Case 2 Anxiety

Description of anxiety

Definition

Anxiety is an unpleasant and often distressing sense of uneasiness, apprehension and/or nervousness. Anxiety is considered to be a standalone, non-pathological symptom (i.e. a normal response to an environmental stessor such as workplace or examination stress), as well as a central feature of ‘anxiety disorder’, a term that is inclusive of generalised anxiety disorder (GAD), phobias, panic disorder, obsessive–compulsive disorder (OCD) and post-traumatic stress disorder (PTSD).¹

Epidemiology

The lifetime prevalence rate of GAD ranges from 10.6 per cent to 16.6 per cent. This disorder is most prevalent in women, and appears to increase with advancing age. For the more specific anxiety disorders, the lifetime prevalence rates range from 0.5–1.3 per cent for OCD, 1.0–1.2 per cent for panic disorder, 1.2–2.1 per cent for PTSD, 3.6–5.3 per cent for phobias and 2.6–6.2 per cent for GAD.²

Anxiety disorders are complex conditions that appear to originate from a number of causes. Genetic predisposition and/or familial history, for instance, have been associated with panic disorder, GAD, phobias and OCD.³ Physiological factors, including group A beta-hemolytic Streptococcus infection and trauma or postpartum events are, respectively, also implicated in OCD and panic disorder. But most attention has focused on the neurochemical aetiology of these disorders. Elevated central nervous system catecholamine levels (e.g. panic disorder), impaired gamma-amino butyric acid metabolism (e.g. panic disorder), carbon dioxide sensitivity (e.g. panic disorder), abnormal serotoninergic and noradrenergic activity (e.g. GAD and PTSD), reduced dopamine (D2) receptor and transporter binding (e.g. phobias), abnormal number and/or function of serotinergic receptors (e.g. OCD), neurological disease (e.g. OCD), increased limbic system activity (e.g. PTSD), impaired lactate metabolism (e.g. panic disorder), and basal ganglia dysfunction and prefrontal hyperactivity (e.g. OCD) are just some of the many neurochemical causes of these disorders.⁴

The pathogenesis of anxiety disorders is only partly explained by these physiological elements. The development of these conditions is also influenced by socioenvironmental factors such as stress, illicit drug use (e.g. marijuana and lysergic acid diethylamide, or LSD), diet (e.g. caffeine), poor social support (e.g. PTSD) and the demise of close relationships (e.g. panic disorder). Behavioural elements also may be implicated in the pathogenesis of anxiety disorder, including the development of abnormal or irrational conditioned responses to fearful situations (e.g. panic disorder), life events (e.g. GAD) or stressful situations (e.g. OCD).^4,⁵

Clinical manifestations

Anxiety is an elusive symptom that can manifest in any person, at any time, in any given situation and to any degree. Anxiety can manifest in any health condition and the physiological features of anxiety can mimic other disorders. As a result, distinguishing anxiety from other medical conditions may be a challenge for some clinicians. A critical first step to identifying anxiety disorder is to understand that anxiety is only one symptom of this condition. Other symptoms that commonly manifest in this group of disorders are irritability, poor concentration, insomnia, restlessness, muscle tension, avoidance behaviour, preoccupation with an event or situation, easy fatigability, tachycardia, palpitations, shortness of breath and an exaggerated startle response.^1,^3,⁴

The duration of anxiety is also important. Panic disorder, for instance, is an acute condition that manifests rapidly and peaks within 10 minutes. PTSD can be acute (i.e. occurring soon after an event) and chronic (i.e. occurring more than 3 months after an event). Conditions such as GAD, OCD and phobias are chronic and can exist for many months, years or decades. While the intensity of symptoms is often most severe in acute panic disorder, the severity of symptoms in other anxiety disorders varies greatly.^1,^3,⁴

A 33-year-old woman presents to the clinic complaining of anxiety. The anxiety (defined by the patient as tremulousness and uneasiness) began 12 months ago when she decided to move to Australia to further her career and get married. The anxiety has continued to increase since then, and it was only one month before her consultation with the CAM practitioner that the client decided to speak to her general practitioner (GP). The GP prescribed temazepam for the insomnia and alprazolam for the anxiety. The GP advised the client that she may have generalised anxiety disorder (GAD), and that if the condition did not improve within 3 months, she would refer the client to a psychiatrist. The GP recommended that the client also take up daily meditation and commence an exercise program to assist with coping.

While the temazepam has helped increase the duration of sleep and the alprazolam has reduced the severity of the anxiety, the client is reluctant to continue with the anxiolytic in the long term. The client also has not commenced meditation or exercise. This is because up until now she was not sure who to approach for this advice. The client has found the anxiety, including concomitant sighing, shortness of breath, muscle tension, restlessness, poor concentration and insomnia, worsens when her husband is away or when she steps up as acting manager at work. These symptoms often improve during the weekends, and even more so during recreational leave.

Diet and fluid intake
Breakfast	Cornflakes® cereal with skim milk, coffee.
Morning tea	Coffee.
Lunch	Wholemeal sandwich with tomato, low fat cheese, lettuce and/or ham.
Afternoon tea	Coffee, sweet biscuits.
Dinner	Lamb and vegetable curry, fish in coconut cream, baked cod with tomato and onion, beef meatballs with sweet potato bake.
Fluid intake	4–5 cups of percolated coffee a day, 1–2 cups of water a day.
Food frequency
Fruit	1 serve daily
Vegetables	2–3 serves daily
Dairy	2 serves daily
Cereals	5 serves daily
Red meat	1 serve a week
Chicken	1 serve a week
Fish	3 serves a week
Takeaway/fast food	1 time a week

The client is Fijian-born with Fijian-born parents. She moved to Australia 12 months ago, leaving behind her parents and all her family members. The client has an English-born husband but no children. She works full time as an optician in an optical store, which she finds stressful at times. The client is buying her own home and is responsible for all household activities and finances as her husband is away every second week for mining-related work. The client finds these periods of absence from her husband distressing, although she does find some peace in her Christian practice.

Physical examination

Lifestyle

Physical exercise (Level I, Strength A, Direction +)

Increasing levels of physical activity are associated with improvements in physiological and psychological health and wellbeing.¹² According to findings from a meta-analysis of 49 RCTs, exercise therapy also demonstrates moderate reductions in anxiety when compared to no-exercise controls or other anxiolytic treatment.¹³ The anxiolytic effect of exercise appears to be less significant in children and adolescents.¹⁴