PSYCHIATRY III EXIMIUS

ANXIETY DISORDER I 2021

Ethel Pagaddu September 08, 2019
Anxiety Disorder Pathological Anxiety
Epidemiology:
Objectives § 1 out of 4 persons met the diagnostic criteria for at least one
ü To Differentiate Anxiety from Fear anxiety disorder
ü To Define Anxiety and Anxiety Disorders § 12-month prevalence rate: 17. 7%
ü To Enumerate and Describe each Anxiety Disorder § Women are more likely to have an anxiety disorder
ü To Know the Different Treatment Modalities for the § The prevalence of anxiety disorders DECREASES with higher
Management of Each Anxiety Disorder socioeconomic status.
Genetic Studies
Overview § Heredity has been recognized as a predisposing factor in the
development of anxiety disorders
Anxiety Disorders § 4% of the intrinsic variability of anxiety within the general
§ the most prevalent psychiatric conditions population is attributed to a polymorphic variant of the gene
§ associated with significant morbidity; for the serotonin transporter.
§ chronic and resistant to treatment o Persons with the variant produce less transporter and
§ exquisite interplay of genetic and experiential factors have higher anxiety level.

ANXIETY DISORDERS
NORMAL ANXIETY § Panic Disorder
§ Normal human response § Agoraphobia
§ An unpleasant emotion § Specific Phobia
§ Clinically characterized by sense of dread, danger and § Social Anxiety Disorder
physiological arousal § Generalized Anxiety Disorder
FEAR VS ANXIETY
§ Are alerting signals
Fear Anxiety
§ Threat: known, § Threat: unknown,
external, definite, internal, vague,
nonconflictual conflictual
§ Sudden § Insidious


STRESS & ANXIETY
§ an event as stressful depends on the following:
o nature of the event
o person's resources
o psychological defenses and coping mechanisms
SYMPTOMS OF ANXIETY
§ 2 components:
o awareness of the physiological sensations
o awareness of being nervous or frightened
§ affects thinking, perception, and learning
§ Important effect: selectivity of attention
PERIPHERAL MANIFESTATIONS OF ANXIETY PANIC ATTACKS
§ A sudden period of intense fear or apprehension that may
last from minutes to hours .
§ Unexpected panic attacks occur at any time and are not
associated with any identifiable situational stimulus
§ Panic attacks need not be unexpected.

PANIC DISORDER
§ An acute intense attack of anxiety accompanied by feelings
of impending doom
§ The anxiety is characterized by discrete periods of intense
fear that can vary from several attacks during one day to only
a few attacks during a year.
§ Agoraphobia – most common comorbid condition

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 PSYCHIATRY III EXIMIUS
ANXIETY DISORDER I 2021
Ethel Pagaddu September 08, 2019
Two main symptoms related to Panic Disorder 6. Chest pain or discomfort.
7. Nausea or abdominal di stress.
8. Feeling dizzy , unsteady, light-headed, or faint.
9. Chills or heat sensations.
10. Paresthesias (numb ness or tingling sensations).
11. Derealization (feelings of unreality) or depersonalization
(being detached from one-self ).
12. Fear of losing control or "going crazy."
13. Fear of dying.
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 (e.g., losing control, having a
heart attack, "going crazy").
2. A significant maladaptive change in behavior related to the
PSYCHODYNAMIC THEMES IN PANIC DISORDER attacks (e.g., behaviors designed to avoid having panic
attacks, such as avoidance of exercise or unfamiliar
situations).
C. The disturbance is not attributable to the physiological effects
of a substance or another medical condition
D. The disturbance is not better explained by another mental
disorder (e.g., the panic attacks do not occur only in response to
feared social situations, as in social anxiety disorder; in response
to circumscribed phobic objects or situations, as in specific phobia;
in response to obsessions, as in obsessive-compulsive disorder; in
response to separation from attachment figures, as in separation
anxiety disorder).

