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Anxiety

Introduction

What should I know about Anxiety?

Anxiety is an emotional state commonly caused by the perception of real or potential danger that threatens the security of the individual. Everyone experiences a certain amount of nervousness and apprehension when faced with a stressful situation. Usually, the response is reasonable and adaptive, and contains a built-in control mechanism to return to a normal physiologic state. For some people, however, anxiety is more than just a temporary discomfort. For these individuals anxiety can be debilitating. It is when anxiety states become excessive or prolonged, particularly if it produces such psychological and physical stress, that the person cannot perform the activities of daily living, that medical help should be sought.

In general, anxiety disorders are a group of illnesses that develop before age 30 and are more common in women and those with a family history of anxiety and depression. Anxiety disorders are among the most frequent mental disorders encountered in a clinical setting. Approximately 8% of the population will experience at least one anxiety disorder in their lifetime. (1) Unfortunately, the majority of people with anxiety disorders receive no professional treatment. (2) This is unfortunate because there is a great deal of success in treating anxiety disorders and a life that has been paralyzed can be renewed with appropriate treatment.

The Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) classifies anxiety disorders into several categories. The characteristics of these illnesses are anxiety and avoidance behavior and include: generalized anxiety disorder, panic disorder (with or without agoraphobia), agoraphobia without history of panic disorder, phobic disorders (social phobia or specific phobia), obsessive-compulsive disorder, post-traumatic stress disorder, and acute stress disorder. (3)

Research studies have shown that there is a difference between normal anxiety and pathologic anxiety states. This difference involves multiple brain structures and neurotransmitter systems. Current drug therapy centers around the use of drugs which alter activity of one or more neurotransmitters, or act at the neurochemical receptor site.

Statistic

Anxiety Disorder Resource Centre, 2007.

  • Anxiety disorders affect approximately 1 in 4 people worldwide at some point in their lives.
  • Anxiety affects twice as many women as men.

National Institutes of Health, 2005. NIH Publication No. 06-4584

    6.8 million Americans have Generalized Anxiety Disorder. Approximately 40 million Americans suffer from all anxiety disorders combined. Approximately 6 million American adults ages 18 and older have panic disorder. Approximately 15 million American adults age 18 and over have social phobia. Approximately 19.2 million American adults age 18 and over have some type of specific phobia.

Surgeon General’s Report on Anxiety Disorders and Mental Health, Dec. 2000.

    Panic Disorder is twice as common among women as men. Age of onset is most common between late adolescence and mid-adult life. There appears to be no specific familial relationship associated with anxiety disorder.

Signs and Symptoms

The following list does not insure the presence of this health condition. Please see the text and your healthcare professional for more information.

According to the DSM-IV, the diagnostic criteria for generalized anxiety disorder (GAD) require persistent symptoms for at least six months. The essential feature of GAD is unrealistic or excessive worry about a number of events or activities. (4)

Panic disorder begins as a series of unexpected panic attacks, involving an intense, terrifying fear, similar to that caused by life threatening danger. The unexpected panic attacks are followed by at least one month of persistent concern about having another panic attack, worry about possible consequences of having another panic attack, or a significant behavior change related to the attacks. (5)

Panic attacks usually last no more than 20-30 minutes, with the strongest symptoms occurring within the first 10 minutes. Many patients eventually develop agoraphobia secondary to the panic attacks. This is due to fear of not being able to escape or find help in the event of a panic attack. Complications also include work impairment, depression, alcohol abuse, and increased use of medications, health services, and emergency rooms. Patients with panic disorders have a high lifetime risk of suicide attempts compared to the general population. (6)

The third category usually considered with anxiety disorders is phobia. Phobias are generally classified into social or specific phobias. Social phobia can be defined as a marked and specific fear of social situations or performance areas, while specific phobias refer to fear of an object or situation (e.g., animals, water, enclosed places). Apart from contact with the feared object or situation, the individual is usually free of symptoms. Most persons simply avoid the feared object and adjust to certain restrictions on their activities. (7)

General

  • Difficult to control worry
  • Restlessness or feeling keyed up or on edge
  • Being easily fatigued
  • Difficulty concentrating or mind going blank
  • Irritability
  • Muscle tension
  • Sleep disturbance
  • Significant impairment in social, occupational, or other important areas of functioning

Panic attacks

  • Palpitations or accelerated heart rate
  • Sweating
  • Trembling or shaking
  • Sensations of shortness of breath or smothering
  • Feeling of choking
  • Chest pain or discomfort
  • Nausea or upset stomach
  • Feeling dizzy, lightheaded, unsteady, or faint
  • Fear of losing control or going crazy
  • Fear of dying
  • Numbness or tingling sensations
  • Chills or hot flushes

Phobias

  • Social phobia - fear of social situations or performance areas
  • Specific phobia - fear of an object or situation such as animals, water or enclosed places

Treatment Options

Conventional

Generalized anxiety disorder is usually treated by a combination of psychotherapy and drug therapy. Treatment often includes counseling, stress management, psychotherapy, meditation, or exercise. Individuals with anxiety disorder should avoid caffeine, nonprescription stimulants, and diet pills. There are several prescription drugs that are used with a general anxiety disorder. Some of these include benzodiazepines, buspirone, adrenergic blocking agents, and antidepressants.

