Understanding Anxiety Disorders: Diagnosis, Biological Factors, and Integrated Treatment Approaches

Anxiety disorders are one of the most common mental conditions although they are relatively more subtle when compared with other conditions such as depression, schizophrenia, or even bipolar disorder which can disrupt normal life. The clinical treatment and diagnosis of the conditions are achieved through dimensional and structural diagnosis. More recent diagnostic approaches have included genetic research and neuroimaging. This approach aims to establish an understanding of how the interaction of stress, biology, and genetics contribute to the symptoms of anxiety disorders. The disorder can be treated through cognitive-behavioral therapy and the use of medications (psychopharmacological therapy). The choice of treatment of anxiety disorder is tailored to target certain different symptoms hence a combination of strategies have to be used for the best outcome.

Keywords: Anxiety disorders, clinical treatment, symptoms, cognitive-behavioral therapy, psychopharmacological therapy.

Anxiety Disorders

Results from large population-based surveys indicate that anxiety disorders plague at least 33.7% of the world population in their lifetime (Bandelow & Michaelis, 2015). The disorder generally does not receive the same attention despite its prevalence as people worry more about other syndromes like psychotic order. Anxiety disorders tend to be passed from parents to their children just like behavioral traits. Studies indicate that if one identical twin has a psychiatric illness, then there’s a 50% chance that the other twin will have the same condition (Hyman, 2010). This means that anxiety disorders can be caused by factors other than genetics including environmental influences. The assessment and treatment of anxiety disorders (AD) are typically done by primary care physicians. AD are responsible for increased mortality and morbidity, decreased productivity as well as an increase in levels of drug and alcohol abuse throughout the country. Research in the area of AD has been publicized by the American Psychiatric Association (2013) in their Diagnostic and Statistical Manual for Mental Disorders (DSM). It is in such publications that disorders like PTSD (post-traumatic stress disorder) and OCD (obsessive-compulsive disorder) have been classified appropriately. This article will review the challenges inherent in the diagnosis of anxiety disorders, highlight the systems affected by the disorders and expound on the roles of various interventions including medical and non-medical remedies.

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Diagnosing Anxiety Disorders

Challenges

Data relating to the incidence, distribution, and control of diseases (epidemiology) in recent years has been useful in categorizing AD. One huddle that has hampered progress in this regard is the presence of one or more additional conditions (comorbidities) among patients with anxiety (Phillips et al., 2010). The presence of comorbidities among patients with SAD (social anxiety disorder) as well as GAD (generalized anxiety disorder) was especially significant and concerning. The co-existence of two or more conditions in one patient is, however, not uncommon in clinical practice. Anxiety disorders, drug and alcohol abuse, and depression typically exhibit symptom overlap.

Also, patients can exhibit different disorders over different periods of their lifetime. A patient can, for instance, initially present with a diagnosable panic disorder which is then treated and resolved. This does not preclude the same patient from being diagnosed with GAD or OCD a few years later. The classification of anxiety disorders faces another challenge relating to a lack of clear causes (etiological factors) of the AD as well as a specific treatment for different categories of AD. Even the study of underlying genetic factors associated with AD through biological techniques has fallen short of producing a single gene responsible for AD, save for OCD. Research, however, indicates potential similarities in the genetic factors relating to various AD, drug and alcohol abuse as well as depression (Shadrina et al., 2018).

The emergence of effective medications that target the neurotransmitter serotonin gives possible clarity to the above ambiguities in diagnosis. The use of such medications to treat a variety of disorders lends credibility to suggestions of using a dimensional model in the treatment or study of AD. Such an approach in clinical psychology allows the clinician more room to determine how severe a condition is instead of a categorical approach. This dimensional model views anxiety disorder as a complex set of symptoms that coexist including social awkwardness, panic, or obsessiveness. Variations in the dimensional model then vary based on biological, hypothetical, or genetic factors and inform the treatment approaches to take. That said, dimensional and categorical approaches in the treatment of AD remain the subject of serious debate in clinical psychology and research.

