Anxiety disorders

11.10.2023
Introduction
• Normal worrying
• Pathological worrying
Anxiety disorders
• State of mind characteristized by excessive or problematic worrying as
a result of which people become distressed or dysfunctional
Anxiety disorders
• Generalized anxiety disorder
• Phobic anxiety disorder
 Agoraphobia
 Social phobia
 Specific phobia
• Panic disorder
• Obsessive compulsive disorder
Generalized Anxiety Disorder (GAD)

“generalized, excessive and persistent fear for no adequate

reason”
Epidemiology
• Starts in teenage years
• Lifetime prevalence 3-4%
• F:M = 2:1
• 60-80% report having been anxious all their lives
Symptoms of anxiety
Psychological symptoms
• Worry
• Fear
• Insomnia
• Sense of panic
• Hyperventilation
• Poor concentration
Symptoms of anxiety
Physical complaints
• Headache
• Dry mouth • Restlessness
• Dizziness • Upset in stomach
• Lump in throat • Paresthesia
• Palpitation • Diarrhoea
• Shortness of breath • Frequent urination
• Chest pain • Ache and pain
• Muscle tension
Symptoms of anxiety
Physical signs
• Sweating
• Cold clammy skin
• Tachycardia
• Flushing and pallor
• Trembling
Diagnosis
• Symptoms of anxiety or tension
• Disturbance of occupational, social and other important areas of
functioning
• Exclusion of substance-related and organic causes
• Not secondary to major mental disorders
• Last for many months, remission and recurrence
• Often triggered by stressful events
 Generalized anxiety disorder
Diagnostic Criteria
• 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 performance).
• 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
presented 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 fatigue.
3. Difficulty concentrating or mind going blank
4. Irritability
5. Muscle tension
6. Sleep disturbance ( difficulty falling 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 to physiological effects of a
substance ( eg. A drug of abuse, a medication) or another medical
condition (eg. Hyperthyroidism)
• F. The disturbance is not better explained by another mental disorder
Differential diagnosis
• Organic anxiety disorders
- Thyrotoxicosis
- Pheochromocytoma
- TLE
• Depression
• Panic disorder
• Phobic disorder
• Substance use disorder
Management
• Educate the patient and family about the illness
• Relaxation
• Counseling
• Medication
• Referral for specialist consultation
Educate about illness
• Explain the nature of anxiety
• Anxiety can be manifested as physical symptoms
• Anxiety and worry can be made worse by stress
• Doing practices to reduce the stress is the most effective method to
relieve the symptoms s/a relaxation, meditation, and regular exercise
Relaxation
• Both mental and physical relaxation about 10 to 15 min two times a
day should be advised
• Meditation
Counseling service
• Plan the short terms activities which are relaxing eg. Visits,
pilgrimage
• Identify exaggerated worries or pessimistic thoughts and discuss ways
to challenge these negative thought when they occurred
• Problem solving
Medication
• If symptoms cause significant distress, anti-anxiety medication can be
used for not longer than two weeks
eg. Diazepam(BDZ) 5 to 10 mg at night
- long term use lead to dependence and is likely to return of symptoms
when discontinuation
• SSRI can be used if long term medication is required
•  blocker may be useful to reduce the physical symptoms
Referral for specialist consultation
• If significant distress can no longer be managed
Course and Prognosis
• Chronic course / waxing and waning
• Made worse by stress
• May diminish as patient gets older
Phobic Anxiety disorders
A group of disorders in which anxiety is evoked only or predominantly,
in certain well-defined situations that are not currently dangerous.
These situations are characteristically avoided or endured with dread.
The patient’s concern may be focused on individual’s symptoms like
palpitations or feeling faint and is often associated with secondary fears
of dying, losing control, or going mad.
Contemplating entry to phobic situation usually generates anticipatory
anxiety.
Phobic anxiety and depression often coexist.
Agoraphobia
• A fairly well-defined cluster of phobias embracing fears of leaving
home, entering shops, crowds and public places, or travelling alone in
trains, buses or planes.
• Depressive and obsessional symptoms and social phobias are also
commonly present as subsidiary features.
• Avoidance of the phobic situation is often prominent, and some
agoraphobias experience little anxiety because they are able to avoid
the phobic situations.
Differential diagnosis
• Generalized anxiety disorder
• Social phobia
• Obsessive compulsive disorder
• Depression
• Post traumatic stress disorder
• Avoidance due to delusions in psychosis
Management
 Pharmacological
Antidepressants
BDZ- short term use only
 Psychological
Behavior methods – exposure techniques, relaxation training
and anxiety management
Cognitive methods – Teaching about bodily responses
associated with anxiety, education about panic attacks,
modification of thinking errors
Social Phobia
• Fear of scrutiny by other people leading to avoidance of social
situations.
• More pervasive social phobias are usually associated with low self-
esteem and fear of criticism.
• They may present as a complaint of blushing, hand tremor, nausea, or
urgency of micturition, the patient sometimes being convinced that
one of these secondary manifestations of their anxiety is the primary
problem.
• Symptoms may progress to panic attacks.
Differential diagnosis
• Normative shyness • MDD
• Agoraphobia • BDD
• Panic disorder • Delusional disorder
• GAD • ASD
• Separation anxiety disorder • Personality disorder
• Specific phobia • ODD
• Selective mutism
Management
Psychological
• CBT – first line
• Relaxation training/Anxiety management, social skills training and
integrated exposure method

