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James L. Holly, M.D. |
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| James L. Holly,M.D. |
| October 16, 2008 |
| Your Life Your Health - The Examiner |
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All of us worry and all of us have been anxious at one time or another in our lives. For instance, which of us have never worried about a test or once having taken a test being anxious (had anxiety) about the outcome? The answer is no one who has ever taken a series of tests can say they have never been without anxiety. Worry is what we often call anxiety. The story is told of an elderly lady who said during an interview, "All my life I have worried and worried and worried about many things. Now that I am 90 years of age, I have discovered that most things I worried about did not happen. This just goes to show you that worrying really works!"
The issue with the anxiety disorders is whether the normal response to stress results in abnormal physical symptoms and/or disabling emotional problems. In the first part of this series, we reviewed the classification of anxiety disorders have been classified according to the severity and duration of their symptoms and specific behavioral characteristics. Those categories include:
- Generalized anxiety disorder (GAD), which is long lasting and low-grade
- Panic disorder, which has more dramatic symptoms
- Phobias
- Obsessive-compulsive disorder (OCD)
- Post-traumatic stress disorder (PTSD)
- Separation anxiety disorder (which is almost always seen in children)
Diagnosis
How do you know if you have an abnormal stress disorder? First, a physical examination and medical and personal history is essential. Because anxiety accompanies so many medical conditions, some serious, it is extremely important for your healthcare professional to uncover any medical problems or medications that might underlie or be masked by an anxiety attack. During your examination, you should describe any occurrence of anxiety disorders or depression in the family and mention any other contributing factors, such as excessive caffeine use, recent life changes, or stressful events. It is very important to be honest with your doctor about all conditions, including excessive drinking, substance abuse, or other psychological or mood states that might contribute to, or result from, the anxiety disorder.
Diagnosing children with an anxiety disorder can be very difficult, since anxiety often results in disruptive behaviors that overlap with attention-deficit hyperactivity or oppositional disorder. Other conditions with symptoms similar to anxiety disorders include pervasive developmental disorders such Asperger syndrome, learning disabilities, bipolar disorder, and depression. Many children have anxiety disorder and a co-occurring condition, which should be treated along with anxiety.
Other Conditions with Similar Symptoms
People with anxiety disorders are more likely to see a family doctor before a mental health specialist, since their symptoms are often physical. Symptoms can include muscle tension, trembling, twitching, aching, soreness, cold and clammy hands, dry mouth, sweating, nausea or diarrhea, or urinary frequency. Anxiety attacks can mimic or accompany nearly every acute disorder of the heart or lungs, including heart attacks and angina (chest pain). In fact, nearly all individuals with panic disorders are convinced that their symptoms are physical and possibly life-threatening.
Studies suggest that up to a third of patients entering the emergency room with chest pain and who are low-to-moderate risk for a heart attack are actually suffering from panic attacks. It is often difficult even for specialists to distinguish between heart conditions and a panic attack. Women who are having an actual heart attack or acute heart problem are much more likely to be misdiagnosed as having an anxiety attack than are men with similar symptoms. Mitral valve prolapse, a common and usually mild heart problem, may have symptoms that are nearly identical to those of panic disorder. The two conditions, in fact, frequently occur together. (Mitral valve prolapse is a disorder in which the mitral valve does not close properly when the heart contracts. When the valve does not close properly it allows blood to backflow into the left atrium. Some symptoms can include palpitations, chest pain, difficulty breathing after exertion, fatigue, cough, and shortness of breath while lying down.) People with a heart-rhythm disturbance called paroxysmal supraventricular tachycardia have many of the same symptoms as those with panic attacks.
Asthma attacks and panic attacks have similar symptoms and can also coexist. Hyperthyroidism (low functioning thyroid) can cause many of the same symptoms of generalized anxiety disorder and must be ruled out. The symptoms of partial seizures and panic attacks often overlap. In addition, anxiety-like symptoms are seen in many other medical problems, including hypoglycemia, recurrent pulmonary emboli, and adrenal-gland tumors. Women can also experience intense anxiety attacks with hot flashes during menopause.
Many drugs, including some for high blood pressure, diabetes, and thyroid disorders, can produce symptoms of anxiety. Withdrawal from certain drugs, often those used to treat sleep disorders or anxiety, can also precipitate anxiety reactions. People with anxiety disorders often drink alcohol or abuse drugs in order to conceal or eliminate symptoms, but substance abuse and dependency can also cause anxiety. In addition, withdrawal from alcohol can produce physiologic symptoms similar to panic attacks. Clinicians often have difficulty determining whether alcoholism or anxiety is the primary disorder. Overuse of caffeine or abuse of amphetamines can cause symptoms resembling a panic attack.
Screening Tests
Anxiety can affect almost all parts of the human body and often manifests itself in physical symptoms. Of course, each of these physical symptoms can also be related to illness so it is important to exclude health problems before ascribing any one symptom to anxiety. One of the most commonly used tools to assess anxiety is the Hamilton Anxiety Scale (HAMA).
The Hamilton Anxiety Scale (HAMA) is a rating scale developed to quantify the severity of anxiety symptomatology, often used in psychotropic drug evaluation. It consists of 14 items, each defined by a series of symptoms. Each item is rated on a 5-point scale, ranging from 0 (not present) to 4 (severe). Once the subject identifies their experience of the symptoms in each category from 0 to 4, the results are tabulated and the presence and/or severity of anxiety is assessed by the following key:
- Mild Anxiety: 18+
- Moderate Anxiety: 25+
- Severe Anxiety: 30+
The 14 categories to be assessed and the symptoms for each category are:
Anxious Mood
- Worries
- Anticipates worst
Fears
- Fear of the dark
- Fear of strangers
- Fear of being alone
- Fear of animal
Intellectual
- Poor concentration
- Memory Impairment
Somatic Complaints: Muscular
- Muscle aches or pains
- Bruxism (grinding of the teeth at night
Cardiovascular Symptoms
- Tachycardia
- Palpitations
- Chest Pain
- Sensation of feeling faint
Gastrointestinal symptoms
- Dysphagia (difficulty swallowing)
- Nausea or Vomiting
- Constipation
- Weight loss
- Abdominal fullness
Autonomic Symptoms
- Dry Mouth
- Flushing
- Pallor
- Sweating
Tension
- Startles
- Cries easily
- Restless
- Trembling
Insomnia
- Difficulty falling asleep or staying asleep
- Difficulty with Nightmares
Depressed Mood
- Decreased interest in activities
- Anhedoni (inability to experience pleasure in normally pleasurable situations)
- Insomnia (difficulty in falling asleep and/or staying asleep)
Somatic Complaints: Sensory
- Tinnitus (ringing in the ears)
- Blurred vision
Respiratory Symptoms
- Chest pressure
- Choking sensation
- Shortness of Breath
Genitourinary symptoms
- Urinary frequency or urgency
- Dysmenorrhea (anbnormal menstrual cycle)
- Impotence
Behavior at Interview
If your score is above 18, you should see your healthcare provider or a thorough evaluation and possible treatment. Next week, we will discuss treatment options for stress disorders.
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