The similarities between distinct disorders have given rise to the use of the word “spectrum” when referring to anxiety disorders. This concept is useful in the evaluation of similarities in response to psychological or medicine-based (pharmacological) treatments. It allows for extension treatment to consider conditions such as panic-agoraphobia, social anxiety, and PTSD (Karsnitz & Ward, 2011). One downside to this approach is that it lumps several disorders together, some of which have nothing in common. It can, therefore, be misleading due to over-inclusiveness that places BDD (body dysmorphic disorder) and pathological gambling in the same spectrum. Moreover, this concept lacks support from genetic neuro-circuitry studies.

Apart from categorical and dimensional diagnosis, the examination of anxiety disorders can also be understood to be part of a gradual psychopathological process. For instance, a patient with symptoms like compulsions or obsessions may indicate OCD, although compulsions normally arise in later stages of OCD. The development of compulsions in OCD patients is similar to other medical conditions in which the body reacts to the presence of a disease-causing organism. The lungs, for example, react to infection with tuberculosis by forming scars around the infected area. Scientists and clinical psychologists in recent years have realized similarities in the underlying anxiety and fear across a variety of anxiety disorders. This realization has assisted in implementing uniform treatment procedures by primary health care providers to develop an overall theory for anxiety.

How to Achieve Better Diagnosis and Management of AD

Anxiety disorders can be more precisely diagnosed and managed by understanding emotional reactivity, coping mechanisms, and core beliefs. AD can be triggered by emotional or psychological sensations or thoughts. The resulting brain reaction is often based on beliefs formed through previous personal or cultural experiences. Information processing about danger among patients with AD seems to be more focused as compared to individuals without the disorder. The patients are unable to make accurate decisions regarding beliefs due to indecision and catastrophic thinking that results from their minds being flooded with details. A particular anxiety disorder then arises after the coping mechanism has evolved. For example, a panic disorder may initially be the brain’s response to a devastating panic attack. The event triggers the part of the brain that processes danger. This, combined with the patient’s personal beliefs about the issue results in heightened concern about safety and personal health. What follows is a specific effort to engage a coping mechanism that decreases the perceived danger and calm the fear. Such processes occur in healthy individuals. The only difference is that in AD patients, coping behavior is more chronic and extensive. Their anxiety is persistent and induces a vicious cycle of distress and worry leading to recurrent panic attacks. If this cycle is not broken, it leads to unhealthy coping behavior such as total avoidance of anything that may trigger panic. Although there could be slight differences at certain stages for different disorders, most anxiety disorders follow this process.

Biological Considerations

To begin with, anxiety syndromes can result from metabolic abnormalities such as hyperthyroidism or arrhythmia sensations can sometimes cause panic attacks. This means that symptoms of one medical illness can lead to anxiety. Alternatively, an illness could be mimicking an anxiety disorder like in cases where perseverations (repetition of a particular response over and over) have been mistakenly diagnosed as OCD instead of mental retardation. It is also possible for a mental illness to be coexisting with an anxiety disorder in a patient. A classic example is the case of pediatric autoimmune neuropsychiatric disorder (PANDAS). The disorder which is linked to streptococcal infections has been reported in certain OCD patients (Greenberg, 2015). Research into anxiety disorders in recent years has shifted investigating brain reactivity and neurochemistry through brain imaging technology. This has been made possible since it is easy to provoke certain symptoms among patients with anxiety disorders. Despite receiving, rave reviews, brain imaging experiments remain incomplete due to the lack of clinical trials.

Stress

Stress has to be considered in any discussion relating to the causes of AD due to the significant role it plays. The main cause of PTSD, for instance, is stress. However, its role is less clear in other disorders such as OCD and GAD. Nevertheless, patients commonly trace back the onset of their anxiety disorders (AD) to a particularly stressful event or being exposed to a continuously stressful environment. Moreover, relapses in chronic anxiety have sometimes been attributed to stress as well. Certain studies even go as far as relating stress to biological changes in certain brain structures (McEwen et al., 2015).

