Anxiety disorders: Diagnosis and treatment

A look at the spectrum and presentation of anxiety disorders and the latest treatment approaches

Anxiety occurs in many forms and many circumstances. A certain amount of anxiety is normal and healthy, especially in situations of stress and expectation. If, however, anxiety becomes constant or disabling, it can reach the diagnostic threshold for an anxiety disorder. These include conditions such as panic disorder, generalised anxiety disorder, obsessive compulsive disorder (OCD), and phobias (eg, agoraphobia, social phobia).

Diagnosing anxiety disorders

Panic disorder is characterised by panic attacks, which are episodes in which the person experiences a sudden onset of palpitation (sensation of the heart fluttering in the chest), shortness of breath, choking sensation, chest pain, dizziness, and/or feelings of unreality, without an apparent physical cause. In addition to the physical symptoms of panic (sweating, shaking, chest pain, etc), the person has psychological symptoms such as extreme anxiety and, often, an irrational fear of dying or losing control. These intense symptoms tend to last for a few minutes, but can feel much longer to the person affected.

Generalised anxiety disorder is characterised by substantial, persistent anxiety which is not restricted to any particular situations or circumstances. Common symptoms include sustained nervousness, shaking, sweating, dizziness, vague stomach pain, and broad, brooding worries. It is not limited to specific triggers or environments, and the anxiety is persistent as opposed to episodic. This can be an extremely distressing disorder, developing slowly and going unrecognised for years in many cases. Often, people adjust and limit their lifestyles so as to minimise symptoms in the short-term.

Obsessive compulsive disorder (OCD) is characterised by obsessional thoughts and/or compulsive acts. Obsessional thoughts are ideas, impulses, or images that keep entering a person’s mind even though the person finds them distressing, if only because they do not want them repeatedly entering their mind. Sometimes, in addition, the thoughts themselves are obscene or violent, and are thus distressing for this reason too. While the person recognises that the thoughts are his or her own thoughts, the person tries to resist having them repeatedly enter his or her mind, generally with limited success (at least in the pre-treatment phase). Compulsive acts are analogous to obsessional thoughts, but take the form of behaviours rather than thoughts: They are repeated over and over again, are not enjoyable, and – at the extent to which they occur – are not goal-directed. 

Finally, phobias are a group of disorders in which anxiety is evoked only, or predominantly, in certain well-defined situations or in connection with certain objects which are not dangerous. This leads to the person either avoiding the situation or object, or enduring it with dread. Anticipatory anxiety may develop, which is anxiety at the prospect of the relevant situation or object, as well as the actual situation or object itself.

‘Agoraphobia’ refers to a phobia of open spaces, crowds, or other situations in which a person perceives difficulty with immediate escape or problems getting to ‘safety’ (eg, home or back into the car). There is usually a well-established pattern of avoidance.

‘Social phobia’ is focused on fear of scrutiny by other people in small groups, usually leading to avoidance of specific social situations (eg, eating in public, chatting informally at parties).

At any given time, approximately 1 per cent of people have panic disorder, and 2-to-4 per cent have generalised anxiety disorder. Social phobia affects up to 10 per cent of people at some point in life and is equally common in men and women. OCD, too, is equally common in women and men, and 2-to-3 per cent of people will develop OCD at some point in their life.

Treating anxiety disorders

Anxiety disorders are treatable conditions. Treatment can involve combinations of psychological therapies, medication, and social inputs. Psychotherapy is usually the mainstay of treatment, augmented by other measures as indicated. For all patients and families, psychoeducation, self-help, and support groups can be extremely important.

In terms of psychotherapy, cognitive-behavioural therapy (CBT) is the most commonly-used psychological treatment. CBT focuses on the use of cognitive strategies (ie, strategies related to thinking patterns and habits) and behavioural strategies (ie, strategies related to actions and behavioural habits) in an effort to re-frame thoughts, enhance coping strategies, reduce symptoms, and promote recovery and wellness.

Usually, the psychotherapist will meet the patient regularly and point out errors or unhelpful thinking patterns which may deepen or prolong symptoms. Together, the patient and psychotherapist identify ways to address these errors and habits, and incrementally improve symptoms. There is strong evidence that CBT is highly effective in the management of depression, generalised anxiety disorder, panic disorder, social phobia, OCD, and a range of other conditions. Its principles can also be applied in online materials, self-help groups, and many other formats.

