Psychiatry

10 ANXIETY DISORDERS
DR. Manood | 04 January 2022

NORMAL ANXIETY
– Diffuse, unpleasant, vague sense of apprehension, often
accompanied by autonomic symptoms
– Alerting signal; it warns of impending danger and enables a person
to take measures to deal with a threat
– anxiety prevents damage by alerting the person to carry out certain
acts that forestall the danger
– Normal and adaptive response

FEAR vs. ANXIETY

FEAR ANXIETY
Known, external, definite, non- Unknown, internal, vague,
conflictual threat conflictual
Sudden Insidious

PERIPHERAL MANIFESTATIONS OF ANXIETY

– Diarrhea – Restlessness (e.g., pacing)
– Dizziness, light-headedness – Syncope
– Hyperhidrosis – Tachycardia
– Hyperreflexia – Tingling in the extremities
– Hypertension – Tremors
– Palpitations – Upset stomach (butterflies) CONTRIBUTIONS OF BIOLOGICAL SCIENCES
– Pupillary mydriasis – Urinary frequency, hesitancy – THE AUTONOMIC NERVOUS SYSTEMS - exhibit increased
sympathetic tone, adapt slowly to repeated stimuli, and respond
excessively to moderate stimuli.
PATHOLOGICAL ANXIETY
– THREE MAJOR NEUROTRANSMITTERS - norepinephrine (NE),
– 1 of 4 persons met the diagnostic criteria for at least one anxiety serotonin, and GABA
disorder – Alterations in hypothalamic-pituitary-adrenal (HPA) axis
– 12month prevalence rate of 17.7% function
– Women - 30.5 percent lifetime prevalence – Hypothalamic levels of CRH are increased by stress, resulting in
– men - 19.2 percent lifetime prevalence activation of the HPA axis
– Prevalence decreases with higher socioeconomic status/

PSYCHOANALYTIC THEORIES
– Freud defined anxiety as a signal of the presence of danger in the
unconscious.
– Anxiety was viewed as the result of psychic conflict between
unconscious sexual or aggressive wishes and corresponding
threats from the superego or external reality.
– In response the ego mobilized defense mechanism
– It was anxiety that caused repression
– The goal of therapy is to increase anxiety tolerance,

BEHAVIORAL THEORIES
– Anxiety is a conditioned response to a specific environmental
stimulus.
o E.g A girl raised by abusive father anxious at the sight of
father; Thru generalization, may come to distrust all men.
– 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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10 Anxiety Disorders
– Heredity has been recognized as a predisposing factor in the
development of anxiety disorders.
– Increased activity in the septohippocampal pathway (anxiety), and
the cingulate gyrus, which has been implicated particularly in the
pathophysiology of OCD.

 Panic disorder
 Agoraphobia
 Specific phobia;
 Social phobia (Social Anxiety Disorder)
 Generalized Anxiety Disorder (GAD)

PANIC DISORDER AGORAPHOBIA

Acute intense attack of anxiety
accompanied by feelings of
impending doom
Discrete periods of intense fear
Refers to a fear of or anxiety
regarding places from which
escape might be difficult.
fear of having a panic attack in a
public place from which escape
would be formidable

PANIC DISORDER
– Lifetime prevalence of panic disorder is in the 1 to 4 percent range;
3 to 5.6 percent for panic attacks
– Women are two to three times more likely to be affected than men
– The only social factor identified as contributing to the development
of panic disorder is a recent history of divorce or separation
– The mean age of presentation is about 25 years old
– Lifetime prevalence of agoraphobia varies between 2 to 6 percent
across studies;
– Of patients with panic disorder, 91 percent have at least one other
psychiatric disorder

15 to 30% - social phobia

2 to 20 % - specific phobia

15 to 30 % - generalized anxiety disorder

2 to 10% - posttraumatic stress disorder (PTSD)

30% - obsessive-compulsive disorder (OCD)

