Overview of Anxiety Disorders

The COVID-19 pandemic was associated with surges in rates of depression and anxiety in people who had not been infected (2 Etiology references Anxiety disorders are characterized by persistent and excessive fear and anxiety and the dysfunctional behavioral changes a patient may use to mitigate these feelings. Anxiety disorders are... read more ). Such psychological reactions may have been exacerbations of underlying issues, but the symptoms are often intensified by media exposure, economic hardship, uncertainty regarding the future, fears of infection (for themselves and loved ones), loss of familiar supports (eg, friends, employment), and behavioral restrictions (eg, masks, social distancing).

Symptomatic COVID-19 infection is also associated with increased anxiety (3 Etiology references Anxiety disorders are characterized by persistent and excessive fear and anxiety and the dysfunctional behavioral changes a patient may use to mitigate these feelings. Anxiety disorders are... read more ). The triggers for this increased anxiety can be physiologic (eg, shortness of breath); psychological (eg, immediate fears of death); social (eg, isolation from loved ones); and pharmacologic (eg, corticosteroids are often used in treatment of COVID-19). In addition, it has been hypothesized that COVID-19 induces a host immune response that directly leads to neuropsychiatric symptoms (eg, anxiety, mood changes, neuromuscular dysfunction); these neuropsychiatric reactions may be acute or part of a syndrome known as long COVID. (See also COVID-Related Neuropsychiatric Manifestations COVID-Related Neuropsychiatric Manifestations COVID-19 is primarily an acute respiratory syndrome, but it can also cause dysfunction of multiple organs and body systems, including the brain and peripheral nervous system. COVID-19 can be... read more .)

Culture influences the expression, conceptualization, and treatment of all psychiatric conditions, including anxiety disorders (3, 4 Diagnosis references Anxiety disorders are characterized by persistent and excessive fear and anxiety and the dysfunctional behavioral changes a patient may use to mitigate these feelings. Anxiety disorders are... read more ). During the psychiatric assessment, it is important to look for ways in which the anxiety symptoms might be affected by the surrounding political, economic, and legal systems, as well as by specific issues related to migrant status, sexual orientation, socioeconomic status, religion, spirituality, and family structures.

Patients may feel intimidated, embarrassed, or reluctant to discuss anxiety with anyone, much less physicians, who may appear to belong to a different and potentially more privileged socioeconomic group. Similarly, people who want to be "good patients" might not be upfront about psychiatric issues if they suspect that their clinicians are too busy to address anything other than their most prominent nonpsychiatric medical issue.

It is useful for the clinician to consider that different individuals or groups use different words to describe distress. For example, people in many countries use the phrase "thinking too much" rather than describing symptoms that match specific psychiatric criteria for disorders such as major depression Depressive Disorders Depressive disorders are characterized by sadness severe enough or persistent enough to interfere with function and often by decreased interest or pleasure in activities. Exact cause is unknown... read more , posttraumatic stress disorder (PTSD) Posttraumatic Stress Disorder (PTSD) Posttraumatic stress disorder (PTSD) is a disabling disorder that develops after exposure to a traumatic event. It is characterized by intrusive thoughts, nightmares, and flashbacks; avoidance... read more , or generalized anxiety disorder Generalized Anxiety Disorder Generalized anxiety disorder is characterized by excessive anxiety and worry about a number of activities or events that are present more days than not for ≥ 6 months. The cause is unknown,... read more (5 Diagnosis references Anxiety disorders are characterized by persistent and excessive fear and anxiety and the dysfunctional behavioral changes a patient may use to mitigate these feelings. Anxiety disorders are... read more ).

It can also be useful to ask patients what they think is causing their problems. Not all patients believe completely in the medical model, and, if tactfully asked, many patients might reluctantly mention that they (or their relatives) believe their symptoms were induced by a religious or other mystical source (eg, an "evil eye").

