Anxiety Disorder

Dr. Reda Roshdy

Professor of Psychiatry, Faculty of
Medicine, AL-Azhar University, Cairo, Egypt.
Objectives learning
1.Student will identify the Anxiety disorders .
2. Student will recognize family related anxiety.
3. Student will identify the diagnostic criteria of Specific
(Simple) phobia, social anxiety disorder, Generalized anxiety
disorders according DSM5.
4. Student will recognize the epidemiology, etiology, differential
diagnosis, treatment, and prognosis of Social anxiety disorder or
phobia, Specific phobia, and Generalized anxiety disorder
 Anxiety Disorders
Anxiety Disorders can be viewed as a family of related but distinct
mental disorders, which include
1. Separation Anxiety Disorder
2. Selective Mutism
3. Panic disorder,
4. Agoraphobia,
5. Social anxiety disorder or phobia,
6. Specific phobia,
7. Generalized anxiety disorder
8. Substance/Medication-induced anxiety disorder
9. Anxiety disorder due to another medical condition
Anxiety Disorders
• Anxiety Disorders Include disorders that share features of excessive fear and
anxiety and related behavioral disturbances. Obviously, these two states overlap,
but they also differ,
1. Fear is the emotional response to a known, external, definite, or non-
conflictual threat, more often associated with surges of autonomic arousal
necessary for fight or flight, thoughts of immediate danger, and escape
behaviors.
2. Anxiety is anticipation of future unknown, threat that is internal, vague, or
conflictual. and anxiety more often associated with muscle tension and vigilance
in preparation for future danger and cautious or avoidant behaviors.
3. Sometimes the level of fear or anxiety is reduced by pervasive avoidance
Anxiety Disorders
Normal anxiety
• Everyone experiences anxiety. It is characterized most commonly as a
diffuse, unpleasant, vague sense of apprehension, often accompanied
by autonomic symptoms such as headache, perspiration, palpitations,
tightness in the chest, mild stomach discomfort, and restlessness,
indicated by an inability to sit or stand still for long
Anxiety becomes pathological when:
• 1. Fear is greatly out-of-proportion to risk or severity of threat.
• 2. Response continues beyond existence of threat.
• 3. Social or occupational functioning is impaired
Anxiety Disorder
1. Separation Anxiety Disorder
• Separation anxiety disorder is diagnosed when
developmentally inappropriate and excessive anxiety emerges
related to separation from the major attachment figure
• The fear, anxiety, or avoidance is persistent, lasting at least 4
weeks in children and adolescents and typically 6 months or
more in adults.
Anxiety Disorder
2. Selective Mutism
• Selective mutism, believed to be related to social anxiety
disorder, although an independent disorder, is characterized in
a child by persistent lack of speaking in one or more specific
social situations, most typically, the school setting despite
speaking in other situations
Anxiety disorders Specific Phobia
3. Specific Phobia
Definition
• The term phobia refers to an excessive fear of a specific object, circumstance, or
situation.
• A specific phobia is a strong, persisting fear of an object or situation.
Epidemiology
• In the United States, the 12-month community prevalence estimate for specific
phobia is approximately 7%-9%.
• Prevalence rates in European countries are largely similar to those in the United
States (e.g., about 6%), but rates are generally lower in Asian, African, and Latin
American countries (2%-4%).
Anxiety disorders Specific Phobia
• The lifetime prevalence of specific phobia is about 10%
• Specific phobia is the most common mental disorder among
women and the second most common among men, second only
to substance-related disorders.
• The 6- month prevalence of specific phobia is about 5 to 10
per 100 persons.
Anxiety disorders Specific Phobia

• The rates of specific phobias in women were double those of

men , although the ratio is closer to 1 to 1 for the fear of blood,
injection, or injury type.
• The peak age of onset for the natural environment type and
the blood-injection-injury type is in the range of 5 to 9 years,
although onset also occurs at older ages.
• In contrast, the peak age of onset for the situational type
(except fear of heights) is higher, in the mid-20s, which is
closer to the age of onset for agoraphobia
Anxiety disorders Specific Phobia
Aetiology
1. Psychodynamic theories
Agoraphobia and specific phobias: unconscious conflicts are repressed
and may be transformed by displacement in phobic symptoms.

