Anxiety: What’s the deal with it? Isn’t it normal to feel anxious?

Flight Fright

In a word, yes.

Anxiety itself is a completely normal, and healthy, emotional state.  We, Homo sapiens that is, needed (and still do) fear – the root of anxiety – to survive as a species.

Let me take you back many thousands of years ago to caveman days.  Back then we needed the “fight, flight or freeze” response to survive and hunt.

If you’re minding your own business, making fire and cooking some delicious steak for dinner whilst the kiddies are playing with their bony toys and a sabre tooth tiger decides to pay a visit you need to act.  NOW!  What happens next isn’t necessarily conscious, it’s a basal instinct that kicks in.  The sight of the tiger sends a signal to the amygdala (our emotional HQ) which in turn activates the autonomic nervous system and a surge of adrenaline and corticosteroids floods our bodies.  “But what branch?” I hear you ask.  Well, it depends.

The sympathetic drive kicks in for fight and flight.  It quickens our heart beat, dries up the mucous membranes, dilates our pupils and tightens up our muscles allowing us to see better, run faster and be stronger in the space of just a few milliseconds – amazing!  And to be fair, we all know what this feels like as we will all have experienced fear to varying degrees in our lives.  I say we know what it feels like for a reason.  Anxiety is a very somatic little (or big) beast – we feel it all over bodies because of this activation.  We get palpitations, shallow breathing, sweaty palms, butterflies in our stomach and so on, you know what I’m talking about!

If we believe, albeit subconsciously, that there is no chance of escape or surviving, our bodies essentially freeze and  play dead.  That’s the parasympathetic drive taking over.  Our heart rate slows, our blood pressure drops, our muscles relax (so we collapse – maintaining blood supply to the noggin) and interesting things happen in the gut.  This is thought to be protective in that some predators don’t want dead prey, or they stop when you’re dead.  A modern day equivalent to this protective mechanism happens in some victims of rape, car accidents or nasty assaults – they effectively mentally leave the situation, don’t feel the pain and sometimes lose memory of the event itself.

Whilst horribly morbid, these capacities are actually pretty neat from an evolutionary stand point!

Unfortunately, as we evolved as a species and adapted to our ever changing world, this fight, flight or freeze response didn’t get the memo – at least not for most of us.  We don’t need this response anywhere near as often as we did back then but that doesn’t mean we don’t need it (look at the examples listed above).

On a smaller scale, having that bit of adrenaline buzzing in our system and a fear that something bad could happen is a fabulous motivator.  Think of your medical school exams, being prepared for ward rounds, or writing a speech or presentation so you don’t look foolish – without anxiety you likely wouldn’t care about the result and would probably not prepare as well for these things.  A small amount of anxiety has been shown to improve performance.

So, if anxiety is as normal as I say it is, when does it become a disorder?

Remember that sympathetic drive and all that adrenaline, sometimes our bodies don’t know when to tone it down or turn it off.  Imagine magnifying that pre-exam anxiety several times over and then imagine it not going away.

How awful must that be?

It would likely get in the way of you leading your very functional lives on a day to day basis.  That’s the key – anxiety becomes a disorder when it rules your life and significantly impacts your social and occupational functioning.

Here’s another exercise for you.  Imagine you’re planning to meet a friend for a coffee date at 11am but it’s 10.55am and you’re sitting there alone.  You’re probably not even worrying about them not being there yet as they’re not late.  Then 11am rocks around, 11.05, 11.10, 11.15.  You’re probably wondering where they’ve gotten to, unless there a perpetual late arriver, but not too concerned.  You might order your own coffee and send them a message to give them a nudge but it’s not the end of the world.

This time, imagine that you’re a person with an anxiety disorder and talk yourself through the same scenario.  You might be ok at 10.55am but as soon as 11am comes round you’re already too far down the rabbit hole.  “They’ve forgotten, they don’t like me, I’m a boring person, nobody likes me, I’m a horrible person, why didn’t they come, they’ve probably crashed their car, they’re lying dead on the side of the road, it’s my fault, I wanted to meet for coffee, who’s going to tell their family, I have to tell their family, what’s going to happen to the kids…” and so it goes on forever and ever.  Ladies and gentlemen: this is catastrophic thinking. Evilness!

