Anxiety Disorders

Misael Benti (MSc, ICCMH)

RVU, 02/17/2025 No health without mental health

 ANXIETY DISORDERS
• Anxiety disorder is a vague, subjective, non-specific
feeling of uneasiness, apprehension, tension, (excessive
nervousness) fears, and a sense of impending doom,
irrational avoidance of objects or situation and anxiety
attack.

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ANXIETY DISORDERS
 Fear versus Anxiety
 Both are an alerting signal

 the body reacts similarly to both fear and anxiety.

 Anxiety- warns 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 a known, external, definite, or

nonconflictual threat
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
 Anxiety vs fear
Anxiety Fear
• Source not • Identifiable
identifiable • Present
• Related to feature • Definite
• Is vague • Discrete physical
• Result of entity
psychological
conflict
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• Anxiety is universal and an integral part of human
existence – everyone becomes anxious at
sometime in life.
E.g. some anxiety is necessary for the scholars to
teach, the artists to create, the builder to construct,
the student to learn, etc.

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 Etiology
I. Psychodynamic factors
Unconscious conflict resulting from:-
 guilt
 Shame
 Repressed wishes
 Drives
 Desires
 Threaten to invade consciousness resulting in anxiety.

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 II. Biologic Factors
Genetic predisposition factors
e.g. - inherited vulnerability,
- CNS and endocrine system interaction.

Neurotransmitters

• The three major neurotransmitters associated with

anxiety on the bases of animal studies and
responses to drug treatment are norepinephrine
(NE), serotonin, and Gamma-aminobutyric acid
(GABA).
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 III. Behavioral factor

• Anxiety is conditioned responses to Certain internal or

environmental stimuli, learned behavior.

IV Environmental
 Disaster, rape, assault, continual trauma, stressors produce anxiety

V. Existential factors

• Loss of meaning in life is cause of anxiety.

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 Clinical Presentations
Physical symptoms- Mental tension
Headaches and stomach- ― Worry,
aches; ―feeling tense or nervous,
Inability to relax or fall asleep ―poor concentration,
– Panic attacks - suddenly ―fear that something
occurrence of:- dangerous will happen
– A fast or pounding heart, and the patient won’t be
– chest pains or tightness, able to cope;
– sweating, trembling ―Hyper-arousal
– lasts a few minutes ―Repetitive, intrusive
mental processes:
―praying, counting
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 Clinical Presentations
Behaviors Psychological symptoms.

― Not wanting to leave home or a • Inability to relax

safe place, • Nervousness, irritability
• Excessive worry
― avoidance of things that are • Disturbance of
reminders of feared objects or concentration
situations
• Panic
― Fear of Speaking in front of people • Feelings of unreality
• Fear of losing control
― Repetitive behaviors – frequent • Fear of going crazy
washing • Fear of dying
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 Autonomic/Somatic Symptoms.
• Chest pain • Hyperventilation
• Choking sensation • Muscle tension
• Diarrhea • Nausea
• Diaphoresis • Palpitations
• Dyspnea • Parasthesias
• Fatigue • Tachycardia
• Flushing • Vertigo
• Headache • Vomiting

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 Classification – Based on DSM IV
1. Generalized anxiety disorder (GAD)
2. Panic disorder without agoraphobia
3. Panic disorder with agoraphobia.
4. Social phobia
5. Specific phobia
6. Obsessive-compulsive disorder
7. Post traumatic and acute stress disorders.
8. Anxiety disorder due to a general medical
condition and substance induced anxiety disorder
9. Anxiety disorder Nos.
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Generalized Anxiety Disorder (GAD)
• generalized anxiety disorder is excessive anxiety and
worry about several events or activities for most days
during at least a 6-month period.
• The worry is difficult to control and is associated with
somatic symptoms.
• The anxiety is not focused on:
features of another Axis I disorder,
is not caused by substance use or
a general medical condition, and
does not occur only during a mood or psychiatric disorder
 Generalized Anxiety Disorder (GAD) con’t
• Patients with GAD, have persistent symptoms of
anxiety, including hyper arousal, that last at least 6
months.

