ANXIETY DISORDER

PGI Maharjan Nayan

AUFMC

OUTLINE
Panic Disorder and Agoraphobia
Specific Phobia and Social Phobia
Obsessive Compulsive Disorder
Post-traumatic Stress Disorder and Acute Stress
Disorder
Generalized Anxiety Disorder
Other Anxiety Disorder

NORMAL ANXIETY
A diffuse, unpleasant, vague sensation of
apprehension
Accompanied by:
Autonomic symptoms urination
Sympathetic response perspiration, palpitations, chest
tightness, stomach discomfort, restlessness

Common and treatable

Can affect ability to carry out everyday task
Does not mean youre crazy, has a weak personality
or has a personality problem

ANXIETY VS FEAR
Anxiety
An alerting signal
Apprehensive anticipation of future danger
Experienced as dysphoric (unpleasant)
Accompanied by somatic symtoms

Fear
Real threat or danger exists
External, definite or non-conflictual threat

IS ANXIETY ALWAYS
PATHOLOGICAL?
NO, it is a warning signal
Some anxieties are advantageous
Helps in novel situations
Helps mobilize individual for quick response

Anxiety can heighten ones awareness,

prepare a defense to threatening
situations
Fear response promotes survival of
individual and species

NORMAL FEAR RESPONSE

Cognitive Appraisal
Recognize and remember real threat

Physiologic Arousal
Signals danger
Enhances alertness

Behaviours
Flight or Flight

FIGHT OR FLIGHT
RESPONSE

When we feel
threatened, our bodies
are hardwired to either
fight or flight or run
away

PERIPHERAL MANIFESTATION
OF FIGHT OR FLIGHT
RESPONSE
Many signs are explained by sympathetic nervous
system activation and release of norepinephrine
from adrenal medulla
Increase in:

Heart rate
BP
Ventilation
Glucose (to propel body into action)

Pupis dilate
Sweating
Piloerection

WHAT MAY TRIGGER ANXIETY

Psychological Stress
Relationship breakups, loss of
someone close, work pressure,
lack of sleep, financial problems

Physical Stress
Physical illness, trauma,
excessive use of drugs and
alcohol

WHEN DOES ANXIETY

BECOME PATHOLOGICAL?
Occurs when safe stimuli requires
meaning of danger
Anxiety is excessive, inappropriate, or
generalized
Response to feared stimuli are
maladaptive
Becomes a disorder when it becomes a
source of significant subjective distress
or functioning is impaired

DSM IV-TR CRITERIA FOR

ANXIETY DISORDER

Panic Disorder with or without agoraphobia

Social Anxiety Disorder
Specific Phobia
Obsessive-Compulsive Disorder
Generalized Anxiety Disorder
Post-traumatic Stress Disorder

Anxiety Disorder due to general medical condition

- Essential feature is that anxiety is judged to be due to direct
physiological effects a GMC (thyrotoxicosis)

Substance induced psychotic disorder

- Judged to be due to direct physiologic effects of a subtance
(drugs etc)

GENETICS AND
EPIDEMIOLOGY
Overall, anxiety disorders are among the most
prevalent psychiatric dosorders
Lifetime prevalence is up to 25% for any anxiety
disorder in the US
M<F
Strong genetic component

PANIC ATTACK

PANIC ATTACK
Discrete period of intense fear or discomfort
accompanied by four or more of the ff:

Palpitation
Sweating
Trembling
Choking
Chest pain

Dizziness,, fainting
Derealization
Fear of losing control
Fear of dying
Numbness
Chills or hot flushes

PANIC ATTACK
Episodes have a sudden onset and peak
rapidly usually in 10min or less
Often accompanied by a sense of imminent
danger or doom and urge to escape
May present to ER the fear of catastrophic
medical event (MI, stroke)
Represents triggering of alarm responsea

PANIC ATTACK
Panic attack can be a symptom of Social
Phobia, PTSD and OCD
Not specific to panic disorder
May herald depression
Secondary to
Underlying medical condition
Medical Side effect
Illicit drug use

PANIC DISORDER
Recurrent, unexpected panic attack
Followed by one or more of the following:
Anticipation of additional attacks
Worry about implications of the attacks
Change in behavior

With or without agoraphobia

AGORAPHOBIA

AGORAPHOBIA
Literally fear of market place or open spaces
Anxiety about being in situation from which escape
might be difficult
Often secondary to panic attacks
Avoided situations included: driving, bridged,
tunnels, elevators, airplanes, malls, sitting in the
middle of the row

AGORAPHOBIA: DEMOGRAPHY &

EPIDEMIOLOGY
M<3F
Lifetime prevalence: 2-5%
Frequently present in primary care
setting

COGNITIVE BEHAVIORAL
THEORIES
Learned by response from
modelling parental behaviour or
through the process of classic
conditioning
A noxious stimulus that occurs with
a neutral stimulus can result to
avoidance of the neutral stimulus

PSYCHOANALYTIC THEORIES
Panic attacks are resulting from unsuccessful
defense against anxiety provoking impulses
Defense mechanism involved: repression,
displacement, avoidance, and symbolization

SOCIAL
PHOBIA/SOCIAL
ANXIETY

SOCIAL PHOBIA/SOCIAL
ANXIETY
Main feature is the fear of being judged or criticized
Worry that they will do something silly or
embarassing to others
Anxiety may be limited to a specific social situation

SOCIAL PHOBIA DSM IV-TR

CRITERIA
Significant fears of situation where the person
maybe scrutinized by others or embarrassed in a
public situation
Fear is that youll do something to cause
embarrassment or theyll see you sweat (show
anxiety)
Exposure to a feared situation almost invariably
provokes anxiety
Person has insight to the excessive nature of their
fear
Feared situations are avoided

