Anxiety Disorders

Moges Ayehu, MD, Psychiatrist

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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 disturbance.

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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

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
about separation from attachment
 is fearful or anxious
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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 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)
A .Excessive anxiety and worry about several events or activities for most days
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during at least a 6-month period
B. The individual finds it difficult to control the worry.
C. 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 the past 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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 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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 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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 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

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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 sites related to the trauma

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 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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