Anxiety; It is a feeling of anxiety that is unknown, sincere, uncertain, fear, anxiety, distress, anxiety that something bad will happen. It is a kind of alarm feeling that threatens life or is perceived as a threat. It is a reaction to internal or external dangers or expectations of danger. It can be of different intensities, from very mild tension and uneasiness to panic. Anxiety has an adaptive function as well as pathological features. It also has a protective, warning and precautionary aspect against internal and external dangers. It tries to cope with these perceived dangers, to take precautions and to protect itself by using self (ego) defense mechanisms. If the ego strength is in place, the problem is solved. Therefore, it is not always easy to distinguish between pathological and normal anxiety.
CAUSES OF Occurrence
1. Psychological assumptions
a. Psychoanalytic assumption: According to this view, anxiety is basically the product of an internal conflict (intrapsychic). The conflict here can occur between the self and the id, or between the self and the superego. In accordance with the pleasure principle from the id, the impulses that seek satisfaction are blocked by the realities of the superego. If the self suppresses the impulse (repression) by resolving the conflict between them, the problem is solved. If the self cannot resolve the conflict, if it cannot suppress it, it perceives it as a danger. This whole process happens unconsciously. In the field of consciousness, anxiety arises. This is called “free-floating anxiety”. If suppression does not work, if he uses other defense mechanisms to cope with this conflict, clinical manifestations of other anxiety disorders develop according to the defense mechanism he uses.
b. Behavioral assumption: According to the behaviorist view, anxiety is a learned process. Conditioned stimuli cause unconditioned responses. In addition, social learning and family reactions are taken as a model.
c. Cognitive assumption: According to this assumption, the cause of anxiety is not the event itself, but how this event is interpreted and perceived by the person. Anxiety occurs as a result of perceiving events with distorted thought patterns.
2) Biological assumptions: It is thought that the sympathetic activity in the autonomic nervous system increases in anxiety disorders, resulting in physiological symptoms. In biochemical studies, neurotransmitters are emphasized and noradrenaline and serotonin levels are thought to increase. In addition, panic attacks can be created artificially by administering some neurochemical substances (such as sodium lactate). Apart from these, it is also mentioned that there is a hereditary predisposition.
Anxiety disorders are covered as subheadings in DSM-IV. These:
1. Generalized Anxiety Disorder
2. Panic Disorder – With Agoraphobia -Without Agoraphobia
3. Specific Phobia
4. Social Phobia
5. Obsessive-Compulsive Disorder
6. Posttraumatic Stress Disorder
7. Acute Stress Disorder
8.Anxiety Disorder Due to General Medical Condition
9. Substance-Related Anxiety Disorder
10. Anxiety Disorder Not Otherwise Specified
Basically, the symptoms are similar in anxiety disorders. However, according to the defense mechanisms used, different clinical pictures occur with different symptoms. Generally speaking, anxiety has 4 basic clinical features.
1) Cognitive symptoms: Change in sense of reality, perception of the environment as changing, distraction, difficulty concentrating, anxiety about losing control, fear of physical harm.
2) Affective symptoms:Fear, restlessness, indifference, helplessness, sense of alarm, panic.
3) Behavioral symptoms: Avoidance of anxiety-provoking situations, freezing.
