Anxiety

A diffuse, unpleasant feeling of vague fear or

apprehension accompanied by characteristic
physical sensations.
Emotion that is experienced in anticipation of
some future misfortune.
A state of apprehension, uncertainty or fear,
resulting from the anticipation of a realistic or
imaginary threatening/frightening/disturbing
event or situation.
May have emotional, behavioural, cognitive
and physical components.
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Symptoms of Anxiety
Somatic/Physical

Emotional

Cognitive

Behavioral

Goosebumps emerge
Muscles tense
Heart rate increases
Respiration accelerates
Respiration deepens
Peripheral blood vessels
dilate
Liver releases
carbohydrates
Bronchioles widen
Pupils dilate
Perspiration increases
Adrenaline is secreted
Stomach acid is inhibited
Salivation decreases

Sense of dread
Terror
Restlessness
Irritability

Anticipation of
harm
Exaggerating of
danger
Problems in
concentrating
Hypervigilance
Worried,
ruminative thinking
Fear of losing
control
Fear of dying
Sense of unreality

Escape
Avoidance
Aggression
Freezing
Decreased
appetitive
responding
Increased
aversive
responding

Anxiety = normal adaptive

function
Anxiety is a normal human emotion that
serves as an adaptive function
A protective function as a warning system and in
helping escape
Anxiety: response to cues of potential danger
Protection may be general or specific depending
on nature of threats
Responses = avoidance
aggression
freezing or
appeasement
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Anxiety vs. Fear

Picture yourself walking along on the sidewalk, enjoying nice, sunny weather.
You are about to cross a quiet street. You come to the corner, and step off
the curb into the street. Suddenly, a car comes rushing toward you!
Your heart races, your breathing rate increases, and with a surge of
adrenaline, you leap out of the way! It was a near miss.
After jumping out of the way to safety, you pause for a moment before
continuing your walk. You are shaking. Your palms are sweaty. Your knees
feel weak. Your heart is still pounding, and you are breathing heavily.
Eventually you resume your walk, and slowly your heart rate and breathing
return to normal, the shaking stops, and you feel like your normal self
again.
The next day, you are out for a walk again. You enjoy the beautiful day. As
you step out to cross the street, you suddenly experience a pounding
heart, trembling, and a great sense of fear! Your mouth is dry, your chest
aches, and you feel dizzy. But there is no car coming.

Anxiety vs. Fear

Anxiety is
a state of preparation for potential danger
characterized by
arousal
vigilance
physiologic preparedness
and, in humans, negative subjective states that are
qualitatively similar to those associated with fear.

triggered in the absence of an immediately threatening

stimulus

Fear is
an emotional response to a known or definite threat.

Fear causes anxiety, and anxiety can cause fear

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Fear/anxiety processing in the

brain
Threatening stimulus
Sensory thalamus
Sensory & association areas of cerebral cortex

Amygdala
primary role in the formation and storage of memories
associated with emotional events
alsoinvolved in mediating the effects of emotional
arousal on the strength of the memory for that event

Efferent projections to numerous effector

sites for cognitive, physiologic & behavioural
aspects of fear response
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Pathophysiology
Theories for biological mechanisms
focus on dysregulation of:
GABA-benzodiazepine receptor complex

endogenous inverse agonists (e.g DBI)

Norardrenergic systems
NA levels in the locus ceruleus = arousal &
anxiety
symptoms

Serotogenic systems
Suggestions that anxiety may represent a
state of 5HT excess

Anxiety disorders
Anxiety disorders are extremes of normal anxiety;
impair role functioning & QoL.
Occur when normal anxiety system becomes
dysregulated - excessive, inappropriate or deficient.
As a group, most common of psychiatric illnesses.
Affect 15% of ppl; more often females.
Less than 1/3 of pathological anxiety cases seek
treatment:
shame
absence of social support
limited finances
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lack of understanding of 10potential benefits of tmt

Classification
DSM-IV classifies 1o ADs as:
Generalised anxiety disorder (GAD)
Panic disorder
Phobic disorders
Obsessive compulsive disorder (OCD)
Post traumatic stress syndrome (PTSD)
**each class involves some form of pathological anxiety as
a prominent symptom.
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11

Generalised Anxiety Disorder

Unrealistic and excessive worry about life
circumstances for 6 months accompanied
by 3 specific anxiety-related symptoms:
Motor tension
Muscle tension, twitching and shaking, restlessness.

