ANXIETY DISORDERS

Most people feel anxious and worried from time to time, especially when faced with stressful situations like going for an exam, having your first date, or having a big presentation. Anxiety is a normal emotion to stressful situations and can help you be more focused and alert. But feeling extremely worried or afraid much of the time, or repeatedly feel panicky, may be signs of an anxiety disorder.

Anxiety disorders are characterised by fear and anxiety.

Fear is the emotional response to something that is perceived as threatening and anxiety is the anticipation of a future threat.

Fear and anxiety are related states but differ in key ways.

Fear is associated with autonomic arousal necessary for fight or flight (e.g. heart rate and breathing rate gets faster), thoughts of immediate danger and escape behaviours (e.g. escaping the perceived threat, neutralising the threat with compulsions).

Anxiety is associated with muscle tension, watchful preparation for future danger, and cautious or avoidant behaviours (e.g. avoiding social situations).

Panic attacks are a particular type of fear response. It is not a disorder in itself but is a symptom of anxiety disorders and other mental disorders such as Post-Traumatic Stress Disorder. It is a sudden increase of intense fear or discomfort that peaks quickly. It is accompanied by physical and/or cognitive symptoms.

Anxiety disorders tend to be two times more common among women, however, both men and women can suffer from an anxiety disorder.

Common types of anxiety disorders include:

  • Specific Phobia
  • Social Anxiety Disorder
  • Panic Disorder
  • Agoraphobia
  • Generalised Anxiety Disorder

Prevalence

The global estimate of the prevalence of anxiety disorders is 24.9% among adults. This would mean more than 7 million Malaysians suffer from a type of anxiety disorder.

The exact prevalence of anxiety disorders in Malaysia is unknown. Further research is needed to determine the prevalence of anxiety disorders in Malaysia. The prevalence rate reported here are taken from studies conducted mostly in Western cultures, and where available, Asian cultures like Singapore.

SPECIFIC PHOBIA

Many of us have things or situations that make us a little uneasy and that we rather avoid. But when push comes to shove, we can get through it without too much trouble.

But people with specific phobias are filled with overwhelming and great feelings of fear and anxiety when faced with the feared object or situation. Some people with specific phobias experience great fear and anxiety just thinking about the object or situation.

Specific phobia is characterised by an intense and severe fear or anxiety about a specific object or situations. Specific phobias commonly focus on animals, insects, germs, heights, thunder, driving, public transportation, flying, dental or medical procedures, and elevators.

The feared object or situation almost always provokes immediate fear or anxiety and is out of proportion to the actual danger posed by the object. People with a specific phobia also go out of their way to avoid the feared object or they endure it with intense fear or anxiety. They will go out of their way to avoid the feared object or situation even if it means avoiding common places or objects. The fear may not make any sense, but they feel powerless to stop it.

Having phobias can disrupt daily routines, limit work efficiency, reduce self-esteem, and place a strain on relationships because people will do whatever they can to avoid the uncomfortable and often-terrifying feelings of phobic anxiety.

To receive a diagnosis of specific phobia:

  • The fear, anxiety or avoidance is persistent and usually last for 6 months or more.
  • The fear, anxiety or avoidance causes clinically significant distress or impairment in social, occupational or other important areas of functioning.

Development

Specific phobia sometimes develops after a traumatic event  (e.g. being attacked by an animal) or observing someone else going through a traumatic event (e.g. seeing a car accident). However, many people are unable to remember the specific reason for their phobia(s). Specific phobias usually develop in early childhood, around the ages between 7 and 11 years of age.

Other Information

To diagnose specific phobias in children, it is important to assess the degree of impairment, the duration of the fear, anxiety or avoidance, and whether it is typical of the child's developmental stage. Excessive fears are common in young children but usually transitory and only mildly impairing. Young children may express their fear and anxiety by crying, tantrums, freezing or clinging.