– Poorly regulated noradrenergic system with occasional bursts of 10 to 15% - major depressive disorder
activity.
– Increased 5-hydroxytryptamine (5-HT) turnover in the prefrontal – Serotonergic dysfunction is quite evident in panic disorder ;
cortex, nucleus accumbens, amygdala, and lateral hypothalamus postsynaptic serotonin hypersensitivity
– Abnormal functioning of their GABA -A receptors – Attenuation of local inhibitory GABAergic transmission in the
– Neuropeptide Y has counterregulatory effects on CRH and LC-NE basolateral amygdala, midbrain and hypothalamus
systems – BRAINSTEM (particularly the noradrenergic neurons of the locus
– Galanin modulates anxiety-related behaviors. ceruleus and the serotonergic neurons of the median raphe
nucleus)
CT SCANS and MRI – The LIMBIC SYSTEM (possibly responsible for the generation of
– Occasionally show some increase in the size of cerebral ventricles. anticipatory anxiety)
(The increase may be correlated with the length of time of – The PREFRONTAL CORTEX (possibly responsible for the generation
benzodiazepine use.) of phobic avoidance).
– Specific defect on right temporal lobe (MRI)
– Abnormal finding in right hemisphere PANICOGENS
RESPIRATORY carbon dioxide (5 to 35 percent mixtures), sodium
PET, SPECT and EEG lactate, and bicarbonate
– Abnormalities in the frontal cortex, occipital and frontal NEUROCHEMICAL yohimbine, m-chlorophenylpiperazine (mCPP),
PANIC DISORDERS Parahipoccampal gyrus m-Caroline drugs; flumazenil (Romazicon),
OCD Caudate nucleus cholecystokinin; and caffeine.
PTSD increased activity of the amygdala ISOPROTERENOL mechanism of action in inducing panic attacks is
poorly understood

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10 Anxiety Disorders
– MRI – cortical atrophy in right temporal lobes DSM V DIAGNOTIC CRITERIA
– PET – dysregulation of cerebral blood flow A. Recurrent unexpected panic attacks;
– Cerebral vasoconstriction which may result in dizziness B. at least one of the attacks has been followed by 1 month (or more)
– No clinical significance or relevance to the association between of one (or more) of the following:
mitral valve prolapse and panic disorder 1. persistent concern about having additional attacks worry
– First-degree relatives of patients with panic disorder have a about the implications of the attack or its consequences
fourfold to eightfold higher risk for panic disorder than first-degree (e.g., losing control, having a heart attack, going crazy)
relatives of other psychiatric patients 2. a significant aldaptive change in behavior related to the
– Monozygotic twins are more likely to be concordant for panic attacks
disorder than are dizygotic twins A. The disturbance is not attributable to the physiological effects of a
– Psychoanalytic theories conceptualize panic attacks as arising from substance (e.g., a drug of abuse, a medication) or another medical
an unsuccessful defense against anxiety-provoking impulses. condition (e.g., hyperthyroidism).
– Higher incidence of stressful life events; greater distress B. The disturbances are not better explained for by another mental
– Separation from mother early in life more likely than paternal disorder.
separation to result in panic disorder
– Childhood physical and sexual abuse seen in adult females with
ASSOCIATED SYMPTOMS
panic disorder
– Depressive symptoms
– Unconscious meaning of stressful event
– Lifetime risk of suicide higher in persons with panic disorder than
– Difficulty tolerating anger
in persons with no mental disorder
– Physical and emotional separation from significant person both in
– Other phobias and OCD can coexist
childhood and adult life
 Psychosocial consequence
– Triggered by situations of increased work responsibilities
 Marital discord
– Perception of parents as controlling, frightening, critical and
 Time lost from work
demanding
 Financial difficulties
– Internal representations of relationships involving sexual and
 Alcohol and other substance abuse
physical abuse
– Chronic sense of feeling trapped
– Vicious cycle of anger at parental rejecting behavior ff by anxiety DIFFERENTIAL DIAGNOSIS
that fantasy will destroy the tie to parents MEDICAL
– Failure of signal anxiety function in ego related to self-
CHF Cushing’s synd Heavy metal poisoning
fragmentation and self-other boundary confusion
– Typical defense mechanisms: reaction formation, undoing,
Asthma Addison’s dse MVP
somatization and externalization

