Anxiety

Anxiety is an extremely common condition that causes suffering worldwide. Those of us who live abroad in a different culture or have moved since childhood are more prone to these challenges. The increased stress of such moves, and the effort required to adjust to new situations and responsibilities, leave us more vulnerable to developing habits such as anxious thinking. Fortunately, anxiety disorders are very treatable. Anxiety Disorders are defined by the World Health Organization in the International Classification of Disease manual (ICD-10). There are a number of anxiety disorders with distinctive features, defined by the persistence of specific symptoms over a period of time. The operational definition for each anxiety disorder is laid out in the ICD-10 to allow psychiatrists to quickly and easily determine whether a patient has an anxiety disorder. This approach lends itself to research to discover effective treatment for different anxiety disorders. Panic Disorder is defined by the presence of discrete anxiety attacks or panic attacks. Panic attacks are characterized by such features as:

• Racing heart
• Feeling a loss of control
• Feeling sweaty or having chills
• Shortness of breath
• Worries of impending doom/death or sense of terror
• Chest pains
• Feeling weak
• Nausea or abdominal distress
• Derealization (feelings of unreality) or depersonalization (detachment from oneself)

Such sensations and symptoms are incredibly uncomfortable. People who experience panic attacks may go to great lengths to avoid future occurrences. This may mean reorganizing their lifestyle to avoid perceived triggers. For example, people may feel the need to avoid social situations, certain activities (such as exercise to maintain a low heart rate), or even leaving home in general. Such avoidance ultimately leads to increased limitations and challenges. Anxiety symptoms typical of Social Anxiety Disorder include avoidance and fear of social situations in which a person perceives a threat of judgement or criticism. Often there is a significant build-up of anxiety preceding an event. The event is followed by self-criticism and anxiety around how the person may have been perceived by others. In social anxiety disorder, often the anxiety is related to being perceived as anxious, lacking confidence, or being at fault.Overemphasis on these thoughts and worries, along with increased engagement in negative self-appraisal, makes social interactions more challenging than normal. To protect themselves from such discomfort and seemingly intolerable sensations, avoidance becomes a strong habit.Social anxiety disorder can cause many limitations. People may decline job opportunities or promotions that require them to be increasingly social or build business relationships. A variety of domains, from daily routines to romantic relationships, are also affected. Specific Phobias are anxiety disorders of exclusion. A person must have a number of anxiety symptoms that mirror panic attacks in response to a specific stimulus, such as flying or heights. While such uneasiness may be common, intense anxiety and the resulting avoidance have very limiting and challenging consequences.Other common phobias are directed towards the following:

• Public speaking
• Spiders
• Snakes
• Dogs
• Being in enclosed spaces
• Injections
• Social situations (Social Anxiety Disorder)
• Being alone in a situation or place where escape may be difficult (agoraphobia; often in connection with panic disorder)
• Storms
• Germs and dirt

Phobias may have a variety of targets, although the underlying mechanism is the same. At some point in a person’s life, fear of a specific stimulus was triggered. Over time this was routinely strengthened by related avoidance and anxious thoughts. These two mechanisms worked to solidify the phobia, often compelling people to go to extreme lengths to avoid the stimulus. This could mean avoiding important social or professional events, neglecting fundamental health needs, living in fear that the stimulus may present itself unexpectedly, or even preferring not to leave one’s home in order to avoid the stimulus. Such avoidance can be frustrating at best, and at worst debilitating. Generalized Anxiety Disorder is typically characterized by excessive and globalized worries (worries pertain to many areas of the person’s life).Symptoms of generalized anxiety disorder may include:

• Difficulty sleeping
• Difficulty with appetite
• Irritability
• Difficulty concentrating
• Self-criticism
• Somatic symptoms such as headaches or muscle tension
• Feeling on edge or as if something bad is going to happen

Such symptoms often amount to an overall sense that things will not be okay, often paired with continued worry. There is often an associated belief that worrying is a positive, effective strategy to prepare for potential risks and challenges. However, if a person is constantly engaged in worrying and preparing for potential negative outcomes, their life is significantly affected. There is a large overlap between Generalized Anxiety Disorder and depression (major depressive disorder). Many patients simultaneously meet the diagnostic criteria for both conditions. Post Traumatic Stress Disorder (PTSD) is rooted in a significant traumatic event or a series of traumatic events, resulting in impaired functioning due to symptoms that are categorized into four domains:

