Anxiety

Dr Huang Bao Xian, Medical Officer

Mr Lim Wee Onn, Senior Clinical Psychologist
Mood Disorders Unit

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 Learning Objectives
Sessions Content
- Recognising symptoms
Session 1:
- Differentiating different types of Anxiety
Introduction of
Disorders
Anxiety
- Demographics of Anxiety Disorders in Singapore
Session 2: - Learn assessment and management principles
Assessment of - Assess & manage comorbid physical conditions
Anxiety - Emergency presentation of Anxiety
Session 3: - Psychosocial & pharmacological interventions
Management of - Management of anxiety symptoms
Anxiety - Community resources
Session 4: Follow-up - Monitoring symptoms at follow-up sessions
procedures - Monitoring pharmacological treatments
Session 5: Review &
- Revision of overall content
Quiz

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 Session 1:
Introduction of Anxiety

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 Activity 1
I have suffered from anxiety since I was little, but it only really started to show a few years ago.
I found myself cancelling plans with friends, family and colleagues. I would accept an invite and
then a couple of days before I would cancel and make something up. I started calling in sick to
work more often because I didn't feel well enough to go in because my anxiety was really bad.
I felt embarrassed to tell people the truth and I would also tell myself that it wasn't anxiety. I was
in denial. It kept getting worse and worse until I went on holiday and I had such a bad panic
attack I was hospitalised. This was a turning point for me to reach out, to admit to myself that I
have anxiety and get help.
My dad did not understand and always thought I was being "dramatic" or "over-exaggerating".
These words from people are what made me embarrassed. I was made to feel like it wasn't a big
deal but it was for me. It feels like people look at anxiety as a modern thing, something that’s
new and can’t be easily understood. Some people describe it as putting a label on ‘being
sensitive’, that ‘everything has a have a diagnosis these days’.
It’s not that simple. My mind makes me analyse everything about a situation and think the
worst, it makes me question all the good things and get overwhelmed by the bad. It’s so much
more than being sensitive, it’s reacting to any situation, big or small, and not knowing what the
rational thing to do is. It’s feeling overwhelmed by physical symptoms, a tightness in my chest,
gasping for air, my head beginning to hurt. Trying to calm myself until eventually it passes,
leaving me in a state of confusion and fatigue.
Anxiety can feel lonely and isolating at times. A lot of people say they are "fine" because of this.
Talking about how you are feeling can be intimidating and you can be made to feel awkward
and embarrassed.
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 Anxiety Disorders
• Social Anxiety Disorder (Social Phobia)
• Agoraphobia
• Specific Phobia
• Generalised Anxiety Disorder (GAD)
• Panic Disorder
Note: There are other Anxiety Disorders that are not included in this
list.

• Obsessive-Compulsive Disorder (OCD)

Note: This is not listed under Anxiety Disorders in DSM-5. It’s under
Obsessive-Compulsive and Related Disorders.

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 Core Features of
Anxiety Disorder

• Excessive fear, anxiety and related

behavioural disturbances
– Fear = emotional response to
real/perceived imminent treat
– Anxiety = anticipation of future threat
• Occurrence of panic/anxiety attacks as
fear response

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 Social Anxiety Disorder
(Social Phobia)
Based on DSM-5:
A.Marked fear or anxiety about one or more social situations in
which the individual 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 and not
just during 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., will be
humiliating or embarrassing: will lead to rejection or offend
others).
C. The social situations almost always provoke fear or anxiety.
Note: In children, the fear or anxiety may be expressed by crying,
tantrums, freezing, clinging, shrinking, or failing to speak in
social situations.
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 Social Anxiety Disorder
(Social Phobia) – cont.

D.The social situations are avoided or endured with intense

fear or anxiety.
E.The fear or anxiety is out of proportion to the actual threat
posed by the social situation and 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 impairment in social, occupational, or other
important areas of functioning.