Among the older population, specific phobias may be more likely to be attributed to medical conditions and tend to occur with medical concerns e.g. coronary heart disease. A specific phobia in older adults is associated with decreased quality of life and may be a risk factor for major neurocognitive disorder.

Prevalance

It is estimated that the lifetime prevalence of specific phobia is approximately 12.5%.

SOCIAL ANXIETY DISORDER

Social anxiety disorder is more than shyness or introversion. Many people occasionally worry about social situations, but someone with social anxiety feels overly worried before, during and after them.

Social Anxiety Disorder is severe fear or anxiety about social situations where the person may be exposed to others' observation or judgment. This includes fear of social interactions (e.g. meeting unfamiliar people), being observed (e.g. eating or drinking) and performing in front of others (e.g. giving a speech).

Someone with social anxiety is afraid that he or she will act in such a way that will be negatively judged by others, offend others or be rejected by others. He/she will experience fear or anxiety in almost all social situation and this will often lead to avoidance. It's an intense fear that affects everyday activities, self-confidence, relationships and work or school life.

To receive a diagnosis of social anxiety disorder:

  • This fear is persistent, typically lasting for 6 months or more.
  • The fear, anxiety or avoidance causes clinically significant distress or impairment in social, occupational or other important areas of functioning.

Development

Social anxiety may develop following stressful or humiliating experiences. Many people with social anxiety disorder first experienced symptoms of anxiety between the ages of 8 and 15 years.

Prevalence

It is estimated that the lifetime prevalence rate of panic disorder is approximately 2.6%.

PANIC DISORDER

Panic disorder is diagnosed in people who experience spontaneous seemingly out-of-the-blue panic attacks and are preoccupied with the fear of a recurring attack. Panic attacks occur unexpectedly, sometimes even during sleep.

What is a Panic Attack?

A panic attack is the abrupt onset of intense fear or discomfort that reaches a peak within minutes and includes at least four of the following symptoms:

  1. Palpitations, pounding heart, or accelerated heart rate.
  2. Sweating
  3. Trembling or shaking.
  4. Sensations of shortness of breath or smothering.
  5. Feelings of choking.
  6. Chest pain or discomfort.
  7. Nausea or abdominal distress.
  8. Feeling dizzy, unsteady, light-headed, or faint.
  9. Chills or heat sensations.
  10. Paresthesias (numbness or tingling sensations).
  11. Derealization (feelings of unreality) or depersonalization (being detached from oneself)
  12. Fear of losing control or "going crazy".
  13. Fear of dying.

A panic attack usually lasts from 5 to 20 minutes.

Many people don't know that their disorder is real and highly responsive to treatment. Some are afraid or embarrassed to tell anyone, including their doctors and loved ones, about what they experience for fear of being considered a hypochondriac. Instead, they suffer in silence, distancing themselves from friends, family, and others who could be helpful or supportive.

To receive a diagnosis of panic disorder:

  • People with a panic disorder usually continue to worry about additional panic attacks or their consequences for 1 month or more after a panic attack.
  • They also start to behave differently because of the panic attack. For instance, they may avoid certain places or people to prevent a panic attack.

Development

The median age of onset for panic disorder is around 20 to 24 years.

Panic attacks and panic disorder is a risk factor for suicide attempts and suicidal ideation.

Prevalence

It is estimated that the lifetime prevalence rate of panic disorder is approximately 1.4 - 2.9%.

AGORAPHOBIA

Some people stop going into situations or places in which they've previously had a panic attack in anticipation of it happening again.

These people have agoraphobia, and they typically avoid public places where they feel immediate escape might be difficult, or help might not be available should they experience a panic attack.It's an intense fear that affects everyday activities, self-confidence, relationships and work or school life.

Agoraphobia is characterised by severe fear or anxiety about two (or more) of the following situations.

  • Using public transportation.
  • Being in open spaces (e.g. parking lots).
  • Being in enclosed places (e.g. shops, theatres).
  • Standing in line or being in a crowd.
  • Being outside of the home alone.