• The symptoms of anxiety in GAD are unrelated to a

specific person or situation called free floating anxiety.

o If you have GAD you may worry about the same things
that other people do: health issues, money, family
problems, or difficulties at work. But you take these
worries to a new level
 Con’t
• The difference between “normal” worrying and
generalized anxiety disorder is that the worrying
involved in GAD is:
– excessive
– intrusive
– persistent
– debilitating
 Epidemiology
• Lifetime prevalence is 5%.
• The female-to-male sex ratio for GAD is 2:1.
• Most patients report excessive anxiety during childhood
or adolescence; however, onset after age 20 may
sometimes occur.
 DSM-IV-TR Diagnostic Criteria for Generalized Anxiety
Disorder

A. Excessive anxiety and worry occurring more days than

not for at least 6 months, about a number of events or

activities (such as work or school performance).
B. The person finds it difficult to control the worry.
 DSM-IV-TR…..
C. The anxiety and worry are associated with three (or more) of

the following symptoms (with at least some symptoms present

for more days than not for the past 6 months).
– restlessness or feeling keyed up or on edge

– being easily fatigued

– difficulty concentrating or mind going blank

– irritability

– muscle tension

– sleep disturbance (difficulty falling or staying asleep, or

 Con’t

D. The focus of the anxiety and worry is not confined to

features of an Axis I disorder.
E. The anxiety, worry, or physical symptoms cause
clinically significant distress or functional impairment
F. The disturbance is not due to the direct physiological
effects of a substance or GMC) and does not occur
exclusively during a mood disorder, a psychotic
disorder, or a pervasive developmental disorder.
 Treatment of GAD
• The combination of pharmacologic therapy and psychotherapy is the
most successful form of treatment.
• Medications:

– Antidepressants (TCAs and SSRIs)

– Benzodiazepines

• Psychotherapy

• Cognitive behavioral therapy, with emphasis on relaxation

techniques and instruction on misinterpretation of physiologic
symptoms,
• Supportive or insight oriented psychotherapy can be helpful in
 Panic Disorder
• Recurrent unexpected panic attacks
• Attack is an abrupt surge of intense fear or intense
discomfort that reaches a peak within minutes
Attacks last 5-20 minutes;
persistent concern of having another attack

• symptoms developed abruptly and reached a peak with 10

minutes.

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 Types
• Panic disorder with agoraphobia

• Panic disorder without agoraphobia

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 Clinical feature of panic attack
• Palpitation, pounding heart, • Derealization
accelerated heart rate • Fear of losing control
• Sweating or going crazy
• Trembling or shaking. • Fear of dying
• Sensation of shortness of
• Parenthesis (numbness
breath or smothering
or tingling sensations
• Feeling of chocking
• Chills or hot flashes.
• Chest pain or discomfort
• Nausea or abdominal • The individual is
disturbance usually nervous and
• Feeling of dizziness, apprehensive between
unsteady, lightheaded or attack and fears the
faint
02/17/2025 next attack.
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Treatment
Goals
• To reduce the frequency, duration, and intensity of panic attacks
• To decreases the anxiety associated with anticipating attacks

Pharmacologic interventions
 selective serotonin reuptake inhibitors

o Fluoxetine

o paroxetine

▪ Tricycle antidepressant (imipramine)

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 Benzodiazepines
- Alprazolam
- Clonazepam
- Diazepam
▪ Monoamine oxidize inhibitors
E.g. phenelzine

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• Psychotherapeutic interventions Includes

 Relaxation training for panic attack

 systematic desensitization for agoraphobic

symptoms

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 III. Phobic Disorders

• Persistent and irrational fear of a specific object or

situation

• desire to avoid the dreaded condition

• Fear recognized as excessive, and unreasonable

• Exposure to the feared stimulus produces anxiety

• Except in children, the individual recognizes the

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(A) Agoraphobia
• Agoraphobia consists of multiple and varied
fears and avoidance behavior that center
around three main themes:

1 . Fear of leaving home

2 . Fear of being alone and

3 . Fear of being away from home in situations

where one can feel trapped, embarrassed or
helplessness
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• According to DSM-IV, the fear is one of
developing; distressing symptoms in such
situation where escape is difficult or help is
unavailable.

