Overview

• Anxiety disorders are among the most Prevalent

Mental Disorders in the general population.
• Women affected nearly twice as frequently as
men.
• Anxiety disorders are associated with significant
morbidity and Chronic and Resistant to
Treatment.
 Normal Anxiety
Everyone experiences anxiety.
 It is characterized most commonly as:-
 Diffuse, Unpleasant, Vague ….
Accompanied by:-
 Autonomic symptoms such as :-
Headache, Perspiration,
Palpitations, Tightness in the chest,
Mild stomach discomfort, and Restlessness.
indicated by an inability to sit or stand still for long.
 Pathologic Anxiety Vs Normal
 Normal Anxiety is adaptive.
 It is an inborn response to threat or to the absence of
people or objects that signify safety
 can result in Cognitive (worry) and Somatic (racing
heart, sweating, shaking, freezing, etc.) Symptoms.
 Pathologic anxiety is
 Excessive, Impairs function.
 Three Pillars of Anxiety
-Uncertainty
-Lack of control
-Perception of danger
 Fear Vs Anxiety
oAnxiety & Fear both are Alerting signals.
oFear is a response to a known, External,
definite, or nonconflictual threat;
oAnxiety is a response to a threat that is
unknown, Internal, vague, or conflictual.
oit warns of impending danger & enables a
person to take measures to deal with a
threat.
 Symptoms of Anxiety
• The experience of anxiety has Two components:

1-The awareness of the Physiological

Sensations (e.g., palpitations and sweating) and

2-The awareness of being Nervous or

Frightened. In addition to motor & visceral
effects.

Anxiety affects Thinking, Perception, and

Learning.
• It tends to produce Confusion and Distortions
of perception, not only of time and place but
also of persons and the meanings of events.
• These Distortions can interfere with learning
by:-
-Lowering concentration,
-Reducing recall, and impairing the ability
to relate one item to another that is, to make
associations.
 Epidemiology
most common groups of psychiatric
disorders.
one of four persons met the diagnostic
criteria for at least one anxiety disorder
Women are more likely to have an anxiety
disorder than men.
 Etiology

1-Contributions of Psychological Sciences

Three major Schools of Psychological theory

A. Psychoanalytic
B. Behavioral, and
C. Existential
have contributed theories about the causes of anxiety.
 A. Psychoanalytic Theories
• Freud believed that Anxiety was viewed as the
result of Psychic Conflict between
• Unconscious Sexual or Aggressive wishes
and
Corresponding threats from the Superego or
External Reality.
• In response to this signal, the Ego mobilized
defense mechanisms to prevent unacceptable
thoughts and feelings from emerging into
conscious awareness.
 Psychodynamic Theory
• The Psychodynamic theory has explained anxiety
as a conflict between the id and ego.
• Aggressive and impulsive drives may be
experienced as unacceptable resulting in
repression.
• These repressed drives may break through
repression, producing automatic anxiety
 B. Behavioral Theories
• The Behavioral or learning theories of anxiety
postulate that anxiety is a Conditioned Response
to a Specific Environmental Stimulus.
• In a model of classic conditioning, a Girl raised by
an Abusive Father,
for example, may become Anxious as soon as she
sees the Abusive Father.
• Through generalization, she may come to distrust
all men.
• In the social learning model, a child may develop
an anxiety response by imitating the anxiety in
the environment, such as in anxious parents.
 C. Existential Theories
• Existential theories of anxiety provide models
for generalized anxiety,
• in which No specifically Identifiable
Stimulus exists for a Chronically Anxious
Feeling.
• The central concept of existential theory is that
persons experience feelings of living in a
purposeless universe.
• Anxiety is their response to the perceived void
in existence and meaning.
 2.Contributions of Biological Sciences
A. Autonomic Nervous System
Stimulation of the autonomic nervous system
causes certain symptoms:-
 Cardiovascular (e.g., tachycardia),
 Muscular (e.g., headache),
 Gastrointestinal (e.g., diarrhea), and
 Respiratory (e.g., tachypnea).
• The autonomic nervous systems of some patients
with anxiety disorder, especially those with panic
disorder, Exhibit Increased Sympathetic Tone,
adapt slowly to repeated stimuli, and respond
excessively to moderate stimuli.
 B. Neurotransmitters

The Three Major Neurotransmitters

associated with anxiety on the bases of animal
studies and responses to drug treatment are:-
 Norepinephrine,
 Serotonin, and
 GABA.
 C-Genetic Studies
• Genetic studies have produced solid evidence
that at least some genetic component
contributes to the development of anxiety
disorders.
• Heredity has been recognized as a
predisposing factor in the development of
anxiety disorders.
• Almost half (50%) of all patients with Panic
Disorder have at least one affected relative.
 Brain imaging studies
Structural Studies – increase in the size
of the ventricles.
Rt. temporal lobe defects
 Abnormal rt. Hemisphere findings
(cerebral asymmetry).
Functional studies – Frontal, Temporal,
Occipital Abnormalities.
Parahipocampal gyrus abnormalities in
panic d/o
Caudate Abnormalities in OCD.
 What are 3 functions that the hippocampus controls?

