Speaker: Dr Rahul Khemani, Consultant Psychiatrist, Heart & Mind Clinic, Mumbai, India

March 18, 2023, Saturday

9.30-10.30am

• Anxiety disorder is a mental health disorder characterized by feelings of worry, anxiety or fear that are strong enough to interfere with day-to-day activities. Anxiety which does not interfere with daily activity is normal anxiety and will not lead to a disorder.
• Almost 3 out of 10 people in the world or almost 33% currently have anxiety disorder. In 2019, worldwide it was seen in 301 million people, while in India it was seen in 44.9 million people. It is more common in females due to the estrogen, which is connected to depression and anxiety more than testosterone.
• Anxiety disorder is the 9^th most common cause of disability, which means that it stops you from going to work and earn your livelihood and connecting with family and friends. It also means that people are not attending schools or colleges.
• Some anxiety is normal. Anxiety is beneficial in the stress performance cycle. It helps us to notice dangerous situations and focuses our attention, so that we stay safe. Normal anxiety is good; it keeps us prepared. 
• But an anxiety disorder goes beyond the regular nervousness and slight fear you may feel from time to time. An anxiety disorder happens when anxiety interferes with the ability to function, you often overreact when something triggers your emotions and you cannot control your responses to situations.
• People with certain traits are specifically at risk like shy, introvert, timid people, who have not interacted with other people, who have stayed indoors are going to face anxiety more commonly. 
• Those who have family history of anxiety or other mental health conditions or those with conditions related to the heart (arrhythmias) or thyroid can experience anxiety as well.
• There are multiple types of anxiety disorders. Generalized anxiety disorder in which there is lot of restlessness. It must be present for at least 6 months before it is diagnosed as generalized anxiety disorder.
• Panic Disorder is like a panic attack, which appears very similar to heart attack, but the ECG and heart are normal. Continuous panic attacks lead to panic disorder.
• Phobia is another type of anxiety disorder. The extent of fear determines whether it is a disorder of phobia or not. Social anxiety disorder where one is scared of going out. Separation anxiety is very common in children and in adults as well. Obsessive compulsive disorder (OCD) and post-traumatic stress disorder (PTSD) are very common.
• Children may feel some amount of anxiety, worry or fear at some points such as during a thunderstorm or in the presence of a barking dog. This is normal.
• But sometimes children approach these situations with overwhelming dread. They often get stuck on their worries and find it hard to go about their daily activities like going to school, playing and falling asleep. 
• “Getting stuck” is the key. It separates the regular worries of childhood from an anxiety disorder that needs professional help. If the anxiety or worry interferes with the child’s ability to function, it may be time to seek help.
• It is important to understand the stress cycle because this is how you go into anxiety and how you can stop going into anxiety. 
• It starts with too little i.e., a kind of phase of bore out when you are not doing anything at all. Here you suggest some activity for these individuals, whether physical or mental. Aimlessly drifting can be fun for a while but eventually it is not good for your health. The optimum point is when your body stress response releases adrenaline and cortisone, which help to perform your best, the vision is sharper, the hearing is more acute. The fight and flight response helps deal with short-term stress and you are optimally adjusted to the environment. 
• Sometimes when you take too much of pressure you become unnecessarily stressed out. Performance starts reducing. It exceeds the comfort zone & fatigue & errors start coming in. Feelings of frustration, anxiety, poor concentration and shame about not being able to do it take over. When it becomes extremely high, it is the stage of burn out. 
• Anxiety is related to a chemical imbalance between serotonin and dopamine, which controls mood. This can happen due to long-lasting stress. Environmental factors also play a role. Experiencing a trauma might trigger an anxiety disorder, especially in someone who has inherited a higher risk to start.
• Anxiety disorders tend to run in families. You may inherit them from one or both parents. The chances of developing anxiety through heredity are though very less.
