ANXIETY DISORDERS

PSYCHOPHYSIOLOGY OF ANXIETY
Anxiety can be conceptualized as a normal and adaptive response to threat that
prepares the organism for flight or fight. Anxiety becomes abnormal when it is excessive or
its timing is inappropriate with regard to the threat.
Pathological anxiety results in strong subjective feelings accompanied by similar
physiological activation as normal anxiety, including muscle tension, shortness of breath,
hyperventilation, heart palpitation or heart pounding, increased perspiration or cold sweat,
and exaggerated scare. Some of these physiological changes, such as skin conductance
(sweat), muscle tension, can be recorded easily.

Anxiety Disorders:

PANIC DISORDER
Symptomatology
Recurrent panic attacks represent the hallmark feature of panic disorder. The panic
attack is defined as an episode of abrupt intense fear accompanied by at least four autonomic
or cognitive symptoms. Such episodes of abrupt fear occur in many situations.
Worldwide, the lifetime prevalence of panic disorder ranges between 1 and 3 percent.
Women are affected approximately twice as often as men. Panic disorder is most common in
young adulthood.
DSM-IV-TR Criteria for Panic Attack
Panic attack is a discrete period of intense fear or discomfort in which four (or more) of the
following symptoms develop abruptly and reach a peak within 10 minutes:
1. Palpitations, pounding heart, or accelerated heart rate
2. Sweating
3. Trembling or shaking
4. Sensations of shortness of breath or smothering
5. Feeling of choking
6. Chest pain or discomfort
7. Nausea or abdominal distress
8. Feeling faint

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10. Fear of losing control or going crazy
11. Fear of dying
12. Chills or hot flashes
In panic disorder, panic attacks occur spontaneously, arising without any trigger or
environmental cue. Panic disorder typically has its onset in late adolescence or early
adulthood.

ETIOLOGY: PANIC DISORDER

Studies have focused on the possible role of environmental as well as genetic factors,
and some have attempted to clarify the interaction between developmental, environmental,
and genetic influences. The many different studies conducted on panic disorder suggest that
familial contributions appear strong; however, the exact genetic mechanisms involved remain
vague.
Family Studies
Panic disorder has been the subject of several family studies, all of which have
revealed increased rates of panic disorder among the first-degree relatives of probands
compared with relatives of subjects with no mental illness.
The age-adjusted morbidity risk to first-degree relatives of probands with panic
disorder ranges from 7 to 20 percent, approximately two to four times higher than the risk to
relatives of unaffected control probands.
The risk for other disorders is also increased among the relatives of probands with
panic disorder, including phobias, alcoholism, and possibly major depression. Panic
disorder may also be increased among the relatives of probands with comorbid panic and
mood disorder.
Twin Studies
The results of several twin studies conducted over the years indicate that monozygotic twins
are at least two to three times more likely to be concordant for panic disorder than dizygotic
twins.
Biochemical abnormalities: infusion of sodium lactate, inhaling carbon dioxide, ingesting
caffeine.
Abnormalities in noradrenergic and serotonergic system
GABA, Amygdala, Limbic system
Behavioural: Classical conditioning.

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 PHOBIAS
Symptomatology
The term phobia refers to an excessive fear of a specific object, circumstance, or
situation. Phobias are classified based on the nature of the feared object or situation, and
DSM-IV-TR recognizes three distinct classes of phobia: agoraphobia, specific phobia, and
social phobia.

Both specific and social phobias also require the fear to either interfere with an
individual's functioning or cause marked distress. Finally, both conditions require that an
individual recognize the fear as excessive or irrational and that the feared object or situation
be either avoided or tolerated with great difficulty.

DSM-IV-TR Criteria for Specific Phobia and Social Phobia

Criteria for specific phobia (300.29)

A. Marked and persistent fear that is excessive or unreasonable cued by the presence or
anticipation of a specific object or situation (e.g., flying, heights, animals, receiving an
injection, seeing blood).
Note: In children, the anxiety may be expressed by crying, tantrums, freezing, or
clinging.
B. The person recognizes that the fear is excessive or unreasonable. Note: In children, this
feature may be absent.
C. The phobic situation(s) is avoided.
D. The avoidance, anxious anticipation, or distress in the feared situation(s) interferes
significantly with the person's normal routine, occupational (or academic) functioning, or
social activities or relationships, or there is marked distress about having the phobia.
E. In individuals under the age of 18 years, the duration is at least 6 months.
F. The anxiety, panic attacks, or phobic avoidance associated with the specific object or
situation are not better accounted for by another mental disorder, such as obsessive-
compulsive disorder (e.g., fear of dirt in someone with an obsession about contamination),
posttraumatic stress disorder (e.g., avoidance of stimuli associated with a severe stressor),
separation anxiety disorder (e.g., avoidance of school), social phobia (e.g., avoidance of
social situations because of fear of embarrassment), panic disorder with agoraphobia, or

