ANXIETY DISORDERS

DR. AMJAD HAKRO

CONSULTANT PSYCHIATRIST & SENIOR REGISTRAR
ATMCH, KARACHI
NORMAL ANXIETY?

• a diffuse, unpleasant, vague sense of apprehension

• autonomic symptoms:
headache,
perspiration,
palpitations,
tightness in the chest,
mild stomach discomfort, and restlessness
inability to sit or stand still for long
Peripheral Manifestations of Anxiety

• Diarrhea
• Dizziness
• Lightheadedness
• Hyperreflexia
• Pupillary mydriasis
• Syncope
• Tachycardia
• Tingling in extremities
• Tremors, upset stomach
• Urinary frequency, urgency
Is Anxiety Adaptive?

• getting down to the hard work of preparing for an examination,

• dodging a ball thrown at the head,
• sneaking into the dormitory after curfew,
• running to catch the last commuter train.

Anxiety prevents damage by alerting the person to carry out certain

acts that forestall the danger.
Epidemiology

• one of the most common groups of psychiatric disorders

• The National Comorbidity Study:
1 in 4 persons
12-month prevalence rate of 17.7 %
• Women (30.5% lifetime prevalence) are more likely to have an
anxiety disorder than men (19.2% lifetime prevalence).
• The prevalence of anxiety disorders decreases with higher
socioeconomic status.
Twelve-month prevalence rates of anxiety disorders
and obsessive–compulsive disorder in population
studies
Types and nature of anxiety

• In generalized anxiety disorders, anxiety is continuous, although

it may fluctuate in intensity.

• In phobic anxiety disorders, anxiety is intermittent, arising in

particular circumstances.

• In panic disorder, anxiety is intermittent, but its occurrence is

unrelated to any particular circumstances.
The classification of anxiety disorders
Generalized Anxiety Disorder

• The symptoms of GAD are persistent and are not restricted to, or
markedly increased in, any particular set of circumstances (in
contrast to phobic anxiety disorders)

Worry and apprehension

Psychological arousal
o Irritability
o Poor concentration
o Sensitivity to noise

Autonomic overactivity
Cont’d

Muscle tension
Hyperventilation
Sleep disturbances
Epidemiology

• The Adult Psychiatric Morbidity Survey found a 12-month

prevalence of 4.4% in England

• The mean age of onset: 21 years

• Associated with lower household income unemployment,

separation
Differential diagnoses?

• Depressive disorder
• Schizophrenia
• Dementia
• Substance misuse
• Hyperthyroidism/thyrotoxicosis
• Pheochromocytoma
• Hypoglycaemia
Etiology

• Stressful events esp. those associated with ‘danger’ rather than

‘loss’
• Genetic
• Early life experiences:
Parental indifference
Physical/sexual abuse
Overprotective parenting style
Lack of emotional warmth
Cont’d

• Neurobiological mechanisms
Amygdala
Thalamus
Somatosensory cortex
Anterior cingulate cortex
• Neurochemical:
5-HT
GABA
Noradrenergic neurons
Prognosis

• Disorder that last for longer than 6 months have a poor prognosis
Management

• Self-help and psychoeducation:

• Group psychoeducation: where one therapist works with up to a
dozen clients in about six weekly sessions of interactive learning
and shared experience

• Relaxation training:
Progressive Muscle Relaxation
Deep Breathing Exercises
Cont’d

• Cognitive behavior therapy (CBT)

• Medication:
 Short-term treatment:
 Diazepam
 Bromazepam
 Alprazolam
 Clonazepam
 Beta-adrenergic antagonists
 Buspirone
Cont’d

Long-term treatment:
SSRIs – 1st choice
SNRIs – Duloxetine, Venlafaxine
Pregabalin

Where patients with GAD respond to medication, the risk of relapse

is substantially reduced if treatment is maintained for at least 6
months, and probably longer.
Phobic anxiety disorders

• Sx. occur only in specific circumstances

• Avoidance
• Anticipatory anxiety

• Anxiety can occur in situations (e.g. crowded places, social

gatherings) ‘objects’ (spiders/certain animals), and natural
phenomena (e.g. thunder)
Specific phobias

• five general types of specific phobia are recognized, which are

concerned with:

 animals
 aspects of the natural environment
 blood, injection, medical care, and injury
 situations (airplanes, lifts, enclosed spaces).
 other provoking agents (fears of choking or vomiting)
Epidemiology

• Around 7% in men and 17% in women

• The age of onset of most specific phobias is in childhood

• Most situational phobias develop in the early twenties

Etiology

• Persistence of childhood fears

• Genetic factors:
heritability ranging from 40% to 60%

• Neural mechanisms:
increased activation in the regions linked to emotional appraisal
and fear (amygdala, insula, anterior cingulate)
Treatment

