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Anxiety Disorders
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Overview
• most prevalent psychiatric disorders
• The National Comorbidity Study reported that one in four person
met the diagnostic criteria of at least one anxiety disorders
• More prevalent among women (30.5% lifetime prevalence) when
compared to men (19.2% lifetime prevalence)
• Prevalence decreases with higher socioeconomic status
• Most anxiety disorders begin in childhood, adolescence, and early
adulthood
• Nearly a century ago, Sigmund Freud coined the term anxiety
neurosis; which he believed as having a biological basis
Normal Anxiety
Experienced by everyone
Defined as a diffuse, unpleasant, vague sense of
apprehension, often accompanied by autonomic symptoms
such as headache, perspiration, palpitations, chest tightness,
mild stomach discomfort and restlessness (inability to sit or
stand still)
 Serves as an adaptive mechanism to warn about an external
threat by activating the sympathetic nervous system (fight or
flight response)
Anxiety Vs Fear
• Alerting signals; warns a person of impending danger and
enables a person to take measures to deal with a threat.
• Anxiety- is a response to a threat that is unknown,
internal, vague or conflictual
• Fear- is a response to known, external, definite nonconflictual threat; has a sudden onset
Symptoms of Anxiety
• Two components:
a)Awareness of physiological
sensations (such as palpitations
and sweating)
b)Awareness of being nervous or
frightened
• Affects thinking, perception and
learning in addition to the
visceral and motor effects
• Tends to produce confusion and
distortions of perception which
interferes with learning by
lowering concentration,
reducing recall and impair ability
to make associations
• Peripheral manifestations of anxiety
includes:
Types of Anxiety Disorders
1. Panic disorder
2. Phobia
3. Obsessive-compulsive disorder
4. Post-traumatic stress disorder
5. Acute stress disorder
6. Generalized anxiety disorder
7. Anxiety disorder due to GMC
8. Substance-induced anxiety disorder
9. Anxiety disorder not otherwise specified
10. Separation anxiety disorder
11. Mixed anxiety-depressive disorder
Etiology
• Three major neurotransmitters based on animal studies and response to drug
treatment are:
a)Norepinephrine – symptoms are characteristic of increased noradrenergic function
Note: The cell bodies of the noradrenergic system are primarily localized to the locus
ceruleus in the rostral pons, and they project their axons to the cerebral cortex, the
limbic system, the brainstem, and the spinal cord. The affected patients may have a
poorly regulated noradrenergic system with occasional bursts of activity.
b)Serotonin - Different types of acute stress result in increased 5-hydroxytryptamine
turnover in the prefrontal cortex, nucleus accumbens, amygdala, and lateral
hypothalamus
c)GABA - decreased levels (strongly supported by the undisputed efficacy of
benzodiazepines, which enhance the activity of GABA at the GABA type A receptor)
Panic Disorder and Agoraphobia
• Panic disorder - an acute intense attack of anxiety accompanied
by feelings of impending doom.
