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Anxiety +Mental Disorder PDF Print E-mail

Anxiety +Mental Disorder

 

 

Anxiety is a psychological and physiological state characterized by somatic, emotional, cognitive, and behavioral components.[2] The root meaning of the word anxiety is 'to vex or trouble'; in either presence or absence of psychological stress, anxiety can create feelings of fear, worry, uneasiness, and dread.[3] Anxiety is considered to be a normal reaction to a stressor. It may help someone to deal with a difficult situation by prompting them to cope with it. When anxiety becomes excessive, it may fall under the classification of an anxiety disorder.[4]

Description

Anxiety is a generalized mood condition that can often occur without an identifiable triggering stimulus. As such, it is distinguished from fear, which is an emotional response to a perceived threat. Additionally, fear is related to the specific behaviors of escape and avoidance, whereas anxiety is related to situations perceived as uncontrollable or unavoidable.[5] Another view defines anxiety as "a future-oriented mood state in which one is ready or prepared to attempt to cope with upcoming negative events",[6] suggesting that it is a distinction between future vs. present dangers which divides anxiety and fear. In a 2011 review of the literature,[7] fear and anxiety were said to be differentiated in four domains: duration of emotional experience, temporal focus, specificity of threat, and motivated direction; fear was defined as short-lived, present-focused, geared towards a specific threat, and facilitating escape from threat while anxiety was defined as long-acting, future-focused, broadly focused towards a diffuse threat, and promoting caution while approaching a potential threat.

Physical effects of anxiety may include heart palpitations, muscle weakness and tension, fatigue, nausea, chest pain, shortness of breath, stomach aches, or headaches. The body prepares to deal with a threat: blood pressure and heart rate are increased, sweating is increased, blood flow to the major muscle groups is increased, and immune and digestive system functions are inhibited (the fight or flight response). External signs of anxiety may include pale skin, sweating, trembling, and pupillary dilation. Someone who has anxiety might also experience it as a sense of dread or panic. Although panic attacks are not experienced by every person who has anxiety, they are a common symptom. Panic attacks usually come without warning, and although the fear is generally irrational, the perception of danger is very real. A person experiencing a panic attack will often feel as if he or she is about to die or pass out.

Emotional effects may include "feelings of apprehension or dread, trouble concentrating, feeling tense or jumpy, anticipating the worst, irritability, restlessness, watching (and waiting) for signs (and occurrences) of danger, and, feeling like your mind's gone blank"[8] as well as "nightmares/bad dreams, obsessions about sensations, deja vu, a trapped in your mind feeling, and feeling like everything is scary."[9]

Cognitive effects of anxiety may include thoughts about suspected dangers, such as fear of dying. "You may...fear that the chest pains [a physical symptom of anxiety] are a deadly heart attack or that the shooting pains in your head [another physical symptom of anxiety] are the result of a tumor or aneurysm. You feel an intense fear when you think of dying, or you may think of it more often than normal, or can’t get it out of your mind."[10]

Behavioral effects may include withdrawal from situations where unpleasant effects of anxiety have been experienced in the past.[11] It can also be affected in ways which include changes in sleeping patterns, nail biting and increased motor tension, such as foot tapping.[11]

Biological and psychological basis

The psychologist David H. Barlow of Boston University conducted a study that showed three common characteristics of people suffering from chronic anxiety, which he characterized as "a generalized biological vulnerability," "a generalized psychological vulnerability," and "a specific psychological vulnerability."[12] While chemical issues in the brain that result in anxiety (especially resulting from genetics) are well documented, this study highlights an additional environmental factor that may result from being raised by parents suffering from chronic anxiety themselves.

Research upon adolescents who as infants had been highly apprehensive, vigilant, and fearful finds that their nucleus accumbens is more sensitive than that in other people when selecting to make an action that determined whether they received a reward.[13] This suggests a link between circuits responsible for fear and also reward in anxious people. As researchers note "a sense of ‘responsibility,’ or self agency, in a context of uncertainty (probabilistic outcomes) drives the neural system underlying appetitive motivation (i.e., nucleus accumbens) more strongly in temperamentally inhibited than noninhibited adolescents."[13]

Neural circuitry involving the amygdala and hippocampus is thought to underlie anxiety.[14] When people are confronted with unpleasant and potentially harmful stimuli such as foul odors or tastes, PET-scans show increased bloodflow in the amygdala.[15][16] In these studies, the participants also reported moderate anxiety. This might indicate that anxiety is a protective mechanism designed to prevent the organism from engaging in potentially harmful behaviors.

Although single genes have little effect on complex traits and interact heavily both between themselves and with the external factors, research is underway to unravel possible molecular mechanisms underlying anxiety and comorbid conditions. One candidate gene with polymorphisms that influence anxiety is PLXNA2.[17]

Varieties---In medicine: Anxiety disorder

Anxiety can be a symptom of an underlying health issue such as chronic obstructive pulmonary disease (COPD), heart failure, or heart arrythmia.[18]

Abnormal and pathological anxiety or fear may itself be a medical condition falling under the blanket term "anxiety disorder". Such conditions came under the aegis of psychiatry at the end of the 19th century[19] and current psychiatric diagnostic criteria recognize several specific forms of the disorder. Recent surveys have found that as many as 18% of Americans may be affected by one or more of them.[20]

Standardized screening tools such as Zung Self-Rating Anxiety Scale, Beck Anxiety Inventory, and HAM-A (Hamilton Anxiety Scale) can be used to detect anxiety symptoms and suggest the need for a formal diagnostic assessment of anxiety disorder.[21] The HAM-A (Hamilton Anxiety Scale) measures the severity of a patient's anxiety, based on 14 parameters, including anxious mood, tension, fears, insomnia, somatic complaints and behavior at the interview.[22]

Existential anxiety

Further information: Angst, Existential crisis, and Nihilism

The philosopher Søren Kierkegaard, in The Concept of Anxiety, described anxiety or dread associated with the "dizziness of freedom" and suggested the possibility for positive resolution of anxiety through the self-conscious exercise of responsibility and choosing. In Art and Artist (1932), the psychologist Otto Rank wrote that the psychological trauma of birth was the pre-eminent human symbol of existential anxiety and encompasses the creative person's simultaneous fear of – and desire for – separation, individuation and differentiation.

The theologian Paul Tillich characterized existential anxiety[23] as "the state in which a being is aware of its possible nonbeing" and he listed three categories for the nonbeing and resulting anxiety: ontic (fate and death), moral (guilt and condemnation), and spiritual (emptiness and meaninglessness). According to Tillich, the last of these three types of existential anxiety, i.e. spiritual anxiety, is predominant in modern times while the others were predominant in earlier periods. Tillich argues that this anxiety can be accepted as part of the human condition or it can be resisted but with negative consequences. In its pathological form, spiritual anxiety may tend to "drive the person toward the creation of certitude in systems of meaning which are supported by tradition and authority" even though such "undoubted certitude is not built on the rock of reality".

According to Viktor Frankl, the author of Man's Search for Meaning, when a person is faced with extreme mortal dangers, the most basic of all human wishes is to find a meaning of life to combat the "trauma of nonbeing" as death is near.

Test and performance anxiety: Test anxiety, Mathematical anxiety, Stage fright, and Somatic anxiety

According to Yerkes-Dodson law, an optimal level of arousal is necessary to best complete a task such as an exam, performance, or competitive event. However, when the anxiety or level of arousal exceeds that optimum, the result is a decline in performance.

Test anxiety is the uneasiness, apprehension, or nervousness felt by students who had a fear of failing an exam. Students who have test anxiety may experience any of the following: the association of grades with personal worth; fear of embarrassment by a teacher; fear of alienation from parents or friends; time pressures; or feeling a loss of control. Sweating, dizziness, headaches, racing heartbeats, nausea, fidgeting, and drumming on a desk are all common. Because test anxiety hinges on fear of negative evaluation, debate exists as to whether test anxiety is itself a unique anxiety disorder or whether it is a specific type of social phobia.

While the term "test anxiety" refers specifically to students, many workers share the same experience with regard to their career or profession. The fear of failing at a task and being negatively evaluated for failure can have a similarly negative effect on the adult.

