Anxiety disorders are blanket terms covering several different forms of abnormal and pathological fear Fear is an emotional response to a perceived threat. It is a basic survival mechanism occurring in response to a specific stimulus, such as pain or the threat of danger. Some psychologists such as John B. Watson, Robert Plutchik, and Paul Ekman have suggested that fear is one of a small set of basic or innate emotions. This set also includes such and anxiety Anxiety is a psychological and physiological state characterized by cognitive, somatic, emotional, and behavioral components. These components combine to create an unpleasant feeling that is typically associated with uneasiness, apprehension, fear, or worry. Anxiety is a generalized mood condition that can often occur without an identifiable which only came under the aegis of psychiatry at the very end of the 19th century.^[1] Current psychiatric diagnostic criteria recognize a wide variety of anxiety disorders. Recent surveys have found that as many as 18% of Americans may be affected by one or more of them.^[2]

Classification

Generalized anxiety disorder

Generalized anxiety disorder (GAD) is a common chronic disorder characterized by long-lasting anxiety that is not focused on any one object or situation. Those suffering from generalized anxiety experience non-specific persistent fear and worry and become overly concerned with everyday matters. Generalized anxiety disorder is the most common anxiety disorder to affect older adults.^[3]

Panic disorder

In panic disorder, a person suffers from brief attacks of intense terror and apprehension, often marked by trembling, shaking, confusion, dizziness, nausea, difficulty breathing Breathing is the process that takes oxygen in and carbon dioxide in and then out of the lungs. Aerobic organisms require oxygen to release energy via respiration, in the form of the metabolism of energy-rich molecules such as glucose. The medical term for normal relaxed breathing is eupnea. These panic attacks Panic attack has been described as an episode of incredibly intense fear or apprehension that is of sudden onset. The DSM-IV describes a panic attack as a discrete period of intense fear or discomfort in which symptoms developed abruptly and reached a peak within 10 minutes, defined by the APA The American Psychiatric Association is the main professional organization of psychiatrists and trainee psychiatrists in the United States, and the most influential worldwide. Its some 38,000 members are mainly American but some are international. The association publishes various journals and pamphlets, as well as the Diagnostic and Statistical as fear or discomfort that abruptly arises and peaks in less than ten minutes, can last for several hours and can be triggered by stress, fear, or even exercise; although the specific cause is not always apparent.

In addition to recurrent unexpected panic attacks, a diagnosis of panic disorder also requires that said attacks have chronic consequences: either worry over the attacks' potential implications, persistent fear of future attacks, or significant changes in behavior related to the attacks. Accordingly, those suffering from panic disorder experience symptoms even outside specific panic episodes. Often, normal changes in heartbeat are noticed by a panic sufferer, leading them to think something is wrong with their heart or they are about to have another panic attack. In some cases, a heightened awareness (hypervigilance Hypervigilance is an enhanced state of sensory sensitivity accompanied by an exaggerated intensity of behaviors whose purpose is to detect threats. Hypervigilance is also accompanied by a state of increased anxiety which can cause exhaustion. Other symptoms include: abnormally increased arousal, a high responsiveness to stimuli and a constant) of body functioning occurs during panic attacks, wherein any perceived physiological change is interpreted as a possible life threatening illness (i.e. extreme hypochondriasis Hypochondriasis, hypochondria refers to an excessive preoccupation or worry about having a serious illness. An individual suffering from hypochondriasis is known as a hypochondriac. Often, hypochondria persists even after a physician has evaluated a person and reassured them that their concerns about symptoms do not have an underlying medical) .

Phobias

The single largest category of anxiety disorders is that of phobic disorders A phobia are groups of anxiety disorders characterized by intense and persistent fear of certain situations, activities, things, animals, or people. The main symptom of this disorder is the excessive and unreasonable desire to avoid the feared stimulus. When the fear is beyond one's control, and if the fear is interfering with daily life, then a, which includes all cases in which fear and anxiety is triggered by a specific stimulus or situation. Sufferers typically anticipate terrifying consequences from encountering the object of their fear, which can be anything from an animal to a location to a bodily fluid.

