Anxiety disorders

To understand how any of these drugs may be useful it is necessary to understand the various types of anxiety. The term ‘anxiety’ covers four sets of experiences, which may be expressed in a variety of symptoms.

First is mental anxiety, which roughly translates as worry or a preoccupation with things that might go wrong. This may also include intrusive ideas, thoughts or impulses of a distressing nature. This form of anxiety may be present without many physical symptoms such as increased muscular tension, heart rate, sweating or shaking. Antipsychotics and antidepressants tend to work on this component of anxiety.

Second is physical tension, which consists of a knotting of the various muscles around the body. This probably results from an inhibition of action. When we get emotional or worried, we review possible things to do to sort our problems out and in the process prepare our muscles for a prospective action – tensing them up and getting them ready to swing into action. If all we do is think about things, and do nothing, the result is that our muscles get tensed up and if that tension is not discharged it may become chronic. Physical relaxation or activity and benzodiazepines work by acting on this component of the anxiety spectrum.

Third is a set of physical symptoms, such as increased heart rate and increased intensity of the heart beat – palpitations. Other symptoms include a shake in the hand, sweating, feeling faint and liable to keel over, butterflies in the stomach and sometimes frank nausea, as well as a loosening of the bowels, which may lead to diarrhoea. There is usually also a tendency to breathe more shallowly and quickly. This hyperventilation can produce symptoms such as tingling in the hands and legs, pins and needles, light-headedness and visual disturbances. Beta-blockers have been thought to help some of these features of anxiety.

• Depersonalisation – a feeling of being detached or removed from oneself or as though one’s body is not operating normally (see Ch. 5)

• Derealisation – an impression that the world seems unreal, flat, or as though everything is happening on a stage (see Ch. 5)

• Out-of-body experiences, which relate closely to depersonalisation and derealisation

• Hallucinations – either auditory or visual

• Recurrent waves of emotion or recurrent short-lived black moods

• Episodic feelings of being numb, either mentally or physically, to the point where one can cut oneself and not feel any pain

• Amnesia for past events – whether the happenings of the day or episodes in one’s past life.

FORMS OF ANXIETY

In addition to the types of anxiety mentioned above, there are a number of situations in which anxiety arises and according to which it is categorised and treatment given.

Stage fright

This is the kind of anxiety that everyone gets when faced with an interview or having to perform in some way for others. Typically stage fright leads to increased muscular tension, sweating, butterflies, a tremor in the hand and palpitations, as well as a feeling perhaps of being unreal or out of touch. In other words, some aspects of all of the forms of anxiety mentioned above may be experienced.

Stage fright can often be helped by either minor tranquillisers or beta-blockers. The basis for a response to these drugs appears to lie in an interruption of the feedback from increased heart rate or muscular tension to the mental state. When we worry about something our heart rate increases, our hands shake and we begin to perspire; these symptoms can in turn lead us to be more anxious. If these signs of anxiety are blocked, we appear to assume that we are less anxious and as a result we become less anxious. This tricking of ourselves is a legitimate manoeuvre and is undoubtedly what human beings have been doing for millennia, mostly by using alcohol to abolish the manifestations of anxiety – giving us Dutch courage.

There are two potential problems with this approach, however. One is that it is normal to feel anxious before a performance of any kind and a certain amount of anxiety probably contributes to a good performance and helps us to perform at a higher level than otherwise. People who are too relaxed may lose a certain amount of ‘edge’ and in this manner overzealous tranquillisation may impair performance.

A further pitfall lies in starting the treatment of anxiety too early. In the case of a concert, a speech or an interview, treatments should be used only on the day of the performance or, at most, to include the night before. Danger arises when performances come close together and an individual is self-medicating for too long before each performance, so that they slide into a routine of constant medication. This may produce dependence in the case of drugs such as alcohol or benzodiazepines.

Another problem is that, while it is probably legitimate to use drugs of this sort in an appropriate way, if they are found to be effective there is an inevitable tendency to rely on the drugs rather than to develop the skills to help manage activities such as interviews or performing in front of others. A judicious use of anxiolytics to combat stage fright, on the other hand, may enable the taker to go on stage and perform and in the process to become accustomed to performing in front of others. In other words, anxiolytic drugs can, if used properly, lead to their own discontinuation.

Neurotic anxiety

We all become acutely anxious on occasions. If the anxiety is intense or long-lasting, or if it catches us at a vulnerable time, there is a tendency for it to organise itself into a neurosis. A neurosis is a relatively long-lasting and self-perpetuating maladaptation to anxiety.

For example, someone who has a shock while out shopping may perhaps be left nervous. They may then subsequently, when they come to go shopping next, find that they are apprehensive about going out. If they do not go out to the shops, perhaps by getting one of their children or a neighbour to go instead, the likelihood is that a certain nervousness about going shopping will become established. Not going shopping to avoid becoming anxious about shopping leads to an inability to go shopping and to even more anxiety when one has to face up to what it is that one has been avoiding. Such problems can be self-perpetuating.

Sometimes the difficulty may clear up spontaneously. Many neuroses also respond very well to behaviour therapies, which act on much the same principle as telling someone who has just fallen off a horse to get up and ride again as quickly as possible. Blocking avoidance responses and exposing oneself to the thing that one is afraid of are the basic behavioural methods for handling neurosis. They work extremely well and are, broadly speaking, the optimal therapy for phobic and obsessive–compulsive neuroses. ¹

However, there are other treatments and anxiolytics that are commonly used for various neuroses. To understand their place we will first lay out the different kinds of neurosis and then indicate where and why drug treatments may also be employed.

Phobic neurosis

There are both general and specific phobias. A general phobia of going out is termed agoraphobia. The specific phobias involve phobias of a particular thing such as a fear of spiders, snakes or thunder and lightning.

Exposure therapy is the treatment of choice for specific phobias and for phobic disorders uncomplicated by depressive illness. Antidepressants are also often used for agoraphobia but rarely for specific phobias. One rationale for using antidepressants in these conditions is that many people who are agoraphobic will also have a depressive disorder and if this is tackled the neurosis may clear up. However, in addition to the clearing up of a depressive disorder, the selective serotonin-reuptake inhibitors (SSRIs) and monoamine oxidase inhibitors (MAOIs) appear to be independently anxiolytic and treatment with these drugs can produce benefits for those who are phobically anxious, but not depressed.

Panic disorder

Panic attacks are episodes of intense anxiety that can come on either in company, out of doors, or indoors at home alone. The primary experience is usually intensely physical – acute awareness of a thumping heart and shaking hands, with feelings of nausea, weakness and shortness of breath, but there are usually also thoughts of impending doom. Panic disorders typically seem to come out of the blue. These attacks may lead secondarily to a phobia of going shopping if, for example, the first attack happens in the supermarket. ²

There have been vigorous attempts to market anxiolytics, particularly the benzodiazepine alprazolam, for panic disorder. Most of the antidepressants have also been tested in panic disorder and shown to have a certain amount of usefulness.

Exposure therapy is used widely to manage panic disorder, as is a recently developed variation of cognitive therapy. ³

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