Stranger and social anxiety: Stranger anxiety and Social anxiety

Anxiety when meeting or interacting with unknown people is a common stage of development in young people. For others, it may persist into adulthood and become social anxiety or social phobia. "Stranger anxiety" in small children is not a phobia. Rather it is a developmentally appropriate fear by toddlers and preschool children of those who are not parents or family members. In adults, an excessive fear of other people is not a developmentally common stage; it is called social anxiety. According to Cutting,[24] social phobics do not fear the crowd but the fact that they may be being judged negatively. Social anxiety varies in degree and severity. Whilst for some people it is characterized by experiencing discomfort or awkwardness during physical social contact (Embracing, Shaking Hands, etc.), in other cases it can lead to a fear of interacting with unfamiliar people altogether. There can be a tendency among those suffering from this condition to restrict their lifestyles to accommodate the anxiety, minimizing social interaction whenever possible. Social Anxiety also forms a core aspect of certain personality disorders, including Avoidant Personality Disorder.

Trait anxiety

Anxiety can be either a short term 'state' or a long term "trait." Trait anxiety reflects a stable tendency to respond with state anxiety in the anticipation of threatening situations.[25] It is closely related to the personality trait of neuroticism. Such anxiety may be conscious or unconscious.[26]

Choice or decision anxiety

Anxiety induced by the need to choose between similar options is increasingly being recognized as a problem for individuals and for organisations:[27][28]

"Today we’re all faced with greater choice, more competition and less time to consider our options or seek out the right advice."[29]

Paradoxical anxiety

Further information: Adverse effects of meditation

Paradoxical anxiety is anxiety arising from use of methods or techniques which are normally used to reduce anxiety. This includes relaxation or meditation techniques[30] as well as use of certain medications.[31] In some Buddhist meditation literature, this effect is described as something which arises naturally and should be turned toward and mindfully explored in order to gain insight into the nature of emotion, and more profoundly, the nature of self.[32]

Positive psychology

Anxiety Arousal Flow (psychology) Overlearning Relaxation (psychology) Boredom Apathy Worry
Mental state in terms of challenge level and skill level, according to Csikszentmihalyi.[33] (Click on a fragment of the image to go to the appropriate article)

In Positive psychology, anxiety is described as the mental state that results from a difficult challenge for which the subject has insufficient coping skills.[33]

See also---Mental state in terms of challenge level and skill level, according to Csikszentmihalyi.[33] (Click on a fragment of the image to go to the appropriate article)

In Positive psychology, anxiety is described as the mental state that results from a difficult challenge for which the subject has insufficient coping skills.[33]

See also--Arousal--Catastrophization--Panic attack--Paranoia--Social anxiety

 

 

 

A mental disorder or mental illness is a psychological or behavioral pattern generally associated with subjective distress or disability that occurs in an individual, and which is not a part of normal development or culture. Such a disorder may consist of a combination of affective, behavioural, cognitive and perceptual components. The recognition and understanding of mental health conditions have changed over time and across cultures, and there are still variations in the definition, assessment, and classification of mental disorders, although standard guideline criteria are widely accepted. A few mental disorders are diagnosed based on the harm to others, regardless of the subject's perception of distress. Over a third of people in most countries report meeting criteria for the major categories at some point in their lives. The causes are often explained in terms of a diathesis-stress model or biopsychosocial model. In biological psychiatry, mental disorders are conceptualized as disorders of brain circuits likely caused by developmental processes shaped by a complex interplay of genetics and experience.[1]

Services are based in psychiatric hospitals or in the community. Diagnoses are made by psychiatrists or clinical psychologists using various methods, often relying on observation and questioning in interviews. Treatments are provided by various mental health professionals. Psychotherapy and psychiatric medication are two major treatment options, as are social interventions, peer support and self-help. In some cases there may be involuntary detention and involuntary treatment where legislation allows.

Classifications--: Classification of mental disorders

The definition and classification of mental disorders is a key issue for mental health and for users and providers of mental health services. Most international clinical documents use the term "mental disorder". There are currently two widely established systems that classify mental disorders—ICD-10 Chapter V: Mental and behavioural disorders, part of the International Classification of Diseases produced by the World Health Organization (WHO), and the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) produced by the American Psychiatric Association (APA).

Both list categories of disorder and provide standardized criteria for diagnosis. They have deliberately converged their codes in recent revisions so that the manuals are often broadly comparable, although significant differences remain. Other classification schemes may be used in non-western cultures (see, for example, the Chinese Classification of Mental Disorders), and other manuals may be used by those of alternative theoretical persuasions, for example the Psychodynamic Diagnostic Manual. In general, mental disorders are classified separately to neurological disorders, learning disabilities or mental retardation.

Unlike most of the above systems, some approaches to classification do not employ distinct categories of disorder or dichotomous cut-offs intended to separate the abnormal from the normal. There is significant scientific debate about the different kinds of categorization and the relative merits of categorical versus non-categorical (or hybrid) schemes, with the latter including spectrum, continuum or dimensional systems.

Disorders--: List of mental disorders as defined by the DSM and ICD

There are many different categories of mental disorder, and many different facets of human behavior and personality that can become disordered.[2][3][4][5][6]

Anxiety or fear that interferes with normal functioning may be classified as an anxiety disorder.[7] Commonly recognized categories include specific phobias, generalized anxiety disorder, social anxiety disorder, panic disorder, agoraphobia, obsessive-compulsive disorder and post-traumatic stress disorder.

Other affective (emotion/mood) processes can also become disordered. Mood disorder involving unusually intense and sustained sadness, melancholia or despair is known as Major depression or Clinical depression (milder but still prolonged depression can be diagnosed as dysthymia). Bipolar disorder (also known as manic depression) involves abnormally "high" or pressured mood states, known as mania or hypomania, alternating with normal or depressed mood. Whether unipolar and bipolar mood phenomena represent distinct categories of disorder, or whether they usually mix and merge together along a dimension or spectrum of mood, is under debate in the scientific literature.[8]

Patterns of belief, language use and perception can become disordered (e.g. delusions, thought disorder, hallucinations). Psychotic disorders in this domain include schizophrenia, and delusional disorder. Schizoaffective disorder is a category used for individuals showing aspects of both schizophrenia and affective disorders. Schizotypy is a category used for individuals showing some of the characteristics associated with schizophrenia but without meeting cut-off criteria.

Personality—the fundamental characteristics of a person that influence his or her thoughts and behaviors across situations and time—may be considered disordered if judged to be abnormally rigid and maladaptive. Categorical schemes list a number of different such personality disorders, including those sometimes classed as eccentric (e.g. paranoid, schizoid and schizotypal personality disorders), to those sometimes classed as dramatic or emotional (antisocial, borderline, histrionic or narcissistic personality disorders) or those seen as fear-related (avoidant, dependent, or obsessive-compulsive personality disorders). If an inability to sufficiently adjust to life circumstances begins within three months of a particular event or situation, and ends within six months after the stressor stops or is eliminated, it may instead be classed as an adjustment disorder. There is an emerging consensus that so-called "personality disorders", like personality traits in general, actually incorporate a mixture of acute dysfunctional behaviors that resolve in short periods, and maladaptive temperamental traits that are more stable.[9] Furthermore, there are also non-categorical schemes that rate all individuals via a profile of different dimensions of personality rather than using a cut-off from normal personality variation, for example through schemes based on the Big Five personality traits.[10]

Eating disorders involve disproportionate concern in matters of food and weight.[7] Categories of disorder in this area include anorexia nervosa, bulimia nervosa, exercise bulimia or binge eating disorder.

Sleep disorders such as insomnia involve disruption to normal sleep patterns, or a feeling of tiredness despite sleep appearing normal.

Sexual and gender identity disorders may be diagnosed, including dyspareunia, gender identity disorder and ego-dystonic homosexuality. Various kinds of paraphilia are considered mental disorders (sexual arousal to objects, situations, or individuals that are considered abnormal or harmful to the person or others).

People who are abnormally unable to resist certain urges or impulses that could be harmful to themselves or others, may be classed as having an impulse control disorder, including various kinds of tic disorders such as Tourette's syndrome, and disorders such as kleptomania (stealing) or pyromania (fire-setting). Various behavioral addictions, such as gambling addiction, may be classed as a disorder. Obsessive-compulsive disorder can sometimes involve an inability to resist certain acts but is classed separately as being primarily an anxiety disorder.

The use of drugs (legal or illegal), when it persists despite significant problems related to the use, may be defined as a mental disorder termed substance dependence or substance abuse (a broader category than drug abuse). The DSM does not currently use the common term drug addiction and the ICD simply talks about "harmful use". Disordered substance use may be due to a pattern of compulsive and repetitive use of the drug that results in tolerance to its effects and withdrawal symptoms when use is reduced or stopped.

