue, strike at random and make people feel powerless, that they are losing control or about to die. A panic attack is really the body’s way of responding to the “flight or fight” response system getting triggered without the presence of an actual external threat or danger. There are several different physical sensations that people experience during a panic attack. These may include:

• Very rapid breathing or feeling unable to breathe
• Palpitations, pounding heartbeat
• Chest pain
• Dizziness, light-headedness, or faintness

Often, the person understandably makes a catastrophic interpretation of what’s happening such as “I feel dizzy - I will faint”; “I feel my throat is dry, tight – I’ll choke/suffocate”; or “I can’t breathe properly - I’ll stop breathing”. Experiences of these sensations help us to understand how patients may repeatedly seek tests, seek reassurance that they will be okay, or have repeated trips to the emergency department. These are signs that may signal one is presenting with a panic disorder.

Panic disorder and agoraphobia

People begin to associate places/situations with having a panic attack. In doing so, they attempt to avoid another attack by avoiding these places/situations where attacks have occurred previously.

Another reason that people develop avoidance of feared situations is that they see themselves being unable to control a panic in that situation. This can put increasing restrictions on a person’s social or occupational functioning with the possibility of the development or other phobic avoidance or agoraphobia.

Agoraphobia

Prolonged panic disorder can lead to agoraphobia, which is defined by anxiety/fear about being in situations from which escape might be difficult or embarrassing in the event of suddenly developing a panic attack or panic-like symptoms, or where help is not readily available. Examples of such situations include:

• Going outside of home alone
• Crowded public places such as department stores or restaurants
• Public transportation such as trains, planes or buses
• Enclosed or confined spaces such as tunnels or lifts.

It can result in a whole range of situations and day-to-day activity being avoided, and in some cases, people may become house-bound. Seeking help and attending the GP practice is difficult as they feel unable to leave home or go far from home to avail of help. They may ask for house calls or suffer alone.

Social anxiety disorder

Social anxiety presents as a fear of negative evaluation by others. People with the disorder have a persistent and intense fear of being scrutinised by others; that people will judge them or think poorly of them. Another common fear is being embarrassed or humiliated by their own actions. Differing cognitions that are shared include “I sound too anxious”; “I sweat too much, and people will think it’s weird”; “I’ll say something stupid”; “I’ll say something offensive”; “I won’t talk enough”; “I’ll talk way too much”; “I’ll go red, and people will think I’m odd”.

Fears can occur in specific social situations (making small talk, professional situations, dating, public speaking) or across a range of social settings. Anticipatory anxiety can occur for days or even weeks in advance of a dreaded situation. To manage the anxiety, behaviours are adopted which includes avoidance of situations or events, going accompanied with a ‘wingman’ and use of alcohol or drugs to reduce the anxiety. Impairment is experienced across all functioning domains, from social to personal and professional.

As GPs, you may be the first person they open up to. When discussing their difficulties, you may find they express embarrassment as they are closed off and hide this side of themselves from others.

Generalised anxiety disorder

Generalised anxiety disorder (GAD) is one of the most common anxiety disorders and affects between 2% and 8% of the population. It is characterised by six months or more of exaggerated worry and tension. The excessive worry is about everyday events rather than single life events or specific threats. In GAD, an overestimation of the likelihood of things going wrong, fearing catastrophe and an intolerance to uncertainty are central cognitive processes. Positive beliefs that worry is a functional activity (it helps prepare, keeps one safe) and is a protective factor (prevents bad things happen) serve to maintain worry.

Behaviours can include information-seeking, avoidance, procrastination, certainty-seeking through questioning, checking, or alternatively planning and preparing to prevent catastrophe. One’s functioning can become very routine, rigid and inflexible, and can cause distress for not only the individual but their family members.

GAD vs agitated depression

In the GP practice, establishing a baseline of one’s functioning and mood will help with diagnosis. In GAD, there is the presence of future-based fears and phobic avoidance. However, with an agitated depression presentation, a general state of anxiousness is experienced with the absence of worry cognitions and phobic avoidance. With a depressed mood, the anxiety is often worst in the morning, where it can be described as “wake with a sense of dread”. There is the presence of diurnal mood variation, and when the mood restores and returns to baseline, the anxiety subsides.

