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Anxiety Disorders


• most prevalent mental disorders in the
general population.
• most common mental disorder in children and
• 2:1 female predominance
Vulnerability factors for anxiety
• anxiety sensitivity: individual response to
physiological alterations associated with
anxiety and fear.
• Genetic predisposition
• Behavioral inhibition: pattern of behavior
involving withdrawal, avoidance, fear of the
unfamiliar, and over-arousal of the
sympathetic nervous system
Anxiety could be due to
• 1. normal response to stressful life events.

• 2. Symptom of an anxiety disorder

• 3. Symptom of another psychiatric disorder

• 4. Symptom of a medical illness

• Sense of impending threat or doom that is
not realistically based or not well defined
Situational or stress-related anxiety
• Usually self-limited that rarely requires
medical treatment. Should ask ourselves

• Is the anxiety harmful to the person? Would

psychosocial treatment (could be CBT) be
enough? What are the risks and benefits of
short-term antianxiety treatment?
Psychological symptoms of anxiety
• Apprehension, worry, fear
• Sense of doom or panic
• Hypervigilance
• Irritability
• Fatigue
• Insomnia
• Derealization
• Difficulty concentration
Somatic complaints of anxiety
• Headache
• Dizziness and light-headedness
• Palpitations and chest pain
• Upset stomach and diarrhea
• Frequent urination
• Dry mouth
• Shortness of breath
• Paresthesias
Physical signs of anxiety
• Diaphoresis
• Cool skin
• Tachycardia and arrhythmias
• Flushing and pallor
• Hyperreflexia
• Trembling
• Easily startling and fidgeting
Classification of DSM IV-TR
• Seperation anxiety disorder
• Selective Mutism
• Specific phobia
• Social Anxiety Disorder
• Panic disorder
• Panic attack
• Agoraphobia without history of panic disorder
• Generalized anxiety disorder
• Substance/Medication induced Anxiety Disorder
• Anxiety Disorder due to another Medical condition
• Acute stress disorder
• Posttraumatic stress disorder
• Substance induced anxiety disorder
• Anxiety disorder due to a general medical condition
• Anxiety disorder not otherwise specified
Seperation anxiety disorder
Definition of panic attack
• Sudden onset of intense apprehension, fearfulness, or terror,
associated with feelings of impending doom accompany with
symptoms such as shortness of breath, palpitations, chest
pain, choking sensation, and fear of “going crazy”, loosing
control or dying.
Criteria for Panic Attack
Intense fear or discomfort , in which four or more of the
following developed abruptly reaching peak within 10 min.
• 1.Palpitations, tachycardia
• 2. sweating
• 3. Trembling or shaking
• 4. Sensation of shortness of breath
• 5. Feeling of choking
Criteria for panic attack
• 6. Chest pain or discomfort
• 7. Nausea or abdominal distress
• 8. Dizziness, unsteady, lightheaded
• 9. derealization or depersonalization
• 10. fear of loosing control or going crazy
• 11. fear of dying
• 12. paresthesias
• 13. chills or hot flushes
Differential diagnosis for panic attacks
• both hypo- and hyperthyroid states
• Hyperparathyroidism
• Pheochromocytomas
• hypoglycemia associated with insulinomas
• seizure disorders
• prescribed and illicit substances on CNS
• arrhythmias, chronic obstructive pulmonary disease, and
Clues of an underlying medical etiology to panic-
like symptoms
• presence of atypical features during panic
attacks, such as ataxia, alterations in
consciousness, or bladder dyscontrol
• onset of panic disorder relatively late in life
• physical signs or symptoms indicative of a
medical disorder.
Panic attacks occur in other anxiety
• social anxiety disorder
• specific phobia
• Posttraumatic stress disorder (PTSD)
• Obsessive compulsive disorder (OCD)
• Generalized anxiety disorder (GAD)
• 1. Anxiety about being in places or situations from which
escape might be difficult (or embarrassing) or in which help
may not be available in the event of having a panic attack

