Anxiety disorders - Causes and Management
Anxiety disorders affect one-eighth of the total population worldwide, and have become a very important area of research interest in psychopharmacology. People with anxiety disorders can benefit from psychological treatments, pharmacotherapy or a combination of the two. Common limitations of conventional antianxiety therapy include co-morbid psychiatric disorders and increase in dose of drugs leading to intolerable side effects. These limitations have prompted the use of traditional and alternative systems of medicine. This paper reviews the causes, and the effective and safe therapy for anxiety disorders.
The environment we are living in is physically, mentally, emotionally, socially and morally dynamic and challenging. We possess effective mechanisms to meet every day stress. Sometimes, normal adaptive mechanisms can be over-activated and, thus, become maladaptive. A common outcome of such over-activation is anxiety and insomnia (Spinella, 2001).
Anxiety is a subjective feeling of unease, discomfort, apprehension or fearful concern accompanied by a host of autonomic and somatic manifestations. Anxiety is a normal, emotional, reasonable and expected response to real or potential danger. However, if the symptoms of anxiety are prolonged, irrational, disproportionate and/or severe; occur in the absence of stressful events or stimuli; or interfere with everyday activities, then, these are called Anxiety Disorders (DSM IV-TR, 2000).
Anxiety disorders are among the most common mental, emotional, and behavioral problems (Kessler et al., 2005a, 2005b; Olatunji et al., 2007; Kessler & Wang, 2008). These affect one-eighth of the total population worldwide, and have become a very important area of research interest in psychopharmacology (Eisenberg et al., 1998; Dopheide & Park, 2002; WHO, 2004).
In addition to the high prevalence, anxiety disorders account for major expenditure for their management (DuPont et al., 1996); and anxiety disorders have a substantial negative impact on quality of life (Gladis et al., 1999; Mendlowicz & Stein, 2000; Olatunji et al., 2007).
Etiology
Anxiety disorders are among the most frequent mental disorders encountered in clinical practice (Kirkwood & Melton, 2002). These represent a heterogenous group of disorders, probably with no single unifying etiology. Various psychodynamic, psychoanalytic, behavioral, cognitive, genetic and biological theories have been proposed to explain the etiology and pathophysiology of anxiety disorders (Cates et al., 1996). These are said to be BioPsychoSocial factors that contribute to anxiety disorders (Pies, 1994; White, 2005; Wong, 2006). Table 1 shows the bifurcation of the factors.
Genetic factors
Genetic factors predispose certain people to anxiety disorders. There is a higher chance of an anxiety disorder in the parents, children and siblings of a person with an anxiety disorder than in the relatives of someone without an anxiety disorder (Torgersen, 1983; Weissman, 1993; Goldman, 2001).
Neurotransmitter imbalance
Brain imaging and functional studies have shown that several neurotransmitters are linked to the neurobiology of anxiety (Cates et al., 1996; Sandford et al., 2000; Millan, 2003; Augustin, 2005). The diagrammatic representation of this has been shown in Figure 2.
Psychological factors
Anxiety can result when a combination of increased internal and external stresses overwhelm one’s normal coping abilities or when one’s ability to cope normally is lessened for some reason. The psychological factors are summarized below:
Social factors
Life experiences like death in the family, divorce, job loss, financial loss, accident or major illness affect a person’s attitude and response to life situations. Long term exposure to abuse, violence, terrorism and poverty may affect an individual’s susceptibility to anxiety disorders (Eysenck, 2004).
Occurrence and Epidemiology
About 500 million people, world wide, suffer from mental and behavioral disorders (Barbotte et al., 2001). Five of the ten leading causes of disability and premature death worldwide are psychiatric conditions. Mental disorders represent not only an immense psychological, social and economic burden to society, but also increase the risk of physical illnesses. Neuropsychiatric conditions account for 13% of the total Disability Adjusted Life Years (DALYs) lost due to all diseases and injuries in the world and are estimated to increase to 15% by the year 2020 (WHO, 2004).
