Anxiety – Diagnosis, Symptoms, and Treatment

What is Anxiety?

Anxiety is a medical condition characterized by excessive worry and fear surrounding upcoming or past events.  There are various forms of anxiety such as generalized anxiety disorder, phobias, and panic attacks.  Obsessive-compulsive disorder is also considered a form of anxiety.  People with anxiety often feel stressed or worried, have muscle tension, and experience symptoms such as palpitations, trouble breathing, headaches, sweating, and fatigue.  They also frequently have trouble sleeping (insomnia).

Severe anxiety is associated with an increased risk of depression and suicide.

What Causes Anxiety?

Anxiety originates from psychological, genetic, and environmental factors.  This condition frequently runs in families and is associated with other psychiatric disorders such as depression.  Symptoms occur due to inappropriate or exaggerated activation of the sympathetic nervous system.  The sympathetic nervous system is beneficial in flight or fight situations – but in patients with anxiety, this system activates in inappropriate situations and stays active for an excessive period of time resulting in undesirable symptoms.  Long-term overactivation of the sympathetic nervous system has also been associated with low serotonin levels in the brain. This is one of the reasons why anxiety is closely associated with depression.

 

Anxiety is what is known as a multifactorial disease, which means that there are several factors that lead to its presence, severity, and triggers. Stress at work, home, school, and in relationships are some of the most common factors involved in anxiety. Specific phobias such as public speaking, high-speed driving, confined spaces, or social situations exist as triggers in some individuals.

There are several risk factors that are highly associated with anxiety:

• Family history of anxiety
• Other psychiatric conditions –PTSD, bipolar disorder, schizophrenia
• Alcohol or drug dependence
• Traumatic brain injury
• Stroke
• Other chronic medical conditions (e.g. systemic lupus erythematosus, heart disease)

How Common is Anxiety?

The prevalence of anxiety in the United States is often underestimated. Many high-school-age children and college students do not seek treatment for symptoms of anxiety. The symptoms of anxiety may also not be reported to primary care physicians, many patients are unaware that their primary care doctor can prescribe effective treatments for anxiety and refer severe cases to specialty treatment. 

General anxiety disorder (GAD) is the most common form of anxiety and is estimated to affect 3% of the U.S. population. More severe forms of anxiety such as social phobia, panic disorder, and obsessive-compulsive disorder each affect an estimated 2% of the population. Many individuals with one form of anxiety or one anxiety disorder will also have others. 

Anxiety most commonly affects individuals between the ages of 25 to 44 years and much less common in individuals over 65 years of age. Anxiety affects younger children less often but is generally more severe when it does present. 

Signs and Symptoms

The most common symptom of anxiety include:

• Fear of losing control
• Fear of death
• Palpitations & tachycardia
• Chest tightness
• Difficulty breathing
• Muscle tension
• Epigastric discomfort
• Nausea

 Sometimes the symptoms of a panic attack can resemble that of a heart attack.  Symptoms that are more suggestive of a heart attack include chest pain/pressure characterized as an elephant sitting on the chest.  Trouble breathing, nausea/vomiting, and sweating are other concerning signs.  If you experience these symptoms and you have cardiovascular risk factors - advanced age, smoking history, high blood pressure, hypercholesterolemia, diabetes, or history of heart attack/stroke – you should consider calling 911 or going to the nearest emergency department.

Diagnosis

Anxiety in its simplest form is referred to as generalized anxiety disorder (GAD). Diagnosing GAD is based on several criteria. 

1. The presence of excessive apprehension (anxiety and worry) surrounding future events occurring for more than 90 days in a 6 month period. 
2. Difficulty controlling these feelings of worry.
3. This anxiety and worry are associated with three or more of the following symptoms. 
   1. Restlessness or feeling on edge
   2. Significant fatigue
   3. Difficulty concentrating
   4. Irritability and anger
   5. Muscle tension, aches, or stiffness
   6. Difficulty falling asleep or staying asleep

Even if all of these criteria are met it is very important to ensure that the signs and symptoms of anxiety are not due to another medical condition. For this reason, your physician will take a complete history and perform a full physical exam. Tests will also be ordered to rule out multiple medical conditions. These tests typically include such as a CMP (comprehensive metabolic panel), CBC (complete blood cell count), and thyroid function (TSH, free T4).  They may also perform a urine drug screen to evaluate for substances such as cocaine or amphetamines.

If you have conditions that increase your risk of a heart attack; such as diabetes, high blood pressure, and high cholesterol, your doctor may order an ECG (electrocardiogram) and refer you to the nearest emergency department for further evaluation.

Anxiety Medication and Treatment

The most effective medications for all forms of anxiety are selective serotonin reuptake inhibitors (SSRI’s). These medications are commonly thought of as depression medications, but they have been proven to be extremely effective and safe for the treatment of anxiety. Many individuals with anxiety also have symptoms of depression making these medications even more effective. Some patients respond better to SNRI’s which are a similar class of medications. 

The most commonly prescribed drugs include:

• Selective serotonin reuptake inhibitors (SSRIs)
  • Zoloft (sertraline) 
  • Prozac (fluoxetine)
  • Celexa (citalopram)
  • Lexapro (escitalopram) 
  • Paxil (paroxetine)
• Serotonin-norepinephrine reuptake inhibitors (SNRIs)
  • Cymbalta (duloxetine)
  • Effexor (venlafaxine)

Patients that experience acute episodes of panic associated with a specific fear or trigger and those with severe symptoms not managed by SSRIs alone may require benzodiazepines. These medications work to decrease the sympathetic overactivation that leads to the fight-or-flight reflex by altering the balance of neurotransmitters in the brain. Unlike SSRIs and SNRIs these medications are habit-forming, addictive, lead to withdrawals, and have potentially severe side effects, especially when combined with alcohol. Despite this, these medications may be required in some patients. 

The most common benzodiazepines are: 

• Ativan (lorazepam)
• Xanax (alprazolam)
• Klonopin (clonazepam)
• Valium (diazepam)
• Librium (chlordiazepoxide)

Conversing with a therapist specialized in the treatment of anxiety and depression is critical to the long term treatment of anxiety. The combination of medication and therapy has been shown to be far more effective than either treatment alone. 

References:

1. Locke AB, Kirst N, Shultz CG. Diagnosis and management of generalized anxiety disorder and panic disorder in adults. Am Fam Physician. 2015 May 1;91(9):617-24. - https://www.ncbi.nlm.nih.gov/pubmed/25955736
2. Bystritsky A, Khalsa SS, Cameron MECurrent diagnosis and treatment of anxiety disorders. P T. 2013 Jan;38(1):30-57. - https://www.ncbi.nlm.nih.gov/pubmed/23599668