• 2. Situations are avoided, or endured with marked distress

or with anxiety about having a panic attack, or require the
presence of a companion.
criteria cont…
• 3. Anxiety or phobic avoidance is not better
accounted for by another mental disorder
such as: social phobia, specific phobia, OCD,
PTSD, separation anxiety disorder.
Panic disorder with or
without agoraphobia
• A. Bothe (1 ) and (2)
• 1. Recurrent unexpected Panic Attacks
• 2. At least ONE of the attacks has been followed by one
month of the following:

• a. persistent concern of more attacks

• b. worry about implications of attacks
• c. change in behavior related to attacks
Panic disorder with or
without agoraphobia cont…
• B. Presence or absence of Agoraphobia

• C. Panic Attack are not due to drugs or medical condition or


• D. Panic Attacks are not better accounted for by another

mental disorder
Panic disorder
in short
• Recurrent unexpected Panic Attacks
• Anticipatory anxiety
• Phobic avoidance
• Rule out drugs, medication, medical and
psychiatric disorders
Panic disorder
• 1. Antidepressants
• a. SSRIs (paroxetine sertraline)
• b. SNRIs (venlafaxine, duloxetine)

• 2. Benzodiazepines
• a. Alprazolam (2 to 6 mg)
• b. Clonazepam (0.5 to 3 mg)

• 3. Psychotherapy ( CBT )
Specific phobia
• Irrational fear of a specific object, place, or situation that is
out of proportion
• Recognized by patient to be unreasonable
• Dx is made if impairs daily activities or cause significant
• Subtypes: animal type, natural environment type, blood-
injection-injury type, situational type and other type
• Treated with systematic desensitization
• No role for medication
Social Anxiety Disorder
• A. Marked and persistent fear of being humiliated or embarrassed in one
or more social situations.
• B. Exposure to the feared social situation provokes anxiety or panic attack.
• C. Person recognizes that fear is excessive or unreasonable.
• D. Social situations are avoided or endured with intense anxiety or
• E. social, occupational, academic impairment.
• F. If under 18 y/o duration at least 6 months.
• G. The fear is not due to drugs, meds, physical or mental disorder
Types of social anxiety
• generalized social phobia: fear most social
situations; fearful of initiating conversations in
many settings, dating or participating in most
group activities or social gatherings, and
speaking with authority figures.
• specific social phobia: fear specific,
circumscribed social situations, e.g. public
Differential diagnosis
• differentiation of social phobia and
• social isolation that accompanies other
psychiatric disorders as depression and early
stages of psychotic disorders
Social Anxiety Disorder
• Treated with SSRI, benzodiazepines, beta-blocker.
• Psychotherapy(CBT)
1. Exposure: patients face social situations so that habituation and
extinction can occur.
2. Cognitive restructuring: challenging maladaptive assumptions and
3. Social skills training: skills required in social situations.
Generalized Anxiety Disorder
• A. Excessive anxiety and worry over every aspect of life for at least
6 months
• B. Difficulty controlling the worry
• C. Anxiety and worry are associated with THREE or more of the following
1. restlessness
2. Being easily fatigue
3. Difficulty concentrating or mind going blank
4. Irritability
5. muscle tension
6. Sleep disturbance(difficulty falling or staying sleep)
Generalized Anxiety Disorder
Criteria Cont…
• D. The focus of the anxiety and worry is not due to: social phobia, OCD,
separation anxiety disorder, anorexia nervosa, somatization disorder,
hypochondriasis, or is not during PTSD.

• E. The anxiety and worry causes impairment in social, occupational,

academic or in other areas of life.

• F. Not due to drugs, medication, medical or mental disorder.

