ANXIETY DISORDERS

Anxiety
 A diffuse, unpleasant, vague sense of
apprehension, usually accompanied by autonomic
Sx.
 Fear Vs Anxiety
 Both alerting signals and have similar autonomic Sx
 Fear is a response to a known, external, or definite threat
 Anxiety is a response to an unknown, vague or internal
threat
 Fear tends to be more sudden whereas anxiety is more
insidious
 Theories of Anxiety
 Freud: psychic conflict between unconscious
sexual or aggressive wishes and the superego
or external reality.
 Behavioral/Cognitive: a conditioned response
to environmental stimuli; due to social
learning; faulty thinking patterns.
 Biological:
 Genetic - higher frequency of anxiety disorders in 1st
degree relatives of affected people.
 Neurotransmitters – NE, Serotonin and GABA
 Neurobiology

• Amygdala – fear conditioning, sensitive to

external threat cues
• Hippocampus – may help in processing the
context of fear conditioning
• Insula – detection and interpretation of internal
bodily states, especially disgust, fear and pain
Amygdala: Anxiety Circuits
CSTC Loops
 Medical Conditions and Anxiety
 Will most likely present similar to panic disorder
 Some of the more common Med Dx are Hypoglycemia,
Hyperthyroidism, Hypothyroidism,
Hypoparathyroidism, B12 deficiency, and
pheochromocytoma
 Basic labs to check: Chem 10, TSH and Utox
 Remember to screen for drugs that may cause or
worsen anxiety:
 Stimulants (cocaine, meth , caffeine)
 LSD
 Ecstasy
 Withdrawal from etoh or benzos
 Epidemiology
 Greatest lifetime prevalence of any class of
psychiatric disorders (~18-30%)
 Specific phobia and social anxiety disorder are the
3rd and 4th most common psychiatric diagnoses
after Etoh abuse and Depression
 Tend to have a chronic course without treatment
 Cause significant impairment, patients tend to
achieve much lower SES
 High comorbiditdy (other anxiety disorders,
depression, substance use)
 Anxious children: 30% with depression
 Depressed children/adolescents: 41% with anxiety
 How do anxious children
present?
 Restless, fidgety  Fears, worries
 Reserved, suspicious  Phobias
 Shy  Panic attacks
 Little movement, rigid  Perceptual
posture abnormalities
 Inhibition of exploration  Somatic complaints
 Proximity to attachment  Sleep troubles
figure  School refusal
 Reluctance to speak  Avoidance
 Frequent trips to restroom  Rituals
 Hypervigilance
 The Disorders
Separation anxiety •Excessive anxiety concerning separation from loved one
disorder (SAD) •Possible risk factor for development of panic disorder or agoraphobia
in adulthood
Social anxiety •Persistent fear of social or evaluative situations
disorder •Behavioral inhibition may be a temperamental predictor of social
phobia in childhood or adulthood
Generalized anxiety •Excessive and uncontrollable worry about multiple issues
disorder (GAD) •At least one somatic complaint

Specific phobia •Extreme fear of a specific situation or object

•Five types of phobias: animal-type, natural-environment-type, blood-
injection-injury type, situational type, other type (clowns)
Panic disorder with or •Unexpected panic attacks accompanied by worry about future attacks
without agoraphobia •Agoraphobia is diagnosed if individual avoids places in which escape
would be difficult or embarrassing
•Panic attacks can be caused by medical conditions (hyperthyroidism,
cardiac abnormalities)

Selective Mutism •persistent failure to speak in specific settings (school) despite full use of
language at home or with family
OCD
• Obsessions are unwanted thoughts, images, or impulses
that are recognized as senseless or unnecessary, intrude into
consciousness involuntarily, and cause functional
impairment and distress.
• Compulsions are actions that are responses to a perceived
internal obligation to follow certain rituals or rules and
cause functional impairment and distress.

Acute Stress Disorder/PTSD

• ASD 2 days – 4 weeks, PTSD >4weeks
• ASD – Dissociative sxs, Re-experiencing, Avoidance,
Increased arousal
• PTSD - Re-experiencing, Avoidance, Increased arousal
 Treatment of Anxiety
 Medication
 SSRIs - First line
 Axiolytic properties take 2-4weeks
 Starting doses are lower than used for depression (~ ¼ -
½ of that used for depression)
 Titrate dose up slowly, pt with anxiety can be
hypersensitive to side effects leading to discontinuation
 Prozac more activating may be less tolerated
 No abuse potential
 Treatment of Anxiety
 Benzodiazepines (for adults)
 Rapid onset of action
 Can be used PRN
 Can be uses concurrently with SSRI until SSRI is
therapeutic (4-12wks) then slowly tapered off over a
4-10wk period.
 Do not abruptly discontinue, can have a withdrawal
syndrome of increased anxiety sx to sz
 Restrictions: no driving or operating dangerous
equipment
 Addictive and abuse potential
 Treatment of Anxiety
 Buspar – 5HT1a partial agonist

 Other anti-depressant – Effexor, MAOIs, TCA’s

 Gabapentin

 β-Blockers
 Treatment of Anxiety
Recommended Dosages for Antipanic Drugs
(Daily Unless Indicated Otherwise)
Starting(mg) Maintenance(mg)
SSRI
Paroxetine 5-10 20-60
Fluoxetine 2-5 20-60
Sertraline 12.5-25 50-200
Fluvoxamine 12.5 100-150
Citalopam 10 20-40
Tricyclic antidepressants
Clomipramine 5-12.5 50-125
Imipramine 10-25 150-500
Desipramine 10-25 150-200
Benzodiazepines
Alprazolam 0.25-0.5 tid 0.5-2 tid
Clonazepam 0.25-0.5 bid 0.5-2 bid
Diazepam 2-5 bid 5-30 bid
Lorazepam 0.25-0.5 bid 0.5-2 bid
MAOIs
Phenelzine 15 bid 15-45 bid
Tranylcypromine 10 bid 10-30 bid
Atypical antidepressants
Venlafaxine 6.25-25 50-150
 Treatment of Anxiety
 Therapy
 CBT/Behavior therapy
 A lot of data supporting it’s use
 Very effective – can be as effective as meds
 Best Tx is possibly a combination of meds and therapy
 Effective in producing log lasting remission

 Dynamic therapy
 Exploration of the psychic conflict