ANXIETY

DISORDERS
BY SAUMU.A.HASHIM
LECTURER DR. NAKUYA
Definition

 Anxiety is defined as an individual’s

emotional and physical fear response to a
perceived threat. Pathologic anxiety occurs
when the symptoms are excessive,
irrational, out of proportion to the
trigger or are without an identifiable
trigger.
introduction

 Anxiety is normal and occurs in response to a real situation

 Pathological if it involves more than temporary fear or
worry and when there is no specific threat.
 Interferes with performances at work, school etc
 Persists for more than 6 months.
 It does not get away and gets worse with time
 In children, it interfes with growth
epidemiology

 Globally 273 million people4 .57% of the population had an

anxiety disorder
 More common in female 5.2% as compared to men-2.8%
 In US lifetime prevalence is 29% while in Africa and Asia is
16%.
 Are the most prevalent psychiatric disorder. Age of onset
varies according to type
 Phobias begin early during childhood.
 Others in young adulthood.
 Prevalence is highest between 25-44 years of age, lowest
after 65 years
pathology

 Combination of psychological, biological and

environmental factors
 Biological-amygdala which regulates fear and emotion plus
is highly sensitive to new or familiar situations and react
with a high response rate.
 Biochemical-Reduced serotonin, GABA,dopamine and
norepinepherine
 Genetic
Key Symptoms

 FEAR- Emotional response to real or perceived imminent

threat. This causes fight or flight responses.
 UNCONTROLLABLE ANXIETY -Anticipation of a future
threat. This causes avoidant behaviors.

 Thes 2 symptoms often lead to panic attacks - Short,

uninterrupted periods up to 20 mins. Individuals feel at least
4 of the following symptoms;
Signs and symptoms of anxiety

 Constitutional : Fatigue, diaphoresis, shivering

 Cardiac :Chest pain, palpitations, tachycardia,
hypertension
 Pulmonary : Shortness of breath hyperventilation
 Neurologic/Musculoskeletal : Vertigo, lightheadedness,
paresthesia's, tremors, insomnia, muscle tension
 Gastrointestinal :Abdominal discomfort, anorexia, nausea,
emesis, diarrhea, constipation
Risk factors

 Being female risk doubled.

 Positive family history of mental illness esp anxiety
disorders
 Personality factors e.g. shy, timid and withdrawn- and those
likely to be at a target of bullies
 General medical conditions esp those that draw attention
 New social demands.
 Negative experience e.g. ever bullied
Medication and substances that
cause anxiety
 Alcohol : Intoxication/withdrawal
 Sedatives, hypnotics or anxiolytics : Withdrawal
 Cannabis : Intoxication
 Hallucinogens (PCP, LSD, MDMA) : Intoxication
 Stimulants (amphetamines, cocaine) : Intoxication/withdrawal
 Caffeine: Intoxication
 Tobacco :Intoxication/withdrawal
 Opioids :Withdrawal
Types according to DSM-5

 Panic disorder.
 Social anxiety disorder.
 Generalized anxiety disorder.
 Separation anxiety disorder-new.
 Selective mutism-new.
 Specific phobias.
 OCD#
 PTSD#
Panic disorder
 Panic disorder recurrent spontaneous and unexpected panic
attacks that often occur without a known trigger.These attacks
occur suddenly, “out of the blue.”
 A panic attack is a discrete period with intense, overwhelming
and uncontrollable feelings of fear or discomfort with at least 4
physical symptoms lasting between 15-30 minutes.
 Thinks they are having a heart attack or about to die
 Intense worry about another attack.
 Attacks can be triggered on by stress
 Symptoms of more than one month is a panic disorder.
 Diagnosis and DSM-5 Criteria

 Recurrent, unexpected panic attacks without an identifiable trigger

 One or more of panic attacks followed by >1 month of continuous
worry about experiencing subsequent attacks or their consequences,
and/or a maladaptive change in behaviors (e.g., avoidance of possible
triggers)
Treatment
Pharmacotherapy and CBT—most effective
 First-line: SSRIs (e.g., sertraline, citalopram, escitalopram)
 Can switch to TCAs (clomipramine, imipramine) if SSRIs not
effective
 Complication: Risk of suicide is increased.
Agoraphobia
 Agoraphobia is intense fear of being in public places
where escape or obtaining help may be difficult.
 Intense fear/anxiety about >2 situations due to concern of
difficulty escaping or obtaining help in case of panic or
other humiliating symptoms:
 outside of the home alone
 open spaces (e.g., bridges)
 enclosed places (e.g., stores)
 public transportation (e.g., trains)
 crowds/lines
 The triggering situations
GAD

