Anxiety Disorders | Medical Science Optional Notes for UPSC PDF Download

Definition

Anxiety, characterized by a subjective feeling of discomfort, apprehension, or anticipation, may signal an underlying psychiatric disorder or manifest as part of, or a response to, an underlying medical condition.
The most commonly occurring mental health disorder within the broader community.

List of Anxiety Disorders

• Generalized Anxiety Disorder (GAD)
• Panic Disorder and Panic Attacks
• Agoraphobia
• Social Anxiety Disorder
• Selective Mutism
• Separation Anxiety
• Obsessive-Compulsive Disorder
• Post-Traumatic Stress Disorder

Non pharmacological management of anxiety disorders

Panic Disorder

Panic disorder is characterized by the occurrence of recurrent and unexpected panic attacks, distinct episodes marked by intense fear and discomfort accompanied by various physical symptoms. These symptoms include palpitations, sweating, trembling, shortness of breath, chest pain, dizziness, and a sense of impending doom or death. Paresthesias, gastrointestinal distress, and feelings of unreality are also commonly experienced.

To meet diagnostic criteria, there must be at least one month of concern or worry about the attacks or a noticeable change in behavior linked to them. The precise cause of panic disorder remains unknown, but it is believed to involve factors such as a genetic predisposition, altered autonomic responsivity, and influences from social learning.

Differential diagnosis involves considering anxiety states resulting from medical conditions such as:

• Pheochromocytoma (assessed through free metanephrines in urine and blood)
• Thyrotoxicosis (evaluated using T3, T4, and TSH)
• Hypoglycemia (measured through blood glucose levels)
• Paroxysmal atrial tachycardia and mitral valve prolapse (examined through ECG, 2D, Echo)

The foundation of pharmacological treatment lies in the use of antidepressant medication. Typically, it takes 2-6 weeks for antidepressants to demonstrate effectiveness, and adjustments to doses may be necessary depending on the clinical response. After patients attain a satisfactory response, it is recommended to continue drug treatment for 1-2 years to mitigate the risk of relapse.

Non- Pharmacological management

• Psychotherapeutic intervention and early education targeting symptom control can amplify the effectiveness of drug treatment.
• Patients can receive instruction in breathing techniques, gain knowledge about the physiological changes associated with panic, and participate in a treatment program spanning 12-15 sessions that includes voluntary exposure to triggering events.
• Integral to successful treatment are homework assignments and monitored compliance, serving as important components in the overall therapeutic approach.

Antidepressant medication (Side effects)

Agoraphobia

Frequently observed in individuals with panic disorders is the development of an irrational fear specific to environments where one might perceive a sense of being trapped or unable to escape. This fear, anxiety, or even panic attacks persist for a duration of at least 6 months in a minimum of two of the following five situations:

• Using public transportation
• Being in open spaces
• Being in enclosed places
• Standing in line or being in a crowd
• Being outside of the home alone

Active avoidance of these settings occurs unless accompanied by a companion.

Generalized Anxiety Disorders

Individuals diagnosed with Generalized Anxiety Disorder (GAD) experience persistent, excessive, and/or unrealistic worry accompanied by symptoms such as muscle tension, impaired concentration, autonomic arousal, a sense of being "on edge" or restless, and insomnia. The onset of GAD typically occurs before the age of 20, and a history of childhood fears and social inhibition may be evident.

These patients often exhibit comorbid substance abuse, with a higher prevalence of alcohol and/or sedative/hypnotic abuse. In GAD, excessive worry extends to minor matters, significantly impacting daily life. Unlike in panic disorder, complaints of shortness of breath, palpitations, and tachycardia are relatively infrequent in individuals with GAD.

Differential Diagnosis

Panic Disorder: 
In Generalized Anxiety Disorder (GAD), panic symptoms are typically triggered by the uncontrolled escalation of anxiety or worry, rather than manifesting spontaneously or acutely in specific situations, as observed in panic disorder.

Depressive Disorders: 
Individuals with GAD often express greater concern about the future, while those with depressive disorders are generally more focused on past-oriented thoughts. Mood swings and suicidal ideation are rare in GAD.

Social Anxiety Disorder: 
Unlike individuals with Social Anxiety Disorder, those with GAD usually feel at ease in social situations and are not notably distressed by the scrutiny or evaluation of others.

Treatment
The management of Generalized Anxiety Disorder (GAD) relies on the combination of psychotherapy and pharmacotherapy.

Pharmacotherapy options include:

• Benzodiazepines (lorazepam, oxazepam, or alprazolam): These may be used temporarily until SSRIs take effect, but should not be employed for long-term management due to the increased risk of benzodiazepine dependence.
• Non-benzodiazepine anxiolytic agent (Buspirone): This option is non-sedative and lacks abuse potential.
• Antidepressants: FDA-approved options for GAD treatment include escitalopram, paroxetine, duloxetine, and venlafaxine.
• Antipsychotics: Reserved for refractory cases, antipsychotics are considered only in specific situations.

Obsessive Compulsive Disorders

Marked by persistent obsessive thoughts and compulsive behaviors that hinder daily functioning, this condition often involves fears of contamination and germs. Common compulsions include repetitive handwashing, counting behaviors, and the need to continually check actions such as ensuring a door is locked. While the disorder typically follows a fluctuating pattern, some cases may exhibit a steady decline in psychosocial functioning.

Cognitive-behavioral therapy, specifically exposure response prevention, can yield improvements comparable to those achieved through medication. This approach involves a gradual escalation of exposure to stressful situations, the maintenance of a stressor diary for clarity, and homework assignments focused on substituting new activities for compulsive behaviors.

Medications

• Clomipramine, fluoxetine, fluvoxamine, and sertraline have received approval for treating OCD in adults (with fluvoxamine also approved for children).
• Deep brain stimulation has proven effective in severe cases of OCD.

Anxiety Disorder - Repeats

1. What is panic disorder? Name the drugs commonly used to treat this disorder. (2012) 
2. An 18-year-old young girl has attacks of restlessness, insomnia, cold sweating and fear. Discuss the differential diagnosis. Outline the principles of management of "generalized anxiety disorder". (2016) 
3. Discuss in brief about non-pharmacological management of Anxiety disorder. (2019)