Anxiety disorders, like depression, are among the most prevalent psychiatric disorders. They comprise a wide range of different disorders. Most anxiety disorders first appear during childhood and adolescence. Evidence shows that a high proportion of children do not grow out of their anxiety disorders during adolescence and adulthood (Majcher & Pollack, 1996; Murray & Lopez, 1996). Different surveys suggest that anxiety affects one-eighth of the total population of the world. The lifetime overall prevalence rate for anxiety disorders is 24.9%. This data suggests anxiety disorders are more chronic than affective or substance abuse disorders (Cates et al., 1996). Prevalence of anxiety disorders is difficult to pinpoint since even small changes in diagnostic criteria, interview tools, or study methodology affect results. World wide prevalence of different types of anxiety disorders varies (Cates et al., 1996).
Management of Anxiety
Anxiety disorders are the most prevalent of psychiatric disorders, yet less than 30% of individuals who suffer from anxiety disorders seek treatment (Lepine, 2002). People with anxiety disorders can benefit from a variety of treatments and services. Following an accurate diagnosis, possible treatments include (Barlow, 2001; NIMH, 2006) psychological treatments and mediation.
Behavioral therapies: These focus on using techniques such as guided imagery, relaxation training, biofeedback (to control stress and muscle tension); progressive desensitization, flooding as means to reduce anxiety responses or eliminate specific phobias. The person is gradually exposed to the object or situation that is feared. At first, the exposure may be only through pictures or audiotapes. Later, if possible, the person actually confronts the feared object or situation. Often the therapist will accompany him or her to provide support and guidance.
Cognitive-behavioral therapy (CBT): In this therapy, people learn to deal with fears by modifying the ways they think and behave. A major aim of CBT and behavioral therapy is to reduce anxiety by eliminating beliefs or behaviors that help to maintain the anxiety disorder. Research has shown that CBT is effective for several anxiety disorders, particularly panic disorder and social phobia (Herbert et al., 2009). It has two components. The cognitive component helps people change thinking patterns that keep them from overcoming their fears. The behavioral component of CBT seeks to change people's reactions to anxiety-provoking situations. A key element of this component is exposure, in which people confront the things they fear, i.e., CBT addresses underlying “automatic” thoughts and feelings that result from fear, as well as specific techniques to reduce or replace maladaptive behavior patterns.
Psychotherapy: Psychotherapy centers on resolution of conflicts and stresses, as well as the developmental aspects of anxiety disorders solely through talk therapy. Psychotherapy involves talking with a trained mental health professional, such as a psychiatrist, psychologist, social worker, or counselor to learn how to deal with problems like anxiety disorders (Knekt et al., 2008).
Psychodynamic therapy: This therapy, first suggested by Freud, is based on the premise that primary sources of abnormal behavior are unresolved past conflicts and the possibility that unacceptable unconscious impulses will enter consciousness.
Family therapy and parent training: Here the focus is on the family and its dynamics. This is based on the assumption that the individuals of a family cannot improve without understanding the conflicts that are to be found in the interactions of the family members. Thus, each member is expected to contribute to the resolution of the problem being addressed (American Psychological Association, 2004; Feldman, 2004).
There are different types of CAMs that are used for the management of anxiety (Kessler et al., 2001; Moquin et al., 2009; NIH, 2009). The most common therapies included relaxation techniques, herbal medicines, massage, chiropractic, spiritual healing by others, and nutritional supplements (Figure 3). In particular, the use of herbal remedies and nutritional supplements rose 380% and 130%, respectively, between 1990 and 1997. These are shown in table 7.
Common limitations of antianxiety drug therapy include co-morbid psychiatric disorders (Regier et al., 1998) and increase in dose leading to intolerable side effects (Cates et al., 1996). These limitations have prompted scientists to investigate plants which are commonly employed in traditional and alternative systems of medicine for sleep disorders and related diseases with a view to find safer drugs (Spinella, 2001; Chung et al., 2005; Kumar, 2006).