People who suffer severe disturbances of their self-identity, memory and general awareness of themselves and their surroundings may be classed as having a dissociative identity disorder, such as depersonalization disorder or Dissociative Identity Disorder itself (which has also been called multiple personality disorder, or "split personality"). Other memory or cognitive disorders include amnesia or various kinds of old age dementia.

A range of developmental disorders that initially occur in childhood may be diagnosed, for example autism spectrum disorders, oppositional defiant disorder and conduct disorder, and attention deficit hyperactivity disorder (ADHD), which may continue into adulthood.

Conduct disorder, if continuing into adulthood, may be diagnosed as antisocial personality disorder (dissocial personality disorder in the ICD). Popularist labels such as psychopath (or sociopath) do not appear in the DSM or ICD but are linked by some to these diagnoses.

Disorders appearing to originate in the body, but thought to be mental, are known as somatoform disorders, including somatization disorder and conversion disorder. There are also disorders of the perception of the body, including body dysmorphic disorder. Neurasthenia is an old diagnosis involving somatic complaints as well as fatigue and low spirits/depression, which is officially recognized by the ICD-10 but no longer by the DSM-IV.[11]

Factitious disorders, such as Munchausen syndrome, are diagnosed where symptoms are thought to be experienced (deliberately produced) and/or reported (feigned) for personal gain.

There are attempts to introduce a category of relational disorder, where the diagnosis is of a relationship rather than on any one individual in that relationship. The relationship may be between children and their parents, between couples, or others. There already exists, under the category of psychosis, a diagnosis of shared psychotic disorder where two or more individuals share a particular delusion because of their close relationship with each other.

Various new types of mental disorder diagnosis are occasionally proposed. Among those controversially considered by the official committees of the diagnostic manuals include self-defeating personality disorder, sadistic personality disorder, passive-aggressive personality disorder and premenstrual dysphoric disorder.

Two recent unique isolated proposals are solastalgia by Glenn Albrecht and hubris syndrome by David Owen. The application of the concept of mental illness to the phenomena described by these authors has in turn been critiqued by Seamus Mac Suibhne.[12]

Causes---: Causes of mental disorders

Mental disorders can arise from a combination of sources. In many cases there is no single accepted or consistent cause currently established. A common belief even to this day is that disorders result from genetic vulnerabilities exposed by environmental stressors. (see Diathesis–stress model). However, it is clear enough from a simple statistical analysis across the whole spectrum of mental health disorders at least in western cultures that there is a strong relationship between the various forms of severe and complex mental disorder in adulthood and the abuse (physical, sexual or emotional) or neglect of children during the developmental years.

An eclectic or pluralistic mix of models may be used to explain particular disorders, and the primary paradigm of contemporary mainstream Western psychiatry is said to be the biopsychosocial (BPS) model, incorporating biological, psychological and social factors, although this may not always be applied in practice. Biopsychiatry has tended to follow a biomedical model, focusing on "organic" or "hardware" pathology of the brain. Psychoanalytic theories have continued to evolve alongside congitive-behavioural and systemic-family approaches. Evolutionary psychology may be used as an overall explanatory theory, and attachment theory is another kind of evolutionary-psychological approach sometimes applied in the context of mental disorders. A distinction is sometimes made between a "medical model" or a "social model" of disorder and disability.

Studies have indicated that genes often play an important role in the development of mental disorders, although the reliable identification of connections between specific genes and specific categories of disorder has proven more difficult. Environmental events surrounding pregnancy and birth have also been implicated. Traumatic brain injury may increase the risk of developing certain mental disorders. There have been some tentative inconsistent links found to certain viral infections,[13] to substance misuse, and to general physical health.

Abnormal functioning of neurotransmitter systems has been implicated, including serotonin, norepinephrine, dopamine and glutamate systems. Differences have also been found in the size or activity of certain brain regions in some cases. Psychological mechanisms have also been implicated, such as cognitive (e.g. reason), emotional processes, personality, temperament and coping style.

Social influences have been found to be important, including abuse, bullying and other negative or stressful life experiences. The specific risks and pathways to particular disorders are less clear, however. Aspects of the wider community have also been implicated, including employment problems, socioeconomic inequality, lack of social cohesion, problems linked to migration, and features of particular societies and cultures.

Gender-specific influences

Female-specific indicators of mental illness incorporate high progesterone oral contraceptives.[citation needed]

Diagnosis

Many mental health professionals, particularly psychiatrists, seek to diagnose individuals by ascertaining their particular mental disorder. Some professionals, for example some clinical psychologists, may avoid diagnosis in favor of other assessment methods such as formulation of a client's difficulties and circumstances.[14] The majority of mental health problems are actually assessed and treated by family physicians during consultations, who may refer on for more specialist diagnosis in acute or chronic cases. Routine diagnostic practice in mental health services typically involves an interview (which may be referred to as a mental status examination), where judgments are made of the interviewee's appearance and behavior, self-reported symptoms, mental health history, and current life circumstances. The views of relatives or other third parties may be taken into account. A physical examination to check for ill health or the effects of medications or other drugs may be conducted. Psychological testing is sometimes used via paper-and-pen or computerized questionnaires, which may include algorithms based on ticking off standardized diagnostic criteria, and in rare specialist cases neuroimaging tests may be requested, but these methods are more commonly found in research studies than routine clinical practice.[15][16]

Time and budgetary constraints often limit practicing psychiatrists from conducting more thorough diagnostic evaluations.[17] It has been found that most clinicians evaluate patients using an unstructured, open-ended approach, with limited training in evidence-based assessment methods, and that inaccurate diagnosis may be common in routine practice.[18] Mental illness involving hallucinations or delusions (especially schizophrenia) are prone to misdiagnosis in developing countries due to the presence of psychotic symptoms instigated by nutritional deficiencies. Comorbidity is very common in psychiatric diagnoses, i.e. the same person given a diagnosis in more than one category of disorder.

Management: Treatment of mental disorders and Services for mental disorders

Treatment and support for mental disorders is provided in psychiatric hospitals, clinics or any of a diverse range of community mental health services. In many countries services are increasingly based on a recovery model that is meant to support each individual's independence, choice and personal journey to regain a meaningful life, although individuals may be treated against their will in a minority of cases. There are a range of different types of treatment and what is most suitable depends on the disorder and on the individual. Many things have been found to help at least some people, and a placebo effect may play a role in any intervention or medication.

Psychotherapy

A major option for many mental disorders is psychotherapy. There are several main types. Cognitive behavioral therapy (CBT) is widely used and is based on modifying the patterns of thought and behavior associated with a particular disorder. Psychoanalysis, addressing underlying psychic conflicts and defenses, has been a dominant school of psychotherapy and is still in use. Systemic therapy or family therapy is sometimes used, addressing a network of significant others as well as an individual.

Some psychotherapies are based on a humanistic approach. There are a number of specific therapies used for particular disorders, which may be offshoots or hybrids of the above types. Mental health professionals often employ an eclectic or integrative approach. Much may depend on the therapeutic relationship, and there may be problems with trust, confidentiality and engagement.

Medication

A major option for many mental disorders is psychiatric medication and there are several main groups. Antidepressants are used for the treatment of clinical depression as well as often for anxiety and other disorders. Anxiolytics are used for anxiety disorders and related problems such as insomnia. Mood stabilizers are used primarily in bipolar disorder. Antipsychotics are mainly used for psychotic disorders, notably for positive symptoms in schizophrenia. Stimulants are commonly used, notably for ADHD.

Despite the different conventional names of the drug groups, there may be considerable overlap in the disorders for which they are actually indicated, and there may also be off-label use of medications. There can be problems with adverse effects of medication and adherence to them, and there is also criticism of pharmaceutical marketing and professional conflicts of interest.

Other

Electroconvulsive therapy (ECT) is sometimes used in severe cases when other interventions for severe intractable depression have failed. Psychosurgery is considered experimental but is advocated by certain neurologists in certain rare cases.[19][20]

Counseling (professional) and co-counseling (between peers) may be used. Psychoeducation programs may provide people with the information to understand and manage their problems. Creative therapies are sometimes used, including music therapy, art therapy or drama therapy. Lifestyle adjustments and supportive measures are often used, including peer support, self-help groups for mental health and supported housing or supported employment (including social firms). Some advocate dietary supplements.[21]

Prognosis

Prognosis depends on the disorder, the individual and numerous related factors. Some disorders are transient, while others may last a lifetime. Some disorders may be very limited in their functional effects, while others may involve substantial disability and support needs. The degree of ability or disability may vary across different life domains. Continued disability has been linked to institutionalization, discrimination and social exclusion as well as to the inherent properties of disorders.