4) Physiological signs:
Cardiovascular system: Palpitations, blood pressure changes, pale color or flushing
Respiratory system: Shortness of breath, air hunger, tightness in the throat, choking sensation
Gastrointestinal system: Difficulty in swallowing, anxiety, vomiting, diarrhea, abdominal pain),
Genitourinary system: Frequent urination, impotence, sexual reluctance
Skin symptoms: Sweating, flushing, hot flashes
Neurological: Tremor, paresthesia, anaesthesia, dizziness, fainting or fainting, muscle tension, motor restlessness
COMMON ANXIETY DISORDER
It is defined as a condition that impairs social and occupational functionality, presenting with symptoms such as anxiety and anxious expectation, restlessness, fatigue, tension, and difficulty concentrating almost every day for at least 6 months. Its prevalence varies between 3-8%. It is twice as common in women. Symptoms such as widespread and intense anxiety, restlessness, irritability, tremor, headache, sweating, palpitation, stomach complaints, feeling of suffocation, anxious expectation are prominent among the clinical features. Most of the patients refer to non-psychiatric physicians because of somatic symptoms, and they are often misdiagnosed. In the premenstrual period, the complaints become more severe. They often faced life challenges in the beginning. It shows a continuous trend. It exacerbates as it encounters stress. Differential diagnosis should be made from thyroid diseases, CVS diseases, and other anxiety disorders. Treatment should last at least 6-12 months. Benzodiazepines should be used for a limited time. Tricyclic antidepressants, beta blockers, buspirone, antihistamines can be used for treatment. They benefit from cognitive-behavioral, supportive psychotherapeutic approaches.
It is a clinical picture with spontaneous and unexpected panic attacks. A panic attack is an intense anxiety attack that occurs suddenly and unexpectedly, lasting ½-1 hour, accompanied by somatic symptoms. 4 or more of the symptoms such as palpitation, sweating, tremor, shortness of breath, feeling of suffocation, chest pain, nausea, dizziness, drowsiness, fear of losing control, fear of going crazy, fear of death, numbness and tingling, chills, chills, feelings of changing environment in attacks. must be.
The first panic attack often occurs spontaneously. Any arousal, physical exercise, emotional trauma, caffeine, alcohol, substance use can trigger the first attack. Attacks begin abruptly, with symptoms reaching their peak in about 10 minutes. The main symptom is fear of death, loss of control, and going crazy. The origin of this fear is unclear. Physiological symptoms of co-anxiety are intense. Leaving the place where they are, seeking help behavior is observed. Apart from the attacks, there is the fear that the attacks will recur, that is, the anxiety of expectation.
It often occurs in late adolescence or mid-30s. Its lifetime prevalence is between 1.5-3%. It is 2-3 times more common in women.
If a panic attack occurs in a situation or place where it is difficult for the person to escape or get help, and such a situation is avoided, it is called “Panic Disorder (with agoraphobia)”. Typically, these environments are situations such as being alone outside the house, being in a crowd, traveling in vehicles such as buses, trains, being on a bridge or in an elevator. The person endures these environments with intense distress. Often avoids being in such environments or can withstand being accompanied by someone. Avoidance behavior disrupts the person’s social and professional life. 20-80% are accompanied by depressive symptoms.
In the differential diagnosis, cardiac problems such as hyperthyroidism, hyperparathyroidism, pheochromocytoma, vestibular dysfunctions, epileptic disorders, arrhythmia and supraventricular tachycardia, substance use, hypoglycemia should be evaluated.
Among the tricyclic antidepressants, cloimipramine and imipramine are the first choice in treatment. If it cannot be tolerated or used due to side effects, SSRIs, MAO inhibitors can be used. Response to the drug is obtained in an average of 8-12 weeks. Initially, benzodiazepines (alprozolam, clonazepam, lorazepam) can be used together. Beta-blockers can be added to soothe autonomic symptoms. An average of 8-12 months of treatment should last. Cognitive-behavioral psychotherapeutic methods can be used together.
An extreme, senseless fear that begins with the expectation of the presence or encounter of a specific object or situation. When the phobic stimulus is encountered, a sudden onset of anxiety response occurs. It can turn into a panic attack. The person knows that the fear is excessive or meaningless. Still, he engages in avoidance behavior to avoid these situations. The avoidance, fear, or anxious anticipation of encountering the phobic stimulus significantly interferes with the person’s normal daily activities, occupational functioning, or social life.
Anxiety in children can be expressed as crying, moodiness, freezing, clinging.