Associated Symptoms
§ Depressive symptoms are often present in panic disorder
§ Lifetime risk of suicide in persons with panic disorder is
higher than it is in persons with no mental disorder.
§ Psychosocial consequences:
o marital discord

o time lost from work
EPIDEMIOLOGY
o financial difficulties related to the loss of work
§ Women are 2 to 3 times more likely to be affected
o alcohol and other substance abuse
§ The only social factor identified as contributing to the
Course and Prognosis
development of panic disorder is a recent history of divorce
§ Panic disorder is a chronic disorder
or separation
o although its course is variable
§ Panic disorder most commonly develops in young adulthood
§ Patients with good premorbid functioning and symptoms of

brief duration tend to have good prognoses.
Panic-induced Substances
TREATMENT
§ Panicogens:
§ Most effective treatments:
o Carbon dioxide
o Sodium lactate
o Bicarbonate
o Yohimbine
o Flumazenil
o Cholecystokinin
o Caffeine


DSM-5 DIAGNOSTIC CRITERIA FOR PANIC DISORDER
A. Recurrent unexpected panic attacks. A panic attack is an abrupt
surge of in tense fear or in tense 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)
1. Palpitations, pounding heart, or accelerated heart rate.
2. Sweating.
3. Trembling or shaking.
4. Sensations of shortness of breath or smothering.
5. Feelings of choking.

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 PSYCHIATRY III EXIMIUS
ANXIETY DISORDER I 2021
Ethel Pagaddu September 08, 2019
AGORAPHOBIA § Agoraphobia without a history of panic disorder is often
§ Refers to a fear of or anxiety regarding places from which incapacitating and chronic
escape might be difficult
§ can be the most disabling of the phobias TREATMENT
§ almost always develops as a complication in patients with panic § Pharmacotherapy
disorder o Benzodiazepines
§ DSM-5 classifies agoraphobia as a SEPARATE CONDITION that § Alprazolam: most commonly prescribed
may or may not be comorbid with panic disorder. o SSRIs
EPIDEMIOLOGY: § Main advantage: safety profile in overdose
§ Persons older than age 65 years have a 0.4% prevalence and more tolerable side-effect burden
rate of agoraphobia § Side-effects: sleep disturbance,
§ At least ¾ of the affected patients have panic disorder drowsiness, lightheadedness, nausea, and
§ Onset of agoraphobia follows a traumatic event. sexual dysfunction.
o Clomipramine and Imipramine: most effective
DSM-5 Diagnostic Criteria for Agoraphobia § Psychotherapy
A. Marked fear or anxiety about two (or more) of the following five o Supportive therapy
situations: § The therapist assist in reality testing and
1. Using public transportation (e.g., automobiles, buses, trains, may offer advice regarding behavior
ships, planes) o Insight-oriented therapy
2. Being in open spaces (e.g., parking lots, marketplaces, bridges) § Goal: to increase patient’s development of
3. Being in enclosed places (e.g., shops, theaters, cinemas) insight into psychological conflicts
4. Standing in line or being in a crowd o Behavior therapy
5. Being outside of the home alone o Cognitive therapy
B. The individual fears or avoids these situations because of § Short-term and interactive
thoughts that escape might be difficult or help might not be o Virtual therapy
available in the event of developing panic -like symptoms or § Computer programs
other incapacitating or embarrassing symptoms (e.g., fear of
falling in elderly adults; fear of incontinence). SPECIFIC PHOBIA
C. The agoraphobic situations almost always provoke fear or
anxiety § PHOBIA refers to an EXCESSIVE FEAR of a specific object,
D. The agoraphobic situations are actively avoided, require the circumstance, or situation.
presence of a companion, or are endured with in tense fear or § A SPECIFIC PHOBIA is a strong, persisting fear of an object
anxiety. or situation.
E. The fear or anxiety is out of proportion to the actual danger o Persons with specific phobias may anticipate harm,
posed by the agoraphobic situations and to the sociocultural such as being bitten by a dog, or may panic at the
context. thought of losing control.
F. The fear , anxiety, or avoidance is persistent, typically lasting
for 6 months or more. PSYCHODYNAMIC THEMES IN PHOBIAS
G. The fear , anxiety, or avoidance causes clinically significant
distress or impairment in social, occupational, or other
important areas of functioning.
H. If another medical condition (e.g., inflammatory bowel
disease, Parkinson's disease) is present, the fear, anxiety, or
avoidance is clearly excessive.
I. The fear , anxiety, or avoidance is not better explained by
the symptoms of another mental disorder -for example, the
symptoms are not confined to specific phobia, situational type;
do not involve only social situations (as in social anxiety
disorder); and are not related exclusively to obsess ions (as in
obsessive-compulsive disorder), perceived defects or flaws in
physical appearance (as in body dysmorphic disorder),
reminders of traumatic events (as in posttraumatic stress

