Anxiety Disorders

Lecturer Dr. Noor Ali Hasan

Al-kindy College of Medicine
Baghdad University
❖ Objectives
● To know types of Anxiety disorders
● To know the main manifestations
● To know the diagnostic criteria
● To know the differential diagnosis
● To know ho to treat
Anxiety disorders include:
1.Generalized Anxiety Disorder
2.Agoraphobia
3.Specific Phobia
4.Social Anxiety Disorder (Social Phobia)
5. Panic Disorder
Introduction

Fear is a response to external threat. Anxiety, a common human

emotion, is an affect; it is an internal state, focused very much
on anticipation of danger. It resembles fear but occurs in the
absence of an identifiable external threat, or it occurs in
response to an internal threatening stimulus. When anxiety
occurs in the absence of substantial stress or when it fails to
dissipate when the stressor abates, an anxiety disorder is likely.
Risk factors common to all anxiety disorders
✓Female
✓Younger age group
✓Single or divorced
✓Poor social support
✓Low socioeconomic status
✓Low education
Anxiety disorders share many features of their clinical
Clinical picture and etiology but are also differences:

✓ In generalized anxiety disorders, anxiety is continuous, although it may

fluctuate in intensity.
✓ In phobic anxiety disorders, anxiety is intermittent, arising in particular
circumstances.
✓ In panic disorder, anxiety is intermittent, but its occurrence is unrelated
to any particular circumstances.
Generalized anxiety disorder is defined as excessive anxiety
and worry about several events or activities for most days
during at least a 6-month period. The worry is difficult to
control and is associated with somatic symptoms, such as
muscle tension, irritability, difficulty sleeping, and
restlessness.
Epidemiology

● The disorder usually has its onset in late adolescence or

early adulthood
● The ratio of women to men with the disorder is about 2 to 1.
Etiology:
1. Genetic
About 25% of first-degree relatives of patients with
generalized anxiety disorder are also affected. Male relatives
are likely to have an alcohol use disorder. Some twin studies
report a concordance rate of 50% in monozygotic
twins and 15% in dizygotic twins.
2. Biological factors:

The regulation of the serotonergic system in generalized

anxiety disorder is abnormal. Other neurotransmitter systems
that have been the subject of research in generalized anxiety
disorder include the norepinephrine, glutamate.
3. Stressful life events:
Trauma (e.g. early parental death, rape, war) & dysfunctional
marital/family relationships.

4.Psychological vulnerability:
Trauma or insecure attachment to primary caregivers.
Parenting—overprotective.
Clinical Features
1. Excessive anxiety and worry about several events or
activities for most days during at least a 6-month period. The
worry is difficult to control.
2. Worries span multiple domains, such as home, family, and
work/school.
3. Is associated with physical symptoms.
4.The symptoms cause significant distress or impairment in
social and occupational functioning.
5.The disorder is not attributed to a medical condition or
substance abuse.
➢ Physical symptoms:
Muscle tension
Tremor, Headache (bilateral , & frontal or occipital),
Aching muscles (shoulders & Back), Inability to relax
Hyperventilation
Dizziness, Tingling in the extremities, Feeling of
breathlessness
Sleep disturbances
Insomnia, Night terror, Intermittent no refreshing sleep
Autonomic arousal

❖Gastrointestinal: Dry mouth, Difficulty in swallowing, Epigastric

discomfort
❖ Respiratory: Constriction in the chest, Difficulty inhaling.
❖ Cardiovascular: Palpitation, Discomfort in the chest
❖ Genitourinary: Frequency or urgent micturition, Menstrual
discomfort, Amenorrhea
Comorbidity
Generalized anxiety disorder is probably the disorder that
most often coexists with another mental disorder, usually
social phobia, specific phobia, panic disorder, depressive
disorder, substance use disorders (including nicotine and
alcohol).
Differential Diagnosis
➢Medical conditions associated with anxiety-like Symptoms:
1. CVS: arrhythmias, IHD, mitral valve disease, cardiac failure.
2. Respiratory: asthma, COPD.
3. Neurological: TLE.
4. Endocrine: hyperthyroidism, hypoglycaemia.