Agoraphobia

Agoraphobia is the specific anxiety about being in a place or situation where escape is difficult or embarrassing or where help may be unavailable.^[4] Agoraphobia is strongly linked with panic disorder Panic disorder is an anxiety disorder characterized by recurring severe panic attacks. It may also include significant behavioral change lasting at least a month and of ongoing worry about the implications or concern about having other attacks. The latter are called anticipatory attacks . Panic disorder is not the same as agoraphobia, although and is often precipitated by the fear of having a panic attack. A common manifestation involves needing to be in constant view of a door or other escape route. In addition to the fears themselves, the term agoraphobia Agoraphobia is an anxiety disorder, traditionally thought to involve a fear of public places and open spaces. However, it is now believed that agoraphobia develops as a complication of panic attacks. However, there is evidence that the implied one-way causal relationship between spontaneous panic attacks and agoraphobia in DSM-IV may be incorrect is often used to refer to avoidance behaviors that sufferers often develop. For example, following a panic attack while driving, someone suffering from agoraphobia may develop anxiety over driving and will therefore avoid driving in the future. These avoidance behaviors can often have serious consequences; in severe cases, one can even be confined to one's home.

Social anxiety disorder

Social anxiety disorder Social anxiety disorder (DSM-IV 300.23), also sometimes called social phobia (SP), is an anxiety disorder characterized by intense fear in social situations causing considerable distress and impaired ability to function in at least some parts of daily life. The diagnosis can be of a specific disorder (when only some particular situations are (SAD; also known as social phobia) describes an intense fear of negative public scrutiny or of public embarrassment or humiliation. This fear Fear is an emotional response to a perceived threat. It is a basic survival mechanism occurring in response to a specific stimulus, such as pain or the threat of danger. Some psychologists such as John B. Watson, Robert Plutchik, and Paul Ekman have suggested that fear is one of a small set of basic or innate emotions. This set also includes such can be specific to particular social situations (such as public speaking) or, more typically, is experienced in most (or all) social interactions. Social anxiety Social anxiety is anxiety about social situations, interactions with others, and being evaluated or scrutinized by other people. It can occur at different times of life, and for different reasons. Developmental social anxiety occurs early in childhood as a normal part of the development of social functioning, and is a stage that most children grow often manifests specific physical symptoms, including blushing, sweating, and difficulty speaking. Like with all phobic disorders, those suffering from social anxiety Social anxiety is anxiety about social situations, interactions with others, and being evaluated or scrutinized by other people. It can occur at different times of life, and for different reasons. Developmental social anxiety occurs early in childhood as a normal part of the development of social functioning, and is a stage that most children grow often will attempt to avoid the source of their anxiety Anxiety is a psychological and physiological state characterized by cognitive, somatic, emotional, and behavioral components. These components combine to create an unpleasant feeling that is typically associated with uneasiness, apprehension, fear, or worry. Anxiety is a generalized mood condition that can often occur without an identifiable; in the case of social anxiety Social anxiety is anxiety about social situations, interactions with others, and being evaluated or scrutinized by other people. It can occur at different times of life, and for different reasons. Developmental social anxiety occurs early in childhood as a normal part of the development of social functioning, and is a stage that most children grow this is particularly problematic, and in severe cases can lead to complete social isolation.

Obsessive–compulsive disorder

Obsessive–compulsive disorder (OCD) is a type of anxiety disorder primarily characterized by repetitive obsessions (distressing, persistent, and intrusive thoughts or images) and compulsions (urges to perform specific acts or rituals). The OCD thought pattern may be likened to superstitions insofar as it involves a belief in a causative relationship where, in reality, one does not exist. Often the process is entirely illogical; for example, the compulsion of walking in a certain pattern may be employed to alleviate the obsession of impending harm. And in many cases, the compulsion is entirely inexplicable, simply an urge to complete a ritual A ritual is a set of actions, performed mainly for their symbolic value. It may be prescribed by a religion or by the traditions of a community. The term usually excludes actions which are arbitrarily chosen by the performers, or dictated purely by logic, chance, necessity, etc triggered by nervousness.