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 Social Anxiety Disorder
(Social Phobia) – cont.
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.
I. The fear, anxiety, or avoidance is not better explained by
the symptoms of another mental disorder, such as panic
disorder, body dysmorphic disorder, or autism spectrum
disorder.
J. If another medical condition (e.g., Parkinson’s disease,
obesity, disfigurement from bums or injury) is present, the
fear, anxiety, or avoidance is clearly unrelated or is
excessive.

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 Agoraphobia
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, marketplaces,
bridges).
3. Being in enclosed places (e.g., shops, theatres, 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).
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 Agoraphobia (cont.)
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
for 6 months or more.
G. The fear, anxiety, or avoidance causes clinically significant
distress or impairment in social, occupational, or other
important areas of functioning.

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 Agoraphobia (cont.)
H. If another medical condition (e.g., inflammatory bowel disease,
Parkinson’s disease) is present, the fear, anxiety, or avoidance is
clearly excessive.
I. The fear, anxiety, or avoidance is not better explained by the
symptoms of another mental disorder—for example, the
symptoms are not confined to specific phobia, situational type;
do not involve only social situations (as in social anxiety
disorder): and are not related exclusively to obsessions (as in
obsessive-compulsive disorder), perceived defects or flaws in
physical appearance (as in body dysmorphic disorder),
reminders of traumatic events (as in posttraumatic stress
disorder), or fear of separation (as in separation anxiety
disorder).

Note: Agoraphobia is diagnosed irrespective of the presence of panic

disorder. If an individual’s presentation meets criteria for panic
disorder and agoraphobia, both diagnoses should be assigned.
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 Specific Phobia
Based on DSM-5:
A. Marked fear or anxiety about a specific object or situation
(e.g., flying, heights, animals, receiving an injection, seeing
blood).
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.
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.

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 Specific Phobia (cont.)

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):
objects or situations related to obsessions (as in obsessive-
compulsive disorder); reminders of traumatic events (as in
posttraumatic stress disorder); separation from home or
attachment figures (as in separation anxiety disorder); or
social situations (as in social anxiety disorder).

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 Generalised Anxiety Disorder
(GAD)

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.

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 GAD – cont.
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.
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)

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 GAD – cont.

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).

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 GAD – cont.
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).

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 Panic Disorder
Based on DSM-5:
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 heart, or accelerated heart rate

2. Sweating
3. Trembling or shaking
4. Sensations of shortness of breath or smothering
5. Feelings of choking
6. Chest pain or discomfort
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 Panic Disorder (cont.)
7. Nausea or abdominal distress
8. Feeling dizzy, unsteady, light-headed, or faint
9. Chills or heat sensations
10. Paraesthesia (numbness or tingling sensations)
11. Derealization (feelings of unreality) or depersonalization
(being detached from oneself)
12. Fear of losing control or “going crazy”
13. Fear of dying

Note: Culture-specific symptoms (e.g., tinnitus, neck soreness,

headache, uncontrollable screaming or crying) may be
seen. Such symptoms should not count as one of the four
required symptoms.

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 Panic Disorder (cont.)
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 behaviour related to
the attacks (e.g., behaviours 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).

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 Panic Disorder (cont.)

D. The disturbance is not better explained by another mental

disorder (e.g., the panic attacks do not occur only in
response to feared social situations, as in social anxiety
disorder: in response to circumscribed phobic objects or
situations, as in specific phobia: in response to obsessions,
as in obsessive-compulsive disorder: in response to
reminders of traumatic events, as in posttraumatic stress
disorder: or in response to separation from attachment
figures, as in separation anxiety disorder).

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 Obsessive-Compulsive Disorder
(OCD)
Based on DSM-5:
A. Presence of obsessions, compulsions, or both:
Obsessions are defined by (1) and (2):
1. Recurrent and persistent thoughts, urges, or images
that are experienced, at some time during the
disturbance, as intrusive and unwanted, and that in
most individuals cause marked anxiety or distress.
2. The individual attempts to ignore or suppress such
thoughts, urges, or images, or to neutralize them
with some other thought or action (i.e., by
performing a compulsion).