Obsessive compulsive disorder

There are a wide variety of sub-types and symptoms in how OCD presents:

• Contamination fears – getting sick, making others sick, being seen as unclean.
• Harm and responsibility – fear of harming others or feeling overly responsible for the safety of others
• Order and symmetry – feeling distressed unless things feel ‘just right’
• Morals and scrupulosity – Obsessional need to do the right thing and worrying about doing wrong
• Magical thinking – believing that intrusive thoughts can cause real world harm unless neutralised
• Checking – Inability to tolerate doubt about having done something (Locks, switches).

Encourage open and sensitive discussion of the presenting problem, especially at the first point of disclosure. Given the nature of some obsessions (religious, sexual or harm obsessions) it can be very difficult for the person to share their difficulties. A fear of stigma, fear of being misunderstood and of been seen as a terrible person for having these thoughts serve as an obstacle in seeking help. Many will suffer in silence and carry shame and guilt daily because of the nature of the disorder. Providing a safe environment to share and helping them to understand the disorder can help guide treatment. Bibliotherapy ‘Overcoming OCD’ and completing an assessment measure form (Yale-Brown Obsessive compulsive Scale) can help aid understanding and inform treatment.

Anxiety disorders: Support vs reassurance

Be supportive but the general guide is to not give reassurance, despite the patient seeking it, and where the automatic instinct is to provide the reassurance. Providing reassurance will unfortunately continue the anxiety cycle. Have an awareness that the need to seek reassurance can result in it being asked for in several ways, hence the nature of anxiety and maintenance cycle.

However, it is important to validate and recognise the distress when discussing their anxiety or when reassurance/certainty-seeking is active and support their action moving forward without providing reassurance. Communication is key, and so offering a supporting role will greatly help:

• Validate – “I can see you're feeling anxious, but me reassuring you won’t help you in long-term”
• Support – “I’m here to help.”

Encourage the patient to seek support from a family member or a loved one. It can be very isolating; people do suffer alone.

Treatment options for anxiety disorders 

Cognitive behavioural therapy

Cognitive behavioural therapy (CBT) is considered the ‘gold standard’ psychotherapeutic treatment for anxiety disorders, recommended as a first line treatment in the NICE guidelines. CBT for anxiety disorders is focused on identifying the specific anxiety cognitions that are causing someone to experience excessive anxiety and to support that person to challenge and change their anxious cognitions through a combination of cognitive restructuring and behavioural interventions such as exposure therapy.

For CBT to be effective, it is important that the therapist incorporates experiential learning and active engagement with the triggers for a person’s anxiety – talking about their anxiety is not enough. CBT for anxiety disorders is empirically supported and can take place though one-to-one therapy sessions or through group psychotherapy programmes such as the Anxiety Disorders programme at St Patrick’s Mental Health Services.  

Other psychotherapeutic modalities

While other psychological interventions such as Acceptance and Commitment Therapy, psychodynamic therapies, such as psychoanalysis, supportive counselling and motivational interviewing, have been explored and utilised in the treatment of anxiety disorders, none have proven superior to CBT to date. 

Medication

SSRIs and SNRIs are the first line pharmacological treatments for anxiety disorders. They can be used in conjunction with CBT, often allowing people to better engage in therapeutic work by lessening the severity of symptoms. Antidepressants can also help with co-morbid depression, making engagement in treatment easier by lifting the burden of low mood. 

Benzodiazepines can provide short-term relief from severe anxiety symptoms but do not address the underlying causes of anxiety disorders in that they do nothing to address the unhelpful cognitions that cause the excessive anxiety. Benzodiazepines can also reduce the effectiveness of CBT for anxiety disorders by preventing a person from fully engaging in exposure work (exposure work is only effective if the person becomes anxious and then allows the anxiety to pass without responding to it – benzodiazepines prevent this) and by reinforcing unhelpful anxious cognitions such as ‘I can only do this if I’ve taken my benzodiazepine first’. By preventing the acquisition of new knowledge about anxious triggers, benzodiazepines can maintain and worsen an anxiety disorder over time even as they reduce symptoms in the short-term. 

Beta blockers can also be used to reduce acute anxiety symptoms but, as with benzodiazepines, they do not treat the underlying causes. It is important that a person can address the anxious cognitions, maintenance factors and anxious behaviours, not just manage the symptoms as they arise.