In a slight minority of cases, sufferers of OCD may only experience obsessions, with no overt compulsions; a much smaller number of sufferers experience only compulsions.^[5]

Post-traumatic stress disorder

Post-traumatic stress disorder (PTSD) is an anxiety disorder which results from a traumatic experience. Post-traumatic stress can result from an extreme situation, such as combat, natural disaster, rape, hostage A hostage is a person or entity which is held by a captor. The original definition meant that this was handed over by one of two belligerent parties to the other or seized as security for the carrying out of an agreement, or as a preventive measure against certain acts of war. However, in modern days, it means someone who is seized by a criminal situations, more serious kinds of child abuse Child abuse is the physical, sexual or emotional mistreatment of children. In the United States, the Centers for Disease Control and Prevention define child maltreatment as any act or series of acts of commission or omission by a parent or other caregiver that results in harm, potential for harm, or threat of harm to a child. Most child abuse, or even a serious accident. It can also result from long term (chronic) exposure to a severe stressor,^[6] for example soldiers who endure individual battles but cannot cope The psychological definition of coping is the process of managing taxing circumstances, expending effort to solve personal and interpersonal problems, and seeking to master, minimize, reduce or tolerate stress or conflict with continuous combat. Common symptoms include hypervigilance Hypervigilance is an enhanced state of sensory sensitivity accompanied by an exaggerated intensity of behaviors whose purpose is to detect threats. Hypervigilance is also accompanied by a state of increased anxiety which can cause exhaustion. Other symptoms include: abnormally increased arousal, a high responsiveness to stimuli and a constant, flashbacks A flashback is a psychological phenomenon in which an individual has a sudden, usually powerful, re-experiencing of a past experience or elements of a past experience. The term is used particularly when the memory is recalled involuntarily, and/or when it is so intense that the person "relives" the experience, unable to fully recognize, avoidant behaviors, anxiety, anger and depression.^[5]

Separation anxiety

Separation anxiety disorder (SepAD) is the feeling of excessive and inappropriate levels of anxiety over being separated from a person or place. Separation anxiety itself is a normal part of development Developmental psychology, also known as human development, is the scientific study of systematic psychological changes that occur in human beings over the course of their life span. Originally concerned with infants and children, the field has expanded to include adolescence, adult development, aging, and the entire life span. This field examines in babies or children, and it is only when this feeling is excessive or inappropriate that it can be considered a disorder.^[7] Separation anxiety disorder affects roughly 7% of adults and 4% of children, but the childhood cases tend to be more severe, in some instances even a brief separation can produce panic.^[8][9]

Childhood anxiety disorders

Children as well as adults experience feelings of anxiousness, worry Worry is thoughts and images of a negative nature in which mental attempts are made to avoid anticipated potential threats. As an emotion it is experienced as anxiety or concern about a real or imagined issue, usually personal issues such as health or finances or broader ones such as environmental pollution and social or technological change. Most and fear Fear is an emotional response to a perceived threat. It is a basic survival mechanism occurring in response to a specific stimulus, such as pain or the threat of danger. Some psychologists such as John B. Watson, Robert Plutchik, and Paul Ekman have suggested that fear is one of a small set of basic or innate emotions. This set also includes such when facing different situations, especially those involving a new experience. However, if anxiety is no longer temporary and begins to interfere with the child's normal functioning or do harm to their learning Learning is acquiring new knowledge, behaviors, skills, values, preferences or understanding, and may involve synthesizing different types of information. The ability to learn is possessed by humans, animals and some machines. Progress over time tends to follow learning curves, the problem may be more than just an ordinary anxiousness and fear common to the age.^[10]