Even those disorders often considered the most serious and intractable have varied courses. Long-term international studies of schizophrenia have found that over a half of individuals recover in terms of symptoms, and around a fifth to a third in terms of symptoms and functioning, with some requiring no medication. At the same time, many have serious difficulties and support needs for many years, although "late" recovery is still possible. The World Health Organization concluded that the long-term studies' findings converged with others in "relieving patients, carers and clinicians of the chronicity paradigm which dominated thinking throughout much of the 20th century."[22][23]

Around half of people initially diagnosed with bipolar disorder achieve syndromal recovery (no longer meeting criteria for the diagnosis) within six weeks, and nearly all achieve it within two years, with nearly half regaining their prior occupational and residential status in that period. However, nearly half go on to experience a new episode of mania or major depression within the next two years.[24] Functioning has been found to vary, being poor during periods of major depression or mania but otherwise fair to good, and possibly superior during periods of hypomania in Bipolar II.[25]

Suicide, which is often attributed to some underlying mental disorder, is a leading cause of death among teenagers and adults under 35.[26][27] There are an estimated 10 to 20 million non-fatal attempted suicides every year worldwide.[28]

Despite often being characterized in purely negative terms, some mental states labeled as disorders can also involve above-average creativity, non-conformity, goal-striving, meticulousness, or empathy.[29] In addition, the public perception of the level of disability associated with mental disorders can change.[30]

Epidemiology: Prevalence of mental disorders

Mental disorders are common. World wide more than one in three people in most countries report sufficient criteria for at least one at some point in their life.[31] In the United States 46% qualifies for a mental illness at some point.[32] An ongoing survey indicates that anxiety disorders are the most common in all but one country, followed by mood disorders in all but two countries, while substance disorders and impulse-control disorders were consistently less prevalent.[33] Rates varied by region.[34]

A review of anxiety disorder surveys in different countries found average lifetime prevalence estimates of 16.6%, with women having higher rates on average.[35] A review of mood disorder surveys in different countries found lifetime rates of 6.7% for major depressive disorder (higher in some studies, and in women) and 0.8% for Bipolar I disorder.[36]

In the United States the frequency of disorder is: anxiety disorder (28.8%), mood disorder (20.8%), impulse-control disorder (24.8%) or substance use disorder (14.6%).[37][38][39]

A 2004 cross-Europe study found that approximately one in four people reported meeting criteria at some point in their life for at least one of the DSM-IV disorders assessed, which included mood disorders (13.9%), anxiety disorders (13.6%) or alcohol disorder (5.2%). Approximately one in ten met criteria within a 12-month period. Women and younger people of either gender showed more cases of disorder.[40] A 2005 review of surveys in 16 European countries found that 27% of adult Europeans are affected by at least one mental disorder in a 12 month period.[41]

An international review of studies on the prevalence of schizophrenia found an average (median) figure of 0.4% for lifetime prevalence; it was consistently lower in poorer countries.[42]

Studies of the prevalence of personality disorders (PDs) have been fewer and smaller-scale, but one broad Norwegian survey found a five-year prevalence of almost 1 in 7 (13.4%). Rates for specific disorders ranged from 0.8% to 2.8%, differing across countries, and by gender, educational level and other factors.[43] A US survey that incidentally screened for personality disorder found a rate of 14.79%.[44]

Approximately 7% of a preschool pediatric sample were given a psychiatric diagnosis in one clinical study, and approximately 10% of 1- and 2-year-olds receiving developmental screening have been assessed as having significant emotional/behavioral problems based on parent and pediatrician reports.[45]

While rates of psychological disorders are the same for men and women, women have twice the rate of depression than men.[46] Each year 73 million women are afflicted with major depression, and suicide is ranked 7th as the cause of death for women between the ages of 20-59. Depressive disorders account for close to 41.9% of the disability from neuropsychiatric disorders among women compared to 29.3% among men.[47]

History: History of mental disorders

http://upload.wikimedia.org/wikipedia/commons/thumb/b/b5/R212F1.jpeg/250px-R212F1.jpegEarly color illustration of psychiatric treatment methods

Ancient civilizations

Ancient civilizations described and treated a number of mental disorders. The Greeks coined terms for melancholy, hysteria and phobia and developed the humorism theory. Mental disorders were described, and treatments developed, in Persia, Arabia and in the medieval Islamic world.

Europe

Middle Ages

Conceptions of madness in the Middle Ages in Christian Europe were a mixture of the divine, diabolical, magical and humoral, as well as more down to earth considerations. In the early modern period, some people with mental disorders may have been victims of the witch-hunts but were increasingly admitted to local workhouses and jails or sometimes to private madhouses. Many terms for mental disorder that found their way into everyday use first became popular in the 16th and 17th centuries.

Eighteenth century

By the end of the 17th century and into the Enlightenment, madness was increasingly seen as an organic physical phenomenon with no connection to the soul or moral responsibility. Asylum care was often harsh and treated people like wild animals, but towards the end of the 18th century a moral treatment movement gradually developed. Clear descriptions of some syndromes may be rare prior to the 19th century.

Nineteenth century

Industrialization and population growth led to a massive expansion of the number and size of insane asylums in every Western country in the 19th century. Numerous different classification schemes and diagnostic terms were developed by different authorities, and the term psychiatry was coined, though medical superintendents were still known as alienists.

Twentieth century

The turn of the 20th century saw the development of psychoanalysis, which would later come to the fore, along with Kraepelin's classification scheme. Asylum "inmates" were increasingly referred to as "patients", and asylums renamed as hospitals.

Europe and the U.S.

In the 20th century in the United States, a mental hygiene movement developed, aiming to prevent mental disorders. Clinical psychology and social work developed as professions. World War I saw a massive increase of conditions that came to be termed "shell shock".

World War II saw the development in the U.S. of a new psychiatric manual for categorizing mental disorders, which along with existing systems for collecting census and hospital statistics led to the first Diagnostic and Statistical Manual of Mental Disorders (DSM). The International Classification of Diseases (ICD) followed suit with a section on mental disorders. The term stress, having emerged out of endocrinology work in the 1930s, was increasingly applied to mental disorders.

http://upload.wikimedia.org/wikipedia/commons/thumb/5/5b/Insulin_shock_therapy.jpg/250px-Insulin_shock_therapy.jpgInsulin Shock Therapy

Electroconvulsive therapy, insulin shock therapy, lobotomies and the "neuroleptic" chlorpromazine came to be used by mid-century. An antipsychiatry movement came to the fore in the 1960s. Deinstitutionalization gradually occurred in the West, with isolated psychiatric hospitals being closed down in favor of community mental health services. A consumer/survivor movement gained momentum. Other kinds of psychiatric medication gradually came into use, such as "psychic energizers" and lithium. Benzodiazepines gained widespread use in the 1970s for anxiety and depression, until dependency problems curtailed their popularity.

Advances in neuroscience and genetics led to new research agendas. Cognitive behavioral therapy was developed. The DSM and then ICD adopted new criteria-based classifications, and the number of "official" diagnoses saw a large expansion. Through the 1990s, new SSRI antidepressants became some of the most widely prescribed drugs in the world. Also during the 1990s, a recovery model developed.

Society and culture

Self.svg

Different societies or cultures and even different individuals in a culture can disagree as to what constitutes optimal versus pathological biological and psychological functioning. Research has demonstrated that cultures vary in the relative importance placed on, for example, happiness, autonomy, or social relationships for pleasure. Likewise, the fact that a behavior pattern is valued, accepted, encouraged, or even statistically normative in a culture does not necessarily mean that it is conducive to optimal psychological functioning.

People in all cultures find some behaviors bizarre or even incomprehensible. But just what they feel is bizarre or incomprehensible is ambiguous and subjective.[48] These differences in determination can become highly contentious.

The process by which conditions and difficulties come to be defined and treated as medical conditions and problems, and thus come under the authority of doctors and other health professionals, is known as medicalization or pathologization.