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agoraphobia without history of panic disorder.
Specify type:
Animal type
Natural environment type (e.g. heights, storms, water)
Blood–injury type
Situational type (e.g., airplanes, elevators, enclosed places)
Other type (e.g., phobic avoidance of situations that may lead to choking, vomiting. or
contracting an illness; in children, avoidance of loud sounds or costumed characters)

Criteria for social phobia (300.23)

A. A marked or persistent fear of one or more social or performance situations in which the
person is exposed to unfamiliar people or to possible scrutiny by others. The individual fears
that he or she will act in a way (or show anxiety symptoms) that will be humiliating or
embarrassing.
Note: In children, there must be evidence of the capacity for age-appropriate social
relationships with familiar people, and the anxiety must occur in peer settings, not just in
interactions with adults.

Note: In children, the anxiety may be expressed by crying, tantrums, freezing, or shrinking
from social situations with unfamiliar people.
B. The person recognizes that the fear is excessive or unreasonable. Note: In children, this
feature may be absent.
C. The feared social or performance situations are avoided or are endured with intense
anxiety or duress.
D. The avoidance, anxious anticipation, or distress in the feared social or performance
situation(s) interferes significantly with the person's normal routine, occupational (academic)
functioning, or social activities or relationships, or there is marked distress about having the
phobia.
E. In individuals under age 18 years, the duration is at least 6 months.
F. The fear or avoidance is not due to the direct physiological effects of a substance (e.g., a
drug of abuse, a mediation) or a general medical condition and is not better accounted for by
another mental disorder (e.g., panic disorder with or without agoraphobia, separation anxiety
disorder, body dysmorphic disorder, a pervasive developmental disorder, or schizoid

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personality disorder).

Specific Phobia
Specific phobia is divided into four subtypes (animal type, natural environment type,
blood–injury type, and situational type). The key feature in each type of phobia is that the
fear is circumscribed to a specific object, both temporally and with respect to other objects.
An individual with specific phobia becomes immediately frightened when presented with a
feared object. This fear may relate to concern about harm from a feared object, concern about
embarrassment, or fear of consequences of exposure to the feared object. For example,
individuals with blood–injury phobia may be afraid of fainting when exposed to blood, and
individuals with fear of heights may be afraid of becoming dizzy at high elevations.
Specific phobia often involves fears of more than one object, particularly within a specific
subcategory of phobia. For example, it is common for an individual with a phobia of
thunderstorms to also have a phobia of water—both phobias are classified as natural
environment type phobias.

Social Phobia
Social phobia, or social anxiety disorder, involves fear of social situations, including
situations that involve scrutiny or contact with strangers. Individuals with social phobia
typically fear embarrassing themselves in social situations, such as at social gatherings,
during oral presentations, or when meeting new people. They may have specific fears about
performing certain activities, such as writing, eating, or speaking in front of others.

DSM-IV-TR provides a specifier for the diagnosis of social phobia. Individuals with
social phobia who fear most social situations are considered to have generalized social
phobia. Such individuals are fearful of initiating conversations in many settings, dating or
participating in most group activities or social gatherings, and speaking with authority
figures.
Like many anxiety disorders, social phobia frequently co-occurs with other mood and
anxiety disorders. Social phobia tends to have its onset in late childhood or early adolescence.
ETIOLOGY: PHOBIAS
Genetics:
Psychodynamic View
Phobia as learned behaviour
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 OBSESSIVE-COMPULSIVE DISORDER
Symptomatology
Obsessions and compulsions are the essential features of OCD.
DSM-IV-TR recognizes obsessions as “persistent ideas, thoughts, impulses, or images
that are experienced as intrusive and inappropriate,” causing distress. Obsessions provoke
anxiety, which accounts for the categorization of OCD as an anxiety disorder. Typical
obsessions associated with OCD include thoughts about contamination (“my hands are
dirty”) or doubts (“I forgot to turn off the stove”).

