by Anothony Dimech

Abstract:

Anxiety is a universal human experience. It is an unpleasant mood and is often accompanied by the physical symptoms of autonomic arousal and fearful cognitions. Its duration, intensity and impact on daily function determine whether it is a disorder or an appropriate response which prepares the individual to successfully manage risk. Maladaptive thought processing underpins a range of anxiety disorders. Cognitive Behavioural Therapy, anxiolytic and antidepressant medications are the mainstay of treatment.

Article: The experience of anxiety in the context of real adverse circumstances is neither necessarily abnormal nor indicative of even mild mental illness. As long as there is no marked discrepancy between the stressful stimulus and the elicited anxious response, both in intensity and duration, and there is no resulting gross impairment in the different domains of daily functioning, anxiety is not only normal, but can become an instrumental component of sound adjustment to calamity. Anxiety is a mood that is universal in human nature. It is usually accompanied by the release of adrenaline and other cathecolamines, resulting in unpleasant physical symptoms affecting most of the physiological systems of the body, such as palpitations, breathlessness, nausea, frequency of urination, trembling, muscle tension, dizziness and headaches.1 It is frequently revived by fear-laden thoughts, the content of which depends on current circumstances, past memories and experiences. It is a natural alarm that danger is imminent and serves to prepare the individual to minimise risk and maximise safety

So when does anxiety become a disorder? Problems start to arise as the intensity and duration of anxiety grow out of proportion to the actual threat that provoked it. Executive functions such as judgement, decision making and problem solving are affected to a certain extent, though symptoms remain reality-based and insight is not lost. In essence, anxiety is maintained and amplified through biased thought processing resulting in overrating of threat and underestimation of personal capability to deal with and contain the risk.2

On Saturday night, Paul, a 53 year old married man with 2 children is watching his favourite TV show. His 19 year old son Julian went out with his friends at 11 pm and promised to come back before three. He knows his son usually sticks to his time plus or minus one hour. Paul experiences thoughts that Julian or his friends might have too much to drink or smoke a bit of weed but reminds himself that he can do very little to prevent this. At times he gets brain images of his son being arrested by the police or getting involved in a traffic accident. These thoughts provoke short-lived palpitations and a bit of chest tightness. Overall, the father has a good relationship with his son, and though he got into some trouble in the past after getting drunk during a barbeque, Paul believes that Julian is likely to act sensibly and steer away from danger in the majority of occasions. This helps to ease his anxiety and he continues to enjoy his TV programme until he dozes off on the settee. He later manages to go to sleep in his bedroom but does wake up 3 hours down the line to check that his son returned home safely. He then manages to go back in the hands of Morpheus for the rest of the night. On the other hand, Katya, Paul’s wife, feels increasingly anxious as the weekend approaches. Her appetite and sleep are affected and she complains of headaches and palpitations which are usually worse from Thursday onwards. Julian is annoyed by her repetitive advice to stay away from drink and drugs, to come home early and to avoid all situations that can possibly lead to danger. Katya knows he is completely against her driving him to his friends and back on Saturday nights but she keeps forcing him to accept. She resorts to diazepam on Fridays and Saturdays but she still feels anxious all day. She spends Saturday nights in the balcony smoking cigarettes and counting the minutes. Lately, she started holding a picture of her son in her hands as soon as he is picked up by his friends. Though Katya is fully aware that there is little sense in this, she feels obliged to kiss it three times repetitively to ensure her son’s safety. 

The above two reactions to the same situation distinguish between anxiety and anxiety disorder. There is a range of anxiety disorders and most people experience symptoms from different disorders in the course of their condition. In almost all anxiety conditions, symptoms of autonomic arousal are prominent and comorbidity with other disorders such as depression, substance use and personality disorder is frequent.3

Generalised anxiety disorder is characterised by persistent uncontrollable worry about different topics whilst episodic paroxysmal anxiety attacks which follow catastrophic misinterpretation of internal events occur in panic. Situational anxiety is the highlight of phobias. In obsessive compulsive disorder anxiety originates from the experience of recurrent intrusive thoughts or mental images with absurd content and urges to perform repetitive and time-consuming rituals intended to neutralise the feared events. Adjustment disorders describe abnormal reactions to stress. There is a delayed and prolonged response to a real and very threatening event in post traumatic stress disorder.

Cognitive behavioural therapy has gained a prime position in the treatment of anxiety problems and is considered as the state of the art psychological approach.4 In the acute phase benzodiazepines can generally be prescribed in low doses for short periods whilst selective serotonin reuptake inhibitors and tricyclic antidepressants produce relief in the medium and long terms. Other medications such as venlafaxine, pregabalin, hydroxyzine, buspirone and antipsychotics in low doses also induce anxiolysis. Etifoxine has anxiolytic and anticonvulsant properties and may be used in the short term as an alternative to benzodiazepines or for longer periods, given it lacks tolerance or withdrawal symptoms.

References

1 Puri B, Treasaden I (2010) Psychiatry – An Evidence-Based Text, Hodder Arnold Publishers. 2 Wells A (1997) Cognitive Therapy of Anxiety Disorders: A Practical Guide, Wiley Publishers. 3 Semple D, Smyth R, Burns J, Darjee R, McIntosh A (2005) Oxford Handbook of Psychiatry (Oxford Handbooks Series) Oxford University Press. 4 Kingdon DG, Dimech A (2008) Cognitive Behavioural Therapies: The state of the art. Psychiatry 7(5): 217-220