Definition of Anxiety

• Anxiety is a feeling of apprehension or fear. The

source of this uneasiness is not always known or
recognized, which can add to the distress you feel.

• Anxiety disorders are a group of psychiatric

conditions that involve excessive anxiety.
 Anxiety disorders
1-Panic disorders
2-Phobic disorders
Social phobia
Specific phobia
3-Generalized anxiety disorder
4-Obsessive compulsive disorder
5-Post traumatic stress disorder
6-Adjustment disorders
Q: A 19 year old boy presented in ER with complaints of
restlessness, apprehension, fear
of impending death, palpitations and sweating. His
brother tells you that he has had similar episodes in the
past which lasted for an hour and settled. (IMDC SENDUP)
(a) what is the likely diagnosis and what D/D? (b) what
investigations will you carry out?
(C)Enlist management?

Q: Discuss the clinical features of panic attacks? (RIHS

SENDUP)
 Panic Disorder

• The abrupt onset of an episode of intense fear or

discomfort, which peaks in approximately 10 minutes,
and includes at least four of the following symptoms:

•The need to escape • Nausea or abdominal discomfort

• Palpitations • Dizziness or lightheadedness
• Sweating • A sense of things being unreal,
• Trembling depersonalization
• Shortness of breath or a smothering • A fear of losing control or "going crazy"
feeling • A fear of dying
• A feeling of choking • Chills or hot flushes
• Chest pain or discomfort
 Panic Disorder

There are three types of Panic Attacks:

1. Unexpected - the attack "comes out of the blue" without

warning and for no discernable reason.

2. Situational - situations in which an individual always has an

attack, for example, upon entering a tunnel.

3. Situationally Predisposed - situations in which an individual is

likely to have a Panic Attack, but does not always have one. An
example of this would be an individual who sometimes has
attacks while driving.
 Phobic disorders
• A phobia is an Abnormal or Excessive fear of
an object or situation.There are two types:

• Specific phobias
• Social phobia
Specific Phobia
 Specific Phobia

• Is characterized by clinically
significant anxiety provoked by
exposure to a specific feared
object or situation, often leading
to avoidance behavior.
• For example
• Fear of heights ( acrophobia)
• Fear of enclosed spaces( claustrophobia)
 Specific Phobia
• Epidemiology
– Up to 15% of general population
– Onset early in life
– Female:Male 2:1
• Etiology
– Learning, contextual conditioning
• Treatment
– Systematic desensitization
 Social Phobia/Anxiety

• Social anxiety disorder, also known as social phobia, is an

intense fear of social situations. This fear arises when the
individual believes that they may be judged, humiliated by
others.
• Individuals with the disorder are acutely aware of the physical
signs of their anxiety and fear that others will notice, judge
them, and think poorly of them.
• In extreme cases this intense uneasiness can progress into a full
blown panic attack.
 Social Phobia/Anxiety
• Common anxiety provoking social situations include:
– public speaking
– talking with people in authority
– dating and developing close relationships
– making a phone call or answering the phone
– interviewing
– attending and participating in class
– speaking with strangers
– meeting new people
– eating, drinking, or writing in public
– using public bathrooms
– driving
– shopping
 Generalized Anxiety Disorder

• Excessive uncontrollable worry about

everyday things is called GAD.
This constant worry affects daily functioning
and can cause physical symptoms.

• GAD can occur with other anxiety disorders,

depressive disorders, or substance abuse.
 Generalized Anxiety Disorder
• Excessive worry more days than not for at least 6
months about a number of events and they find it
difficult to control the worry.
• 3 or more of the following symptoms:
1-Restlessness or feeling keyed up or on edge
2-Easily fatigued
3-Difficulty concentrating
4-Irritability
5-Muscle tension
6-sleep disturbance
7-bowel Disturbance.
• Causes significant distress or impairment
 Generalized Anxiety Disorder
Epidemiology

 4-7% of general
population
 Median onset=30 years
but large range
 Female:Male 2:1
 Obsessive-Compulsive Disorder

Characterized by uncontrollable obsessions and compulsions

which the sufferer usually recognizes as being excessive or
unreasonable.

• Obsessions are recurring thoughts or impulses that are

intrusive or inappropriate and cause the sufferer anxiety:
– Thoughts about contamination, for example, when an individual fears
coming into contact with dirt, germs or "unclean" objects;
– Persistent doubts, for example, whether or not one has turned off the
iron or stove, locked the door or turned on the answering machine;
– Extreme need for orderliness;
– Aggressive impulses or thoughts, for example, being overcome with the
urge to yell 'fire' in a crowded theater
 Obsessive-Compulsive Disorder

• Compulsions are repetitive behaviors acts or rituals performed by the OCD

sufferer, performance of these rituals neutralize the anxiety caused by
obsessive thoughts, relief is only temporary.