*Is one of many types of ‘negative automatic thoughts’ in CBT. Catastrophic thinking can be defined as ruminating about irrational worst-case outcomes. Needless to say, it can increase anxiety and prevent people from taking action in a situation where action is required. This can be especially true in a crisis situation. 

Now wouldn’t it be lovely if there was just the one anxiety disorder to look through?  Well, I’ve got good news and bad news: the bad news is that there’s a decent handful of them to know but the good news is that you’ll see a pattern emerging, particularly with regards to its management.  This is only meant as a starting block to get you off in the right direction with your further reading, it is by no means a comprehensive guide but I will leave some links down the bottom (or as we go – I haven’t decided yet!). Right, let’s get started!

Anxiety disorders are common

Like super common.

I bet you have all come across someone, either during your clinical contact or personal lives, who either is currently struggling with, or has a history of, an anxiety disorder.

Think back to some recent histories you’ve taken or read through and I bet there would be a few who list “Depression & Anxiety”.  In Australia, anxiety disorders are the most common of any mental illness with about 14% of experiencing one in any given year for adults.  The lifetime prevalence is a whopping 18% for women and 11% for men though there is likely a fair amount of under-reporting – especially from you blokes.  This means you need to know about these disorders, as no matter what dark and dank corner of medicine you choose to practice in down the long road ahead of you, you will absolutely be looking after people with anxiety disorders.

Not only are the anxiety disorders the most common mental illness around, they are also the most commonly co-morbid ones (see the “Depression & Anxiety” quote above).  Are we all keeping up?  Now for the juicy bits…

Generalised Anxiety Disorder

GAD is exactly what it says it is… sort of. It’s pretty much just being worried sick about everything, all of the time, non-stop, worry being the key word. People often avoid situations that will trigger worry (e.g. making decisions, reading about illness) and often frequently and repeatedly seek reassurance to try to reduce their anxiety (e.g. see the doctor because of feared illness, check on the whereabouts of loved ones, ask others to check that something they have done is right).

Tricky, I know!  It’s pretty much just being worried sick about everything, all of the time, non-stop.

Think back to that line about our bodies not knowing when to turn off that sympathetic drive so it just keeps on going. Eurgh!  With most of the other disorders we’ll dip into there is often some reprieve from this but not here. This worry is excessive and uncontrollable and the person will know that it’s excessive but feels powerless to change this.  I’ll not go into the diagnostic criteria in full but you can have a squiz for yourself here.

Wikipedia, I know, but it has a lot of good info!

But how do we manage GAD? It’s reasonably straight forward, at least in theory.  In practice, things are a bit more tricky.  As with everything we do, we look at management in terms of the biopsychosocial model* (OSCE buzz word alert!).

*Attributed to Psychiatrist Georg Engel in 1977. The Biopsychosocial model hypothesizes that illness is a combination of factors attributable to biological, psychological and social factors.

Not everyone with GAD will require medication but everyone should be offered psychological input and pointers towards lifestyle factors that will make a difference (namely good sleep, a good diet, staying hydrated, getting exercise, using their supports and generally being kind to themselves).  The key psychological issue is intolerance of uncertainty (“What if …?” followed by catastrophising ++), so psychological therapy focusses on that. How? You can read more here.

Medication wise we use antidepressants.  They’re a bit of a misnomer as they’re not just for depression.

Again, I won’t bore you with all of the specifics as you can treat your own insomnia by reading some guidelines here.  Essentially, first line agents should be an SSRI (there’s not a huge amount of difference between them but some are better tolerated than others), then second line is to trial another SSRI or switch to an SNRI.  And we always try to avoid benzodiazepines if at all possible.