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 (OCD) – cont.
Compulsions are defined by (1) and (2):
1. Repetitive behaviours (e.g., hand washing, ordering,
checking) or mental acts (e.g., praying, counting,
repeating words silently) that the individual 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 anxiety or distress, or preventing some
dreaded event or situation; however, these behaviours
or mental acts are not connected in a realistic way
with what they are designed to neutralize or prevent,
or are clearly excessive.
Note: Young children may not be able to articulate the aims
of these behaviours or mental acts.
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 (OCD) – cont.

B. The obsessions or compulsions are time-consuming

(e.g., take more than 1 hour per day) or cause clinically
significant distress or impairment in social, occupational,
or other important areas of functioning.

C. The obsessive-compulsive symptoms are not

attributable to the physiological effects of a substance
(e.g., a drug of abuse, a medication) or another medical
condition.

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 (OCD) – cont.
D. The disturbance is not better explained by the symptoms of
another mental disorder (e.g., excessive worries, as in
generalized anxiety disorder; preoccupation with appearance,
as in body dysmorphic disorder; difficulty discarding or parting
with possessions, as in hoarding disorder; hair pulling, as in
trichotillomania [hair-pulling disorder]; skin picking, as in
excoriation [skin-picking] disorder; stereotypies, as in
stereotypic movement disorder; ritualized eating behaviour, as
in eating disorders; preoccupation with substances or gambling,
as in substance-related and addictive disorders; preoccupation
with having an illness, as in illness anxiety disorder; sexual urges
or fantasies, as in paraphilic disorders; impulses, as in disruptive,
impulse-control, and conduct disorders; guilty ruminations, as in
major depressive disorder; thought insertion or delusional
preoccupations, as in schizophrenia spectrum and other
psychotic disorders; or repetitive patterns of behaviour, as in
autism spectrum disorder).
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 Common Presentation of
Anxiety

• Panic attacks which tend to be misattributed

as “heart attack”

• Somatic symptoms such as stomachache,

muscle tension, tiredness, etc.

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 Contributing Factors

Biology
Genetic vulnerability,
neurohemistry,
immune/stress
response, physical
health

Psychological Social
Personality, SES, culture, family
temperament, coping circumstances,
skills, situational
attitude/beliefs, self- stressors, work,
esteem, perceptions school

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 Differential
diagnoses

Taken from: Kyrios et al. (2011), p.371

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 Anxiety Disorders

Anxiety
Disorders

Generalised
Panic disorder Specific Phobia Agoraphobia Social Phobia
Anxiety Disorder

Obsessive-
Compulsive
Disorder

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Anxiety in Public
Health

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 Anxiety in Public Health

• Prevalence of Anxiety Disorders

• Demographics
• Socioeconomics

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Prevalence of Anxiety

Taken from: M. Subramaniam et al., 2019. p.4

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 Demographics
(Lifetime Prevalence)

Taken from: M. Subramaniam et al., 2019. p.4

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 Demographics
(12-month Prevalence)

Taken from: M. Subramaniam et al., 2019. p.5

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SMHS 2010 VS. SMHS 2016
(Lifetime Prevalence)

Taken from: M. Subramaniam

et al., 2019. p.8

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SMHS 2010 VS. SMHS 2016 (12-
month Prevalence)

Taken from: M. Subramaniam

et al., 2019. p.8
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 Next Session
Sessions Content
- Recognising symptoms
Session 1:
- Differentiating different types of Anxiety
Introduction of
Disorders
Anxiety
- Demographics of Anxiety Disorders in Singapore
Session 2: - Learn assessment and management principles
Assessment of - Assess & manage comorbid physical conditions
Anxiety - Emergency presentation of Anxiety
Session 3: - Psychosocial & pharmacological interventions
Management of - Management of anxiety symptoms
Anxiety - Community resources
Session 4: Follow-up - Monitoring symptoms at follow-up sessions
procedures - Monitoring pharmacological treatments
Session 5: Review &
- Revision of overall content
Quiz

