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Thursday, August 24, 2017

Co-Occurring Anxiety Disorders

Anxiety disorders are characterized by feelings of excessive fear and anxiety that can result in behavioral dysfunction and physiological reactions. There are six categories of anxiety disorders:
co occurring anxiety disorders

  • generalized anxiety disorder
  • stress-related anxiety
  • panic disorder
  • social phobias
  • anxiety induced by medical illnesses
  • anxiety symptoms that are part of a primary mental disorder


While the anxiety disorders tend to be highly comorbid with one another, they differ in the specific triggers or situations that induce anxiety, the resulting behaviors, the content of associated cognitions, and the duration of symptoms.

The etiology of anxiety disorders also varies depending on the specific diagnosis, however it is generally understood that most mental health issues are a result of a complex interaction between environmental factors, genetics, cultural influences, psychological composition, and biological influences. Some anxiety disorders appear to be more strongly linked to biochemical and genetic factors while others are primarily linked to cognitive bias and/or environmental influences.

Treatment for anxiety disorders varies depending on the specific diagnosis. In some cases, medication that directly alters the neurochemical processes associated with anxiety is indicated. In other cases, psychotherapy or a combination of pharmacological and therapeutic interventions is more effective. In order to determine the most effective mode of treatment, a provider must conduct a thorough evaluation that includes differential diagnosing, ruling out certain conditions and causes, and identifying any comorbid disorders that might better explain the anxiety symptoms.

There are several things to consider when determining the possible etiology of anxiety disorders including genetic, biological, environmental, and temperamental factors. Additionally, some anxiety symptoms can be explained by a medical condition, medication and/or substance use. In other cases, certain underlying traits may predispose individuals to anxiety symptoms in addition to environmental risk factors such as childhood maltreatment, adversity, abuse, family dynamics, and substance use. Genetic and physiological factors also play a role in some anxiety disorders. For example, one-third of the risk of experiencing generalized anxiety disorder is genetic, heritability for agoraphobia is 61%, and there is an increased risk for panic disorder among children of parents with anxiety, depressive, and bipolar disorders. It is well understood that most disorders are a result of a complex interaction between genes and environment.

The brain regions typically associated with anxiety include the amygdala, pre-frontal cortex, and structures within the limbic system. The amygdala is a key structure in managing fear and anxiety responses. Individuals with anxiety disorders often show heightened responses in the amygdala when presented with anxiety cues. The orbital frontal cortices (OFT) have also been implicated in anxiety disorders. Individuals with anxiety disorders have shown an increase in overall chemical concentrations in the OFC, thus lending further support to the neurobiological explanations for anxiety.

Some of the primary mediators of anxiety symptoms exist within the central nervous system and include norepinephrine, serotonin, dopamine, and gamma-aminobutyric acid (GABA). Brain imaging has demonstrated reduced serotonin receptor binding and smaller temporal lobe volume in individuals with panic disorder. Research also suggests that abnormalities in serotonin levels and dopaminergic transmission are implicated in obsessive-compulsive disorder (OCD). Additionally, brain imaging has shown increases in blood flow and metabolic activity in the orbitofrontal cortex, limbic structures, caudate, and thalamus in individuals suffering from OCD. This indicates that symptoms of OCD may be a result of impairment in the brain structures that mediate strong emotions and the autonomic responses to those emotions (Baxter et al., 1992).

Psychological theories are also used to explain the etiology of anxiety disorders and typically consider cognitive, emotional, behavioral, and internal constructs as important factors that influence the development and expression of anxiety related symptoms. Cognitive theories state that anxiety is a result of an individual’s negative interpretation of anxiety related cues, cognitive distortions, and possibly a hypersensitivity to internal cues. Individuals with an anxiety disorder may overestimate the potential for danger and/or anticipate the worst-case scenario causing them to avoid certain situations and triggers. Behavioral theories view anxiety as a learned or conditioned response resulting from past associations between specific stimuli and anxiety responses. As a result, an avoidance response or a fear-based response becomes linked to these situations.

There are also considerable cross-cultural and gender differences in the prevalence and expression of anxiety disorders. For example, the female to male ratio for anxiety disorders is 3:1. The prevalence of GAD, panic disorder, and social anxiety in Asian, Latin American, and other non-western cultures is significantly lower relative to predominantly Caucasian American cultures. Explanations for these cultural variations include possible cultural and gender related differences in risk factors for the development of anxiety disorders, culturally specific concerns, beliefs, and evaluations of symptoms. 

Treatment for anxiety depends on the specific type of anxiety disorder, so it is important to conduct a thorough assessment in order to make an accurate diagnosis before considering specific interventions. The duration of anxiety disorders is also quite variable. Some individuals may only require short-term treatment while others may need years of ongoing treatment. It is also important to recognize that anxiety and stress are normal parts of daily living and should only be treated when the symptoms become excessive and interfere with normal functioning.

