The inverted U diagram depicting performance vs anxiety demonstrates that there is a an optimum amount of anxiety for optimum performance. The complete removal of anxiety does not improve performance. This seems logical but as we develop more and more sophistication we can sometimes impede ourselves. Example of this is the recent psychiatry board examination. This is an oral examination. As such candidates with excessive levels of anxiety may perform poorly due to the difficulty with concentration which accompanies their excess anxiety. Others may fear being too anxious and take beta blockers to block anxiety and subsequently have a deterioration in performance. The question of when and whether someone should take beta blockers to treat performance anxiety is a complicated one. Clearly there should be some discomfort in performing many important roles. The anxiety heightens our awareness and concentration. A good rule of thumb is that you should take tests under the conditions that you perform on a daily basis.
In the HPA axis, the hypothalamus produces and releases CRH, which in turn controls the release of ACTH from the pituitary. ACTH stimulates glucocorticoid secretion from the adrenal cortex. This pathway is very useful as a a means of increasing metabolism and preparing an organism for quick action in the face of acute stress. The downside, though, is that chronic stress is neurotoxic
What does the pharm. Of these drugs, which effectively treat GAD, tell us about the cause of the disorder?…
Anxiety DisordersAnxiety Disorders
((General FeaturesGeneral Features))
Professor of Psychiatry.
Suez Canal University, Egypt.
Everybody must be aware of AnxietyEverybody must be aware of Anxiety
Anxiety disorders are very commonAnxiety disorders are very common ~30%~30% ofof
any population.any population.
They are the mostThey are the most common mental illnesscommon mental illness..
Anxiety disorders have symptoms that mimicAnxiety disorders have symptoms that mimic
physical diseasesphysical diseases..
Anxiety disorders can lead to many problemsAnxiety disorders can lead to many problems
ranging fromranging from losing jobslosing jobs (due to many missed(due to many missed
days of work) todays of work) to disabilitydisability as in PTSD.as in PTSD.
Anxiety disorders areAnxiety disorders are treatabletreatable..
All medical personnelAll medical personnel must have knowledgemust have knowledge
and skills to deal with anxious patientsand skills to deal with anxious patients
regardless of their specialties.regardless of their specialties.07/27/1307/27/13 22
• Definition: Experiencing events that are
perceived as endangering one’s physical,
social or psychological well-being.
• Response to stressors is influenced by
Controllability, predictability & challenge to
• Psychological Responses To Stress:
- Anger & Aggression.
- Apathy & Depression.
- Cognitive Impairment.
FEARFEARA normal response.A normal response.
A realistic response to an identifiable stimulus.A realistic response to an identifiable stimulus.
Imagine that you are facing a wild animal,Imagine that you are facing a wild animal,
What is your normal response?What is your normal response? Fear is normal.Fear is normal.
RealisticRealistic response toresponse to an identifiablean identifiable stimulus.stimulus.
UnrealisticUnrealistic response toresponse to an identifiablean identifiable stimulus.stimulus.
UnrealisticUnrealistic (Pervasive)(Pervasive) fear tofear to indefinableindefinable
stimulusstimulus (Future Oriented)(Future Oriented)..
Justifiable Fears vs.Justifiable Fears vs.
Anxiety DisorderAnxiety Disorder
What make fears pathological?What make fears pathological?
If fears are:If fears are:
Out of proportion with the actualOut of proportion with the actual
Difficult to be controlled.Difficult to be controlled.
Interfering with daily activities.Interfering with daily activities.
Primary vs. SecondaryPrimary vs. Secondary
Anxiety may be due toAnxiety may be due to
A primary psychiatric disorder.A primary psychiatric disorder.
A secondary psychiatric disorder:A secondary psychiatric disorder:
- Substance abuse.- Substance abuse.
- Substance-Induced Anxiety Disorder.- Substance-Induced Anxiety Disorder.
- A medical condition.- A medical condition.
- Another psychiatric condition.- Another psychiatric condition.
- Psychosocial Stressors.- Psychosocial Stressors.
