ANXIETY DISORDERS NCMH Lecture
What is anxiety?
- A feeling state consisting of physical, emotional
and behavioral responses to perceived threats
- dif fuse, unpleasant sense of apprehension
accompanied by physical symptoms such as
headache, sweating, palpitations, chest tightness,
stomach upset, restlessness
- normal and necessary part of everyday life
ANXIETY VS. FEAR
Anxiety
- response to a threat that is unknown, internal,
vague or conflictual
Fear
- response to a known, external, definite threat
Anxiety as a Disorder
When does anxiety become a disorder?
1) Greater intensity and/or duration than expected
given the circumstances
2) Leads to impairment or disability
3) Daily activities are disrupted by avoidance of
certain situations or objects to decrease anxiety
4) Includes clinically significant unexplained
physical symptoms, obsessions, compulsions, or
intrusive recollections of trauma
Anxiety = Likelihood x Harm ↑ over estimate
Ability to cope ↓ under estimate
Pathophysiology of Anxiety
- Caudate nucleus has been implicated in OCD
- MRI studies have found increased activity in the
amygdala in PTSD
- Abnormalities in parahippocampal gyrus in Panic
Disorder
- 3 major neurotransmitters involved:
norepinephrine, serotonin and GABA
Neurobiology of Anxiety
Neurotransmitters
- Norepinephrne (NE), serotonin, and Gamma-
aminobutyric acid (GABA)
- One experiment to study anxiety was the conflict
test in which the animal is simultaneously
presented with stimuli that are positive (e.g. food)
and negative (e.g. electric shock) conflict test, in
which the animal is simultaneously presented with
stimuli that are positive (e.g., food) and negative
(e.g., electric shock)
1
- Anxiolytic drugs (e.g., benzodiazepines) tend to
facilitate the adaptation of the animal to this
situation, but other drugs (e.g., amphetamines)
further disrupt the animal’s behavioral responses
Anxiety
- Patients try to alleviate the unpleasant feeling kf
anxiety by:
1) Avoiding the trigger
2) Developing a safety behavior (i.e. having someone
else accompany them)
3) Using a substance or medication
Anxiety Disorders in DSM-5
1. Separation Anxiety Disorder
2. Selective Mutism
3. Specific Phobia
4. Social Anxiety Disorder (Social Phobia)
5. Panic Disorder
6. Agoraphobia
7. Generalized Anxiety Disorder
8. Substance/Medication-Induced Anxiety Disorder
9. Anxiety Disorder due to Another Medical
Condition
10. Other specified Anxiety Disorder
11. Unspecified Anxiety Disorder
Epidemiology
- Lifetime prevalence for any anxiety disorder ranges
from 10%-29%
- 12 month prevalence 18%
- Common presentation in primary care
- 1:5 to 1:112 patients presenting to primary care
will have anxiety disorder
- Suicide rate 10x higher than general population
Initial Assessment of Patients with Anxiety
Four scenarios:
1) Anxiety disorder is primary and there is no
physical disorder present (any physical symptoms
present are due to the anxiety)
2) The anxiety is secondary to a physical illness (e.g.
hyperthyroidism)
3) The anxiety is secondary to a medication or
substance
4) Both an anxiety and physical disorder are present
but not causally related
Medical Conditions That Mimic or Worsen Anxiety
Symptoms
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ANXIETY DISORDERS NCMH Lecture 2

Key Features

Panic • Fear of losing control, dying or going

Disorder crazy
• Avoid situations in which attacks

may occur

Agoraphobia • Fear of situations from which escape

may be difficult or help unavailable
(crowds, bus, bridge etc.)

OCD • Intrusive, unwanted thoughts or

urges (obsessions) and/or repetitive
behaviours or mental acts
(compulsions)
• Fear of harm, uncertainty,
uncontrollable actions