• Characterized by spontaneous, unexpected occurrence of panic
attacks, that is, discrete periods of intense fear that can vary from
several attacks during one day to only a few attacks during a year
• Often accompanied by agoraphobia – fear of being alone in
public places
• Most disabling of the phobias, as it significantly interferes with a
persons ability to function at work and social situations outside
home
Panic Disorder
• First panic attack is completely spontaneous and unexpected
• often begins with a 10-minute period of rapidly increasing symptoms
• major mental symptoms are extreme fear and a sense of impending
death and doom
• physical signs often include tachycardia, palpitations, dyspnea, and
sweating
• The attack generally lasts 20 to 30 minutes
• May experience depression or depersonalization during an attack
• MSE during an attack may reveal rumination, difficulty speaking and
impaired memory
Agoraphobia
• Avoid situations in which it would be difficult to obtain help
• Fear of being in places from which escape might be difficult,
embarrassing, or in which help may be unavailable in the
event of having a panic attack
• Prefer to be accompanied by a friend or a family member
• Severely affected patients may simply refuse to leave the
house
Epidemiology
• Panic disorder:
a)Lifetime prevalence 1-4%
b)Women are two to three times more likely to be affected than men
c)Most commonly develops in young adulthood
Agoraphobia:
a)lifetime prevalence of 4-6%
b)At least three fourths of the affected patients have panic disorder
c)Both panic disorder and agoraphobia can occur at any age
Diagnosis based on DSM-IV-TR Criteria
• Panic Attack:
A discrete period of intense fear or discomfort, in which
four (or more) of the following symptoms developed
abruptly and reached a peak within 10 minutes
a) Palpitations
b) Sweating
c) Trembling or shaking
d) Sensations of shortness of breath
e) Feeling of choking
f) Chest pain or discomfort
g) Nausea or abdominal distress
h) Dizziness, lightheaded or faint
i) Derealization (feeling of unreality) or depersonalization
(being detached from oneself)
j) Fear of losing control or going crazy
k) Fear of dying
l) Paresthesia (tingling sensations or numbness)
m)Chills or hot flushes
• Panic Disorder with Agoraphobia or without
Agoraphobia
A) Both (1) and (2):
1) recurrent unexpected panic attacks
2) at least one of the attacks has been followed by 1 month
(or more) of one (or more) of the following:
a) persistent concern about having additional attacks
b) worry about the implications of the attack or its
consequences (e.g., losing control, having a heart attack,
“going crazy”)
c) a significant change in behavior related to the attacks
B) Absence of agoraphobia or presence of agoraphobia
C) The panic attacks are not due to the direct physiological
effects of a substance (e.g., a drug of abuse, a medication) or
a general medical condition (e.g., hyperthyroidism)
D) Panic attacks are not better accounted for by any other
mental disorder e.g. social phobia, OCD, specific phobias,
PTSD, or separation anxiety disorder
DSM-IV-TR Criteria for Agoraphobia
• Anxiety about being in places or situations:
a) from which escape might be difficult (or embarrassing)
b)in which help may not be available in the event of having an
unexpected or situationally predisposed panic attack or paniclike symptoms.
• The situations are avoided or else are endured with marked
distress or with anxiety about having a panic attack or panic-like
symptoms, or require the presence of a companion
• The anxiety or phobic avoidance is not better accounted for by
another mental disorder, such as social phobia , specific phobia,
obsessive-compulsive disorder, posttraumatic stress disorder, or
separation anxiety disorder
DSM-IV-TR Criteria for Agoraphobia without
history of Panic Disorder
• The presence of agoraphobia related to fear of developing panic-like symptoms
(e.g., dizziness or diarrhea)
• Criteria have never been met for panic disorder
• The disturbance is not due to the direct physiological effects of a substance (e.g.,
a drug of abuse, a medication) or a general medical condition
• If an associated general medical condition is present, the fear described in
Criterion A is clearly in excess of that usually associated with the condition
Treatment
• Pharmacotherapy:
a)Selective serotonin reuptake inhibitors e.g. paroxetine,
sertraline or fluvoxamine
b)Benzodiazepines e.g. alprazolam
c)Tricyclic and Tetracyclic drugs e.g. clomipramine and
imipramine
d)MAOIs e.g. phenelzine, 8-12 weeks, dietary restrictions
Treatment nonresponse: if patients fail to respond to one class
of drugs, another should be tried
Duration of treatment: once it becomes effective, continue for 8
to 12 months
Cognitive and Behavioral Therapy
• Cognitive therapy: explain about panic attacks not being life threatening
• Applied relaxation: instill sense of control over their level of anxiety and
relaxation
• Respiratory Training: train pts to control the urge to hyperventilate
enabling them to control hyperventilation during a panic attack
• In vivo exposure: sequentially greater exposer of patient to the feared