DSM-IV-TR Criteria for Obsessive-Compulsive Disorder (OCD)

A. Either obsessions or compulsions:
Obsessions are defined by
1. Recurrent and persistent thoughts, impulses, or images that are experienced at some time
during the disturbance as intrusive and inappropriate and that cause marked anxiety or
distress
2. The thoughts, impulses, or images are not simply excessive worries about real-life
problems
3. The person attempts to ignore or suppress such thoughts, impulses, or images, or to
neutralize them with some other thought or action
4. The person recognizes that the obsessional thoughts, impulses, or images are a product of
his or her own mind (not imposed from without as in thought insertion)
Compulsions are defined by
1. Repetitive behaviours (e.g., hand washing, ordering, checking) or mental acts (e.g.,
praying, counting, repeating words silently) that the person feels driven to perform in
response to an obsession, or according to rules that must be applied rigidly
2. The behaviours or mental acts are aimed at preventing or reducing distress or preventing
some dreaded event or situation; however, these behaviours or mental acts either are not
connected in a realistic way with what they are designed to neutralize or prevent or are
clearly excessive
B. At some point during the course of the disorder, the person has recognized that the
obsessions or compulsions are excessive or unreasonable. Note: This does not apply to
children.

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C. The obsessions or compulsions cause marked distress, are time consuming (take more than
1 hour a day), or significantly interfere with the person's normal routine, occupational (or
academic) functioning, or usual social activities or relationships.
D. 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.

Compulsions are defined as repetitive acts, behaviours, or thoughts that are designed
to counteract the anxiety associated with an obsession. The key characteristic of a compulsion
is that it reduces the anxiety associated with the obsession. Although many compulsions are
acts associated with specific obsessions, such as hand washing or checking, compulsions can
also manifest as thoughts. For example, a patient with the obsession that he or she has
committed a sin might relieve the anxiety from this obsession by repetitively saying a silent
prayer to him or herself.
Obsessions and compulsions must cause an individual marked distress, consume at
least 1 hour per day, or interfere with functioning to be considered above the diagnostic
threshold.

ETIOLOGY: OBSESSIVE-COMPULSIVE DISORDER (OCD)

Long considered a learned behaviour, OCD is now recognized as having an
important genetic basis. Twin studies show that most of the familiarity of OCD has a genetic
basis.

Family Studies
Relatives of probands with OCD consistently have a three- to fivefold higher
probability of having OCD or obsessive-compulsive features than families of control
probands.

Twin Studies
Data from twin studies of OCD suggest that OCD is heritable, with higher
concordance rates for monozygotic twins than for dizygotic twins. However, all twin studies
published to date suffer from significant methodological limitations.
Cognitive Biases and distortion: Supress negative thoughts, low confidence in memory
ability.

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Biological Causal Factors: Abnormalities in neurotransmitters
Abnormalities in brain functions: Abnormally active metabolic levels in the caudate
nucleus, the orbital frontal cortex, and cingulate cortex.
Psychosocial Factors: Classical conditioning, Positive reinforcement.

POSTTRAUMATIC STRESS DISORDERS (PTSD)

Symptomatology
PTSD is characterized by the onset of psychiatric symptoms immediately after
exposure to a traumatic event.
DSM-IV-TR Criteria for Posttraumatic Stress Disorder

Criteria for posttraumatic stress disorder (PTSD)

A. The person has been exposed to a traumatic event in which both of the following were
present:
1. The person experienced, witnessed, or was confronted with an event that involved actual or
threatened death or serious injury, or a threat to the physical integrity of self or others.
2. The person's response involved intense fear, helplessness, or shock.
Note: In children this may be expressed, in its place, by disorganized or agitated behaviour.
B. The traumatic event is persistently re-experienced in one (or more) of the following ways:
1. Recurrent and intrusive distressing recollections of the event, including images, thoughts,
or perceptions.
Note: In young children, repetitive play may occur in which themes or aspects of the trauma
are expressed.
2. Recurrent distressing dreams of the event.
Note: In children, there may be frightening dreams without recognizable content.
4. Intense psychological distress at exposure to internal or external cues that symbolize or
take after an aspect of the traumatic event.
5. Physiological reactivity on exposure to internal or external cues that symbolize or take
after an aspect of the traumatic event.
C. Persistent avoidance of stimuli associated with the trauma and numbing of general
responsiveness (not present before the trauma), as indicated by three (or more) of the

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following:
1. Efforts to avoid thoughts, feelings, or conversations associated with the trauma
2. Efforts to avoid activities, places, or people that arouse recollections of the trauma
3. Failure to recall an important aspect of the trauma
4. Markedly reduced interest or participation in significant activities
5. Feeling of detachment from others
6. Restricted range of affect (e.g., unable to have loving feelings)
7. Sense of a foreshortened future (e.g., does not expect to have a career, marriage, children,
or a normal life span)
D. Persistent symptoms of increased arousal (not present before the trauma), as indicated by
two (or more) of the following:
1. Difficulty falling or staying asleep
2. Irritability or outbursts of anger
3. Difficulty concentrating
4. Exaggerated shock response
E. Duration of the disturbance (symptoms in Criteria B, C, and D) is more than 1 month.
F. The disturbance causes clinically significant distress or impairment in social, occupational,
or other important areas of functioning.
Finally, the diagnosis of PTSD is only made when symptoms persist for at least 1
months.

