Specific classification of simple phobias.
Abstract
Anxiety disorders are the most common of all psychiatric illnesses and result in significant functional impairment and distress. In DSM 5, anxiety disorders are divided into eleven subgroups. Anxiety, which we consider normal (mild and moderate anxiety), plays an important role in the development of the individual. However, if the level of anxiety increases, it may lead to mental problems. A high level of anxiety, long duration, and intensification of anxiety symptoms may cause anxiety disorders. These are; separation anxiety disorder, selective mutism, panic disorder, agoraphobia, specific phobia, social anxiety disorder, generalized anxiety disorder, other unspecified anxiety disorder, anxiety disorder related to another medical condition, anxiety disorder caused by substance or medication, anxiety disorders caused by substances and medication are unspecified anxiety disorders. Treatment methods used in anxiety disorders are individual psychotherapy, cognitive therapy, behavioral therapy, systematic sensitization, exposure, and psychopharmacology.
Keywords
- anxiety disorders
- panic disorder
- phobia
- social anxiety disorder
- generalized anxiety disorder
- selective mutism
1. Introduction to anxiety disorders
1.1 Anxiety concept
Anxiety is a feeling that individuals experience at different levels throughout their lives. Anxiety is a healthy, normal response to perceived threats or unique experiences, and it is a necessary motivating force for survival. Mild anxiety is a driving force necessary for adaptation and advancement to the higher stage of spiritual development. However, when the anxiety level increases too much, it, on the contrary, serves as a hindering function [1].
1.2 Anxiety and fear
Anxiety and fear are emotions that people are usually confused about. Fear is a response to a known threat. However, anxiety can be defined as fear, tension, uneasiness, or restlessness expected from an unidentified or unknown source. We can evaluate anxiety as a cognitive state of fear [2]. Physical symptoms of anxiety include palpitations, difficulty breathing, rapid breathing, tremors in the hands and feet, and excessive sweating. Psychological symptoms, on the other hand, include distress, excitement, sudden feeling, and fear that something terrible will happen [3].
Anxiety, which we consider normal (mild and moderate anxiety), plays an important role in the development of the individual. However, if the level of anxiety increases, it may lead to mental problems. A high level of anxiety, long duration, and intensification of anxiety symptoms may cause anxiety disorders. Anxiety can be evaluated as pathological when it begins to have an impact on social and occupational actions, achievement of desired goals, and emotional state [4].
In short, anxiety can be deemed pathological if the following situations occur:
When anxiety is not proportional to the situation that creates anxiety,
When anxiety inhibits social, occupational, and other important functional areas.
Example: Ms. M., who was involved in a serious traffic accident a month ago, refuses to drive even to places in short distances. Her father has to take Ms. M. whenever she needs to go somewhere. Ms. M., who constantly refuses to drive, has even had to quit her job because of her anxiety about driving.
1.3 Epidemiology
Anxiety disorders are the most common of all psychiatric illnesses and result in significant functional impairment and distress [5, 6]. Its prevalence per year is reported as 17.7%. This rate is 30.5% for women and 19.2% for men, and the frequency decreases with the increase in socioeconomic level [7]. In a study conducted by Özcan et al. (2006), anxiety disorder was found to be the most common diagnosis among 950 psychiatric patients, and it was mostly observed in women, housewives, married people, and people with a low education level [8].
2. Etiology of anxiety disorders
2.1 Biological factors
In twin studies conducted, it was concluded that genetics was a huge factor. Structural neuroimaging studies in patients with panic disorder indicate pathological involvement in the temporal lobes, especially in hippocampus [9].
Although many neurotransmitters are effective in the pathophysiology of anxiety disorders, disorders in serotonin, norepinephrine, and gamma-aminobutyric acid (GABA) appear to be the most important. GABA has an important place among the causes of anxiety disorder. As the drugs used in the treatment of anxiety disorders increase GABA, it is thought that the insufficiency and imbalance in GABA are directly related to the anxiety experienced [3, 5]. Serotonin is another neurotransmitter linked to anxiety disorder. Deficiency or an imbalance of serotonin in the amygdala is observed in anxiety-related disorders. It is known that there is imbalance in the regions related to norepinephrine in anxiety disorders.