Apprehension
Feeling on edge,unable to cope, poor concentration, insomnia,
irritability, easy fatiguability

Autonomic over-activity
Light-headedness, sweating, tachycardia, dry mouth, epigastric
discomfort
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GAD

contd

Physical symptoms similar to panic disorder and

OCD.
However, relatively more constant course of
symptoms in GAD.
Most common AD; equal in both sexes.
Gradual onset; chronic course.
Onset usually in 20s.

Panic Disorder
Presence of 2 unexpected attacks of severe
anxiety characterised by 4 somatic symptoms
(develop abruptly and peak within 10mins)

Palpitations, chest pain, trembling, choking sensation,

dizziness, breathlessness, tingling in the hands and feet,
sweating, faintness, abdominal distress, fear of losing
control, fear of dying.

Panic disorder is diagnosed when multiple panic

attacks occur or when one or a few attacks are
followed by persistent fear ( 1 mnth) of having
another attack.
May occur with or w/out agoraphobia.
More common in females.
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Panic disorder

contd

3 charateristic types of panic attacks:

Unexpected/uncued
not assocd w situational trigger

Situationally bound
invariably occur on exposure to trigger
xteristic of phobia

Situationally pre-disposed
likely to, but do not invariably occur on
exposure to trigger

Kindling Model of Panic Disorder

Poor regulation in locus ceruleus

Panic Attacks
Lowers threshold for chronic anxiety in limbic system
Chronic anxiety increases likelihood
of dysregulation
in locus ceruleus
Panic Attacks

Phobic disorders
Anxiety evoked by specific circumstances or
situations.
Fear is out of proportion to the situation and is
beyond voluntary control.
intense fear of and avoidance of specific stimuli,
such as snakes, dogs, airplane travel, or exposure
to heights.

Occurs with or w/out panic disorder.

Avoidance is a characteristic feature.
Strong association with depression.
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Social phobia
Persistent fear of one or more social situations
involving possible exposure to scrutiny by others,
and associated fear of humiliation. e.g stage fright.
A social phobia may generalize, in which case it
may lead to avoidance of all social situations,
resulting in substantial social and occupational
disability.
The boundary between shyness and this type of
social phobia has not been well clarified.
Frequent symptoms = muscle twitching,
stammering, trembling.
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Agoraphobia
Fear of situations where an immediately available exit is
lacking
Include but not limited to:
Fear of open spaces, crowds or public places.
Fear of travelling by public transport
Fear that it may be difficult to get to a place of safety (e.g home)

Autonomic symptoms - faintness, palpitations, sweating

Panic attacks : marker of severity
Psychological symptoms - fear, dread
Behavioural symptoms - avoidance to the extent that the person
becomes house-bound
Cognitive
symptoms - I might19have died
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Obsessive Compulsive Disorder

(OCD)

Recurrent unwanted obsessions or compulsive acts

Obsession = recurrent and intrusive thought,
feeling, idea, image or impulse:
Usually distressing e.g., contamination,
obscenity, violence
Sometimes futile e.g., quasi-philosophical
Indecision between two alternatives
Attempts to resist/neutralize with other thoughts
or actions but this causes tension
Recognised as the persons own thoughts

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OCD

contd

Compulsions are stereotyped behaviours

repeated again and again

Cleaning, checking, tidying, counting,

Sometimes marked indecision or slowness
Not enjoyable or useful
May be thought of as protective in some way and can
reduce anxiety
Clearly excessive and unrealistic

Autonomic symptoms present

Close links with depression
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Post-traumatic stress disorder

(PTSD)

Delayed or protracted response to trauma ( often

involving threat to life)
Onset usually within 6 months of event
Core symptom is re-experiencing the event
Flashbacks, nightmares, waking dreams

Emotional numbness and detachment

Anhedonia, restricted affect

Avoidance of activities, situations that remind person of

trauma
Symptoms typically last 1 month
Acute stress disorder = new diagnostic category of PSTD
Duration 2 days 4 weeks

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PTSD contd
2 persistent symptoms of arousal
(absent b4 event):
Autonomic hyper arousal
Hypervigilance, increased startle,
insomnia
Mood disorder - anxiety or depression
Difficulty concentrating
Abuse of alcohol or drugs
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2o ADs (underlying medical

cause/substance-induced)
Electrolyte imbalances
Hypoglycaemia
Hyperthyroidism
Angina pectoris

*COPD
*Parkinsons disease
*cardiomyopathy
*Graves disease
Chronic illnesses shown to markedly
prevalence of
anxiety as compared to healthy controls