American Psychological Association (2004). Anxiety Disorders: The Role of Psychotherapy in Effective Treatment. Retrieved from http://www.apahelpcenter. org/articles/article.php
Augustin, S. G. (2005). Anxiety disorders. In M. A. Koda-Kimble, L. Y. Young, W.
A. Kradian (Eds.), Applied Therapeutics: The Clinical Use of Drugs (8th ed., pp. 76-1 – 76-47). Philadelphia, PA: Lippincott Williams and Wilkins.
Baldessarini, R. J. (2001). Drugs and the treatment of psychiatric disorders. In J. G.
Hardman & L. E. Limbird (Eds.), Goodman and Gilman’s The Pharmacological
Basis of Therapeutics (10th ed., pp. 447-483). New York, NY: McGraw-Hill.
Barbotte, E., Guillemin, F., Chan, N., & Group, L. (2001). Prevalence of impairments, disabilities, handicaps and quality of life in the general population: a review of recent literature. The International Journal of Public Health (Bulletin of World Health Organization), 79, 1047-1055.
Barlow, D. H. (2001). Clinical handbook of psychological disorders (3rd ed.). New York, NY: Guilford.
Bhattacharyya, D., Sur, T. K., Jana, U., & Debnath, P. K. (2008). Controlled programmed trial of Ocimum sanctum leaf on generalized anxiety disorders. Nepal Medical College Journal, 10(3), 176-179.
Brannon, L., Feist, J. (2004). Health psychology: An introduction to behavior and health (5th ed.). Belmont, CA: Wadsworth.
Carlini, E. A. (2003). Plants and the central nervous system. Pharmacology, Biochemistry and Behavior, 75, 501-512.
Cates, M., Wells, B. G., & Thatcher, G. W. (1996). Anxiety Disorders. In E. T.
Herfindal and D. R. Gourley (Eds.). Textbook of Therapeutics: Drug and Disease Management (6th ed., pp. 1073-1093). Hagerstown, MD: Lippincott Williams and Wilkins.
Cauffield, J. S. (2000). The Psychosocial Aspects of Complementary and Alternative Medicine. Pharmacotherapy, 20(11), 1289-1294.
Keywords: anxiety disorders, psychological treatments, pharmacotherapy,alternative therapy.
Anxiety disorders affect one-eighth of the total population worldwide, and have become a very important area of research interest in psychopharmacology. People with anxiety disorders can benefit from psychological treatments, pharmacotherapy or a combination of the two. Common limitations of conventional antianxiety therapy include co-morbid psychiatric disorders and increase in dose of drugs leading to intolerable side effects. These limitations have prompted the use of traditional and alternative systems of medicine. This paper reviews the causes, and the effective and safe therapy for anxiety disorders.
Anxiety disorders
The environment we are living in is physically, mentally, emotionally, socially and morally dynamic and challenging. We possess effective mechanisms to meet every day stress. Sometimes, normal adaptive mechanisms can be over-activated and, thus, become maladaptive. A common outcome of such over-activation is anxiety and insomnia (Spinella, 2001).
Anxiety is a subjective feeling of unease, discomfort, apprehension or fearful concern accompanied by a host of autonomic and somatic manifestations. Anxiety is a normal, emotional, reasonable and expected response to real or potential danger. However, if the symptoms of anxiety are prolonged, irrational, disproportionate and/or severe; occur in the absence of stressful events or stimuli; or interfere with everyday activities, then, these are called Anxiety Disorders (DSM IV-TR, 2000).
Anxiety disorders are among the most common mental, emotional, and behavioral problems (Kessler et al., 2005a, 2005b; Olatunji et al., 2007; Kessler & Wang, 2008). These affect one-eighth of the total population worldwide, and have become a very important area of research interest in psychopharmacology (Eisenberg et al., 1998; Dopheide & Park, 2002; WHO, 2004).