Pharmacological
blocker ( reduce autonomic arousal for specific social phobia)
• SSRI, MAOI for generalized social anxiety
Course
• Without treatment, social phobia may be a chronic lifelong condition
• With treatment, response rates may be up to 90%, especially with
combined approaches.

• Medication best regarded as long term as relapse rate are high on

discontinuation.
Specific phobia
• Phobia restricted to highly specific situations such as proximity to
particular animals, height, thunder, darkness, flying, closed spaces.
Urinating or defecating in public toilets, eating certain foods,
dentistry, or the sight of blood or injury.
• Though the triggering situation is discrete, contact with it can evoke
panic as in agoraphobia or social phobia.
• Acrophobia – height
• Animal phobia
• Claustrophobia – enclosed space
Management
• Psychological
Behavior therapy ( systemic desensitization with relaxation and
grated exposure)
Cognitive therapy

• Pharmacological
Generally not used except in severe case to reduce fear
avoidance.
Panic disorder (episodic paroxysmal anxiety)
• Recurrent attacks of severe anxiety (panic) which are not restricted to
any particular situation or set of circumstances and are therefore
unpredictable.
• sudden onset of palpitations, chest pain, chocking sensations, dizziness,
and feelings of unreality ( depersonalization or derealization).
• Secondary fear of dying, losing control or going mad.
• Panic disorder should not be given as the main diagnosis if the patient
has a depressive disorder at the time the attacks starts; in these
circumstances the panic attacks are probably secondary to depression.
Diagnosis
• Recurrent unexpected panic attacks
• A panic attack is an abrupt surge of intense fear or intense discomfort
that reaches a peak within minutes and during which time four or
more of the following symptoms occur:
• Note: The abrupt surge can occur from a calm state or an anxious
state
 Symptoms
1. Palpitations, pounding heart, or 9. Chills or heat sensations
accelerated heart rate 10. Paresthesia ( numbness or
2. Sweating tingling sensations)
3. Trembling or shaking 11. Derealization
4. Sensations of shortness of (feelings of unreality) or
breath or smothering
depersonalization
5. Feelings of choking
( being detached from oneself)
6. Chest pain or discomfort
12. Fear of loosing control or going
7. Nausea or abdominal distress crazy
8. Feeling dizzy, unsteady, light- 13. Fear of dying
headed, or faint
 Panic disorder
Diagnostic criteria
A. Recurrent and unexpected panic attacks.
B. At least one of the attacks has been followed by 1 month (or more) of
one or both of the following:
1)Persistent concern or worry about additional panic attacks or their
consequences
2)A significant maladaptive change in behavior related to attacks
C. The disturbance is not attributable to the physiological substance
D. The disturbance is not explained by another mental disorder
Differential diagnosis
Psychiatric conditions
• Depression
• Schizophrenia
• Obsessive compulsive disorder
• Social phobia
Differential diagnosis
organic causes
• Substance withdrawal state- alcohol , amphetamines , caffeine sedatives-
hypnotics
• Carcinoid syndrome
• Cushing’s disorder
• Hyperthyroidism
• Hypoglycemia
• Phaeochromocytoma
• Anaemia
• Cardiac arrhythmias
• Mitral valve prolapse
• Angina ,M I
• Temporal lobe epilepsy
• Vestibular function
Management
Pharmacological
• SSRI (paroxetine, fluoxetine, fluvoxamine, citalopram, sertraline)
• TCA ( imipramine, clomipramine)
• BDZ