When children suffer from a severe anxiety disorder their thinking, decision-making Decision making can be regarded as the mental processes resulting in the selection of a course of action among several alternatives. Every decision making process produces a final choice. The output can be an action or an opinion of choice ability, perceptions of the environment, learning and concentration In chemistry, concentration is the measure of how much of a given substance there is mixed with another substance. This can apply to any sort of chemical mixture, but most frequently the concept is limited to homogeneous solutions, where it refers to the amount of solute in the solvent get affected. They not only experience fear, nervousness, and shyness In humans, shyness is a social psychology term used to describe the feeling of apprehension, lack of confidence, or awkwardness experienced when a person is in proximity to, approaching, or being approached by other people, especially in new situations or with unfamiliar people. Shyness may come from genetic traits, the environment in which a but also start avoiding places and activities. Anxiety also raises blood pressure Blood pressure is a force exerted by circulating blood on the walls of blood vessels, and is one of the principal vital signs. During each heartbeat, BP varies between a maximum (systolic) and a minimum (diastolic) pressure. The mean BP, due to pumping by the heart and resistance in blood vessels, decreases as the circulating blood moves away from and heart rate Heart rate is the number of heartbeats per unit of time - typically expressed as beats per minute - which can vary as the body's need for oxygen changes, such as during exercise or sleep. The measurement of heart rate is used by medical professionals to assist in the diagnosis and tracking of medical conditions. It is also used by individuals, and can cause nausea Nausea , is a sensation of unease and discomfort in the upper stomach with an urge to vomit. An attack of nausea is known as a qualm, vomiting Vomiting is the forceful expulsion of the contents of one's stomach through the mouth and sometimes the nose. Vomiting may result from many causes, ranging from gastritis or poisoning to brain tumors, or elevated intracranial pressure. The feeling that one is about to vomit is called nausea, which usually precedes, but does not always lead to,, stomach pain, ulcers, diarrhea Diarrhea , also spelled diarrhoea, is the condition of having three or more loose or liquid bowel movements per day. It is a common cause of death in developing countries and the second most common cause of infant deaths worldwide. The loss of fluids through diarrhea can cause dehydration and electrolyte imbalances. In 2009 diarrhea was estimated, tingling, weakness, and shortness of breath Dyspnea or dyspnoea , (from Latin dyspnoea, from Greek dyspnoia from dyspnoos, shortness of breath), also called shortness of breath (SOB) or air hunger, is a debilitating symptom that is the experience of unpleasant or uncomfortable respiratory sensations. It is a common symptom of numerous medical disorders, particularly those involving the.^[11] Some other symptoms are frequent self-doubt and self-criticism Self-criticism refers to the pointing out of things critical/important to one's own beliefs, thoughts, actions, behaviour or results; it can form part of private, personal reflection or a group discussion. It is an essential element of critical thought comments, irritability Irritability is an excessive response to stimuli. The term is used for both the physiological reaction to stimuli and for the pathological, abnormal or excessive sensitivity to stimuli; It is usually used to refer to anger or frustration, sleep problems, and in extreme cases, thoughts of not wanting to be alive.

If these children are left untreated, they face different risks such as poor results at school, avoidance of important social activities, and substance abuse Substance abuse, also known as drug abuse, refers to a maladaptive pattern of use of a substance that is not considered dependent. The term "drug abuse" does not exclude dependency, but is otherwise used in a similar manner in nonmedical contexts. The terms have a huge range of definitions related to taking a psychoactive drug or. Children who suffer from an anxiety disorder are likely to suffer other disorders such as depression Major depressive disorder is a mental disorder characterized by an all-encompassing low mood accompanied by low self-esteem, and by loss of interest or pleasure in normally enjoyable activities. The term "major depressive disorder" was selected by the American Psychiatric Association to designate this symptom cluster as a mood disorder, eating disorders Eating disorders are a group of conditions characterized by abnormal eating habits that may involve either insufficient or excessive food intake to the detriment of an individual's physical and emotional health, binge eating disorder, bulimia nervosa, anorexia nervosa being the most common specific forms in the United States, Primarily thought of, and attention deficit disorders Attention-Deficit Hyperactivity Disorder is a neurobehavioral developmental disorder. It is primarily characterized by "the co-existence of attentional problems and hyperactivity, with each behavior occurring infrequently alone" and symptoms starting before seven years of age, both hyperactive and inattentive.^[12]

About 13 of every 100 children and adolescents between 9 to 17 years experience some kind of anxiety disorder and girls are more affected than boys. The basic temperament of children may be key in some of their childhood and adolescent disorders.

Research in this area is very difficult to be performed because as children grow their fears change making it difficult for researchers to obtain enough data and thus more reliable results. For instance, between the ages of 6 and 8, children's fear of the dark and imaginary creatures decreases, but they become more anxious about school performance and social relationships An interpersonal relationship is an association between two or more people that may range from fleeting to enduring. This association may be based on limerence, love and liking, regular business interactions, or some other type of social commitment. Interpersonal relationships take place in a great variety of contexts, such as family, friends,. If children experience an excessive amount of anxiety during this stage, this could later lead to development of anxiety disorders later in life.^[13]

According to research, children anxiety disorders are caused by biological and psychological factors. Also, it is suggested that when children have a parent with anxiety disorders, they are more likely to have an anxiety disorder, too. Stress Stress is a term in psychology and biology, first coined in the 1930s, which has in more recent decades become a commonplace of popular parlance. It refers to the consequence of the failure of an organism – human or animal – to respond appropriately to emotional or physical threats, whether actual or imagined also can trigger anxiety disorders, but also, children and adolescents with anxiety disorders seem to have an increased physical and psychological reaction to stress. Their reaction to danger, even if it is a small one, is more quickly and more strongly.^[14]

