ANXIETY  TCAs, MOI, Benzodiazepines, Buspirone (adjuvant), β

blocker (autonomic symptoms for panic attack/

Def: individual’s emotional and physical fear response to performance anxiety)
a perceived threat.  CBT (exposure therapy) , Psychodynamic
 Major neurotransmitter: ↑ Norepinephrine (NE), psychotherapy, exercise, caffeine elimination
↓Serotonin (5-HT), ↓ GABA
 Women > Men Panic Disorder
 Female > Men
Normal Fear Anxiety Disorder  Age onset: 20 – 24 y/o
- Emotional reaction to - Occur with / without  Chronic and relapse is common upon stopping Tx
the real, external threats obvious external threat  Co morbidity : Major Depressive Disorder,
- Emotional response is - Response to the threat Agoraphobia , Bipolar disorder, Alcohol use disorder
appropriately related to is excessive  ↑ risk of suicide
the actual danger  Prognosis: good

Sign & Symptoms Aetiology

Constitutional Fatigue, diaphoresis (sweating), - Genetic
shivering - Neurobiology: fear circuit overactivity
Cardiac Chest pain, palpitation, - Psychosocial factor: ↑ incidence of stressor prior to
tachycardia, HTN onset (divorce/ separation), H/o childhood abuse
Pulmonary SOB, Hyperventilation
Neurologic/ Vertigo, light-headedness, DSM 5 Criteria
Musculoskeletal paraesthesia, tremors, insomnia,
muscle tension A Recurrent unexpected panic attack. A panic
Gastrointestinal Abdominal discomfort, anorexia, attack is an abrupt surge of intense fear /
nausea, emesis (act of vomit), discomfort that reaches a peak within minutes,
diarrhoea, constipation and during which > 4 of the following occurs
1. Palpitations
Aetiology 2. Sweating
 Medication & Substance 3. Shaking
4. Feeling of SOB
Alcohol Intoxication/ withdrawal 5. Feeling of choking
Sedatives, hypnotic/ Withdrawal 6. Feeling of Dizzy/ unsteady/ light-
anxiolytic headedness/ faint
Cannabis Intoxication 7. Chest pain
Hallucinogen (PCP, LSD, Intoxication 8. Nausea/ abdominal distress
MDMA) 9. Chills/ heat sensation
10. Paresthesias
Stimulant Intoxication/ withdrawal
11. Derealisation / depersonalization
(amphetamine, cocaine)
12. Fear of going crazy
Caffeine Intoxication
13. Fear of dying
Tobacco Intoxication/ withdrawal
Opiods Withdrawal
Da PANICS (panic attack)
 Medical Conditions
Dizziness, Disconnectedness, Derealisation,
Neurologic Epilepsy, migraine, brain tumour, Depersonalization
multiple sclerosis, Huntington ds Palpitation Paresthesias
Endocrine Hyperthyroidism, thyrotoxicosis, Abdominal distress
hypoglycaemia, Numbness Nausea
pheochromocytoma, carcinoid Intense fear of dying/ going crazy
syndrome Chills Chest pain
Metabolic Vit B def, electrolyte abnormality, Sweating Shaking SOB
porphyria
Respiratory Asthma, COPD, hypoxia, pulmonary FREE FROM SYSMPTOMS BETWEEN ATTACK
embolism, pneumonia, B At least 1 attack has been followed by 1 month
pneumothorax of ≥ 1 of the following
Cardiovascular CHF, angina, arrhythmia, MI 1. Persistent concern/ worry about additional
panic attacks or their consequences
Treatment 2. A significant maladaptive change in
 First Line : SSRI and SNRI behaviour related to the attacks
C Not attribute to physiological effect of
substance/ medical condition
 D Not better explained by another mental disorder Selective Mustism
Panic Attack Panic Disorder  Failure to speak in specific situations ≥ 1 month
- A symptom and not a - A disorder  Young children
disorder -Unexpected, recurrent
- Episodic sudden intense panic attacks Shyness Selective Mutism
of anxiety - ≥ 1 panic attacks Slow warm up period Warm up time much
- Can be a part of any followed by > 1 month longer than expected
disorder (panic disorder, of continuous worry Can often respond with Can’t respond at all –
phobia, PTSD) about experiencing nod/ small smile may appear frozen
- Unexpected/ situational subsequent attacks Same demeanour Dual personality –
bound - Changes in behaviour everywhere – quiet & restrained at school and
(avoidance) reserved talkative at home
- not caused by direct
effect of substance/ Aetiology
other mental disorder/ - Genetic
medical condition - Sensory disorder (hard to process sensory information/
misinterpret social cues)
Separation Anxiety Disorder - Brain studies ( ↓ activity at amygdala)
 Stranger anxiety: start 6 months , peak 9 months - Speech problems
 Separation anxiety: start 1 year, peak 18 months - Influence of language
 Separation anxiety disorder: > 6 y/o, excessive &
DSM 5 Criteria
developmentally inappropriate, > 4 week
A Consistent failure to speak in specific social
Aetiology
situations in which there is expectation for
- Life stress/ loss that result in separation speaking (school) despite speaking in other
- Temperament (lack emotional deregulation (susah nk situation
move on), vigilance avoidance pattern) B Disturb education/ occupational achievement/
- Parental factor (overprotective, Overcontrolling, Overly social communication
critical parenting style) C ≥ 1 month (not limited to the 1st month of
- Family history (anxiety disorder) school)
- Environmental (disaster that cause separation) D Not d/t lack of knowledge/ comfort with/
- Economical factor (low socioeconomic status) spoken language required in the social situation
E Not better explained by communication
DSM 5 Criteria disorder/ during course of autism spectrum
disorder/ schizo/ another psychotic disorder