2. Cognitive theories
Agoraphobia and specific phobias: conditioned fear responses lead to
learned avoidance.
Anxiety disorders Specific Phobia
DSM-5 Diagnostic Criteria of Specific Phobia
A. Marked fear or anxiety about a specific object or situation (e.g.,
flying, heights, animals, receiving an injection, seeing blood).
Note: In children, the fear or anxiety may be expressed by crying,
tantrums, freezing, or clinging.
B. The phobic object or situation almost always provokes immediate
fear or anxiety.
C. The phobic object or situation is actively avoided or endured with
intense fear or anxiety.
Anxiety disorders Specific Phobia
• D. The fear or anxiety is out of proportion to the actual danger posed by the
specific object or situation and to the sociocultural context.
• E. The fear, anxiety, or avoidance is persistent, typically lasting for 6
months or more.
• F. The fear, anxiety, or avoidance causes clinically significant distress or
impairment in social, occupational, or other important areas of functioning.
• G. The disturbance is not better explained by the symptoms of another
mental disorder, including fear, anxiety, and avoidance of situations
associated with panic-like symptoms or other incapacitating symptoms (as in
agoraphobia ).
Anxiety disorders Specific Phobia
• Specify if:
• Code based on the phobic stimulus:
• Animal (e.g., spiders, insects, dogs).
• Natural environment (e.g., heights, storms, water).
• Blood-injection-injury (e.g., needles, invasive medical procedure
• Select specific fear of blood; fear of injections and transfusions; fear of
other medical care; or fear of injury.
• Situational (e.g., airplanes, elevators, enclosed places).
• Other (e.g., situations that may lead to choking or vomiting: in children,
e.g., loud sounds or costumed characters).
Anxiety disorders Specific Phobia
Differential Diagnosis
1. Substance-Induced Anxiety Disorder.
• Substances such as caffeine, amphetamines and cocaine can mimic phobic
symptoms.
• Alcohol or benzodiazepine withdrawal can also mimic phobic symptoms.
2.Panic Disorder, Obsessive-Compulsive Disorder, Social Phobia,
Hypochondriasis or Anorexia Nervosa.
• Many psychiatric disorders present with marked anxiety, and the diagnosis
of specific phobia should be made only if the anxiety is unrelated to
another disorder.
• , For example, phobias regarding eating or weight gain are not diagnosed
if they are secondary to an underlying eating disorder.
Anxiety disorders Specific Phobia
3. Anxiety Disorder Due to a General Medical Condition.
Hyperthyroidism and other medical conditions may produce
significant anxiety.
4. Mood and Psychotic Disorders.
Excessive worry and anxiety occurs in many mood and
psychotic disorders. If anxiety occurs only during the course of
the mood or psychotic disorder, then specific phobia should not
be diagnosed.
Anxiety disorders Specific Phobia
Treatment
1. The primary treatment is behavioral therapy. A
commonly used technique is systemic desensitization,
consisting of gradually increasing exposure to the feared
situation, combined with a relaxation technique such as deep
breathing.
2. Beta-blockers may also be useful prior to confronting the
specific feared situation.
Anxiety disorders Social Anxiety Disorder
(Social Phobia)
Definition
• Marked fear or anxiety about one or more social situations in which
the Individual is exposed to possible scrutiny(close examination) by
others.
• Or irrational fear of public situations (e.g., speaking in public, eating
inpublic, using public bathrooms[shy bladder]).
• The term social anxiety reflects the distinct differentiation of social
anxiety disorder from specific phobia, which is the intense and
persistent fear of an object or situation.
 Anxiety disorders Social Anxiety Disorder (Social
Phobia)
Epidemiology
• Lifetime prevalence is 13%.
• The 6-month prevalence is about 2 to 3 per 100 persons
• Sex. Equally common in men and women.
• Age. Onset usually occurs in adolescence, with a childhood history of
shyness.
• Social phobia is more frequent (up to tenfold) in first-degree relatives of
patients with generalized social phobia.
• Social phobia is often a lifelong problem, but the disorder may remit or
improve in adulthood.
Anxiety disorders Social Anxiety Disorder (Social
Phobia) Etiology
1. Biological
A. Neurochemical.
• The success of pharmacotherapies in treating social anxiety disorder
has generated two specific neurochemical hypotheses about two types of
social anxiety disorder.
• Specifically, the use of β-adrenergic receptor antagonists—for
example, propranolol (Inderal)—for performance phobias (e.g., public
speaking) has led to the development of an adrenergic theory for these
phobias.
Anxiety disorders Social Anxiety Disorder (Social Phobia)
Etiology
Aetiology
1) Biological factors
1. Neurochemical.
a. The success of pharmacotherapies in treating social anxiety disorder has
generated two specific neurochemical hypotheses about two types of social
anxiety disorder.
• Specifically, the use of β-adrenergic receptor antagonists—for example,
propranolol (Inderal)—for performance phobias (e.g., public speaking) has
led to the development of an adrenergic theory for these phobias.
• Patients with performance phobias may release more norepinephrine or
epinephrine, both centrally and peripherally, than dononphobic persons, or
such patients may be sensitive to a normal level of adrenergic stimulation.
Anxiety disorders Social Anxiety Disorder (Social
Phobia) Etiology
d. The success of selective serotonin reuptake inhibitors (SSRIs), serotonin
and noradrenaline reuptake inhibitors (SNRI) and monoamine oxidase
inhibitors (MAOIs) in treating social anxiety disorder suggests
• That dysregulation of the serotonin and dopamine neurotransmitter
system may also play a role, but studies that establish a causal
relationship for such dysregulation in the development of the condition
have not yet been reported.
2. Genetic
a. First-degree relatives of persons with social anxiety disorder are about
three times more likely to be affected with social anxiety disorder than are
first-degree relatives of those without mental disorders.
Anxiety disorders Social Anxiety Disorder (Social
Phobia) Etiology
b. Some preliminary data indicate that monozygotic twins are more
often concordant than are dizygotic twins.
3. Neuroimaging studies so far suggest different activation of specific
parts of the brain (the amygdalae, the insula and the dorsal anterior
cingulate – all structures that are involved in the regulation of anxiety)
when threatening stimuli are presented compared with healthy
volunteers.
Anxiety disorders Social Anxiety Disorder (Social
Phobia) Etiology
2) Psychosocial factors
1. Several studies have reported that some children possibly have a trait
characterized by a consistent pattern of behavioral inhibition. Underlying
traits that predispose individuals to social anxiety disorder include behavioral
inhibition and fear of negative evaluation.
2. Negative experiences. also may contribute to this disorder,
including: bullying family conflict sexual abuse emotional abuse
3. Environmental. childhood maltreatment and adversity are risk
factors for social anxiety disorder
Anxiety disorders Social Anxiety Disorder (Social Phobia)
Differential Diagnosis