Hyperventilation Hyperthyroidism hypoPTHism

PANIC ATTACK
– Sudden period of intense fear or apprehension that may last from CVD Amphetamine intox Menopause
minutes to hours;
– Begins with a ten- minute period of rapidly increasing symptoms Epilepsy Cocaine intox Theophylline
– Extreme fear and sense of impending death or doom
– Usually cannot name the source of fear Huntingtons dse Anticholinergics Marijuana
– Generally lasts 20 to 30 min
– Rumination, difficulty speaking(stammering) and impaired memory. Infection Alcohol withdrawal Nicotine
– Anticipatory anxiety about having another attack
– Somatic concerns of death from cardiac or respiratory problem Meniere’s dse Anaphylaxis Hallucinogens
may be a major focus of attention
– Hyperventilation can produce respiratory alkalosis and other DM B12 def SLE
symptoms
Carcinoid synd FEI uremia
4 or More Developed Abruptly Reaching a Peak
Within 10 Minutes
 palpitations, pounding heart, or accelerated heart rate PSYCHIATRIC
 sweating  Specific phobia
 trembling or shaking  Social phobia
 sensations of shortness of breath or smothering  PTSD
 OCD
 feeling of choking
 GAD
 chest pain or discomfort
 nausea or abdominal distress
 feeling dizzy, unsteady, lightheaded, or faint AGAROPHOBIA
 derealization (feelings of unreality) or depersonalization – Fear or anxiety regarding places from which escape might be
(being detached from oneself) difficult.
 fear of losing control or going crazy – Most disabling of the phobias
 fear of dying – Persons older than age 65 have a 0.4% prevalence rate
 paresthesias (numbness or tingling sensations) – At least ¾ have panic disorders
 chills or hot flushes

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10 Anxiety Disorders
DSM V DIAGNOSTIC CRITERIA – Self-exposure to the feared situation is a basic principle of all
A. Marked fear or anxiety about two (or more) of the ff five situations: treatment.
1. Using public transportation
2. Being in open spaces -PHOBIA FEAR OF…
3. Being in enclosed spaces Acro- heights
4. Standing in line or being in a crowd Agora- open places
5. Being outside of home alone Ailuro- cats
B. The individual fears or avoids these situations because of thoughts Hydro- water
that escape might be difficult or help might not be available Claustro- closed spaces
C. The agoraphobic situation almost always provokes fear or anxiety. Cyno- dogs
D. The agoraphobic situation is actively avoided, requires companion Myso- dirt and germs
or endured with intense fear or anxiety; Pyro- fire
E. The fear or anxiety is out of proportion to the actual danger posed Xeno- strangers
by the agoraphobic situation and to the sociocultural context. Zoo- animals
F. The fear, anxiety, or avoidance is persistent, typically lasting for 6
months or more.
SPECIFIC PHOBIA:
G. The fear, anxiety, or avoidance causes clinically significant distress
DSM V DIAGNOSTIC CRITERIA
or impairment to social, occupational, or other important areas of
A. Marked fear or anxiety about a specific object or situation (e.g.,
functioning.
flying, heights, animals, receiving an injection, seeing blood).
H. If another medical condition (e.g. Inflammatory bowel
Note: In children, the anxiety may be expressed by crying,
disease,Parkinsons disease) is present, the fear, anxiety or
tantrums, freezing, or clinging
avoidance is clearly excessive;
B. The phobic object almost always provokes immediate fear or anxiety
I. The fear, anxiety or avoidance is not better explained by the
C. The phobic object or situation is actively avoided, or endured with
symptoms of another mental disorder – for example, specific
intense fear or anxiety.
phobia, situational type; social anxiety disorder,OCD, body
D. The fear or anxiety is out of proportion to the actual danger posed
dysmorphic disorder, PTSD or separation anxiety disorder.
by the specific object or situation and to the sociocultural context.
E. The fear, anxiety, or avoidance is persistent, typically lasting for 6
DIFFERENTIAL DIAGNOSIS months or more.
 Medical disorders that can cause anxiety or depression F. The fear, anxiety, or avoidance causes clinically significant distress or
 MDD impairment to social, occupational, or other important areas of
 Schizophrenia functioning.
 Paranoid PD G. The disturbance is not better explained by the symptoms of another
 Avoidant PD mental disorder.
 Dependent PD
SOCIAL PHOBIA:
SPECIFIC PHOBIA AND SOCIAL PHOBIA DSM V DIAGNOSTIC CRITERIA
– PHOBIA refers to an excessive fear of a specific object, A. Marked fear or anxiety about one or more social situations in which
circumstance, or situation. the individual is exposed to possible scrutiny by others.
SPECIFIC SOCIAL Note: In children, the anxiety must occur in peer settings and
strong, persisting fear of an object strong, persisting fear of situations just during interaction with adults
or situation in which embarrassment can occur B. The individual fears that he or she will act in a way or show anxiety
most common mental disorder may have a history of other symptoms that will be negatively evaluated
among women and the second anxiety disorders, mood disorders, C. The social situation almost always provoke fear or anxiety.
most common among men substance-related disorders, and D. The social situation are avoided or endured with intense fear or
bulimia nervosa anxiety.
more common than social phobia E. The fear or anxiety is out of proportion to the actual danger posed
by the social situation and to the sociocultural context.
comorbidity range from 50 – 80%
F. The fear, anxiety, or avoidance is persistent, typically lasting for 6
Common: anxiety, mood, and substance-related disorders.
months or more.
G. The fear, anxiety, or avoidance causes clinically significant distress or
PSYCHODYNAMIC THEMES IN PHOBIAS impairment to social, occupational, or other important areas of
– Principal defense mechanisms include displacement, projection, functioning.
and avoidance. H. The fear, anxiety, or avoidance is not attributable to the
– Environmental stressors, including humiliation and criticism from physiological effects of a substance or another medical condition.
an older sibling, parental fights, or loss and separation from I. The fear, anxiety, or avoidance is not better explained by the
parents, interact with a genetic-constitutional diathesis. symptoms of another mental disorder.
– A characteristic pattern of internal object relations is externalized in J. If another medical condition (eg Parkinsons disease, obesity,
social situations in the case of social phobia. disfigurement from burns or injury) is present, the fear, anxiety or
– Anticipation of humiliation, criticism, and ridicule is projected onto avoidance is clearly unrelated or is excessive.
individuals in the environment.
– Shame and embarrassment are the principal affect states. Specify if: Performance only: if the fear is restricted to speaking or
– Family members may encourage phobic behavior and serve as performing in public.
obstacles to any treatment plan.

