PSYCHOPATHOLOGICAL DISORDERS

    Anxiety as a psychopathological phenomenon is ubiquitous; it manifests itself above all in abnormal ways, often disabling and hindering the free expansion of existence. Throughout the history of psychiatry, various diagnostic systems have been proposed to classify psychiatric disorders, but currently, by far the most influential system is the American Psychiatric Association's Diagnostic and Statistical Manual (1994), the fourth edition of which (DSM- IV) identifies many types of disorders. In two anxiety disorders, generalized anxiety disorder and panic attack disorder, anxiety is not triggered by specific external elements. In the first case, patients suffer from widespread, irrational anxiety about a wide range of circumstances. Anxiety is accompanied by muscle tension, which leaves the person in pain, scared and tense. Subject experiences sympathetic nervous system overactivity, rapid breathing, and palpitations.

    From a cognitive point of view, patients are alert and scan the environment to identify the sources of a possible threat: they are easily frightened, irritable and have difficulty concentrating. The obsolete terms 'anxiety with floating sensation' or 'pervasive anxiety' reflect the fact that the level of anxiety is constantly high and concerns various aspects. This disorder is quite common and 2/3 of those affected are women. In panic disorder (see panic) intense anxiety is experienced that persists for a period of time ranging from a few minutes to more than an hour. The attacks seem to come out of nowhere and are therefore unpredictable. In these moments the subject is exposed to very strong sensations (palpitations, dizziness, dyspnoea, tingling in the hands and feet, sweating, sensations of detachment from reality), is extremely frightened, afraid of making rash gestures (shouting, running away), of fainting, of dying of a heart attack. In Western countries 4% of the population (but the percentage can reach 7%) suffers from this disorder and this makes these patients the most widespread psychiatric category. The majority of individuals with this disorder are women, and the disorder usually begins in early adulthood. If the panic attacks occur mostly in public places, the patient defines himself as suffering from panic disorder with agoraphobia (from ἀγορά, "square"). In Western countries 4% of the population (but the percentage can reach 7%) suffers from this disorder and this makes these patients the most widespread psychiatric category. The majority of individuals with this disorder are women, and the disorder usually begins in early adulthood. If the panic attacks occur mostly in public places, the patient defines himself as suffering from panic disorder with agoraphobia (from ἀγορά, "square"). In Western countries 4% of the population (but the percentage can reach 7%) suffers from this disorder and this makes these patients the most widespread psychiatric category. The majority of individuals with this disorder are women, and the disorder usually begins in early adulthood. If the panic attacks occur mostly in public places, the patient defines himself as suffering from panic disorder with agoraphobia (from ἀγορά, "square").

    The DSM-IV defines phobias (see phobia) as a sort of destructive and fear-mediated avoidance of stimuli and situations that are absolutely without danger. The type of phobia is identified by the Greek word denoting the nature of the feared object: the fear of flying, 'aerophobia', the fear of spiders, 'arachnophobia' etc. Phobic objects can be inanimate (fear of altitude or thunderstorms), or identified as members of another species (fear of snakes). Subjects may also suffer from a social phobia: many individuals experience some degree of stress when they are examined, but this fear becomes extreme and disabling in social phobics. The social phobic is afraid, for example, of speaking in public and tries to conceal the fear by hiding behind unfriendly attitudes.

    Another anxiety disorder is an obsessive-compulsive disorder. It consists of two components that we find in the very name of the disorder: obsessions and compulsions.

    Obsessions are recurring ideas, impulses, or images that enter consciousness and are experienced as strongly adverse; on the other hand, the subject finds it difficult or impossible to dismiss them as intruders. Obsessions are often connected to aggression, sex or blasphemy. Obsessive intrusions are quite frequent, yet most people are not bothered by them and dismiss them from their minds as irrelevant elements of the stream of consciousness. Obsessional patients, on the other hand, are very disturbed by these intrusions and can experience them up to a hundred times a day. Negative intrusion is infrequent in healthy individuals. Compulsions are behavioral acts that occur in response to a threatening thought. They are repetitive, stereotyped behaviors, that the person does not want to assume but also cannot avoid, resisting the impulse to act in that way. Many compulsions are related to hygiene and motivated by fear of contamination; others concern the repeated control, for example, of the gas, water, door locks, and are accompanied by precise, quantifiable rituals (closing something a specific number of times).

    Finally, one type of anxiety disorder is what is known as post-traumatic stress disorder. While other DSM-IV diagnoses are developed in terms of psychiatric symptoms regardless of their origins, the picture of post-traumatic stress disorder is different. In this case, one has been precipitated into ailment by one or more catastrophes that are beyond the reach of ordinary suffering. Examples are being held hostage, rape, war, and witnessing someone being killed or tortured. Generally, the disorder begins soon after the trauma, but the existence of a 'delayed post-traumatic stress syndrome' is also claimed. This, however, appears to be the exception rather than the rule. Three types of symptoms characterize the disorder. In the first, patients relive the trauma in dreams, in flashbacks or when exposed to stimuli that symbolically represent an aspect of the traumatic situation. In the second, there is a reduced interest in the world and an attempt to avoid the thoughts, feelings, and situations that remind the person of the trauma suffered. In the third, there is an emotional lability that manifests itself in moments of anger or in a strong shock in the face of elements that refer to the trauma.