Treatment Strategies

Pharmacological Therapy

Anxiety disorders are significantly influenced by neurotransmitters which can be targeted by medication as a way of treating AD. The below classes of medication are used by clinical practitioners to treat or manage anxiety disorders.

Selective Serotonin Reuptake Inhibitors (SSRIs)

These are considered the first medical treatment option for anxiety disorders. They include drug classes such as fluoxetine, sertraline, fluvoxamine, escitalopram, citalopram, paroxetine, and vilazodone (Bhagat et al., 2019). These medications appear to desensitize serotonin receptors and inhibit the transportation of serotonin altogether, hence restoring the associate pathways to normal.

Benzodiazepines

These are no-longer the first to be considered in the AD treatment due to the adverse side effects associated with their continuous use. The side effects, when administered in high doses, include dependence, potentially fatal withdrawal symptoms, and reduced body coordination and cognition. Benzodiazepines can also lead to death when mixed with alcohol or opioids. Nevertheless, when given in small doses, they are quite effective in reducing acute anxiety.

Anti-seizure Medications

Physicians have resorted to anti-sure medications as an alternative to benzodiazepines which have side effects. These drugs were previously used to stabilize mood among AD patients. They are now extensively used to treat anxiety due to their anxiolytic (anxiety-relieving) properties. They are, however, administered in small doses due to their side effects in high doses are just as adverse as benzodiazepines (Hellwig et al., 2010).

Cognitive–Behavior Therapy

The treatment of anxiety disorders is incomplete without cognitive-behavior therapy (CBT) sessions. The primary care setting needs proper staff training and education to ensure the availability of good therapy to supplement medicinal treatments. The increasing number of self-administered internet-based therapies is a clear indicator of the need for additional research in CBT. Self-treatment may not adequately address complex AD as it would a specific phobia. Koszycki et al. (2010) addressed the possibility of patients administering CBT on their own and concluded that self-administered CBT might be effective when combined with other therapies.

There are undoubtedly many treatments available to effectively treat anxiety disorders. However, their effectiveness is not universal for all patients and all anxiety disorders. A complex case of PTSD is not as easy to treat as a simple phobia. SSRIs and CBT, however, have numerous studies to support their efficacy in the treatment of AD. CBT may have a long-lasting effect on patients who stick to the skills they acquire in therapy although there’s room for more research.

CBT Technique

CBT techniques are not too different from other forms of psychotherapy. The patient consults the professional caregiver who develops a warm and safe space within which the patient can receive treatment. The objective of the caregiver, in this case, has to be enabling the patient to function effectively in their daily life. The therapist has to establish clear goals for the patient and use science-based techniques to re-align the patient’s bodily and mental sensations with reality while discouraging irrational and dysfunctional thinking.

The relationship between the CBT care-giver and the patient has to inspire support and trust. This way, the patient can examine their erroneous behaviors and beliefs that cause them to be paralyzed by fear and anxiety. The therapist has to give careful consideration to the origins, development, and progress of the patient’s disorder over time. They can rely on psychoeducational resources and manuals to propose daily activities that can help the patient learn more constructive ways of managing and reducing their reactions. The objective of such activities would be to change the patient’s dysfunctional and irrational beliefs. Exposure exercises can then be used to help the patient develop adaptive coping mechanisms. AD patients must understand the relationship between thoughts, feelings, and behaviors based on reality.

The effectiveness of the treatment will have a direct impact on the patient’s continued compliance with the therapy. Therapists can assist patients to conduct a cost-benefit analysis of their irrational behaviors and thoughts to improve the effectiveness of the therapy and increase compliance (Aviram & Westra, 2011).

