Anxiety
The conditions listed here have a lot of features in common both in terms of their psychological causes, the neurobiological effects observed and the way in which they are treated. The way that the brain processes emotions including anxiety changes from childhood through to adolescence and then into adulthood and further on into old age. For example as we grow older there are changes in emotional memory, the perception of emotions in oneself and in others and also in how emotions are regulated. It is believed that the changes are, at least due in part, due to changes in connectivity between different regions of the brain.
Our understanding of these processes is increasing as new techniques in brain imaging provide us with new insights. Key pathways involved in regulation of anxiety include connections between the frontal parts of the brain and an area deep in the brain called the amygdala. The frontal parts of the brain exert judgement and control. The amygdala functions like an early warning system constantly monitoring for danger. When it is overactive individual experiences anxiety and there are physical changes, which occur in the body such as increased levels of circulating adrenaline and the stress hormone cortisol.
This condition is diagnosed when people have persistent worrying. The symptoms need to have been there for a few months to make the diagnosis. The worry is not confined to specific situations and is often what we describe as free-floating in nature. GAD can often occur with other anxiety disorders such as obsessive-compulsive disorder and can also often occur with depression. Patients have physical symptoms as well as psychological symptoms. It can usually be effectively treated with psychological therapy. Some patients may need medication to achieve full resolution of their symptoms. Untreated GAD can lead to worse health outcomes both in mental and physical health terms. Untreated GAD is associated with a wide range of physical illnesses for example heart disease and stroke.
With this condition the person experiences sudden unexpected surges of anxiety. One characteristic of this condition is that anxiety can be present in anticipation of a panic attack occurring. When someone experiences a panic attack it usually lasts about 10 minutes. The after effects may last as long as up to an hour. Most patients will also experience agoraphobia. This is a fear of not being able to escape from certain situation. This could be for example a fear of being on public transport or being in a shop. This anxiety can then lead to the person avoiding certain situations, which in turn has a negative effect on their life. Like most anxiety disorders Panic Disorder can usually be effectively treated with psychological therapy. Some patients may need medication to achieve full resolution of their symptoms.
In this condition the person experiences marked unreasonable fears of other people thinking negatively about them. The fears are persistent often occurring in social situations. The fears may also occur when the person needs to perform at work, for example giving a presentation to a group of people. The anxiety associated with this condition can also mean that person avoids certain situations. Like most anxiety disorders Social Phobia can usually be effectively treated with psychological therapy. Some patients may need medication to achieve full resolution of their symptoms.
The person experiences repeated obsessive worrying. They may also get repeated intrusive images or impulses to do things. There may be also repeated physical or mental rituals that the person feels they need to go through. The thoughts and behaviour are often distressing. The person recognises the thoughts and impulses as their own but does not want them and usually will try and resist them. The thoughts and behaviours can take up a lot of time and affect the social and work functioning of the person. Fears of contamination, accidents happening, religious or sexual matters are common. Washing, checking, cleaning, counting and touching are the rituals that are most commonly seen. OCD can usually be effectively treated with psychological therapy. Some patients may need medication to achieve full resolution of their symptoms. Sometime high doses of antidepressants may be required to achieve full resolution of symptoms.
In this condition the person has been exposed to a serious life-threatening trauma. This could be an actual or a threatened death situation, a serious injury or threat to the person's integrity or the integrity of others. Following the trauma there is often intense fear, helplessness or horror. Later on the person may develop intrusive symptoms such as remembering the event, experiencing flashbacks or having disturbing dreams. The symptoms may lead to person avoiding certain activities or thoughts linked with the trauma. There can be changes in how people think and what their mood is like. People can be over aroused. This could include being excessively vigilant for example whilst driving following a road traffic accident. The person may also experience disturbed sleep.
PTSD can usually be effectively treated with psychological therapy. Some patients may need medication to achieve full resolution of their symptoms. Quite often patients may also be suffering from a depressive disorder.