The precise components of CBT vary between disorders. In generalised anxiety disorder, CBT can focus on identifying and modifying preemptory anxious thoughts, and replacing them with more reality-based thoughts and better coping methods. Psychoeducation, self-help, relaxation techniques, and breathing exercises are also very helpful in anxiety disorders.

A number of antidepressant medications are licensed for use in generalised anxiety disorder and can prove extremely useful elements of the treatment package. Certain anti-anxiety medications such as benzodiazepines, however, should only be used in short-term crises (when symptoms are severe, disabling, or causing extreme distress), and for extremely short periods, if at all, owing to their addiction potential and possible paradoxical effects.

In panic disorder, too, treatment is generally centred on CBT as well as certain antidepressants licensed for the disorder.

For phobias, CBT often involves graded exposure to the feared stimulus and response prevention. In agoraphobia, for example, graded exposure to the anxiety-provoking situation is used, with appropriate distraction and cognitive re-structuring; and antidepressants can also play a useful role in certain cases with co-existing panic disorder.

Treatment of social phobia or social anxiety disorder involves CBT, self-help, and social skills, as well as certain antidepressant medications, if needed. Further assistance is available from Social Anxiety Ireland, which offers information, support, and assistance (www.socialanxietyireland.com).

In OCD, treatment involves psychoeducation and CBT, which often centres on exposure to the relevant triggers and response prevention, and can be delivered in the form of individual or group therapy. Certain selective-serotonin reuptake inhibitors are also used. The response rate to CBT and/or medication is around 75 per cent.

Additional treatment considerations

For many anxiety disorders, there can be a role for psychotherapeutic approaches other than CBT, depending on the situation at hand and the patient’s preference.

Mindfulness-based techniques, for example, can be very helpful for many people. Mindfulness involves focusing on the present moment rather than worrying about the future or dwelling on the past. With a qualified teacher, mindfulness can help people to reduce overthinking, observe their anxious thoughts without judgment, and detach from the thoughts rather than being consumed by them.

Mindfulness practices such as body scanning can activate the body’s relaxation response, which counters the physical symptoms of anxiety, such as rapid breathing, increased heart rate, and muscle tension. Mindfulness can also help people to become more aware of the early signs of anxiety (both mental and physical), and thus allow them to intervene early and manage their anxiety before it escalates. In addition, mindfulness can enhance emotional regulation, increase acceptance, and deepen awareness of reality, provided mindfulness is practiced under the guidance of a qualified teacher or therapist.

Psychoanalysis is another therapeutic technique that has been unjustly neglected in recent decades and can be of assistance to many, including those who find that CBT is helpful in reducing anxiety symptoms, but does not provide sufficient meaning or growth in personal understanding. It is important that space is made for many different kinds of therapy for anxiety disorders and other conditions, not least because each person is an individual, with a unique combination of weaknesses and strengths, problems, and solutions. This diversity should be reflected in the variety of treatments available.

The vast majority of people with anxiety disorders are treated in primary care or by psychotherapists in the community, without referral to secondary mental health services (ie, psychiatrists and multidisciplinary community mental health teams). For the minority who require referral to secondary mental health services, the vast majority are treated as outpatients by community mental health teams in outpatient clinics, day hospitals, or day centres, using the approaches outlined above.

A small proportion of people with anxiety disorders are admitted for inpatient psychiatric care when the disorder is especially severe (eg, life-threatening OCD), previous treatments have failed to produce sufficient improvement, or there is significant risk to self or others. Inpatient care tends to involve a more intensive version of the treatments already discussed above.

Prognosis in anxiety disorders

The vast majority of people with anxiety disorders are treated in primary care or as outpatients. The outlook for improvement is very good in the absence of complicating factors (eg, alcohol misuse) and provided there is sensible, sustained treatment in the context of a good, steady therapeutic relationship. A wider variety of psychotherapeutic approaches is, however, needed, in order to reflect the broad diversity of anxiety disorders that present and the even wider variety of people who experience them.

Finally, it is important to note that depression can co-exist with all anxiety disorders. There can also be mixed anxiety and depressive disorders, in which symptoms of both anxiety and depression occur together in approximately equal measure. In such cases, attention is required to both sets of symptoms, which can sometimes be so closely related as to be virtually indistinguishable from each other.

Prof Kelly’s latest book, The Modern Psychiatrist’s Guide to Contemporary Practice: Discussion, Dissent, and Debate in Mental Health Care, is now available. (Open access: www.taylorfrancis.com/books/oa-mono/10.4324/9781003378495/modern-psychiatrist-guide-contemporary-practice-brendan-kelly)