stimulus; overtime patient becomes desensitized to the experience
• Other psychosocial therapies:
Family therapy – education and support of family members
Insight-oriented psychotherapy – help patient understand the meaning of
anxiety and need to repress impulses
Phobia
• an excessive fear of a specific object, circumstance, or situation that produces conscious
avoidance of the stimuli
• Two common types:
1. Specific phobia
2. Social phobia
The diagnosis of both specific and social phobias requires the development of intense
anxiety, even to the point of panic, when exposed only to the feared object or situation
Specific Phobia
• is a strong, persisting fear of an object or situation
• Persons with specific phobias may anticipate harm such as being bitten by
a dog or if they fear being in an elevator
• More common than social phobia and more prevalent among women
• Lifetime prevalence of is about 11 percent
• The feared objects and situations in specific phobias includes:
1)Animal type
2)Natural environment type (e.g., heights, storms, water)
3)Blood-injection-injury type
4) Situational type (e.g., airplanes, elevators, enclosed places)
5)Other type (e.g., fear of choking, vomiting, or contracting an illness; in
children, fear of loud sounds or costumed characters)
DSM-IV-Diagnostic Criteria
• Marked and persistent fear that is excessive or unreasonable, cued by the presence of a
specific object or situation
• Exposure to the phobic stimulus almost invariably provokes an immediate anxiety
response equivalent to a panic attack Note: In children, the anxiety may be expressed by
crying, freezing, or clinging.
• The person recognizes that the fear is excessive or unreasonable. Absent in children
• The phobic situation(s) is avoided or else is endured with intense anxiety or distress.
• The avoidance, anxious anticipation, or distress in the feared situation(s) interferes
significantly with the person's normal routine, occupational (or academic) functioning,
or social activities
• In individuals under age 18 years, the duration is at least 6 months.
• The anxiety, panic attacks, or phobic avoidance associated with the specific object or
situation are not better accounted for by another mental disorder, such as OCD, PTSD,
social phobia, panic disorder with agoraphobia or agoraphobia without history of panic
disorder
Management
• Exposure therapy - therapists desensitize patients by using a series of gradual, self-paced exposures to
the phobic stimuli
• Various techniques to deal with anxiety including relaxation, breathing control, and cognitive
approaches are involved
• Pharmacotherapy (e.g., benzodiazepines), psychotherapy, or combined therapy directed to the attacks
is beneficial
• Hypnosis, supportive therapy, and family therapy may be useful in the treatment of phobic disorders
• Successful treatment is dependent upon patients commitment and ability to cope with the feelings
Social Phobia
• Is a strong, persisting fear of situations in which embarrassment can
occur such as speaking in public, urinating in a public rest room and
speaking to a date
• A generalized social phobia, which is often a chronic and disabling
condition, characterized by a phobic avoidance of most social
situations
• Feared social or performance situations are avoided or endured with
intense anxiety or distress
• Lifetime prevalence of 3 – 13 %
• Mean age of onset teen-age ( range 5 – 35 yrs.). More prevalent among
women
DSM-IV-TR Diagnostic Criteria for Social
Phobia
• Marked and persistent fear when exposed to unfamiliar people or possible scrutiny by others. Individual fears
being embarrassed or humiliated by ones action
• Exposure to the feared social situation almost invariably provokes anxiety, which may take the form of a
situationally bound or situationally predisposed panic attack
• The person recognizes the fear being excessive or unreasonable
• The feared social or performance situations are avoided or else are endured with intense anxiety or distress
• The avoidance, anxious anticipation, or distress in the feared social situation(s) interferes significantly with
the person's normal routine e.g. occupational functioning, social activities or relationship
• In individuals under age 18 years, the duration is at least 6 months
• The fear is not due to direct physiological effects of a substance (e.g. drug abuse) or general medical
condition or other mental disorders
• If a general medical condition or another mental disorder is present, the fear in Criterion A is unrelated to it
e.g. trembling in Parkinson’s disease
Management
• Both psychotherapy and pharmacotherapy are useful in treating social phobias
• Effective drugs for the treatment of social phobia include:
a)SSRIs (first line choice for pts with generalized social phobia)
b)Benzodiazepines e.g. alprazolam
c)MAOIs such as phenelzine (severe cases – therapeutic dosage ranges from 45-90 mg
a day)
d)Venlafaxine (SNRI – antidepressant)
Treatment of social phobia associated with performance situations frequently
involves the use of B-adrenergic receptor antagonists shortly before exposure e.g.
