Anxiety Disorders

Generalized Anxiety Disorder (GAD)

Clinical Picture: Generalized Anxiety Disorder is characterised by excessive anxiety or worry about several events or activities for most days during at least a 6-month period. This worry is difficult to control and is often associated with somatic symptoms such as muscle tension, irritability, difficulty sleeping, and restlessness. The worry is non-specific, meaning it is not focused on a particular situation or object, such as having a panic attack, social embarrassment, or contamination. Individuals with GAD may experience psychological arousal, manifesting as irritability, difficulty in concentration, and/or sensitivity to noise. They often seek help for somatic symptoms, which can include palpitations, sweating, dry mouth, gastric disturbance, and dizziness due to autonomic overactivity. Muscle tension can also be present as restlessness, trembling, difficulty in relaxation, headache, and shoulder and backache. Sleep disturbances, including waking suddenly with intense anxiety and night terrors, may also occur. GAD frequently coexists with other mental disorders, such as social phobia, specific phobia, panic disorder, or depressive disorder.

Etiology: The etiology of anxiety disorders, including GAD, has psychological and neurobiological bases. From a psychoanalytic theory perspective, anxiety is viewed as a result of psychic conflict between unconscious sexual/aggressive wishes and threats from the superego. Behavioural theory suggests that anxiety can be understood as a conditioned response developed over time to a specific environmental stimulus. Existential theory proposes that for chronically anxious individuals, no specific identifiable stimulus exists, and they experience feelings of living in a purposeless universe.

Phobias

The term 'phobia' generally refers to an excessive fear of a specific object, circumstance or a situation.

Specific Phobia

Clinical Picture: Specific phobia involves a strong, persisting fear of an object or situation. When exposed to the feared object, the individual develops intense anxiety, even to the point of panic. There is also the presence of anticipatory anxiety, and the person tends to avoid the situation. The DSM-5 includes five general types of specific phobias related to animals, aspects of the natural environment, blood/injection/medical care/injury, situations (e.g., airplanes, lifts), and other provoking agents (e.g., choking, vomiting).

Social Anxiety Disorder (Social Phobia)

Clinical Picture: Social anxiety disorder involves the fear of social situations, including those involving scrutiny or contact with strangers. Individuals with social phobia are fearful of embarrassing themselves in social gatherings and exhibit an avoidance pattern for socially demanding situations. This disorder causes significant distress and impairment to the person, preventing participation in desired activities or causing marked distress during such activities. Individuals experience marked distress in situations where they perceive themselves exposed to possible scrutiny or negative evaluation by others, such as opening a conversation, attending a party, or delivering a speech. They often fear embarrassment and rejection. Similar to other phobias, avoidance is frequently present, and obvious psychological and somatic symptoms of anxiety may be experienced in dreaded situations.

Etiology of Phobias: According to the behavioural model of abnormality, classical conditioning has been said to account for the development of phobias. The feared object (conditioned stimulus) is associated with fear or anxiety from the past (unconditioned stimulus), subsequently evoking a powerful fear response characterised by avoidance and the emotion of fear whenever the object is encountered.

Panic Disorder

Clinical Picture: Panic disorder is characterised by acute, discrete episodes of severe anxiety known as panic attacks, which involve feelings of impending doom or anticipation of a catastrophic outcome. These episodes can vary in frequency. The first attack is often spontaneous, with symptoms often beginning with a 10-minute period of rapidly increasing intensity. Mental symptoms include extreme fear and a sense of impending death and doom, while physical signs include tachycardia, palpitations, dyspnoea, and sweating. An attack generally lasts 20 to 30 minutes, rarely more than an hour. Between attacks, patients may experience anticipatory anxiety about having another attack. Key characteristic features of a panic attack include rapidly rising anxiety, intense symptoms, and a feeling of impending doom or catastrophic outcome.

Etiology: Similar to other anxiety disorders, panic disorder has a psychological and neurobiological basis.

Obsessive Compulsive Disorder (OCD)

Clinical Picture: Obsessive-Compulsive Disorder is a chronic disorder where a person has uncontrollable, reoccurring thoughts (obsessions) and behaviours (compulsions) that they feel the urge to repeat over and over. These obsessions are recurrent and persistent thoughts, impulses, or images that cause distressing emotions such as anxiety or disgust. These intrusive thoughts cannot be settled by logic or reasoning. Typical obsessions include excessive concerns about contamination or harm, the need for symmetry or exactness, or forbidden sexual or religious thoughts. Compulsions are repetitive behaviours or mental acts that a person feels driven to perform in response to an obsession. Although the compulsion may temporarily relieve the worry, the obsession returns, and the cycle repeats. Common compulsions include cleaning, repeating, checking, ordering and arranging, and mental compulsions. These obsessions and compulsions are severe enough to cause significant distress or impairment in social, occupational, and other important areas of functioning.

Etiology: There are several etiological factors implicated in OCD:

  • Biological Factors: There is evidence of genetic predisposition, with first-degree relatives and identical twins having a higher risk. Neurotransmitters such as serotonin, dopamine, and glutamate may be imbalanced in individuals with OCD. Neuroanatomical factors also play a role, with evidence of abnormal brain structure and activity, including enlarged Basal Ganglia and increased glucose metabolism in parts of the basal ganglia.

  • Psychoanalytic Theory: OCD may arise when unacceptable wishes and impulses from the id are only partially repressed, causing anxiety. Ego defence mechanisms are unconsciously used in the form of acts, such as hand washing, to reduce this anxiety.

  • Cognitive Theory: Dysfunctional beliefs are considered a root cause of OCD, with the strength of these beliefs influencing the risk of developing the disorder.

  • Behaviour Theory: Obsessions can be explained as a conditioned stimulus to anxiety, while compulsions are seen as learned behaviours that decrease the anxiety associated with the obsessions. This anxiety reduction positively reinforces the compulsive acts, making them stable learned behaviours.

  • Psychosocial Factors: Factors such as a disturbed mother-child relationship, fear of abandonment, recent object loss, emotional neglect, and childhood abuse (physical, emotional, or sexual) have been implicated.