Anxiety Disorders

What is an anxiety disorder?

Anxiety is one of the most common emotional states that humans express. Hence it is generally considered “normal”. Fear and anxiety often go hand in hand but fear is  a response to an imminent danger similar to one expressed by a man being approached by a bear . However anxiety occurs even when there is no obvious imminent danger. This seem to be a developmentally advanced form of  “fear” stemming out of a human beings ability to predict, symbolically represent or often misrepresent emotionally relevant stimuli. This could be based on past experience or learning for instance, a child brought up in an environment of family violence is likely to be more “sensitive” to perceived threat of violence from others.  However, a diagnosis of anxiety disorder is made only when your anxiety gets out of control and starts to affect multiple aspects of your life. Anxiety disorders are Australia and New Zealand’s most prevalent mental health issue. At some point in our lives, about 1 in 3 of us will have an anxiety disorder.

What causes anxiety

It’s normal and healthy to feel anxious sometimes. Anxiety actually helps us. It makes us alert and helps us do things well. For instance, you may want to perform well in the exams and have prepared well too, however, you can’t stop thinking about the possibility of messing up on the day. Hence the “reward” of getting a good result and the “punishment” of  a bad result co-occur at the same time in your mind. So most of us try to prepare well to ensure we get rewarded at the end, but if we feel it is too hard, we might as well think of the alternate possibility of punishment (bad result). Hence there is a delicate balance of “appraisal of the situation” which is yet to happen. Most rewarding things in life often come with significant risk of punishment otherwise called failure. The way we appraise such situations depends a lot on our “personality”. A perfectionist might underestimate their exam preparation and exaggerate their risk of failure. However actual results might prove otherwise. Over a period of time, they might become aware of this pattern and may be able to go through this anxiety. However, for some others, this might lead to avoidance. This can happen if someone has a poor self esteem coupled with a need for external validation or if one has a childhood which made them feel inferior or inadequate. Hence anxiety disorders originate from a erroneous appraisal of a situation but it becomes a disorder only when it becomes entrenched  patterns of behaviour causing dysfunction in more than one area of life. 

Signs and symptoms of anxiety disorders

People with an anxiety disorder have very strong feelings of worry or fear. They are disproportionately more anxious than most people would be in the same situation.They may go out of their way to avoid things, people, events or places.

Anxiety is a perfect example of the mind-body continuumSome people would recognise that they are anxious as they start shaking, their hear starts pounding or when they feel dry in their mouth or are unable to speak or breathe. Those who had severe panic attacks often go the emergency department thinking it is a heart attack or stroke. But in retrospect, most people are able to link it with their emotional state. Studies have shown that the anxiety states are liked to heart rate variability, respiratory changes and EEG (Electrical tracing of the brain)and EMG(tracing of the muscle) changes.

Who gets anxiety disorders?

Anxiety disorders most often start when people are teenagers. However, it can start as early as in their childhood.They are more common among women and girls. They are also more common in people who were neglected/abused as children, or who are neglected/abused as adults. A person doesn’t need to have suffered trauma to have anxiety. Some anxiety disorders can run in families .There is a 3-5 fold increased chance of someone developing an anxiety disorder if they have a close relative with Anxiety. 

For some individuals, a single event can trigger an episode of anxiety but for some, it can build up over time from various sources such as events at home, work, and in relationships until the worry and distress develop into an anxiety disorder.

How does brain produce Anxiety?

Our emotion is an evolutionary gift that nature has given us. Although other mammals are also able to express emotions, humans are different as they able to modify raw emotions by virtue of  a more developed brain(neocortex). This also comes with its pitfalls, our ability for abstraction and symbolic representation might also lead us to misrepresent our competence, conceal motivations or express emotions triggered by past experiences rather than based on current circumstances. 

Why does this happen to us but not other animals?. This is because broadly there are two brain centres for regulation of emotion, one  the Limbic system- the primitive seat of emotion and the frontal cortex , the more advanced and rational part of the brain which makes us humans. Our sensations, movements and emotions flow through nerves which are packed closely together connecting these centres.

From your own experience you might have noticed that some events or goals are more emotionally relevant to you than the others. Yet your responses may vary or even can be contradictory. Why would this happen?

Certain brain regions such as Amygdala, Anterior Cingulate cortex (parts of limbic system) together with the pre-frontal cortex (PFC) determine the significance (reward-punishment) of these stimuli. Whilst the left cortex might ask you to seek out the rewarding stimuli , the right cortex might activate avoidance. You may be able to relate it to a date night situation where you contemplate whether or not to approach a person you feel attracted to. If you have had prior negative social experiences, the seat of emotional memory-hippocampus would remember it. Hippocampus will then create a fear response by activating amygdala and pituitary adrenal axis. Moreover, this might also activate the adrenergic centres of the brain causing a flight or fight response. The subsequent neuro-chemical cascade would also reduce your attention span, your ability to think rationally and to act logically. As explained above, it can cause sensory and motor symptoms commonly known as “dissociation” as these centres are closely packed together. Once you had such a negative experience, your brain would remember it ,code it and store it mainly via hippocampus and process it later via the Pre-frontal cortex. When you think about another date night, this might trigger a fear response via the activation of  a centre called bed nucleus of stria terminals (BNST), which we call anticipatory anxiety. 

What is the role of chemicals in causing Anxiety?

Monoamine systems are implicated in the causation of depression as they seem to regulate a wide range of emotions. They are also intricately linked and counter-balance each other. 