• Re-experiencing symptoms may include distressing dreams with content related to the traumatic event, spontaneous and intrusive memories or flashbacks, or other dissociative reactions in which the person feels or acts as if the traumatic event is happening again. There is also a sense of being disconnected with the present.
• Avoidance symptoms may look like avoidance of stimuli that reminds one of the traumatic event. These stimuli could be external, such as people, places, situations, conversations or physical sensations. However, the avoided stimuli are also often internal, such as thoughts or feelings related to the events.
• Negative thoughts and beliefs affect a person with PTSD through persistent and exaggerated negative appraisals of themselves, others, or the world. They often endure negative states, such as low moods, guilt, shame, anger or fear; decreased ability to enjoy previously pleasurable activities or happiness; or an overall sense of detachment from others and/or the world.
• Hyperarousal symptoms can look like heightened irritability or feeling easily angered; increased reckless behavior or decreased ability to assess risk; enduring state of feeling on-edge; difficulty sleeping soundly; and difficulty concentrating.

Obsessive Compulsive Disorder (OCD) is experienced through a combination of cognitive obsessions, along with either behavioral or cognitive compulsions to carry out specific actions. With OCD, obsessions and compulsions are related. Compulsions are carried out in an attempt to prevent, reduce, or neutralize the discomfort or anxiety caused by the obsessions.Obsessions take the form of unwanted or disturbing thoughts, images, or urges, such as a fear of hurting others, contamination, or troubling religious or sexual thoughts. Compulsions of a behavioral nature may take the form of hand washing, checking or cleaning. Those of a cognitive nature may take the form of counting, praying, or other mental repetition.Often, people are occupied by intrusive obsessions and compulsions for a considerable amount of time. However, they may be able to maintain work or school responsibilities. Over time, resistance to such symptoms may weaken. Time-consuming rituals may make it increasingly difficult to maintain relationships, work or school responsibilities, fundamental health needs, and even financial stability.

There has been less academic research on anxiety disorders than depression. Therefore, structured assessment tools such as questionnaires are less sophisticated and well-developed than in the field of depression. Some simple questionnaires are available online, which can help you determine if you might have an anxiety disorder. Doctors use operationally defined criteria such as those in ICD-10.Anxiety disorders are usually diagnosed by a doctor or psychiatrist after a review of the patient’s symptoms and a general health assessment. Occasionally, physical causes can be found, such as hyperthyroidism. Commonly, symptoms occur with no clear concurrent medical illness. For patients where a physical cause is suspected, or where the condition does not respond to treatment, blood tests, urine tests, and occasionally brain imaging are necessary. Anxiety treatment can be divided into three broad areas: biological treatment, psychological treatment, and social or lifestyle interventions.Biological treatment refers mainly to psychiatric medication, such as antidepressants that are used to treat anxiety disorders. There are a wide range of effective medications with different side effects that can be chosen.Psychological treatment includes familiar approaches such as counseling and psychotherapy. New evidence-based therapies such as cognitive behavioral therapy and relaxation techniques are also an option.Social or lifestyle interventions refer to strategies such as exercise programs, breathing exercises, meditation, healthy eating, addressing lifestyle factors, such as alcohol use, and social issues, such as employment problems, career stress, and financial debt.About one third of people with an anxiety disorder also have a mood disorder such as depression. It is important that your treating doctor checks to see if you are also depressed. This is important when considering your treatment options.

In general, evidence-based psychological approaches to anxiety disorders have been shown to be about as effective as medication. Cognitive and behavioral therapies have the best evidence for the treatment of anxiety disorders. There is also evidence supporting brief psychodynamic therapeutic approaches. These can be done with a counselor, therapist, psychologist or psychiatrist. There are also a wide range of self-help books and online programs that use cognitive therapy and interpersonal therapy techniques to help manage symptoms. If you think you are suffering from symptoms of anxiety or an anxiety disorder, you should seek assessment from a doctor and discuss what sort of treatment might be helpful.Come see us at our Tokyo-based psychiatry clinic at American Clinic Tokyo in Akasaka for assessment. Dr Andrew Kissane, our UK-trained, British psychiatrist is a native English speaker. He is on the General Medical Council’s specialist medical register in the UK, a member of the Royal College of Psychiatrists, and holds a Japanese medical license.If you do not wish to take a medical approach to your anxiety, but instead prefer to explore a psychological approach, such as cognitive behavioral therapy, breathing exercises, stress management, counseling or behavioral interventions, please email us requesting a therapy assessment at our Shintomi office. We have a growing team of English-speaking psychologists and therapists who would be delighted to help.