Being an integral part of the Limbic system,

Hippocampus plays a vital role in regulating
• Learning,
• Memory Encoding,
• Memory Consolidation, and
• Spatial Navigation
Cont…
 What are Three Functions of the Amygdala?

• The main job of the Amygdala is to

Regulate Emotions, such as Fear and
Aggression.
• The Amygdala is also involved in tying
emotional meaning to our memories.
• reward processing, and decision-making
Cont…
Anxiety Disorders DSM 5TR

1. Specific phobia
2. Social anxiety disorder (social phobia)
3. Agoraphobia
4. Panic disorder
5. Generalized anxiety disorder
6. Separation anxiety disorder
7. Selective mutism
8. Substance/medication-induced anxiety disorder
9. Anxiety disorder due to another medical condition
10.Other specified/ unspecified
 Cont…
1-Panic disorder
 Recurrent unexpected Panic attacks characterized by four
or more of the following:
 developed abruptly and reached a peak within 10 minutes:
-Palpitations
-Sweating
-Trembling or shaking
-Shortness of breath
-Feeling of choking (also known as air hunger)
-Chest pain or discomfort
-Nausea or abdominal distress
-Feeling dizzy, lightheaded, or faint
 Derealization or depersonalization
 Fear of losing control or going crazy
 Fear of dying
 Numbness or tingling
 Chills or hot flashes
 Persistent concern of future attacks
 Worry about the meaning of or consequences of the
attacks (e.g., heart attack or stroke)
 Significant change in behavior related to the attacks
(e.g., avoiding places at which panic attacks have
occurred)
 ± Presence of agoraphobia
 Treatment
Pharmacotherapy: - SSRIs-

-TCAs
-BDZ
 Psychotherapy: -Relaxation training for panic
attack
-Systemic desensitization for
Agoraphobia
 2-PHOBIAS
Phobia is an irrational fear of objects or situations

Can be divided in to:-

Agoraphobia
Social phobias
Specific phobias
 A-Agoraphobia
 Fear of being in places or situations from which escape
might be difficult, Embarrassing, or in which help may be
unavailable in the event of having a panic attack,
Often results in avoidance of the feared places or
situations,
for example:
Crowds
Stores
Bridges
Tunnels
Traveling on a bus, train, or airplane
Theaters
Standing in a line
Small enclosed rooms
Marked fear or anxiety about two or more of the
following five situations:
1.using public transportation (e.g.,
automobiles, buses, trains, ships, planes)
2.being in open spaces (e.g., parking lots,
market places, bridges)
3.being in enclosed places (e.g. shops,
theatres, cinemas)
4.standing in line or being in a crowd
5.being outside of the home alone.
 Treatment
 Cornerstone of treatment for anxiety disorders is
increasing serotonin. SSRI-
 CBT may correct maladaptive cognitions or
behavior
 Behavioral therapy

E.g. Systemic Desensitization

 Flooding-massive exposure to the feared object or
situation
 B-Social phobia
Marked and persistent fear of one or more
social or performance situations in which the
person is concerned about negative evaluation
by others,
 for example:
-Public speaking
-Writing, eating, or drinking in public
- Initiating or maintaining conversations
-Fears humiliation or embarrassment,
 by manifesting anxiety symptoms (e.g.,
blushing or sweating)
 Treatment

Β-blockers e.g. Propranolol

SSRIs e.g. Sertraline, Fluoxetine
Cognitive Behavioral Therapy (CBT)
BDZs
 C-Specific Phobia
 Marked and persistent fear that is excessive,
unreasonable, cued by the presence or anticipation of a
specific object or situation,
 for example:
Flying
Enclosed spaces
Heights
Storms
Animals (e.g., snakes or spiders)
Receiving an injection
Blood
Provokes an immediate anxiety response
Recognition that the fear is excessive or unreasonable
e.g. of specific phobias

Heights Acrophobia

Water Hydrophobia

Enclosed places Claustrophobia

Animals Zoophobia

Death Thanatophobia
 Fear of Women/ sex Gynophobia

Pain Algophobia
 Treatment

 Behavioral therapy
E.g. Systemic Desensitization
 Flooding-massive exposure to the feared object
or situation
 4.Generalized anxiety disorder
 Excessive anxiety and worry about a number of events or activities
(future oriented),
 occurring more days than not for at least 6 months
- Worry is difficult to control
- Worry is associated with at least three of the following
symptoms:

Note: Only one item is required in children.

