Generalized anxiety disorder is characterized by excessive, uncontrollable worry about everyday life events. Symptoms include restlessness, fatigue, difficulty concentrating, irritability, muscle tension and sleep disturbance. It is believed to have both genetic and environmental contributors, including stressful life events and early adverse experiences. Treatment involves cognitive behavioral therapy and medication such as antidepressants.

1. ANXIETY DISORDERS
Dr Opadotun O.A.
BUTH

2. INTRODUCTION
• A normal response to danger, but abnormal when
severity is out of proportion to the threat or
when it outlasts the threat.
• Has a protective value when normal but counter-
productive when abnormal.
• Mild to moderate anxiety enhances most
performances but high levels inhibit
performance.
• Pathological anxiety that follow a general medical
condition or substance misuse are classified
differently and are not subject of this discussion.

3. • The term anxiety neurosis was given by
Sigmund Freud in 1895 and later used in
DSMII to designate an ill-defined condition
which included patients who had chronic
tension, excessive worry , frequent headaches
and recurrent attacks of anxiety.
• The symptoms of anxiety are present in many
other conditions, but in anxiety disorders,
they are more severe and prominent.

4. • Anxiety disorders are abnormal states in which the
most striking features are the mental and physical
symptoms of anxiety.
• The disorders share many of the symptoms and
aetiology but there are also differences: Generalized
anxiety disorder -anxiety tends to be continuous,
while it is intermittent in Phobic anxiety disorders,
arising in particular circumstances and in panic
disorder it is intermittent but unrelated to any
particular set of circumstances.

5. Symptoms of anxiety
• 1.Symptoms of psychological arousal:
- fearful anticipation
- irritability
-sensitivity to noise
- restlessness
- poor concentration
-worrying thoughts
• 2. Symptoms of autonomic arousal:
• GIT- dry mouth
-difficulty in swallowing
- epigastric discomfort

6. Symptoms of anxiety
- frequent or loose stool
• CVS - palpitations
discomfort in the chest
fast heart beat
• RESPIRATORY – fast, shallow breathing
constriction in the chest
feelings of breathlessness, dizziness
and tingling sensation in extremities
• GUS – frequent or urgent urination
failure of erection
menstrual discomfort

7. Symptoms of anxiety
• 3. Muscle tension :
aching muscles
headaches
tremors
• 4. Sleep disturbances:
insomnia
night terror

8. Classification of anxiety disorders
ICD 10 DSM-IV
F4 Anxiety disorders Anxiety disorders
F40 Phobic anxiety disorder
Agoraphobia Agoraphobia
without panic disorder without a history of panic disorder
with panic disorder panic disorder with agoraphobia
Social phobia Social phobia
specific phobia Specific phobia
F41 Other anxiety disorders
Panic disorder Panic disorder without agoraphobia
Generalized anxiety disorder Generalized anxiety disorder
Mixed anxiety and depressive disorder -

9. Generalized anxiety disorder
• Anxiety is a normal and adaptive response to threats,
however an individual who seems to be anxious about
almost everything is likely to be described as having
GAD. Usually described as a “worrier”.
• The worries and apprehension are more prolonged and
widespread than the normal concerns of daily living –
“free floating”. These worries are experienced as
difficult to control.
• Patients also have symptoms of psychological arousal
such as sensitivity to noise, irritability and poor
concentration.

10. Generalized anxiety disorder
• There are also symptoms of autonomic arousal,
most commonly sweating, dry mouth, epigastric
discomfort and dizziness. Patients may therefore
seek help because of these symptoms without
mentioning the psychological symptoms.
• Muscle tension manifesting as restlessness,
trembling, inability to relax, headaches (usually
bilateral and frontal) and aches in the shoulders.

11. Generalized anxiety disorder
• Sleep disturbances – mainly difficulty falling
asleep with worrying thoughts.
• Other features include tiredness, depressive ,
depersonalization and obsession symptoms. If
these are prominent however, another diagnosis
should be considered.
• ICD10 diagnosis requires a period of at least 6
months in which the patient has prominent
tension and apprehension, with at least 4 out of a
list of 22 autonomic arousal, psychological
arousal and other symptoms.

12. • It also requires that patient does not meet the
criteria for other anxiety disorders and is not
better accounted for by a general medical
condition or psychoactive substance use
disorder.
• Lifetime prevalence of 3-4%, mean age of
presentation of 21yrs ,females more than
males.

13. Aetiological considerations
• Stressful life events- especially those threatening in
nature rather than loss events are known to precipitate
GAD.
• Adverse early experience – women reporting early
adverse experience had higher rates(Brown and Harris,
1993) so also women separated from their mother
before the age of 17(Kendler, 1992).
• Psychoanalytic theories – posits that GAD arises from
intrapsychic conflict when the ego is burdened by
outside world, instinctual id and superego especially
when the ego is weakened by developmental failures
such as separation and loss of parents.

