Anxiety & Stress Disorders

Anxiety disorders are some of the most common mental health problems that confront clinicians, either as a primary diagnosis or as comorbid conditions.

In part 1 of this column, I reviewed research findings of the most substantiated nonpharmacological and integrative treatments for anxiety, such as kava-kava, L-theanine, applied relaxation, yoga, meditation and mindfulness training, virtual reality graded exposure therapy, and biofeedback training.

A recent longitudinal study examined the potential relationship between social anxiety disorder during adolescence and young adulthood and the subsequent development of depression.1

Patients with chronic pain and head injury frequently have comorbid anxiety and depressive disorders, with depressive disorders appearing to be more predominant. A number of studies show that depressive spectrum illness develops in 40% to 80% of patients with chronic pain; in a majority of these cases, the mood disorder is caused by chronic pain.

Comorbidity of psychiatric syndromes is quite common-in a 12-month period, almost 50% of adults in the United States with any psychiatric disorder had 2 or more disorders.

Almost one third of US mental health care costs (approximately $50 billion) go toward the treatment of anxiety disorders. Conventional pharmacological treatments for anxiety are often beneficial but have limited efficacy.

Department of Defense (DOD) medical centers, community hospitals, and clinics throughout the United States were tasked with hiring 44 "contract" psychiatrists over the summer as a response to growing concerns about inadequate mental health care for soldiers in Iraq and Afghanistan and those returning home.

The comorbidity of anxiety disorders with bipolar disorder is a rule, not an exception, with a negative impact on both course and treatment outcome. So far, there are no guidelines or consensus for the treatment of this comorbidity.

A new set of guidelines confirms the value of psychotherapy, medications-including SSRIs-and combinations of therapy in managing anxiety disorders in children.

In this article, we examine the relationship between anxiety disorders and SDs, using DSM-IV-TR categories, although we are conscious of the limits of this approach. In doing so, we will consider not only the dichotomy between normal and pathological functioning but also the issue of sexual satisfaction as part of wellness.

Up Against the Wall

It is not uncommon for combat veterans to exhibit a wide range of psychological conditions, from schizophrenia to depression to posttraumatic stress disorder (PTSD), but how do these disorders affect domestic partners, who often serve as veterans' caregivers?

Worsening anxiety is a common symptom that may result in psychiatric consultation or evaluation in an emergency setting. Aneurysms are rarely considered in the medical differential for anxiety disorders, and the available literature and research regarding this possible connection are very limited. Overlooking this diagnosis, however, can have disastrous consequences. Here we present 2 case reports as well as a review of the literature regarding a possible relationship between aortic and thoracic aneurysms and psychiatric symptoms.

Treatment interventions via telephone, Internet, and through other telemedical services are gaining popularity, especially in rural areas where licensed clinicians might not be available. Dr Per Carlbring and colleagues recently evaluated a 10-week, Internet-based, self-help program with weekly telephone calls for patients who had panic disorder with or without agoraphobia. The results were published in the December 2006 issue of the American Journal of Psychiatry.

Panic disorder occurs in about 1 in 5 individuals who have bipolar disorder. Anxiety amplifies the distress caused by depression and mania, but pharmacological approaches are tricky and under-studied. Frequent comorbidity and evidence of a possible genetic relationship of bipolar and panic disorders are suggestive of a causal relationship between the 2. Thus, it may be fruitful to look more closely at evidence for common biological abnormalities in both disorders to find a pathophysiological mechanism that links mania, depression, and panic attacks. Mood episodes and panic attacks can both be modeled as the result of deficits in amygdala-mediated emotional conditioning. From this model, some insight may be gained for potentially helpful treatment strategies for the 2 disorders when they occur together.

Anxiety is a ubiquitous, natural affective state that is essential for evolutionary survival. Nearly as common, however, are experiences of anxiety that exceed social, psychological, or physiological needs, leading to functional impairment. Indeed, primary anxiety disorders, including panic disorder, social phobia, and generalized anxiety disorder (GAD), represent the most common category of mental illness in the United States. Secondary, or reactive, anxiety is also widespread and can arise not only from numerous medical causes but also from the psychological process of coping with illness.

Generalized anxiety disorder (GAD) is characterized by excessive or unrealistic anxiety and worries about life circumstances. In the general population, the prevalence of GAD is 2% to 5%. It is the most frequent anxiety disorder seen in primary care, where 22% of patients complain of anxiety problems.1 DSM-IV lists 6 somatic symptoms associated with GAD: restlessness, increased fatigability, difficulty in concentrating, irritability, muscle tension, and sleep disturbance. These symptoms may present with hyperarousal, hypervigilance, and heightened muscle tension; autonomic symptoms are milder than in other anxiety disorders and can be absent.

Persons who have anxiety disorders commonly self-medicate with alcohol and other drugs, a recent survey confirmed. The results were published in the November 2006 issue of The Journal of Nervous and Mental Disease.

Anxiety disorders are the most prevalent psychiatric disorders in the United States. Although effective treatments are available, such as the SSRIs and cognitive-behavioral therapy (CBT), it is estimated that in about 40% of patients, anxiety disorders are partially or completely resistant to first-line treatment.

While social anxiety disorder (SAD) may cause observable signs of anxiety and social awkwardness in some, many others suffer silently. Cognitive-behavioral therapy can be helpful for most patients with SAD, with alternative therapies such as psychodynamic therapy and interpersonal therapy filling the gaps.

Mental health screening and treatment plans for soldiers deployed to Iraq and Afghanistan are being scrutinized after criticisms of the program have appeared in print and Web publications.

Cognitive-behavioral therapy (CBT) for children with anxiety disorders may be especially effective when the family is included in treatment.

Should physicians be allowed to assist in their patients' dying, and how can physician-assisted suicide be reconciled with the physician’s role as a healer?

The focus of this Special Report on anxiety disorders is not accidental. Anxiety disorders are, probably next to substance abuse, the most common mental disorders in the general population, and definitely the most common mental disorders among children and adolescents.

Generalized anxiety disorder (GAD) is a chronic, impairing and highly comorbid psychiatric condition. A small but sufficient group of empirically supported instruments to assess the severity of GAD are now available.

Anxiety disorders are the most common mental conditions in the general population, including in children and adolescents. Young people can present with a pattern of anxiety symptoms somewhat different from that typically seen in adults. One of the most common aspects of this difference is that children (especially younger ones) may not report overt worries or fears, but instead manifest pronounced physical symptoms.

Panic disorder is a common psychiatric illness that can have a chronic, relapsing course. The question of whether pregnancy represents a time of increased risk for recurrence of panic symptoms has been a matter of debate.

Despite high prevalence and negative consequences of anxiety disorders in later life, this area has received little research attention. A relatively small number of outcome investigations on late-life anxiety have focused on the impact of pharmacological and psychotherapeutic treatments.

Insights Into Depression & Anxiety: Living With an Ambiguity in Clinical Practice: Antidepressant Drug-Drug Interactions

Insights Into Depression and Anxiety: Overview of the Anxiety Disorders