In the scientific and academic literature on the definition or classification of mental disorder, one extreme argues that it is entirely a matter of value judgements (including of what is normal) while another proposes that it is or could be entirely objective and scientific (including by reference to statistical norms).[49] Common hybrid views argue that the concept of mental disorder is objective but a "fuzzy prototype" that can never be precisely defined, or alternatively that it inevitably involves a mix of scientific facts and subjective value judgments.[50]

Professions and fields--: Mental health professional

A number of professions have developed that specialize in the treatment of mental disorders, including the medical speciality of psychiatry (including psychiatric nursing),[51][52][53] a subset of psychology known as clinical psychology,[54] social work,[55] as well as mental health counselors, marriage and family therapists, psychotherapists, counselors and public health professionals. Those with personal experience of using mental health services are also increasingly involved in researching and delivering mental health services and working as mental health professionals.[56][57][58][59] The different clinical and scientific perspectives draw on diverse fields of research and theory, and different disciplines may favor differing models, explanations and goals.[29]

Movements

The consumer/survivor movement (also known as user/survivor movement) is made up of individuals (and organizations representing them) who are clients of mental health services or who consider themselves "survivors" of mental health services. The movement campaigns for improved mental health services and for more involvement and empowerment within mental health services, policies and wider society.[60][61][62] Patient advocacy organizations have expanded with increasing deinstitutionalization in developed countries, working to challenge the stereotypes, stigma and exclusion associated with psychiatric conditions. An antipsychiatry movement fundamentally challenges mainstream psychiatric theory and practice, including asserting that psychiatric diagnoses of mental illnesses are neither real nor useful.[63][64][65]

Intangible experiences

Religious, spiritual, or transpersonal experiences and beliefs are typically not defined as disordered, especially if widely shared, despite meeting many criteria of delusional or psychotic disorders.[66][67] Even when a belief or experience can be shown to produce distress or disability—the ordinary standard for judging mental disorders—the presence of a strong cultural basis for that belief, experience, or interpretation of experience, generally disqualifies it from counting as evidence of mental disorder.

Western bias

Current diagnostic guidelines have been criticized as having a fundamentally Euro-American outlook. They have been widely implemented, but opponents argue that even when diagnostic criteria are accepted across different cultures, it does not mean that the underlying constructs have any validity within those cultures; even reliable application can prove only consistency, not legitimacy.[68]

Advocating a more culturally sensitive approach, critics such as Carl Bell and Marcello Maviglia contend that the cultural and ethnic diversity of individuals is often discounted by researchers and service providers.[69]

Cross-cultural psychiatrist Arthur Kleinman contends that the Western bias is ironically illustrated in the introduction of cultural factors to the DSM-IV: that disorders or concepts from non-Western or non-mainstream cultures are described as "culture-bound", whereas standard psychiatric diagnoses are given no cultural qualification whatsoever, reveals to Kleinman an underlying assumption that Western cultural phenomena are universal.[70] Kleinman's negative view towards the culture-bound syndrome is largely shared by other cross-cultural critics, common responses included both disappointment over the large number of documented non-Western mental disorders still left out and frustration that even those included were often misinterpreted or misrepresented.[71]

Many mainstream psychiatrists are dissatisfied with the new culture-bound diagnoses, although for different reasons. Robert Spitzer, a lead architect of the DSM-III, has hypothesized that adding cultural formulations was an attempt to appease cultural critics and stated that the formulations lack any scientific motivation or support. Spitzer also posits that the new culture-bound diagnoses are rarely used, maintaining that the standard diagnoses apply regardless of the culture involved. In general, mainstream psychiatric opinion remains that if a diagnostic category is valid, cross-cultural factors are either irrelevant or are significant only to specific symptom presentations.[68]

Relationships and morality

Clinical conceptions of mental illness also overlap with personal and cultural values in the domain of morality, so much so that it is sometimes argued that separating the two is impossible without fundamentally redefining the essence of being a particular person in a society.[72] In clinical psychiatry, persistent distress and disability indicate an internal disorder requiring treatment; but in another context, that same distress and disability can be seen as an indicator of emotional struggle and the need to address social and structural problems.[73][74] This dichotomy has led some academics and clinicians to advocate a postmodernist conceptualization of mental distress and well-being.[75][76]

Such approaches, along with cross-cultural and "heretical" psychologies centered on alternative cultural and ethnic and race-based identities and experiences, stand in contrast to the mainstream psychiatric community's active avoidance of any involvement with either morality or culture.[77] In many countries there are attempts to challenge perceived prejudice against minority groups, including alleged institutional racism within psychiatric services.[78]

Laws and policies

Three quarters of countries around the world have mental health legislation. Compulsory admission to mental health facilities (also known as involuntary commitment or sectioning), is a controversial topic. From some points of view it can impinge on personal liberty and the right to choose, and carry the risk of abuse for political, social and other reasons; from other points of view, it can potentially prevent harm to self and others, and assist some people in attaining their right to healthcare when unable to decide in their own interests.[79]

All human-rights oriented mental health laws require proof of the presence of a mental disorder as defined by internationally accepted standards, but the type and severity of disorder that counts can vary in different jurisdictions. The two most often utilized grounds for involuntary admission are said to be serious likelihood of immediate or imminent danger to self or others, and the need for treatment. Applications for someone to be involuntarily admitted may usually come from a mental health practitioner, a family member, a close relative, or a guardian. Human-rights-oriented laws usually stipulate that independent medical practitioners or other accredited mental health practitioners must examine the patient separately and that there should be regular, time-bound review by an independent review body.[79] An individual must be shown to lack the capacity to give or withhold informed consent (i.e. to understand treatment information and its implications). Legal challenges in some areas have resulted in supreme court decisions that a person does not have to agree with a psychiatrist's characterization of their issues as an "illness", nor with a psychiatrist's conviction in medication, but only recognize the issues and the information about treatment options.[80]

Proxy consent (also known as substituted decision-making) may be given to a personal representative, a family member or a legally appointed guardian, or patients may have been able to enact an advance directive as to how they wish to be treated.[79] The right to supported decision-making may also be included in legislation.[81] Involuntary treatment laws are increasingly extended to those living in the community, for example outpatient commitment laws (known by different names) are used in New Zealand, Australia, the United Kingdom and most of the United States.

The World Health Organization reports that in many instances national mental health legislation takes away the rights of persons with mental disorders rather than protecting rights, and is often outdated.[79] In 1991, the United Nations adopted the Principles for the Protection of Persons with Mental Illness and the Improvement of Mental Health Care, which established minimum human rights standards of practice in the mental health field. In 2006, the UN formally agreed the Convention on the Rights of Persons with Disabilities to protect and enhance the rights and opportunities of disabled people, including those with psychosocial disabilities.[82]

The term insanity, sometimes used colloquially as a synonym for mental illness, is often used technically as a legal term. The insanity defense may be used in a legal trial (known as the mental disorder defence in some countries).

Perception and discrimination--Stigma

The social stigma associated with mental disorders is a widespread problem. Some people believe those with serious mental illnesses cannot recover, or are to blame for problems.[83] The US Surgeon General stated in 1999 that: "Powerful and pervasive, stigma prevents people from acknowledging their own mental health problems, much less disclosing them to others."[84] Employment discrimination is reported to play a significant part in the high rate of unemployment among those with a diagnosis of mental illness.[85]

Efforts are being undertaken worldwide to eliminate the stigma of mental illness,[86] although their methods and outcomes have sometimes been criticized.[87]

A 2008 study by Baylor University researchers found that clergy in the US often deny or dismiss the existence of a mental illness. Of 293 Christian church members, more than 32 percent were told by their church pastor that they or their loved one did not really have a mental illness, and that the cause of their problem was solely spiritual in nature, such as a personal sin, lack of faith or demonic involvement. The researchers also found that women were more likely than men to get this response. All participants in both studies were previously diagnosed by a licensed mental health provider as having a serious mental illness.[88] However, there is also research suggesting that people are often helped by extended families and supportive religious leaders who listen with kindness and respect, which can often contrast with usual practice in psychiatric diagnosis and medication.[89]

Media and general public--: Mental disorders in art and literature

Media coverage of mental illness comprises predominantly negative depictions, for example, of incompetence, violence or criminality, with far less coverage of positive issues such as accomplishments or human rights issues.[90][91][92] Such negative depictions, including in children's cartoons, are thought to contribute to stigma and negative attitudes in the public and in those with mental health problems themselves, although more sensitive or serious cinematic portrayals have increased in prevalence.[93][94]

In the United States, the Carter Center has created fellowships for journalists in South Africa, the U.S., and Romania, to enable reporters to research and write stories on mental health topics.[95] Former US First Lady Rosalynn Carter began the fellowships not only to train reporters in how to sensitively and accurately discuss mental health and mental illness, but also to increase the number of stories on these topics in the news media.[96][97] There is a World Mental Health Day, which the US and Canada subsume under a Mental Illness Awareness Week.

