Anxiety Disorders

By Dr Nathan B.

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 General overview
 Anxiety Vs Fear

Fear: a psychological (and physiological) reaction to a

known danger.
Anxiety: experience of fear or apprehension but the source of

the danger is unknown, not recognized or inadequate to

account for the symptoms.
The physiological manifestations of anxiety and fear are

similar such as shakiness, palpitation, sweating, GI and GU

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 Classification of Anxiety Disorders

 DSM-IV classification of anxiety disorders are

1. Panic Disorder

2. Phobias: Social phobias ,Simple phobias &

Agoraphobia

3. Generalized anxiety disorder (GAD)

4. Obsessive-compulsive disorder (OCD)

5. Posttraumatic stress disorder (PTSD)

6. Acute stress disorder

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 Classification of Anxiety
Disorders…. Con’t
DSM-V
 Panic Disorder

 Phobias: Social phobias ,Simple phobias & Agoraphobia

 Generalized anxiety disorder (GAD)

 Separation anxiety disorder

 Selective mutism

o Trauma- and Stressor-Related Disorders

o Obsessive-compulsive disorder (OCD), body dysmorphic

disorder, hoarding disorder, trichotillomania (hairpulling

disorder), excoriation (skin-picking) disorder

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 Separation anxiety disorder
 is fearful or anxious about separation from attachment
figures to a degree that is developmentally inappropriate.
 There is persistent fear or anxiety about harm coming to

attachment figures and events that could lead to loss of or

separation from attachment figures and reluctance to go
away from attachment figures, as well as nightmares and
physical symptoms of distress.
 Although the symptoms often develop in childhood, they

can be expressed throughout adulthood as well.

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 Selective mutism
 is characterized by a consistent failure to speak in social

situations in which there is an expectation to speak (e.g.,

school) even though the individual speaks in other situations.
 The failure to speak has significant consequences on

achievement in academic or occupational settings or

otherwise interferes with normal social communication.

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 specific phobia
 are fearful or anxious about or avoidant of circumscribed objects

or situations.
 specific cognitive ideation is not featured in this disorder, as it is

in other anxiety disorders.

 The fear, anxiety, or avoidance is almost always immediately

induced by the phobic situation, to a degree that is persistent and

out of proportion to the actual risk posed.
 There are various types of specific phobias: animal; natural

environment; blood-injection-injury; situational; and other

situations.
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 Table showing specific phobias

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 Social anxiety disorder (social phobia)
 The individual is fearful or anxious about or avoidant of social

interactions and situations that involve the possibility of being

scrutinized.
 These include social interactions such as meeting unfamiliar

people, situations in which the individual may be observed eating

or drinking, and situations in which the individual performs in
front of others.
 The cognitive ideation is of being negatively evaluated by others,

by being embarrassed, humiliated, or rejected, or offending others.

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 panic disorder
 the individual experiences recurrent unexpected panic attacks

and is persistently concerned or worried about having more

panic attacks or changes his or her behavior in maladaptive
ways because of the panic attacks (e.g., avoidance of exercise
or of unfamiliar locations).
 Panic attacks are abrupt surges of intense fear or intense

discomfort that reach a peak within minutes, accompanied by

physical and/or cognitive symptoms.
 Limited-symptom panic attacks include fewer than four

symptoms.
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 panic disorder…
 Panic attacks may be expected, such as in response to a typically

feared object or situation, or unexpected, meaning that the panic

attack occurs for no apparent reason.
 Panic attacks function as a marker and prognostic factor for severity

of diagnosis, course, and comorbidity across an array of disorders,

including, but not limited to, the anxiety disorders (e.g., substance
use, depressive and psychotic disorders).
 Panic attack may therefore be used as a descriptive specifier for any

anxiety disorder as well as other mental disorders

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 Summary of symptoms panic
disorders
Triggering event(our physiology…racing heart)

…..misinterpret(something wrong is going)…… ..

