Anxious all the time? Seek help to relax

Anxiety is a feature of many uncomfortable mental states called ‘Anxiety Disorders’. They include panic attacks, generalised anxiety, phobias, obsessive-compulsive disorder and persisting reactions to traumatic experiences. Treatment of each of these states involves the control of anxiety, followed by more specific measures. This is because anxiety can be crippling, reducing the patient to a nervous wreck incapable of dealing with even the basic things he needs to do, like going to work, interacting with people or even simply sleeping and eating normally.

One of the commonest complaints for which physicians refer patients to psychiatrists is severe anxiety.

A patient usually meets a physician because he is worried that his heart seems to suddenly beat very fast, and he can actually hear it thump loudly in his chest. This may happen several times a day and last for a few seconds to minutes. He feels unsteady or may faint, has difficulty in breathing due to a constriction in the chest, and may feel abdominal discomfort. He may sweat profusely and feel terrified, and wonder if he is going to lose control and go mad, or die.

“Do you think I’m going to have a heart attack?” he anxiously asks. This is called a panic attack. After a physical examination the physician tries to ascertain reasons for the anxiety and suggests ways to bring it down. He also orders appropriate blood tests and an ECG, and may prescribe an anxiety-reducing medication for a few days to help him along. If the panic attacks do not come under control with these measures a psychiatry referral is usually given.
Some people feel anxious all the time but do not have panic attacks. They worry about everyday matters like work, finances, relationships, health and safety, their worry being out of proportion to actual circumstances. They present with headache, irritability and sleeplessness, and are so tense that they jump out of their skins at the slightest noise or an unexpected touch.

What causes anxiety?
In 1937, the neuroanatomist, James Papez, demonstrated that emotion is not a function of any specific brain centre but of a circuit involving four basic structures that are interconnected: the hypothalamus, the thalamus, the cingulate gyrus and the hippocampus. This circuit is responsible for both, the emotion as well as the physical symptoms.

Later, Paul McLean showed that a few more brain structures are also involved. He named the entire collection of structures concerned with emotions the Limbic System. It is important to note that all these structures are interconnected and none of them is solely responsible for any particular emotion, but may contribute a little more to a certain kind of emotion.

The amygdala is the part of the limbic system that identifies danger. It is fundamental for self preservation.

It detects potential threats and mobilises defensive responses. This produces a state of alertness and anxiety, getting the person ready for flight or fight, through the release of hormones.
The amygdala contains memories of the emotional aspect of things that have happened. For example, if a person has been in a fire accident, the sight of any fire may trigger anxiety.

Treatment of anxiety
If symptoms are minor and related to a situational stressor, helping a patient make the connection between the stressor and his physical symptoms is often enough to stop him getting anxious. If he stops seeing situations as threatening, they cannot make him anxious.

If symptoms are severe and sleeplessness is a major problem, anxiety-reducing medicines are given temporarily, in a low dose. These should never be continued beyond the number of days for which they are prescribed. They must not be treated as ‘sleeping pills’ because they are not.

If there is accompanying depression, a course of antidepressants is better as it takes care of the anxiety as well. Recent research suggests that anti-depressants promote growth of new nerve cells in the hippocampus and this helps reduce response to stress.

Medicines control the physical symptoms within a few days. Pharmacotherapy is always augmented by supportive psychotherapy by the treating doctor. Supportive psychotherapy focuses on the present problem, elucidates connections to relevant past experiences and helps the patient learn to think and, therefore, react differently to situations that have been generating unnecessary fear in him; this latter part of the treatment is called Cognitive Therapy.

In addition, the patient is free to avail of other resources such as other types of psychotherapy, to augment the primary treatment.

— Dr Shyamala Vatsa is a consultant psychiatrist