So why no?  Well, the first reason is that they are very easy to become dependent on but that’s not the major issue.  The big reason is that they don’t treat the anxiety.  Let me take you on another journey:

Imagine anxiety as a room filled to bursting with junk.  Old food, dirty clothes, magazines, mail, random bits and pieces and to look at it is extremely confronting and way too overwhelming to even think about going in there to look at the stuff, never mind sort it out.

Then someone gives you a lovely big blanket, your benzodiazepine, to cover it all up. Ah, that’s better, I can’t see it now, I’m good to have a look in the room now.  Phew! BUT, the blanket is only a loaner and it gets taken away again pretty quickly and boom, the mess is back.  Exactly the same as it was before.  Covering it up didn’t actually get in there and sort it out and clean it up, it just covered it for a while.  So you keep needing to get the blanket back to cover it all up, nice and quick, but to what end?

Your antidepressant, and CBT (we’ll get there), however, can actually get into the room to start to fix it all up.  It takes a long time and is pretty messy and nasty along the way, but bit by bit you’re chipping away at it, and it becomes easier and easier to face.

There are many types of psychotherapy that can treat GAD but the major player is Cognitive Behavioural therapy*.  CBT should be a blog post in itself but it involves a range of strategies for treating a large number of conditions and can include learning about triggers, relaxation, and distraction techniques whilst challenging thinking pathways that have become automatic thoughts.  Neat, huh?!  It’s a nice short form of therapy and, bonus, GPs can give patients Mental Health Care Plans which entitles folk to an initial 6 (and 4 more if needed) sessions with a psychologist through Medicare.

Cognitive behavioural therapy (CBT) is the psychosocial intervention that is the most widely used evidence-based practice for treating GAD. Guided by empirical research, CBT for GAD focuses on the development of personal coping strategies that target solving current problems and changing unhelpful patterns in cognitions (e.g., thoughts, beliefs, and attitudes), behaviours, and emotional regulation.  Exposure therapy in CBT for GAD encourages the person to confront situations they have been avoiding (e.g. making decisions) and resist reassurance-seeking (e.g. not phoning their partner every hour to check they are OK).

Social Anxiety Disorder

SAD comes in two different forms.

One is about being anxious out and about, usually in situations where there are lots of people, and one is more performance based (a common example is public speaking) with a fear of social scrutiny in both.

Note how this differs from GAD above.

The anxiety can hit hard in these situations and can make life incredibly difficult – “sorry, we can’t have dinner tonight as I couldn’t force myself out of the house to get food and I don’t like people coming to my house, so, yeah – hungry it is”.

With this condition, there is usually a safe space, such as home, or person whom the person can just about manage to get out with. Go here for the diagnostic criteria.

The management of SAD is pretty similar to GAD, and CBT is the gold standard psychological treatment.  Similar strategies to GAD are used but there is an emphasis on graded exposure – that is, facing feared situations one step at a time.

Here’s a link to some guidelines for a detailed breakdown.  The medication arm isn’t needed for everyone but when it is, first line agents are SSRIs.  Another option that can be used for performance situations is propranolol.  It helps calm those down without being sedated by something like a benzodiazepine or as addictive as one.  But it’s not curative and only meant for specific and infrequent situations where anxiety is overwhelming.

Agoraphobia, panic attacks and Panic Disorder

These two come as a package as it’s easier to explain this way.

Agoraphobia can look a lot like SAD, in that busy, crowded places are often avoided. However, the underlying fear is not of social scrutiny, but of the panic attacks themselves. The person fears that the panic attacks may cause catastrophic physical damage (e.g. a stroke or heart attack) or send them crazy. People with agoraphobia are usually most comfortable having just a few people around, especially trusted friends or family – in case they have a panic attack and need help. They don’t like crowded places or situations that would be difficult to be out of, and they don’t like being alone, even in their own home.

They literally find it difficult step foot outside their own front door.  A reason for adding in the panic attacks is because they are a specifier for the disorder.  Panic attacks occur in all anxiety disorders but they get a special mention here.