The 6-month prevalence is around 5-10%. It is 2 times more common in women.
The basic psychodynamic view among the causes of phobias is the transfer of impulses that are not accepted by the unconscious self to external objects by replacement.
Animal type: Usually begins in childhood.
Natural environment type: Environments such as storms, high places. It often begins in childhood.
Blood-injection-wound type: It is usually familial. Vasovagal response is often seen.
Situational type: Occurs when faced with situations such as tunnels, elevators, getting on a plane, driving, closed places. It is common in childhood and twenties. Other type: Space phobia, childhood fear of fairy tale heroes or loud noises.
In the differential diagnosis, it should be differentiated from panic disorder with agoraphobia. In situational-type phobia, the focus of fear is on what will happen in those environments (like falling, getting injured). In panic disorder with agoraphobia, the focus of fear is about not being able to get help or escape.
TCA’s, SSRI’s, beta-blockers are useful in its treatment. They also benefit from behavioral approaches (going to the top).
It is characterized by excessive anxiety and fear that it will be negatively evaluated, humiliated, humiliated when performing an action (such as speaking, eating, making phone calls) in social environments (especially by strangers, in the presence of others, in the crowd). When the feared stays in a social environment, symptoms of anxiety always appear and can lead to a panic attack. The person knows that this is excessive or meaningless. However, he avoids such situations, which impairs his social and professional functioning.
The age of onset is adolescence. Its 6-month prevalence is around 2-3%. It is more common in women than men.
At the core of social phobia is the desire to make a positive impression on others and insecurity about being able to do so. The fact that social phobics focus their attention selectively on negative situations in order to find evidence of their thoughts and beliefs that they will be negatively evaluated also increases their anxiety. They may be afraid to speak in public because they are worried that others will notice that their hands or voices are shaking, or they may be extremely anxious when talking to others for fear of appearing as if they cannot speak properly.
Social phobia can be seen together with avoidant personality disorder and obsessive compulsive personality disorder. Along with personality disorder, social phobia has a high frequency of symptoms, social anxiety and significant impairment in function, and these patients have a poor response to treatment.
MAO inhibitors (moclobemide), SSRI’s, benzodiazpines can be used in its treatment. In addition, cognitive and behavioral treatment methods and social skills training are useful.
OBSESSIVE COMPULSIVE DISORDER
Obsessions are recurrent, persistent, anxiety-inducing, unwanted, alien (ego dystonic) thoughts, impulses, or fantasies. Compulsion (compulsion); Repetitive behaviors or mental acts that are done to banish obsessions. The person sees his obsessions as a product of his own mind and knows that they are illogical or absurd. Compulsions, on the other hand, are done to reduce the anxiety caused by the obsession, are not related to reality, are obviously exaggerated, and provide temporary relief. It is aimed at neutralizing the obsession. Obsessions and compulsions cause waste of time, disruption of daily work, and deterioration of social and occupational functionality.
The average age of onset is in the 20s. Its lifetime prevalence is around 2-3%. Most of the time, it starts insidiously and has a chronic exacerbation and remission. These exacerbations may be related to stress.
Biological reasons have an important place among the causes of occurrence. The effectiveness of serotonin reuptake inhibitors used in its treatment suggested that the serotonergic system plays a role in the disorder. In brain imaging studies, there is evidence of shrinkage, especially in the caudate nucleus. In hereditary studies, similar disease history is found 5-10 times more often in first-degree relatives of patients with OCD.
According to classical psychoanalytic theory, regression to the anal stage is the main mechanism. Characteristics of this period (stinginess, indecision, excessive regularity, meticulousness, stubbornness) are common in these people. These are people with intense magical thoughts and a rigid and punitive superego. Isolation, jigsaw puzzle (undoing), counter reaction (reaction-formation), displacement are frequently used defense mechanisms.