    As far as explaining anxiety disorders, Freudian theory (see anxiety) has dominated the field for a long time. However, in the last twenty years of this century, numerous experimental studies have been conducted which have highlighted the biological aspects, the learning mechanisms, the cognitive processes involved in these disorders. Two types of theories can be distinguished: 'representational theories' and 'biological deficiency theories'. The former find their roots in learning theory and cognitive psychology and argue that anxiety disorders result from an unrealistic and maladaptive representation of the world. In cases of anxiety disorders, the conditioned stimulus-unconditioned stimulus representation does not correspond to reality; the conditioned stimulus activates the representation of a catastrophic unconditioned stimulus which in reality is not catastrophic or which in any case is unlikely to occur (e.g., the mere sight of a spider can activate the representation of the animal jumping on the subject, looking down from a very high tower can induce the idea that one can fall down, dirty hands can make one fear the attack of an illness). According to representational models, something analogous occurs in the case of panic disorders. In fact, these are not situational but tend to start with the perception of bodily sensations, in themselves harmless, such as, for example, feeling the heartbeat or feeling a slight tremor. Such sensations are read by patients as signals of an impending catastrophe.

    Patients understandably try to avoid exposure to the conditioned stimulus: if the conditioned stimulus is there, they predict that the unconditioned stimulus will follow. If the conditioned stimulus cannot be avoided, they actively try to prevent the dreaded disaster from happening (unconditioned stimulus): the compulsive patient may wash his hands frantically, the panicked patient who feels his heart may reduce his motor activity and lie down to rest. A different situation is represented by obsessions and post-traumatic stress disorders. The stimuli that arouse fear, in fact, in this case, are aroused by thoughts and images. Subjects try to fend off horrific intrusions. Ultimately, representational theories hold that anxiety are the result of an element (conditioned stimulus) that activates the representation of something horrible (unconditioned stimulus). Because anxious people avoid exposure to the conditioned stimulus, they fail to learn that the conditioned stimulus does not in fact predict any catastrophes. Therefore, a plausible therapy could be that of exposing the patient to the feared conditioned stimulus and having him verify firsthand that this is not followed by an unconditioned stimulus.

    Theories of biological deficiency are based on three pillars. First of all, there is evidence that there is a genetic component in anxiety disorders. Second, there are certain chemicals that cause anxiety symptoms in some patients but not in others, suggesting that these chemicals trigger pathophysiological abnormalities already present in some patients but not in others. Finally, certain drugs are effective in the treatment of anxiety disorders, suggesting that these disorders have a pathophysiological basis. It is quite evident that if a specific pharmacological agent produces anxiety in predisposed patients but not in normal people, the substance activates a specific pathogenetic mechanism of the sick subjects. Sodium lactate was the first substance that had specific effects on patients subject to panic: unlike healthy ones and other patients who experience a wide range of physical sensations after the administration of an infusion containing lactate, predisposed patients they are the only ones to experience intense subjective anxiety. Other substances that cause similar effects are caffeine, inhaled carbon dioxide in high concentrations, yohimbine (a substance that increases noradrenergic activity in the brain), and isoproterenol, which activates the sympathetic branch of the autonomic nervous system, but does not penetrate the brain. predisposed patients are the only ones to experience intense subjective anxiety. Other substances that cause similar effects are caffeine, inhaled carbon dioxide in high concentrations, yohimbine (a substance that increases noradrenergic activity in the brain), and isoproterenol, which activates the sympathetic branch of the autonomic nervous system but does not penetrate the brain. predisposed patients are the only ones to experience intense subjective anxiety. Other substances that cause similar effects are caffeine, inhaled carbon dioxide in high concentrations, yohimbine (a substance that increases noradrenergic activity in the brain), and isoproterenol, which activates the sympathetic branch of the autonomic nervous system, but does not penetrate the brain.

    An important characteristic of all panic-producing substances is that they produce the same bodily sensations feared by panic-prone patients. Thus, the subjective fear following the administration of lactate or carbon dioxide may not be due to physiological deregulation triggered by the drugs, but rather to the tendency of patients to respond fearfully to bodily sensations. The purpose of pharmacotherapy is not to produce symptoms, but to reduce or eliminate them. Several classes of antianxiety drugs have been identified. The first group is made up of benzodiazepines, which enhance the emission of gamma-amino-butyric acid, thereby reducing neural excitation, and are especially indicated in cases of generalized anxiety disorders.

    A third class of drugs that has a well-established anxiolytic effect consists of the so-called tricyclic antidepressants (see antidepressants), among which imipramine is the most studied. Most tricyclics act primarily on the noradrenergic channels in the brain, but newer types also affect the serotonin system. An important drug in this sense is clomipramine, which, in the same way as imipramine, has anti-panic effects, but is also effective in the treatment of obsessive-compulsive disorders. Selective serotonin reuptake inhibitors (SSRIs) may be mentioned among the most recently developed anti-anxiety drugs. These drugs block the rise of serotonin, which results in increased availability of the neurotransmitter. In particular, patients suffering from panic disorder and obsessive-compulsive disorder respond well to inhibitors. One last question may concern, from a comparative point of view, the validity of psychological treatments and pharmacological interventions. Which of the two therapies is more effective? It is difficult to give a straight answer.

    Few studies directly compare the two therapies: some have indicated the superiority of drug treatment; on the other hand, in panic-agoraphobia and OCD-type disorders, psychological treatments tend to give somewhat better results. The advantages of this latter therapy lie in the fact that it allows for a more stable improvement, has no negative side effects, and does not cause drug dependence, as occurs in the case of benzodiazepines. However, while most physicians can correctly prescribe anti-anxiety drugs and monitor their effects, the availability of adequate psychological treatment is generally less. It is still too early to reach definitive conclusions. Meanwhile, it is clear that, as the 20th century declined, anxiety and its manifestations are among the most studied phenomena in psychiatry and clinical psychology. And it is equally clear that the efforts made in the field of research have borne fruit: anxiety disorders, with suitable therapy, have become 'treatable'.