Assessing and Treating Clients With Anxiety Disorders

chapter9_introduction.pdf

Home >Nursing homework help >Assessing and Treating Clients With Anxiety Disorders

Anxiety disorders and anxiolytics

This chapter will provide a brief overview of anxiety disorders and their treatments. Included here are descriptions of how the anxiety disorder subtypes overlap with each other and with major depressive disorder. Clinical descriptions and formal criteria for how to diagnose anxiety disorder subtypes are mentioned only in passing. The reader should consult standard reference sources for this material. The discussion here will emphasize how discoveries about the functioning of various brain circuits and neurotransmitters - especially those centered on the amygdala - impact our understanding of fear and worry, symptoms that cut across the entire spectrum of anxiety disorders.

The goal of this chapter is to acquaint the reader with ideas about the clinical and biological aspects of anxiety disorders in order to understand the mechanisms of action of the various treatments for these disorders discussed along the way. Many of these treatments are extensively discussed in other chapters. For details of mechanisms of anxiolytic agents used also for the treatment of depression (i.e., certain antidepressants), the reader is referred to ; for those anxiolyticChapter 7 agents used also for chronic pain (i.e., certain anticonvulsants), the reader is referred to .Chapter 10 The discussion in this chapter is at the conceptual level, and not at the pragmatic level. The reader should consult standard drug handbooks (such as Stahl's Essential Psychopharmacology: the

) for details of doses, side effects, drug interactions, and other issues relevant toPrescriber's Guide the prescribing of these drugs in clinical practice.

Symptom dimensions in anxiety disorders

When is anxiety an anxiety disorder?

Anxiety is a normal emotion under circumstances of threat and is thought to be part of the evolutionary "fight or flight" reaction of survival. Whereas it may be normal or even adaptive to be anxious when a saber-tooth tiger (or its modern-day equivalent) is attacking, there are many circumstances in which

Figure 9-1. . Although the core symptoms ofOverlap of major depressive disorder and anxiety disorders anxiety disorders (anxiety and worry) differ from the core symptoms of major depression (loss of interest and depressed mood), there is considerable overlap among the rest of the symptoms associated with these disorders (compare the "anxiety disorders" puzzle on the right to the "MDD" puzzle on the left). For example, fatigue, sleep difficulties, and problems concentrating are common to both types of disorders.

the presence of anxiety is maladaptive and constitutes a psychiatric disorder. The idea of anxiety as a psychiatric disorder is evolving rapidly, and is characterized by the concept of core symptoms of excessive fear and worry (symptoms at the center of anxiety disorders in ), compared toFigure 9-1 major depression, which is characterized by core symptoms of depressed mood or loss of interest (symptoms at the center of major depressive disorder in ).Figure 9-1

Anxiety disorders have considerable symptom overlap with major depression (see those symptoms surrounding core features shown in ), particularly sleep disturbance, problemsFigure 9-1 concentrating, fatigue, and psychomotor/arousal symptoms. Each anxiety disorder also has a great

Downloaded from http://stahlonline.cambridge.org by IP 100.101.44.120 on Tue Mar 24 15:37:10 UTC 2020 Stahl Online © 2020 Cambridge University Press. All rights reserved. Not for commercial use or unauthorized distribution.

deal of symptom overlap with other anxiety disorders ( through ). Anxiety disorders areFigures 9-2 9-5 also extensively comorbid, not only with major depression, but also with each other, since many patients qualify over time for a second or even third concomitant anxiety disorder. Finally, anxiety disorders are frequently comorbid with many other conditions such as substance abuse, attention deficit hyperactivity disorder, bipolar disorder, pain disorders, sleep disorders, and more.

So, what is an anxiety disorder? These disorders all seem to maintain the core features of some form of anxiety or fear coupled with some form of worry, but their natural history over time shows them to morph from one into another, to evolve into full syndrome expression of anxiety disorder symptoms (

) and then to recede into subsyndromal levels of symptoms only to reappear again as theFigure 9-1 original anxiety disorder, a different anxiety disorder ( through ), or major depression (Figures 9-2 9-5

). If anxiety disorders all share core symptoms of fear and worry ( and ) and,Figure 9-1 Figures 9-1 9-6 as we shall see later in this chapter, are all basically treated with the same drugs, including many of the same drugs that treat major depression, the question now arises, what is the difference between one anxiety disorder and another? Also, one could ask, what is the difference between major depression and anxiety disorders? Are all these entities really different disorders, or are they instead different aspects of the same illness?

Overlapping symptoms of major depression and anxiety disorders

Although the core symptoms of major depression (depressed mood or loss of interest) differ from the core symptoms of anxiety disorders (fear and worry), there is a great deal of overlap with the other symptoms considered diagnostic both for a major depressive episode and for several different anxiety disorders

Figure 9-2. . The symptoms typically associated with GAD are shownGeneralized anxiety disorder (GAD) here. These include the core symptoms of generalized anxiety and worry as well as increased arousal, fatigue, difficulty concentrating, sleep problems, irritability, and muscle tension. Many of these symptoms, including the core symptoms, are present in other anxiety disorders as well.

