ANXIETY DISORDER

  

According to DSM V, anxiety disorders include disorders that share features of excessive fear and anxiety and related behavioral substances. According to (Munir et al. 2019) anxiety disorders are the ones that crop up the most frequently, making them the most prevalent kind of mental illness in this world. Fear is the emotional response to a real or perceived imminent threat, whereas anxiety is the anticipation of future threats. Obviously, these two states overlap, but they also differ, with fear more often associated with surges of autonomic arousal necessary for fight or flight, thoughts, immediate danger, and escape behaviors, and anxiety more often associated with muscle tension and vigilance in preparation for future danger and cautions or avoidant behaviors. Panic attacks feature prominently within anxiety disorders as a particular type of fear response. Panic attacks are not limited to anxiety disorders but rather can be seen in other mental disorders as well. The picture below explains in a simple way differences between fear and anxiety. 

The majority of anxiety problems begin in childhood and, if untreated, are likely to continue throughout adulthood. The vast majority manifest themselves more commonly in females than in males (approximately 2:1 ratio). A diagnosis of an anxiety disorder can only be made if the symptoms cannot be attributed to the physiological effects of a substance or medicine. Anxiety, which can be seen as the pathological counterpart of normal fear, is characterized by mood disruptions, as well as changes in thinking, behavior, and physiological activity.

The anxiety disorders include separation anxiety disorder, selective mutism, specific phobias, social anxiety disorder (social phobia), panic disorder, agoraphobia, and generalized anxiety disorder (GAD). In addition, there are adjustment disorders with anxiety features and disorders due to general medical conditions and substance-induced anxiety disorders (Greenberg et al. 1999). Anxiety disorders differ from one another in the types of objects or situations that induce fear, anxiety, or avoidance behavior, and the associated cognitive ideation. Thus, while anxiety disorders tend to be highly comorbid with each other, they can be differentiated by close examination of the types of situations that are feared or avoided and the content of the associated thoughts or beliefs. The various kinds of anxiety disorders, along with an explanation of each, are outlined in the picture below. 

TREATMENT TECHNIQUE

As recommended in the S3 guideline on the treatment of anxiety disorders issued in May 2014 (Bandelow et al. 2014), psychotherapy and pharmacotherapy should both be offered, and the two are considered comparably effective. Decisions about treatment should be made in light of the severity of the disorder, the preference of the informed patient, the expected latency and durability of the treatment effect, the expected side effects, and the availability of the treatment in question. If one form of the treatment proves to be ineffective, the other (or a combination of both) should be tried. Only for the specific phobias is there very good evidence, and therefore a very strong recommendation, for psychotherapy alone; drugs are not indicated in the treatment of the specific phobias. For all types of anxiety disorder, cognitive behavioral therapy is the type of psychotherapy for which there is the strongest evidence and which receives the highest-level recommendation. For Pharmacotherapy, the drugs most commonly used are selective serotonin reuptake inhibitors (SSRI) and selective noradrenaline reuptake inhibitors (SNRI) (Ströhle, Gensichen & Domschke 2018). The table below shows the method of treatment and the side effects of each type of anxiety. 