It has been revealed that the CRF (Corticotropin-Releasing Factor) system plays an important role among the biological causes of anxiety disorders [1].
2.2 Brain areas affected in anxiety disorders
The brain areas affected by anxiety disorders and the symptoms they cause are listed below:
Amygdala: Fear, which is especially important in panic and phobic disorders.
Hippocampus: Depends on memory which is related to fear responses.
Locus coeruleus: Vigilance
Brain stem: respiratory movement, heartbeat
Hypothalamus: activation of the stress response
Frontal cortex: Cognitive interpretations
Thalamus: Integration of sensory impulses
Basal ganglia: Tremors [10]
3. Psychological theories
Freud argued that the child experiences anxiety specific to each period during the development process. These are superego anxiety, castration anxiety, fear of losing love, separation anxiety, annihilation anxiety, and disintegration anxiety.
4. Classification of anxiety disorders
In DSM 5, anxiety disorders are divided into eleven subgroups. These are:
Separation anxiety disorder,
Selective mutism,
Panic disorder,
Agoraphobia,
Specific Phobia,
Social anxiety disorder,
Generalized anxiety disorder,
Other unspecified anxiety disorder,
Anxiety disorder related to another medical condition,
Anxiety disorder caused by substance or medication,
Anxiety disorders caused by substances and medication are unspecified anxiety disorders [12].
4.1 Separation anxiety disorder
Separation anxiety disorder can be defined as experiencing fear and anxiety that is more than expected and repetitive in terms of developmental level resulting from separation from home or someone the person is attached to for at least four weeks in children, and for at least six months or longer in adults. It is seen that individuals with separation anxiety disorder do not want to go to school or elsewhere because of the fear of separation. The main feature of separation anxiety disorder is excessive anxiety caused by leaving the mother, father, home or familiar environment. It is seen equally in boys and girls.
Symptoms in separation anxiety disorder differ according to the developmental period. In children aged 5-8 years, the fear of a bad event and rejection of school, intense distress during separation at the age of 9-12, school refusal in adolescents aged 13-16, and physical complaints appear as symptoms.
4.2 Selective Mutism
The most important feature of this disorder is that although the individual can speak in other situations, s/he constantly does not speak in certain specific social situations (when s/he meets people s/he does not know, etc.) where s/he is expected to speak. The disorder must last at least one month and affect the person’s education, work success, and social life. It usually occurs in the preschool period.
4.3 Panic disorder
In the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) [American Psychiatric Association (APA)] it is stated that at least four of the following symptoms must be present to determine the presence of a panic attack. These are:
Palpitations, pounding heart or accelerated heart rate
Sweating
Shaking or trembling
Feeling short of breath or smothering
Choking sensation
Chest pain or discomfort
Nausea or abdominal distress
Feeling dizzy, lightheaded, unsteady or faint
Chills or hot flushes
Paresthesias (tingling and numbness sensations)
Derealization (unreal feelings) or depersonalization (feelings of being detached from oneself)
Fear of losing control and going crazy
Fear of dying [12]
Panic disorder, which is a very old disease, is a syndrome characterized by sudden and extreme anxiety with unreasonable and unpredictable panic attacks. Its most important feature is that it is accompanied by intense physical discomfort. Panic attacks can occur only once, or frequently, on a weekly, monthly or even annual basis. Panic attack disorder is usually seen in the 20s. The panic attack is an unreasonable and severe state of anxiety. During panic attacks, symptoms such as palpitations, accelerated heart rate, sweating, trembling/shaking, shortness of breath, feeling of choking, breathlessness, chest pain, fainting, fear of losing control or going crazy, numbness, tingling, chills or hot flushes can be seen.
The presence of a medical drum that may cause anxiety should first be investigated in a patient presenting with panic attack. All the drugs used by the individual should be questioned, and the side effects of the drugs should be considered. Below are some medical conditions that cause symptoms similar to panic attacks.
Alcohol Withdrawal Syndrome
Substance Withdrawal Syndrome
Cardiac arrhythmias
Hyperthyroidism
Hypoglycemia
Asthma
Cushing’s Disease
The majority of patients have challenging life events before the first panic attack occurs. Low socio-economic level, delay in treatment, presence of additional diagnoses cause a negative course in panic disorder.