Generalized • Anxiety regarding a number of

Anxiety everyday events
• Future and uncertainty difficult to

accept

Social •Fear of humiliation, embarrassment

Anxiety or scrutiny by others

PTSD • Re-experiencing of trauma through

flashbacks, dreams, recollections

Specific • Fear of a specific object, animal or

phobia situation

Substance Abuse and Anxiety

- substance abuse is often co-morbid with anxiety Separation Anxiety Disorder 309.21 (F93.0)
A. Developing inappropriate and excessive fear or
disorders as patients often try to self medicate to
anxiety concerning separation from those to
cope with anxiety
- 37% of patients with GAD and 20-40% of patients whom the individual is attached, as evidenced by
at least three of the following:
with Panic Disorder have alcohol abuse/
• Recurrent excessive distress when anticipating or
dependence
experiencing separation from home or from major
- Drug intoxication can mimic anxiety:
attachment figures.
- Amphetamines
•Persistent and excessive worry about losing major
- Caffeine
attachment figures or about possible harm to them, such
- Nicotine
as illness, injury, disasters or death.
- Cocaine
•Persistent and excessive worry about experiencing an
- Phencyclidine
untoward event (eg. Getting lost, being kidnapped, having
- Marijuana
an accident, becoming ill) that causes separation from a
- Hallucinogens
major attachment figure.
- Ecstasy
•Persistent reluctance or refusal to go out, be away from
- Excessive alcohol consumption
home, go to school, go to work, or elsewhere because of
- Drug withdrawal also associated with anxiety
fear of separation.
- Alcohol
•Persistent and excessive fear or reluctance about being
- Benzodiazepines
alone or without major attachment figures at home or In
- Opiate
other settings.
- Barbiturate
•Persistent reluctance or refusal to sleep away from home
- Anti-hypertensives
or to go to sleep without being near a major attachment
figure.
•Repeated nightmares involving the theme of separation.
•Repeated complaints of physical symptoms
(eg.headaches, stomach aches, nausea, vomiting) when
separation from major attachment figures occurs or is
anticipated.
B. The fear, anxiety, or avoidance is persistent,
lasting at least 4 weeks in children and adolescents
and typically 6 months or more in adults.
C. The disturbance causes clinically significant
distress or impair ment in social, academic,
occupational, or other important areas of
functioning.
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ANXIETY DISORDERS NCMH Lecture
D. The disturbance is not better explained by another
mental disorder, such as refusing to leave home
because of excessive resistance to change in autism
spectrum disorder; delusions or hallucinations
concerning separation in psychotic disorders; refusal
to go outside without a trusted companion in
agoraphobia; worries about ill health or other harm
befalling significant others in generalized anxiety
disorder; or concerns about having an illness in
illness anxiety disorder.
Selective Mutism 312.23 (F94.0)
A. Consistent failure to speak in specific social
situations (in which there is an expectation for
speaking, e.g., at school) despite speaking in other
situations.  C. The social situations almost always provoke fear
B. The disturbance interferes with educational or
occupational achievement or with social
communication.  crying, tantrums, freezing, clinging, shrinking, or failing to
C. The duration of the disturbance is at least 1
month (not limited to the first month of school).  D. The social situations are avoided or endured with
D. The failure to speak is not due to a lack of
knowledge of, or comfort with, the spoken language
required in the social situation.  actual threat posed by the social situation and to the
E. The disturbance is not better accounted for by
a Communication Disorder (e.g., Stuttering) and does
not occur exclusively during the course of a Pervasive
Developmental Disorder,  Schizophrenia, or other
Psychotic Disorder.
Specific Phobia
A. Marked fear or anxiety about a specific object or
situation
B. The phobic object or situation almost always
provokes immense immediate fear or anxiety
C. The phobic object or situation is actively avoided
or endured with intense fear or anxiety
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 impair ment in social,
occupational, or other important areas of functioning
G. The disturbance is not better explained by
symptoms of another mental disorder, including fear,
anxiety, and avoidance of situations associated with
panic-like symptoms or other incapacitating
symptoms (as in agoraphobia); objects or situations
related to obsessions (as in OCD); reminders of
traumatic events (as in PTSD); separation from home
or attachment figures (as in SepAnx); or social
situations (as in social anxiety d/o)
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Social Anxiety Disorder (Social Phobia) 300.23
(F40.10)
A. A marked fear or anxiety about one or more social
situations in which the person is exposed to possible
scrutiny by others.  Examples include social
interactions (e.g. having a conversation, meeting
unfamiliar people), being observed (e.g. eating or
drinking), and performing in front of others (e.g.
giving a speech)
Note: In children, the anxiety must occur in peer settings,
not just in interactions with adults. 
B. The individual fears that he or she will act in a
way (or show anxiety symptoms) that will be
negatively evaluated (i.e. humiliating or
embarrassing; will lead to rejection or offend others)
or anxiety
Note: In children, the fear or anxiety may be expressed by
speak in social situations
intense anxiety or fear. 
E. The fear or anxiety is out of proportion 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 impair ment in social,
occupational or other important areas of functioning
H. The fear, anxiety, or avoidance is not attributable
to the physiological effects of a substance (e.g., a
drug of abuse, a medication) or another medical
condition
Panic Disorder 300.01 (F41.0)
A. 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:
Note: the abrupt surge can occur from a calm state or an
anxious state
1. palpitations, pounding 8. feeling dizzy, unsteady,
heart, or accelerated heart light-headed or faint
rate
2. Sweating 9. chills or heat sensations
3. Trembling or shaking 10. parenthesis (numbness
or tingling sensations)
4. sensations of shortness 11. derealization (feelings of
of breath or smothering unreality) or
depersonalization (being
detached from oneself)
5. feeling of choking (also 12. fear of losing control or
known as air hunger) “going crazy”
6. chest pain or discomfort 13. fear of dying
7. nausea or abdominal
distress
Note: culture-specific symptoms (e.g. tinnitus, neck
soreness, headache, uncontrollable screaming or crying)
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ANXIETY DISORDERS NCMH Lecture
may be seen. Such symptoms should not count as one of
the four required symptoms.
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 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 (e.g., a drug of
abuse, a medication) or another medical condition
(e.g., hyperthyroidism, cardiopulmonary disorders)
D. The disturbance is not better explained by another
mental disorder
Panic Attack Specifier
Note: symptoms are presented for the purpose of
identifying a panic attack; however, panic attack is
not a mental disorder and cannot be coded. Panic
attacks can occur in the context of any anxiety
disorder as well as other mental disorders (e.g.,
depressive disorders, PTSD, substance use disorders)
and some medical conditions (e.g. cardiac,
respiratory, vestibular, gastrointestinal). When the
presence of a panic attack is identified, it should be
noted as a specifier (e.g., “PTSD with panic attacks”).
For panic disorder, the presence of panic attack is
contained within the criteria for the disorder and
panic attack is not used as a specifier
Agoraphobia 300.22 (F40.00)
A. Marked fear or anxiety about two (or more) of the
following five situations:
1. Using public transportation (e.g., automobiles, buses,
trains, ships, planes)
2. Being in open spaces (e.g., parking lots, market places,
bridges)
3. Being in enclosed spaces (e.g., shops, theaters, cinemas)
4. Standing in line or being in a crowd
5. Being outside of the home alone
B. The individual fears or avoids these situations
because of thoughts that escape might be difficult or
help might not be available in the event of developing
panic-like symptoms or other incapacitating or
embarrassing symptoms (e.g., fear of falling in the
elderly; fear of incontinence
C. The agoraphobic situations almost always provoke
fear or anxiety
D, The agoraphobic situations are actively avoided,
require the presence of a companion, or are endured
with intense fear or anxiety
E, The fear or anxiety is out of proportion to the
actual danger posed by the agoraphobic situations
and to the sociocultural context
F. The fear, anxiety or avoidance is persistent
typically lasting 6 months or more
G. The fear, anxiety or avoidance causes clinically
significant distress or impair ment 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
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Generalized Anxiety Disorder 300.02 (F41.1)
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 person 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 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 important areas of
functioning. 
E. The disturbance is not due to the direct
physiological effects of a  substance  (e.g., a drug of
abuse, a medication) or a general medical condition
(e.g., hyperthyroidism)
Substance/Medication-Induced Anxiety Disorder
292.8 (F19.18)
A . P r o m i n e n t a n x i e t y ,  P a n i c A t t a c k s ,
or  obsessions  or  compulsions  predominate in the
clinical picture. 
B. There is evidence from the history, physical
examination, or laboratory findings of either: 
(1) the symptoms in Criterion A developed during, or within
1 month of, Substance Intoxication or Withdrawal
(2) medication use is etiologically related to the disturbance 
C. The disturbance is not better accounted for by
an  Anxiety Disorder  that is not  substance  induced.
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 293.84 (F06.4)
A. Prominent anxiety, Panic Attacks, or obsessions or
compulsions predominate in the clinical picture.
B. There is evidence from the history, physical
examination, or laboratory findings that the
disturbance is the direct physiological consequence
of a general medical condition.
C. The disturbance is not better accounted for by
another mental disorder (e.g., Adjustment Disorder
With Anxiety in which the stressor is a serious
general medical condition).
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.
Other Specified Anxiety Disorder 300.09 (F41.8)
This is done by recording “other specified anxiety
disorder” followed by the specific reason (e.g.,
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ANXIETY DISORDERS NCMH Lecture 5