Emotion(fear, hyperventilate, muscular tightness, clenching fist)
….give more attention to our physiological change…more
catastrophic interpretation( I am dying with heart attack , I am
losing my control)… full-blown panic attack
Usually symptoms become climax at 10 minutes and disappear

after 30 minutes
Panic disorders…two or more panic attack

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 Agoraphobia
 are fearful and anxious about two or more of the following situations:

using public transportation; being in open spaces; being in enclosed

places; standing in line or being in a crowd; or being outside of the
home alone in other situations.
 The individual fears these situations because of thoughts that escape

might be difficult or help might not be available in the event of

developing panic-like symptoms or other incapacitating or embarrassing
symptoms.
 These situations almost always induce fear or anxiety and are often

avoided and require the presence of a companion.

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 Generalized Anxiety Disorder (GAD)
 Excessive anxiety and worry about several events or activities for most days during at least a 6-month

period
 The individual finds it difficult to control the worry.

 The anxiety and worry are associated with three (or more) of the following six symptoms (with at least

some symptoms having been present for more days than not for thepast 6 months); Note: Only one item
is required in children.
 1. Restlessness or feeling keyed up or on edge.

 2. Being easily fatigued.

 3. Difficulty concentrating or mind going blank.

 4. Irritability.

 5. Muscle tension.

 6. Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep).

 D. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social,

occupational, or other important areas of functioning .

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 Etiology of anxiety disorders
 Biologic, psychological and social factors may contribute to the

development of the anxiety disorders.

 Neurotransmitters involved include:

 Gamma-aminobutyric acid (GABA; decreased activity),

 Serotonin (5-HT; decreased activity), and

 Norepinephrine (NE; increased activity)

 There are several medical conditions associated with anxiety

symptoms such as:

 Hyperthyroidism, hypoglycemia, pheochromocytoma (an adrenal

medullary tumor)…
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  The autonomic nervous systems - exhibit increased

sympathetic tone, adapt slowly to repeated stimuli, and

respond excessively to moderate stimuli

Substances such as excessive intake of caffeine

can cause anxiety.

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 Behavioral Theories :
- anxiety is a conditioned response to a specific

environmental stimulus.
- In the social learning model, a child may develop an

anxiety response by imitating the anxiety in the

environment, such as in anxious parents

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 Epidemiology of anxiety disorders

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 Treatment of anxiety d/os
 Medications:

 Antidepressants (TCAs and SSRIs)

 Benzodiazepines - 2 to 6 weeks, followed by 1 or 2 weeks of tapering

 Buspirone

 Venlafaxine

 Psychotherapy

 Cognitive behavioral therapy, with emphasis on relaxation techniques and

instruction on misinterpretation of physiologic symptoms, may improve

functioning in mild cases.
 Supportive or insight oriented psychotherapy can be helpful in mild cases of

anxiety.
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 Obsessive Compulsive Disorder (OCD)
Definitions:

Either Obsessions or Compulsions are present

1. Obsessions

a. Recurrent, persistent
 thoughts,
 Impulses
 images experienced as intrusive and causing marked anxiety.

b. The thoughts, impulses, or images are not limited to excessive worries about real problems.

c. The person attempts to ignore or suppress symptoms, or attempts to neutralize them with some
other thought or action.

d. The person recognizes the thoughts, impulses or images as a product of his or her own mind.

2. Compulsions

a. Repetitive behaviors or acts that the person feels driven to perform in response to an obsession.
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 Signs and symptoms cont..
Common themes of obsessional thoughts:
• Dirt and contamination- the idea that the hands are contaminated

with bacteria
• Aggressive actions- the idea that the person may harm another

person or shout angry remarks

• Orderliness- the idea that objects have to be arranged in a special

way or clothes put on in a particular order

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 Signs and symptom cont…
• Illness- the idea that the person may have cancer (idea of

contamination may also refer to illness-that the disease may

result from the feared bacterial contamination)
• Sex- usually thoughts or images of practices that the person

finds disgusting
• Religion- doubts about the fundamentals of belief –eg. Does

God exist? Or about the adequacy or completeness of a religious

ritual such as confession

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 Signs and symptoms cont…
• Compulsions- abnormal actions, repeated, stereotyped