14. • Cognitive –Behavioural theories – conditioning
theories posit that inherited predisposition to
excessive response of autonomic nervous system
leads to anxiety which then gets generalized through
conditioning to even neutral stimuli.
• Cognitive theories assume that GAD arises from
tendency to worry unproductively and focusing
attention on threats.

15. Aetiological considerations
• Biological theories- genetic: - increased rates in the
first degree relatives of the proband, as well as higher
concordance in monozygotic twins (Slater and Sheilds,
1969) suggest a role for genetics.
• Neurobiology - suggests a role for the various brain
systems and neurotransmitters.
• The role of Amygdala, Hippocampus in regulating
anxiety is suggested from animal studies.
• Noradrenalin, serotonin, Gamma amino butyric acid
(GABA), CRF have all been implicated in anxiety.

16. Differential Diagnosis of GAD
• Depression :- especially the agitated depression.
Though anxiety symptoms may occur in
depression, there is usually no depressive
thoughts or suicide ideas in anxiety and there is
no nocturnal variation of symptoms as seen in
depression.
• Schizophrenia :- ask patient what he thinks
caused his symptoms. The bizarre answer may
reveal the delusion of a schizophrenic.
• Dementia :- assess memory in middle aged and
elderly patients presenting with first GAD.

17. • Substance abuse :- ask also for drugs used as self
medication as their withdrawal symptoms may
mimic GAD.
• Thyrotoxicosis :- enlarged thyroid gland, atrial
fibrillation, exolphtalmos and deranged thyroid
function test may differentiate the two.
• Pheochromocytoma :- appropriate examination
and investigation will differentiate them.

18. Management
• Counseling : this shares with psychotherapy the
non specific factors but has a relatively more
emphasis on giving information and allowing for
release of emotion. In problem-solving
counseling, the patient is helped to identify and
list problems that cause distress, consider courses
of action that might help, select
problems/courses that appear feasible and
review result.
• Relaxation training

19. • Cognitive behaviour therapy, this involves
relaxation training and cognitive restructuring
(through distraction, neutralization, challenging
beliefs and reassessing patients responsibilities).
• Medications :- Benzodiazepines, Buspirone, and
Beta adrenergic antagonists for short term
control of symptoms. Antidepressants ( TCAs,
SSRI, MAOI) and low dose antipsychotics for
longer term treatment.

20. Panic attack
• A panic attack is a discrete period of intense fear or
discomfort in which 4 or more of the following develop
abruptly and reach peak within 10 minutes:-
palpitation, sweating, trembling, sensation of
shortness of breath, feeling of choking, chest pain,
nausea or abdominal discomfort, dizziness, feeling
faint, derealization or depersonalization, fear of
losing control or fear of dying, paraesthesia etc.
• A panic attack can occur in other psychiatric disorders
such as in social phobia, specific phobia or post
traumatic stress disorder but in these conditions it is
specifically bound to the cues i.e. in the context of the
feared situations.

21. Panic disorder
• Typically an attack occurs when a patient is
engaged in her routine activity, then suddenly
develops overwhelming fear, terror,
apprehension and a sense of impending doom.
• Attack usually lasts 5-20 minutes and rarely as
long as an hour.
• Some patients do not progress beyond having
repeated unexpected attacks but others may
have anticipatory anxiety of repeated attacks.

22. Panic disorder
• Panic disorder is diagnosed when there is recurrent
unexpected panic attacks , with at least one of the
attacks followed by one of the following:- (1) persistent
concern about having additional attacks (2) worry
about the implication of the attack (3) a significant
change in behaviour related to the attacks.
• the DSM-IV requires that there may or may not be
agoraphobia unlike in ICD 10.
• These panic attacks are not due to the direct
physiological effects of drugs of abuse, a medication
or a general medical condition and is not better
accounted for by another mental disorder.

23. Epidemiology of panic disorder
• Lifetime prevalence estimated at 1-4% of the
general population.
• Women more affected than men
• Rates similar in both whites and blacks.
• Recent history of divorce or separation commonly
associated with it.
• Most commonly diagnosed in young adults, a
mean age of presentation of 25 yrs. Probably
under-diagnosed in children, adolescents and
men.

