Anxiety disorders

An overview
What should you know ?

 Criteria for the disorder (it will include clinical features)

 Etiology
 Epidemiology (if significant)
 Co morbidity
 Differential diagnosis
 Management – pharmacological and non-pharmacological
Introduction

 Normal worrying is essential for solving problems

 Pathological worrying results in distress and dysfunction

 The problematic worries involve areas like health, injury, illness

and finance.
Normal anxiety
 Anxiety—a diffuse, unpleasant, vague sense of apprehension to a
threat that’s internal and unknown

 Response to threatening situations

 Accompanied by physiological changes

 This is essentially to prepare the organism for defense or escape

(flight or fight reaction)

 Attention is focused on threatening situation

Abnormal anxiety
 Similar to normal anxiety except for

 Emotional response out of proportion to threat/no threat

 More prolonged

 Focus of attention is not on threat but on the physiological

response like palpitation, accompanied by the concern about the
cause of symptom
What are anxiety disorders?

 Group of disorders characterized by anxiety as the predominant

symptom. There is association of a substantial proportion of
these disorders with psychological causation. They lead to
intense distress and dysfunction as a result of pathological
worrying.
What disorders do you include under
this category?
 Panic disorder
 Agoraphobia
 Generalized anxiety disorder
 Specific phobias
 Social phobia
 Obsessive compulsive disorder
 Post traumatic stress disorder
Overview of Etiology
 Social Factors
 Stressful life events
 E.g. Threats to one’s security
 Early adverse experiences
 E.g. Inadequate parenting

 Psychological Factors
 Learning maladaptive responses
 Principles of classical conditioning, operant conditioning, and
observational
 learning
 Maladaptive cognitive processes
 Catastrophic misinterpretations
 Excessive attention to threat cues and
 rumination
 Perception of lack of control
ETIOLOGY contd.
 Biological Factors
 Genetics
 For each anxiety dr., concordance rates are higher in
MZ twins than DZ twins.

 Neuroanatomy
 Specific neural pathways/fear circuits, limbic
systemamygdala are involved in fear responses.

 Neurochemistry
 Serotonin, norepinephrine, dopamine, & GABA
systems are involved in panic responses.

Panic attack
Spontaneous onset of extreme anxiety with at least 4 of
thefollowing symptoms:

 Sweating
 Trembling
 Shortness of breath, rapid and shallow breathing choking, chest
pain, palpitation
 Nausea
 Fear of dying, fear of losing control, fear of going crazy
 Paraesthesia, chills
 Feelings of depersonalisation/derealisation
 What is a panic disorder (episodic
paroxysmal anxiety)
 Presence of recurrent and spontaneous panic attacks for 1 month

 Intense fear (of impending doom) that develops rapidly, reaches

a peak in about 10 min usually lasting for 10 – 20 min and subsides
then on

 Later the attacks may become conditional

What follows a panic attack ?
 Anticipatory anxiety about a future attack

 Avoidance/Safety behavior – Avoid situations precipitating the

attack or use safety measures to cope with the attack

 Worry about implications of attacks or its consequences

Panic Anticipatory
Attack Anxiety
Cognitive model of panic
EPIDEMIOLOGY
 Two to three times more common in women than men

 Lifetime prevalence 1.5-3.5%

 First degree relatives have three to four times greater chance

of developing this disorder

 Age of onset – Bimodal distribution (first peak at 15-24 yrs and

second peak at 45-54yrs)
ETIOLOGY
 False suffocation Carbon dioxide hypothesis (hypersensitive
suffocation alarm in the brain is prematurely activated by
increased PCo2)

 Increased adrenergic activity

 Fear network in the brain involved – amygdala, hypothalamus and

brainstem

 Genetic vulnerability upto 30-40%

COMORBIDITY
Panic disorder is associated with

 Increased risk of Suicide

 Depression

 Agoraphobia

 Other anxiety disorders

 Substance abuse
Differential diagnosis-Psychiatric
conditions
 Depression

 Generalized anxiety disorder

 PTSD

 Obsessive compulsive disorder

 Social phobia
Differential diagnosis-organic causes
 Substance withdrawal  Phaeochromocytoma
state- alcohol
amphetamines caffeine,
sedatives hypnotics  Anaemia

 Carcinoid syndrome  Cardiac arrhythmias

 Cushing’s disorder  Mitral valve prolapse

 Hyperthyroidism  Angina ,M I

 Hypoglycemia  Temporal lobe epilepsy

Management
 Chronic course with remissions and exacerbations

 50% recover with treatment

 Education: Information to explain the panic attacks as a warning

of non existent danger

 Self help methods/Writing down thoughts/carrying a card

 Relaxation exercises/Controlled breathing

CONTD>>>
 Interoceptive exposure

 Antidepressant Drugs
Imipramine, SSRIs, Benzodiazepines

 Cognitive therapy - to reduce focus on and misinterpretation

of bodily signals

 Support group to venture out and gradually reduce avoidance

behaviors
Hyperventilation syndrome
 50-60% of patients with panic disorder have symptoms of HVS

 Etiology is unknown (triggers are panicogenic agents such as

sodium lactate, caffeine, isoproterenol, , CO2)

 Symptoms include chest pain, tachypnoea, dizziness, weakness,

paraesthesias

 Treatment includes abdominal breathing, paper bag technique

Specific Phobia
 Irrational fear considered excessive and unreasonable resulting
in conscious avoidance of specific situation.