In addition to the high prevalence, anxiety disorders account for major expenditure for their management (DuPont et al., 1996); and anxiety disorders have a substantial negative impact on quality of life (Gladis et al., 1999; Mendlowicz & Stein, 2000; Olatunji et al., 2007).
Symptoms of Anxiety Disorders
The subjective experience of anxiety typically has two components namely physical component and emotional component which affect the cognitive processes of the individual (Cates et al., 1996; Charles and Shelton, 2004; Augustin, 2005; Shri, 2006; Rang et al., 2007) and these have been shown in Figure 1.Anxiety disorders
Etiology
Anxiety disorders are among the most frequent mental disorders encountered in clinical practice (Kirkwood & Melton, 2002). These represent a heterogenous group of disorders, probably with no single unifying etiology. Various psychodynamic, psychoanalytic, behavioral, cognitive, genetic and biological theories have been proposed to explain the etiology and pathophysiology of anxiety disorders (Cates et al., 1996). These are said to be BioPsychoSocial factors that contribute to anxiety disorders (Pies, 1994; White, 2005; Wong, 2006). Table 1 shows the bifurcation of the factors.
Genetic factors
Genetic factors predispose certain people to anxiety disorders. There is a higher chance of an anxiety disorder in the parents, children and siblings of a person with an anxiety disorder than in the relatives of someone without an anxiety disorder (Torgersen, 1983; Weissman, 1993; Goldman, 2001).
Neurotransmitter imbalance
Brain imaging and functional studies have shown that several neurotransmitters are linked to the neurobiology of anxiety (Cates et al., 1996; Sandford et al., 2000; Millan, 2003; Augustin, 2005). The diagrammatic representation of this has been shown in Figure 2.
Psychological factors
Anxiety can result when a combination of increased internal and external stresses overwhelm one’s normal coping abilities or when one’s ability to cope normally is lessened for some reason. The psychological factors are summarized below:
- Psychodynamic: When internal competing mental processes, instincts and impulses conflict, causing distress.
- Behavioral: Anxiety is a maladaptive learned response to specific past experiences and situations that become generalized to future similar situations.
- Spiritual: When people experience a profound, unquenchable emptiness and nothingness to their lives, often leading to distress concerning their mortality and eventual death (Sarason & Sarason, 2000; Brannon & Feist, 2004).
Social factors
Life experiences like death in the family, divorce, job loss, financial loss, accident or major illness affect a person’s attitude and response to life situations. Long term exposure to abuse, violence, terrorism and poverty may affect an individual’s susceptibility to anxiety disorders (Eysenck, 2004).
Occurrence and Epidemiology
About 500 million people, world wide, suffer from mental and behavioral disorders (Barbotte et al., 2001). Five of the ten leading causes of disability and premature death worldwide are psychiatric conditions. Mental disorders represent not only an immense psychological, social and economic burden to society, but also increase the risk of physical illnesses. Neuropsychiatric conditions account for 13% of the total Disability Adjusted Life Years (DALYs) lost due to all diseases and injuries in the world and are estimated to increase to 15% by the year 2020 (WHO, 2004).
Anxiety disorders, like depression, are among the most prevalent psychiatric disorders. They comprise a wide range of different disorders. Most anxiety disorders first appear during childhood and adolescence. Evidence shows that a high proportion of children do not grow out of their anxiety disorders during adolescence and adulthood (Majcher & Pollack, 1996; Murray & Lopez, 1996). Different surveys suggest that anxiety affects one-eighth of the total population of the world. The lifetime overall prevalence rate for anxiety disorders is 24.9%. This data suggests anxiety disorders are more chronic than affective or substance abuse disorders (Cates et al., 1996). Prevalence of anxiety disorders is difficult to pinpoint since even small changes in diagnostic criteria, interview tools, or study methodology affect results. World wide prevalence of different types of anxiety disorders varies (Cates et al., 1996).