Comorbidity: Depression is seen with social phobia, specific phobia, traumatic stress disorder and alcoholism.
Treatment: Specific serotonin reuptake inhibitors should be the first choice in the treatment of panic disorder. If the patient does not respond to treatment, switching to other specific serotonin reuptake inhibitors is recommended. If there is no response to two specific serotonin reuptake inhibitors and there is severe tolerance, it is recommended to switch to SNRI. Alprazolan is also highly effective. Drug treatment should last at least a year. Behavioral-cognitive psychotherapy is an effective method in panic disorder. This method attempts to change the patient’s perception of physical symptoms. It will be useful to teach breathing exercises to the patient [15].
4.4 Agoraphobia
Agoraphobia, which is shortly defined as the fear of open space, is the fear of being deprived of help or being in places where it is difficult to escape.
4.5 Social phobia (social anxiety disorder)
It is a disorder characterized by blushing, sweating, and trembling of the hands when one believes that s/he is perceived negatively by others while sitting or talking in public. The individual is afraid of social or performance situations where embarrassment can occur and firmly believes that s/he will be subject to possible reproach by others [12]. The onset of the symptoms of this disorder often occurs in late childhood or early adolescence and becomes chronic and sometimes continues throughout life. It is equally prevalent in males and females (Puri & Treasaden, 2011). The disorder affects social or occupational functionality or causes significant distress.
4.6 Specific phobia
It is an excessive, illogical and meaningless fear of a specific object (snake, dog, etc.) or a situation (injection, darkness, etc.). Exposure to phobic stimulus produces compelling panic symptoms, including palpitations, sweating, dizziness and difficulty in breathing. Phobias can begin at any age. People can be phobic towards almost any object or situation. Those that start in childhood often disappear without treatment. But those that start in adulthood or are persistent often require therapeutic support. The disorder is diagnosed more often in females than in males [16]. The specific classification of simple phobias is given in Table 1 .
Clinical name | Feared object or situation |
---|---|
Acrophobia | Heights |
Agoraphobia | Open spaces |
Claustrophobia | Closed spaces |
Hematophobia | Blood |
Zoophobia | Animals |
4.7 Generalized anxiety disorder
It is an anxiety disorder characterized by being chronic and unrealistic, and extreme anxiety that must last at least 6 months. Symptoms can cause distress to the person in social, professional and other important areas. Individuals with this disorder are constantly worried. Restlessness, excessive excitement, fatigue, sleep disturbance and muscle tension are significant symptoms. Anxiety often results in difficulty in making self-decisions, and the person seeks constant approval from those around him. They always feel like they are going to get bad news. It usually starts in childhood and adolescence [2].
4.8 Anxiety disorder associated with another medical condition and substance/medication-induced anxiety
Symptoms associated with these disorders are evaluated directly as a physiological consequence of another medical condition or directly due to substance intoxication or deprivation or exposure to the drug. Many medical conditions are related to the development of anxiety symptoms. Some of these include cardiac conditions such as myocardial infarction, congestive heart failure and mitral valve prolapse, endocrine conditions such as hypoglycemia, hypo/hyperthyroidism and pheochromocytoma, respiratory conditions such as chronic obstructive pulmonary disease and hyperventilation, and complex partial seizures, neoplasms and encephalitis [12].
5. Treatment methods in anxiety disorders
5.1 Cognitive - behavioral therapy
It is a widely used, successful and easy method in the treatment of anxiety disorders. This short-term treatment method focuses on changing the patient’s thoughts and behaviors. This treatment includes emotional and behavioral changes to help the person to adapt to the environment perceived to be dangerous, as well as the initial definition and restructuring of cognitions related to anxiety in the form of unreal interpretation of danger [9, 18, 19, 20]. In their study, Andrews et al. (2005) also found that virtual reality practice therapy is effective in treating public speaking anxiety [21].
5.1.1 Systematic desensitization
In systematic desensitization, the patient is gradually exposed to the effect of phobia stimuli in real or imaginary situations. The concept was first introduced by Joseph Wolpe in 1958 and is based on the principles of behavior conditioning. Emphasis is placed on mutual inhibition or mutual conditioning [22].
