Anxiety disorder is a neurological disorder characterized by predominantly anxious emotions, with generalized and persistent anxiety or recurrent panic attacks, often accompanied by autonomic disorders, muscle tension and motor restlessness, and clinically divided into two main forms: generalized anxiety disorder and panic disorder.
Anxiety disorders have been variously referred to as cardiac neurosis, agitated heart, neurocirculatory debilitation, vasomotor neurosis, and autonomic dysfunction. The prevalence is 1.48 per 1,000, with more women than men, about 2:1. Generalized anxiety disorder mostly starts in the 20s to 40s, while panic attacks tend to occur in late adolescence or early adulthood.
The prognosis of anxiety disorders is largely related to the quality of the individual, and most patients can get better within six months if they are handled properly. In general, the prognosis is better for those with a short duration of illness, mild symptoms, intact pre-morbid social adjustment, and non-significant pre-morbid personality defects, and vice versa. It is also believed that those with syncope, agitation, reality dissociation, hysteria-like manifestations and suicidal ideas often suggest a poor prognosis.
I. Etiology and pathogenesis
1.Genetic factors It is believed that anxiety disorders have a clear genetic predisposition.
2.Biochemical factors The mechanism of occurrence is still unclear.
3.Psychological factors: Behaviorist theory believes that anxiety is a conditioned reflex formed by fear of certain environmental stimuli. Psychodynamic theory believes that anxiety originates from internal psychological conflicts, which are suppressed in the subconscious during childhood or adolescence and are activated in adulthood, thus forming anxiety.
Clinical manifestations
(I) Generalized anxiety disorder
Also known as chronic anxiety disorder, it is the most common form of anxiety disorder. It often starts slowly, with frequent or persistent anxiety as the
The main clinical phase. It has the following manifestations.
1. mental anxiety Excessive mental worry is the core of anxiety symptoms. It is a frequent worry about a possible, unpredictable alkaline or unfortunate event that may occur in the future. Some patients are not clearly aware of the object or content of their worries, but only a
Some patients are not clearly aware of the object or content of their worries, but only have a strong inner experience of fear and anxiety, which is called free-floating anxiety. Some patients worry about what may happen in real life, but the degree of worry, anxiety and annoyance is very disproportionate to reality, which is called anticipatory anxiety. Patients often have a sense of panic, and are distracted, worried and restless all day long, as if there is a sense of imminent disaster.
2. Somatic anxiety is characterized by motor anxiety and various somatic symptoms. Motor restlessness: It can be manifested as rubbing hands and feet, not being able to sit still, constantly walking back and forth, and increasing aimless small movements. Some patients show tremors of the tongue, lips and finger muscles or muscle tremors. Somatic symptoms: A feeling of compression behind the sternum is a common manifestation of anxiety, often accompanied by shortness of breath. Muscle tension: It manifests as subjective uncomfortable tension in one or more groups of muscles, with muscle aches and pains in severe cases, mostly in the chest, neck and shoulder muscles, and tension headaches are also common. Autonomic dysfunction: Symptoms include rapid heartbeat, flushed or pale skin, dry mouth, constipation or diarrhea, sweating, and frequent urination. Some patients may experience premature ejaculation, impotence, menstrual disorders and other symptoms.
3.Increased wakefulness The symptoms are excessive alertness, sensitivity to external stimuli, easy to have startle reaction, difficult to concentrate, easy to be disturbed; difficult to fall asleep, easy to wake up during sleep, easy to be emotionally irritable; sensory allergy, some patients can experience the beating of their own muscles, blood vessels, peristaltic movement of the gastrointestinal tract, etc.
4, other symptoms Generalized anxiety disorder patients often combined with fatigue, depression, obsessive-compulsive, fear, panic attacks and depersonalization and other symptoms, but these symptoms are often not the main clinical phase of the disease.
(B) Panic disorder
Panic disorder is also known as acute anxiety disorder. It is characterized by the unpredictability and suddenness of the attack, the intensity of the reaction, and the fear and dread that the patient is often on the verge of a catastrophic end, and the termination is rapid.
Patients often experience a sudden and frightening experience in the absence of a specific fearful situation, with a sense of near death or loss of control and severe autonomic dysfunction. Patients seem to feel that death or disaster is imminent, or run, scream, and call for help, with autonomic symptoms such as chest tightness, tachycardia, irregular heartbeat, dyspnea or hyperventilation, headache, dizziness, vertigo, numbness and abnormal sensation in the extremities, sweating, flesh jumping, general shaking or general weakness. Panic attacks usually have a rapid onset and termination, usually lasting 5 to 20 minutes, rarely more than an hour, but can soon recur suddenly. The patient is always conscious and highly alert during the attack, and still has palpitations after the attack, fearing a recurrence, but the experience of anxiety is no longer prominent, but replaced by weakness, and it takes several hours to several days to recover. 60% of patients have avoidance behavior due to fear of not getting help during the attack, such as not daring to go out alone, not daring to go to crowded places, developing into place phobia.
III. Diagnosis and differential diagnosis
(I) Diagnosis
The CCMD-3 diagnostic criteria for generalized anxiety and panic attacks are as follows.
1. Generalized anxiety
(1) Meet the diagnostic criteria of neurosis.
(2) Predominantly persistent primary anxiety symptoms that meet both of the following: frequent or persistent fear or panic attacks without a clear object and fixed content; accompanied by autonomic symptoms and motor restlessness.