- Adjustment Disorder with Anxiety.- Adjustment Disorder with Anxiety.07/27/1307/27/13 77
General Features ofGeneral Features of
Anxiety DisordersAnxiety Disorders
Anxiety disorders are psychiatric disordersAnxiety disorders are psychiatric disorders
characterized by:characterized by:
1- Fears.1- Fears.
2- Tension.2- Tension.
3- Autonomic Over-Activity.3- Autonomic Over-Activity.
4- Apprehension.4- Apprehension.
5- Continuous vigilance for danger.5- Continuous vigilance for danger.07/27/1307/27/13 88
Shared Features of AnxietyShared Features of Anxiety
Substantial proportion of etiology isSubstantial proportion of etiology is
stress related.stress related.
Reality testing is intact.Reality testing is intact.
Symptoms are ego dystonic (distressing).Symptoms are ego dystonic (distressing).
Disorders are enduring or recurrent.Disorders are enduring or recurrent.
Demonstrable organic factors are absent.Demonstrable organic factors are absent.
Symptoms of Anxiety DisordersSymptoms of Anxiety Disorders
Cognitive symptoms.Cognitive symptoms.
Emotional & Behavioral symptoms.Emotional & Behavioral symptoms.
Somatic symptoms.Somatic symptoms.
Impairment of social orImpairment of social or
occupational function.occupational function.07/27/1307/27/13 1010
Emotional & BehavioralEmotional & Behavioral
Excessive Worry.Excessive Worry.
Difficulty Controlling The Worry.Difficulty Controlling The Worry.
Restlessness and Irritability.Restlessness and Irritability.
Fear of Losing Control or Dying.Fear of Losing Control or Dying.
Avoidance Behavior.Avoidance Behavior.
Compulsive Acts.Compulsive Acts.07/27/1307/27/13 1212
Somatic SymptomsSomatic Symptoms
Muscle Tension.Muscle Tension.
Sleep Disturbances.Sleep Disturbances.
Accelerated Heart Rate.Accelerated Heart Rate.
Feeling of Choking or Chest Pain.Feeling of Choking or Chest Pain.
Feeling Dizzy.Feeling Dizzy.
Chills or Hot Flashes.Chills or Hot Flashes.
Numbness or Tingling Sensations.Numbness or Tingling Sensations.07/27/1307/27/13 1313
Impairment of Social orImpairment of Social or
Occupational FunctionOccupational Function
Prevalence of ADsPrevalence of ADs
Psychiatric Disorders:Psychiatric Disorders: (30 - 50%).(30 - 50%).
Anxiety Disorders:Anxiety Disorders: (15% - 30%).(15% - 30%).
SAD and SPh:SAD and SPh: (10%).(10%).
PD:PD: (1-2%); lifetime prevalence (3.5%).(1-2%); lifetime prevalence (3.5%).
Gender & Anxiety DisordersGender & Anxiety Disorders
FemaleFemale is at higher risk than Male for all anxietyis at higher risk than Male for all anxiety
GAD, PD , PTSD and SPh:GAD, PD , PTSD and SPh: F:M ratio (2:1).F:M ratio (2:1).
OCD:OCD: F:M ratio (3:2).F:M ratio (3:2).
-- 60% M60% M && 50% F50% F report exposure to at least one life-report exposure to at least one life-
threatening situation during their life.threatening situation during their life.
-- ~ 10% F~ 10% F && 5% M5% M will develop PTSD at some time inwill develop PTSD at some time in
their life.their life.
-- 10% F10% F && 8% M8% M of the exposed persons.of the exposed persons.
These data emphasizeThese data emphasize the role of female reproductivethe role of female reproductive
hormones and activitieshormones and activities in producing Anxietyin producing Anxiety
Generalized Anxiety DisorderGeneralized Anxiety Disorder
• A very important
disorder as it mimics
many chronic medical
• Most of the patient are
referred from GP, Family
Physician or Internist.
Excessive constant uncontrollable worryExcessive constant uncontrollable worry aboutabout
many everyday events and issues.many everyday events and issues.
The focus of GAD worryThe focus of GAD worry can shift, usuallycan shift, usually
focusing on issues like job, finances, health offocusing on issues like job, finances, health of
self and family; but it can also include moreself and family; but it can also include more
mundane issues such as, chores, car repairsmundane issues such as, chores, car repairs
and being late for appointments.and being late for appointments.