Eliciting such information improves the patient-clinician alliance, deepens the understanding of both the patient and the presenting complaints, and improves the likelihood that the patient will be more transparent and adherent going forward.

Psychoeducation is typically fundamental to the treatment of anxiety disorders. It can feel liberating for the patient to understand how a sometimes bewildering array of symptoms and behaviors can be conceptualized into a diagnosis. Education also provides a cognitive structure to help patients pursue a treatment that may feel uncomfortable.

Relaxation techniques should be taught early in the treatment. These techniques are useful both because fear and anxiety are fundamental to anxiety disorders and because the treatment can transiently intensify the disabling thoughts and feelings. Without a tool for controlling anxiety, many patients will not adhere to treatment. Relaxation techniques may include muscle relaxation, breathing management, yoga, hypnosis, and/or meditation, but patient preference is important in determining the specific approach. Relaxation techniques can be briefly described and then "prescribed" as homework. Adherence and effectiveness are more likely to be optimized if the clinician periodically demonstrates the techniques (eg, slow, steady breathing) with enthusiasm.

Various psychotherapies are equally efficacious for most psychiatric disorders. This equivalency appears to be related to so-called nonspecific factors, which include the personal characteristics of the therapist and a positive therapeutic climate that allows the patient to effectively engage in the talk therapy and remain adherent with agreed-upon practices and medications.

Cognitive-behavioral therapy (CBT) has the most robust evidence as a psychosocial treatment for anxiety disorders (4 Treatment references Anxiety disorders are characterized by persistent and excessive fear and anxiety and the dysfunctional behavioral changes a patient may use to mitigate these feelings. Anxiety disorders are... read more ). Psychoeducation and relaxation techniques Psychoeducation and relaxation techniques Anxiety disorders are characterized by persistent and excessive fear and anxiety and the dysfunctional behavioral changes a patient may use to mitigate these feelings. Anxiety disorders are... read more should be introduced early in CBT.

CBT involves both cognitive restructuring and exposure therapy. Cognitive restructuring begins with the idea that patients with anxiety disorders overestimate the danger (catastrophize) and underestimate their ability to deal with the danger. These inaccurate thoughts and antecedent triggers are clarified during treatment. Often, the pattern of anxiety can be neatly laid into a characteristic cycle of triggers, behaviors, and anxiety. As this cycle is clarified, patients are taught to recognize and confront their inaccurate thoughts (ie, cognitive restructuring).

CBT also focuses on the behavioral elements of the anxiety disorder. Typically, patients with anxiety disorders respond to perceived danger with a "fight-or-flight" response. Some patients with prominent anxiety are able to "fight" their anxiety, often with a counter-phobic response (eg, an actor with prominent social anxiety), but most respond with avoidance. Exposure therapy aims to identify the avoidance behavior and then present the patient with gradually intensifying opportunities to be safely exposed to the fearful trigger, gradually desensitizing the patient.

Other psychotherapies used for treatment of anxiety disorders combine aspects of CBT, relaxation, and mindfulness along with other strategies that appear to be helpful. These treatments include mindfulness-based stress reduction, hypnosis, panic-focused psychodynamic psychotherapy, interpersonal therapy, and supportive psychotherapy:

Pharmacotherapy is typically helpful in the management of anxiety disorders, especially when used in conjunction with any of the above psychotherapeutic techniques. Antidepressants and benzodiazepines are the 2 medication classes with the strongest evidence base, though there is also a role for nonbenzodiazepine anxiolytics (such as buspirone) and atypical antipsychotics (9 Treatment references Anxiety disorders are characterized by persistent and excessive fear and anxiety and the dysfunctional behavioral changes a patient may use to mitigate these feelings. Anxiety disorders are... read more ).