The general public have been found to hold a strong stereotype of dangerousness and desire for social distance from individuals described as mentally ill.[98] A US national survey found that a higher percentage of people rate individuals described as displaying the characteristics of a mental disorder as "likely to do something violent to others", compared to the percentage of people who are rating individuals described as being "troubled".[99]

Violence

Despite public or media opinion, national studies have indicated that severe mental illness does not independently predict future violent behavior, on average, and is not a leading cause of violence in society. There is a statistical association with various factors that do relate to violence (in anyone), such as substance abuse and various personal, social and economic factors.[100]

In fact, findings consistently indicate that it is many times more likely that people diagnosed with a serious mental illness living in the community will be the victims rather than the perpetrators of violence.[101][102] In a study of individuals diagnosed with "severe mental illness" living in a US inner-city area, a quarter were found to have been victims of at least one violent crime over the course of a year, a proportion eleven times higher than the inner-city average, and higher in every category of crime including violent assaults and theft.[103] People with a diagnosis may find it more difficult to secure prosecutions, however, due in part to prejudice and being seen as less credible.[104]

However, there are some specific diagnoses, such as childhood conduct disorder or adult antisocial personality disorder or psychopathy, which are defined by or inherently associated with conduct problems and violence. There are conflicting findings about the extent to which certain specific symptoms, notably some kinds of psychosis (hallucinations or delusions) that can occur in disorders such as schizophrenia, delusional disorder or mood disorder, are linked to an increased risk of serious violence on average. The mediating factors of violent acts, however, are most consistently found to be mainly socio-demographic and socio-economic factors such as being young, male, of lower socioeconomic status and, in particular, substance abuse (including alcoholism) to which some people may be particularly vulnerable.[29][101][105][106]

High-profile cases have led to fears that serious crimes, such as homicide, have increased due to deinstitutionalization, but the evidence does not support this conclusion.[106][107] Violence that does occur in relation to mental disorder (against the mentally ill or by the mentally ill) typically occurs in the context of complex social interactions, often in a family setting rather than between strangers.[108] It is also an issue in health care settings[109] and the wider community.[110]

In animals

Psychopathology in non-human primates has been studied since the mid-20th century. Over 20 behavioral patterns in captive chimpanzees have been documented as (statistically) abnormal for frequency, severity or oddness—some of which have also been observed in the wild. Captive great apes show gross behavioral abnormalities such as stereotypy of movements, self-mutilation, disturbed emotional reactions (mainly fear or aggression) towards companions, lack of species-typical communications, and generalized learned helplessness. In some cases such behaviors are hypothesized to be equivalent to symptoms associated with psychiatric disorders in humans such as depression, anxiety disorders, eating disorders and post-traumatic stress disorder. Concepts of antisocial, borderline and schizoid personality disorders have also been applied to non-human great apes.[111]

The risk of anthropomorphism is often raised with regard to such comparisons, and assessment of non-human animals cannot incorporate evidence from linguistic communication. However, available evidence may range from nonverbal behaviors—including physiological responses and homologous facial displays and acoustic utterances—to neurochemical studies. It is pointed out that human psychiatric classification is often based on statistical description and judgement of behaviors (especially when speech or language is impaired) and that the use of verbal self-report is itself problematic and unreliable.[111][112]

Psychopathology has generally been traced, at least in captivity, to adverse rearing conditions such as early separation of infants from mothers; early sensory deprivation; and extended periods of social isolation. Studies have also indicated individual variation in temperament, such as sociability or impulsiveness. Particular causes of problems in captivity have included integration of strangers into existing groups and a lack of individual space, in which context some pathological behaviors have also been seen as coping mechanisms. Remedial interventions have included careful individually tailored re-socialization programs, behavior therapy, environment enrichment, and on rare occasions psychiatric drugs. Socialization has been found to work 90% of the time in disturbed chimpanzees, although restoration of functional sexuality and care-giving is often not achieved.[111][113]

Laboratory researchers sometimes try to develop animal models of human mental disorders, including by inducing or treating symptoms in animals through genetic, neurological, chemical or behavioral manipulation,[114][115] but this has been criticized on empirical grounds[116] and opposed on animal rights grounds.

See also--Technology and mental health issues--Drift Hypothesis

 

 

Panic disorder is an anxiety disorder characterized by recurring severe panic attacks. It may also include significant behavioral change lasting at least a month and of ongoing worry about the implications or concern about having other attacks. The latter are called anticipatory attacks (DSM-IVR). Panic disorder is not the same as agoraphobia (fear of public places), although many with panic disorder also suffer from agoraphobia. Panic attacks cannot be predicted, therefore an individual may become stressed, anxious or worried wondering when the next panic attack will occur.[1] There are other schools of thought that Panic disorder is differentiated as a medical condition, or chemical imbalance. The DSM-IV-TR describes Panic disorder and Anxiety differently. Panic attacks have a sudden or out-of-blue cause that lasts shorter with more intense symptoms, as opposed to Anxiety attacks having stressors that build to less severe reactions and can last for weeks or months.[2] Panic attacks can occur in children, as well as adults. Panic in young people may be particularly distressing because the child has less insight about what is happening, and his/her parent is also likely to experience distress when attacks occur.

Background

Panic disorder is a potentially disabling disorder, but can be controlled and successfully treated. Because of the intense symptoms that accompany panic disorder, it may be mistaken for a life-threatening physical illness such as a heart attack. This misconception often aggravates or triggers future attacks (some are called Anticipatory Attacks). People frequently go to hospital emergency rooms when they are having panic attacks, and extensive medical tests may be performed to rule out these other conditions, thus creating further anxiety. Nonetheless, Coryell et al. found death rates in panic disorder patients exceeded those in the general population. In their study, 20% of deaths in 113 former psychiatric inpatients with panic disorder followed 35 years later were suicides; however, due to the co-morbidity of anxiety disorders, it is unclear whether panic disorder was the main cause of suicide. This study also found that men with panic disorder had twice the risk of cardiovascular mortality compared to men in the general population. Effective treatment of panic disorder has been shown to offset costs of medical care by as much as 94%.[5] There are three types of panic attacks: unexpected, situationally bounded and situationally predisposed (American psychiatric association 2000).

Signs and symptoms

Panic disorder sufferers usually have a series of intense episodes of extreme anxiety during panic attacks. These attacks typically last about ten minutes, but can be as short-lived as 1–5 minutes and last as long as twenty minutes or until medical intervention. However, attacks can wax and wane for a period of hours (panic attacks rolling into one another), and the intensity and specific symptoms of panic may vary over the duration. Common symptoms of an attack include rapid heartbeat, perspiration, dizziness, dyspnea, trembling, uncontrollable fear and hyperventilation. Other symptoms are sweating, shortness of breath, sensation of choking, chest pain, nausea, numbness or tingling, chills or hot flashes, and some sense of altered reality.[6] In addition, the person usually has thoughts of impending doom.[7] Individuals suffering from an episode have often a strong wish of escaping from the situation that provoked the attack. The anxiety of Panic Disorder is particularly severe and noticeably episodic compared to that from Generalized Anxiety Disorder. There are instances when panic attacks are provoked by exposure to certain stimuli e.g. seeing a mouse. Other attacks may emanate out of nowhere or in specific settings e.g. the dentist's office.[6] Some individuals deal with these events on a regular basis, sometimes daily or weekly. The outward symptoms of a panic attack often cause negative social experiences (e.g. embarrassment, social stigma, social isolation, etc.).

Limited symptom attacks are similar to panic attacks, but have fewer symptoms. Most people with PD experience both panic attacks and limited symptom attacks.

Causes

There is no single cause for panic disorder, however, panic disorder has been found to run in families, and suggests that inheritance plays a strong role in determining who will get it. It has also been found to exist as a co-morbid condition with many hereditary disorders, such as bipolar disorder, and a genetic predisposition to alcoholism[citation needed].

Psychological factors, stressful life events, life transitions, environment, and thinking in a way that exaggerates relatively normal bodily reactions are also believed to play a role in the onset of panic disorder. Often the first attacks are triggered by physical illnesses, major stress, or certain medications. People who tend to take on excessive responsibilities may develop a tendency to suffer panic attacks. Post-traumatic stress disorder (PTSD) patients also show a much higher rate of panic disorder than the general population.

There is some evidence to suggest hypoglycemia, hyperthyroidism, mitral valve prolapse, labyrinthitis, pheochromocytoma and respiratory conditions can cause or aggravate panic disorder.