1. Substance-Induced Anxiety Disorder. Substances such as

caffeine, amphetamines, cocaine, alcohol or benzodiazepines may cause a withdrawal
syndrome that can mimic symptoms of social phobia
2. Obsessive-Compulsive Disorder, Specific Phobia, Hypochondriasis, or Anorexia
Nervosa.
The diagnosis of social phobia should be made only if the anxiety is unrelated to another
disorder.
3. Anxiety Disorder Due to a General Medical Condition.
Hyperthyroidism (and other medical conditions) may produce significant anxiety, and
should be ruled out.
4. Mood and Psychotic Disorders. If anxiety occurs only during the course of the mood
or psychotic disorder, then social phobia should not be diagnosed
Anxiety disorders Social Anxiety Disorder (Social Phobia)

Treatment
1. SSRIs, such as paroxetine (Paxil) 20-40 mg/day or sertraline (Zoloft) 50-
100 mg/day, are first-line medications for social phobia.
2. SNRI, such as Venlafaxine (Effexor XR75-225mg/day) may also be used.
3. Benzodiazepines, such as clonazepam (Klonopin) 0.5-2 mg per day, may
be used if antidepressants are ineffective.
4. Social phobia with performance anxiety responds well to beta-blockers,
such as propranolol. The effective dosage can be very low, such as 10-20 mg
qid. It may also be used on a prn basis; 20-40 mg given 30-60 minutes prior
to the anxiety provoking event.
Anxiety disorders Social Anxiety Disorder (Social Phobia)

4. Social phobia with performance anxiety responds well to beta-blockers,

such as propranolol. The effective dosage can be very low, such as 10-20
mg qid. It may also be used on a prn basis; 20-40 mg given 30-60 minutes
prior to the anxiety provoking event
3. Cognitive/behavioral therapies are effective and should focus on
cognitive retraining, desensitization, and relaxation techniques.
4. Combined pharmacotherapy and cognitive or behavioral therapies is the
most effective treatment.
irrational fear of a specific object, situation or activity, often leading to persistent avoidance of the feared object, situation or activity.