“generalized anxiety not occurring more days than

not”

Examples of presentations that can be specified

using “other specified” designation including the
following:
1. Limited symptom attack
2. Generalized anxiety not occurring more days than not
3. panic attack
4. Ataque de nervios (attack of nerves)

Unspecified Anxiety Disorder 300.00 (F41,9)

This category applies to presentations in which
symptoms characteristic of an anxiety disorder that
cause clinically significant distress or impairment in
social occupational, or other important areas of
functioning predominate but do not meet the full
criteria for any of the disorders in the anxiety
disorders diagnostic class

The unspecified anxiety disorder category is used in

situations in which the clinician chooses not to
specify the reason that the criteria are not met for a
specific anxiety disorder, and includes presentations
in which there is insufficient information to make a
more specific diagnosis (e.g., in emergency room
settings)
____________________________________________________

To understand fully a particular patient’s anxiety

from a psychodynamic view, it is often useful to
relate the anxiety to developmental issues. At the
earliest level, disintegration anxiety may be present.
This anxiety derives from the fear that the self will
fragment because others are not responding with
needed affirmation and validation. Persecutory
anxiety can be connected with the perception that psychoanalytic theories
the self is being invaded and annihilated by an
outside malevolent force. Another source of anxiety
involves a child who fears losing the love or approval
of a parent or loved object.

Behavioral Theories
The behavioral or learning theories of anxiety
postulate that anxiety is a conditioned response to a
specific environmental stimulus. In a model of classic
conditioning, a girl raised by an abusive father, for
example, may become anxious as soon as she sees
the abusive father. Through generalization, she may
come to distrust all men. In the social learning
model, a child may develop an anxiety response by
imitating the anxiety in the environment, such as in
anxious parents.

Existential Theories
Existential theories of anxiety provide models for
generalized anxiety, in which no specifically
identifiable stimulus exists for a chronically anxious
feeling. The central concept of existential theory is
that persons experience feelings of living in a
purposeless universe. Anxiety is their response to the
perceived void in existence and meaning. Such
existential concerns may have increased since the
development of nuclear weapons and bioterrorism.

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