• Typical agoraphobia fears are of using public

transportation

(buses, trains, sub ways (metro), planes, being in

crowds, theaters , elevators, hotels, Supermarket ,
department of stores, waiting in line or traveling, a
duration from home.
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• The criteria have never been met for panic
disorder

• The disturbance is not due to the direct

physiological effects of substance

(e.g. a drug abuse, medication) or general

medication.

• If a general medical condition is present,

the fear described in criteria “A” all is clearly in
excess of the usually associated with the condition.
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 (B) Social Phobia

• The central fear is that they will act in such a way as to humiliate
or embarrass themselves in front of others.

• Typical social phobias are of speaking, eating, to perform a task

in front of other, waiting in public, attending parties or interviews.

Epidemiology
Occurs predominance in women and is common in children.
• The prevalence is 9% of the population.

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 Treatment

• Cognitive-behavioral therapies

• SSRIs(Selective serotonin reuptake inhibitors)

• Phenelzine

• Beta blockers (e.g. propranolol)

• Benzodiazepine
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 ( C) Specific Phobias
• Feature of specific phobia is strong fear and
avoidance of a specific object or situation.
Epidemiology
- Occurs predominantly in women and is common
in children.

- The prevalence is 9% of the population.

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 Subtypes include
 animal type,
natural- environment type,
 blood injection – Injury type
situational type.

• The person usually acknowledge the intense

anxiety that result from exposure to the object or
situation as excessive and unreasonable, but the
avoidance continues

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 Common specific phobias
• Acrophobia - Fear of heights
• Aerophobia - Fear of flying
• Aichmophobia - Fear of needles or pointed objects
• Amaxophobia - Fear of riding in a car
• Androphobia - Fear of men
• Gynophobia – fear of women
• Anginophobia - Fear of angina or choking
• Arachnophobia - Fear of spiders
 Common specific phobias…
• Astraphobia - Fear of thunder and lightnig
• Cynophobia - Fear of dogs
• Elurophobia - Fear of cats
• Entomophobia - Fear of insects
• Gamophobia - Fear of marriage
• Hemophobia - Fear of blood
• Hydrophobia - Fear of water
 Treatment
Includes behavioral therapies:
a) Systematic desensitization,
 feared stimuli are paired with relaxation
training,
e.g. an individual with blood injection injury
phobia gradually exposed to hypodermic
needles at an ever-increasing distance.
b) Flooding involves massive exposure to a
feared stimuli until anxiety subsides

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Post traumatic Stress disorder(PTSDs)
 …PTSDs

• Posttraumatic stress disorder (PTSD) is a condition

marked by the development of symptoms after
exposure to traumatic life events.
• The person reacts to this experience with fear and
helplessness, persistently relives the event, and tries to
avoid being reminded of it.
PTSD con’t

• To make the diagnosis, the symptoms must last for more

than a month after the event and must significantly affect
important areas of life, such as family and work

• The stressors causing both acute stress disorder and PTSD

are sufficiently overwhelming to affect almost anyone.
PTSD con’t

• They can arise from experiences in:

war,
torture,
natural catastrophes,
assault, rape, and
serious accidents, for example, in cars and in
burning buildings.
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%.
• The most important risk factors for this disorder are the severity,
duration, and proximity of a person's exposure to the actual
trauma
• Individuals with a personal history of maladaptive responses to
stress may be predisposed to developing PTSD.
DSM-IV-TR Diagnostic Criteria for PTSD