Clinical features: An idea or impulse spontaneously and persistently enters one’s consciousness. The anxiety caused by this pushes the person to take precautions. To counter them, compulsions arise to neutralize them. There are 4 main symptom patterns.
1. Contamination: It is the most common. The person thinks that they are contaminated with urine, feces, dust or germs. It believes that this contagion is transmitted from object to object, from person to person. To eliminate this, he engages in washing, cleansing actions, or tries to avoid them.
Doubt 2: The person believes that he did not do some actions, forgot, neglected (in the form of leaving the door, tap, air gas open). This is followed by compulsions to control. He checks repeatedly whether the stove is closed or not.
3. Thoughts of sexual or aggressive actions (such as thoughts of killing or sexually harassing your child)
4. Symmetry-prescriptive: It is in the form of wanting some situations to be in a certain order. It is in the form of repetitive actions (e.g. eating, washing face).
5. The most common obsessions are contagion (55%), suspicion, sexual or aggressive thoughts. The most common compulsions are washing, cleaning, checking, counting, praying and asking questions.
In its treatment, cloimipramine and SSRIs are useful. Response is received in 8-16 weeks. It should be used in higher doses than the antidepressant dose. If necessary, anxiolytics, antipsychotics can be added. Behavioral psychotherapy (confrontation, reaction delay, desensitization) is very helpful.
POSTTRAUMATIC STRESS DISORDER
Occurring after encountering a stressful event that can cause serious distress in almost everyone; It is a clinical picture that goes with re-experiencing the traumatic event in dreams and thoughts, avoiding events or situations that remind the trauma, emotional unresponsiveness, autonomic hyperarousal, alertness, and startle. Traumas that can lead to this situation are war, natural disasters, life-threatening accidents, assault or rape. The person has experienced or witnessed the threat of death or injury in these events. Avoids anything that evokes the traumatic event. If he has to face it, he experiences intense anxiety. He experiences the trauma over and over again in his dreams and thoughts. Due to his avoidance behavior, he moves away from people and his functionality is impaired. Excessive startle, arousal state, difficulty falling asleep, inability to concentrate, irritability can be seen.
Posttraumatic stress disorder can begin at any age, including childhood. The prevalence is around 1-3%. Symptoms are considered acute if they begin within 3 months of the traumatic event, and chronic if they begin after 3 months.
If the condition that occurs after the traumatic event lasts less than 1 month, it is diagnosed as “Acute Stress Disorder”.
Providing psychological support to the patient, encouraging discussion of the event, relaxation exercises and pharmacotherapeutic approaches such as imipramine and amitriptyline are helpful in the treatment.
GENERAL MEDICAL CONDITION ANXIETY DISORDER
The main feature is the presence of clinically significant anxiety due to the physiological effects of a general medical condition. Symptoms may include generalized anxiety disorder, panic attacks, or obsessions. Evidence related to a general medical condition may be found in the history, physical examination, and laboratory. Hyperthyroidism, hypothyroidism, pheochromocytoma, vitamin B12 deficiency, cardiac arrhythmia, hypoglycemia, anemia, chronic obstructive pulmonary diseases, SLE, Parkinson’s, multiple sclerosis are clinical conditions that often cause anxiety disorders. It usually resolves when the underlying disease is treated. Specific treatment can be given if needed.
ANXIETY DISORDER CAUSED BY SUBSTANCE USE
The main feature of anxiety disorder caused by substance use is; The presence of prominent anxiety symptoms that are judged to be due to the physiological effects of a substance. In cases of intoxication of alcohol, amphetamine, cocaine, cannabis, hallucinogens, inhalants, phencyclidine and similar substances; Anxiety symptoms may occur during withdrawal of alcohol, cocaine, sedatives, hypnotics, and anxiolytics. Anesthetics, analgesics, insulin, thyroid preparations, oral contraceptives, antihistamines, antiparkinsonian drugs, corticosteroids, antihypertensives, cardiovascular drugs, anticonvulsions may cause anxiety.