 7-11% prevalence; onset in adolescence

 Acrophobia (heights)
 Claustrophobia (closed spaces)
 Algophobia (pain)
 Thanatophobia (death)
 Xenophobia (strangers)
 Commoner in women (onset is late childhood)
ETIOLOGY
 Psychoanalytical theory
 Failure of repression

 Displacement of the fear onto an external object

 Symbolisation (the external object symbolises the feared

object)

 Behavioral theory - Learned avoidance

TREATMENT
 Drugs – Tricyclics, BZDs, MAO inhibitors

 Psychological – Systematic desensitization (Wolpe), Flooding,

Cognitive therapy, Graded exposure

 Runs chronic course, good prognosis with treatment

Graded exposure - example
 Clinicians begin by exposing a patient to less-anxiety provoking
stimuli (eg, if they are afraid of snakes, perhaps a picture of a
snake, or a small snake in a box on the other side of the room),
and gradually transition the patient to increasingly direct
exposure (eg, touching a larger snake).
Agoraphobia (fear of market place)
 Symptoms of incapacitating anxiety restricted to places or
situations where escape may be difficult or embarrassing,
leading to avoidance
Examples: crowds, public places, shops, traveling alone in train,
buses, underground etc.

 Lack of an immediately available exit is the key feature

 Not secondary to delusion or obsessive thoughts
Epidemiology
 M:F=1:3

 Bimodal distribution ,first being 13-35 years

 In later years, it develops secondary to physical fraility and

medical problems

 High comorbidity with panic disorder and other anxiety

disorders
Aetiology
 Genetic

 Ethological-Evolutionary perspective says it results from innate

adaptive fear to ward off threats

 Psychoanalytical- Repression of conflicts and transformation to

phobic symptoms

 Learning theory
Conditioning leading to avoidance

High correlation with separation anxiety in childhood.

Differential diagnosis
 Generalised anxiety disorder
 Social phobia
 Obsessive compulsive disorder
 Depression
 Post traumatic stress disorder
 Avoidance due to delusions in psychosis
Management
 Pharmacological
treatment of panic attacks

 Self help methods

Patients are encouraged to return to situations that are avoided
Use of distraction methods and relaxation exercises are taught

 Cognitive therapy for handling anxious cognitions

Social phobia
 Symptoms of incapacitating anxiety restricted to particular
social situations leading to a desire for escape or avoidance. Eg.
Eating in public, to be introduced to others, public speaking,
encounters with opposite sex

 Not secondary to delusion or obsessive thoughts

 May lead to educational ,social problems and difficulty in

maintaining social/sexual relationships

 Suicidal thoughts are common

Epidemiology
 Bimodal distribution with peak at 5 years and 11-15 years.
Equally common in both sexes.

 Patients seek consultation quite late

 Etiology – Genetic and environmental

 Increased Nor adrenergic activity and dopamine

 Comorbid conditions
Depression and alcoholism
Anticipatory
Anxiety Phobic
Anxiety

Social Stress
Signs and symptoms
 Excessive fear of humiliation/scrutiny , embarrassment or
others noticing how anxious they are when exposed to the
social situation.

 Direct eye to eye contact may be stressful

 Low self esteem and fear of criticism

 Somatic symptoms such as blushing, trembling, dry mouth,

perspiration

 Avoidance of situations
Differential diagnosis
 Panic disorder
 Generalized anxiety disorder
 Substance use
 Depression
 Post traumatic stress disorder
 Agoraphobia
 Avoidance due to delusions in psychosis
 Anxious avoidant personality disorder
Treatment
 Cognitive behavior therapy
This includes social skills training, relaxation exercises, graded
exposure

 Pharmacological
SSRIS, Monoamine oxidase inhibitors, addition of a
benzodiazepine, buspirone
Social Skills Training
 You might start the first week by just making eye contact and
uttering a simple hello to someone passing by. The second week,
initiate a simple conversation in a line at the grocery store. It
can be on the weather or any other event you feel comfortable
with.
Generalized anxiety disorder
 Anxiety disorder with chronic free-floating anxiety