There are two important elements in systematic desensitization by mutual inhibition:
Practicing relaxation techniques
Gradual exposure to fear stimuli in a relaxed state.
The individual is taught the art of relaxation by using techniques that are more effective for him/her (e.g. progressive relaxation, mental imagination, tension and relaxation, meditation). After the individual learns relaxation techniques, exposure to phobic stimuli is initiated. The patient is asked to rank hierarchically the situations that cause phobic stimuli from the most disturbing to the least disturbing. In case of maximum relaxation, the patient may be asked to visualize the phobic stimulus in his/her mind. First of all, the exposure focuses on the phobic stimulus that causes the least fear or anxiety. In subsequent sessions, the individual is exposed to the effects of increasingly more fearful stimuli. Sessions can be conducted in imaginary, real-life situations (live), or sometimes a combination of both [1].
5.1.2 Flooding therapy
5.1.3 Relaxation exercise
Relaxation exercise is a method that effectively reduces tension and anxiety. It can be used alone or in conjunction with other cognitive-behavioral techniques [25].
5.2 Family therapy
Families have difficulties in understanding the symptoms of their relatives with anxiety disorders and may find it hard to tolerate, and this situation can disrupt the healthy family structure. It is important to remind family members of their roles in therapy and to emphasize that support is important. Besides, it is necessary to inform them about anxiety disorder symptoms and treatments [1]. In another study conducted, it was concluded that treatments aimed at reducing symptoms only were insufficient in the treatment of anxiety disorders and that programs for improving interpersonal relationships, communication skills and anger management of the individual should be added [26].
5.3 Psychopharmacology
Buspirone, which as an anti-anxiety agent, is effective in approximately 60% to 80% of patients with a generalized anxiety disorder [3]. The only disadvantage of buspirone is the 10-14 day delay in relieving symptoms. However, the lack of physical addiction and tolerance disadvantage of buspirone makes it the drug of choice in the treatment of generalized anxiety disorders. The effects and side effects of anxiolytic agents are given in Table 2 .
Anxiolytic agents | Effect | Side effects |
---|---|---|
Benzodiazepines | The GABA receptor increases the affinity of GABAA. | Sedation, dizziness, weakness, ataxia, decreased motor performance, addiction, withdrawal |
SSRIs | Inhibiting serotonin reuptake at the presynaptic nerve end, increasing serotonin synaptic concentration. | Nausea, diarrhea, headache, insomnia, sleepiness, sexual dysfunction |
SNRIs | Inhibition of neural serotonin and norepinephrine reuptake, mild reuptake of dopamine | Headache, dry mouth, nausea, drowsiness, insomnia, weakness, dizziness, constipation, diarrhea |
Noradrenergic agents (propranolol, clonidine) | Propranolol: inhibits beta adrenergic receptor activity. Clonidine: stimulates alpha-adrenergic receptors. | Propranolol: bradycardia, hypotension, weakness, fatigue, impotence, gastrointestinal disorder, bronchospasm |
Barbiturates | CNS depression also produces effects in the hepatic and cardiovascular systems. | Clonidine: dry mouth, sedation, fatigue, hypotension |
Buspirone | 5-HT1A receptor partial antagonist | Drowsiness, agitation, confusion, ataxia, dizziness, bradycardia, hypotension, constipation |
SSRIs are effective in treating panic disorders. Paroxetine, fluoxetine, and sertraline have been approved by the US Food and Drug Administration (FDA) for these purposes. The dosage of these drugs should be increased gradually, as patients with panic disorder are sensitive to overstimulation caused by SSRIs [1].
The use of anti-depressants in the treatment of generalized anxiety disorders is still under investigation. Some success has been reported with tricyclic, imipramine and SSRI drugs. The FDA has approved paroxetine, escitalopram, duloxetine and extended-release venlafaxine for the treatment of generalized anxiety disorders [28].
Beta blockers: Clonid and beta-blockers such as propranolol and atenolol are also used especially in maintenance treatment. These drugs are most effective in treating state anxiety [1].
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