What is a panic attack? It is basically hell on earth and one of the worst and most frightening experience you can have.  If any of you have had the misfortune to have one you will know that this statement is accurate.  Think back to that catastrophic thinking but then add into that the somatic symptoms.  The worse the thoughts get the worse the physical feelings become until there is this sense of doom and dread and a feeling you are going to die.  There are often triggers but many people will not be able to identify the triggers straight up (a little easier in agoraphobia) and they generally pass by themselves after a few minutes to half an hour or so.

A quick mention for panic disorder is that it is fear of having panic attacks which sounds a bit redundant but there it is.

Anywho, diagnostic criteria are here for agoraphobia and here for panic disorder.

Management – have you spotted the pattern yet?  Biopsychosocial model is helpful in formulating and once again CBT is very effective (focus on education about anxiety, changing unhelpful thinking patterns, learning to tolerate feeling panicky and confronting feared situations). SSRIs as medication may be required as well by some people.

Obsessive Compulsive Disorder

OCD is a term that gets thrown around casually these days – “I’m a bit OCD, I like things neat” and the like.

OCD isn’t just about being neat and tidy as I’m sure you’re aware, so what is it?  To understand that you first need to know what obsessions and compulsions are.

An obsession is a recurrent, persistent thought, image, or impulse that is unwanted and distressing ego-dystonic* and comes involuntarily to mind despite attempts to ignore or suppress it.

*Refers to thoughts, impulses, and behaviors that are felt to be repugnant, distressing, unacceptable or inconsistent with one’s self-concept.

Common obsessions involve violence, contamination, and doubts.  They are incredibly intrusive with the ego-dystonic meaning that it is absolutely not in keeping with their personality, morals or values.  An example of this would be seeing a knife and then having the image of stabbing a loved one.  It would never happen but the image is there.

compulsion on the other hand is a difficult to resist urge to perform an act or think a thought, in order to neutralise the anxiety. In adults, the compulsion is generally pretty predictable based on the obsession – e.g. if I touch that computer terminal in the library that everyone else has been using, my hands feel dirty and I have a strong urge to go wash them.  In kids the obsession may be vaguer and there may not seem to be a logical connection to the obsession, e.g. they may worry about the house burning down and feel the urge to walk around the room over and over. People with OCD often avoid a lot of situations that might trigger their obsessions – e.g. with an obsessional that they might stab someone the person will avoid all knives, even blunt cutlery knives.  Here are your diagnostic criteria as always.

Management of OCD, whilst still keeping within the biopsychosocial model is a bit trickier.

The same general principles apply as you’ll see here using SSRIs first line and CBT but second line treatment here is to go to a TCA … Perhaps make it clearer that either CBT or SSRI can be used first line; a slight advantage for combined therapy. A second or third SSRI would be used before going to TCA, and the rationale for clomipramine should be explained (i.e. serotonergic).

And finally

Post-Traumatic Stress Disorder

PTSD can be quite complex, often very horrible, very messy and sometimes difficult to treat.  Some people find it incredibly difficult to come forward about this, such as war Vets, and so people can often be incredibly disabled by their trauma.

I won’t go into too much detail about it but feel free to have a good read through this and this.  SSRIs are often used again as first line but psychotherapy is a bit different as it needs to be trauma focused.  The area is quite complex but includes variants of CBT such as exposure therapy* (as used in other anxiety disorders) as well as EMDR**.

*Involves the exposure of the patient to the feared object or context without any danger, in order to overcome their anxiety and/or distress.

**The goal of EMDR is to reduce the long-lasting effects of distressing memories by engaging the brain’s natural adaptive information processing mechanisms, thereby relieving present symptoms. The therapy uses an eight-phase approach that includes having the patient recall distressing images while receiving one of several types of bilateral sensory input, such as side to side eye movements.

And that’s anxiety in a nutshell! Congrats on making it through ????

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