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10 Anxiety Disorders

GENERALIZED ANXIETY DISORDER GENEREALIZED ANXIETY DISORDER

– 1-year prevalence range from 3 to 8 percent. – Venlafaxine is approved by the FDA for treatment of generalized
– The ratio of women to men with the disorder is about 2 to 1 anxiety disorder
– 50 to 90 percent of patients with generalized anxiety disorder have – Benzodiazepines have been the drugs of choice for generalized
another mental disorder anxiety disorder
– Buspirone, a 5-HT1A receptor partial agonist, is most likely
effective in 60 to 80 percent of patients with generalized anxiety
DSM-IV-TR DIAGNOSTIC CRITERIA
disorder
A. Excessive anxiety and worry (apprehensive expectation), occurring – a2-adrenergic receptor antagonists may reduce the somatic
more days than not for at least 6 months, about a number of manifestations of anxiety, but not the underlying condition
events or activities (such as work or school performance).
B. The person finds it difficult to control the worry.
C. The anxiety and worry are associated with three (or more) of the REFERENCES
following six symptoms (with at least some symptoms present for
more days than not for the past 6 months). Dra. Manood’s PPT Canvas
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.
E. The disturbance is not attributable physiological effects of a
substance (e.g., a drug of abuse, a medication) or a general
medical condition (e.g., hyperthyroidism)
F. The disturbance is not better explained by another medical
disorder (e.g., the anxiety or worry is not about having a panic
attack (as in panic disorder), being embarrassed in public (as in
social phobia), being contaminated (as in obsessive-compulsive
disorder), being away from home or close relatives (as in
separation anxiety disorder), gaining weight (as in anorexia
nervosa), having multiple physical complaints (as in somatization
disorder), or having a serious illness (as in hypochondriasis), and
the anxiety and worry do not occur exclusively during
posttraumatic stress disorder.

TREATMENT
PANIC DISORDERS
– Alprazolam (Xanax) and paroxetine (Paxil) - approved by the US
Food and Drug Administration (FDA) for the treatment of panic
disorder
– All SSRIs are effective for panic disorder
– Among tricyclic drugs, clomipramine and imipramine (Tofranil)
are the most effective in the treatment of panic disorder.
– MAOIs appear less likely to cause overstimulation than either SSRIs
or tricyclic drugs, but they may require full dosages for at least 8 to
12 weeks to be effective
– Once it becomes effective, pharmacological treatment should
generally continue for 8 to 12 months.
PHOBIAS
– The most studied and most effective treatment for phobias is
probably behavior therapy.
SPECIFIC PHOBIA
– Common treatment for specific phobia is exposure therapy

SOCIAL PHOBIA
– Effective drugs for the treatment of social phobia:
o Selective Serotonin Reuptake Inhibitors (SSRIS)
o Benzodiazepines
o Venlafaxine (Effexor)
o Buspirone (BuSpar).

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