Panic disorder is treated slightly differently than GAD. Individuals with panic disorder should be educated to avoid substances that may precipitate panic attacks including caffeine, drugs of abuse, and nonprescription stimulants. (8) If agoraphobia is present, cognitive-behavioral therapy is recommended to help the patient focus on correction of thoughts and behaviors. Panic disorder is effectively treated with several drugs including Benzodiazepines (alprazolam, clonazepam, diazepam, lorazepam), tricyclic antidepressants (imipramine, desipramine), MAO inhibitors (phenelzine), and Selective Serotonin Reuptake Inhibitors (fluoxetine, fluvoxamine, paroxetine, sertraline). These SSRIs are usually the first drug prescribed because they are well tolerated; however, they are significantly more expensive than tricyclic antidepressants and benzodiazepines.

Nutritional Suplementation


Magnesium

Magnesium is a mineral that has as one of its many functions, muscle relaxing characteristics. It may provide benefit for people with anxiety. It has been documented that anxiety is one of the symptoms that can occur in individuals with magnesium depletion. (9) Symptoms of magnesium deficiency include anxiety, nervousness, insomnia, muscle fatigue, and tachycardia.


Vitamin B6

Vitamin B6 is required for the conversion of tryptophan to serotonin. Therefore, a deficiency of vitamin B6 may result in symptoms of anxiety and depression due to inhibition of serotonin synthesis. (10) In a study of individuals suffering from frequent anxiety attacks, patients were given vitamin B6 (125mg, 3 times daily) and tryptophan (2 grams daily). This regime enabled in 70 percent of patients (9 of 13) to become free of anxiety attacks within three weeks. (11)

Oral contraceptives are known to deplete vitamin B6, which may cause anxiety in susceptible women. In one particular study, administration of 40mg of vitamin B6 daily restored normal biochemical values and also relieved the clinical symptoms in the vitamin B6 deficient women taking oral contraceptives. (12) There are other drugs that deplete B6 in addition to oral contraceptives.


5-Hydroxytryptophan (5-HTP)

Tryptophan and 5-hydroxytryptophan (5-HTP) are necessary for the body to make serotonin. Tryptophan is an essential amino acid that the body cannot manufacturer. Tryptophan is converted into 5-HTP, which in turn is converted into serotonin. (13) There is ample evidence that tryptophan depletion causes reduced synthesis of serotonin, which can result in anxiety and other mood disorders. (14)


Tyrosine

Tyrosine is the precursor to some of the more important neurotransmitters which function to influence and regulate mental and emotional states. In one study, one group of women was placed on a controlled diet that caused the depletion of phenylalanine and tyrosine while a second group was put on a diet that caused the depletion of tryptophan. In both cases, a similar level of anxiety and irritability developed. (15) Oral contraceptives can cause a depletion of tyrosine in women users, which increases the risk of depression. (16) At this time, there are only a few studies that mention the link between tyrosine depletion and anxiety, so this relationship is not strongly supported with scientific documentation.

Herbal Suplementation


Kava

South Pacific natives have used kava for centuries. The root is used in the preparation of a recreational beverage known by a variety of local names (kava, yaqona, awa) and occupies a prominent position in the social, ceremonial, and daily life of Pacific island peoples as coffee or tea does in the Western cultures. In European phytomedicine, kava has long been used as a safe, effective treatment for mild anxiety states, nervous tension, muscular tension, and mild insomnia. (17) , (18) The results of a study revealed that kava may be effective and safe when used for sleep disturbances associated with anxiety disorders. (19) Studies have reported that kava preparations compare favorably to benzodiazepines in controlling symptoms of anxiety and minor depression, while increasing vigilance, sociability, memory, and reaction time. (20) , (21)


Passionflower

In humans, passionflower has been reported effective when used in combination with other sedative and anti-anxiety herbs such as valerian, making it beneficial in conditions such as hyperthyroidism where CNS (central nervous system) stimulation occurs. (22)


Valerian

Valerian has long been used as an agent to soothe the nervous system in response to stress. It has been reported that valerian helps improve sleep quality. (23) , (24) , (25) The usefulness of valerian is reported to be due to several principal components, including valepotriates, valeric acid, and pungent oils, which have a sedative effect on the central nervous system, as well as a relaxing effect on the smooth muscles of the GI tract. (26) , (27)

Diet & Lifestyle

Dietary changes may be helpful. All sources of caffeine should be avoided, including coffee, tea, chocolate, caffeinated sodas, and caffeine-containing medications. Also avoid sugar and refined carbohydrates.

Stress reduction can take form in a variety of ways. Some of the more structured forms of anxiety relief include; counseling, tai chi, yoga, meditation, and deep breathing.