Causes

Biological

Low levels of GABA, a neurotransmitter that reduces activity in the central nervous system, contribute to anxiety. A number of anxiolytics achieve their effect by modulating the GABA receptors.^[15][16][17]

Selective serotonin reuptake inhibitors, the drugs most commonly used to treat depression, are also frequently considered as a first line treatment for anxiety disorders.^[18] A recent study using functional brain imaging techniques suggests that the effects of SSRIs in alleviating anxiety may result from a direct action on GABA neurons rather than as a secondary consequence of mood improvement.^[19]

Severe anxiety and depression are commonly induced by sustained alcohol abuse which in most cases abates with prolonged abstinence. Even moderate, sustained alcohol use may increase anxiety and depression levels in some individuals.^[20] Caffeine, alcohol and benzodiazepines can worsen or cause anxiety and panic attacks.^[21] In one study in 1988–1990,^[22] illness in approximately half of patients attending mental health services at one British hospital psychiatric clinic, for conditions including anxiety disorders such as panic disorder or social phobia, was determined to be the result of alcohol or benzodiazepine dependence. In these patients, cessation of their anxiety symptoms corresponded with stopping the use of the benzodiazepine or alcohol.

Intoxication from stimulants is likely to be associated with repetitive panic attacks.^{[citation needed]}

There is evidence that chronic exposure to organic solvents in the work environment can be associated with anxiety disorders. Painting, varnishing and carpet laying are some of the jobs in which significant exposure to organic solvents may occur.^[23]

People with obsessive-compulsive disorder (sometimes considered an anxiety disorder), evince increased grey matter volumes in bilateral lenticular nuclei, extending to the caudate nuclei, while decreased grey matter volumes in bilateral dorsal medial frontal/anterior cingulate gyri.^[24][25] These findings contrast with those in people with other anxiety disorders, who evince decreased (rather than increased) grey matter volumes in bilateral lenticular / caudate nuclei, while also decreased grey matter volumes in bilateral dorsal medial frontal/anterior cingulate gyri.^[25]

Amygdala

The amygdala is central to the processing of fear and anxiety, and its function may be disrupted in anxiety disorders.^[26] Sensory information enters the amgydala through the nuclei of the basolateral complex (consisting of lateral, basal, and accessory basal nuclei). The basolateral complex processes sensory related fear memories, and communicate their threat importance to memory and sensory processing elsewhere in the brain, such as the medial prefrontal cortex and sensory cortices.

Another important area is the adjacent central nucleus of the amygdala, which controls species-specific fear responses, via connections to the brainstem, hypothalamus, and cerebellum areas. In those with general anxiety disorder, these connections functionally seem to be less distinct, with greater gray matter in the central nucleus. Another difference is that the amygdala areas have decreased connectivity with the insula and cingulate areas that control general stimulus salience, while having greater connectivity with the parietal cortex and prefrontal cortex circuits that underlie executive functions.^[26]

The latter suggests a compensation strategy for dysfunctional amygdala processing of anxiety. Researchers have noted "Amygdalofrontoparietal coupling in generalized anxiety disorder patients may .. reflect the habitual engagement of a cognitive control system to regulate excessive anxiety."^[26] This is consistent with cognitive theories that suggest the use in this disorder of attempts to reduce the involvement of emotions with compensatory cognitive strategies.

Clinical and animal studies suggest a correlation between anxiety disorders and difficulty in maintaining balance.^{[27][28][29][30]} A possible mechanism is malfunction in the parabrachial nucleus, a brain structure that, among other functions, coordinates signals from the amygdala with input concerning balance.^[31]

Anxiety processing in the basolateral amygdala has been implicated with dendritic arborization of the amygdaloid neurons. SK2 potassium channels mediate inhibitory influence on action potentials and reduce arborization. By overexpressing SK2 in the basolateral amygdala, anxiety in experimental animals can reduced together with general levels of stress-induced corticosterone secretion.^[32]

Stress

Anxiety disorder can arise in response to life stresses such as financial worries or chronic physical illness. Somewhere between 4% and 10% of older adults are diagnosed with anxiety disorder, a figure which is probably an underestimate due to the tendency of adults to minimize psychiatric problems or to focus on their physical manifestations. Anxiety is also common among older people who have dementia. On the other hand, anxiety disorder is sometimes misdiagnosed among older adults when doctors misinterpret symptoms of a physical ailment (for instance, racing heartbeat due to cardiac arrhythmia) as signs of anxiety.^[3]

Diagnosis

Anxiety disorders are often debilitating chronic conditions, which can be present from an early age or begin suddenly after a triggering event. They are prone to flare up at times of high stress and are frequently accompanied by physiological symptoms such as headache, sweating, muscle spasms, palpitations, and hypertension, which in some cases lead to fatigue or even exhaustion.