(3) Impaired social functioning, where the patient is distressed by unbearable but unresolved pain.
(4) Meet the symptom criteria for at least 6 months.
(5) Exclude: anxiety secondary to somatic diseases such as hyperthyroidism, hypertension, coronary artery disease, anxiety associated with euphoric drug overdose and drug dependence withdrawal; anxiety associated with other types of mental illness or neurosis.
2.Panic disorder
(1) Meet the diagnostic criteria of neurosis.
(2) Panic attacks must meet the following four items: no obvious trigger, no specific context. The seizure is unpredictable; in the interictable period, there are no obvious symptoms except the fear of having another seizure; the seizure shows strong fear, anxiety and obvious autonomic symptoms, and there is often a painful experience such as depersonalization, disintegration of reality, near-death fear, or a sense of loss of control; the seizure is sudden and reaches its peak quickly, and the patient is conscious during the seizure and can recall it afterwards.
(3) The patient is distressed because it is unbearable but cannot be relieved.
(4) At least 3 panic attacks in a month, or anxiety secondary to fear of reoccurrence lasting 1 month after the first attack.
(5) Exclusion: panic attacks secondary to other psychiatric disorders; panic attacks secondary to somatic diseases such as epilepsy, heart attack, pheochromocytoma, hyperthyroidism or spontaneous hypoglycemia.
(B) Differential diagnosis
1, anxiety due to somatic diseases thyroid disease, heart disease, certain neurological diseases such as encephalitis, cerebrovascular disease, cerebral degenerative disease, systemic lupus erythematosus, etc. are prone to anxiety symptoms. Clinically, patients who are first diagnosed, old, without psychological stress factors and with good personality quality before the disease should be highly alert to whether anxiety is secondary to physical diseases.
2, pharmacogenic anxiety Many drugs can cause typical anxiety disorders after intoxication, withdrawal or long-term application. For example, certain sympathomimetic drugs such as amphetamines, cocaine, caffeine, certain hallucinogens and opioids, long-term application of hormones, sedative-hypnotics, antipsychotics and so on. According to the history of medication can be distinguished.
3, anxiety due to psychiatric disorders Patients with schizophrenia can be accompanied by anxiety, as long as the symptoms of schizophrenia are found, the diagnosis of anxiety disorders are not considered; depression is the disease that is most often accompanied by anxiety. When the severity of depression and anxiety is unclear, the diagnosis of depression should be considered first to prevent delayed treatment of depression and adverse consequences such as suicide; when other neurological disorders are accompanied by anxiety, anxiety symptoms are often not the main clinical phase in these diseases or are secondary symptoms.
IV. Treatment
(A) Psychological treatment
1. Health education Patients with anxiety disorders are generally receptive to new information, especially information that can help explain or reduce the degree of anxiety. Therefore, it is necessary to provide health education to such patients. The content of health education should include explanation of the nature of the disease, such as the nature of anxiety; why anxiety arises, etc., so that patients can understand the nature of the disease and eliminate certain worries. It is also important to understand the patient’s own understanding of the disease and to gain timely insight into certain adverse perceptions of the patient. Instruct the patient to carry out some simple and practical methods to cope with anxiety and to change certain bad lifestyles, etc.
2. Cognitive therapy Patients with anxiety disorders are prone to two types of logical errors: one is to overestimate the possibility of negative events, especially those related to themselves; the other is to overly dramatize or catastrophize the outcome of the event, and some distorted perceptions of anxiety patients are one of the reasons for the persistence of the disease. After a comprehensive assessment of the patient, the therapist should help the patient to change the unmilk perception or carry out cognitive reconstruction.
3.Behavior therapy Patients with anxiety disorders often have muscle tension caused by anxiety, cardiovascular system and digestive system symptoms caused by autonomic dysfunction. The use of behavioral therapy methods such as breathing training, relaxation training, and distraction techniques are often effective. For patients who avoid social interaction due to anxiety or panic attacks, systematic desensitization (exposure) therapy can be applied.
(B) Drug treatment
1.Benzodiazepines are widely used, with strong anxiolytic effects and fast onset of action. According to the length of the half-life can be divided into long-range, course and short-range action drugs. Clinical applications generally start with small doses, gradually increase to the optimal amount of treatment, maintain 2-6 weeks after the gradual discontinuation of drugs to prevent addiction. The discontinuation process should not be shorter than 2 weeks to prevent the rebound of symptoms.
2, antidepressants tricyclic antidepressants such as mipramine, amitriptyline; selective 5-HT reuptake inhibitors.
According to the antidepressants have a slow onset of action. But no addictive. While benzodiazepines have a rapid onset of action. But the long-term use of addictive characteristics, the clinical use of benzodiazepines and tricyclics or SSRIs in the early combination, and then gradually stop benzodiazepines. Benzodiazepines are rarely used alone as a long-term treatment.
3, β-adrenergic receptor blockers Propranolol (Takayasu) is commonly used. These drugs are effective in reducing somatic symptoms such as palpitations, tachycardia, tremor, excessive sweating and shortness of breath caused by autonomic hyperfunction in patients with anxiety disorders. Caution should be exercised when used by patients with asthma, congestive heart failure, diabetics taking hypoglycemic drugs, or those prone to hypoglycemia.
4, other drugs Butrospirenone, because of non-dependence, is also commonly used in the treatment of anxiety disorders. The disadvantage is the slow onset of action.