Anxiety and Stress-Related Disorders

Posttraumatic stress disorder is a psychiatric illness characterized by overwhelming stress and anxiety experienced after exposure to a life-threatening event. Symptoms last more than 1 month and involve re-experiencing the event as flashbacks or nightmares, avoiding reminders of the event, irritability, hyperarousal, and poor memory and concentration. Treatment is mainly based on CBT and eye movement desensitization. Pharmacological regimens, such as antidepressants, might be indicated in some cases.

Obsessive-compulsive disorder (OCD) is a condition characterized by obsessions (recurring and intrusive thoughts, urges, or images) and/or compulsions (repetitive actions the person is compelled to perform) that are time-consuming and associated with functional impairment. Many psychiatric disorders such as depression coexist with OCD. The mean age of onset is about 20 years of age, although the condition can occur earlier. Obsessions present as unwanted thoughts (e.g., fear of contamination) that cause distress and anxiety. The suffering individual attempts to ignore or suppress these thoughts by neutralizing them with another thought or action, which is a compulsion. The individual is driven to perform certain acts or behaviors, which are typically related to an obsession. However, the compulsions are unrealistic or excessive (e.g., washing rituals). The treatment regimen generally includes psychotherapy and pharmacotherapy (with selective serotonin reuptake inhibitors (SSRIs)).

Benzodiazepines work on the gamma-aminobutyric acid type A (GABAA) receptor to produce inhibitory effects on the CNS. Benzodiazepines do not mimic GABA, the main inhibitory neurotransmitter in humans, but instead potentiate GABA activity. The drug class of benzodiazepines has anxiolytic, muscle-relaxant, hypnotic, sedative, and anticonvulsant properties. These agents are not generally recommended for long-term use, as patients can develop physiological and psychological dependence. Side effects may include cognitive impairment, somnolence, and respiratory depression.

Panic disorder is a condition marked by recurrent and episodic panic attacks that occur abruptly and without a trigger. These episodes are time-limited and present with cardiorespiratory (palpitations, shortness of breath, choking), GI (nausea, abdominal distress), and neurologic (paresthesias, light-headedness) symptoms. Fear of dying or going crazy can occur. Patients may develop agoraphobia (fear of being in places or situations where leaving or escape is difficult). These findings lead to impaired daily functioning. Diagnosing panic disorder is challenging because panic attacks can also occur with other anxiety and mental disorders. Additionally, organic diseases can have similar symptoms. Thorough history and examination, along with a focused workup (based on patient age, risk, and comorbidities) aid in the diagnosis. Management includes both psychotherapy and medications (selective serotonin reuptake inhibitor (SSRIs) and serotonin–norepinephrine reuptake inhibitor (SNRIs)).

Agoraphobia is fear or anxiety in a situation that would be difficult to leave or to obtain help in the event that one develops panic-like symptoms. Situations include being in public or open spaces, lines, crowds, or public transport. If severe, the condition results in significant social and occupational disability in which patients actively avoid the situation, and in certain cases, refuse to leave their homes alone. Diagnosis is clinical, based on the presenting symptoms. Agoraphobia occurs frequently with panic disorder. Management is best approached with CBT and medications (selective serotonin reuptake inhibitors (SSRIs)).

Specific phobia is irrational fear or anxiety arising from a specific object or situation, leading to avoidance. The main types of phobias are animal (e.g., spiders, dogs), natural environment (e.g., water, storms), blood-injection injury (e.g., needles), situational (e.g., enclosed spaces), and others not categorized under the preceding specifiers. The symptoms cause functional impairment and persist for ≥ 6 months. CBT is 1st-line treatment; medications have a limited role.

Psychotherapy is interpersonal treatment based on the understanding of psychological principles and mechanisms of mental disease. The treatment approach is often individualized, depending on the psychiatric condition(s) or circumstance. Psychodynamic therapy seeks to bring forward unconscious or repressed thoughts to help address the current behavior. Cognitive-behavioral therapy corrects faulty assumptions and tries to replace maladaptive behavior with healthier alternatives. Psychoeducation provides patients with information about the disorder, including anticipated problems and treatment so that they are able to manage. Other forms include supportive therapy (short-term therapy to help through a life crisis), motivational interviewing (changing maladaptive behaviors by guiding the patient to be the agent of change for themself), interpersonal therapy (focusing on the relationships rather than repressed thoughts), and dialectical behavioral therapy (using a hierarchy of treatment targets, like reduction of suicidal and dangerous behavior). Treatment is offered in different formats (individual, family, couple, or group). The goals vary and can include changing the individual’s behaviors and thoughts, improving relationships, reducing psychiatric symptoms as well as functional impairment, and involving the family to enhance treatment.