Agoraphobia Social phobia Specific (Simple)

phobia.
• irrational fear of • irrational fear of • Irrational fear of a
situations performing activities in specified object or
• Most common the presence of other situation. Leads to
Open spaces, people or interacting persistent avoidant
public places, with others. Behaviour
Crowded places, Eg. Fear of Eg. Fear of
Any place from which Blushing Acrophobia (high
there is no easy escape (erythrophobia), Public places),
speaking/ performance Zoophobia (animals),
Speaking to strangers Xenophobia (strangers)
Claustrophobia (closed
places)
 Generalized Anxiety Disorder

7. Generalized Anxiety Disorder

Definition. Generalized anxiety disorder (GAD) is the most common of the anxiety
disorders. It is characterized by unrealistic or excessive anxiety and worry about two
or more life circumstances for at least six months.

Epidemiology
1. 1-year prevalence range from 3 to 8%.
2. A lifetime prevalence is close to 5% with the Epidemiological Catchment Area
(ECA) study suggesting a lifetime prevalence as high as 8%
3. In anxiety disorder clinics, about 25% of patients have generalized anxiety
disorder.
Generalized Anxiety Disorder
4. Age. The disorder usually has its onset in late adolescence or early
adulthood, although cases are commonly seen in older adults.
5. Gender. Women more come than men with ratio 2:1, but the ratio of
women to men who are receiving inpatient treatment for the disorder is
about 1 to 1.
6. Prevalence of generalized anxiety disorder is particularly high in
primary care settings
7. Stressful or traumatic life events are important precipitant for GAD
and it may lead to alcohol misuse.
Generalized Anxiety Disorder
Aetiology
1) Biological factors
A. Neurochemical
1. Noradrenaline (NA)
• downregulation of α2 receptors and increase in autonomic arousal;
• Electrical stimulation of locus ceruleus releases noradrenaline and
generates anxiety.
2. Serotonin (5-HT). Dysregulation of 5-HT system.
3. GABA. Decrease in GABA activity.
Generalized Anxiety Disorder
B. Genetic. Heritability in germanized anxiety disorder is 30%.
C. Endocrine causes. 30% of patients have reduced suppression to
dexamethasone suppression test.
D. Organic causes. Cardiac, thyroid, medication such as thyroxine.
2) Psychosocial Factors
1. Psychodynamic theories. Symptoms of unresolved unconscious
conflicts, early loss of parents, separation in childhood, overprotective
parenting, anxious parent or parenting lacking warmth and
responsiveness
Generalized Anxiety Disorder
2. Cognitive-behavioral theories.
a. Patients with generalized anxiety disorder respond to
incorrectly and inaccurately perceived dangers.
b. The inaccuracy is generated by selective attention to
negative details in the environment, by distortions in
information processing, and by an overly negative view of the
person’s own ability to cope
Generalized Anxiety Disorder
DSM-5 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
present for more days than not for the past 6 months);
Note: Only one item is required in children.
Generalized Anxiety Disorder
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).
Generalized Anxiety Disorder
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 the physiological effects of a
substance (e.g., a drug of abuse, a medication) or another medical
condition (e.g., hyperthyroidism).
Generalized Anxiety Disorder
F. The disturbance is not better explained by another mental
disorder
(e.g., anxiety or worry about having panic attacks in panic disorder,
negative evaluation in social anxiety disorder [social phobia],
contamination or other 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).
Generalized Anxiety Disorder
Differential Diagnosis
1. Substance-Induced Anxiety Disorder.
• Substances such as caffeine, amphetamines, or cocaine can cause anxiety
symptoms.
• Alcohol or benzodiazepine withdrawal can mimic symptoms of GAD.
• These disorders should be excluded by history and toxicology screen.
2. Panic Disorder, Obsessive-Compulsive Disorder, Social Phobia,
Hypochondriasis and Anorexia Nervosa
• Many psychiatric disorders present with marked anxiety, and the diagnosis of
GAD should be made only if the anxiety is unrelated to the other disorders.
• For example, GAD should not be diagnosed in panic disorder if the patient has
excessive anxiety about having a panic attack, or if an anorexic patient has anxiety
about weight gain.
Generalized Anxiety Disorder
3. Anxiety Disorder Due to a General Medical Condition.
• Hyperthyroidism, cardiac arrhythmias, pulmonary embolism,
congestive heart failure, and hypoglycemia, may produce significant
anxiety and should be ruled out as clinically indicated.
4. Mood and Psychotic Disorders
• Excessive worry and anxiety occurs in many mood and psychotic
disorders.
• If anxiety occurs only during the course of the mood or psychotic
disorder, then GAD cannot be diagnosed.
Generalized Anxiety Disorder
Course and prognosis
1. Because of the high incidence of comorbid mental disorders in patients
with generalized anxiety disorder, the clinical course and prognosis of the
disorder are difficult to predict.
2. 70% of patients have mild or no impairment and 9% have severe
impairment.
3. Poor prognostic factors include severe anxiety symptoms, frequent
syncope, and derealization and suicide attempts
4. Generalized anxiety disorder is a chronic condition that may well be
lifelong
Generalized Anxiety Disorder
Treatment
1. The combination of pharmacologic therapy and psychotherapy is the
most successful form of treatment.
2. Pharmacotherapy
• Antidepressants can be considered as first-line agents over
benzodiazepines in the treatment of generalized anxiety disorder over
the long term.
• 3. Hydroxyzine 50 mg/day has shown efficacy for treatment of
generalized anxiety disorder.
Generalized Anxiety Disorder
• For GAD not responding to at least two types of intervention, consider
venlafaxine. Before prescribing, the psychiatrist should consider the
presence of pre-existing hypertension.
3 Non-Drug Approaches to Anxiety
• Patients should stop drinking coffee and other caffeinated beverages,
and avoid excessive alcohol consumption.
• Patients should get adequate sleep, with the use of medication if
necessary.
• Moderate exercise each day may help reduce the intensity of anxiety
symptoms
Generalized Anxiety Disorder
3. Psychotherapy
A. Cognitive behavioral therapy
• CBT in generalized anxiety disorder delivered by an experienced therapist
shows good evidence of efficacy. Two-thirds of patients show clinically
significant improvement at 6 months follow-up.
• Cognitive behavioral therapy, with emphasis on relaxation techniques and
instruction on misinterpretation of physiologic symptoms, may improve
functioning in mild cases.
B. Supportive or insight oriented psychotherapy can be helpful in mild cases
of anxiety.
Substance/Medication-Induced Anxiety Disorder