Restlessness or feeling keyed up or on edge

Easily fatigued

Difficulty concentrating

Irritability

Muscle tension
 The disturbance is not due to the direct
physiological effects of a substance (e.g., a drug of
abuse, a medication) or
 General Medical Condition (e.g., hyperthyroidism)
and does not occur exclusively during a mood
disorder, a psychotic disorder, or a pervasive
developmental disorder.
 TREATMENT FOR GAD
Antidepressants
e.g. SSRIs
Benzodiazepines
Some form of behavioral psychotherapy
e.g. Relaxation training.
 Peripheral Manifestations of Anxiety
• Diarrhea • Restlessness (e.g.,
• Dizziness, pacing)
• light-headedness • Syncope
• Hyperhidrosis • Tachycardia
• Hyper-reflexia • Tingling in the
extremities
• Hypertension
• Tremors
• Palpitations
• Upset stomach
• Pupillary mydriasis
• Urinary frequency,
• hesitancy, urgency
 Posttraumatic Stress Disorder
 Marked by the development of symptoms after
exposure to traumatic life events.
The person reacts to this experience with
Fear and Helplessness,
Persistently relives the event, and
Tries to avoid being reminded of it.
• To make the diagnosis, the symptoms must
last for more than a month after the event
and must significantly affect important areas
of life, such as family and work.
 Epidemiology
• The lifetime incidence is estimated to be 9 to
15 percent
• The lifetime prevalence is estimated to be
about 8 percent of the general population,
• The lifetime prevalence is significantly higher
in women
• The disorder is most likely to occur in those
who are single, divorced, widowed, socially
withdrawn, or of low socioeconomic level.
 Comorbidity

Common comorbid conditions include

depressive disorders,
substance-related disorders,
other anxiety disorders, and
bipolar disorders.
Comorbid disorders make persons more
vulnerable to developing PTSD.
 Etiology

