Anxiety Disorders

Nagy Ghattas Henein

A s s . L e c t u r e r, N e u r o p s y c h i a t r y
 ANXIETY DISORDERS
Generalized Anxiety Disorders.

Panic disorders.

Agoraphobia.

Social phobia.

Specific phobia.

OCD.
 AETIOLOGY

Genetics
 GAD: 30%
 Panic disorder: 30%
 Agoraphobia relatives: ↑social phobia, other neurotic disorders,
alcoholism & depressive disorders.
 Social phobia: 50% MZ:DZ = 24%:15%
 Animal phobia MZ:DZ = 26%: 11%
 COGNITIVE THEORIES

GAD: selective attention to negative details, distortions in information processing

and negative views on coping.

Panic disorder: classical conditioning and negative catastrophic thoughts during

attacks.

Agoraphobia and specific phobias: conditioned fear responses lead to learned

avoidance
 PSYCHODYNAMIC THEORIES

GAD: symptoms of unresolved unconscious conflicts, early loss of parents, separation

in childhood, overprotective parenting, anxious parent or parenting lacking
warmth and responsiveness.

Panic disorder: arise from unsuccessful attempts to defend

against anxiety provoking impulses.

Agoraphobia and specific phobias: unconscious conflicts are repressed and may be
transformed by displacement in phobic symptoms.
 ORGANIC CAUSES

GAD: cardiac, thyroid, medication such as thyroxine.

Panic disorder: hypoglycaemia, thyrotoxicosis, phaeochromocytoma

OCD: cell-mediated autoimmune factors against basal ganglia are involved.

 INVESTIGATIONS

􀁸 Thyroid function test: thyrotoxicosis

􀁸 Blood glucose: hypoglycaemia

􀁸 ECG or cardiac echocardiogram: atrial fibrillation, arrhythmias, other cardiac problems

􀁸 Urine drug screen in cases of suspected stimulant use

􀁸 Lung function test in cases of suspected COPD

􀁸 24 hour urine catecholamine (to rule out phaeochromocytoma especially if there is

coexisting

hypertension and panic attacks)

Generalized Anxiety Disorder
DSM-5 Diagnostic Criteria
Individuals must have had experienced excessive anxiety and worries for most everyday
events for at least 6 months in duration.
These excessive worries are difficult to control, must have caused significant impairment
in functioning,
must be associated with at least 3 of the following symptoms:
 a. Restlessness
 b. Easily tired
 c. Attention and concentration difficulties
 d. Feeling irritable
 e. Muscle tension
 f. Sleep difficulties
 DIFFERENTIAL DIAGNOSES

1. Panic disorder, stress-related disorder, phobia, mixed anxiety and depression

2. Arrhythmia, ischaemic heart disease, mitral valve prolapse, congestive heart

failure

3. Asthma, COPD

4. Hyperthyroidism, hypoparathyroidism, hypoglycaemia, phaeochromocytoma,

anaemia

5. Medications: antihypertensives, antiarrhythmics, bronchodilators,

anticholinergics, anticonvulsants, thyroxine, NSAIDS
 MANAGEMENT
Psychotherapy
Cognitive Behaviour Therapy (CBT)
Duration: weekly/fortnightly sessions of 1-2 hours completed within 4- 6 months;

Pharmacotherapy
SSRIs (first-line)
SNRI
Panic Disorder and Agoraphobia
 DSM-5 Diagnostic Criteria
Sudden onset of intense fear that usually peaks within minutes during which the
following symptoms might occur:
Physical symptoms:
a. Palpitations
b. Sweating
c. Tremors
d. Difficulties breathing
e. Choking sensations
f. Chest pain or discomfort
g. Abdominal discomfort
h. Dizziness
i. Feeling hot or cold
Mental symptoms:
1. Derealisation
2. Depersonalization
3. Feelings of losing control and going crazy
4. Feelings of death
At least one of the attacks must be followed by at least 1 month of either:
a. Persistent concerns about having additional attacks, or
b. Marked changes in behaviour in relation to the attacks
 DIFFERENTIAL DIAGNOSES
hypoparathyroidism,
phaeochromocytoma,
chronic obstructive pulmonary disease, asthma.
mitral valve prolapse,
Diabetes mellitus, hypoglycaemia,
thyrotoxicosis and anaemia.
Agoraphobia
DSM-5 Diagnostic Criteria
There must have been significant anxiety and fear in at least 2 of the following
situations, during which, the individual has preoccupation of worries that escape
might be difficult or help might not be available when needed:
a. Being alone outside of home
b. Being in a crowd
c. Being in enclosed places
d. Being in open spaces
e. Using public transport modalities
These anxieties and worries must have affected an individual’s level of functioning for at
least 6 months in duration.
Agoraphobia can be diagnosed either in the presence or absence of panic disorder
 MANAGEMENT
Evidence supports the use of combined cognitive behavioral therapy (CBT) with
medication as superior to either therapy alone in the longer term maintenance
phase.
Medications;
 SSRIs: for 6 months
 Benzodiazepines: effective in providing rapid relief.

