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Anxiety may be defined as apprehension, tension, or uneasiness that stems from the anticipation of danger, which may be internal or external (Diagnostic and Statistical Manual of Mental Disorders, 1980). Although some definitions distinguish between fear as being an emotional reaction to a real and consciously recognized threat and anxiety as being a fear response when reality does not justify such a response, it is important to remember that the manifestations of anxiety and fear in the body are the same. Since 2 to 4% of the general population has been estimated to experience sufficient symptoms of anxiety to be classified as having an anxiety disorder, it is extremely important that careful inquiry for the presence of anxiety be made.
Most patients who feel anxious will express this by saying that they feel nervous or worried. Patients usually see this condition as distressing and wish to find relief for it. In some cases, the anxiety appears in the form of phobias. For example, a patient may become phobic about driving a car following an automobile accident. Often the patient recognizes that the anxiety is not realistic but nevertheless is unable to control it. Since most patients do not understand the unconscious roots of the anxiety, the physician should inquire carefully concerning the circumstances in which the anxiety was first felt. By noting the situations in which anxiety is most intense, the physician can often gain clues regarding underlying etiology. The physician should ask how the anxiety has affected the patient's daily life routine. Finding the roots of anxiety is often a complex process requiring many visits. During the initial contacts with the patient, the clinician should endeavor to determine the severity of the anxiety. It is usually of some help to ask for the patient's opinion concerning the reason for his or her anxiety. Some patients have bizarre ideas about why they are anxious. If the patient, for example, believes that someone has cast a spell on him or her, the physician needs to know this.
During this portion of the psychiatric history, it is particularly important to look frequently and carefully at the patient. If the physician does not do this, important data, such as fleeting changes in expression, will often be missed. Anxious patients should be carefully observed for such signs as apprehensiveness, tremor, increased sweating, and rapid breathing, as is discussed in more detail in Chapter 207 on the Mental Status Examination.
Anxiety is sometimes referred to as the psychologic equivalent of physical pain. It is apparent that the mind has difficulty dealing with strongly conflicting emotions. One mental mechanism that the mind uses to deal with such conflict is repression. In the process of repression, the mind simply blocks out one side of the conflicting emotions. When this act of repression is not entirely successful, the repressed material is constantly struggling to erupt into consciousness. The anxiety felt by the patient is often closely correlated with the amount of mental effort spent in keeping this material out of consciousness. A number of mental maneuvers, referred to as defense mechanisms, are utilized in the effort to prevent repressed material from reaching consciousness. These mental mechanisms include such things as reaction formation, projection, rationalization, and displacement. These mental mechanisms are discussed at length in standard textbooks of psychiatry (e.g., Muskin and Kornfeld, 1982).
One reason that extensive utilization of defense mechanisms creates problems for patients is that such use tends to distort reality. The patient forced to block out one side of a conflict has created a situation that limits the ability to see all aspects of a problem. This, in turn, makes it difficult to choose the most appropriate solution for difficulties.
An increasing body of research now suggests that there are biologic roots for the anxiety experienced by some patients who have panic attacks. The discovery of cell receptor sites for benzodiazepines has stimulated search for a similar naturally occurring substance that may serve the function of reducing anxiety.
In some patients, panic attacks can be reproduced by intravenous infusion of sodium lactate. Inhalation of moderate amounts of carbon dioxide is also reported to reproduce panic attacks in many patients. Carr (1984) has postulated that lactate and carbon dioxide act on central chemoreceptors to produce an arousal state that stimulates the body to obtain more oxygen. This arousal state, when marked, is subjectively accompanied by feelings of anxiety. According to this hypothesis, panic disorder may result from an oversensitivity to carbon dioxide of central chemoreceptors or pathologic lability of the first stages of the ventilation-arousal cycle activated by these chemoreceptors.
It is also likely that some patients with anxiety disorders have abnormalities in the metabolism of norepinephrine. In this regard, it is of interest that monoamine oxidase inhibitors and tricyclic antidepressants are often effective in treating patients with anxiety disorders. Both classes of drugs have marked effect on norepinephrine in nerve cells. Alprazolam (Xanax) acts directly on benzodiazepine receptor sites and has also brought relief to many patients who have panic attacks. The increased effectiveness of pharmacologic treatment of anxiety has greatly stimulated interest in the investigation of organic factors in anxiety.
Many patients who show evidence of anxiety neither seek nor desire treatment. Such persons usually regard themselves as having a nervous temperament and have no expectation of ever being different. When questioned about their anxiety, these patients usually state that they have always been nervous and that there has been no recent change in the extent of their nervousness.
Patients who require treatment for anxiety are those who have either experienced significant impairment of function, are asking for relief of the internal distress associated with their anxiety, or both. The primary physician utilizing pharmacologic agents and supportive counseling can often treat acute conditions that have a strong environmental component. Examples might include anxiety related to job change, divorce, moving to a new location, physical illness, and financial difficulties.
Anxiety states related to long-standing emotional patterns, such as those found in phobias, conversion reactions, compulsions, and personality disorders, usually are best treated by referral to a mental health professional.