• Stressor
For example,
 Disaster
 Catastrophe may experience guilt feelings
(survivor guilt) that can predispose to, or
exacerbate, PTSD.
 War…..
 Predisposing Vulnerability Factors in
Posttraumatic Stress Disorder
Presence of childhood trauma
Borderline, paranoid, dependent, or antisocial
personality disorder traits
Inadequate family or peer support system
Being female
Genetic vulnerability to psychiatric illness
Recent stressful life changes
Perception of an external locus of control (natural
cause) rather than an internal one (human cause)
Recent excessive alcohol intake
 Clinical Features
• Painful re-experiencing of the event, a pattern
of avoidance and emotional numbing, and fairly
constant hyper arousal.
• The disorder may not develop until months or
even years after the event.
• The mental status examination often reveals
feelings of guilt, rejection, and humiliation.
• Patients may also describe dissociative states
and panic attacks, and illusions and
hallucinations may be present.
• Associated symptoms can include aggression,
violence, poor impulse control, depression,
and substance-related disorders.
• Cognitive testing may reveal that patients have
impaired memory and attention.
 DSM- Diagnostic Criteria
1-The person has been exposed to a traumatic
event in which both of the following were present:
A.the person experienced, witnessed, or was
confronted with an event or events that involved
actual or threatened death or serious injury, or a
threat to the physical integrity of self or others
B.the person's response involved intense fear,
helplessness, or horror.
Note: In children, this may be expressed instead by
disorganized or agitated behavior.
2-The traumatic event is persistently re
experienced in one (or more) of the following
ways:
A.recurrent and intrusive distressing recollections
of the event, including images, thoughts, or
perceptions.
Note: In young children, repetitive play may occur
in which themes or aspects of the trauma are
expressed.
B. recurrent distressing dreams of the event.
Note: In children, there may be frightening dreams
without recognizable content.
C. acting or feeling as if the traumatic event were
recurring (includes a sense of reliving the experience,
illusions, hallucinations, and dissociative flashback
episodes, including those that occur on awakening or
when intoxicated).
D. intense psychological distress at exposure to
internal or external cues that symbolize or resemble an
aspect of the traumatic event
E. physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
3-Persistent avoidance of stimuli associated with
the trauma and numbing of general responsiveness
(not present before the trauma), as indicated by
three (or more) of the following:
A.efforts to avoid thoughts, feelings, or conversations
associated with the trauma
B.efforts to avoid activities, places, or people that
arouse recollections of the trauma
C.inability to recall an important aspect of the trauma
D. markedly diminished interest or participation
in significant activities
E. feeling of detachment or estrangement from
others
F. restricted range of affect
(e.g., unable to have loving feelings)
G. sense of a foreshortened future
(e.g., does not expect to have a career, marriage,
children, or a normal life span)
4. Persistent symptoms of increased arousal (not present
before the trauma), as indicated by two (or more) of the
following:
A.difficulty falling or staying asleep
B.irritability or outbursts of anger
C.difficulty concentrating
D.Hyper vigilance
E.exaggerated startle response
5. Duration of the disturbance (symptoms in Criteria B, C,
and D) is more than 1 month.
6. The disturbance causes clinically significant distress or
impairment in social, occupational, or other important
areas of functioning.
 DSM- Diagnostic Criteria for Acute Stress
Disorder
ASD is diagnosed
in persons experiencing or witnessing a
traumatic event and
experiencing associated symptoms of intrusion,
negative mood, dissociation, avoidance, and
arousal, and significant distress or impairment.
Symptoms should be present at a severe level to
warrant diagnosis
A.The person has been exposed to a traumatic
event in which both of the following were
present:
1.the person experienced, witnessed, or was
confronted with an event or events that involved
actual or threatened death or serious injury, or a
threat to the physical integrity of self or others
2.the person's response involved intense fear,
helplessness, or horror
B. Either while experiencing or after
experiencing the distressing event, the individual
has three (or more) of the following dissociative
symptoms:
1.a subjective sense of numbing, detachment, or
absence of emotional responsiveness
2.a reduction in awareness of his or her surroundings
3.derealization
4.depersonalization
5.dissociative amnesia (i.e., inability to recall an
important aspect of the trauma)
C. The traumatic event is persistently re-experienced
in at least one of the following ways: Recurrent
images, Thoughts, Dreams, Illusions, Flashback
Episodes, or a sense of reliving the experience; or
distress on exposure to reminders of the traumatic
event.
D. Marked avoidance of stimuli that arouse
recollections of the trauma (e.g., thoughts, feelings,
conversations, activities, places, people).
E. Marked symptoms of anxiety or increased arousal
(e.g., difficulty sleeping, irritability, poor concentration,
hypervigilance, exaggerated startle response, motor
restlessness).
F. The disturbance causes clinically significant distress
or impairment in social, occupational, or other important
areas of functioning or impairs the individual's ability to
pursue some necessary task, such as obtaining necessary
assistance or mobilizing personal resources by telling
family members about the traumatic experience.
G. The disturbance lasts for a minimum of 2 days and
a maximum of 4 weeks and occurs within 4 weeks of
the traumatic event.
H. The disturbance is not due to the direct physiological
effects of a substance (e.g., a drug of abuse, a
medication) or a general medical condition, is not better
accounted for by brief psychotic disorder, and is not
merely an exacerbation of a preexisting Axis I or Axis II
disorder.
 Treatment
Psychotherapy:- Group psychotherapy with
other survivors
 Pharmacotherapy:-SSRIs, BZDs

 β-blockers e.g. Propranolol is important

for prophylaxis.
Selective serotonin reuptake inhibitors
(SSRIs), are considered first-line treatments
for PTSD
Anxiety Disorder Due to Another Medical
Condition
A. Panic attacks or anxiety is predominant in the
clinical picture.
B. There is evidence from the history, physical
examination, or laboratory findings that the
disturbance is the direct pathophysiological
consequence of another medical condition.
C. The disturbance is not better explained by
another mental disorder.
D. The disturbance does not occur exclusively
during the course of a delirium.
E. The disturbance causes clinically significant
distress or impairment in functioning
A number of medical conditions are known to include
anxiety as a symptomatic manifestation.

• Endocrine disease (e.g., hyperthyroidism,

pheochromocytoma, hypoglycemia,
hyperadrenocortisolism),
• Cardiovascular disorders (e.g., congestive heart
failure, pulmonary embolism, arrhythmia such as
atrial fibrillation),
• Respiratory illness (e.g., chronic obstructive
pulmonary disease, asthma, pneumonia),
• Metabolic disturbances (e.g., vitamin B12
deficiency, porphyria),
• Neurological illness (e.g., neoplasms, vestibular
dysfunction, encephalitis, seizure disorders)