24. Aetiological consideration
• Biological Factors:
• major NT implicated include NA, 5HT, and GABA
• Major brain sites implicated include locus
ceruleus, median raphe nucleus and prefrontal
cortex (believed to generate phobic avoidance)
• Abnormality in brain function and structure. E.g.
abnormal regulation of brain noradrenergic
system due to finding increased sympathetic
tone in PD patients, they adapt slowly to
repeated stimuli and respond excessively to
moderate stimuli

25. • Panic inducing substances include:
respiratory panicogens ( 5-35% mixture of
CO2, sodium lactate, sodium bicarbonate) and
neurochemical panicogens ( yohimbine, m-
carboline, CCK, caffeine, Isoproterenol). They
tend to produce an attack of panic in PD
patients but not in normal subjects.
• Yohimbine, an alpha adrenergic antagonist is
anxiogenic in patients.

26. Aetiological consideration
• Brain imaging findings have implicated the temporal
lobe especially the hippocampus and amygdala.
Cerebral vasoconstriction has been suspected in the
production of dizziness.
• Mitral valve prolapse – the current evidence has erased
the erroneous association of PD with MVP. The
prevalence is similar in both MVP and non MVP
patients.
• Genetic : 1st degree relatives of PD patients have a 4
fold increase in PD than 1st degree relatives of other
psychiatric disorders and monozygotic concordance
more than in dizygotic twins.

27. Psychosocial theories in PD
• Behaviourists see anxiety as a learned behaviour, while
psychoanalysts see it as resulting from unsuccessful
defense against anxiety provoking impulses.
• Pointers to the relevance of psychosocial factors include :
(1) traumatic experience in childhood can affect children’s
developing CNS in such a way that they become susceptible
to anxiety disorders in adults. (2) patients with PD have a
higher incidence of stressful life events (loss) months
before onset of disorder. (3) PD strongly associated with
parental death or separation before age 10. (4) about 60%
of women with PD have a childhood history of sexual abuse
compared with 31% of women with other anxiety
disorders. (5) patients receive successful treatment from
cognitive therapy.

28. Differential diagnoses of PD
• CVS- Angina, Anaemia, CCF, MVP, MI
• RS- Asthma, Hyperventilation Syndrome, Pulmonary
Embolism
• CNS- CVD, Epilepsy, TIA, Tumors
• ENDOCRINE- Carcinoid Syndrome, Hypoglycaemia,
Hyperparathyroidism, Hyperthyroidism,
Pheochromocytoma
• Drug intoxication- Amphetamine, cocaine, theophyline,
cannabis, hallucinogens etc
• Drug withdrawal- alcohol, antihypertensive, opiates,
sedative – hypnotics.
• Other anxiety disorders.

29. Treatment of PD
• Drugs – SSRI, TCAs, BDZ, MAOI are all effective
in the treatment. Patient may require up to 8-
12 months of treatment.
• CBT – involves cognitive therapy, applied
relaxation, respiratory training and in vivo
exposure.
• Other psychosocial therapies- family therapy,
insight oriented psychotherapy.

30. Phobic anxiety disorders
• Share the core symptoms of anxiety but
symptoms manifest only in particular
circumstances, with the patient symptom –free in
absence of the provoking stimulus.
• The patient avoids circumstances that provoke
the anxiety and experiences anticipatory anxiety
when there is prospect of encountering the
stimulus.
• classified into specific phobia, social phobia and
agoraphobia.

31. Specific phobia
• Inappropriate anxiety in the presence of a
particular object or situation.
• Anticipatory anxiety is common.
• The stimulus usually animals or aspects of nature
such as thunder.
• Specified by the stimulus e.g. arachnophobia for
spider.
• Lifetime prevalence among adults – 4% in men
and 13% in women. Age of onset usually in
childhood.

32. Aetiology of SP
• Persistence of childhood fears.
• Genetic – 31% of 1st degree relatives have specific phobia.
• Psychoanalytic – internalized source of anxiety and
displaced .
• Conditioning and cognition – role of association learning or
observation learning. Cognitive factors maintain the fear
e.g. fearful anticipation and selective attention.
• Prepared learning – in primates, the young monkeys are
prepared with the fear of snakes.
• Cerebral location- increased activity in anterior cingulate,
amygdala and hippocampal areas in PET when exposed to
the stimulus.

33. Treatment
• Exposure form of behavior therapy. This can
be implosion or flooding.
• Short course BDZ.

34. Social phobia
• Inappropriate anxiety experienced in social
settings in which the person feels observed by
others or could be scrutinized or criticized.
• Patient avoids such situations or endures it when
inevitable with great distress.
• Patient experiences anticipatory anxiety when
there is prospect of encountering the situation.
• Settings include restaurants, lecture halls, party,
seminars, board meetings etc.
• Any of the symptoms of anxiety could be
experienced but blushing and trembling.

35. Social phobia
• The cognition centers on being evaluated critically by
others.
• They may be particularly bordered and unable to urinate in
public lavatory or have frequent urge to micturate, with
fear of incontinence. Some may fear they may vomit in
public places.
• Alcohol misuse and depression are common co morbidities.
• Patients may adopt safety behaviours such as avoiding eye
contact in the hope that this would limit their distress.
• Occurs in 3-7% of 18-54 yr olds , equally frequent among
males and females seeking for help.