SOCIAL PHOBIA:
DEMOGRAPHIC &
EPIDEMIOLOGY
Lifetime Prevalence of 2.3%
M<F
However in clinical samples, M>F
High comorbidity with alcohol abuse and
depression

SOCIAL PHOBIA: SUBTYPES

Performance
Restricted to public speaking, giving
recital, etc
Common but usually does not require
medical treatment

Generalized
Involves a number of different situations
Avoidance is common
More severe and affects general
functioning

SPECIFIC PHOBIA OR SIMPLE

PHOBIA
Persistent or irrational fears of certain
objects or situations
Examples: snakes, closed-in-spaces,
flying, blood/injury, storms and bridges
Common in general population
Present up to 5% men and 10% women
Rarely causes sufficient impairment or
distress to warrant diagnosis

COMMONLY FEARED OBJECT OR

SITUATION

Animals
Storms
Heights
Illness
Injury
Death

COMMON SPECIFIC PHOBIAS

Animals
Snakes (Ophidiophobia)
Spiders (Arachnophobia)
Dogs (Cynophobia)

Objects
Blood (Hemophobia)

Situations
Heights (Acrophobia)
Closed Spaces (Claustrophobia)
Flying (Aerophobia)
Dentist (Dentophobia)

OBSESSIVECOMPULSIVE
DISORDER (OCD)

OCD CHECKLIST
1. Do you wash or clean a lot?
2. Do you check things a lot?
3. Is there any thought that keeps
bothering you?
4. Do your daily activities take a long
time to finish?

OCD
Obsessions recurrent, unwanted and
distressing thoughts
- Majority have both obsessions and compulsions
- Insight present: acknoeledged as senseless or
excessive at some point during illness
- Compulsions usually reduce anxiety but are not
pleasurable (ego dystonic)
- Sx produce subjective distress are time-consuming
(1hr/day) or interfere with function
- Recurrent and disturbing thoughts, impulses and
images

OCD
- Not just excessive worries about real life events
such as in GAD
- Experienced as intrusive (ego dystonic)
- Attempts are made to ignore, suppress, or
neutralize the thoughts or actions
- Typical concerns include:
- Contamination
- Aggression
- Safety or harm
- Sex
- Religion
- Somatic Fears
- Need for sympathy or exactness

OCD
Compulsions repetitive, irresistible
behaviours
- Repetitive behaviors or mental acts the person feels
driven to perform either:
- In response to an obsession or
- According to rigid rules

- Designed to prevent or reduce distress or to prevent

some dreaded event from occurring
- The acts are clearly excessive or senseless

 Common compulsions
Typical behavior includes:
-

Cleaning and washing

Checking
Ordering/Arranging
Counting
Repeating
Hoarding/Collecting

OCD: SYMPTOMS
1. Contamination most common
2. Pathological Doubt 2nd most common;
- Obsessional doubt, followed by checking
compulsion

3. Intrusive thoughts sexual or aggressive acts

4. Other symptom pattern
- symmetry

OCD DEMOGRAPHY AND

EPIDEMIOLOGY
Lifetime prevalence 2-3%
Childhood onset >50%
Chronic sometimes disabling
M=F

MAJOR DEFENSE
MECHANISMS
Isolation
Undoing
Reaction

GENERALIZED
ANXIETY DISORDER

GAD: ETIOLOGY
A certain degree of anxiety is normal and adaptive
Biological and psychosocial
Excessive worries about real life problems such as
school and work performance
Typically seek help for somatic concerns

GAD: ETIOLOGY
Accompanied by anxiety syndrome: 3 or more of the
following
Restlessness or feeling keyed-up or on edge
Easy fatigability
Trouble concentrating
Irritability
Muscle Tension
Sleep disturbance

GAD: EPIDEMIOLOGY
Lifetime prevalence: 5.1%
M<2F
High comorbidity with other psychiatric
disorders
Rare to see Pure GAD in the clinics
2nd most common psychiatric disorder after
depression in primary care

POST-TRAUMATIC
STRESS DISORDER
Aka shell shock aka combat fatigue

PTSD DSM IV-TR

Exposure to a traumatic event in which there is:
- Serious risk of death or dismemberment to
self or others
Their response is key, must involve:
Intense Fear
Helplessness
Horror
The traumatic event is persistently experienced
Person avoids reminder of the trauma
May experience a numbing of emotions
Chronic State of hyper arousal
- must last more than 1month

HOW IS THE EVENT REEXPERIENCED?

Recurring images, memories,
thoughts
Misperceptions, hallucinations
Dreams/nightmares
Flashbacks-reliving the experience

WHAT ABOUT
AVOIDANCE/NUMBING?
Avoid thinking about or talking about the trauma
Avoid reminders, triggers, cues
Inability to recall parts of the trauma
Loss of enjoyment of life, sense of no future
Feeling detached and emotionally aloof

Increased arousal state

Insomnia
Irritability or anger outbursts
Trouble concentrating
Hypervigilance
Easily statrled

PTSD: EPIDEMIOLOGY
Lifetime prevalence: 1-3%, far higher in combat
veterans
Common after natural disaster, wars, rape, assaults,
car accidents
PTSD consist of a triad of
Reexperiencing of trauma through dreams and
waking thoughts
Persistent avoidance of reminders to trauma
Persistent hyperarousal

MEDICAL CONDITIONS
THAT MAY PRESENT
WITH ANXIETY

MEDICAL CONDITIONS THAT MAY PRESENT

WITH ANXIETY
Tumors
Hypoxia
Hyperthyroidism
Myocardial infarction, arrhythmias
Hypoglycemia

SUBTANCE INDUCED ANXIETY

Alcohol/Sedative withdrawal
Cocaine/Stimulant intoxication
Cannabis intoxication
Caffeine intoxication