Prepulse inhibition has been found to be reduced in patients with Panic Disorder.[8]

Stimulants like caffeine, in excess, are a rather common cause for panic attacks. Many SSRIs also have stimulant side-effects during the beginning of treatment which may exacerbate the condition and have actually caused first-time panic attacks in otherwise healthy individuals being treated for depression.

FlĂśttmann describes the genesis of panic psychodynamically. Panic is a stress symptom. Fear is characteristic of each developmental stage because of feeling of guilt or symbiotic binding. Floating fear or panic stands for the parental stressing call: "Come back to me. You'll panic in your life, you'll have fear of sexuality, fear of separation from me, of being autonomous, and you'll have fear in any situation in your life! You'll feel anxiously, if you do anything that is separating you from mother or father. Don't grow up!" It is the panic that appears in any developmental moment of life.[9]

There are other researchers looking at some individuals with panic disorder as having a chemical imbalance within the limbic system and one of its regulatory chemicals GABA-A. The reduced production of GABA-A sends false information to the amygdala which regulates the body's "fight or flight response" mechanism and in return, produces the physiological symptoms that lead to the disorder. Clonazepam, an anticonvulsant benzodiazepine with a long half-life, has been successful in keeping the condition in check [1].

Mediators and Moderators of Panic Disorder

Recently, researchers have begun to identify mediators and moderators of aspects of panic disorder. One such mediator is the partial pressure of carbon dioxide, which mediates the relationship between panic disorder patients receiving breathing training and anxiety sensitivity; thus, breathing training affects the partial pressure of carbon dioxide in a patient’s arterial blood, which in turn lowers anxiety sensitivity.[10] Another mediator is hypochondriacal concerns, which mediate the relationship between anxiety sensitivity and panic symptomatology; thus, anxiety sensitivity affects hypochondriacal concerns which, in turn, affect panic symptomatology.[11]

Perceived threat control has been identified as a moderator within panic disorder, moderating the relationship between anxiety sensitivity and agoraphobia; thus, the level of perceived threat control dictates the degree to which anxiety sensitivity results in agoraphobia.[12] Another recently-identified moderator of panic disorder is genetic variations in the gene coding for galanin; these genetic variations moderate the relationship between females suffering from panic disorder and the level of severity of panic disorder symptomatology.[13]

Substance abuse and panic disorder

A growing body of evidence exists that shows a link between substance abuse and panic disorder.

Smoking

Several studies have found that cigarette smoking increases the risk of panic attacks and panic disorder in young people.[14] [15][16] While the mechanism of how smoking increases panic attacks is not fully understood, a few hypotheses have been derived. Smoking cigarettes may lead to panic attacks by causing changes in respiratory function (e.g. feeling short of breath). These respiratory changes in turn can lead to the formation of panic attacks, as respiratory symptoms are a prominent feature of panic.[14][17] Respiratory abnormalities have been found in children with high levels of anxiety, which suggests that a person with these difficulties may be susceptible to panic attacks, and thus more likely to subsequently develop panic disorder. Nicotine, a stimulant, could contribute to panic attacks.[18][19] However, nicotine withdrawal may also cause significant anxiety which could contribute to panic attacks.

Alcohol and sedatives

About 30% of people with panic disorder use alcohol and 17% use other psychoactive drugs.[20] This is in comparison with 61% (alcohol)[2] and 7.9% (other psychoactive drugs) [3] of the general population who use alcohol and psychoactive drugs, respectively. Utilization of recreational drugs or alcohol generally make symptoms worse.[21] Most stimulant drugs (caffeine, nicotine, cocaine) would be expected to worsen the condition, since they directly increase the symptoms of panic, such as heart rate.

Deacon and Valentiner (2000)[22] conducted a study that examined co-morbid panic attacks and substance use in a non-clinical sample of young adults who experienced regular panic attacks. The authors found that compared to healthy controls, therapeutic alcohol and sedative use was greater for non-clinical participants who experienced panic attacks. These findings are consistent with the suggestion made by Cox, Norton, Dorward, and Fergusson (1989)[23] that panic disorder patients self-medicate if they believe that certain substances will be successful in alleviating their symptoms. If panic disorder patients are indeed self-medicating, there may be a portion of the population with undiagnosed panic disorder who will not seek professional help as a result of their own self-medication. In fact, for some patients panic disorder is only diagnosed after they seek treatment for their self-medication habit.[24]

While alcohol initially helps ease panic disorder symptoms, medium- or long-term alcohol abuse can cause panic disorder to develop or worsen during alcohol intoxication, especially during alcohol withdrawal syndrome.[25] This effect is not unique to alcohol but can also occur with long term use of drugs which have a similar mechanism of action to alcohol such as the benzodiazepines which are sometimes prescribed as tranquilizers to people with alcohol problems.[25] The reason chronic alcohol misuse worsens panic disorder is due to distortion of the brain chemistry and function.[26][27][28]

Approximately 10% of patients will experience notable protracted withdrawal symptoms, which can include panic disorder, after discontinuation of benzodiazepines. Protracted withdrawal symptoms tend to resemble those seen during the first couple of months of withdrawal but usually are of a subacute level of severity compared to the symptoms seen during the first 2 or 3 months of withdrawal. It is not known definitively whether such symptoms persisting long after withdrawal are related to true pharmacological withdrawal or whether they are due to structural neuronal damage as result of chronic use of benzodiazepines or withdrawal. Nevertheless such symptoms do typically lessen as the months and years go by eventually disappearing altogether.[29]

A significant proportion of patients attending mental health services for conditions including anxiety disorders such as panic disorder or social phobia have developed these conditions as a result of alcohol or sedative abuse. Anxiety may pre-exist alcohol or sedative independence, which then acts to perpetuate or worsen the underlying anxiety disorder. Someone suffering the toxic effects of alcohol abuse or chronic sedative use or abuse will not benefit from other therapies or medications for underlying psychiatric conditions. as they do not address the root cause of the symptoms. Recovery from sedative Symptoms may temporarily worsen during alcohol withdrawal or benzodiazepine withdrawal.[30][31][32][33] The World Council of Anxiety does not recommend benzodiazepines for the long term treatment of anxiety disorders due to a range of problems associated with long term use of benzodiazepines including tolerance, psychomotor impairment, cognitive and memory impairments, physical dependence and a benzodiazepine withdrawal syndrome upon discontinuation of benzodiazepines.[34]

Panic Attack DSM Disorder Criteria Summary include: Palpitations, pounding heart, or accelerated heart rate, sweating, trembling or shaking, Sensations of shortness of breath or smothering, feeling of choking, chest pain or discomfort, Nausea or abdominal distress, Feeling dizzy, unsteady, lightheaded, faint, derealization, fear of losing control or going crazy, fear of dying, paresthesias, chills or hot flushes. This is DSM Disorder Criteria Summary for panic attacks.

Diagnosis

The DSM-IV-TR diagnostic criteria for panic disorder require unexpected, recurrent panic attacks, followed in at least once instance by at least a month of a significant and related behavior change, a persistent concern of more attacks, or a worry about the attack's consequences. There are two types, one with and one without agoraphobia. Diagnosis is excluded by attacks due to a drug or medical condition, or by panic attacks that are better accounted for by other mental disorders.[35]

Treatment

Identification of treatments that engender as full a response as possible, and can minimize relapse, is imperative.[36] Cognitive behavioural therapy is the treatment of choice for panic disorder. When cognitive behavioural therapy is not an option pharmacotherapy can be used. SSRIs are considered a first line pharmacotherapeutic option.[37][38]

In addition, people with panic disorder may need treatment for other emotional problems. Comorbid clinical depression, personality disorders and alcohol abuse are known risk factors for treatment failure.[39]

As with many disorders, having a support structure of family and friends who understand the condition can help increase the rate of recovery. During an attack, it is not uncommon for the sufferer to develop irrational, immediate fear, which can often be dispelled by a supporter who is familiar with the condition. For more serious or active treatment, there are support groups for anxiety sufferers which can help people understand and deal with the disorder.

Current treatment guidelines American Psychiatric Association and the American Medical Association primarily recommend either cognitive-behavioral therapy or one of a variety of psychopharmacological interventions. Some evidence exists supporting the superiority of combined treatment approaches.[40][41][42]

Psychotherapy

Panic Disorder is not the same as phobic symptoms, although phobias commonly result from panic disorder.[43] CBT and one tested form of psychodynamic psychotherapy have been shown efficacious in treating panic disorder with and without agoraphobia.[41][44][45] A number of randomized clinical trials have shown that CBT achieves reported panic-free status in 70-90% of patients.[46]

For children with panic disorder, CBT is the only scientifically-proven psychotherapeutic treatment. The methods used are similar to those used with adults, but may be modified to be developmentally-appropriate "Evidence-Based Treatment for Anxiety".