disorder), or fear of separation (as in separation anxiety
disorder). COUNTERPHOBIC ATTITUDE
Note: Agoraphobia is diagnosed irrespective of the § Otto Fenichel
presence of panic disorder. If an individual' s presentation o phobic anxiety can be hidden behind attitudes
meets the criteria for panic disorder and agoraphobia, both and behavior patterns that represent a denial,
diagnoses should be assigned. either that the dreaded object or situation is
dangerous or that the person is afraid of it.
COURSE AND PROGNOSIS Epidemiology
§ Most cases of agoraphobia are thought to be caused by § Specific phobia is the most common mental disorder among
panic disorder. women
§ When the panic disorder is treated, the agoraphobia often § Specific phobia is the second most common among men
improves with time. (second only to substance-related disorders).

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Ethel Pagaddu September 08, 2019
§ The rates of specific phobias in women (14 to 16 %) were § Insight-oriented psychotherapy
double those of men § Virtual therapy
§ Peak age of onset: § Other useful therapeutic modalities:
o Natural environment type and the Blood-injection- o Hypnosis
injury type: 5 to 9 yrs/old o Supportive therapy
o Situational type: mid-20’s o Family therapy

DSM-5 Diagnostic Criteria for SPECIFIC PHOBIA SOCIAL PHOBIA
A. Marked fear or anxiety about a specific object or situation (e.g., § Social anxiety disorder
flying, heights, animals, receiving an injection, seeing blood). § involves the fear of social situations, including situations
Note: In children, the fear or anxiety may be expressed by that involve scrutiny or contact with strangers.
crying, tantrums, freezing, or clinging. § The fear in social anxiety disorder is of the embarrassment
B. The phobic object or situation almost always provokes that may occur in the situation, not of the situation itself.
immediate fear or anxiety.
C. The phobic object or situation is actively avoided or endured Epidemiology
with in tense fear or anxiety. § Females are affected more often than males
D. The fear or anxiety is out of proportion to the actual danger § The peak age of onset:
posed by the specific object or situation and to the socio- o TEENS
cultural context. o although onset is common as young as 5 years of
E. The fear, anxiety, or avoidance is persistent, typically lasting age and as old as 35 years.
for 6 months or more.
F. The fear, anxiety, or avoidance causes clinically significant
distress or impairment in social, occupational, or other DSM-5 Diagnostic Criteria for SOCIAL PHOBIA
important areas of functioning. A. Marked fear or anxiety about one or more social situations in
G. The disturbance is not better explained by the symptoms of which the individual is exposed to possible scrutiny by others.
another mental disorder , including fear , anxiety, and avoid- Examples include social interactions (e.g., having a
ance of situations associated with panic-like symptoms or other conversation, meeting unfamiliar people), being observed
in capacitating symptoms (as in agoraphobia); objects or (e.g., eating or drinking), and performing in front of others
situations related to obsessions (as in obsessive-compulsive (e.g., giving a speech).
disorder); reminders of traumatic events (as in posttraumatic Note: In children, the anxiety must occur in peer settings and
stress disorder); separation from home or attachment figures just during interactions with adults.
(as in separation anxiety disorder); or social situations (as in B. The individual fears that he or she will act in a way or show
social anxiety disorder). anxiety symptoms that will be negatively evaluated (i.e., will
be humiliating or embarrassing; will lead to rejection or off end
PHOBIAS others).
C. The social situations almost al ways provoke fear or anxiety.
Note: In children, the fear of anxiety may be expressed by
crying, tantrums, freezing , clinging, shrinking, or failing to
speak in social situations.
D. The social situations are avoided or endured with intense fear
or anxiety
E. The fear of anxiety is out of proportion to the actual threat
posed by the social situations and to the sociocultural context.
F. The fear , anxiety, or avoidance is persistent, typically lasting
for 6 months or more.
G. The fear , anxiety, or avoidance causes clinically significant
distress or impairment in social, occupational, or other
important areas of functioning.
H. The fear , anxiety, or avoidance is not attributable to the
Course and Prognosis physiological effects of a substance (e.g., a drug of abuse, a
§ Bimodal age of onset medication) or another medical condition.
o a childhood peak for animal phobia, natural I. The fear , anxiety, or avoidance is not better explained by
environment phobia, and blood-injection-injury the symptoms of another mental disorder , such as panic
phobia disorder , body dysmorphic disorder , or autism spectrum
o an early adulthood peak for other phobias, such disorder .
as situational phobia. J. If another medical condition (e.g., Parkinson' s disease, obe-
§ Most specific phobias that begin in childhood and persist into sity, disfigurement from burns or in jury) is present, the fear
adulthood will continue to persist for many years. , anxiety, or avoidance is clearly unrelated or is excessive.
Specify if:
TREATMENT Performance only: If the fear is restricted to speaking or
§ Behavior therapy performing in public
o Systematic desensitization
o Imagery
o Implosion