Management of Anxiety
Anxiety disorders are the most prevalent of psychiatric disorders, yet less than 30% of individuals who suffer from anxiety disorders seek treatment (Lepine, 2002). People with anxiety disorders can benefit from a variety of treatments and services. Following an accurate diagnosis, possible treatments include (Barlow, 2001; NIMH, 2006) psychological treatments and mediation.
Psychological treatments
Psychotherapy is almost always the treatment of choice except in cases where anxiety is so severe that immediate relief is necessary to restore functioning and to prevent immediate and severe consequences. This includes the following:Behavioral therapies: These focus on using techniques such as guided imagery, relaxation training, biofeedback (to control stress and muscle tension); progressive desensitization, flooding as means to reduce anxiety responses or eliminate specific phobias. The person is gradually exposed to the object or situation that is feared. At first, the exposure may be only through pictures or audiotapes. Later, if possible, the person actually confronts the feared object or situation. Often the therapist will accompany him or her to provide support and guidance.
Cognitive-behavioral therapy (CBT): In this therapy, people learn to deal with fears by modifying the ways they think and behave. A major aim of CBT and behavioral therapy is to reduce anxiety by eliminating beliefs or behaviors that help to maintain the anxiety disorder. Research has shown that CBT is effective for several anxiety disorders, particularly panic disorder and social phobia (Herbert et al., 2009). It has two components. The cognitive component helps people change thinking patterns that keep them from overcoming their fears. The behavioral component of CBT seeks to change people's reactions to anxiety-provoking situations. A key element of this component is exposure, in which people confront the things they fear, i.e., CBT addresses underlying “automatic” thoughts and feelings that result from fear, as well as specific techniques to reduce or replace maladaptive behavior patterns.
Psychotherapy: Psychotherapy centers on resolution of conflicts and stresses, as well as the developmental aspects of anxiety disorders solely through talk therapy. Psychotherapy involves talking with a trained mental health professional, such as a psychiatrist, psychologist, social worker, or counselor to learn how to deal with problems like anxiety disorders (Knekt et al., 2008).
Psychodynamic therapy: This therapy, first suggested by Freud, is based on the premise that primary sources of abnormal behavior are unresolved past conflicts and the possibility that unacceptable unconscious impulses will enter consciousness.
Family therapy and parent training: Here the focus is on the family and its dynamics. This is based on the assumption that the individuals of a family cannot improve without understanding the conflicts that are to be found in the interactions of the family members. Thus, each member is expected to contribute to the resolution of the problem being addressed (American Psychological Association, 2004; Feldman, 2004).
Alternative treatments for anxiety disorders
Complementary and alternative medicine (CAM) plays a significant role in health care systems. CAM therapies have increasingly attracted the attention of medical doctors and researchers as well as the public, the government, and the media. Between 1990 and 1997, the number of consumers using CAM therapies rose significantly, from 33.8% to 42.1% (Ernst, 2006). Patients with chronic pain conditions, including arthritis, chronic neck and backache, headache, digestive problems and mental health conditions (including insomnia, depression, and anxiety) were high users of CAM therapies (Cauffeild, 2000; Kessler et al., 2001; Elkins et al., 2005; Saeed et al., 2007). These disorders are not easily treated with conventional medical therapies (Figure 2). Of the reported cases of anxiety, more than 40% patients use CAM.There are different types of CAMs that are used for the management of anxiety (Kessler et al., 2001; Moquin et al., 2009; NIH, 2009). The most common therapies included relaxation techniques, herbal medicines, massage, chiropractic, spiritual healing by others, and nutritional supplements (Figure 3). In particular, the use of herbal remedies and nutritional supplements rose 380% and 130%, respectively, between 1990 and 1997. These are shown in table 7.
Common limitations of antianxiety drug therapy include co-morbid psychiatric disorders (Regier et al., 1998) and increase in dose leading to intolerable side effects (Cates et al., 1996). These limitations have prompted scientists to investigate plants which are commonly employed in traditional and alternative systems of medicine for sleep disorders and related diseases with a view to find safer drugs (Spinella, 2001; Chung et al., 2005; Kumar, 2006).