Although in casual discourse the words anxiety and fear are often used interchangeably, in clinical usage, they have distinct meanings; anxiety is defined as an unpleasant emotional state for which the cause is either not readily identified or perceived to be uncontrollable or unavoidable, whereas fear is an emotional and physiological response to a recognized external threat. The term anxiety disorder, however, includes fears (phobias) as well as anxieties.

Anxiety disorders are often comorbid with other mental disorders, particularly clinical depression, which may occur in as many as 60% of people with anxiety disorders. The fact that there is considerable overlap between symptoms of anxiety and depression, and that the same environmental triggers can provoke symptoms in either condition, may help to explain this high rate of comorbidity.^[33]

Studies have also indicated that anxiety disorders are more likely among those with family history of anxiety disorders, especially certain types.^[34]

Sexual dysfunction also often accompanies anxiety disorders, although it is difficult to determine whether anxiety causes the sexual dysfunction, or whether they arise from a common cause. The most common manifestations in individuals with anxiety disorder are avoidance of intercourse, premature ejaculation or erectile dysfunction among men and pain during intercourse among women. Sexual dysfunction is particularly common among people affected by panic disorder (who may fear that a panic attack will occur during sexual arousal) and posttraumatic stress disorder.^[35]

Treatment

The most important clinical point to emerge from studies of social anxiety disorder is the benefit of early diagnosis and treatment. Social anxiety disorder remains under-recognized in primary care practice, with patients often presenting for treatment only after the onset of complications such as clinical depression or substance abuse disorders.

Treatment options available include lifestyle changes; psychotherapy, especially cognitive behavioral therapy; and pharmaceutical therapy. Education, reassurance and some form of cognitive-behavioral therapy should almost always be used in treatment.^{[citation needed]} Research has provided evidence for the efficacy of two forms of treatment available for social phobia: certain medications and a specific form of short-term psychotherapy called Cognitive-behavioral therapy (CBT), the central component being gradual exposure therapy.

Psychotherapy

Research has shown that cognitive-behavioral therapy (CBT) can be highly effective for several anxiety disorders, particularly panic disorder and social phobia.^[36] CBT, as its name suggests, has two main components, cognitive and behavioral. In cases of social anxiety, the cognitive component can help the patient question how they can be so sure that others are continually watching and harshly judging him or her. The behavioral component seeks to change people's reactions to anxiety-provoking situations.

As such it serves as a logical extension of cognitive therapy, whereby people are shown proof in the real world that their dysfunctional thought processes are unrealistic. A key element of this component is gradual exposure, in which the patient is confronted by the things they fear in a structured, sensitive manner. Gradual exposure is an inherently unpleasant technique; ideally it involves exposure to a feared social situation that is anxiety provoking but bearable, for as long as possible, two to three times a week. Often, a hierarchy of feared steps is constructed and the patient is exposed to each step sequentially.

The aim is to learn from acting differently and observing reactions. This is intended to be done with support and guidance, and when the therapist and patient feel they are ready. Cognitive-behavioral therapy for social phobia also includes anxiety management training, which may include techniques such as deep breathing and muscle relaxation exercises, which may be practiced 'in-situ'. CBT can also be conducted partly in group sessions, facilitating the sharing of experiences, a sense of acceptance by others and undertaking behavioral challenges in a trusted environment (Heimberg).

Some studies have suggested social skills training can help with social anxiety^[37]. However, it is not clear whether specific social skills techniques and training are required, rather than just support with general social functioning and exposure to social situations.^[38]

Additionally, a recent study has suggested that interpersonal therapy, a form of psychotherapy primarily used to treat depression, may also be effective in the treatment of social phobia.^[39]

