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Anxiety Disorders
Clinical features and assessment
Dr Babu Mani
Specialty Registrar (6)
Liaison Psychiatry
27/09/2011
Anxiety Response
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Psychological – feelings of
dread and apprehension
accompanied by
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Restlessness
narrowing of attention focussing
on source of danger,
worrying thoughts,
increased alertness and
irritability
Somatic – Muscle tension and
respiratory rate
increase/effects of
hyperventilation (e.g. –
dizziness)
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Autonomic – heart rate and
sweating increase, dry mouth,
urge to urinate or defecate
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Avoidance of danger – phobia
is persistent, irrational fear of a
specific object or situation.
Fear is out of proportion to
objective threat
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Phobias include animate objects,
natural phenomena and situations
Anticipatory anxiety – not just
exposure to the object or
situation but also when thinking
about it
Anxiety disorders
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Found in many disorders
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In DSM IV obsessional disorders are classified as anxiety
disorder
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Anxiety disorders are abnormal states in which the
striking features are mental and physical symptoms of
anxiety occurring in the absence of organic brain disease
or another psychiatric disorder
Anxiety disorders
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All symptoms can occur in the anxiety disorders but the
patterns of occurrence are different
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GAD – continuous anxiety but fluctuate in intensity
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Phobic anxiety – intermittent anxiety arising in particular
circumstances – Agoraphobia, social phobia, specific phobia
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Panic disorder – intermittent anxiety but occurrence unrelated
to any circumstance
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Freud first suggested that cases with mainly anxiety
symptoms should be recognised as a separate entity
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According to Freud, Anxiety neurosis and anxiety hysteria
were related to sexual conflicts – later accepted wide
range of causes
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First systematic entry about phobic disorders was by Le
Camus in the eighteenth century – early nineteenth
century classification assigned the phobias to the group
monomania which were disorders of thinking – Freud
classified as common phobia and specific phobia
Classification of anxiety disorders
ICD 10
 F4 Anxiety disorders
 F40 Phobic anxiety disorders
 Agoraphobia
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DSM IV
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with panic disorder
Without panic disorder
Social phobia
Specific phobia
F41 Other anxiety disorders
 Panic disorder
 Generalized anxiety disorder
 Mixed anxiety and
depression
Agoraphobia
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With panic disorder
Without history of panic
disorder
Social phobia
Specific phobia
Panic disorder without
agoraphobia
Generalised anxiety disorder
Classification
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In ICD 10 anxiety disorders are divided into two named
groups
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Panic disorder is classified differently in two schemes
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OCD is classified as anxiety disorder in DSM IV
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ICD 10 contains mixed anxiety depressive disorder but
DSM IV does not have similar entity
Generalized anxiety disorder
GAD
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Symptoms are persistent and are not restricted to any particular set
of circumstances
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All symptoms of anxiety can occur but a characteristic pattern is
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Worry and apprehension – widespread worries, not focussed on specific
issues – find the ‘widespread’ worries difficult to control
Psychological arousal – irritability, poor concentration, sensitive to noise,
sometimes poor memory
Autonomic overactivity – sweating, palpitatiosn, dry mouth, epigastric
discomfort, dizziness
Muscle tension – restlessness, trempbling, inability to relax, headache
Hyperventilation – dizziness, tingling in extremities
Disturbed sleep – intermittent, unrefreshing unpleasant dreams – early
morning awakening is not a feature of GAD
The symptoms of general anxiety disorder (GAD) often develop slowly
and can vary in severity from person to person.
Some people experience only one or two symptoms, while others
experience many more.
Psychological symptoms
Psychological symptoms of GAD
include:
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restlessness
a sense of dread
feeling constantly 'on edge'
difficulty concentrating
irritability
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impatience
being easily distracted
withdrawal from social contact
(seeing family and friends) to
avoid feelings of worry and
dread.
difficult and stressful going to
work and may take time off sick
worry even more
increased lack of self-esteem.