atenolol 50-100 mg every morning or an hour before performance
Psychotherapy involves a combination of behavioral and cognitive methods
including cognitive retraining, desensitization, rehearsal during sessions, and a range
of homework assignments
Obsessive Compulsive Disorder
• Obsession - is a recurrent and intrusive thought, feeling, idea, or sensation
• Compulsion - is a conscious, standardized, recurrent behavior, such as counting,
checking, or avoiding
• Obsessions are upsetting and irrational thoughts which keep reoccurring.
• They cause great anxiety, which cannot be controlled through reasoning
• Common obsessions include preoccupations with dirt or germs, nagging doubts,
and a need to have things in a very particular order
• The compulsive act may be carried out in an attempt to reduce the anxiety
associated with the obsession
• Examples include repeated hand washing, constant rechecking to satisfy doubts,
and following rigid rules of order
• Compulsive behavior can be very disruptive to normal daily routines and social
relationships
Epidemiology
• Lifetime prevalence of 2-3%
• Men and women are equally likely to be affected
• Mean age of onset is about 20 years
• Single people are commonly affected with OCD
• Higher incidence in those with first degree relatives with OCD than in
the general population
DSM-IV-TR Diagnostic Criteria for OCD
A. Either obsessions or compulsions:
Obsessions defined by:
• recurrent and persistent thoughts, impulses, or images that are experienced, at some time during
the disturbance, as intrusive and inappropriate and that cause marked anxiety or distress
• the thoughts, impulses, or images are not simply excessive worries about real-life problems
• Person attempts to ignore or neutralize them with some thought or action
• the person recognizes that the obsessional thoughts, impulses, or images are a product of his or
her own mind
Compulsions are defined by:
• repetitive behaviors (e.g. hand washing) or mental acts (e.g. praying) that the person feels driven
to perform in response to an obsession or according to rules
• the behaviors or mental acts are aimed at preventing or reducing distress; however, these are
either not connected in a realistic way with what they are designed to neutralize or are clearly
excessive
B. At some point during the course of the disorder, the person has recognized
that the obsessions or compulsions are excessive or unreasonable
C. The obsessions or compulsions cause marked distress, are time-consuming
(> hour a day), or significantly interfere with the person's normal routine
D. If another Axis I disorder is present, the content of the obsessions or
compulsions is not restricted to it (e.g. preoccupation with food in the presence
of an eating disorder or guilty ruminations in the presence of major depressive
disorder)
E. The disturbance is not due to the direct physiological effects of a substance
(e.g. a drug of abuse, a medication) or a general medical condition
Management
Pharmacotherapy:
• SSRIs e.g. paroxetine, fluoxetine
• Clomipramine
• Mood stabilizers e.g. valproate, lithium
Behavioral Therapy:
• includes exposure and response prevention
• Patients must be truly committed
A combination of both is effective in significantly reducing the symptoms of
patients with OCD
Post Traumatic Stress Disorder
• is a syndrome that develops after a person sees, is involved in or hears of
an extreme traumatic stressor
• Person reacts to such experience with fear and helplessness, persistently
relieves the event(in their dreams or daily thoughts) and tries to avoid
being reminded of it
• Usually undergo a numbing of responsiveness along with a state of
hyperarousal