• Exposure form of behavior therapy – mainstay treatment

• Virtual-reality exposure
• Benzodiazepines – short term
Social phobia

• experienced in social situations

• feels observed by others
• Avoidance
• Anticipatory anxiety

Don’t confuse it with shyness

Epidemiology

• usually begins in the early teenage years

• Lifetime prevalence: 12% in community
Differential diagnoses

• Agoraphobia
• panic disorder
• Generalized anxiety disorder
• depressive disorder
• Schizophrenia
• Anxious-Avoidant PD
• Body dysmorphic Disorder
• Inadequate social skills
Etiology

• Genetic factors:

heritability has been estimated to be around 55%

• Cognitive factors:

fear of negative evaluation

excessively high standards for social performance
negative beliefs about the self (e.g. ‘I’m boring’)
excessive monitoring of one’s own performance in social situations
 intrusive negative images of the self as supposedly seen by others
Cont’d

safety behaviors:
avoiding eye contact during communication

• Neural mechanisms:
Increased amygdala responses, hippocampus, and insula
Diminished activation of cortical regulatory areas such as the
prefrontal cortex
Treatment

• Cognitive behavior therapy (CBT)

• SSRIs
• SNRI – Venlafaxine
• MAOIs
• Benzos – Short term
• Beta-blockers – for tremors, palpitations, performance anxiety
Agoraphobia

• Anxious esp. when away from home,

• in crowds,
• in situations that they cannot leave easily

Situations may include:

buses and trains,
shops and supermarkets
Differential diagnoses

• Social phobia
• GAD
• Panic disorder
• Depressive disorder
• Paranoid/Delusional disorders
Epidemiology

• lifetime risk - 2.6%

Etiology

• Dependent PD
• Neurobiological
• Overprotective family attitudes
Prognosis

• agoraphobia that has lasted for 1 year generally remains for the
next 5 years
Treatment

• Exposure treatment
• CBT
• Medications:
Benzodiazepines - short-term
SSRIs – 1st line
Clomipramine
Imipramine
Venlafaxine
Panic Disorder

• anxiety builds up quickly

• the symptoms are severe
• the person fears a catastrophic outcome.

Some people with panic disorder hyperventilate, and this adds to their
symptoms.
Hyperventilation is breathing in a rapid and shallow way that leads to a
fall in the concentration of carbon dioxide in the blood.
Sx. due to Hyperventilation

• Dizziness
• Tinnitus
• Headache
• Feeling of weakness
• Faintness
• Numbness
• Tingling in the hands, feet, and face
• Carpopedal spasms
• Precordial discomfort
Differential diagnoses

• GAD
• Phobic anxiety disorders – Agoraphobia
• Acute organic disorder
• Depressive disorder
Epidemiology

• 12-month prevalence – 2.7%

• Lifetime risk – 4.7%
Etiology

• Genetics
heritability of about 40%
• Neurochemicals/ neurobiological:
 lowered cortical GABA levels
 Diminished benzodiazepine-receptor binding
 lowering of cortical 5-HT1A receptor binding
Prognosis

• About 30% of patients remit without subsequent relapse

Treatment

• Benzodiazepines:
Alprazolam
• Other long term Rx.
Imipramine
Clomipramine
Lofepramine
Reboxetine
Other SSRIs (Citalopram, Escitalopram, Sertraline)
Cont’d

• CBT
OCD

• Inner sense of compulsion and of efforts at resistance

• Principal features of obsessive–compulsive disorder:
- Obsessional symptoms
Thoughts
Ruminations
Impulses
Phobias
- Compulsive rituals
Abnormal slowness
Cont’d

• Obsessional thoughts: words, ideas, beliefs

• Obsessional ruminations: internal debates, arguemts for and
against
• Obsessional rituals
Themes of obsessions

• dirt and contamination

• aggression
• orderliness
• illness
• sex
• religion
Compulsive acts

• Checking rituals
• Cleaning rituals
• Counting rituals
• Dressing rituals
Epidemiology

• 1-year prevalence - 2.1%

Etiology

• Genetics
• Brain disorders/ neurobiological:
 Encephalitis lethargica
 Sydenham’s chorea
 PANDAS (pediatric autoimmune neuropsychiatric disorder associated with
streptococcal infection)
 increase in grey matter volume in the striatum
 decrease in orbitofrontal, dorsomedial, and anterior cingulate cortex
 Abnormal 5-HT mechanisms
Differential Diagnoses

• Other anxiety disorders

• Depressive disorder
• Delusional disorder
• Schizophrenia
• Hypochondriasis
• Encephalitis
• Tics/Tourette syndrome
Treatment

• Medications:
 Clomipramine
 SSRIs
 Low doses of Risperidone and Aripiprazole to SSRIs in resistant cases
• Psychological treatments:
 Exposure and Response Prevention
• Neurosurgical:
 Deep Brain Stimulation (DBS)
 Stereotactic procedures (orbitomedial or cingulate lesions)
Thank you