Psychological
Behavior methods: to treat phobic avoidance by exposure, use of
relaxation, and control of hyperventilation (58-83% effective)
Cognitive methods
Obsessive compulsive disorder
• Persistent intrusive unwanted thoughts, images or impulses
• Difficult to control
• Recognizes that the thoughts are his /her own and tries to resist them
at the expense of mounting anxiety
• May develop behaviors to reduce the anxiety and distress caused
(compulsions)
Themes
• Dirt and contamination
• Doubt
• Sacrilege and blasphemy
• Orderliness
• Aggression
The thoughts, impulses, or images are not simply excessive worries
about real-life problems (e.g., concerns about current ongoing
difficulties in life, such as financial, work, or school problems) and are
unlikely to be related to a real-life problem.
Impact on the individual
• Distressed with the thoughts
• Avoidance in certain kinds of behavior
• Increase in certain kinds of behavior
• Impact on social, occupational and personal life/functioning
Epidemiology
• Mean age: 20 yrs,
• 70% onset before age 25 yrs, 15% after age 35 yrs.
• Sex distribution equal.
• Prevalence: 0.5-2%
Diagnostic Criteria
• A. Present of obsessions, compulsions, or both:
Obsessions are defined by (1) and (2):
1. Recurrent and persistent thoughts, urges, or images that are
experienced, at some time during the disturbance, as intrusive and
unwanted, and that in most individuals cause marked anxiety or
distress.
2. The individual attempts to ignore or suppress such thoughts, urges,
or images, or to neutralize them with some other thought or action
(i.e. by performing a compulsion).
• Compulsions are defined by (1) and (2)
1. Repetitive behaviors (eg. Hand washing, ordering, checking) or
mental acts (eg, praying, counting, repeating words silently) that the
individual feels driven to perform in response to an obsession or
according to rules that must be applied rigidly.
2. The behaviors or mental acts are aimed at preventing or reducing
anxiety or distress, or preventing some dreaded event or situation:
however, these behaviors or mental acts are not connected in a
realistic way with what they are designed to neutralize or prevent or
are clearly excessive.
Differential diagnosis

• Normal (but recurrent) thoughts, worries, or habits

• Depressive disorder
• Anankastic Personality disorder
• Schizophrenia
• Phobias
• Hypochondriasis (Illness Anxiety Disorder)
• Body dysmorphic disorder
• Trichotillomania
Management
Pharmacological
SSRIs: fluoxetine, fluvoxamine, sertraline, or paroxetine should be
considered first-line
Clomipramine has specific anti-obsessional action (first-or second-line
choice).
Addition of low dose antipsychotics ( risperidone, aripiprazole)
Anxiolytic drugs
Management
Psychological
Supportive psychotherapy
Behavior therapy
1. Exposure-Response prevention useful in ritualistic behavior
2. Thought stopping
3. Exposure techniques for obsessions
4. Cognitive therapy/Behavior therapy/CBT
5. Dynamic psychotherapy

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