No.	Anxiety Type	Method of Treatment (Pharmacotherapy)	Side Note	Method of Treatment (Psychotherapy)	Side Note
1	Agoraphobia	Tricyclic antidepressants (imipramine) – stop panic attacks, but are not effective in reducing anxiety in general Alprazolam (Xanax), a type of benzodiazepine - Fast reaction, effective. Side effects - addiction & psychological & physical dependence	- 60% panic attack free with effective drugs, - 20% - 50% experience relapse when tricyclic antidepressants are discontinued - 90% experience recurrence when benzodiazepines are discontinued	Focus - reduce the avoidance behavior of agoraphobia through exposure to the feared situation Relaxation Exercises & Breathing Techniques – 70% effective in reducing anxiety, panic, and avoidance behavior of agoraphobia. Panic Control Training – Exposure to feared physical sensations Cognitive Therapy – Identify & modify cognitive processes, attitudes & perceptions towards feared situations or places	-80-100% panic free after 12 weeks in treatment. -Follow-up study shows no relapse, improved after 2 years
2	General Anxiety Disorder (GAD)	Benzodiazepine – Reduces anxiety & muscle tension	-Lack of long-term effectiveness -Side effect: lack of cognitive & motor functionality -Physical & psychological dependence	Cognitive Behavioral Treatment Focus on the process of anxiety & anxious feelings -Confront images that raise anxiety and anxious thoughts -Learning techniques to prevent or control the anxiety process
3	Social Anxiety Disorder (Social Phobia)	Tricyclic Antidepressant & Monoamine Oxidase Inhibitors (MOIs) - Effective for treating severe social phobia	When drug intake is stopped, relapse occurs	Group psychotherapy   Role Play - Facing problematic social situations in groups -Therapists and group members give feedback.   Cognitive Therapy -Identify and modify negative perceptions about perceptions or expectations of danger in social situations	-Follow-up studies, after 5 years still show the effectiveness
4.	Specific Phobias	Drugs are not indicated in the specific phobias		Cognitive Therapy -Gradual, consistent, and structured exposure to feared objects or situations -If one’s are afraid of panic attacks, one’s can focus on panic attack treatment. - If a person has a phobia of blood, injections, or injury, he/she can be given gradual, consistent, and structured exposure, as well as muscle tension exercises to increase blood pressure
5.	Selective mutism	Antidepressant (Carlson et al 1999) showed that antidepressants were used most commonly to treat selective mutism. After antidepressants, anti-anxiety medications and other psychotropic interventions are also employed depending on the child's comorbidities   SSRIs -SSRIs (fluvoxamine and fluoxetine in particular), have yielded decreased selective mutism symptoms in selective case reports.   Combine Therapy Other case report studies suggest the enhanced effectiveness of combination treatments. For example, Wright et al. (1995) reported a positive response to treatment with fluoxetine in a combined treatment plan that also included family and behavioral therapy. The four-year-old female patient in the case report at the beginning of this article began talking in familiar surroundings after just five days of medication and continued to improve so that talking in all settings was observed by 20 days.	- In a trial by (Black and Uhde 1999) among six children with selective mutism, children actively administered fluoxetine over a period of 12 weeks showed improved ratings on mutism and anxiety although other symptoms remained unchanged. -In a separate case report written by (Black and Uhde 1995), a 12-year-old girl who had never spoken at school was treated successfully with fluoxetine. Although other approaches to treatment including psychotherapy, behavioral therapy, and desipramine failed to demonstrate efficacy for this individual, taking fluoxetine for one month resulted in this girl speaking freely with teachers and peers. Moreover, at seven months, other social communication and interactions were normal after the evaluation	Psychodynamic therapy Psychodynamic therapy in children is called individual play therapy (Krysanski V. L. 2003) This form of treatment is time-intensive and involves a comprehensive exploration of the individual case history. The focus is on exposing an underlying intrapsychic conflict   -Behavioral therapy Behavioral therapy is typically a multimethod approach that must account for symptoms in the broader context of the child's environment. Specific techniques including reinforcement, stimulus fading, token procedures, shaping or prompting, contingency management, self-modeling, and response initiation provide more empirical data-substantiating efficacy. - Treatment ideally begins with addressing the verbal and nonverbal negative reinforcement that sustains selective mutism behavior. For example, teachers who withdraw requests for children to speak exhibit one form of negative reinforcement that sustains behavior. - Self-modeling is one approach that involves viewing edited videotapes modeling appropriate behaviors. The child watches himself receive the desired reward (the mystery motivator) for speaking in an audible and clear tone in front of the class.   Family therapy -Family therapy is another treatment option that is especially relevant when family factors play a role in the potential development and perpetuation of selective mutism	- Since only a few case studies have been examined, the efficacy of this psychodynamic therapy is unknown.   - While the effectiveness of family therapy is unproven, incorporating the family in the therapeutic process can play a vital role in the child's recovery. Cooperation and understanding from parents and siblings help the child overcome anxiety and avoidance. Collaborating with school staff is another vital component of healing given that the diagnosis is usually made as children become school age. Education about selective mutism should be clearly communicated to teachers and guidance counselors, as teachers can play an invaluable role in breaking cycles of negative reinforcement
6.	Separation Anxiety Disorder	Benzodiazepines are an available treatment option in adults but are generally not appropriate for treating children.	-SSRIs are normally prescribed for at least six months past the initial response before being gradually discontinued. Pharmacological treatment is limited due to a paucity of FDA-approved medications for children younger than six years resulting in clinicians providing CBT alone   - Limited evidence exists regarding serotonin-norepinephrine reuptake inhibitors (SNRIs) or antidepressants such as tricyclic antidepressants, and they are therefore not prescribed.	Cognitive behavior therapy (CBT) -Cognitive behavior therapy utilizes both cognitive restructuring and exposure techniques to reduce anxiety and enable anxious individuals to cope more effectively with their anxiety.   - If CBT is not sufficient to reduce symptoms, combination therapy with second-line psychopharmacological intervention may be initiated (Level 1). Several RCTs showed that combined CBT and administration of an SSRI are the most effective in improving anxiety symptoms	- CBT is considered the first-line treatment of SAD, given its efficacy and very few adverse effects associated with treatment.   -Additionally, CBT often includes psychoeducation about the nature and treatment of anxiety and anxiety reduction techniques, including breathing retraining and progressive muscle relaxation. While several controlled studies have shown the efficacy of CBT for anxiety disorders in children and adolescents, the majority of these investigations have excluded youth under the age of seven (Ehrenreich, Santucci & Weiner. 2008).

