Health and Anxiety

SOM 207
Dr Masupe
May 2014
Learning objectives
• Define what is meant by anxiety
• Define psychological nature and function of anxiety
• Describe the adverse consequences of anxiety
• Understand when anxiety becomes pathological and affects
health and health seeking behavior
• Be able to describe and recognize phobia and social anxiety
• Understand clinical and economic impact of anxiety in primary
care and hospital
Anxiety defined
• Anxiety can be defined as a vague feeling of dread or
apprehension in response to external or internal stimuli that
can result in behavioral, emotional, cognitive, and physical
symptoms
• Apprehension about a future threat
• Response mechanism to stress
• Not always bad
• Different from fear
Fear vs. anxiety
Fear
• Feeling afraid due to a
clearly identifiable threat
• Triggers flight, fight,
fright usually to save life
• Physiological arousal via
sympathetic nervous
system
• Tends to be short lived
Anxiety
• Feeling afraid due to a
possible future threat
• Increases preparedness
for future event
• Enhances performance if
mild to moderate
• Physiological arousal via
sympathetic nervous
system
Psychological Nature of Anxiety
• Sigmund Freud –father of psychoanalysis
• Personality is composed of the Id, the ego and superego
• Clash between these leads to anxiety
• They explain the learned behavioral response
The Id
• Present from birth
• Unconscious part of the person
• Driven by pleasure principle
• Strives for immediate gratification- pleasure principle
• If needs not met immediately anxiety results
The Ego

• Responsible for dealing with reality

• Thought to develop from the Id
• Ensures impulses of the Id can be expressed in a manner acceptable in
the real world
• Functions in the conscious and preconscious and unconscious
• Preconscious
• Composed of memories which can be retrieved anytime if needed
• E.g. what did you have for supper last night
• What did you watch on TV last night
• Ego operates based on reality principle
• Keeps Id demands in touch with the real world, socially appropriate
• Weighs costs and benefits
• Applies the process of delayed gratification
The Superego
• Last component of personality to develop
• Deals with moral standards and ideals acquired from parents and society
• Sense of right or wrong
• Provides guidelines for making judgments
• Emerges around 5 years of age
• The ego ideal
• Includes rules and standards
• Obeying these rules leads to feeling of pride, value and accomplishment
• Parental and authority influenced
• The conscience
• Info on things seen as bad by parents or authority
• Forbidden behaviours attract punishment
• May lead to guilty feelings and remorse
• Imbalance between Id, Ego and Superego leads to anxiety
Biologic theories of Anxiety

• Possibility of inheritance
• Abnormalities in Neuro-transmitters
Risk factors for anxiety disorders
• Gender male : female of 1:2
• Sociocultural factors
• Japanese
• Negative life events
• Genetic vulnerability
• Twin studies especially panic disorder and generalized anxiety
disorder
Risk factors cont.
• Neuro-biological
• Neurotransmitters
• Fear circuitry hyperactivity
• Personality
• Neuroticism
• Behavioral inhibition (shy 4 month old babies!)
• Cognitive
• Pre-occupation with threats in the environment
• Loss of control
Adverse consequences of anxiety
• Generalized anxiety disorder
• Social anxiety
• Phobias
• Panic attacks
• Behavioral disorders
• Obsessive compulsive disorder
• Post traumatic stress disorder
• Depression
Generalized Anxiety Disorder(GAD)

• Anxiety becomes chronic > 6 months

• Inability to control worry which becomes excessive
• Worry is about general issues e.g. health, work,
finances, relationships
• Inability to cope
• Interferes with normal daily activities of living
GAD-Associated symptoms
• Cognitive
• Poor short term memory
• Poor concentration
• forgetfulness
• Behavioral
• Comfort eating
• Substance misuse
• Abusive behaviour
• General
• Fatigued easily
• Insomnia
• Irritability
• Musculoskeletal
Phobias
• Excessive fear of a particular object or situation
• Fear is disproportionate to actual or perceived threat
• Causes severe distress and interferes with aspects of daily life
or work
• Sufferer is aware that fear is excessive
• Sufferer uses avoidance as a coping mechanism
• Two types of phobias:
• Specific
• Social
Specific phobias
• Intense excess fear of specific objects or situations
• Cause extreme anxiety
• Avoidance is used as a coping mechanism
Specific Phobias –examples
Fear Phobia
• Books • Bibliophobia
• Dancing • Chorophobia
• Peanut butter sticking to • Arachybutyrophobia
roof of the mouth
• Garlic • Alliumphobia
• Spiders • Arachnophobia
• Open spaces • Agoraphobia
• New things • Neophobia
• Claustrophobia • Confined spaces
Social Phobia
• Extreme version of social anxiety…extreme shyness
• Characterized by persistent, intense fear of social situations
• Can be generalized or specific as well
• Fear of
• being scrutinized or receiving a negative evaluation
• Humiliation
• Social embarrassment