Patients can be motivated to confront their anxieties through symptom reduction and self-monitoring techniques. Relation and breathing techniques can be incorporated as a way of strengthening them mentally to deal with stressors that trigger their anxiety. The patient is then able to notice whether their stressors are growing over time. The patient’s thoughts are critical to the CBT model of treating anxiety disorders (Howells, 2018) Irrational beliefs have to be changed for the triggers to be reduced and for the coping mechanisms to change from escapism and avoidance.

Exposure

Although it may seem counterintuitive, exposing the patient to the thought, situation, or image that triggers the anxiety is an essential component of CBT. The technique’s main objective is to substantially reduce the patient’s irrational or exaggerated thoughts. The patient is systematically and gradually presented with the thought causing their anxiety over a long period. The objective is to enable development mechanisms of decreasing their anxiety without escaping or avoiding them. For instance, a patient with an irrational fear of parrots might initially be shown a picture of a parrot, then asked to walk on a street with a pet shop, before finally coming into contact with an actual parrot. The therapist would take the patient through each of these steps repeatedly while taking care not to overwhelm them. The idea is for the patient to gradually experience their anxiety lessening at each step of the exercise before progressing to the next. In this way, the anxiety-trigger is reduced and the irrational or exaggerated fear of parrots can be modified to a more rational belief that most birds are harmless.

Acceptance or Mindfulness

The evolution of CBT for anxiety has resulted in an approach that is based on acceptance. This is not a strictly behavioral approach nor is it a cognitive approach (Germer, 2005, p. 3). On the contrary, it is a Buddhist-inspired meditation that encourages awareness and acceptance of present experiences. The integration of mindfulness into CBT has yielded what is termed mindfulness-based cognitive therapy (MBCT). It has been applied in the treatment of anxiety disorders, especially panic disorders. It proposes mindful awareness as a way of preventing relapse by enabling patients to distinguish between their current symptoms and relapsing. The therapy requires mental focus and involves meta-cognitive exercises aimed at helping the patient cope with their anxiety disorder. It encourages observing and accepting thoughts that cause anxiety instead of struggling to change them (Hayes et al., 2003).

Conclusion

From the above, it is clear that anxiety disorders are manageable and treatable. Indeed there are a variety of effective treatment approaches that have been developed to treat anxiety disorders. However, treatment of and response to anxiety disorders can be further refined through research that integrates the available knowledge on the biological mechanisms of anxiety into their treatment. An understanding of the biological and psychological factors at play is important in developing therapies for anxiety disorders. Additionally, the triggers and processes responsible for the development of symptoms associated with AD need to be investigated. There’s also a need to refine the ways by which the available treatment is effectively administered in health-care facilities especially by primary care providers as well as create public awareness through the media. Moreover, the effectiveness of alternative therapies in the treatment and/or prevention of AD should continuously be tested as a way of helping patients who fail to find relief through conventional treatments. The care given to AD patients can also be enhanced by fully appreciating their feelings toward mental illness and providing them with treatment early enough.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. American Psychiatric Pub.

Aviram, A., & Alice Westra, H. (2011). The impact of motivational interviewing on resistance in cognitive behavioural therapy for generalized anxiety disorder. Psychotherapy Research, 21(6), 698-708. https://doi.org/10.1080/10503307.2011.610832

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Bhagat, V., Symbak, N. B., Husain, R., & Mat, K. C. (2019). The role of selective serotonin reuptake inhibitors and cognitive behavioral therapy in preventing relapse of major depressive disorder. Research Journal of Pharmacy and Technology, 12(8), 3818. https://doi.org/10.5958/0974-360x.2019.00654.1

Germer, C. K. (2005). Mindfulness (1st ed.). Guilford Press.

Greenberg, R. (2015). Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections/pediatric acute-onset neuropsychiatric syndromes vs. pediatric bipolar disorder—A possible connection? Neurology, Psychiatry and Brain Research, 21(3), 127. https://doi.org/10.1016/j.npbr.2015.08.002

Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (2003). Acceptance and commitment therapy: An experiential approach to behavior change. Guilford Press.

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