 Excessive anxiety and worry occurring more days than not for
atleast 6 months about number of events or activities
Other features of GAD
 Easily fatigued
 Feeling keyed up or on edge
 Poor concentration
 Irritability
 Muscle tension
 Sleep disturbance
 Distress in important areas of functioning
Epidemiology of G A D
 Starts in teenage years

 60-80% report having been anxious all their lives

 Lifetime prevalence 3-4%

ETIOLOGY
 Genetic etiology

 Hyperactive Locus Ceruleus/Abnormalities in ANS

responsiveness

 Altered neurotransmitters – Decreased GABA, Increased

serotonin

 Focus on negative details in the environment – cognitive theory

 Childhood negative events (death of parent, rape etc)

Management
 Pharmacological
 Benzodiazepines
 Propranolol
 Antidepressants Venlafaxine , S S R I s, Buspirone

 Non pharmacological
Cognitive therapy
Obsessive compulsive disorder
 Persistent, intrusive ,Irrational, unwanted thoughts, images or
impulses

 Difficult to control

 Recognizes that the thoughts are his /her own and considers
them excessive and unreasonable

 Tries to resist them at the expense of mounting anxiety

 May develop behaviors to reduce the anxiety and distress

caused (compulsions)
Themes
 OBSESSIONS
 COMPULSIONS
 Dirt and contamination
 Washing and cleaning
 Checking
 Doubt
 Repetitive praying
 Sacrilege and blasphemy
 Arranging
 Orderliness
 Counting/Touching
 Aggression
 EPIDEMIOLOGY
 Mean age: 20 yrs. 70% onset before age 25 yrs, 15% after age
35 yrs.

 Sex distribution equal.

 Prevalence: 0.5-2%

 Comorbid condition – Depression (about 80%)

 Chronic course with waxing and waning pattern

ETIOLOGY
 Dysregulation of 5 HT system

 Involvement of basal ganglia (caudate)

 Genetic

 Psychoanalytic – Regression from oedipal to anal stage of

development (anxiety/guilt over her part in a murder –
compulsive hand washing to get rid of imagined blood)
Caudate nucleus

Orbital
frontal
cortex
Differential diagnosis

 Normal (but recurrent) thoughts, worries, or habits

 Depressive disorder
 Anankastic PD
 Schizophrenia
 Phobias
 Hypochondriasis
 Body dysmorphic disorder
 Trichotillomania
Management
 Psychological
Supportive psychotherapy
Psychoeducation about the illness

Behaviour therapy
1. Exposure-Response prevention useful in ritualistic
behavior
2. Thought stopping
3. Exposure techniques for obsessions.
4. Cognitive therapy.
Contd…
 Exposure response prevention: This behavioral treatment
breaks the link between anxiety and compulsive behavior. Induce
anxiety and prevent the compulsive behavior from occurring .

 Cognitive therapy – Habituation training is a form of exposure in

which you elicit anxiety provoking thoughts repeatedly to
diminish their power in the long run. Teach distraction
techniques to overcome compulsions.
Management
 Pharmacological -Antidepressants

SSRIs: fluoxetine, fluvoxamine, sertraline, or paroxetine

should be considered first-line

Clomipramine has specific anti-obsessional action (first-or

second-line choice).

Risperidone, haloperidol, pimozide if psychotic features, tics,

or schizotypal traits;

Psychosurgery is tried in intractable resistant OCD.

Case Vignette
 When I have to call people up to tell them that their order is in,"
"I know my voice is going to be weak and break, and I will be
unable to get my words out. I’ll stumble around and choke
up....then I’ll blurt out the rest of my message so fast I’m afraid
they won’t understand me. Sometimes I have to repeat myself
and that is excruciatingly embarrassing
Case Vignette
 Jim is a 31 year old successful salesman. He was referred by the
nurse practitioner in his MD office. He complains of muscle
tension, headaches, and difficulty sleeping. He worries about not
having enough money for his family in the event he dies suddenly
or is fired from his job. He worries about job stability and feels
he would be unable to get another job that paid as well. He has
elevated blood pressure, heart palpitations, and has missed
several work deadlines.
Case Vignette
 Mr. A who is good at instruments was asked to play the piano in a
recital. He became so nervous and anxious on seeing the crowd
gathered in front of him to the extent that his hand muscles
became tensed and he started making frequent mistakes in
fingering and sound production during the recital performance.
Case Vignette
 Ms A, 20 year old college girl was driving home after her work.
As she was curving around a corner she suddenly began to feel
that something dreadful is going to happen and she may die. She
could feel her heart beating rapidly and she became short of
breath. She pulled her car over to the side held the steering
wheel tightly to calm herself. The feelings increased in intensity
and then subsided.
Thank you