GADGAD can occur with other anxiety disorders,can occur with other anxiety disorders,
depressive disorders, or substance abuse.depressive disorders, or substance abuse.
Over concern regarding the future.
The worry seriously interferes withThe worry seriously interferes with
The intensity, duration and
frequency of the worry are
disproportionate to the issue.
The disturbance occurs most of
the days for at least 6 months.
PrevalencePrevalence ~3-6%~3-6% of population.of population.
Panic Disorder (PD)Panic Disorder (PD)
• A very important
disorder as it mimics
acute cardiac conditions.
• Most of the patients are
referred by Emergency
Recurrent, unexpected, rapid onsetRecurrent, unexpected, rapid onset
attacks ofattacks of intense and severe autonomicintense and severe autonomic
manifestations: accelerated heart rate,manifestations: accelerated heart rate,
sweating, trembling, feeling of choking orsweating, trembling, feeling of choking or
chest pain, nausea, dizziness, chills or hotchest pain, nausea, dizziness, chills or hot
flashes, numbness or tingling sensations.flashes, numbness or tingling sensations.
In-between:In-between: Persistent concern of havingPersistent concern of having
an attack and avoidance of situations.an attack and avoidance of situations.
Must be differentiated from:Must be differentiated from: substancesubstance
abuse: caffeine and amphetamines.abuse: caffeine and amphetamines.
Classify:Classify: with or without agoraphobia.with or without agoraphobia.
Three types of Panic Attacks:Three types of Panic Attacks:
1. Unexpected:1. Unexpected: the attack comes withoutthe attack comes without
warning and for no discernable reason.warning and for no discernable reason.
2. Situational:2. Situational: situations in which ansituations in which an
individual always has an attack, forindividual always has an attack, for
example (Always, he has attack uponexample (Always, he has attack upon
entering a tunnel).entering a tunnel).
3. Situational Predisposed:3. Situational Predisposed: situations insituations in
which an individual is likely to have awhich an individual is likely to have a
Panic Attack but does not always havePanic Attack but does not always have
Fear ofFear of open placesopen places..
Fear of being in places orFear of being in places or
situations where somethingsituations where something
terrible could happen andterrible could happen and
escape might be difficultescape might be difficult..
AvoidanceAvoidance of theof the
situations with markedsituations with marked
Usually associated withUsually associated with
panic disorderpanic disorder..07/27/1307/27/13 2424
Obsessive-Compulsive DisorderObsessive-Compulsive Disorder
• A disorder of
• It can be
• Most patients
are referred by
Obsessive Subtype:Obsessive Subtype:
Intrusive and inappropriate thoughts, images or urges,Intrusive and inappropriate thoughts, images or urges,
causing anxiety or distress such as: Contamination,causing anxiety or distress such as: Contamination,
pathological doubt, need for symmetry, somatic, sexualpathological doubt, need for symmetry, somatic, sexual
and aggressive.and aggressive.
Compulsive Subtype:Compulsive Subtype:
Repetitive behaviors/ mental acts performed inRepetitive behaviors/ mental acts performed in
response to obsession to reduce anxiety & distress.response to obsession to reduce anxiety & distress.
Obsessive Compulsive Subtype.Obsessive Compulsive Subtype.
Hoarding Subtype: (DSM-V & ICD-11)Hoarding Subtype: (DSM-V & ICD-11)
Unable to throw away useless items, such as oldUnable to throw away useless items, such as old
newspapers, junk mail & even broken appliances.newspapers, junk mail & even broken appliances.
Marked distress/ time-consuming/Marked distress/ time-consuming/
interferes with ability to function.interferes with ability to function.
OC spectrum Disorders:OC spectrum Disorders:
Impulse control disorders- Tourette’sImpulse control disorders- Tourette’s
Syndrome (Tics)- Body dysmorphicSyndrome (Tics)- Body dysmorphic
disorder- Self injury- OC personality.disorder- Self injury- OC personality.