Physical symptoms
The physical symptoms of GAD can include:
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dizziness
drowsiness and tiredness
pins and needles
irregular heartbeat
(palpitations)
muscle aches and tension
dry mouth
excessive sweating
shortness of breath
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stomach ache
nausea
diarrhoea
headache
excessive thirst
frequent urinating
painful or missed periods
difficulty falling or staying
asleep (insomnia)
GAD – clinical signs
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Face appears strained
Tense posture
Person is restless
Skin is pale and sweating is common
Readiness to tears (may suggest depression but could
reflect the generally apprehensive state)
GAD - Diagnosis
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No dividing line between GAD and normal anxiety
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Extent and duration of symptoms differentiates GAD
from normal
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Duration – DSM IV and research version ICD 10 –
symptoms must have been present for 6 months – ICD
10 criteria is more flexible – present on most days for at
least several weeks at a time and usually several months
GAD
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Anxiety and depression – Co morbidity
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Possible to diagnose other anxiety disorders along with
Generalized anxiety disorder as per DSM IV
Differential diagnosis - GAD
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Depressive disorder
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Schizophrenia
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Dementia
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Substance misuse
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Physical illness – thyrotoxicosis, phaechromocytoma
Aetiology
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Stressful events – involving threat are particularly related to anxiety
disorder – loss events are associated with depression
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Genetic – more frequent among first degree relatives
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Twin studies – higher concordance for anxiety disorder between
monozygotic than dizygotic pairs
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Early adverse experiences – parental indifference, physical, sexual
abuse, separation from mother (women)
Treatment
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Counselling
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Relaxation training
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CBT
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Medication – Benzos, SSRIs. TCA, MAO inhibitors
Management of GAD
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Check diagnosis and co morbidity
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Evaluation of psychosocial maintaining factors – persistent social
problems, marital conflict
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Explanation of the evaluation and proposed treatment
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Psychological help
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Consider medication
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Discuss plan with patient, GP and community team (if referred to)
Phobic anxiety disorders
Phobic anxiety disorders
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Very similar to generalised anxiety disorder but occus in particular
circumstances
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The situations can be grouped into
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Situations – eg crowded places
Objects – eg living things like spiders
Natural phenomena – eg thunder
Classification
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Specific phobias
Social phobia
agoraphobia
Specific phobias
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Four specific phobias are recognised DSM IV
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Animals
Aspects of natural environment
Blood, injection, injury
Situations and other provoking agents – fear of choking, dental and
medical situations
Treatment is usually exposure form of behaviour therapy
Social phobia
Social Phobia
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Social Phobia (also known as social anxiety
disorder) is a marked and persistent fear of one
or more social or performance situations in which
the person is exposed to unfamiliar people or to
possible scrutiny by others
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Aware that their idea is groundless even
though they are preoccupied that they are being
observed critically
Social Phobia
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The main feature of this disorder is the patient’s
fear that he or she will act in a way (or show
anxiety symptoms) that will be humiliating or
embarrassing (American Psychiatric Association,
1994)
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It is often associated with anticipatory anxiety,
leading the patient to avoid situations in which
there is the risk of social exposure.
Social phobia
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Can be generalized – wide range of social situations
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Some times in specific situations
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Can experience any anxiety symptoms but blushing and
trembling are frequent
Social phobia
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Some patients take alcohol to relieve anxiety – much
more common in social phobia
Co morbid depression and suicide attempts seem to be
more frequent (Schneider et al, 1992)
Usually starts in early teenage years
First episode occurs in public place
Episodes become progressively more severe with
increasing avoidance
Phobia of excretion/phobia of vomiting
Diagnostic criteria
ICD 10
 Marked fear or avoidance of being the
focus of attention or of behaving in an
embarrassing or humiliating way –
manifested in social situations
 Two general symptoms of anxiety + at
least one from
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Blushing/shaking
Fear of vomiting
Fear or urgency of micturition or
defecation
Significant emotional distress
recognised as excessive or
unreasonable
Symptoms restricted to or
predominate in feared situations
Not secondary to another disorder
DSM IV
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Marked fear or avoidance of situations
in which the person is exposed to
unfamiliar people or to scrutiny with
fear of behaving in an embarrassing or
humiliating way
Recognises the fear is excessive or
unreasonable, interferes with
functioning or causes marked distress
Not secondary to another disorder
Duration at least 6 months if the
person is under 18 years of age
Differential diagnosis – social phobia
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Agoraphobia and panic disorder – history
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General anxiety disorder and depressive disorder – history and
mental state
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Schizophrenia
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Body dysmorphic disorder – History
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Avoidant personality disorder
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Normal shyness – feeling ill at ease in company
Aetiology
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Genetics
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Suggested by finding that social phobias are more common among the
relatives of social phobics than in the population
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Conditioning – begin with sudden episode of anxiety in
circumstances similar to those becoming the stimulus – subsequent
development is partly due to conditioning
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Cognitive factors
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Undue concern about other people being critical
Excessive high standards for social performance
Negative beliefs about oneself
Excessive monitoring of their own performances
Intrusive negative images of self (supposedly as seen by others)
Often develop safety behaviours (like avoiding eye contact)
Neural mechanisms – social phobia
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PET study found increased blood flow in
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Right dorso-lateral prefrontal cortex
Left inferior temporal cortex
Left amygdaloid-hippocampal region
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Pattern is seen in anticipatory anxiety in healthy individuals except
amygdala is not activated and the activation is less widespread
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Amygdala is a region involved in response to threat
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Treatment with CBT, Citalopram results in decreased blood flow in
amygdala (Fulmark et al, 2002)
Treatment
Psychological
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CBT
Relaxation training – less effective that cognitive therapy
Dynamic psychotherapy – may be helpful in those associated
with pre-existing problems in personal relationships
Drugs
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SSRIs – continued usually upto a year.