• The physical symptoms of anxiety disorder include cold or sweaty hands, dry mouth, heart palpitations, nausea, numbness or tingling in hands or feet, muscle tension and shortness of breath.
• The most common symptoms are palpitations, breathlessness, feeling of impending doom. Then come sweating, tremors, numbness, cold hands and feet.
• The mental symptoms include feeling panic, fear and uneasiness, nightmares, repeated thoughts or flashbacks of traumatic experiences and uncontrollable obsessive thoughts.
• Behavioral symptoms include inability to be still and calm and ritualistic behaviors such as washing hands repeatedly, trouble sleeping
• The Hamilton Anxiety Rating Scale (HAM-A) is used to assess severity. The questions are marked from 0 to 4 (between not present to very severe). This scale gives us an idea about the level of anxiety and whether the anxiety is present or not.
• There are two approaches to management. The first is psychotherapy. It is one of the most effective forms and cognitive behavioral therapy (CBT) is the most commonly used. It is a structured, goal oriented and didactic therapy. It focuses on helping individuals identify and modify maladaptive thinking patterns and beliefs that act as trigger in developing symptoms of anxiety.  CBT focuses on building behavioral skills. Thus, the patients can behave and react more adaptively to anxiety producing situation. 
• Medications are also an option. Benzodiazepenes like alprazolam, chlordiazepoxide, clonazepam lorazepam, nitrezapam. The second group of drugs is called selective serotonin reuptake inhibitors (SSRIs) such as escitalopram, fluoxetine and paroxetine.
• Anxiety cannot be prevented, but steps can be taken to control or reduce symptoms. Limit intake of caffeine, live a healthy lifestyle (regular exercise and healthy balanced diet), seek help if you have experienced a traumatic or disturbing event.
• Anxiety disorders can often go undiagnosed and untreated. But treatment can help.
• The right treatment can help improve quality of life, relationships and productivity. It can also support overall well-being.
• If you notice symptoms of anxiety disorder, talk to your healthcare provider. It is best to get diagnosed and treated as soon as possible. This will limit the problems that the anxiety disorder may cause.
• A combination of medications and counselling can help you feel your best.
• In young children, group counselling sessions can be tried. This will improve awareness for those children who are not visiting the counsellor. The benefit of group counselling is that each child helps raise the other child as well and helps them to also realize that this is quite common problem and something that we should talk about freely. This also reduces the problem of individual counselling time. Children who require medication can seek help from a psychiatrist.
• Anxiety is more a feeling of nervousness and depression is more of low mood but both are related to the same chemical serotonin. They usually happen together and the treatment is also quite similar.
• In patients with mild to moderate symptoms, psychotherapy is the initial line of treatment. A combination of therapy and medication is suggested for moderate to severe anxiety.
• There is no age limit for having anxiety.
• Lot of people post covid have experienced a different form of anxiety. Some people call it brain fog as well. This does not get better with anti-anxiety medication. It takes longer to get better. Somewhere covid has been affecting the brain in the recovery process. It makes you physically exhausted as well, which again adds on to the anxiety.
• Normal grief stays for few weeks to months but when it extends beyond 6 months to a year then it is pathological grief.
• These conditions are definitely treatable. But there remains a stigmatization for seeking psychiatric help globally, especially in the less developed societies. 

Participants

Member National Medical Associations

Dr Wasiq Qazi, Pakistan, President CMAAO

Dr Yeh Woei Chong, Singapore, Chair of Council CMAAO

Dr Angelique Coetzee, South Africa

Dr Akhtar Hussain, South Africa

Dr Qaisar Sajjad, Pakistan

Invitees

Dr Russell D’Souza, Australia UNESCO Chair in Bioethics

Dr EC Ng

Dr Maria Enedina Scuarcialupi, Brazil

Dr Swee Eng Goh

Dr PC Pah

Dr Archna Singh Yadav

Dr Shashi S Bala Sodhi

Dr Pushkar Gadkari

Dr Vineet Banga

Dr Neeraj Gupta

Dr Nishi Kumari

Dr Indu Sharma

Dr Poonam Chablani

Dr Poonam Gupta 

Dr Sakshi Paul

Dr DR Rai

Dr Meena Bajaj

Dr Madhusoodan

Dr Mohammed Adil

Dr Sunita Gupta

Dr Swati Ephraim

Dr S Sharma, Editor IJCP Group

Moderator

Mr Saurabh Aggarwal