Medications such as SSRIs, venlafaxine, and busprione have been shown to be effective in the treatment of Generalized Anxiety Disorder (GAD), however many experts recommend psychotherapy as the primary modality of treatment for this disorder. While benzodiazepines can be an effective anti-anxiety medication, this class of medications poses significant risks for those including increased depression and risk of dependence. They should only be used if other medications prove to be ineffective and provided that the individual does not have a history of substance use or depression. If an individual is suffering from situational or stress related anxiety, medication may not be indicated, and if it is, it should only be prescribed on a short-term basis. 

When treating any mental illness, it is important to conduct a thorough evaluation in order to make an accurate diagnosis. Anxiety symptoms can result from a variety of factors including environmental or situational causes, medical conditions, substance use, medication side effects, or other mental disorders. It is therefore essential for a provider to determine the main cause of the anxiety symptoms and treat the primary causes and conditions.

When an individual presents with anxiety symptoms the following conditions should be ruled out before implementing a course of treatment: trauma or stressor-related anxiety, Substance/Medication-Induced Anxiety Disorder, Anxiety Disorder Due to Another Medical Condition, a medical illness, or Adjustment Disorder With Anxiety. Common issues that may cause anxiety include substance use particularly alcoholism and stimulant use, heart conditions, CNS diseases, hypoglycemia, hyperthyroidism, steroids, caffeine use, and other medications (Preston & Johnson, 2014). It is important to assess for any medical conditions, medications, and/or substance use issues that could be causing anxiety related symptoms.

Additionally, various mental illnesses can also cause anxiety related symptoms. Anxiety frequently accompanies mental health issues such as depression, schizophrenia, substance use, and organic brain dysfunctions. Anxiety disorders also have a high comorbidity rate with one another and require careful assessment to determine accurate diagnoses. Some anxiety disorders are frequently associated with a range of other mental health disorders. It is important to consider the presence of and possible relationship between the anxiety symptoms and other mental disorders.

Once an accurate diagnosis has been made, then a course of treatment should be determined in collaboration with the individual and other providers if necessary. For many mental disorders, therapeutic approaches are the first recommended course of treatment or a combination of pharmacological treatment and therapeutic interventions. Psychotherapeutic approaches such as behavioral modification, graded exposure therapy, psycho-education, skills training, and cognitive behavioral therapy are often effective in treating anxiety. If the anxiety symptoms are acute and/or likely to be of short duration, medications are not always indicated and, if they are, they should only be prescribed for a short period of time. If the anxiety is situational, a result of a specific crisis, or due to typical life stressors, then the anxiety is likely to resolve once the situation or stressor has passed without therapeutic or pharmacological intervention.

Some anti-anxiety medications can offer quick symptomatic relief and reduce suffering, however they do not necessarily “cure” the disorder. In order to achieve long-term recovery, the primary source of the anxiety must be altered. Therapeutic techniques have proven to be effective in addressing the main cause of some anxiety symptoms while facilitating lasting relief. If medication is indicated,it is important to educate those seeking treatment on the risks and benefits of medications including the differences between short-term and long-term use of medications.

Education and skills training such as meditation, mindfulness strategies, and distress tolerance techniques as well as CBT and behavioral interventions are quite effective approaches to the treatment of anxiety. Specific therapeutic techniques might include behavioral activation, physical and cognitive relaxation strategies, thought stopping techniques, and training in how to identify triggers, automatic thoughts, cognitive distortions, and methods to develop reassuring cognitions. These interventions have proven to result in significant reduction in anxiety symptoms particularly for pervasive chronic anxiety characteristic of GAD. The effectiveness of CBT based interventions lends additional support to the overwhelming evidence that many forms of anxiety are associated with cognitive distortions, hypersensitivity to internal cues, and a tendency to interpret events negatively.

When developing any course of treatment it is imperative that a provider view the individual and his or her symptoms within the larger context of culture and gender. Cultural variations in cognitions, beliefs, and unique ways of understanding physiology and psychology may affect the presentation, risk factors, course, and interpretation of anxiety symptoms. Similarly, gender frequently influences the expression of anxiety as well as the presence of co-occurring disorders. For example, women with social anxiety disorder report a greater number of comorbid depressive, anxiety, and bipolar disorders, whereas men are more likely to have conduct disorder or a substance use disorder as a means to manage anxiety symptoms. As a result, culturally sensitive interventions and gender-related diagnostic issues must be considered when formulating a treatment plan. This includes assessing the culture that the individual identifies with as well as determining the degree to which the individual endorses specific cultural practices and beliefs.

It is clear that the etiology of anxiety disorders, like most mental disorders, is complex and varies depending on the specific disorder. Dynamic interactions between neurological, biological, and environmental factors shape and influence the expression of anxiety related symptoms. These etiological factors have important implications for diagnosing and subsequent treatment planning. Some anxiety disorders are rooted in neurological and/or biological dysfunction and therefore respond well to medical and/or psychopharmacological treatments, while other anxiety symptoms can be linked to cognitive and/or behavioral abnormalities and require therapeutic interventions.

Marie Tueller, MEd, LPC

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