Medications

When medication is indicated SSRIs, such as fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil) and escitalopram (Lexapro) are generally recommended as first line agents. SNRIs such as venlafaxine (Effexor) are also effective. Benzodiazepines, such as alprazolam (Xanax), clonazepam (Klonopin) and diazepam (Valium) are also sometimes indicated for short-term or PRN use. They are usually considered as a second line treatment due to disadvantages such as cognitive impairment and due to their risks of dependence and withdrawal problems.^[40] MAOIs such as phenelzine (Nardil) and tranylcypromine (Parnate) are also considered an effective treatment and are especially useful in treament resistant cases, however dietary restrictions and medical interactions may limit their use.^[41][42] There is also evidence that certain newer medications including the GABA analogue pregabalin (Lyrica), and the novel antidepressant mirtazapine (Remeron) are also effective treatments for anxiety disorders.^[43][44] TCAs such as imipramine, as well as atypical antipsychotics such as quetiapine, and piperazines such as hydroxyzine are also occasionally prescribed.^[45]

These medications need to be used with extreme care among older adults, who are more likely to suffer side effects because of coexisting physical disorders. Adherence problems are more likely among elderly patients, who may have difficulty understanding, seeing, or remembering instructions.^[3]

SSRIs

Selective serotonin reuptake inhibitors (SSRIs), a class of antidepressants, are considered by many to be the first choice medication for generalised social phobia. These drugs elevate the level of the neurotransmitter serotonin, among other effects. The first drug formally approved by the Food and Drug Administration was paroxetine, sold as Paxil in the U.S. or Seroxat in the UK. Compared to older forms of medication, there is less risk of tolerability and drug dependency.^[46] However, their efficacy and increased suicide risk has been subject to controversy.

In a 1995 double-blind, placebo-controlled trial, the SSRI paroxetine was shown to result in clinically meaningful improvement in 55% of patients with generalized social anxiety disorder, compared with 23.9% of those taking placebo.^[47] An October 2004 study yielded similar results. Patients were treated with either fluoxetine, psychotherapy, fluoxetine and psychotherapy, placebo and psychotherapy, or a placebo. The first four sets saw improvement in 50.8% to 54.2% of the patients. Of those assigned to receive only a placebo, 31.7% achieved a rating of 1 or 2 on the Clinical Global Impression-Improvement scale. Those who sought both therapy and medication did not see a boost in improvement.^[48]

General side-effects are common during the first weeks while the body adjusts to the drug. Symptoms may include headaches, nausea, insomnia and changes in sexual behavior. Treatment safety during pregnancy has not been established.^[49] In late 2004 much media attention was given to a proposed link between SSRI use and juvenile suicide. For this reason, the use of SSRIs in pediatric cases of depression is now recognized by the Food and Drug Administration as warranting a cautionary statement to the parents of children who may be prescribed SSRIs by a family doctor.^[50] Recent studies have shown no increase in rates of suicide.^[51] These tests, however, represent those diagnosed with depression, not necessarily with social anxiety disorder. However, it should be noted that due to the nature of the conditions, those taking SSRIs for social phobias are far less likely to have suicidal ideation than those with depression.

Other drugs

Although SSRIs are often the first choice for treatment, other prescription drugs are also used, sometimes only if SSRIs fail to produce any clinically significant improvement.

In 1985, before the introduction of SSRIs, anti-depressants such as monoamine oxidase inhibitors (MAOIs) were frequently used in the treatment of social anxiety. Their efficacy appears to be comparable or sometimes superior to SSRIs or benzodiazepines. However, because of the dietary restrictions required, high toxicity in overdose, and incompatibilities with other drugs, its usefulness as a treatment for social phobics is now limited. Some argue for their continued use, however, or that a special diet does not need to be strictly adhered to.^[52] A newer type of this medication, Reversible inhibitors of monoamine oxidase subtype A (RIMAs) inhibit the MAO enzyme only temporarily, improving the adverse-effect profile but possibly reducing their efficacy.

Benzodiazepines such as alprazolam and clonazepam are an alternative to SSRIs. These drugs are often used for short-term relief of severe, disabling anxiety.^[53] Although benzodiazepines are still sometimes prescribed for long-term everyday use in some countries, there is much concern over the development of drug tolerance, dependency and recreational abuse. It has been recommended that benzodiazepines are only considered for individuals who fail to respond to safer medications.^[54] Benzodiazepines augment the action of GABA, the major inhibitory neurotransmitter in the brain; effects usually begin to appear within minutes or hours.

The novel antidepressant mirtazapine has been proven effective in treatment of social anxiety disorder.^[55] This is especially significant due to mirtazapine's fast onset and lack of many unpleasant side-effects associated with SSRIs (particularly, sexual dysfunction).