 Feels anxious on most days worrying about lots of different

things for a period of 6 months or more, in most of the
situations
 Their worries relate to several aspects of everyday life i.e
work,health,finances,family,etc
 Even minor things like household chores can be a focus of
anxiety,
 Prevalence is 3-30%
 Begins around 8 to 9 years of age.
Diagnosis and DSM-5 Criteria

 Excessive, anxiety/worry about various daily events/activities > 6 months

 Difficulty controlling the worry
 Associated > 3 symptoms: restlessness, fatigue, impaired concentration,irritability,
muscle tension, insomnia
 Impairs life eg missing deadlines or skipping work.
 Not due to drug medication or medical conditions eg hyperthyroidism
 Not better explained by another mental disorder.
Treatment
The most effective treatment approach combines psychotherapy and pharmacotherapy:
 CBT
 SSRI (e.g., sertraline, citalopram) or SNRI (e.g., venlafaxine)
 Can also consider a short-term course of benzodiazepines or augmentation
 with buspirone
 Much less commonly used medications are TCAs and MAOIs
specific phobias

 A phobia is an overwhelming and unreasonable fear of an

object or situation that poses real danger but provokes
anxiety and avoidance.
 Commonest of all anxiety disorders
 Prevalence is between 5 to 12% of the general population
 Phobic stimulus-some react by exaggerating the irrational
danger or imaging it.
 Always associated with panic attacks.
 Subdivided into animal type,enviromental type, injury type,
situational type and others.
Specific phobias continued
Usually first appears in childhood, by 10 years of age
Compromises performance at work and school
Sleep disturbances.
Treatment
Specific phobia:
Treatment of choice: CBT
Social anxiety disorder

 Marked fear of social or performance in situations when

they feel judged,criticised,embrassed,humiliated,rejected or
in fearful of offending others.
 E.g. being watched when doing work or giving a speech
 Individuals fear they will be negatively evaluated by
colleagues
 Shyness,female,divorced,anxiety in biological relative,
exposure to stressful life events are predisposers
 Complicated by substance abuse, isolation and depression.
 Prevalence is 2-16%
SAD continued
 Unrealistic worry that something will happen to either of the two incase of separation.
 Refusal of school so as to stay with the caregiver refusal to sleep without a care taker nearby
 Night mares, fear of being alone, bed wetting
 Constant physical symptoms like headache and abdominal pain.

Social anxiety disorder (social phobia):

 Treatment of choice: CBT
 First-line medication, if needed: SSRIs (e.g., sertraline, fluoxetine) or
 SNRI (e.g., venlafaxine) for debilitating symptoms
 Benzodiazepines (e.g., clonazepam, lorazepam) can be used as
scheduled
 or PRN
 Beta-blockers (e.g., atenolol, propranolol) for performance
anxiety/public speaking
Separation anxiety
 Individual experiences excessive worry regarding separation from home or
from ones with a strong emotional attachment
 Common in infants and toddlers
 Prevalence is 4-5%
 Children have severe cases, When it occurs in a child above 6 years
 Lasts for more than 4 weeks
 Treatment; CBT, play therapy, family therapy(goal is to teach children coping
skills.
 Treatment
 Psychotherapy: CBT, family therapy
 Medications: SSRIs can be effective as an adjunct to therapy
Selective mutism
 Person who is normally capable of speech does not in specific
situations or to specific people.
 Predisposing factors include new language and new
environment like new school.
 Recurrent, lasting for at least 1 month. And should interfere
with ones work or education
 Prevalence is 0.05%
 Not the same as mutism.
 Coexists with shyness or SAD.
 Treatment
 Psychotherapy: CBT, family therapy
 Medications: SSRIs for anxiety (especially with comorbid
social anxiety disorder)
Post traumatic stress disorder