– Cleaning. Repeatedly washing their hands, showering, or constantly cleaning

their home;
– Checking. Individuals may check several or even hundreds of times to make sure
that stoves are turned off and doors are locked;
– Repeating. Some repeat a name, phrase or action over and over;
– Slowness. Some individuals may take an excessively slow and methodical
approach to daily activities, they may spend hours organizing and arranging
objects;
– Hoarding. Hoarders are unable to throw away useless items, such as old
newspapers, junk mail, even broken appliances

• In order for OCD to be diagnosed, the obsessions and/or compulsions

must take up a considerable amount of the sufferers time, at least one
hour every day, and interfere with normal routines .
 Management Of Anxiety Disorders
• PSYCHOLOGICAL TREATMENT

1-Explanation and Reassurance:

Especially When Patient fear that they have a serious medical illness.
2-Relaxation and stress management
3- Graded Exposure (Desensitization) to feared situations
for Phobic Disorders
4-Cognitive Behavioural Therapt CBT
5-Behavioral Therapy
6-Psychodynamic Psychotherapy
 DRUG TREATMENT
1-Anti-Depressants
2-Benzodiazapines are useful in short term.
3-Beta Blocker such as propranolol can help
when somatic symptoms are prominent.
 Post-traumatic Stress Disorder
• Is characterized by the re-experiencing of an
extremely traumatic event accompanied by
symptoms of increased arousal and by avoidance
of stimuli associated with the trauma.
Q: A 25 year old woman met a RTA 3 months ago. Her best friend died at the
spot.
• Now she experiences heightened anxiety, flashbacks of the incident in the
form of
• nightmares. She also gets irritable and avoids the crossing where the
accident took
• place. (YMDC SENDUP)
 Post-Traumatic Stress Disorder

• Exposure to traumas such as a serious accident, a natural

disaster, or criminal assault can result in PTSD. When the after
month of a traumatic experience interferes with normal
functioning, the person may be suffering from PTSD.

• Symptoms of PTSD are:

– Re-experiencing the event, which can take the form of intrusive thoughts and
recollections, or recurrent dreams;
– Avoidance behavior in which the sufferer avoids activities, situations, people
and/or conversations which he/she associates with the trauma;
– A general numbness and loss of interest in surroundings;
– Hypersensitivity, including: inability to sleep, anxious feelings, overactive startle
response, irritability and outbursts of anger.
 TREATMENT
• STRUCTURED PSYCHOLOGICAL APPROACHES

1-CBT
2-Eye movement desensitization and
Reprocessiong (EMDR)
3-Anti-Depressant Drugs

Most patients recover within 2 years.

LAB Investigations in anxiety
 Common Causes
• There is no one cause for anxiety disorders. Several factors can
play a role
– Genetics
– Brain biochemistry
– Overactive "fight or flight" response
• Can be caused by too much stress
– Life circumstances
– Personality
• People who have low self-esteem and poor coping skills may be more prone
• Certain drugs, both recreational and medicinal, can lead to
symptoms of anxiety due to either side effects or withdrawal
from the drug.
• In very rare cases, a tumor of the adrenal gland
(pheochromocytoma) may be the cause of anxiety.
 Social Effects of Anxiety
• Depression
– Not as involved with family and friends the way you used
to be
– Lowered quality of relationships
– Low energy
– Lack of motivation to do the things you once looked
forward to doing
• Unable to convey the person that you are
• Fear and avoidance of situations where previous
attacks occurred
 CLINICAL FEATURES OF MANIA
MOOD CHANGES THOUGHT PROCESS
Elation of mood Pressure of talk
Hostility Flight of ideas
Irritability BEHAVIORAL
Transient depression DISINHIBITION
Diurnal variation of mood Increased sexuality
MOTOR ACTIVITY Increased drug intake
Overactivity PSYCHOTIC SYMPTOMS
Delusions
Hallucinations
Ideas of reference
 DIAGNOSING A MANIC EPISODE
A. 1 WEEK of ; 3. more talkative
Abnormally and persistently 4. flight of ideas
elevated, expansive or 5. distractibility
irritable mood 6. increased activity or
B. During mood agitation
disturbance, three or 7. excessive involvement
more of following; in pleasurable activities
1. inflated self-esteem or C. Marked impairment of
grandiosity(sense of social and occupational
superiority) functioning
2. decreased need for sleep
 TREATMENT OF MANIA
ACUTE PHASE:
1-Hospitalization
2-Benzodiazepines
3-Antipsychotics; Typical and Atypical
4-ECT
MAINTENANCE PHASE:
Mood stabilizers such as;
1-Lithium Carbonate
2-Sodium Valproate
3-Carbamazepine.