Psychotherapy: CBT is the psychotherapy of choice for panic disorder.

Possible treatment components for panic disorder with or without agoraphobia include
 psychoeducation,
 exposure to symptoms or situations,
 cognitive restructuring, breathing exercise and monitoring for panic attacks.
Social Phobia (Social Anxiety Disorder)
DSM-5 Diagnostic Criteria
 Individuals must have had significant anxiety about one or more social situations, for which
they worry about being evaluated negatively by others. Consequently, these social
situations are avoided.
 This must have existed for at least 6 months and there must be significant impairment in
terms of functioning.
 Subtype: performance-only (characterized as social anxiety disorder restricted only to
public performances)
 MANAGEMENT

Medications: selective serotonin reuptake inhibitor (SSRI)

antidepressants are effective for the treatment of social phobia,

Paroxetine has been the most extensively studied SSRI fo social

phobia.

Duration at least 6 months.

Psychotherapy: cognitive behaviour therapy (CBT) is recommended

as effective treatment for social anxiety disorder.

Exposure to feared situations is a crucial component. Group

approaches are useful and often include elements of social skills
training.
Specific Phobia
DSM-5 Diagnostic Criteria: There must be:
1. Significant anxiety about a particular object or situation
2. Encounters with the object or situation always cause marked anxiety
3. The specified object or situation is avoided
4. The anxieties and worries are excessively out of proportion in consideration of the
actual threat posed.
A time duration of at least 6 months is necessary to make a diagnosis of specific
phobia and there must be
significant impairments functioning.
Subtypes include:
a. Animal
b. Natural environment
c. Blood injection injury type
d. Others
 MANAGEMENT
Beta-blockers are effective for specific anxiety, especially for patients with prominent
sympathetic hyperarousal such as palpitations and tremors.

Propranolol 10-40 mg taken 45-60 minutes before performance is sufficient for most
patients.
Obsessive Compulsive Disorder
(OCD)
 EPIDEMIOLOGY

􀁸 Incidence: 0.55 per 1000 person-years

􀁸 Prevalence: 1%

􀁸 Gender ratio: F:M = 1.5:1

􀁸 Mean age of onset: ~20 years

o 70% before 25 years

o 15% after 35 years

Obsessions
Obsessions are persistent, intrusive thoughts, recognized to be the patient’s own, which
cause the patient significant distress.

These thoughts can be in the form of doubts, impulses, ruminations and thoughts, and are
not simply excessive worries about real-life problems.

The patient attempts to ignore or suppress these thoughts (egodystonic)

􀁸 Doubts: repetitive themes expressing uncertainty about previous actions e.g turning
off taps

􀁸 Impulses/Images: repetitive urges to carry out actions that are usually embarrassing
or undesirable e.g. mentally seeing disturbing images such as stabbing oneself

􀁸 Ruminations: repetitive worrying themes of more complex thought e.g. worrying

about the end of the world

􀁸 Thoughts: repetitive and intrusive words/phrases.

Compulsions
Compulsions are repetitive behaviors or mental acts usually associated with an
obsession.

they have the function of reducing distress caused by obsessions e.g. cleaning, checking
and counting.

Carrying out the compulsive act should not be pleasurable to the patient.
DSM-5 Diagnostic Criteria
There must be the presence of (a) obsessions and (b) compulsions that have caused much
impairment in terms of functioning.

Obsessions must fulfill the following criteria:

a. Repetitive thoughts, urges or images that are experienced recurrently, found to be

intrusive, and result in significant anxiety

b. Efforts made to try to suppress these thoughts, urges or images with other thoughts or
actions
Compulsions must fulfill the following criteria:

a. Repetitive behaviors or mental acts that the individual feels obliged to perform as a
response to the underlying obsessive thoughts

b. These repetitive behaviors or mental acts are being performed in order to reduce
the anxiety experienced, or to prevent some dreadful event from happening
It is important to distinguish the 3 subtypes of OCD;

with good or fair insight,

with poor insight

with absent insight or delusional beliefs.

OCD Spectrum Disorders
1. Body dysmorphic disorder
2. Hoarding disorder
3. Trichotillomania
Pharmacotherapy

First-line: 10-12 week trial of selective serotonin reuptake inhibitor (SSRI) at

adequate doses, Fluvoxamine, Fluoxetine , Sertraline.

Clomipramine (TCA), Used when:

􀁸 There is an adequate trial of at least one SSRI found to be ineffective

􀁸 SSRI is poorly tolerated

􀁸 There has been a previous good response to clomipramine

􀂃 ECG and blood pressure measurement necessary before prescribing

􀂃 Effective dose range: 150-300mg/day

Psychotherapy

o Behaviour therapy (exposure response-prevention therapy): treatment of choice for

limiting dysfunction resulting from obsessions and compulsions

o Cognitive therapy: anxiety management, keeping a diary, cognitive restructuring,

coping strategies
Psychotherapy

Cognitive Behavioral Therapy: anxiety management, keeping a diary, cognitive

restructuring, coping strategies.