 Post-traumatic stress disorder (PTSD) is a mental health

condition that's triggered by a terrifying event — either
experiencing it or witnessing it. Symptoms may include
flashbacks, nightmares and severe anxiety, as well as
uncontrollable thoughts about the event.
Symptoms of PTSD

 PTSD symptoms are generally grouped into four types:

intrusive memories, avoidance, negative changes in thinking
and mood, or changes in emotional reactions.
 Intrusive memories
 Symptoms of intrusive memories may include:
 Recurrent, unwanted distressing memories of the traumatic
event
 Reliving the traumatic event as if it were happening again
(flashbacks)
 Upsetting dreams about the traumatic event
 Severe emotional distress or physical reactions to something
that reminds you of the event
Symptoms continued
 Avoidance
 Symptoms of avoidance may include:
 Trying to avoid thinking or talking about the traumatic event
 Avoiding places, activities or people that remind you of the traumatic
event
 Negative changes in thinking and mood
 Symptoms of negative changes in thinking and mood may include:
 Negative feelings about yourself or other people
 Inability to experience positive emotions
 Feeling emotionally numb
 Lack of interest in activities you once enjoyed
 Hopelessness about the future
 Memory problems, including not remembering important aspects of
the traumatic event

ptsd

Changes in emotional reactions

Symptoms of changes in emotional reactions (also called arousal
symptoms) may include:
 Irritability, angry outbursts or aggressive behavior
 Always being on guard for danger
 Overwhelming guilt or shame
 Self-destructive behavior, such as drinking too much or
driving too fast
 Trouble concentrating
 Trouble sleeping
 Being easily startled or frightened
CAUSES OF PTSD

 Inherited mental health risks, such as an increased risk of

anxiety and depression
 Life experiences, including the amount and severity of
trauma you've gone through since early childhood
 Inherited aspects of your personality — often called your
temperament
 The way your brain regulates the chemicals and hormones
your body releases in response to stress
RISK FACTORS

 Experiencing intense or long-lasting trauma

 Having experienced other trauma earlier in life, including
childhood abuse or neglect
 Having a job that increases your risk of being exposed to
traumatic events, such as military personnel and first
responders
 Having other mental health problems, such as anxiety or
depression
 Lacking a good support system of family and friends
 Having biological (blood) relatives with mental health
problems, including PTSD or depression
COMPLICATIONS

 Post-traumatic stress disorder can disrupt your whole life:

your job, your relationships, your health and your
enjoyment of everyday activities.
 Having PTSD also may increase your risk of other mental
health problems, such as:
 Depression and anxiety
 Issues with drugs or alcohol use
 Eating disorders
 Suicidal thoughts and actions
MANAGEMENT

 Pharmacological:
 First-line antidepressants: SSRIs (e.g., sertraline, citalopram)
or SNRIs (e.g., venlafaxine)
 Prazosin, α1 -receptor antagonist, targets nightmares and
hypervigilance
 May augment with atypical (second-generation)
antipsychotics in severe cases.
 Psychotherapy:
 Specialized forms of CBT (e.g., exposure therapy, cognitive
processing therapy)
 Supportive and psychodynamic therapy
 Couples/family therapy
Body dysmorphic disorder

 ■ Patients with body dysmorphic disorder are preoccupied with nonexistent or

 minor physical defects that they regard as severe, grotesque, and repulsive.
 ■ These individuals spend significant time trying to correct perceived flaws
 with makeup, dermatological procedures, or plastic surgery.
 Diagnosis and DSM-5 Criteria
 ■ Preoccupation with one or more perceived defects or flaws in physical
 appearance that are not observable by or appear slight to others.
 ■ In response to the appearance concerns, repetitive behaviors (e.g., skin
 picking, excessive grooming) or mental acts (e.g., comparing appearance to
 others) are performed.
 ■ Preoccupation causes significant distress or impairment in functioning.
 ■ Appearance preoccupation is not better accounted for by concerns with
 body fat/weight in an eating disorder.
 Epidemiology
 ■ Slightly more common in women than men.
Hoarding Disorder