Selective serotonin reuptake inhibitors Selective Serotonin Reuptake Inhibitors (SSRIs) Several drug classes and drugs can be used to treat depression: Selective serotonin reuptake inhibitors (SSRIs) Serotonin modulators (5-HT2 blockers) Serotonin-norepinephrine reuptake inhibitors... read more (SSRIs) are generally considered first-line based on their efficacy and safety profiles. These "antidepressant" medications address the symptoms of the anxiety disorders regardless of whether there is a comorbid depressive disorder.

SSRI antidepressants are generally started at the lowest available dose to minimize adverse effects. Patients with anxiety may be sensitive to bodily changes and may discontinue treatment if they experience adverse effects early on. Once the patient has tolerated the initial dose, the antidepressant can be gradually increased until a therapeutic dose or therapeutic effect is reached. A positive clinical effect may occur at any time but often takes 6 or more weeks to achieve.

Serotonin-norepinephrine reuptake inhibitors Serotonin-Norepinephrine Reuptake Inhibitors Several drug classes and drugs can be used to treat depression: Selective serotonin reuptake inhibitors (SSRIs) Serotonin modulators (5-HT2 blockers) Serotonin-norepinephrine reuptake inhibitors... read more (SNRIs) , particularly duloxetine and venlafaxine, have also demonstrated safety and efficacy for the treatment of anxiety disorders.

Benzodiazepines may be used for acute relief of anxiety but can create dependence Sedatives Sedatives include benzodiazepines, barbiturates, and related drugs. High doses can cause decreased level of consciousness and respiratory depression, which may require intubation and mechanical... read more and a desire for increasing levels that limit their benefit/risk ratio for chronic use (10 Treatment references Anxiety disorders are characterized by persistent and excessive fear and anxiety and the dysfunctional behavioral changes a patient may use to mitigate these feelings. Anxiety disorders are... read more ). They are often used in conjunction with an antidepressant and psychotherapy. The benzodiazepine can often be tapered once the anxiety symptoms have improved.

When present, comorbid substance use disorders and other psychiatric conditions must also be appropriately managed.

Comorbid substance use disorders Substance Use Disorders Substance use disorders involve a pathologic pattern of behaviors in which patients continue to use a substance despite experiencing significant problems related to its use. Diagnosis of substance... read more are often not spontaneously reported (11 Treatment references Anxiety disorders are characterized by persistent and excessive fear and anxiety and the dysfunctional behavioral changes a patient may use to mitigate these feelings. Anxiety disorders are... read more ). Substances such as alcohol, marijuana, and benzodiazepines are often used to self-medicate by those with anxiety disorders. Patients may be reluctant to give up these substances until they trust that the clinician has a viable alternative treatment. Self-medication often leads to a vicious cycle. For example, the alcohol use that quickly reduces anxiety may be followed by rebound anxiety, followed by an increased urgency to self-medicate.

Comorbid bipolar disorder Bipolar Disorders Bipolar disorders are characterized by episodes of mania and depression, which may alternate, although many patients have a predominance of one or the other. Exact cause is unknown, but heredity... read more can cause specific management difficulties. Many people with bipolar disorder are initially misdiagnosed, particularly because they often have far more periods of depression than mania. Treatment with an antidepressant medication may be an appropriate first-line treatment for an anxiety disorder with comorbid major depression Depressive Disorders Depressive disorders are characterized by sadness severe enough or persistent enough to interfere with function and often by decreased interest or pleasure in activities. Exact cause is unknown... read more . However, for an individual with both anxiety and a bipolar disorder, that same medication choice can trigger a manic episode consisting of intensified anxiety and irritability. A missed bipolar disorder can result in decades of inappropriate treatments.

Comorbid medical disorders can also be challenging to manage. For example, asthma can physiologically cause anxiety, but so can some of the medications used to treat asthma. Anxiety can contribute to an asthma exacerbation, and fears of an asthma exacerbation can lead to avoidance behaviors (eg, diminished activity, medication nonadherence) that in turn can exacerbate asthma and lead to a diminished quality of life.