Last month, in response to a reader’s query, I briefly described a type of anxiety called phobias. This month I thought I will write a more comprehensive description of this group of conditions called anxiety disorders. They are among the commonest of psychiatric conditions and have been called the ‘cough and cold’ of psychiatry. Anxiety [...]

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Afraid of lifts, injections, dentists? You’re not alone


Last month, in response to a reader’s query, I briefly described a type of anxiety called phobias. This month I thought I will write a more comprehensive description of this group of conditions called anxiety disorders. They are among the commonest of psychiatric conditions and have been called the ‘cough and cold’ of psychiatry.

Anxiety is a normal emotion. It is a necessary emotion for normal human functioning and survival. A person without anxiety would not function at an optimal level and would also not be alert enough to avoid danger. However anxiety that is excessive, long lasting or inappropriate to a situation would cause impairment of functioning and therefore could be termed pathological.

The commonest such disorder are specific phobias which I described briefly last month. They usually arise in childhood and may continue into adulthood. Four types of specific phobias are recognised. They are concerned with animals, aspects of the natural environment, blood, injection, and injury or certain situations such as hospitals. All human beings have some phobia or the other but these are not pathological and do not interfere too much with day to day living. But in some circumstances these fears could be quite disabling. For example a fear of dental treatment may lead to avoidance of all dental care and serious dental caries. Even more seriously a fear of hospitals may lead to avoidance of essential medical care with even lethal consequences.

As mentioned in my previous article specific phobias can be successfully treated with a type of therapy called graded exposure. In the past it was thought that these specific phobias arose from hidden or forgotten childhood traumas. The best treatment at the time was thought to be psychoanalysis which was aimed at uncovering these hidden traumas. Any other treatment was thought to be superficial and lead to replacement of one phobia with another. However this has been shown to be incorrect. Graded exposure therapy if carried out properly is a permanent cure.

Another group of anxiety disorders is called agoraphobia. Agora is the Greek word for marketplace and literally means ‘fear of the market place’. People with agoraphobia are anxious when they are away from home, in crowds, or in situations which they cannot leave easily such as a crowded bus. They avoid such situations and feel anxious even when anticipating them. One of my patients was unable to get into crowded buses and when going to office had to wait a long time for a bus that was not crowded. She invariably got late for work.

A closely related condition is claustrophobia from the Latin claustrum for ‘shut in place’. People with this problem feel very anxious and find it difficult to breathe in enclosed spaces, for example in small rooms or elevators. I remember another of my patients who walked all the way up to the 14th floor of the high rise building he worked in as he was too fearful to use the lift. Claustrophobia and agoraphobia often coexist, and in the past was known as the agoraphobia-claustrophobia syndrome.

Some patients with agoraphobia have short extreme bursts of anxiety called panic attacks. Panic attacks can also occur in people without agoraphobia. Symptoms of a panic attack include, choking, palpitations, chest discomfort or pain, sweating, dizziness or nausea. Some patients hyperventilate, which is breathing in a rapid and shallow way leading to a fall in the concentration of carbon dioxide, which in turn could lead to tingling of the hands and feet or even spasms. The first aid for such a situation is holding a bag over the nose and mouth and asking the person to breathe into it. This increases the level of carbon dioxide and relieves the symptoms.

A panic attack could be quite distressing for a person. Persons having panic attacks may fear that they would collapse and die. The fear makes the anxiety even more and worsens the situation. Panic attacks are often misdiagnosed, as the symptoms mimic a heart attack or an attack of asthma. Persons having panic attacks have ended up in intensive care units of hospitals. After a series of rather expensive investigations they are discharged as ‘normal’.

The treatment for agoraphobia could be medicines, psychotherapy or a combination of both. Medicines belonging to the benzodiazepine group which are often used as sleeping tablets are effective. However the side effects such as drowsiness could be troublesome. Long term unsupervised usage could lead to addiction. Antidepressants are also effective in a lower dose than for depression. The response is slower than for the benzodiazepines but there is no risk of addiction. The recommended psychotherapy is called cognitive behavioural therapy and is a combination of change of behaviour and thoughts regarding the anxiety provoking situations. The therapy is effective but time consuming and may not be readily available.

Another type of phobia is social phobia. Also called social anxiety disorder it is characterised by intense anxiety in social situations. This condition usually arises in adolescence and could be quite disabling for students who have to do presentations in front of an audience. Some may even have difficulty in entering a crowded lecture hall. These students usually come early and sit at the back of the hall. In the past this condition was not recognised and was thought to be just a more severe form of social shyness. The most effective treatment for social anxiety is, like in agoraphobia, cognitive behavioural therapy or CBT. Though antidepressants have been used in its treatment they are of little benefit.

The last major category of anxiety disorders I would like to discuss is generalised anxiety disorder or GAD for short. It is characterised by uncontrollable, irrational excessive worry about everyday things. For diagnosis these symptoms should have been present for at least six months. The excessive worry interferes with daily functioning as persons with this condition are always anticipating a disaster and are overly worried about day to day matters such as finances and health. People affected often have a number of physical complaints such as head ache, muscle aches, numbness, difficulties in concentration, swallowing and breathing. Again as in panic disorder this could lead to unnecessary medical investigation which are usually negative. The best treatment for GAD is also CBT but antidepressants may help to reduce symptoms.

Anxiety disorders are relatively common and could lead to significant impairment of functioning. They are also mistaken for other medical conditions leading to inappropriate, ineffective and even harmful treatment. So if you think you have an anxiety disorder please do see a psychiatrist as they would have the expertise to diagnose and deliver the most effective treatment.

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