• Other symptoms are depression, anxiety, sleep disturbances and poor
concentration
Epidemiology
• Prevalence is estimated to be about 8% in general population
• Can occur at any age. However, common among young adults, children and
women
• Risks factors include:
a)Recent traumatic event
b)Single, divorced or widowed
c)Low socioeconomic status
d)Low self esteem
e)Low education level
f) Female gender
g)Family history of psychiatric illness
h)Inadequate family or peer support
Types of Traumatic Events
The stressors or experiences can arise from:
• War
• Torture
• Natural catastrophes
• Assault
• Rape
• Serious accidents e.g. burning buildings
• Childhood abuse
• Diagnosis of terminal illness
DSM-IV-TR Diagnostic Criteria FOR PTSD
A. Exposed to a traumatic event in which both of the following were present:
• the person experienced, witnessed, or was confronted with an event or events that involved actual or
threatened death or serious injury, or a threat to the physical integrity of self or others
• the person's response involved intense fear, helplessness, or horror
B. The traumatic event is reexperienced in at least one of the following ways
• Recurrent and intrusive distressing recollections of the event including images, thoughts or perceptions
• Recurrent distressing dreams of the event
• acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience,
illusions, hallucinations, and dissociative flashback episodes)
• intense psychological distress at exposure to internal or external cues that symbolize or resemble an
aspect of the traumatic event
• Physiological reactivity on exposure to internal or external cues that resemble an aspect of the
traumatic event
C. Physiological reactivity on exposure to internal or external cues that resemble an aspect
of the traumatic event:
• Efforts to avoid activity, people or places that arouse recollections of the trauma.
• Inability to recall an important aspect of the trauma (dissociative amnesia)
• Markedly diminished interests or participation in significant activities.
• Feeling of detachment from others
• Restricted range of affect (unable to have loving feelings)
• Sense of foreshortened future (not expecting to have a career, marriage or children)
D. Marked symptoms of anxiety or increased arousal (e.g., difficulty sleeping, irritability,
poor concentration, hypervigilance, exaggerated startle response, motor restlessness)
E. Duration of disturbance is ≥ 1 month
F. The disturbance causes clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
Management
Psychotherapy
• Involves support, education, development of coping skills and acceptance of the event
• The first is exposure therapy, in which the patient reexperiences the traumatic event
through imaging techniques or in vivo exposure (desensitization)
• The second approach is to teach the patient methods of stress management, including
relaxation techniques and cognitive approaches to coping with stress
Pharmacotherapy
• SSRIs, such as sertraline (Zoloft) and paroxetine (Paxil), are considered first-line
treatments
• Tricyclic drugs such as imipramine and amitriptyline
• Other drugs include the monoamine oxidase inhibitors and the anticonvulsants
Acute Stress Disorder
•
•
•
•
defines a disorder that is similar to PTSD
it is transient, immediate onset within an hour in response to exceptional stress
The disturbance lasts for a minimum of 2 days and a maximum of 4 weeks
occurs within 4 weeks of the traumatic event
• The disturbance is not due to:
a) the direct physiological effects of a substance (e.g., a drug of abuse, a
medication)
b) a general medical condition
c) not better accounted for by brief psychotic disorder and is not merely an
exacerbation of a preexisting Axis I or Axis II disorder.
