Anxiety

Anxiety is an extremely common condition that causes much suffering across the world. Indeed, those of us who live abroad in different cultures or have always moved around 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 in general 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, all with distinctive features, defined by the persistence of specific symptoms of anxiety over a certain period of time. The ‘operational’ definition for each anxiety disorder is laid out in ICD-10 to allow psychiatrists across the world to quickly and easily determine whether a patient has an anxiety disorder, and if so, which one. This approach lends itself to research to discover what effectively treats different anxiety disorders.

Panic Disorder is defined by the presence of discrete anxiety attacks or panic attacks. Panic attacks are characterized by by features such 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 (being detached from oneself)

Anxiety symptoms typical of Social Anxiety Disorder include avoidance and fear of various types 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. Then the event is followed by self-criticism and anxiety around how the person may have been perceived by others during the event. In social anxiety disorder, often the anxiety is related to being perceived as anxious, lacking confidence, or at fault in some way.

Overemphasis on these types of thoughts and worries, in conjunction with increased engagement in negative self-appraisal, makes social interactions more challenging than they would normally feel. For the person to protect themself from such discomfort and seemingly intolerable sensations, avoidance becomes a strong habit.

Social anxiety disorder can cause many limitations in the lives of those who experience it. People may find themselves declining 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. This means that 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 uneasiness in relation to such stimuli may be common, intense anxiety and the resulting avoidance have very limiting and challenging consequences on their life.

• Public speaking
• Spiders and other arachnids
• 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

Generalized Anxiety Disorder is typically characterized by excessive and globalized worries (meaning the worries pertain to many areas of the person’s life).

• Difficulties with sleep
• Difficulties with appetite regulation
• Irritability
• Difficulty concentrating
• Pattern of self-criticism
• Somatic symptoms such as headaches or muscle tension
• Feeling ‘on edge’ or ‘as if something bad is going to happen’

Post Traumatic Stress Disorder (PTSD) is rooted in a significant traumatic event or a series of traumatic events a person has experienced, 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 related to the event, 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. The often endure negative states, such as low moods, guilt, shame, anger or fear; lowered ability to enjoy previously pleasurable activities or to feel 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’; difficulties with sleeping soundly; and difficulties 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 or images. Compulsions of a behavioral nature may take the form of handwashing, checking or cleaning. Those of a cognitive nature may take the form of counting, praying, or other mental repetition.

Often, people are occupied by such intrusive obsessions and compulsions for a considerable amount of time each day. 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 much less research on anxiety disorders than depression in the academic world. Therefore, structured assessment tools, such as questionnaires for anxiety disorders, are less sophisticated and well-developed than in the field of depression. Still, 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 for anxiety can be found, such as hyperthyroidism, or a pheochromocytoma. More commonly the 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 3 broad areas: biological treatment, psychological treatment, and social or lifestyle interventions.

Biological treatment refers mainly to psychiatric medication, such as ‘antidepressant medications’ that are used to treat anxiety disorders. There are a wide range of effective medications with differing side effects that a person seeking treatment can choose.

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 refers to strategies, such as exercise programs, breathing exercises, meditation, healthy eating, taking part in social activities, 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 ‘co-morbid’ mood disorder such as depression. It is important that your treating doctor also checks to see if you are also depressed as this might be important in considering your best 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 further 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 Ginza office. We have a growing team of English-speaking psychologists and therapists who would be delighted to help.