8. Substance/Medication-Induced Anxiety Disorder

• Substance-induced disorder is the direct result of a toxic substance,
including drugs of abuse, medication, poison, and alcohol, among others.
DSM-5 Diagnostic Criteria
A. Panic attacks or anxiety is predominant in the clinical picture.
B. There is evidence from the history, physical examination, or laboratory
findings of both (1)and (2):
1. The symptoms in Criterion A developed during or soon after substance
intoxication or withdrawal or after exposure to a medication.
2. The involved substance/medication is capable of producing the symptoms
in Criterion A.
Substance/Medication-Induced Anxiety Disorder

C. The disturbance is not better explained by an anxiety disorder that is not

substance/ medication-induced. Such evidence of an independent anxiety
disorder could include the following: The symptoms precede the onset of the
substance/medication use; the symptoms persist for a substantial period of
time (e.g., about 1 month) after the cessation of acute withdrawal or severe
intoxication: or there is other evidence suggesting the existence of an
independent non-substance/medication-induced anxiety disorder (e.g., a
history of recurrent non-substance/medication-related episodes).
D. The disturbance does not occur exclusively during the course of a
delirium.
E. The disturbance causes clinically significant distress or impairment in
social, occupational, or other important areas of functioning.
Anxiety Disorder Due to Another Medical Condition

9. Anxiety Disorder Due to Another Medical Condition

1. Many medical disorders are associated with anxiety. Symptoms can include
panic attacks, generalized anxiety, and other signs of distress.
2. In all cases, the signs and symptoms will be due to the direct physiological
effects of the medical condition.
• Etiology
1. A wide range of medical conditions can cause symptoms similar to those of
anxiety disorders.
• 2. Hyperthyroidism, hypothyroidism, hypoparathyroidism, and vitamin B12
deficiency are frequently associated with anxiety symptoms.
9. Anxiety Disorder Due to Another Medical Condition

3. A pheochromocytoma produces epinephrine, which can

cause paroxysmal episodes of anxiety symptoms.
4. Other medical conditions, such as cardiac arrhythmia, can
produce physiological symptoms of panic disorder.
5. Hypoglycemia can also mimic the symptoms of an anxiety
disorder.
9. Anxiety Disorder Due to Another Medical Condition

DSM-5 Diagnostic Criteria

A. Panic attacks or anxiety is predominant in the clinical picture.
B. There is evidence from the history, physical examination, or laboratory
findings that the disturbance is the direct pathophysiological consequence of
another medical condition.
C. The disturbance is not better explained by another mental disorder.
D. The disturbance does not occur exclusively during the course of a
delirium.
E. The disturbance causes clinically significant distress or impairment in
social, occupational, or other important areas of functioning.
 Thank you

Dr. Reda Roshdi , Professor of Psychiatry, Faculty of Medicine,

AL-Azhar University, Cairo, Egypt.