Generalized Anxiety Disorder
• Excessive anxiety and worry about several events or activities for most days during at
least a 6-month period
• The anxiety is difficult to control, is subjectively distressing, and produces functional
impairment
• Associated with somatic symptoms, such as muscle tension, irritability, difficulty
sleeping, and restlessness
• Prevalence of 3-8%
• The ratio of men to women with the disorder is 2:1
• Generalized anxiety disorder is probably the disorder that most often coexists with
another mental disorder (50-90%)
• Common risks include stressful life events, history of physical or emotional childhood
abuse or family history of GAD
DSM-IV-TR Diagnostic Criteria FOR GAD
• Excessive anxiety and worry about a number of events or activities occurring for most days for at least 6 months e.g. work
or school performance
• The person finds it difficult to control the worry
• The anxiety and worry are associated with at least 3 of the following symptoms:
a) restlessness or feeling keyed up or on edge
b) being easily fatigued
c) difficulty concentrating or mind going blank
d) irritability
e) muscle tension
f) sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep)
Note: only one symptom is need in children. Presence of some symptoms most days
• Focus of anxiety and worry are not confined to Axis I disorder e.g. panic attack or phobia
• Causes clinically significant distress or functional impairment e.g. social or occupational disturbance
• Disturbance is not due to a substance or GMC and does not occur exclusively during a mood disorder or psychotic disorder
Management
• Most effective treatment is one that combines psychotherapeutic, pharmacotherapeutic, and supportive
approaches
Psychotherapy
• Cognitive approaches address patients' hypothesized cognitive distortions directly
• Behavioral approaches address somatic symptoms directly (techniques include relaxation and biofeedback)
• Supportive therapy offers patients reassurance and comfort
• Insight-oriented psychotherapy focuses on uncovering unconscious conflicts and identifying ego strengths
Pharmacotherapy
• Benzodiazepines (drug of choice, however, begin with low dose then increase slowly to achieve therapeutic effect.
Impairs alertness
• Buspirone (effective in reducing cognitive symptoms)
• SSRIs (patients with comorbid depression)
• B adrenergic receptor antagonists may reduce the somatic manifestations of anxiety
Other Anxiety Disorder
A.Due to General Medical Condition
• Symptoms can include panic attacks, generalized anxiety, obsessions and compulsions,
and other signs of distress
• History, physical examination, or laboratory findings show that the disturbance is the
direct physiological consequence of a general medical condition
• E.g. Hyperthyroidism, hypothyroidism, hypoparathyroidism, vitamin B12 deficiency,
pheochromocytoma or hypoglycemia
• Treat the underlying medical condition
B. Substance Induced Anxiety Disorder
• disorder is the direct result of a toxic substance including drugs of abuse, medication,
poison, and alcohol
• Signs and symptoms vary with the particular substance involved
• Treatment is removal of the substance
C. Anxiety Disorder Not Otherwise Specified
• Symptoms that do not meet the criteria for any specific DSM-IV-TR anxiety disorder or
adjustment disorder with anxiety or mixed anxiety and depressed mood
D.Mixed Anxiety–Depressive Disorder
• Has both anxiety and depressive symptoms for at least a month e.g. difficulty concentrating,
sleep disturbance, fatigue, irritability, pessimistic thinking, low self-esteem or feelings of
worthlessness
• Do not meet diagnostic criteria for either anxiety or mood disorders
• The symptoms are not better accounted for by any other mental disorder
• The symptoms cause clinically significant distress or impairment in social or occupational
functioning
• The symptoms are not due to the direct physiological effects of a substance or a general
medical condition
• Treatment is based on the symptoms, their severity and experience of the clinician with
various treatment modalities
Separation Anxiety
• Excessive distress concerning separation from home or to an attachment figure
• Physical symptoms (headache, stomach-ache, nausea, vomiting) when separation
occurs or is anticipated
• Characterized by at least 3 of the following:
a)Recurrent and excessive distress when separation occurs or anticipated
b)Persistent and excessive worry that an event will lead to separation
c)Persistent worry that the major attachment figure will be lost or harmed
d)Fear of being alone without the attachment figure
e)Reluctance or refusal to sleep away from home or without attachment figure
• Duration of at least 4 weeks
• Age of onset before 18 years
• The symptoms cause clinically significant distress or impairment in social or
occupational functioning
Summary
Recommended Dosages of
Antipanic Drugs
Physiological Symptoms of Anxiety
Disorders
Reference
• Synopsis Of Psychiatry – Behavioral Sciences/ Clinical Psychiatry,
Kaplan & Shaddock, 10th Edition