• Genetic vulnerability postulated

• Onset during adolescence
• Avoidant personality disorder
• Negatively affects health seeking behavior
• Results in adverse coping mechanisms
Panic Attacks
• Sudden, intense episode of anxiety attack characterized
by feelings of impending doom and gloom, severe
apprehension and terror
• Intensity tends to peak within few minutes
• Other associated symptoms: at least 4 of these
• Dizziness
• Palpitations
• Lightheadedness
• Profuse sweating
• Hyperventilation
• Gastrointestinal upset
Other Symptoms associated with PA
• Other symptoms may include:
• Depersonalization
• Feeling unreal
• Watching self from the outside
• Feeling that thoughts and actions are not their own
• May result in self mutilation
• Derealization
• Dissociation from one’s environment
• Objects may seem diminished in size or un-solid
• Like being inside some glass container
• Looking at the world through fog
• These can be a main psychiatric condition
• Can be part of other psychiatric conditions
• Ecstasy known to cause these
Aetiology of panic disorder

Willey & Sons 2009 NY

Behavioral disorders due to anxiety
related disorders
• Substance misuse
• Alcohol
• Drugs
• food
• Poor health seeking behavior
• Avoidance of health care facilities
• Lack of adherence to treatment
• Excess use of health care facilities
• Poor interpersonal relationships
• Relationship breakdown
• Unemployment
• Social exclusion
Treatments of Anxiety Disorders
• Depends on cause and type
• Patient education
• Medication
• Anxiolytics
• Benzodiazepines
• antidepressants
• Psychological therapies
• Combination of drugs and therapy more effective than either
alone
Psychological Treatments: CBT
• Cognitive behavioral therapy
• Challenges negative thoughts and expectations about adverse
outcomes
• Individual empowerment to cope with triggers through changing
maladaptive behaviors
• Worry only during scheduled times
• Focus on the present rather than unknown future
• Used for GAD, agoraphobia and PTSD
Other Cognitive Approaches
• Exposure
• Incremental approach
• Good for phobias
• Relaxation training
• Breathing techniques
• Yoga
• Panic control therapy
• Exposure to panic inducing sensations in a controlled setting
• Relaxation techniques
Economic Impact of Anxiety
• Commonest psychiatric disorders
• Most anxiety disorders begin in childhood, adolescence, and
early adulthood
• Social phobia is the most common anxiety disorder; it has an
early age of onset—by age 11 years in about 50% and by age
20 years in about 80% of individuals
• Anxiety disorders have high rates of comorbidity with major
depression and alcohol and drug abuse.
• Chronic anxiety may be associated with increased risk for
cardiovascular morbidity and mortality.
Economic impact cont.
• Anxiety disorders are estimated to affect 26.9 million
individuals in the United States at some point during their
lives.
• In 1990, costs associated with anxiety disorders in USA were
$46.6 billion, 31.5% of total expenditures for mental illness.
• over three-quarters were attributable to lost or reduced
productivity.
• Most of these indirect costs were associated with morbidity,
as mortality accounted for just 2.7% of the total.
• Greater availability of effective, relatively low-cost outpatient
treatment could substantially reduce the economic and
social burden of these disorders.
References
• http://emedicine.medscape.com/article/286227-clinical
• Economic costs of anxiety disorders.
• DuPont RL, Rice DP, Miller LS, Shiraki SS, Rowland CR, Harwood
HJ. Economic costs of anxiety disorders Anxiety.
1996;2(4):167-72.
• Alder B, Abraham C, Teilingen E, Porter M. 2009. psychology
and sociology applied to medicine: an illustrated colour text.
Churchill Livingstone: Edinburgh