References

  1. Surgeon General’s Report on Anxiety Disorders and Mental Health. Washington DC; Dec1999.
  2. View Abstract: Kessler RC, McGonagle KA, Zhao S, et al. Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States. Results from the National Comorbidity Survey. Arch Gen Psychiatry. 1994;51:8-19.
  3. American Psychiatric Association. Diagnostic and statistical manual of Mental Disorders, 4th ed. DSM-IV, Washington DC: American Psychiatric Press; 1994:393-444.
  4. American Psychiatric Association. Diagnostic and statistical manual of Mental Disorders, 4th ed. DSM-IV, Washington DC: American Psychiatric Press; 1994:393-444.
  5. American Psychiatric Association. Diagnostic and statistical manual of Mental Disorders, 4th ed. DSM-IV, Washington DC: American Psychiatric Press; 1994:393-444.
  6. Davidson JRT. Quality of life in panic disorder. J Clin Psychiatry. 1997;58:127-129.
  7. American Psychiatric Association. Diagnostic and statistical manual of Mental Disorders, 4th ed. DSM-IV, Washington DC: American Psychiatric Press; 1994:393-444.
  8. View Abstract: Goddard AW, Charney DS. Toward an integrated neurobiology of panic disorder. J Clin Psychiatry. 1997;58(suppl):4-11.
  9. View Abstract: Seelig MS, et al. Latent tetany and anxiety, marginal magnesium deficit, and normocalcemia. Dis Nerv Syst. Aug1975;36(8):461-5.
  10. View Abstract: Hartvig P, et al. Pyridoxine effect on synthesis rate of serotonin in the monkey brain measured with positron emission tomography. J Neural Transm Gen Sect. 1995;102(2):91-7.
  11. Hoes MJ, et al. Hyperventilation syndrome, treatment with L-tryptophan and pyridoxine: Predictive value of xanthurenic acid excretion. J Orthomol Psychiatry. 1981;10(10):7-15.
  12. View Abstract: Bermond P. Therapy of side effects of oral contraceptive agents with vitamin B6. Acta Vitaminol Enzymol. 1982;4(1-2):45-54.
  13. View Abstract: Birdsall TC. 5-Hydroxytryptophan: a clinically-effective serotonin precursor. Altern Med Rev. Aug1998;3(4):271-80.
  14. View Abstract: Klaassen T, et al. Effects on mood of acute phenylalanine/tyrosine depletion in healthy women. Neuropsychopharmacology. Jan2000;22(1):52-63.
  15. View Abstract: Leyton M, et al. Effects on mood of acute phenylalanine/tyrosine depletion in healthy women. Neuropsychopharmacology. Jan2000;22(1):52-63.
  16. View Abstract: Moller SE. Effect of oral contraceptives on tryptophan and tyrosine availability: evidence for a possible contribution to mental depression. Neuropsychobiology. 1981;7(4):192-200.
  17. View Abstract: Volz HP, et al. Kava-kava Extract WS 1490 Versus Placebo in Anxiety Disorders - A Randomized Placebo-controlled 25-week Outpatient Trial. Pharmacopsychiatry. Jan1997;30(1):1-5.
  18. View Abstract: Singh YN. Kava: An Overview. J Ethnopharmacol. Aug1992;37(1):13-45.
  19. View Abstract: Lehrl S. Clinical efficacy of kava extract WS 1490 in sleep disturbances associated with anxiety disorders. Results of a multicenter, randomized, placebo-controlled, double-blind clinical trial. J Affect Disord. Feb2004;78(2):101-10.
  20. View Abstract: Munte TF, et al. Effects of Oxazepam and an Extract of Kava Roots (Piper methysticum) on Event-related Potentials in a Word Recognition Task. Neuropsychobiology. 1993;27(1):46-53.
  21. Drug Therapy of Panic Disorders. Kava-specific Extract WS 1490 Compared to Benzodiazepines. Nervenarzt. Jan1994;65(1Supp):1-4.
  22. View Abstract: Bourin M, et al. A Combination of Plant Extracts in the Treatment of Outpatients with Adjustment Disorder with Anxious Mood: Controlled Study Versus Placebo. Fundam Clin Pharmacol. 1997;11(2):127-132.
  23. View Abstract: Lindahl O, Lindwall L. Double Blind Study of Valerian Preparations. Pharmacol Biochem Behav. 1989;32(4):1065-66.
  24. View Abstract: Leathwood PD, et al. Aqueous Extract of Valerian Root (Valeriana officinalis L.) Improves Sleep Quality in Man. Pharmacol Biochem Behav. 1982;17:65-71.
  25. View Abstract: Balderer G, et al. Effect of Valerian on Human Sleep. Psvchopharmacology. 1985;87:406-09.
  26. View Abstract: Houghton PJ. The scientific basis for the reputed activity of Valerian. J Pharm Pharmacol. May 1999;51(5):505-12.
  27. Hendriks H, et al. Pharmacological Screening of Valerenal and Some Other Components of Essential Oil of Valeriana officinalis. Planta Medica. 1985;51:28-31.