 Diagnosis and DSM-5 Criteria

 ■ Persistent difficulty discarding possessions, regardless of value.
 ■ Difficulty is due to need to save the items and distress associated with
discarding them.
 Results in accumulation of possessions that congest/clutter living areas and
 compromise use.
 ■ Hoarding causes clinically significant distress or impairment in social,
 occupational, or other areas of functioning.
 ■ Hoarding is not attributable to another medical condition or another
mental
 disorder.
 Epidemiology/Etiology
 ■ Point prevalence of significant hoarding is 2–6%.
 ■ Hoarding is three times more prevalent in the elderly population.
 ■ Onset often preceded by stressful and traumatic events.
Hair pulling disorder

 TRICHOTILLOMANIA (HAIR-PULLING DISORDER)

 Diagnosis and DSM-5 Criteria
 ■ Recurrent pulling out of one’s hair, resulting in hair loss.
 ■ Repeated attempts to decrease or stop hair pulling.
 ■ Causes significant distress or impairment in daily functioning.
 ■ Hair pulling or hair loss is not due to another medical condition or
 psychiatric disorder.
 ■ Usually involves the scalp, eyebrows, or eyelashes. May include facial,
 axillary, or pubic hair
 ■ More common in women than in men (10:1 ratio).
 Treatment
 ■ Recommended: Specialized types of cognitive-behavior therapy (e.g., habit
 reversal training).
 ■ Pharmacologic treatment includes SSRIs, second-generation antipsychotics,
 lithium, or N-acetylcysteine (NAC).
OCD

 OCD is characterized by obsessions and/or compulsions that

are time-consuming, distressing, and impairing. Obsessions
are recurrent, intrusive, undesired thoughts that ↑ anxiety.
Patients may attempt to relieve this anxiety by performing
compulsions, which are repetitive behaviors or mental
rituals.
 Anxiety may increase when a patient resists acting out a
compulsion
.

Diagnosis and DSM-5 Criteria

 Experiencing obsessions and/or compulsions that are time-
consuming (e.g., >1 hour/daily) or cause significant distress or
dysfunction
Obsessions: Recurrent, intrusive, anxiety-provoking thoughts, images,
or urges that the patient attempts to suppress, ignore, or neutralize by
some other thought or action (i.e., by performing a compulsion)
Compulsions: Repetitive behaviors or mental acts the patient feels
driven to perform in response to an obsession or a rule aimed at stress
reduction or disaster prevention. The behaviors are not realistically
linked with what they are to prevent or are excessive
Treatment
 Utilize a combination of psychopharmacology and CBT
 CBT focuses on exposure and response prevention: prolonged,
graded exposure
 to ritual-eliciting stimulus and prevention of the relieving
compulsion
 First-line medication: SSRIs (e.g., sertraline, fluoxetine), typically at
higher doses
 Can also use the most serotonin selective TCA, Clomipramine
 Can augment with atypical antipsychotics
Note
 Although similar sounding with superficial resemblance, OCD and
obsessive-compulsive personality disorder (OCPD) have distinct
presentations. Individuals with OCPD are obsessed with details,
control, and perfectionism; they are not intruded upon by unwanted
preoccupations nor compelled to carry out compulsions.
Medical causes of anxiety

 Hyperthyroidism
 Asthma
 Mitral valve collapse, adrenal gland tumors
 Heart problems,hypoglycaemia,pulmonary embolism
Medication side effects
 Withdrawal from certain drugs
 Substance abuse
 Use of caffeine and amphetamines
Management

Depends on
 Severity of the diagnosis
 Pre morbid personality
 the type of anxiety
 Co morbid conditions
 Mild/life style changes i.e. exercise, rest and good nutrition
Biological management

 Complete clinical evaluation-comobidity

 Investigate to rule out an organic cause.
 Medications
 Benzodiazepines
 Antidepressants-SSRIS,SNRIS,TCAS
 B-blockers
psychological

 CBT-Thinking-feelings-behaviour
 Cognitive-identifying,challenging and neutralizing
unhelpful thoughts underlying the anxiety disorder
 Exposure therapy-confront the fears underlying the disorder
so as to engage in what they were avoiding previously
 Relaxation therapy
 Desensitization
Life style changes

 Avoid alcohol and sedatives.

 Body exercise to be physically fit.
 Avoid caffeine
 Enough rest.
 Quit smoking
prognosis

Good if
 Good adherence to treatment
 No co morbid conditions
 Generally, are chronic and remitting, flare up during periods
of high stress.