To receive a diagnosis of agoraphobia:

  1. Being in these agoraphobia situations almost always lead to fear or anxiety and are actively avoided or require the presence of a companion.
  2. This fear, anxiety or avoidance is persistent, typically lasting for 6 months or more.
  3. The fear or anxiety is out of proportion to the actual danger posed by the agoraphobic situations.
  4. The fear, anxiety or avoidance causes clinically significant distress or impairment in social, occupational or other important areas of functioning.

Development

About 30 to 50% of people who have experienced a panic attack develop agoraphobia. Many of them develop the agoraphobia before age 35. Agoraphobia is usually persistent and chronic unless treated.

Other Information

Agoraphobia is a risk factor for major depressive disorder, persistent depressive disorder and substance use disorder.

Prevalence

It is estimated that the lifetime prevalence rate of agoraphobia is 5.6-7%.

GENERALISED ANXIETY DISORDER

Generalised Anxiety Disorder (GAD) is a long-term condition characterised by persistent and excessive worry about a wide range of situations and issues, rather than one specific event. Individuals with GAD find it difficult to control their worry and feel anxious most days. They often struggle to remember the last time they felt relaxed. They may worry more than seems warranted about actual events or may expect the worst even when there is no apparent reason for concern. As soon as one anxious thought is resolved, another may appear about a different issue.

People with GAD often experience physical symptoms along with their persistent apprehension and worry.

Common symptoms include:

  1. Feeling restless and on edge.
  2. Easily tired.
  3. Difficulty concentrating.
  4. Irritable.
  5. Muscle tension, aches or soreness.
  6. Sleep problems such as difficulty falling asleep or difficulty staying asleep.

To receive a diagnosis of generalised anxiety disorder:

  • These symptoms are present for at least 6 months.
  • The fear, anxiety or avoidance causes clinically significant distress or impairment in social, occupational or other important areas of functioning.

Development

Many people with GAD have struggled with feeling anxious most of their lives. The average age of onset for GAD is 30 years old. The content of worry and anxiety often changes depending on the life context of the person. Young people worry more about school and performance, whereas older people tend to worry more about their physical health or about their loved ones. These worries may occur even when there does not seem to be an objective reason for concern. For instance, a student may worry about academic performance even when there are no immediate evaluations.

Prevalence

It is estimated that the lifetime prevalence rate of GAD is approximately 5.1%.

References
  • https://www.moh.gov.sg/content/dam/moh_web/HPP/Doctors/cpg_medical/current/2015/anxiety_disorders/cpg_Anxiety%20Disorders%20%20Apr%202015%20-%20Full%20Guidelines.pdf
  • https://www.nimh.nih.gov/health/topics/anxiety-disorders/index.shtml
  • https://www.psychiatry.org/patients-families/anxiety-disorders/what-are-anxiety-disorders
  • http://www.health.harvard.edu/topics/anxiety
  • American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub.
  • Bandelow, B., & Michaelis, S. (2015). Epidemiology of anxiety disorders in the 21st century. Dialogues in Clinical Neuroscience, 17(3), 327–335.
  • Maideen, S. F. K., Sidik, S. M., Rampal, L., & Mukhtar, F. (2015). Prevalence, associated factors and predictors of anxiety: a community survey in Selangor, Malaysia. BMC psychiatry, 15(1), 262.
  • Martin, Patrick. “The Epidemiology of Anxiety Disorders: A Review.” Dialogues in Clinical Neuroscience 5.3 (2003): 281–298. Print.
  • Wong, C. H., Shah, Z. U. B. S., Teng, C. L., Lin, T. Q., Majeed, Z. A., & Chan, C. W. (2016). A systematic review of anxiety prevalence in adults within primary care and community settings in Malaysia. Asian journal of psychiatry, 24, 110-117.

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