Generalized Anxiety Disorder
• SSRIs( paroxetine, escitalopram)
• SNRIs(venlafaxine, duloxetine)
• Benzodiazepines(diazepam, clonazepam, lorazepam, alprazolam)
• Buspirone: partial agonist serotonin 5-HT1A receptor, does not produce
dependence or abuse. Takes 4-6 weeks to be effective. Dose: 5-60 mg day;

• Psychotherapy
• 1. CBT is probably the best
• 2. Relaxation therapy
Post Traumatic Stress Disorder
PTSD Epidemiology

• 7-9% of general population

• 60-80% of trauma victims
• 30% of combat veterans
• 50-80% of sexual assault victims
• Increased risk in women, younger people
• Risk increases with “dose” of trauma, lack of
social support, pre-existing psychiatric
Post-traumatic Stress Disorder
A. Exposure to traumatic event
1. experience or witnessed event that threatened with death or
serious injury.
2. person responded with intense fear, horror or helplessness.
B. Traumatic event is persistently reexperienced
1. recurrent distressing recollection of event(thought,
2. recurrent distressing dreams of event
3. acting or feeling the event recurring(illusions, hallucinations,
4. significant psychological and physiological distress when
exposed to stimuli that resembles traumatic event
Post-traumatic Stress Disorder
criteria cont…
• C. persistent avoidance associated with trauma
1. avoid thoughts, feelings or conversations associated with trauma
2. avoid activities, places, people related to trauma
3. inability to recall important aspect of trauma
4. decreased interest in significant activities
5. feelings of detachment from others
6. restricted range of affect
7. sense of foreshortened future
Post-traumatic Stress Disorder
criteria cont…
• D. Persistent symptoms of hyperarousal
1. difficulty falling or staying asleep
2. irritability or outburst of anger
3. difficulty concentrating
4. hypervigilance
5. exaggerated startle response

E. Duration of disturbance(B,C,D) is more than ONE month

Post-traumatic Stress Disorder
• F. significant distress or impairment in social,
occupational or other areas of functioning.
• Specify if:
• 1. acute: duration less than 3 months
• 2. chronic: more than 3 months.
• 3. delayed onset: 6 months after stressor
PTSD in short
• History of exposure to a traumatic event
• Recurrent reexperiencing of event
• Persistent avoidance of stimuli associated with trauma
• Numbing responsiveness
• Symptoms of hyperarousal
• Treat with antidepressants(SSRIs), Benzodiazepines,
• Other Tx: anticonvulsants, atypical antipsychotics such as risperidone,
olanzapine as adjunct therapy if others failed.
• Psychotherapy
Obsessive Compulsive Disorder
• Recurrent obsessions and compulsions
• Obsessions : intrusive thoughts, ideas or images that cause
• Compulsions: repetitive acts in response to obsessions
• Marked distress and psychosocial impairment
• Treated with SSRI , clomipramine, and augmentation strategy
with antipsychotics
Psychiatric disorders associated with
• Depression: 70% experience anxiety
20 to 50 % have panic attacks

• Pt experiences psychosis due to mania, or

schizophrenia display anxiety

• Delirium and dementia: anxiety is the most

common emotion
Psychiatric disorders associated with
• Adjustment disorder with anxiety: ptes
experience anxiety or impairment in excess of
those that would normally be expected within
3 months of exposure to an obvious stress.
Expected to resolve within 6 months.
• Factious disorder; consciously simulate
anxiety for the purpose of becoming a patient
Illnesses that cause anxiety
• Cardiovascular disorders
-arteriosclerotic heart disease
-paroxysmal tachycardias
-mitral valve prolapse

• Pulmonary disorders
-pulmonary embolism
-hypoxemia, asthma, COPD
Illnesses that cause anxiety
• Disorders of the endocrine system
-Cushing syndrome
Illnesses that cause anxiety
• Tumors
-characinoid tumor

• Neurologic disorders
-multiple sclerosis
-temporal lobe epilepsy
• A patient with panic attack can become
agoraphobic if:
A. the patient has deep-seated conflicts
B. medications side effects predominate
C. a stressful experience occurs
D. patient becomes frightened of situations in
which panic attacks were experienced
Answer #1

• D. patients with panic attacks become

progressively more phobic of situations in
which they experienced spontaneous panic
Question #2
• In contrast to generalized anxiety , panic
attacks are best described as:
A. unrealistic
B. excessive
C. concerned with everyday events
D. spontaneous
Answer #2