MAO inhibitors – Phenelzine /Moclobemide
Benzos – short term /avoid in co-morbid alcohol misuse
Beta Blockers – short term control of tremor and palpitations
– overall effectiveness not greater than placebo
Agoraphobia
Agoraphobia
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Get anxious when away from home, in crowds
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They experience similar symptoms of anxiety but two are
very important
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Panic attacks – response to environmental stimuli or arise
spontaneously
Anxious thoughts about fainting and loss of control
In DSM IV, cases with more than four panic attacks in 4
weeks are not classified as agoraphobia but as panic
disorder with secondary agoraphobic symptoms
situation
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3 common themes – distance from home, crowding and
confinement
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Examples are buses, trains, shops and supermarkets
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Progressively patients avoid these situations – in severe
cases, they are more or less confined to the house –
housebound housewife syndrome
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Variations can occur in the pattern when symptoms
‘reduce’.
Anticipatory anxiety
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Common
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Severe cases – hours before the person enters the feared
situation adding to distress (sometimes misdiagnosed as
generalised anxiety)
Other symptoms
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Depressive symptoms are common
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Depersonalization can be severe
Agoraphobia
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Most cases begin in early or middle twenties (and another
peak in thirties) – these ages are later than the average
ages of onset of simple phobias (childhood) and social
phobias (teenage years)
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Some patients clearly able to describe the first episode
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Pattern of recurrent attacks and gradual development of
avoidance
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Increasingly dependent of friends and family
Diagnostic criteria
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ICD 10
Marked, consistent fear in or
avoidance of at least two situation
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from crowds
public places
travelling alone
travel away from home
Significant distress caused by the
avoidance or the anxiety recognised as
excessive or unreasonable
At least one symptom of autonomic
arousal plus one other anxiety
symptom in the feared
Symptoms restricted to or
predominate in the feared situations
or contemplations thereof
Not the result of another disorder
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DSM IV
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Anxiety in situations in which escape
may be difficult, or help unavailable
were there a panic attack, eg
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outside the home
crowds
travel
bridges
These situations are avoided or
endured with distress
Criteria for panic disorder never met
Not accounted for by another
disorder
Differential diagnosis
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Social phobia
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Generalized anxiety disorder
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Panic disorder
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Depressive disorder
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Paranoid disorders
Treatment
Anxiolytic drugs
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Antidepressant drugs
Selective serotonin re-uptake inhibitors
MOA inhibitors
Psychological
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Exposure treatment – behavioural treatment – more effective
when combined with anxiety management – prognosis better
in people with good marital relationships and poor in those
experiencing chronic life stress
CBT – short term it is as effective as medication and long term
it is probably more effective
Panic disorder
Panic disorder
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The diagnosis did not appear in the nomenclature until 1980
(introduced in DSM III)
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Sudden attacks of anxiety in which physical symptoms predominate
and are accompanied by fear of a serious medical consequence such
as hear attack.
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Irritable heart, Da Costa’s syndrome, Neurocirculatory asthenia,
disorderly action of heart and effort syndrome (these early terms
assumed that patients were correct in fearing a disorder of heart)
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Wood (1941) showed that the condition was a form of anxiety
disorder
Symptoms (DSM IV)
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Shortness of breath and smothering sensation
Choking
Palpitations and accelerated heart rate
Chest discomfort or pain
Sweating
Dizziness, unsteady feelings or faintness
Nausea or abdominal distress
Depersonalisation or derealization
Numbness or tingling sensation
Flushes or chills
Trembling or shaking
Fear of dying
Fear of going crazy or doing something uncontrolled
Symptoms due to hyperventilation
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Dizziness
Tinnitus
Headache
Feeling of weakness
Faintness
Numbness
Tingling in the hands, feet, face
Carpopedal spasms
Precordial discomfort
Clinical features
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Symptoms as listed before (DSM requires the presence of
only four or more symptoms)
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Important features
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Anxiety builds up quickly
Severe symptoms
Person fears a catastrophic outcome
Hyperventilation – hypocapnia causing medically
unexplained symptoms
Diagnosis
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DSM IV – panic attacks occur unexpectedly more than
four attacks in 4 week period or one attack followed by 4
weeks of persistent fear of another attack and worry
about implications.
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ICD 10 – recurrent attacks and not consistently
associated with a phobic situation or object, or with
marked exertion or exposure to dangerous or life
threatening situations
Differential diagnosis
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Panic attacks can occur in generalized anxiety disorder,
phobia, depression and acute organic disorders
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Two important criteria – persistent marked concern
about having further attacks and worrying about the
implications of the attacks
Treatment
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Cognitive therapy
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Benzos
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Imipramine and clomipramine
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SSRIs
Mixed anxiety and depressive disorder
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Anxiety and depressive symptoms occurring together
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Overlap is greatest when symptoms are mild
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Antidepressant with anxiolytic effect
Transcultural variations
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Koro
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Men in Asia – more common among Chinese
Similar to panic disorder
Suk-yeong (Cantonese) – meaning shrinking of penis
Acute anxiety last from 30 minutes to a day or two – person complains of
palpitations, sweating, pericardial discomfort, and trembling
Convinced that the penis will retract into the abdomen and when complete,
he will die.
Occur at night, sometimes after sexual activity
Parallels the belief in panic disorder that heart is damaged and they will die
Variations of social phobia have also been described – taijin-kyofusho (Japanese) or phobia of interpersonal relations
Thank You