In Japan, the serotonin-norepinephrine reuptake inhibitor (SNRI) Milnacipran is used in the treatment of Taijin kyofusho a Japanese variant of social anxiety disorder.

Some people with a form of social phobia called performance phobia have been helped by beta-blockers, which are more commonly used to control high blood pressure. Taken in low doses, they control the physical manifestation of anxiety and can be taken before a public performance.

A novel treatment approach has recently been developed as a result of translational research. It has been shown that a combination of acute dosing of d-cycloserine (DCS) with exposure therapy facilitates the effects of exposure therapy of social phobia (Hofmann, Meuret, Smits, et al., 2006). DCS is an old antibiotic medication used for treating tuberculosis and does not have any anxiolytic properties per se. However, it acts as an agonist at the glutamatergic N-methyl-D-aspartate (NMDA) receptor site, which is important for learning and memory (Hofmann, Pollack, & Otto, 2006). It has been shown that administering a small dose acutely 1 hour before exposure therapy can facilitate extinction learning that occurs during therapy.

Treatment controversy arises because while some studies indicate that a combination of medication and psychotherapy can be more effective than either one alone, others suggest pharmacological interventions are largely palliative, and can actually interfere with the mechanisms of successful therapy.^[56] Meta-analysis indicates that psychotherapeutic interventions have better long-term efficacy compared to pharmacotherapy.^[57] However, the right treatment may very much depend on the individual patient's genetics and environmental factors.

Natural Treatments

Regular aerobic exercise,^[58] improving sleep hygiene^{[citation needed]} and reducing caffeine^{[citation needed]} are often useful in treating anxiety.

Herbal drugs are often used in patients with somatoform disorders. In one clinical trial, butterbur in a fixed herbal drug combination (Ze 185 = 4-combination versus 3-combination without butterbur and placebo) was used in patients with somatoform disorders.^[59] For a 2-week treatment in patients with somatization disorder (F45.0) and undifferentiated somatoform disorder (F45.1), 182 patients were randomized for a 3-arm trial (butterbur root, valerian root, passionflower herb, lemon balm leaf versus valerian root, passionflower herb, lemon balm leaf versus placebo). Anxiety (visual analogue scale - VAS) and depression (Beck's Depression Inventory - BDI) were used as primary parameters, and Clinical Global Impression (CGI) was used a secondary parameter. The 4-combination was significantly superior to the 3-combination and placebo in all the primary and secondary parameters (PP-population), without serious adverse events.

Many other natural remedies have been used for anxiety disorder. These include kava, where the potential for benefit seems greater than that for harm with short-term use in patients with mild to moderate anxiety.^[60][61] Based on Cochrane's systematic review of seven RCTs (n = 380), with findings supported by five lower-quality trials (n = 320), the American Academy of Family Physicians (AAFP) recommends use of kava for patients with mild to moderate anxiety disorders who are not using alcohol or taking other medicines metabolized by the liver, but who wish to use “natural” remedies.^[62] Side effects of kava in the clinical trials were rare and mild.

Inositol has been found to have modest effects in patients with panic disorder or obsessive-compulsive disorder. St. John's wort^{[63][64][65][66]} and Sympathyl^[67] have also been used to treat anxiety, but with little scientific evidence.^[62]

Epidemiology

In the United States the lifetime prevalence of anxiety disorders is about 29%.^[68]

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Further reading

• Khouzam, HR (March 2009). "Anxiety Disorders: Guidelines for Effective Primary Care. Part 1: Diagnosis". Consultant 49 (3). http://www.consultantlive.com/display/article/10162/1387611.
• Khouzam, HR (April 2009). "Anxiety Disorders: Guidelines for Effective Primary Care. Part 2: Treatment". Consultant 49 (4). http://www.consultantlive.com/display/article/10162/1399819.
• Vanin, John; Helsley, James (2007). Anxiety Disorders: A Pocket Guide For Primary Care. Humana Press. ISBN 978-1-58829-923-9.
• Craske, Michelle Genevieve (2003). Origins of Phobias and Anxiety Disorders: Why More Women than Men?. Amsterdam: Elsevier. ISBN 0-08-044032-0. http://books.google.com/?id=OSaH4i37SPsC.
• Schutz, Samantha (2006). I Don't Want to Be Crazy: A Memoir of Anxiety Disorder. PUSH. ISBN 978-0-4398-0518-6.

External links

• Support Group Providers for / Anxiety disorder at the Open Directory Project

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