➢Substance induced: Drug Intoxications as amphetamine and

cocaine, drug withdrawal as alcohol and opiates.
➢Panic disorder
➢Phobias
➢Obsessive-compulsive disorder (OCD)
➢Posttraumatic stress disorder (PTSD).
Investigations

1. laboratory tests: FBC, glucose, U&Es, Ca2+, TFTs, LFTs,

urine drug screen.
2. ECG, CXR.
Treatment
The most effective treatment is combination of pharmacotherapy
and psychotherapy. Duration of treatment is 6- to 12-month
treatment.
Psychotherapy
❖ Relaxation training
If practiced regularly, relaxation appears to be able to reduce
anxiety in less severe cases. A critical element of this treatment is
the application of learned relaxation skills to anxiety-provoking
situations.
❖ Cognitive behaviour therapy
This treatment combines relaxation with cognitive procedures
designed to help patients to control worrying thoughts. Compared
with treatment as usual, cognitive behaviour therapy produces quite
substantial benefits in terms of symptom resolution, with relatively
few dropouts.
Pharmacotherapy
➢Benzodiazepines: The drugs of choice for generalized anxiety
disorder, but might cause dependence, prescribed for a limited
period, during which psychotherapy are implemented. The most
common clinical mistake with benzodiazepine treatment is
routinely to continue treatment indefinitely.
➢ Selective serotonin reuptake inhibitors(SSRIs) as Fluoxetine,
Citalopram, or Paroxetine. Begin treatment with SSRI plus a
benzodiazepine, then to taper benzodiazepine use after 2 to 3
weeks.
Pharmacotherapy
➢ Buspirone; 5-HT1A receptor partial agonist and is most likely
effective in patients with generalized anxiety disorder.
➢ Venlafaxine: effective in treating the insomnia, poor concentration,
restlessness, irritability, and excessive muscle tension
Panic disorder
An acute intense attack of anxiety accompanied by
feelings of impending doom.
The prevalence in women is about twice that in men.
Patients with panic disorder have increased rates of other
anxiety disorders, major depression, and alcohol misuse.
Aetiology
1. Genetics
Panic disorder is familial, with about a fivefold increase in
risk in first degree relatives. Numerous linkage and
candidate gene studies have been conducted in panic
disorder as the gene for catechol- O-methyltransferase.
2.Biological Factors: The major neurotransmitter systems
that have been implicated are those for norepinephrine,
serotonin, and GABA.
Serotonergic dysfunction, attenuation of local inhibitory
GABAergic transmission, sensitivity of presynaptic α2-
adrenergic receptors.
3. Psychosocial Factors
Patients with panic disorder have a higher incidence of
stressful life events (particularly loss) as a recent history of
divorce or separation.
Women with panic disorder have a history of childhood
sexual abuse.
Diagnostic criteria
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;
➢ Sweating
➢ Trembling or shaking
➢ Sensations of shortness of breath or smothering
➢ Feelings of choking
➢ Chest pain or discomfort
➢ Nausea or abdominal distress
➢ Feeling dizzy, unsteady, light-headed, or faint
➢ Chills or heat sensations
➢ Parasthesias (numbness or tingling sensations)
➢ Derealization (feelings of unreality) or depersonalization (being detached
from oneself)
➢ Fear of losing control or “going crazy.”
➢ Fear of dying.
Diagnostic criteria: MNEMONIC
STUDENTS FEAR the 3 C's
sweating
trembling
unsteadiness, dizziness
depersonalization, derealization
excessive heart rate,(palpitations)
nausea
tingling
shortness of breath
FEAR of dying, losing control, going crazy
3 C'S
CHEST PAIN
CHILLS
CHOKING
Differential Diagnosis
1.Medical Disorders
Hyperthyroidism
Pheochromocytomas.
Episodic hypoglycemia associated with insulinomas
Heart respiratory diseases including arrhythmias,
chronic obstructive pulmonary disease, and asthma.
2. Mental Disorders
Generalized anxiety disorder
Social phobia
Specific phobia
PTSD
OCD
The key to correctly diagnosing panic disorder and
differentiating the condition from other anxiety
disorders involves the documentation of recurrent
spontaneous panic attacks.
Treatment
A. Pharmacotherapy: Selective serotonin reuptake
inhibitors (SSRIs) and clomipramine (Anafranil) are
superior over the benzodiazepines and tricyclic drugs in
terms of effectiveness and tolerance of adverse effects.
Alprazolam and paroxetine are the two drugs approved
by the Food and Drug Administration (FDA) for the
treatment of panic disorder.
Treatment
B. Cognitive and Behavior Therapies
Controlled studies have shown that cognitive therapy is as
effective as antidepressant medication in the treatment of
panic disorder, the therapist goes on to question the
patient’s belief in the feared outcome.