Behaviour
Feelings
Body
Thoughts
Avoidance, flight
Feelings of tension, worry, panic, unreality, fear of going crazy, of dying, of losing control
Trembling, sweating, heart pounding, light-headedness, dizziness, muscle tension, nausea, breathlessness, numbness, stomach pains, tingling sensation
Something terrible is going to happen, I have got to get out of here, I am despairing
Relevance
In anxiety disorders often physical symptoms, as so-called affective equivalents, are in place of consciously perceived fear. This aspect is particularly important in psychosomatic primary care, since patients experiencing physical symptoms primarily turn to their GP or a specialist, if necessary. Anxiety disorders are often not diagnosed, misdiagnosed or diagnosed too late, and are rarely treated specifically and appropriately. Untreated, anxiety disorders usually run a chronic course and spontaneous remissions are rare. There are high comorbidities with other mental disorders such as depression and somatoform disorders. All this suggests that timely detection saves huge costs in primary care.
Theory
Symptoms
In a large number of patients with anxiety disorder, feelings are hidden behind physical symptoms. Table 10.2 shows an overview of physical symptoms of anxiety, arranged by organ systems.
Table 10.2
Physical symptoms of fear
Heart | Irregular, rapid or pounding heartbeat to palpitations, left-thoracic sensation of pressure |
Vascular system | Pallor or flush in the face and extremities, cold-sweaty hands and feet, hypertension |
Musculature | Tremors, weak knees, motor restlessness, muscle tension, feeling of paralysis, pain in the joints, arms and legs, tingling and numbness |
Respiratory tract | Hyperventilation, feeling of constriction and shortness of breath, fear of suffocation |
Gastrointestinal tract | Lump in the throat (Globus) with difficulty swallowing, swallowing air and belching, vomiting, stomach ache, diarrhoea |
Vegetative/autonomic nervous system | Sweating, dilated pupils, need to urinate |
Central nervous system | Dizziness and giddiness, tremors, spots before the eyes, impaired vision, such as double vision, headache, insomnia, impaired concentration, fatigue, weakness, depersonalisation and derealisation |
Diagnostic Categories
Panic Disorder (ICD 10 F 40.01)
The most essential characteristics are recurrent phases of intensive acute fear, so-called panic attacks . They do not refer to a certain situation and are experienced by the patient usually as spontaneously occurring palpitations, chest pain, feeling of suffocation, severe dizziness, headache, up to a feeling of alienation. In addition, fear of dying or going mad does occur. These occur spontaneously, are completely unexpected, and last from a few minutes to an hour .
Case Study: “Panic disorder”
A 36-year-old patient, mother of three sons, developed severe panic attacks, which completely undermined her stability, after her husband changed his behaviour—for her unexpectedly and inconceivably. He dyed his hair and announced that from then on, he was going to do his own thing and do as he pleased. In the preceding years, at high personal cost, the two had renovated the house they had taken over from the parents.
The patient felt completely overwhelmed, helpless and unable to act and hardly able to cope with the daily tasks of keeping the house. She was repeatedly overcome by great feelings of fear, coupled with palpitations, severe dizziness, sweating and trembling. Often she felt herself on the border of “losing control” or “flipping out”, so her husband sometimes thought she might jump off the balcony under the pressure of the situation.
She was able, little by little, to cope better with her fears, bear unpleasant states of tension and become able to conduct her life only after intensive long-term psychotherapy, several months of in-hospital treatment in a special clinic and a temporary use of anxiolytics and antidepressives.
A deep underlying rift in the marital relationship was identified which had long been building up under the surface. The two finally decided to separate.
Phobic Anxiety Disorders (F40)
Agoraphobia (ICD-10: F 40.00 Without Panic Attacks, F40.01 with Panic Attacks)
Many patients with panic attacks come to avoid places in which anxiety attacks occurred. The avoidance behaviour may reach a stage in which many patients are unable to leave their house. Agoraphobia describes not only the fear of open places, but also, for example, of crowds, or the desire to be able to leave on the spot and to retreat easily to a safe place. Typical situations which these patients avoid or endure only with severe anxiety include department stores, cinemas, restaurants, public transportation, driving a car, lifts or heights. Most patients report they can endure the feared situation better in company. As a substitute for a fear-reducing trusted person, the patient may take along medications, smelling substances or the doctor’s telephone number. Agoraphobia may also develop without any preceding acute anxiety attack or panic attacks. These patients often report a rather diffuse feeling of eeriness and threat which comes over them when they leave their familiar environment.
Case Study: “Agoraphobia” (continued)
Numerous specialist examinations and hospital treatment follow to definitely rule out any possibly organic cause of the illness. She does not tolerate antidepressive medications. A 2-month rehabilitation programme in hospital and outpatient group psychotherapy is needed to enable her to work at least part time and to cope with everyday life without more significant limitations.