OCD:OCD: Recurrent absurd ideas. TheRecurrent absurd ideas. The
patient knows that they are absurd. Hepatient knows that they are absurd. He
tries to resist them but he fails. So, he getstries to resist them but he fails. So, he gets
anxiety. Then compulsive acts start toanxiety. Then compulsive acts start to
relief anxiety.relief anxiety.07/27/1307/27/13 2727
Posttraumatic Stress DisorderPosttraumatic Stress Disorder
Disasters Sep 11th
• A very
disorder as it
leads to disability.
• It needs unusual
Exposure to an unusual stress (Exposure to an unusual stress (Extra-
ordinary TraumasTraumas) such as a serious) such as a serious
accident, a natural disaster, or criminalaccident, a natural disaster, or criminal
A response to an event involvingA response to an event involving panicpanic
like attackslike attacks with persistent avoidance ofwith persistent avoidance of
associated stimuli.associated stimuli.
Re-experienceRe-experience of the event, such as:of the event, such as:
intrusive thoughts and images, distressingintrusive thoughts and images, distressing
dreams and flashbacks.dreams and flashbacks.
Acute onsetAcute onset (within 3 months).(within 3 months).
Chronic onsetChronic onset (from 3 to 6 months).(from 3 to 6 months).07/27/1307/27/13 2929
Social Anxiety DisorderSocial Anxiety Disorder
It was called
it is better
to call it
It isIt is inappropriate public behaviorinappropriate public behavior duedue
to exposure to unfamiliar people.to exposure to unfamiliar people.
1-1- Generalized Social AnxietyGeneralized Social Anxiety ((GSPGSP):):
Multiple fears, some of which are non-Multiple fears, some of which are non-
speaking fears.speaking fears. (95%)(95%)
(You Must Treat).(You Must Treat).
2-2- Specific Social AnxietySpecific Social Anxiety ((SSPSSP):):
Fears to specific situation, similar toFears to specific situation, similar to
specific phobias.specific phobias. (5%)(5%)
(You May Not Treat).(You May Not Treat).
Common Anxiety Provoking SituationsCommon Anxiety Provoking Situations
Public speaking.Public speaking.
Talking with people in authority.Talking with people in authority.
Developing close relationships.Developing close relationships.
Making or answering a phone call.Making or answering a phone call.
Attending and participating in class.Attending and participating in class.
Speaking with strangers.Speaking with strangers.
Meeting new people.Meeting new people.
Eating, drinking or writing in public.Eating, drinking or writing in public.
Using public bathrooms.Using public bathrooms.
Specific Phobias (SPh)Specific Phobias (SPh)
Intense, irrational fear that is out ofIntense, irrational fear that is out of
proportion to the threat.proportion to the threat.
Avoidance of the feared stimulus.Avoidance of the feared stimulus.
Immediate anxiety upon encountering theImmediate anxiety upon encountering the
It is called by the stimulus name e.g.,It is called by the stimulus name e.g.,
Animals and Insects.Animals and Insects.
Natural Environment (e.g., Water).Natural Environment (e.g., Water).
Blood, Injection, Injury.Blood, Injection, Injury.
Situational (Planes & Elevators).Situational (Planes & Elevators).07/27/1307/27/13 3333
Co-Morbidity of Anxiety DisordersCo-Morbidity of Anxiety Disorders
1- Other Psychiatric Disorders:1- Other Psychiatric Disorders:
Major Depressive Disorders:Major Depressive Disorders: GADGAD
60%, PD 50% & OCD 25%.60%, PD 50% & OCD 25%.
OCD:OCD: with SAD (40%).with SAD (40%).
Substance Abuse:Substance Abuse: most probably as amost probably as a
self medication to relief anxiety andself medication to relief anxiety and
SOME DISEASES THAT MAY BE CAUSEDSOME DISEASES THAT MAY BE CAUSED
BY OR MADE WORSE BY ANXIETYBY OR MADE WORSE BY ANXIETY
Cardiac:Cardiac: ANGINA & HEART CONDITIONS.ANGINA & HEART CONDITIONS.
GIT:GIT: STOMACH OR DUODENAL ULCERS,STOMACH OR DUODENAL ULCERS,
ULCERATIVE COLITIS; IBS.ULCERATIVE COLITIS; IBS.