36. Differential diagnosis
• Agoraphobia
• Panic disorder
• GAD
• Depression
• Schizophrenia
• Body dysmorphic disorder
• Avoidant personality
• Normal shyness

37. Aetiology
• Genetic factors
• Conditioning
• Cognitive factors –undue concern that others
would be critical of them ( fear of negative
evaluation), excessive high standard for social
performance, negative belief about self,
excessive monitoring of own performance in
social settings and intrusive negative images
of self as supposedly seen by others.

38. Treatment
• CBT- directed at the cognitive errors and
measures to reduce safety behaviours
• Relaxation training
• Dynamic psychotherapy
• Drugs – SSRI, MAOI,B- blockers

39. Agoraphobia
• Literally means fear of the market place.
• Patients become anxious when away from
home, in crowd, or in situations which they
can not leave easily (i.e. confinement) without
attracting attention.
• They avoid such situations, feel anxious when
anticipating it.

40. Agoraphobia
• They may have panic attacks either in response to the
environment or spontaneously, also there are anxious
cognitions about fainting or losing control.
• Patients may continue avoiding the situations until they are
unable to leave home, a situation called “housebound
housewife syndrome”. Some are helped when in company
of a trusted friend, a child or even a pet. They then become
more dependent on their partners or relatives for help in
situations that provoke the anxiety.
• Most cases begin in early or middle 20s, and also in mid
30s.
• 1-year prevalence is 1.7% in males and 3.8% in females,
with a lifetime prevalence of 6-10%.

41. Differential diagnosis of agoraphobia
• Social phobia
• GAD
• Panic disorder
• Depression
• Paranoid disorders

42. Aetiology of agoraphobia
• For onset:
• Cognitive – unreasonable fear about some
aspects of the situation or certain physical
symptoms experienced in the situations of onset.
• Biologic - chance environmental stimuli acting on
an individual with a predisposition to over-
respond with anxiety.
• Psychoanalytic – unconscious mental conflicts
related to unacceptable sexual or aggressive
impulses triggered indirectly by the original
situation.

43. • For spread and maintenance
• Conditioning -could account for spreading to
other situations
• Personality – patients often described as
dependent and tends to avoid rather than
confront problems.
• Family influences – it could be maintained by
family problems or over protective family
members.

44. Treatment
• Exposure treatment quite effective especially
when combined with anxiety management skills.
• The anxiety management skills are general
treatment for anxiety and involve:
• (1) Assessment- the patient keeps a diary record
of the frequency and severity of the symptoms,
the situations in which they occur and the
avoidance behaviours.
• (2) Information- given about the physiology of
anxiety and any other matters that would correct
misconceptions.

45. • (3) Explanation- of the various vicious cycles in anxiety.
• (4) Relaxation- training as a means of controlling
anxiety.
• (5) Exposure- to situations that provoke the anxiety.
• (6) Distraction- to reduce the impact of anxiety
provoking or inducing thoughts.
• CBT
• Drugs- Anti-anxiety drugs e.g. BDZ on specific short
term basis, SSRI, MAOI, TCAs.

46. Transcultural variations in anxiety
• Presentation of anxiety is mainly somatic rather
than psychological in most cultures.
• This difference parallels the different words used
to describe anxiety in the corresponding
languages.
• There is no word for anxiety in most African,
oriental and American-Indian languages. Phrases
are rather used to describe these experiences.
• Some conditions are believed to be variants of
anxiety e.g. Koro, Brain fag syndromes.

47. Thank you for your attention.
•Questions?

48. References
• Brown GW and Harris TO (1993). Aetiology of anxiety
and depressive disorders in an inner-city population. 1
early adversity. Psychological medicine, 23,143-54.
• Kendler KS, Neale MC, Kessler RC et al (1992).
Childhood parental loss and adult psychopathology in
women: a twin study perspective. Archives of General
psychiatry, 49, 109-16.
• Bhatia MS, 2006. Essentials of psychiatry, CBS
publishers, New Delhi.
• Sadock BJ, Sadock VA, 2007. Synopsis of Psychiatry,10th
Ed. Lippincott William &Wilkins, Philadelphia.

49. • Ndetei DM, 2006. The African textbook of clinical
psychiatry and mental health, The African
medical and research foundation, Nairobi.
• Hales RE, Yudofsky SC, 2006. Textbook of clinical
psychiatry, 4th Ed,American psychiatric publishing,
Washington DC.
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oxford textbook of psychiatry, 5th Ed, oxfrd
university press, oxford.