ETIOLOGY: POST TRAUMATIC STRESS DISORDER

PTSD is a condition marked by the development of symptoms after exposure to
traumatic life events. The lifetime incidence of PTSD is estimated to be 9 to 15 percent.

Family and Twin Studies

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 GENERALIZED ANXIETY DISORDER
Symptomatology
Generalized anxiety disorder is characterized by a pattern of frequent, persistent
worry and anxiety that is out of proportion to the impact of the event or circumstance that is
the focus of the worry. For example, although college students often worry about
examinations, a student who persistently worries about failure despite consistently getting
outstanding grades shows a pattern of worry that is typical of generalized anxiety disorder.
Patients with generalized anxiety disorder may not acknowledge the excessive nature of their
worries, but they must be bothered by their degree of worry. Such symptoms include feelings
of restlessness, fatigue, muscle tension, and insomnia.
Finally, worry is a global feature of many anxiety disorders, as patients with panic
disorder often worry about panic attacks, patients with social phobia worry about social
encounters, and patients with OCD worry about their obsessions. The worries in generalized
anxiety disorder must exceed in range or scope the worries that characterize these other
anxiety disorders. Children with marked and persistent worry can also be diagnosed with
generalized anxiety disorder, but, unlike adults, they must only meet one of the six somatic or
cognitive symptom criteria.

DSM-IV-TR Criteria for Generalized Anxiety Disorder

A. Excessive anxiety and worry (apprehensive expectation) about a number of events or

activities (such as work or school performance) occurring more days than not for at least 6
months.
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
2. Being easily fatigued
3. Difficulty concentrating

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4. Irritability
5. Muscle tension
6. Sleep disturbance
D. The focus of the anxiety and worry is not confined to features of an Axis I disorder—e.g.,
the anxiety or worry is not about having a panic attack (as in panic disorder), being
embarrassed in public (as in social phobia), being contaminated (as in obsessive-compulsive
disorder), being away from home (as in separation anxiety disorder), gaining weight (as in
anorexia nervosa), having multiple physical complaints (as in somatization disorder), or
having a serious illness (as in hypochondriasis), and the anxiety or worry does not occur fully
during posttraumatic stress disorder.
E. The anxiety, worry, or physical symptoms cause clinically significant distress or
impairment in social, occupational, or other important areas of functioning.
F. 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., hypothyroidism) and does not
occur fully during a mood disorder, a psychotic disorder, or a pervasive developmental
disorder.
ETIOLOGY: GENERALIZED ANXIETY DISORDER
Generalized anxiety disorder is marked by the presence of diffuse, chronic, and
continuous fear or apprehension, with feelings of tension and restlessness.
Genetics
Family Studies
Several family studies have found an increased rate of generalized anxiety disorder
among the relatives of probands with generalized anxiety disorder.
Twin Studies
The large twin studies present a mixed picture for generalized anxiety disorder.
Whereas some studies suggest at least moderate heritability, others do not.
Unpredictable and uncontrolled events

Deficiency in GABA

Corticotrophin releasing hormones

Limbic system

Anxiety Disorders: Psychodynamic Aspects: Sigmund Freud: Psychological conflict

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 When Freud turned his attention to a study of clinical anxiety, he concluded that it
was a purely physiological phenomenon. Observing that anxiety was common in individuals
who practiced coitus interrupts, he concluded that anxiety was the result of a physiological
transformation of blocked, un-discharged libido.

Anxiety Disorders: Somatic Treatment

Anxiety disorders are among the most common psychiatric syndromes, affecting
approximately 25 percent of persons in the general population during their lifetimes.

SSRIs, the serotonin–norepinephrine reuptake inhibitors (SNRIs) (also known as dual

reuptake inhibitors), and several cyclic antidepressants (e.g., clomipramine [Anafranil]).
Medications: Benzodiazepines: Alprazolam, Clonazepam, Lorazepam
SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIS): Fluoxetine, Sertraline,
Paroxetine, Fluvoxamine, Citalopram, Escitalopram. These medications, as a group, have
been shown to help reduce or prevent various forms of anxiety, including panic anxiety,
obsessive-compulsive symptoms, generalized anxiety, posttraumatic stress symptoms, and
social anxiety.
Psychosocial Management:
Cognitive Behaviorual Therapy,
Cognitive Therapy
Exposure Therapy
Systematic Desensitization
Social Skills Training
Exposure and Response Prevention
Supportive counselling and relaxation

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