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 Session 2:
Assessment of Anxiety

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 Screening Tools

• K-10
• DASS-21
• Penn State Worry Questionnaire
(PSWQ)

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 K-10

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 DASS-21

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 PSWQ

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 Activity 2: Video Demo
Taken from:
University of Nottingham’s Youtube Channel -
Psychiatric Interviews for Teaching: Anxiety
https://www.youtube.com/watch?v=Ii2FHbtVJzc

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 Key Learning Points

• Assess the degree of distress

(DASS-21; K-10; PSWQ)
• To look out for ongoing stressors
• To screen for other psychiatric
conditions
• Emergency presentation of anxiety

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 Physical Impacts of Anxiety
Taken from: https://www.healthline.com/health/anxiety/effects-on-body

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 Physical Impacts of Anxiety (cont.)
Taken from: https://www.healthline.com/health/anxiety/effects-on-body

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 Physical Conditions
relating to Anxiety

Taken from: Kariuki-Nyuthe & Stein (2015), p.82

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 Next Session
Sessions Content
- Recognising symptoms
Session 1:
- Differentiating different types of Anxiety
Introduction of
Disorders
Anxiety
- Demographics of Anxiety Disorders in Singapore
Session 2: - Learn assessment and management principles
Assessment of - Assess & manage comorbid physical conditions
Anxiety - Emergency presentation of Anxiety
Session 3: - Psychosocial & pharmacological interventions
Management of - Management of anxiety symptoms
Anxiety - Community resources
Session 4: Follow-up - Monitoring symptoms at follow-up sessions
procedures - Monitoring pharmacological treatments
Session 5: Review &
- Revision of overall content
Quiz

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 Session 3:
Management of
Anxiety

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 Case Study
Dave is a 41-year-old male who was seen by his GP after
presenting to the ER with difficulty breathing. Dave’s physician was
unable to find a medical explanation for his symptoms, which left
Dave feeling confused, stressed, and angry. Over the last 6 months,
Dave has had several instances where he felt an intense fear that
would reach a peak within a few minutes. During these instances,
he would also experience sweating, heart palpitations, chest pain
and discomfort, and shortness of breath. At times, Dave worried
that might die. As a result, Dave has persistent worry about having
another attack. In addition, he has begun to avoid unfamiliar places
and people where it may be difficult to get help in the event of
another panic attack. The panic and associated avoidance are
significantly impacting Dave’s life as he has been turning down
social invitations, making excuses to stay at home whenever
possible, and relying on his wife to drive their children to their
various activities. Although she was understanding at first, Dave’s
wife has grown frustrated with what she perceives as his irrational
fear of panic attacks.
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 Case Study – cont.
• What were the presenting issues?
Dave is a 41-year-old male who was seen by his GP after presenting
to the ER with difficulty breathing. Dave’s physician was unable to find
a medical explanation for his symptoms, which left Dave feeling
confused, stressed, and angry. Over the last 6 months, Dave has had
several instances where he felt an intense fear that would reach a
peak within a few minutes. During these instances, he would also
experience sweating, heart palpitations, chest pain and discomfort,
and shortness of breath. At times, Dave worried that might die. As a
result, Dave has persistent worry about having another attack. In
addition, he has begun to avoid unfamiliar places and people where it
may be difficult to get help in the event of another panic attack. The
panic and associated avoidance are significantly impacting Dave’s life
as he has been turning down social invitations, making excuses to
stay at home whenever possible, and relying on his wife to drive their
children to their various activities. Although she was understanding at
first, Dave’s wife has grown frustrated with what she perceives as his
irrational fear of panic attacks.
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• Which Anxiety Disorder(s) does his
symptoms resemble of?