Skin:Skin: ECZEMA, PSORIASIS & HAIR LOSS.ECZEMA, PSORIASIS & HAIR LOSS.
Gyne:Gyne: MENSTRUAL DISTURBANCES.MENSTRUAL DISTURBANCES.
Dental:Dental: MOUTH ULCERS.MOUTH ULCERS.
General Causal FactorsGeneral Causal Factors
NTs & H
Genetic FactorsGenetic Factors
Genetic Tendency:Genetic Tendency:
– Higher concordance in MZ than DZHigher concordance in MZ than DZ
twins (All anxiety disorders).twins (All anxiety disorders).
– Adoption studies (GAD).Adoption studies (GAD).
– Family studies (PD).Family studies (PD).
Gene Studies:Gene Studies: (OCD).(OCD).
Gene-Environment Interaction:Gene-Environment Interaction: (PTSD).(PTSD).
Anatomical FactorsAnatomical Factors
Limbic System and
[GAD, PD, ASR, PTSD]
Autonomic N S
[GAD, PD, SAD, SPh]
[OCD and its spectrum]
Hormones: The HPAAxisHormones: The HPAAxis
PTSD, Acute stress,
chronic stress and GAD
A Biological Model for Panic
and Social Anxiety Disorders
Psychological FactorsPsychological Factors
Psychoanalytical Theory:Psychoanalytical Theory:
-- GAD:GAD: Conflict betweenConflict between Id & Ego.Id & Ego.
-- OCD:OCD: Personality arrest atPersonality arrest at Anal Stage.Anal Stage.
-- Phobia:Phobia: Anxiety due to repressedAnxiety due to repressed Id Impulses.Id Impulses.
Psychological Vulnerability:Psychological Vulnerability:
-- Tendency to believe that unexpected bodilyTendency to believe that unexpected bodily
sensations are dangerous.sensations are dangerous.
-- Worry about a panic attack makes the futureWorry about a panic attack makes the future
attack more likely (attack more likely (Vicious circleVicious circle) () (PDPD).).
The Cognitive Theory: PanicThe Cognitive Theory: Panic
Cognitive Behavioral Theory:Cognitive Behavioral Theory:
-- Phobia:Phobia: Conditioning of anxietyConditioning of anxiety to externalto external stimuli.stimuli.
Behavioral Theory:Behavioral Theory:
-- OCD:OCD: Learned behavior reinforced by fear reduction.Learned behavior reinforced by fear reduction.
The Fear of Fear Hypothesis:The Fear of Fear Hypothesis:
-- Some people have an overly aroused NS.Some people have an overly aroused NS.
- A tendency to be upset by the sensation generated by- A tendency to be upset by the sensation generated by
their NS.their NS.
Intensity of Trauma:Intensity of Trauma: ((PTSDPTSD).).
Psychological Factors:Psychological Factors: ((PTSDPTSD););
– Family instability.Family instability.
– Less influence at high levels of trauma.Less influence at high levels of trauma.
– Social support.Social support.
Anxiety disorders are commonAnxiety disorders are common (~ 30%)(~ 30%)..
Although there are many psychosocialAlthough there are many psychosocial
factors that induce anxiety disorders,factors that induce anxiety disorders,
biological causesbiological causes are more evident.are more evident.
There are co-morbidity particularly withThere are co-morbidity particularly with
manymany physical diseasesphysical diseases which necessitatewhich necessitate
the psychiatric care for these physicalthe psychiatric care for these physical
Anxiety disorders have cognitive,Anxiety disorders have cognitive,
behavioral & somatic symptoms & canbehavioral & somatic symptoms & can
lead to disability.lead to disability.
So,So, differential diagnosisdifferential diagnosis is veryis very
So, we have to deal with them asSo, we have to deal with them as
A Bio-Psycho-SocialA Bio-Psycho-Social approach.approach.
There are different effective & safeThere are different effective & safe
medications and effective psychotherapy aremedications and effective psychotherapy are
available now.available now.
So, anxiety disorders are more treatable thanSo, anxiety disorders are more treatable than
Anxiety disorders can lead to many seriousAnxiety disorders can lead to many serious
condition. So, we have to fight anxietycondition. So, we have to fight anxiety