Common themes of compulsion

• Checking rituals –often concerned with safety, -eg-checking

repeatedly that a gas tap has been turned off

• Cleaning rituals- such as repeated handwashing or domestic

cleaning

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 Signs and symptoms cont…
• Counting ritual- such as counting to a particular number or

counting in threes
• Dressing rituals- in which the clothes are set out or put on in a

particular way

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 OCD Epidemiology
 2% of general population

 Mean onset 19.5 years, 25% start by

age 14! Males have earlier onset than

females
 Female: Male 1:1

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 OCD Etiology
 Genetics

 Serotonergic dysfunction

 Cortico-striato-thalamo-cortical

loop
 Autoimmune- PANDAS

 conditioned stimuli

 Magical Thinking… thought is

equal to the deed.

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 Treatment of OCD
 Pharmacotherapy

Usually indicated

TCAs: clomipramine is the most important

medications in this category used to treat OCD

SSRIs: such as fluoxetine (higher doses are needed)

 Psychotherapy

Cognitive behavior therapy(exposure & response

prevention)
 surgery

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 Posttraumatic stress Disorder
 The person has been 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 e.g. Car accident, burn injury
the person's response involved intense fear, helplessness, or

horror

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 Core Symptoms of PTSD
3 Primary Symptom Clusters:

 Re-Experiencing of Trauma

 Acting or feeling as if the trauma was re-occurring (flashbacks)

 Avoidance / Numbing

 Avoidance of thoughts, feelings or conversations associated with the trauma

 Avoidance of activities that will arouse recollection of the trauma (places or people)

 Inability to recall an important aspect of the event

 Markedly diminished interest in significant activities

 Hyperarousal

 Difficulty falling or staying asleep, Irritability or outbursts of anger, Difficulty concentrating,

Hypervigilance, Exaggerated startle response

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 PTSD in children
 Repetitive dreams of the event, nightmares of monsters, and the development

of physical symptoms such as stomachaches and headaches

 Traumatic play - repetitive acting out of the trauma or trauma-related themes

in play
 Older children may incorporate aspects of the trauma into their lives –

reenactment
 Fantasized actions of intervention or revenge are common;

 Increased risk for impulsive acting out secondary to anger and revenge fantasies

 Sexual acting out, substance use, and delinquency

 Regressive behaviors, such as enuresis or fear of sleeping alone, may also occur

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 Epidemiology of Post-Traumatic Stress Disorder
 The lifetime prevalence of PTSD is 8% and is highest in young

adults.
 The prevalence in combat soldiers and assault victims is 60%.

 Individuals with a personal history of maladaptive responses to

stress may be predisposed to developing PTSD.

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 Classification of PTSD

A. Acute(Acute stress disorders). Symptoms have been present for

less than three months.

B. Chronic. Symptoms have been present for greater than three

months.

C. With Delayed Onset. Symptoms begin six months after the

stressor.

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 Treatment of PTSD
 Medications:

 Antidepressants such as TCAs (amitriptyline, imipramine, clomipramine) and

SSRIs (fluoxetine…).

 Psychotherapy, behavioral therapy

Best evidence:
 Exposure therapy- based on learning theory that repeated exposure to

feared stimulus will lead to habituation

 Imaginable exposure- recounting events repeatedly in present tense

 In vivo exposure- confrontation of the situation with actual visits to

37 sites related to the trauma

 Treatment of Acute Stress Disorder
A. The presence of acute stress disorder precede PTSD.

B. The clinical approach to acute stress disorder is similar to

PTSD.

C. Treatment of acute stress disorder consists of supportive

psychotherapy.

D. Sedative hypnotics are indicated for short-term treatment of

insomnia and symptoms of increased arousal.

E. Antidepressant medications are indicated if these agents are

ineffective.
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 Thank you

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