Social phobias (ICD-10: F 40.1)
Predominant is an inappropriate fear and avoidance of situations in which the patient has to deal with other people and may be judged. They are afraid of failure, being laughed at or being belittled because of clumsy behaviour. A social phobia may be limited to specific situations, such as eating or speaking in public, or meeting someone they do not know very well. The patients express complaints as blushing, trembling hands, nausea or the urge to urinate.
Case Study: “Social Phobia”
A 25-year-old medical student has increasing problems eating in the company of others, in the cafeteria, for example. He has the feeling he cannot swallow a bite or suffers from a severe, almost irresistible urge to gag. With time, he avoids such situations, which means he is often alone, can concentrate entirely on his studies, but sometimes is so restless that the eating problem even occurs at home, though in a weaker form. It is found that he often felt insecure in dealing with others, and even before, he thought he was too fat, sweats too much and would make others uncomfortable by his presence.
Although he is studying nearly 750 km away from home, he is in very close contact with his family and is often asked for advice by his father, for instance. His father is very proud of him because he is the first one in the whole family to attend university.
The patient’s problem is a separation problem from the parental home. His need for autonomy surfaces only indirectly. When he receives the news that after his exams next year he can participate in a research project in the USA, he is able to eat an entire meal at McDonald’s with no problem. In this situation, he does not experience any symptoms any more.
Specific (isolated) Phobias (ICD-10: F 40.2)
Here, the fear is limited to the proximity to certain animals, heights, thunder, darkness, flying, the sight of blood, injuries or the fear of being exposed to certain diseases, such as AIDS. The extent of the disorder depends on how easily the patient can avoid the phobic situation or the phobic object.
Generalised Anxiety Disorder (ICD-10 F 41.1)
Typical are generalised and persistent fears, which are not, however, limited to certain situations in the environment . They refer to fears and worries in several areas of life, such as workplace, partnership etc.
Case Study: “Generalised anxiety disorder”
A 38-year-old patient reacts to a change in his job, which for him is completely unexpected when his boss retires, with very severe anxiety and deep helpless despair. He feels incapable of resisting these feelings, experiences to be passively doomed, like falling into a chasm. Only intensive psychiatric-psychotherapeutic support can very gradually give him more stability.
After he tried—from his perspective in vain—for several months to get along with the new boss, by reducing his working time, for example, he decides to resign, which throws him into a new crisis after an extremely short phase of relief. Again, his situation does not stabilise for several months, until he has the opportunity to enter an extensive training programme offered by the state employment office.
It is discovered that he has suffered severe fear of illness, permanent lack of self-confidence and considerable trouble in making decisions since his childhood, which were interrupted for only brief periods by phases of greater stability.
Hypochondriacal Disorder (ICD-10: F 45.2)
The patient is constantly concerned with the possibility of having one or more serious and progressive physical diseases. General physical sensations are interpreted as abnormal and stressful and ascribed to a serious disease.
Somatoform Autonomic Dysfunction of the Heart and Cardiovascular System (ICD-10: F 45.3)
In this discrete phobia, the feared object is not part of the external world, but part of one’s own body. The focus is fear of an unrecognised heart disease and the fear of dying a cardiac death. The symptoms often correspond to those of angina pectoris, but are demonstratively dwelt upon. Heart phobics do not have an elevated risk of heart attack. But by continually undergoing examination, despite unremarkable findings, the patient’s conviction that he is suffering from a serious disease becomes stronger.
Obsessive–Compulsive Disorder (ICD-10: F42)
The core features of these disorders are obsessions (intrusive, unwanted thoughts) and compulsions (performance of highly ritualised behaviours intended to neutralise the negative thoughts and emotions resulting from the obsessions). One symptom pattern might be repetitive hand washing beyond the point of skin damage to neutralise fears of contamination.
Differential Diagnosis
The following important somatic differential diagnoses must be taken into consideration:
Hyperthyroidism
Coronary heart disease
Paroxysmal tachycardia
Pheochromocytoma
Hypoglycaemia
Cerebral seizures
Drug side effects
Drug abuse
Frequency and Course
Anxiety disorders have a lifetime prevalence of 14 % in European countries, making them the most common emotional disorders among the general public. The following lifetime prevalence rates are found for individual anxiety disorders: specific phobia 6.4 %, social phobia 2.3 %, agoraphobia, 2 %, panic disorder 1.8 % and generalised anxiety disorder, 1.7 % (young people) to 3.4 % (elderly) (Wittchen et. al. 2011) .
There is a risk of chronicity mainly in secondary abuse of alcohol and/or medication, comorbid depression and an excessive number of visits of the medical and psychosocial institutions.
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