A Developmentally inappropriate and excessive
fear/ anxiety concerning separation from those
to whom the individual is attached, as
evidenced by > 3 of the following
1. Excessive distress when anticipating
separation from home/ major attachment
figures
2. Excessive worry about losing/ possible harm Negative
Child
Child & prompted
reinforcement
Child
Adult
Adult get
Child
to talk
anxiety
anxious
rescue
avoids ↓
to major attachment figures
3. Excessive worry about experiencing an
untoward events
4. Refusal to go out away from home (school,
work, elsewhere d/t separation)
5. Excessive fear/ reluctance being alone/
without major attachment figure
6. Refuse to sleep from home/ go to sleep
without being near a major attachment
figure
7. Repeated nightmares with separation theme Negative
Child
Positive prompted
reinforcement
Child to talk
Reinforcement
get anxious
Adult
Child give
answer
opportunity
and praised
to talk
8. Repeated complaint of physical symptoms
when seperated
B The illness is persistent ≥ 4 weeks (children and
adolescent) / ≥ 6 months in adult
C Significant functional impairment
D Not better explained by other illness/
substances
Specific Phobia
 Phobia def: irrational fear that lead to endurance of
the anxiety and/or avoidance of the feared situation. Agoraphobia
 Female > Male (most common psychiatric disorder  Intense fear of being in public places where escape/
in women, 2nd most common in men after substance obtaining help may be difficult
related)  Comorbid: Panic disorder, other anxiety disorder,
 Onset 10 y/o depressive disorder, substance use disorder
 Onset < 35 y/o
Animal Spiders, insects, dogs, snakes, mice  Prognosis: persistent & chronic, with rare full
Natural Heights, storms, water remission
environmen
t Aetiology
Situational Elevators, airplanes, enclosed space, - Genetic
buses - Psychosocial: follows a traumatic event
Blood- Needles, injections, blood, invasive
injection- medical procedures, injuries A Marked fear/ anxiety ≥ 2 of the following
injury 1. Using public transportation
2. Being in open spaces
3. Being in enclosed places
Aetiology 4. Standing in line/ being in crowd
- Environmental: traumatic encounter with the feared 5. Being outside of the home alone
situation B The individual fears/ avoids these situations
- Genetic (blood-injection-injury type) because of thoughts that escape might be
difficult or help might not be available in the
DSM 5 Criteria event of developing panic-like symptoms/ other
incapacitating/ embarrassing symptoms
A Marked anxiety about a specific object/ C Agoraphobic situation always provoke fear/
situation (children: crying, tantrum, freezing, anxiety
clinging) D Agoraphobic situation are actively avoided,
B The phobic object/situation always provoke require the presence of a companion
immediate anxiety/ fear E The anxiety is out of proportion to the actual
C The phobic object/ situation is actively avoided/ danger to the sociocultural context
endured with intense fear/ anxiety F The symptoms persistent ≥ 6 months
D The fear/anxiety is out proportion to the actual G Functional impairment
danger posed to the social cultural context H If another medical condition present, the fear,
E Persistent > 6 months anxiety, avoidance is clearly excessive
F Significant functional impairment I Not better explained by other things
G Not better explained by other things
(agoraphobia, OCD, PTSD, separation anxiety,
social anxiety) Generalized Anxiety Disorder
 Persistent, excessive anxiety about many aspects of
their daily lives (risau menda2 kecik and x de
Social Anxiety Disorder
spontaneous panic attack, in panic disorder x der
 Def: fear of scrutiny (critical observation) by others/
sebab untuk risau “out of blue”)
fear of acting in a humiliating or embarrassing way.
 Women > Men
 Domain:
 Onset: late adolescent and early adulthood
- Speaking in public
 Somatic symptoms: fatigue, muscle tension
- Eating in public
 Usually has treatment seeking behaviour (doctor
- Using public restroom
shopping)
 Female> Male
 Comorbid: Other anxiety, depressive disorder
Aetiology  Mnemonic (Worry WARTS ): Worried, Wound up
- Behavioural inhibition : parent with panic disorder/ (tense & nervous/ angry), Worn up, Absent minded
parents’ patients are less caring, more rejecting, more (forgetful), Restless, Tense, Sleepless
overprotective  Prognosis: Rates of full remission are low
- Genetic
- Neurochemical: ↑ adrenergic (use β blocker), ↓
dopamine

DSM 5 Criteria - similar to specific phobias except the

phobic stimulus is social scrutiny/ negative evaluation
DSM 5 Criteria

A Excessive anxiety and worry about various daily

events ≥ 6 months
B Difficult to control the worry
C Associated with ≥ 3 of the following
1. Restless
2. Easily fatigued
3. Difficulty concentrating / blank mind
4. Irritability
5. Muscle tension
6. Sleep disturbance (difficult falling/ staying
sleep. Restless, unsatisfied sleep)
D Functional impairment
E Not d/t substance/ medical condition
F Not better explained by other mental disorder

GAD Panic Disorder

-Continuous -Symptomless between
episodes (can have
anticipatory anxiety)
-Worry about daily event -Spontaneous and can’t
name the source of fear

 If patient with MDD and develop anxiety later,

diagnosis will be MDD with anxiety attack (not
disorder)