Anxiety Disorders

Diagnosis

The first symptoms of an anxiety disorder (see Table 2) usually occur relatively early in life and the course of the disorder is often chronic, with relapsing or recurrent episodes of illness and periods of disability.

Anxiety disorders are mental and physical manifestations of anxiety. The feelings of anxiety are not attributable to real danger and occur either in attacks or as a persisting state.

Table 2: Common Symptoms of Anxiety Disorders

Phobia: an unnatural, irrational fear of an item or situation, which the person with anxiety realises is not dangerous, but still takes measures to avoid
Egodystonic: thoughts, feelings or actions that are unusual or do not fit into normal behaviour (ego [self]; dystonic [alien])
Compulsion: an irresistible impulse, urge, desire to perform an irrational act, that relieves anxiety and is seen as egodystonic, eg washing hands repeatedly or counting steps taken
Obsession: an idea, emotion, thought or impulse that is repetitive and/or, unwelcome and provokes anxiety eg constant urge to wash hands or count objects; the person with anxiety may feel uneasy for having thought but not actually carried out the act
Panic: a sudden, overwhelming anxiety that produces terror and physiological and psychological changes
Agoraphobia: the fear of crowded spaces, public places or places where help cannot be reached, which causes a panic attack

Factsheet: Diagnosis of mental disorders

The symptoms and diagnosis of some specific anxiety disorders are discussed in more detail below.

Obsessive-Compulsive Disorder

People with obsessive-compulsive disorder (OCD) experience repeated unwanted thoughts or compulsive behaviours that seem impossible to stop or control. Examples of obsessive behaviour include checking (eg that the lights are all switched off) and cleaning (eg housework or self-care).

Social Phobia

People with social phobia experience a marked fear of being the focus of attention, or fear of behaving in a way that will be embarrassing or humiliating, and deliberately avoid situations where there is any perceived chance of this occurring. These fears are manifested in social situations, such as eating or speaking in public, or enduring small group situations.

The principal symptoms of social phobia are blushing, shaking, fear of vomiting and urgency or fear of bladder or bowel movements. Significant emotional distress is caused by the symptoms or by the avoidance, and people with social phobia recognise that their behaviour is excessive and unreasonable.

Specific Phobias

People with a specific phobia experience persistent, unreasonable fear of specific objects (eg animals such as snakes or spiders) or situations (eg flying, heights).

Post-Traumatic Stress Disorder

People who have experienced a traumatic event may suffer from recurring nightmares, flashbacks, numbing of emotions, depression, feelings of anger and/or irritability and loss of concentration. People who experience any of these symptoms may have post traumatic stress disorder (PTSD).

Generalised Anxiety Disorder

Although generalised anxiety disorder (GAD) is a common type of anxiety disorder, people with the disorder frequently do not recognise it as a treatable illness and so do not generally seek medical help. People with GAD feel anxious most of the time, worrying about normal daily issues, such as money, family problems and household chores, often for no apparent reason and always for no fault of their own. The anxiety and worry felt by people with GAD, and the physical symptoms they experience, causes much distress and can seriously affect people's work, family and social life.

GAD is defined, according to the DSM-IV criteria, by a period of anxiety or worry lasting 6 months or longer, accompanied by associated symptoms that cannot be attributed to other anxiety disorders, Including

feelings of tiredness and lack of energy
irritabilitytense muscles
difficulty in falling or staying asleep
other physical symptoms, such as trembling, twitching, headaches and sweating.

Panic Attacks

Often, people with GAD, social phobia, specific phobias, PTSD or major depressive disorder experience panic attacks. These attacks are not always indicative of a mental disorder and as many as 10% of otherwise healthy people experience an isolated panic attack each year. Panic attacks (and panic disorder) are associated with numerous symptoms, classified by the DSM-IV as including:

palpitations
sweating
trembling
shortness of breath
sensations of choking or smothering
chest pain
nausea
dizziness
tingling sensations
chills or blushing
'hot flushes'.

Panic attacks start suddenly. Feelings of anxiousness build up gradually and peak after approximately 30 minutes. Most people report a feeling of 'dying' or 'going crazy' at the height of a panic attack. These feelings do go away and panic attacks rarely last longer than 30 minutes.

People who have experienced at least two unexpected attacks and who have developed persistent concern or worry about having further attacks, may have panic disorder.

Rating Scales

There are many rating scales used to measure the severity of psychiatric disorders and the Hamilton Anxiety Rating (HAM-A) Scale is used most commonly for assessing symptom severity in people with anxiety disorders.

The HAM-A scale consists of 14 items and was introduced by Max Hamilton in 1959. The HAM-A scale measures the severity of symptoms such as anxiety, tension, depressed mood, palpitations, breathing difficulties, sleep disturbances, restlessness and other physical symptoms (see Table 3). This is a widely used scale and an accepted outcome measure in clinical trials.

Table 3: Item 6 of the HAM-A Rating Scale

Depressed mood

Unknown.

0 = Natural mood.

1 = When it is doubtful whether the patient is more despondent or sad than usual, eg the patient vaguely indicates being more depressed than usual.

2 = When the patient is clearly more concerned with unpleasant experiences, although he/she is still without helplessness or hopelessness.

3 = The patient shows clear non-verbal signs of depression and/or hopelessness.

4 = The patient remarks on despondency and helplessness or the patient cannot be distracted from non-verbal signs of depression that dominate the interview.

Factsheet: Rating Scales

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