Nabil Numan, MD. Ph.

D
Professor of Psychiatry
Anxiety Disorders
Classification of anxiety disorders
ICD- 10 DSM- 5
 Anxiety disorders Anxiety disorders*
 Phobic anxiety disorder

 Agoraphobia Agoraphobia
 Without panic disorder

 With panic disorder

 Social phobia Social phobia

 Specific phobia Specific phobia
 Other anxiety disorders

 Panic disorder Panic disorder

 Generalized anxiety disorder Generalized anxiety disorder
 Mixed anxiety and
Source: data from The ICD- 10 classification of mental and behavioural disorders: clinical descriptions and
depressive disorder
diagnostic guidelines, Copyright (1992), World Health Organization; Diagnostic and Statistical Manual of Mental
Disorders, Fifth Edition, Copyright (2013), American Psychiatric Association.
Anxiety or fear includes the following:
1. palpitations
2. sweating
3. trembling or shaking
4. shortness of breath or sensation of smothering
5. feeling of choking
6. chest pain or discomfort
7. nausea or abdominal distress
8. feeling dizzy, unsteady, light-headed, or faint
9. derealization (feelings of unreality) or depersonalization (being
detached from oneself)
10. fear of losing control or going crazy
11. fear of dying
12. paresthesia (numbness or tingling sensations)
13. chills or hot flushes
Specific Phobia
 Marked or persistent fear (>6 months) that is excessive or
unreasonable cued by the presence or anticipation of a
specific object or situation
◦ Anxiety must be out of proportion to the actual danger
or situation
◦ It interferes significantly with the persons routine or
function
 Epidemiology
◦ Up to 15 % of general population
◦ Onset early in life
◦ Female: Male 2:1
 Etiology
◦ Learning, contextual conditioning
 Treatment
◦ Systematic desensitization
DSM-5 criteria of specific phobia
A. Marked fear or anxiety about a specific object or situation (flying,
spiders, injections)
B. The phobic object or situation almost always provokes immediate
fear.
C. Phobic object avoided or endured with intense anxiety
D. Fear is out of proportion to the actual danger

Many individuals with simple phobias are able to live a relatively

normal life, making minor adjustments to avoid the feared object.
Sub-classification
1. animal type
2. natural environment type
3. situational type (for example, aeroplanes, lifts, enclosed
spaces).
4. blood/injection, medical care, and injury
5. other type
DSM criteria of Social anxiety disorder
A. A marked of persistent fear of one or more social situations
in which the individual is exposed to the possible scrutiny by
others – conversation, observed eating, giving a speech.
B. The individual fears that he or she will act in a way or show
anxiety symptoms that will be humiliating or embarrassing.
C. The social situation almost always provokes fear or anxiety.
D. These situations are avoided or endured with intense
anxiety.
E. The anxiety is out of proportion to the actual threat.
F. The person recognizes that the fear is excessive or
unreasonable.
SAD epidemiology:
 7% of general population

 Age of onset teens; more common in women

Treatment
 Social skills training, behavior therapy, cognitive therapy

 Medication – SSRIs, SNRIs, MAOIs, benzodiazepines, gabapentin

Panic Disorder
 Recurrent unexpected panic attacks and for a one month
period or more of:
◦ Persistent worry about having additional attacks
◦ Worry about the implications of the attacks
◦ Significant change in behavior because of the attacks
Panic disorder epidemiology
 2-3% of general population; 5-10% of primary care patients

---Onset in teens or early 20’s

 Female:male 2-3:1

Panic Disorder Comorbidity

 50-60% have lifetime major depression
◦ One third have current depression
 20-25% have history substance dependence
DSM-5 Diagnostic criteria for Panic disorder
A. Recurrent unexpected panic attacks – abrupt surge of intense fear which
reaches a peak in 4 minutes, and includes 4 or more of the following:
1. palpitations
2. sweating
3. trembling or shaking
4. shortness of breath or sensation of smothering
5. feeling of choking
6. chest pain or discomfort
7. nausea or abdominal distress
8. feeling dizzy, unsteady, light-headed, or faint
9. derealization (feelings of unreality) or depersonalization (being
detached from oneself)
10. fear of losing control or going crazy
11. fear of dying
12. paresthesia (numbness or tingling sensations)
13. chills or hot flushes
B. At least one of the attacks has been followed by 1 month of one or both:
1. Persistent concern about additional attacks
2. Maladaptive change in behaviour related to attacks (designed to avoid
attacks, such as avoiding unfamiliar situations)
Panic Disorder Etiology

 Drug/Alcohol Treatment
 Genetics  70% or better treatment
response
 Social learning  Education, reassurance,
 Cognitive theories elimination of caffeine,
alcohol, drugs, OTC
 Neurobiology/ stimulants
condi-tioned fear  Cognitive-behavioral
 Psychosocial therapy
stessors
 Medications – SSRIs,
venlafaxine, tricyclics,
◦ Prior separation MAOIs, benzodiazepines,
anxiety valproate, gabapentin
Agoraphobia
 Marked fear or anxiety for more than 6 months about two or more of the
following 5 situations:
◦ Using public transportation
◦ Being in open spaces
◦ Being in enclosed space
◦ Standing in line or being in a crowd
◦ Being outside of the home alone
Prevalence
 The individual fears or avoids these situations 2% of the population
because escape might Females to males:2:1
be difficult or help might not be available Mean onset is 17 years
 The agoraphobic situations almost always 30% of persons with agoraphobia
have panic attacks or panic disorder,
provoke anxiety
higher risk of other anxiety
 Anxiety is out of proportion to the actual threat
disorders, depressive and
posed by the situation substance-use disorders
 The agoraphobic situations are avoided or

endured with intense anxiety

 The avoidance, fear or anxiety significantly interferes
with their routine or function
Generalized Anxiety Disorder
DSM-5 Criteria for GAD
A. Excessive anxiety and worry (apprehensive
expectation), occurring more days than not for at
least 6 months, about a number of events or activities
(such as work or school activities).
B. The person finds it difficult to control the worry.
C. The anxiety and worry are associated with three (or Epidemiology
more) of the following
 4-7% of
1. restlessness or feeling keyed up or on edge general population
2. being easily fatigued  Median
3. difficulty concentrating or mind going blank onset=30 years
4. irritability  Female: Male
5. muscle tension 2:1
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.