Figure 9-3. . The characteristic symptoms of panic disorder are shown here, with corePanic disorder symptoms of anticipatory anxiety as well as worry about panic attacks. Associated symptoms are the unexpected panic attacks themselves and phobic avoidance or other behavioral changes associated with concern over panic attacks.

( ). These overlapping symptoms include problems with sleep, concentration, and fatigueFigure 9-1 as well as psychomotor/arousal symptoms ( ). It is thus easy to see how the gain or loss ofFigure 9-1 just a few additional symptoms can morph a major depressive episode into an anxiety disorder (

) or one anxiety disorder into another ( through ).Figure 9-1 Figures 9-2 9-5

From a therapeutic point of view, it may matter little what the specific diagnosis is across this spectrum of disorders ( through ). That is, first-line psychopharmacological treatmentsFigures 9-1 9-5 may not be much different for a patient who currently qualifies for a major depressive episode plus the symptom of anxiety (but not an anxiety disorder) versus a patient who currently qualifies for a major depressive episode plus a comorbid anxiety disorder with full criteria anxiety symptoms. Although it can be useful to make specific diagnoses for following patients over time and for documenting the evolution of symptoms, the emphasis from a psychopharmacological point of view is increasingly to take a symptom-based therapeutic strategy to patients with any of these disorders because the brain is not organized according to the DSM, but according to brain

Figure 9-4. . Symptoms of social anxiety disorder, shown here, include the coreSocial anxiety disorder symptoms anxiety or fear over social performance plus worry about social exposure. Associated symptoms are panic attacks that are predictable and expected in certain social situations as well as phobic avoidance of those situations.

Figure 9-5. . The characteristic symptoms of PTSD are shown here.Posttraumatic stress disorder (PTSD) These include the core symptoms of anxiety while the traumatic event is being re-experienced as well as worry about having the other symptoms of PTSD, such as increased arousal and startle responses, sleep difficulties including nightmares, and avoidance behaviors.

circuits with topographical localization of function. That is, specific treatments can be tailored to the individual patient by deconstructing whatever disorder the patient has into a list of the specific symptoms a given patient is experiencing (see through ), and then matching theseFigures 9-2 9-5 symptoms to hypothetically malfunctioning brain circuits regulated by specific neurotransmitters in order to rationally select and combine psychopharmacological treatments to eliminate all symptoms and get the patient to remission.

Overlapping symptoms of different anxiety disorders

Although there are different diagnostic criteria for different anxiety disorders ( though ),Figures 9-2 9-5 these are constantly changing, and many do not even consider obsessive-compulsive disorder to be an anxiety disorder any longer (OCD is discussed in on impulsivity). All anxiety disordersChapter 14 have overlapping symptoms of anxiety/fear coupled with worry ( ). Remarkable progressFigure 9-6 has been made in

Figure 9-6. . Anxiety can be deconstructed, or broken down, into the two coreAnxiety: the phenotype symptoms of fear and worry. These symptoms are present in all anxiety disorders, although what triggers them may differ from one disorder to the next.

understanding the circuitry underlying the core symptom of anxiety/fear based upon an explosion of neurobiological research on the amygdala ( through ). The links between theFigures 9-7 9-14 amygdala, fear circuits, and treatments for the symptom of anxiety/fear across the spectrum of anxiety disorders are discussed throughout the rest of this chapter.

Worry is the second core symptom shared across the spectrum of anxiety disorders ( ).Figure 9-7 This symptom is hypothetically linked to the functioning of cortico-striato-thalamo-cortical (CSTC) loops. The links between the CSTC circuits, "worry loops," and treatments for the symptom of worry across the spectrum of anxiety disorders are discussed later in this chapter (see also Figures 9-15 through , , and ). We shall see that what differentiates one anxiety disorder from9-17 9-26 9-29 another may not be the anatomical localization, or the neurotransmitters regulating fear and worry in each of these disorders ( and ), but the specific nature of malfunctioning within theseFigures 9-6 9-7 same circuits in various anxiety disorders. That is, in generalized anxiety disorder (GAD), malfunctioning in the amygdala and CSTC worry loops may be hypothetically persistent, and unremitting, yet not severe ( ), whereas malfunctioning may be theoretically intermittent butFigure 9-2 catastrophic in an unexpected manner for panic disorder ( ) or in an expected manner forFigure 9-3 social anxiety ( ). Circuit malfunctioning may be traumatic in origin and conditioned inFigure 9-4 posttraumatic stress disorder (PTSD: ).Figure 9-5