A. The person has been exposed to a traumatic event in

which both of the following were present:
1. 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

2. the person's response involves intense fear,

helplessness, or horror.
 DSM-IV Cri con’t

B. The traumatic event is persistently re-experienced in one (or more) of the

following ways:

1. recurrent and intrusive distressing recollections of the event,

2. recurrent distressing dreams of the event..
3. acting or feeling as if the traumatic event were recurring
4. Intense psychological and physiological distress at exposure
to internal or external cues that symbolize or resemble an
aspect of the traumatic event
DSM-IV Cri con’t
C. Persistent avoidance of stimuli associated with the trauma and
numbing of general responsiveness (not present before the trauma), as
indicated by three (or more) of the following :
1. efforts to avoid thoughts, feelings, or conversations associated with the
trauma
2. efforts to avoid activities, places, or people that arouse recollections of
the trauma
3. inability to recall an important aspect of the trauma
4.markedly diminished interest or participation in significant activities
5. feeling of detachment or estrangement from others
6. restricted range of affect (e.g., unable to have loving feelings).
7. sense of a foreshortened future
DSM-IV Cri con’t

D. Persistent symptoms of increased arousal (not present

before the trauma), as indicated by two (or more) of the
following:
1. difficulty falling or staying asleep
2. irritability or outbursts of anger
3. difficulty concentrating
4. hypervigilance
5. exaggerated startle response
 DSM-IV Cri con’t

E. Duration of the disturbance is more than 1 month.

F. The disturbance causes clinically significant distress or
impairment in functioning.
 TREATMENT

Goals are to relieve the patient from intrusive recollection, to

decrease symptom of anxiety, and to improve the patient’s
social relations and capacity for enjoyment.
Group psychotherapy with other survivors is often the
treatment of modality choice.
Pharmacological treatment- usually it is symptomatic treatment,
with antidepressants and anxiolytics may be helpful; however,
there is a significant risk for substance abuse in patients with this
disorder.
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 1. Obsessive– Compulsive Disorder
Obsessions as defined by
– Recurrent and persistent thoughts, impulses, or
images that are experienced,
– The thoughts, impulses or images are intrusive and
inappropriate and cause marked anxiety or distress.
– The thoughts, impulses, or images are not simply
excessive worries about real-life problems.
– The person attempts to ignore or suppress.
– The person recognizes that the obsessional thoughts,
impulses, or images are a product of his or her own
mind.
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Compulsions as defined by:
– Repetitive behaviors like hand washing, ordering,
checking or mental act like praying, counting, repeating
words silently
– person feels driven to perform in response to an
obsession.
– The behaviors or mental acts are aimed at preventing or
reducing distress.
– are not connected in a realistic, clearly excessive
– person has recognized that the obsessions or
compulsions are excessive or unreasonable.

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Common Example of compulsion:
Counting
 checking
 shouting
 closing or avoiding
washing

Suicide is a special risk in this disorder.

 Treatment of OCD
• Clomipramine-drug of choice
• SSRI- Flouxetin – high dose requered
• Other Drugs. If treatment with clomipramine or an SSRI is
unsuccessful, many therapists augment the first drug by the
addition of valproate, lithium, or carbamazepine.
• Other drugs that can be tried in the treatment of OCD are
venlafaxine, and the monoamine oxidase inhibitors
(MAOIs), especially phenelzine
• Buspirone (BuSpar) -for the treatment of unresponsive
patients
• Adding an atypical antipsychotic such as risperidone
(Risperdal) has helped in some cases.
 Behavior Therapy

• The principal behavioral approaches in OCD are exposure

and response prevention. Desensitization, thought
stopping, flooding, implosion therapy, and aversive
conditioning have also been used in patients with OCD.
 In behavior therapy, patients must be truly committed to
improvement.