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ANXIETY DISORDER I 2021
Ethel Pagaddu September 08, 2019
COURSE AND PROGNOSIS
§ Social anxiety disorder tends to have its onset in late COURSE AND PROGNOSIS
childhood or early adolescence § Because of the high incidence of comorbid mental disorders
§ Social anxiety disorder is typically chronic in patients with generalized anxiety disorder, the clinical
§ Patients whose symptoms do remit tend to stay well. course and prognosis of the disorder are difficult to
predict.
TREATMENT § The occurrence of several negative life events greatly
§ Both psychotherapy and pharmacotherapy are useful in increases the likelihood that the disorder will develop.
treating social anxiety disorder. § a chronic condition that may be lifelong.
§ Effective drugs for the treatment of social anxiety disorder:
o (1) SSRIs TREATMENT
o (2) Benzodiazepines § The most effective treatment of generalized anxiety disorder
o (3) venlafaxine is probably one that combines:
o (4) buspirone o Psychotherapy
§ Treatment of social anxiety disorder associated with per- o Pharmacotherapy
formance situations frequently involves the use of B- o Supportive approach
adrenergic receptor antagonists shortly before exposure to a
phobic stimulus. OTHER TYPES OF ANXIETY DISORDER
ANXIETY DISORDER ATTRIBUTABLE TO ANOTHER MEDICAL
GENERALIZED ANXIETY DISORDER CONDITION
§ GAD: the most common of the anxiety disorders § Symptoms can include:
o lifetime prevalence: 5% o Panic attacks: cardiomyopathy
§ excessive anxiety and WORRY about several events or o Generalized anxiety: Sjogren’s syndrome; Grave’s
activities for most days during at least a 6-month period. Disease
§ The worry is difficult to control and is associated with o Other signs of distress
somatic symptoms § The signs and symptoms will be due to the direct
physiological effects of the medical condition.
DSM-5 Diagnostic Criteria for GENERALIZED ANXIETY DISORDER § Treatment: Treat the underlying medical condition
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 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 areas of functioning.
E. The disturbance is not attributable to the physio logical effects
of a substance (e.g., a drug of abuse, a medication) or another
medical condition (e.g., hyperthyroidism)
F. The disturbance is not better explained by another medical
disorder (e.g., anxiety or worry about having panic attacks in
panic disorder , negative evaluation in social anxiety disorder
[social phobia], contamination or obsessions in obsessive-
compulsive disorder , separation from attachment figures in
separation anxiety disorder , reminders of traumatic events in
posttraumatic stress disorder , gaining weight in anorexia
nervosa, physical complaints in somatic symptom disorder ,
perceived appearance flaws in body dysmorphic disorder ,
having a serious illness in illness anxiety disorder , or the
content of delusional beliefs in schizophrenia or delusional
disorder).

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