Yes, clinically significant anxiety may occur in 5–7% of the general population and in 25% or more of patients seen by physicians. The lifetime incidence of anxiety disorders can exceed 30%. Anxiety in adolescence and adolescence often develops into depression. The line between a “normal” threat response and pathological anxiety disorder is often very blurred, and there can be a continuum from personality disorder to mental disorder. This is the reason for the difficulties in diagnosing pathological anxiety, which is diagnosed half as often as depression.

Psychological or biological stress causes a normal (physiological) response of the body in the form of a psychophysiological reaction, manifested by alarming symptoms and autonomic dysfunction. Symptoms are usually transient and well within the individual’s control. Probably, such an alarm performs a signal function (“alarm” mechanism) to prepare the body to “meet” danger (“fight” or “flight”)

Anxiety symptoms acquire clinical significance when:

  • the severity of symptoms is severe;
  • the duration of symptoms is prolonged;
  • symptoms develop in the absence of stressors;
  • symptoms interfere with the physical, social anxiety disorder, or professional functioning of the individual.

Diagnosis of pathological anxiety

Reliable diagnostic criteria for anxiety disorders set out in ICD-10 can provide some assistance in the diagnosis of pathological anxiety. According to modern classifications of mental disorders, anxiety disorders are divided into eight discrete categories: panic disorder (PD), generalized anxiety disorder (GAD), agoraphobia with panic disorder, obsessive-compulsive disorder, social phobia, specific phobias, post-traumatic stress disorder, acute stress disorder.

Among the chronic forms of anxiety, panic disorder and generalized anxiety disorder are the most commonly diagnosed by general practitioners. Any of the listed anxiety disorders can be subclinical

A neurologist in his daily practice encounters anxiety disorders that are in various causal relationships with the underlying (neurological) disease. There are at least three such categories:

  • Primary pathological anxiety, manifested by “neurological” signs and symptoms (anxiety is manifested by symptoms that mimic a neurological disease);
  • an anxiety disorders comorbid with a current neurological disease, or a mixed anxiety-depressive disorder comorbid with a current neurological disease;
  • drug-induced anxiety resulting from the treatment of the underlying disease.

Primary pathological anxiety

Primary pathological anxiety

Patients suffering from primary pathological anxiety are monitored by neurologists for a long time, that is, they have a chronic course of the disease. Most often, they are diagnosed with the following: vegetative dystonia, neurocirculatory dystonia, vegetative crises, sympathoadrenal crises. 

The category of patients visiting a neurologist is characterized by complaints of “somatic” symptoms of anxiety, which are mostly a consequence of the activation of the sympathetic division of the autonomic nervous system. Mental symptoms may not be recognized by the patient or be regarded as a normal reaction to an “incomprehensible” painful condition.

Only active questioning of patients makes it possible to identify, along with autonomic dysfunction, mental anxiety symptoms. Patients suffering from GAD and panic attacks (PA) are most often in the field of vision of a neurologist.

List of panic-associated symptoms:

  • Throbbing, palpitations, rapid pulse.
  • Sweating.
  • Chills, tremors, feeling of inner trembling.
  • Feeling of lack of air, shortness of breath.
  • Choking.
  • Pain or discomfort on the left side of the chest.
  • Nausea or abdominal discomfort.
  • Feeling dizzy, unsteady, lightheaded.
  • Feeling of derealization, depersonalization.
  • Fear of losing your mind or committing an uncontrollable act.
  • Fear of death.
  • Feeling of numbness or tingling (paresthesia) in the limbs.
  • Feeling of heat or cold waves passing through the body.

Anxiety disorder in patients with a comorbid neurological or somatic disease can present with various symptoms that are described in primary pathological anxiety.

Anxiety is especially often associated with the following chronic neurological diseases: epilepsy, stroke, multiple sclerosis, chronic pain syndromes, migraine, Parkinson’s disease, and other degenerative diseases. 

The need to differentiate many of the somatic symptoms of anxiety from those of somatic or neurological disease in some cases becomes a significant problem. Anxiety symptoms can be mistakenly regarded as signs of a neurological disease, which often leads to unnecessary therapy.

It is well known that abolishing alcohol causes anxiety and agitation. Many pathological anxiety symptoms appear during the period of withdrawal. Withdrawal symptoms of sedatives and hypnotics are similar in pathogenesis and clinical manifestations to alcohol withdrawal symptoms, but are often underestimated by clinicians as a potential cause of anxiety.

Withdrawal is characterized by the following alarming symptoms: 

  • nervousness, 
  • tachycardia,
  •  tremors, 
  • sweating, 
  • and nausea. 

At the same time, sedatives (benzodiazepines) are used to treat anxiety symptoms. Therefore, it is difficult to differentiate the symptoms of underlying anxiety disorder from the withdrawal symptoms associated with the use of these medications.

Principles of Anxiety Disorder Therapy

Principles of Anxiety Disorder Therapy

Anxiety disorders are diagnosed in only 50% of patients with obvious symptoms. Less than 50% of patients receive any treatment and less than 30% receive adequate therapy. Mild anxiety disorders are often not considered targets for treatment at all. As a result, anxiety becomes chronic, transforms into more severe psychopathological syndromes, and greatly impairs the quality of life. 

In addition, in the case of comorbidity with somatic pathology, anxiety significantly complicates and aggravates the course of the underlying disease. Despite the obligatory nature of autonomic dysfunction and the often masked nature of emotional disorders, psychopharmacological treatment is the basic method of treating anxiety. The therapeutic strategy must be built depending on the type of dominant disorder and the degree of its severity. The choice of the drug depends on the severity of the level of anxiety and the duration of the disease.

There are no clear guidelines for the duration of therapy for anxiety syndromes. However, most studies have proven the benefits of long courses of therapy. It is believed that after the reduction of all symptoms, at least four weeks of drug remission should elapse, after which an attempt is made to discontinue the drug.

Too early withdrawal of the medication can lead to an exacerbation of the disease. Residual symptoms (most often symptoms of autonomic dysfunction) indicate incomplete remission and should be considered as a marker of prolongation of therapy and transition to an alternative treatment regimen. On average, course therapy is at least two months.