7

Panic Disorder

-Counseling, -Psycho-education about anxiety and anxiety disorders, -Instructions for anxiety-confronting exercises in real-life situations -The use of self-help manuals

SSRI -Citalopram, Escitalopram, Paroxetine, Setraline SNRI Venlafaxine

Among patients with panic disorder, for example, relapse is seen in 15–50% within 6–12 months of the discontinuation of tricyclic antidepressants, SSRIs, or venlafaxine. It is therefore recommended that maintenance therapy with SSRI or SNRI be continued for at least 6–12 months after the end of the acute phase, at the effective final dose that was attained. Any attempt to discontinue medication should be gradual, e.g., over the course of 12 weeks if the duration of treatment until now has been 40 weeks (Perna et al. 2016)

Everyone gets anxious at times, but how can you tell when it crosses the line and needs attention? 😓

Learn more by watching the video here: 

                                                           ANXIETY DISORDER VIDEO

Prepared by/Editor: Nurul Izzati Bt Azhar 

Position: Internship Student from UKM 

REFERENCES 

Bandelow, B., Wiltink, J., Alpers, G. W., Benecke, C., Deckert, J., Eckhardt-Henn, A., & Beutel, M. E. 2014. Deutsche S3-Leitlinie Behandlung von Angststörungen.

Black, B., & Uhde, T. W. 1995. Psychiatric characteristics of children with selective mutism: a pilot study. Journal of the American Academy of Child and Adolescent Psychiatry, 34(7):847–856.

Ehrenreich, J. T., Santucci, L. C., & Weiner, C. L. 2008. SEPARATION ANXIETY DISORDER IN YOUTH: PHENOMENOLOGY, ASSESSMENT, AND TREATMENT. Psicologia conductual 16(3): 389–412.

Greenberg, P. E., Sisitsky, T., Kessler, R. C., Finkelstein, S. N., Berndt, E. R., Davidson, J. R., Ballenger, J. C., & Fyer, A. J. 1999. The economic burden of anxiety disorders in the 1990s. The Journal of clinical psychiatry 60(7): 427–435.

Krysanski V. L. 2003. A brief review of selective mutism literature. The Journal of psychology 137(1): 29–40.

Munir, S., Gondal, A.Z., & Takov, V., 2019. Generalized anxiety disorder. https://www.ncbi.nlm.nih.gov/books/NBK441870/ [ 14 September 2022].

Perna, G., Alciati, A., Riva, A., Micieli, W., & Caldirola, D. (2016). Long-Term Pharmacological Treatments of Anxiety Disorders: An Updated Systematic Review. Current psychiatry reports 18(3): 23.

Ströhle, A., Gensichen, J., & Domschke, K. 2018. The Diagnosis and Treatment of Anxiety Disorders. Deutsches Arzteblatt international 155(37): 611–620.

Wright, H. H., Cuccaro, M. L., Leonhardt, T. V., Kendall, D. F., & Anderson, J. H. 1995. Case study: fluoxetine in the multimodal treatment of a preschool child with selective mutism. Journal of the American Academy of Child and Adolescent Psychiatry 34(7): 857–862.