Clinically, a combination of psychotherapy and medication can often produce good results, although research evidence of this approach has been less robust. Some improvement may be noticed in a fairly short period of time — about 6 to 8 weeks. Psychotherapy can improve the effectiveness of medication, reduce the likelihood of relapse for someone who has discontinued medication, and offer help for people with panic disorder who do not respond at all to medication.[46]

The goal of cognitive behavior therapy is to help a patient reorganize thinking processes and anxious thoughts regarding an experience that provokes panic. An approach that proved successful for 87% of patients in a controlled trial is interoceptive therapy, which simulates the symptoms of panic to allow patients to experience them in a controlled environment.[46]

Symptom inductions generally occur for one minute and may include:

The key to the induction is that the exercises should mimic the most frightening symptoms of a panic attack. Symptom inductions should be repeated three to five times per day until the patient has little to no anxiety in relation to the symptoms that were induced. Often it will take a period of weeks for the afflicted to feel no anxiety in relation to the induced symptoms. With repeated trials, a person learns through experience that these internal sensations do not need to be feared and becomes less sensitized or desensitized to the internal sensation. After repeated trials, when nothing catastrophic happens, the brain learns (hippocampus & amygdala) to not fear the sensations, and the sympathetic nervous system activation fades.

For patients whose panic disorder involves agoraphobia, the traditional cognitive therapy approach has been in vivo exposure, in which the affected individual, accompanied by a therapist, is gradually exposed to the actual situation that provokes panic.[46]

Another form of psychotherapy which has shown effectiveness in controlled clinical trials is panic-focused psychodynamic psychotherapy, which focuses on the role of dependency, separation anxiety, and anger in causing panic disorder. The underlying theory posits that due to biochemical vulnerability, traumatic early experiences, or both, people with panic disorder have a fearful dependence on others for their sense of security, which leads to separation anxiety and defensive anger. Therapy involves first exploring the stressors that lead to panic episodes, then probing the psychodynamics of the conflicts underlying panic disorder and the defense mechanisms that contribute to the attacks, with attention to transference and separation anxiety issues implicated in the therapist-patient relationship.[47]

Comparative clinical studies suggest that muscle relaxation techniques and breathing exercises are not efficacious in reducing panic attacks.[46] In fact, breathing exercises may actually increase the risk of relapse.[48]

Appropriate treatment by an experienced professional can prevent panic attacks or at least substantially reduce their severity and frequency — bringing significant relief to percent of people with panic disorder.[49] Relapses may occur, but they can often be effectively treated just like the initial episode.

Medication

Appropriate medication is highly effective for panic disorder. Although there is little evidence that pharmacological interventions can directly alter phobias, few studies have been performed, and medication treatment of panic makes phobia treatment far easier. Medications can include:

  • Antidepressants (SSRIs, MAOIs, tricyclic antidepressants): these are taken regularly every day, and alter neurotransmitter configurations which in turn can help to block symptoms. Although these medications are described as "antidepressants", nearly all of them — especially the tricyclic antidepressants — have anti-anxiety properties, in part, due to their sedative effects. SSRIs have been known to exacerbate symptoms in panic disorder patients, especially in the beginning of treatment and have even provoked panic attacks in otherwise healthy individuals. SSRIs are also known to produce withdrawal symptoms which include rebound anxiety and panic attacks. Comorbid depression has been cited as imparting the worst course, leading to chronic, disabling illness.[50][51]
  • Anti-anxiety drugs (benzodiazepines): Use of benzodiazepines for panic disorder is controversial with opinion differing in the medical literature. The American Psychiatric Association states that benzodiazepines can be effective for the treatment of panic disorder and recommends that the choice of whether to use benzodiazepines, antidepressants with antipanic properties or psychotherapy should be based on the individual patient's history and characteristics. They reported that in their view there is insufficient evidence to recommend one treatment over another for panic disorder. The APA noted that while benzodiazepines have the advantage of a rapid onset of action, that this is offset by the risk of developing a benzodiazepine dependence.[52] The National Institute of Clinical Excellence came to a different conclusion, they pointed out the problems of using uncontrolled clinical trials to assess the effectiveness of pharmacotherapy and based on placebo controlled research they concluded that benzodiazepines were not effective in the long-term for panic disorder and recommended that benzodiazepines not be used for longer than 4 weeks for panic disorder. Instead NICE clinical guidelines recommend alternative pharmacotherapeutic or psychotherapeutic interventions.[53] Other experts believe that benzodiazepines are best avoided due to the risks of the development of tolerance and physical dependence.[54] The World Federation of Societies of Biological Psychiatry, say that benzodiazepines should not be used as a first line treatment option but are an option for treatment resistant cases of panic disorder.[55] Despite increasing focus on the use of antidepressants and other agents for the treatment of anxiety as recommended best practice, benzodiazepines have remained a commonly used medication for panic disorder.[56][57]

Epidemiology

http://upload.wikimedia.org/wikipedia/commons/thumb/6/6f/Panic_disorder_world_map_-_DALY_-_WHO2002.svg/220px-Panic_disorder_world_map_-_DALY_-_WHO2002.svg.png

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Disability-adjusted life year for panic disorder per 100,000 inhabitants in 2002.

no data

less than 10

10-96.25

96.25-97.5

97.5-98.75

98.75-100

100-101.25

101.25-102.5

102.5-103.75

103.75-105

105-106.25

106.25-107.5

more than 107.5

Panic disorder is a serious health problem that in many cases can be successfully treated, although there is no known cure. It typically strikes in early adulthood; roughly half of all people who have panic disorder develop the condition before age 24, especially if the person has been subjected to a traumatic experience. However, some sources say that the majority of young people affected for the first time are between the ages of 25 and 30. Women are twice as likely as men to develop panic disorder.[58]

Panic disorder can continue for months or even years, depending on how and when treatment is sought. If left untreated, it may worsen to the point where the person's life is seriously affected by panic attacks and by attempts to avoid or conceal the condition. In fact, many people have had problems with friends and family or employment while struggling to cope with panic disorder. Some people with panic disorder may begin to lie to conceal their condition, because of the stigma of mental illness. In some individuals, symptoms may occur frequently for a period of months or years, then many years may pass symptom-free. In others, the symptoms persist at the same level indefinitely. There is also some evidence that many individuals (especially those who develop symptoms at an early age) may experience a cessation of symptoms naturally later in life (i.e. past age 50).[citation needed]

Panic disorder in children

A retrospective study has shown that 40% of adult panic disorder patients reported that their disorder began before the age of 20.[59] In an article examining the phenomenon of panic disorder in youth, Diler et al. (2004)[60] found that only a few past studies have examined the occurrence of juvenile panic disorder. They report that these studies have found that the symptoms of juvenile panic disorder almost replicate those found in adults (e.g. heart palpitations, sweating, trembling, hot flashes, nausea, abdominal distress, and chills).[61][62][63][64][65] The anxiety disorders co-exist with staggeringly high numbers of other mental disorders in adults.[66] The same comorbid disorders that are seen in adults are also reported in children with juvenile panic disorder. Last and Strauss (1989)[67] examined a sample of 17 adolescents with panic disorder and found high rates of comorbid anxiety disorders, major depressive disorder, and conduct disorders. Eassau et al. (1999)[63] also found a high number of comorbid disorders in a community-based sample of adolescents with panic attacks or juvenile panic disorder. Within the sample, adolescents were found to have the following comorbid disorders: major depressive disorder (80%), dysthymic disorder (40%), generalized anxiety disorder (40%), somatoform disorders (40%), substance abuse (40%), and specific phobia (20%). Consistent with this previous work, Diler et al. (2004) found similar results in their study in which 42 youths with juvenile panic disorder were examined. Compared to non-panic anxiety disordered youths, children with panic disorder had higher rates of comorbid major depressive disorder and bipolar disorder.

Despite the evidence pointing to the existence of early-onset panic disorder, the DSM-IV-TR currently only recognizes six anxiety disorders in children: separation anxiety disorder, generalized anxiety disorder, specific phobia, obsessive-compulsive disorder, social anxiety disorder (a.k.a. social phobia), and post-traumatic stress disorder. Panic disorder is notably excluded from this list.