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 Interventions

• Psychoeducation
• Pharmacological interventions
• Social support
• Functioning in daily
activities/community
• Refer to external agencies for support
• Psychological interventions

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 Psychoeducation

• Psychoed about anxiety, i.e. symptoms,

causes, triggers and common experiences
• Clarify any misconceptions that patients
have about anxiety symptoms
• Lead patients to some treatment options
such as CBT, relaxation, exercise, etc.
• May increase patient’s willingness to
participate in treatment

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 Pharmacological Interventions
• Selective Serotonin Reuptake Inhibitors (SSRIs)
– Examples: Escitalopram (Lexapro), Fluoxetine (Prozac),
Fluvoxamine (Faverin), Paroxetine (Seroxat, Paxil), Sertraline
(Zoloft)
• Serotonin Noradrenaline reuptake inhibitors (SNRIs)
– Examples: Venlafaxine (Effexor), Duloxetine (Cymbalta)
• Noradrenergic Specific Serotonergic Antidepressant (NaSSA)
– Example: Mirtazapine (Remeron)
• Tricyclic Antidepressants
– Examples: Amitryptyline, Clomipramine, Dothiepin, Imipramine
• Benzodiazepines
– Examples: Lorazepam (Lorans), Diazepam (Valium), Alprazolam
(Xanax), Clonazepam (Rivotril)
• Anti-histamines with anxiolytic properties
– Example: Hydroxyzine
• Beta-blockers
– Example: Propranolol
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 Social Support &
Improve Functioning

• Exercise
• Regular sleep routine
• Relaxation exercises
• Journaling
• Regular catchups with friends
• Seek support

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 Available Resources

• Family Service Centre (FSCs)

• Tinkle Friend (for children aged 7-12) @
1800 2744 788
• CHAT (for younger population)
• CREST (for elderly population)
• Samaritans of Singapore (SOS) 24-hour hotline @
1800 221 4444 (to work with AIC for community
resources)
• TOUCHline 1800-377-2252
• Singapore Association for Mental Health (SAMH)
Helpline 1800-783-7019

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 Psychological Interventions

• Cognitive-Behavioural Therapy
– Psychoeducation about anxiety
– Training patients in relaxation; problem-solving techniques
– Help patients develop adaptive coping and interpersonal skills
– Relapse prevention strategies
• Graded exposure therapy
– Exposing patient to the feared stimuli in a graded fashion
until anxiety reduces
– Usually coupled with behavioural strategies to address
avoidance behaviour
– Cognitive strategies that challenge specific maladaptive
beliefs

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 When do we need to seek
specialist intervention?

• In its mild form, an anxiety will not affect

normal life
• However, when patient’s anxiety start to
affect their normal functioning and is
not able to resolve on its own  refer to
specialist services such as psychiatrists,
clinical psychologists, etc. for
management

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 Roleplay of
psychosocial interventions

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 Next Session
Sessions Content
- Recognising symptoms
Session 1:
- Differentiating different types of Anxiety
Introduction of
Disorders
Anxiety
- Demographics of Anxiety Disorders in Singapore
Session 2: - Learn assessment and management principles
Assessment of - Assess & manage comorbid physical conditions
Anxiety - Emergency presentation of Anxiety
Session 3: - Psychosocial & pharmacological interventions
Management of - Management of anxiety symptoms
Anxiety - Community resources
Session 4: Follow-up - Monitoring symptoms at follow-up sessions
procedures - Monitoring pharmacological treatments
Session 5: Review &
- Revision of overall content
Quiz

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 Session 4:
Follow-up procedures

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 Video Demo on follow-ups
Taken from:
mhGAP Training’s Youtube Channel - mhGAP OTH module -
assessment, management and follow-up
https://www.youtube.com/watch?v=t6EP24FTzn8

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 Summary of a
Follow Up Session

• To monitor effectiveness of
pharmacological treatment and
psychosocial intervention

• To discuss medications titration and

additional intervention if and when
required

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Thank You

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