With this condition the person has excessive or out of proportion worries about having a serious illness or getting a serious illness. The person then, because of high levels of alarm about the health issue, engages in excessive health seeking behaviour. This may lead to the person having investigations that they don't need and sometimes this can actually make their psychological health worse. Careful listening is required to fully understand how the patient has developed these symptoms. Sometimes there may have been significant parental ill health or childhood illnesses. It is important not to dismiss the physical symptoms, as sometimes there is a physical basis for at least part of them. Psychological treatment with medical input into the care plan should lead to symptoms improving.
It is important to take a very detailed history to get an idea of the duration of and the severity of the problem. I try to get an understanding of what the underlying psychological factors are that may have lead to the condition arising. Care needs to be taken not to miss a depressive illness. It is important to consider possible physical causes that might be leading to the symptoms that the person is experiencing. A review of the medication the person is taking might reveal a medication-induced cause of anxiety. Understanding the response to previous treatments is also essential.
Sometimes a depressive illness may present with prominent anxiety symptoms and the person may say that they don't have any problems with depressed mood. However it is important two make sure that a detailed enquiries made so that it depressive illness is not missed.
Anxiety disorders may lead to substance misuse as a person tries to treat the underlying condition with drugs or alcohol. Sometimes these substances themselves made and cause rebound anxiety problems.
Anxiety may be presenting feature in somebody who has cognitive disorder developing such as dementia. Anxiety symptoms can be prominent clinical features in epilepsy or Parkinson's disease.
It may be necessary to do blood tests for example to check thyroid hormone levels in the blood, which might be contributing to anxiety. Sometimes they can be hormonal problems that can lead to anxiety such as too much adrenaline.
The effectiveness of psychological and pharmacological treatments is similar in the treatment of anxiety disorders. I discuss the balance between the potential risks and benefits risks of specific psychological treatments with my patients before starting treatment. Psychological therapists work to evidence-based treatment protocols and are supervised regularly. The response to psychological treatment may take time, sometimes months and it is important for patients to understand this. During this time it might be appropriate for medication to be prescribed particularly in the early stages of treatment. I often combine pharmacological and psychological treatments.
Cognitive Behavioural Therapy
This evidence-based treatment is very effective in treating all the anxiety disorders. Once a psychiatrist has made the diagnosis a decision is made as to whether the patient needs medication. If medication is not required the psychiatrist will normally refer the patient to psychologist. The treatment takes place usually over approximately 12 weeks. The sessions last 50 minutes the usually take place weekly. Quite often insurance companies expect the psychiatrist to provide the information, which enables funds to be released for this treatment to take place.
During treatment a therapist helps the patient understand the links between the thoughts, emotions, behaviour and physical sensations that they experience. Usually the patient will keep a diary and record times when their symptoms have been significant. A record is made of the thoughts, emotions, behaviour and physical sensations that the patient experiences at these critical times. Each week the records made are discussed in detail. From the discussion comes an understanding of way in which that individual processes information.
Mindfulness theory and practice in becoming more widely used and many more therapists are using this alongside CBT.
Eye Movement Desensitisation and Reprocessing (EMDR)
This relatively new technique is an alternative treatment to CBT for PTSD. The treatment involves distraction techniques when the patient is recalling the traumatic events. It is not entirely clear how the treatment works but it is thought to work by modulating emotional memories in areas and circuits in the brain where these memories are held and regulated.
Medication
The SSRIs (selective serotonin receptor reuptake inhibitors) are useful in treating all of the disorders above and may be regarded as a "broad-spectrum" treatment. If an SSRI is ineffective then an SNRI (serotonin–noradrenaline reuptake inhibitor) such as Duloxetine can be used. It is important that the patient was made aware that in the early days of treatment with SSRIs that there can be and increase in anxiety and agitation. The symptoms can be treated in the short term the class a drug called benzodiazepines. The benzodiazepines are very effective drugs to treat anxiety problems but they should only be used in the short term where possible. There are some exceptions where longer-term treatment with benzodiazepines is deemed appropriate for an individual patient.
When treating obsessive-compulsive disorder high doses of SSRI drugs are required in some cases. If this treatment is ineffective, then the drug Clomipramine is often used. Sometimes SSRI medication is combined with antipsychotic medication, which can boost the efficacy of the SSRI.
An anti-epileptic medicine called Pregabalin is very effective in treating GAD. It has a license to treat the condition and is approved by NICE (National Institute for Clinical Excellence).