Noradrenaline (NA)is involved in alertness and emotional memory. It is involved in the regulation stress related behavioural and physiological responses.Chronic adrenergic surge (chronic stress) can cause a state of learned helplessness. This can also lead to a state of low energy, attentional deficits and anhedonia. There is ample evidence from research suggesting dysfunction of NA in PTSD. There is increased NA activity both peripherally and centrally in those with PTSD or childhood sexual trauma and they are often hyper-sensitive to NA blockers such as Catapres.

Cortisol is considered to be the “stress hormone” which contributes to increased arousal, vigilance, focussed attention and memory formation. It can also inhibit the reproductive system and immune response.  The secretion of cortisol is regulated via the amygdala and hippocampus but through a feedback system it does modify the function of amygdala and hippocampus in addition to influencing the NA system. 

Dopamine mediates motivational responses. The dopamine in the medial prefrontal cortex is sensitive to stress and this sensitivity in part, genetically determined. The dopamine receptor gene called DRD2 may be involved in the pathogenesis of not only PTSD but also substance use and ADHD and Tourettes. As explained in other sections, many behavioural disorders are likely to have few underlying traits as explained by the inverted Iceberg hypothesis.

The Inverted Iceberg Hypothesis

This empirically construed  model tries to simplify the complexity of  an individuals emotional experience and their actions by focusing on their core traits rather than the number of  different and often changing psychiatric diagnosis. 

People with long history of psychological problems often get confused about the number of psychiatric diagnosis given to them over the years by various medical practitioners. It is not uncommon to be diagnosed with Autism spectrum disorder (ASD), Attention deficit hyperactivity disorder (ADHD)  or Tourette’s in childhood only to be re-diagnosed as Borderline, Anti-social, Anxiety disorder, eating disorder, substance use, adjustment disorder or with body image issues in adolescence and then to be diagnosed with depression, PTSD, bipolar, OCD or Panic disorder in adulthood. To me, this indicate a developmental trajectory rather than misdiagnosis. 

All of us seem to share the same traits but in varying shades. These are genetically determined entities called temperamental traits. It can be subdivided into impulsive and compulsive traits. This division is arbitrary as most people tend to have a combination of both. Nonetheless, those with predominant impulsivity tend to be energetic from the very beginning, they are physically active, pleasure driven, need immediate gratification and usually show low persistence or harm avoidance. Their attention span is generally low and they tend to react physically to stress. Classical pathological version of this is ADHD. Those with significant compulsivity on the other hand, are usually introverted, cautious, anxious and reassurance seeking. They tend to show high level of persistence and task completion, they usually  have attention to detail but often has a low self esteem. They prefer to be by themselves, are kind to others and take up altruistic pursuits. They can have rigid rules for themselves or others. Again, the classical pathological counterpart for this would be ASD. Those with Impulsive traits tend to have more panic attacks and those with compulsive trials tend to have more anticipatory anxiety. One common theme for social, agoraphobia and PTSD could be abnormal facial emotion recognition of others. Hence any ambiguous facial expression others could be potentially mis-represented as a “threat” that should be avoided.

Types of anxiety disorders

Generalised anxiety disorder

People with generalised anxiety disorder worry much of the time about all sorts of everyday things. They worry something terrible might happen, even if there’s no real reason to think so.They can’t stop feeling anxious, even though it’s affecting their life. Most people spend more time worrying about getting another anxiety attack than worrying about a true problem. People with generalised anxiety disorder don’t sleep well, and often complain of headaches and muscle tension.

Social anxiety disorder

Someone with social anxiety disorder worries about other people noticing their appearance, behaviour or their anxiety state and fear that they might embarrass themselves or may be ridiculed by others.

Panic disorder

Someone with a panic disorder has repeated panic attacks and then they worry a lot about having more panic attacks.

A panic attack is a sudden surge of fear or anxiety in situations where others would not be afraid. The panic symptoms are usually a combination of  psychological and physical symptoms.

Agoraphobia

Agoraphobia is when someone is very fearful about certain situations, because they’re afraid that they might have a panic attack, or something awful might happen to them. They then go out of their way to avoid these situations and often have a “zone of safety” beyond which they dread to go without a companion. 

Specific phobia

If someone is very fearful of one particular thing or situation, they might have a specific phobia. People can have phobias about things such as those for animals – for example spiders or dogs, flying in aeroplanes, fear of heights or fear of needles. The fear is usually out of proportion to the actual danger, and can cause problems with people’s day-to-day lives. 

PTSD

Post-traumatic stress disorder (PTSD) is a mental illness which comes after an event where a person is exposed to actual or threatened death, serious injury or sexual violence.The event could be something that People with PTSD have intrusive memories of the event. The memories affect their physical and mental health, relationships, work and daily activities. PTSD affects about 4% of adults in Australia and New Zealand. It is diagnosed more in women than in men. War veterans and emergency services workers generally have higher rates of PTSD.

OCD

Obsessive-compulsive disorder (OCD) is a mental illness with obsessions – unwanted thoughts about, for example, dirt and disease, terrible things happening, sex, violence, or religious themes and compulsions – overwhelming urges to do activities such as cleaning, checking, counting or praying. The obsessive thoughts can be quite overwhelming, while compulsions can take up hours of a person’s day.

What can psychiatrists do to help with your anxiety?

Psychiatrists at Mindoc are highly experienced in treating anxiety disorders. The first step in helping you with your anxiety would be a detailed evaluation to understand you as a person and your circumstances. We’ll try to identify the components of your anxiety and its predispositions, will aim to make an accurate diagnosis and prepare a management plan in collaboration with you. We are happy to work with your psychologist or your GP to ensure the best outcome for you.