• D. panic attacks arise spontaneously and are

not associated with any specific event or
Question #3
• A 25 year old woman who recently had an
extramarital affair feels that her physician
disapproves of her behavior which is not really
objectionable. This is an example of the defense
of :
A. denial
B. repression
C. reaction formation
D. projection
Answer #3

• D. projection is attributing to others one’s own

unacceptable feelings, thoughts, or impulses
Question #4
• A 25 year old man has had long-standing fears
of humiliating himself in social interactions.
Lately he has become isolated, presents with
insomnia and suicide ideations. What is the
best treatment?
A. chlordiazepoxide
B. phenelzine
C. buspirone
Answer #4
• B. the diagnosis is probably social phobia
complicated by depression.
Monoamine oxidase inhibitors(MAO) such as
phenelzine can treat both depression and
social phobia
Questions #5
• A 30 year old man complains of panic attacks
and anticipatory anxiety. Which of the
following drugs would be effective for his
A. haloperidol
B. fluoxetine
C. carbamazepine
Answer #5

• B. antidepressants, including SSRI such as

fluoxetine are effective treatment for panic
Question #6
• Treatment modalities that are usually helpful
for PTSD include all of the following EXCEPT:

A. discussion of the precipitating event

B. relaxation techniques
C. systematic desensitization
Answer #6

• C. systematic desensitization is a treatment for

agoraphobia and specific phobias.
Question #7
• A 37-year-old woman who was raped 5 years ago has
recurrent vivid memories of the incident accompanied by
intense anxiety. These memories frequently intrude during
her daily activities, and nightmares about the event often
wake her. Her symptoms intensified when
a coworker was raped 2 months ago. This patient's symptoms
most closely suggest
Question #7 cont…
• (A) post-traumatic stress disorder
• (B) panic disorder
• (C) adjustment disorder
• (D) acute stress disorder
• (E) malingering
Answer #7
• This patient is most likely to be suffering from
post-traumatic stress disorder (PTSD)
characterized by symptoms of anxiety and
intrusive memories and nightmares of this life
threatening rape
Question # 8
• A 23-year-old female medical student comes to
the emergency room with increased heart rate,
sweating, and shortness of breath. She is convinced that she
is having an asthma attack and that she will suffocate. The
symptoms started suddenly during a car ride to school. She
has no history of asthma and, other than an increased pulse
rate, physical findings are normal.
What is the diagnosis?
• (A) Hypochondriasis
• (B) Obsessive-compulsive disorder
• (C) Panic disorder
• (D) Generalized anxiety disorder
• (E) Acute stress disorder
most effective immediate
treatment for this patient is?
• (A) an antidepressant
• (B) psychotherapy
• (C) a benzodiazepine
• (D) buspirone
• (E) a B-blocker
the most effective long term
treatment for this patient is?
• (A) an antidepressant
• (B) psychotherapy
• (C) a benzodiazepine
• (D) buspirone
Answer #8
• This patient is most likely to be suffering from panic disorder

• Most effective immediate treatment for this patient is a

benzodiazepine because it works quickly

• long-term (maintenance) treatment for this patient is an

Question #9
• A 45-year-old woman says that she frequently
feels "nervous" and often has an "upset stomach“ which
includes heartburn, indigestion
and diarrhea. She has had this problem since
she was 25 years of age and notes that other
family members also are "tense and nervous."
Which of the following disorders best fits
this clinical picture?

• (A) Hypochondriasis
• (B) Obsessive-compulsive disorder
• (C) Panic disorder
• (D) Generalized anxiety disorder
• (E) Acute stress disorder
Which of the following additional signs or
symptoms is this patient most likely to show?

• (A) Flight of ideas

• (B) Hallucinations
• (C) Tingling in the extremities
• (D) Ideas of reference
• (E) Neologisms
The most effective long-term treatment for
this patient is?

• (A) An antidepressant
• (B) psychotherapy
• (C) a Benzodiazepines
• (D) buspirone
Answer #9
• This patient is most likely to be suffering from
generalized anxiety disorder(GAD).

• Additional signs or symptoms of anxiety

include tingling in the extremities

• most effective long-term treatment for this

patient is buspirone