Introduction to Anxiety Disorders

Pathophysiology

  • Complex interaction of specific characteristics related to the person and their environment - psychological, biological, social
    • Genetic factors may include a biological vunerability to inherit a fearful disposition
    • Behavioural factors include aquisition of fear through classical conditioning and maintenance through operant conditioning
    • Cognitive factors incluce attentional biases and selective attention

The stress response

  • Exposure to stress results in instantaneous and concurent biological responses
    • To assess the danger
    • To organise an appropriate response
  • Amygdala acts as the emotional filter of the brain for assessing whether sensory material via the thalamus requires a stress or fear response
  • This is modified by later-received cortically processed signals
  • There are a series of responses to the stressor prior to the point at which stimulation of the adrenal gland causes the release of cortisol
  • Acute stress leads to dose-dependent increase in catecholamines and cortisol
  • Cortisol acts to mediate the stress response - through negative feedback it acts on the pituitary, hypothalamus, hippocampus and amygdala
    • These sites are responsible for the stimulation of cortisol release, therefore acute stress increases cortisol levels

Clinical presentation

Physical symptoms

  • Sweating, hot flushes or cold chills
  • Trembling or shaking
  • Muscle tension or aches and pains
  • Numbness or tingling sensations
  • Feeling dizzy, unsteady, faint or lightheaded
  • Dry mouth (not due to medication or dehydration)
  • Feeling of choking
  • A sensation of a lump in the throat, or difficulty in swallowing
  • Difficulty breathing
  • Palpitations or pounding heart, or accelerated heart rate
  • Chest pain or discomfort
  • Nausea or abdominal distress (e.g. churning in stomach)

Cognitive symptoms

  • Fear of losing control, 'going crazy' or dying
  • Feeling keyed up, on edge or mentally tense
  • Difficulty in concentrating, 'mind going blank'
  • Feeling that objects are unreal - derealization
  • Feeling that the self is distant or 'not really here' depersonalisation
  • Hypervigilance (internal and external)
  • Racing thoughts
  • Meta-worry (worry about everything, worrying about worrying)
  • Health anxiety
  • Beliefs about the importance of worry
  • Preference for order and routine

Behavioural symptoms

  • Avoidance of certain situations
  • Exaggerated response to minor surprises or being startled
  • Difficulty in getting to sleep because of worrying
  • Excessive use of alcohol/drugs (prescription or 'recreational')
  • Restlessness and inability to relax
  • Persistent irritability
  • Seek reassurance from family/GP
  • Checking behaviours