Plants used for management of anxiety
The World Health Organisation estimates that 80% of the world population relies on herbal medicine (Eisenberg et al., 1998). Various plants have been investigated for their anxiolytic effects (Carlini, 2003) and many have shown marked antianxiety activity. Monoherbal preparations containing Scutellaria laterifolia, Centella asiatica, Paullinia cupana, Piper methysticum, Bacopa monniera, Cymbopogan citratus, Passiflofa incarnata and Valeriana officinalis were subjected to randomised clinical trials to study their effect in alleviation of anxiety (Ernst, 2006). According to the reported data, Piper methysticum (Pittler et al., 2002) and Bacopa monniera, (Stough et al., 2001) are associated with anxiolytic activity in humans. In another trial on generalized anxiety disorder (GAD) in hospital based clinical set-up, Ocimumn sanctum significantly attenuated generalized anxiety disorders and also attenuated its correlated stress and depression (Bhattacharyya et al., 2008).Conclusion
Epidemiological research suggests that anxiety disorders have the highest prevalence rate among psychiatric disorders. Conventional pharmacotherapy is limited by side effects such as psychomotor impairment, potentiation of other central depressant drugs and dependence liability. Hence, complementary and alternative medicine and plant-derived medications are being investigated as potential anxiolytic agents.References
American Psychiatric Association. (2000). Diagnostic and Statistical Manual for Mental Disorders (DSM-IV-TR) Text Revision (4th ed.). Arlington, VA: American Psychiatric Publishing.American Psychological Association (2004). Anxiety Disorders: The Role of Psychotherapy in Effective Treatment. Retrieved from http://www.apahelpcenter. org/articles/article.php
Augustin, S. G. (2005). Anxiety disorders. In M. A. Koda-Kimble, L. Y. Young, W.
A. Kradian (Eds.), Applied Therapeutics: The Clinical Use of Drugs (8th ed., pp. 76-1 – 76-47). Philadelphia, PA: Lippincott Williams and Wilkins.
Baldessarini, R. J. (2001). Drugs and the treatment of psychiatric disorders. In J. G.
Hardman & L. E. Limbird (Eds.), Goodman and Gilman’s The Pharmacological
Basis of Therapeutics (10th ed., pp. 447-483). New York, NY: McGraw-Hill.
Barbotte, E., Guillemin, F., Chan, N., & Group, L. (2001). Prevalence of impairments, disabilities, handicaps and quality of life in the general population: a review of recent literature. The International Journal of Public Health (Bulletin of World Health Organization), 79, 1047-1055.
Barlow, D. H. (2001). Clinical handbook of psychological disorders (3rd ed.). New York, NY: Guilford.
Bhattacharyya, D., Sur, T. K., Jana, U., & Debnath, P. K. (2008). Controlled programmed trial of Ocimum sanctum leaf on generalized anxiety disorders. Nepal Medical College Journal, 10(3), 176-179.
Brannon, L., Feist, J. (2004). Health psychology: An introduction to behavior and health (5th ed.). Belmont, CA: Wadsworth.
Carlini, E. A. (2003). Plants and the central nervous system. Pharmacology, Biochemistry and Behavior, 75, 501-512.
Cates, M., Wells, B. G., & Thatcher, G. W. (1996). Anxiety Disorders. In E. T.
Herfindal and D. R. Gourley (Eds.). Textbook of Therapeutics: Drug and Disease Management (6th ed., pp. 1073-1093). Hagerstown, MD: Lippincott Williams and Wilkins.
Cauffield, J. S. (2000). The Psychosocial Aspects of Complementary and Alternative Medicine. Pharmacotherapy, 20(11), 1289-1294.
Keywords: anxiety disorders, psychological treatments, pharmacotherapy,alternative therapy.
