This document provides an overview of panic disorder, agoraphobia, and generalized anxiety disorder. It discusses the etiology, diagnosis, diagnostic criteria, differential diagnosis and management of each condition. Panic disorder is characterized by spontaneous panic attacks followed by at least 1 month of worries about additional attacks. Cognitive behavioral therapy and pharmacotherapy including SSRIs are used to treat panic disorder. Agoraphobia involves an intense fear of two or more situations where escape may be difficult, such as crowds or public transportation. It often co-occurs with panic disorder. Generalized anxiety disorder involves excessive, uncontrollable worry about everyday life events.

1. Panic Disorder, Agoraphobia, and Generalized Anxiety Disorder
ANXIETYDISORDERS
😱
SREE UPPALAPATI

2. - Introduction
- Panic Disorder
- Panic attacks
- Etiology
- Diagnosis and DSM-5 Criteria
- Hyperventilation Syndrome and Di
ff
erential
Diagnosis
- Management
- Agoraphobia
- Etiology
- Diagnosis and DSM-5 Criteria
- Di
ff
erential Diagnosis
- Management
OUTLINE
- Generalized Anxiety Disorder
- Etiology
- Diagnosis and DSM-5 Criteria
- Di
ff
erential Diagnosis
- Management

3. INTRODUCTION

4. - Anxiety has two main components: fearful thoughts, and physical symptoms of
autonomic arousal.
- Feelings of anxiety or fear are both common and essential to the human experience. It is
the very uncomfortable nature of this experience that makes anxiety such an e
ff
ective
alerting, and therefore harm-avoiding, device.
- However, for the same reasons, when anxiety is excessive and unchecked it can create
an extremely debilitating condition.
- To distinguish between normal and pathological anxiety it is important to observe the
patient’s level of functioning.
GENERALREVIEWOFANXIETY

5. The Yerkes–Dodson
law states that the
relationship between
performance and
anxiety has the shape
of an inverted U: mild
to moderate levels of
anxiety improve
performance, but high
levels impair it.

6. - Generalized (free-
fl
oating) anxiety does not occur in discrete episodes and tends to last
for hours, days or even longer and is of mild to moderate severity.
- It is not associated with a speci
fi
c external threat or situation (i.e. free-
fl
oating); it is
excessive worry or apprehension about many normal life events (e.g. job security,
relationships and responsibilities).
- Paroxysmal anxiety has an abrupt onset, occurs in discrete episodes and tends to be
quite severe. In its severest form, paroxysmal anxiety presents as panic attacks. These are
discrete episodes of short-lived (usually less than 1 hour), intense anxiety.
- They are accompanied by strong autonomic symptoms, which may lead patients to
believe that they are dying, having a heart attack or going mad.
- Paroxysmal anxiety can further be subdivided into episodes of anxiety that occur
seemingly spontaneously, without a speci
fi
c imagined or external threat (eg, Panic
disorder) and those episodes that occur in response to a speci
fi
c imagined or external
threat (eg, Speci
fi
c Phobias).
TWOPATTERNSOFPATHOLOGICALANXIETY

7. Comparison of panic attacks and free-
fl
oating (generalized) anxiety.
Quite often the two co-occur: someone with a background moderately
elevated anxiety level can also have superimposed panic attacks.

8. PANICDISORDER

9. - A panic attack is a period of intense anxiety that begins suddenly and can last from
several minutes to an hour.
- It can begin from an anxious or calm state, and the intensity quickly escalates within
minutes to a cluster of at least 4 symptoms of sympathetic arousal.
- Panic attack is not a mental disorder and cannot be coded.
- Panic attacks can occur in the context of any anxiety disorder as well as other mental
disorders (e.g., depressive disorders, posttraumatic stress disorder, substance use
disorders) and some medical conditions (e.g., cardiac, respiratory, vestibular,
gastrointestinal).
- When the presence of a panic attack is identi
fi
ed, it should be noted as a speci
fi
er (e.g.,
“posttraumatic stress disorder with panic attacks”).
-
WHATISAPANICATTACK?

10. - An abrupt surge of intense fear or intense
discomfort that reaches a peak within minutes,
and during which time four (or more) of the
following symptoms occur:
- Da PANICS
- Dizziness, Disconnectedness, Derealization
(unreality), Depersonalization (detached from self)
- Palpitations, Paresthesias
- Abdominal distress
- Numbness, Nausea
- Intense fear of dying, losing control or “going
crazy”
- Chills, Chest pain
- Sweating, Shaking, Shortness of Breath
PANICATTACKSYMPTOMS

11. - There are two characteristic types of panic attacks: expected and unexpected.
- Expected panic attacks are attacks for which there is an obvious cue or trigger, such as
situations in which panic attacks have typically occurred.
- Unexpected panic attacks are those for which there is no obvious cue or trigger at the
time of occurrence (e.g., when relaxing or out of sleep [nocturnal panic attack])
- Nocturnal panic attack (i.e., waking from sleep in a state of panic), which di
ff
ers from
panicking after fully waking from sleep.
- Cultural interpretations may in
fl
uence their determination as expected or unexpected.
Culture-speci
fi
c symptoms (e.g., tinnitus, neck soreness, headache, uncontrollable
screaming or crying) may be seen; however, such symptoms should not count as one of
the four required symptoms.
PANICATTACKFEATURES

12. - Panic disorder is characterized by spontaneous, recurrent panic attacks. These attacks
occur suddenly, out of the blue.
- Patients may also experience some panic attacks with a clear trigger. The frequency of
attacks ranges from multiple times per day to a few monthly. Patients develop debilitating
anticipatory anxiety about having future attacks—“fear of the fear.”
- In addition, persons with panic disorder have a much higher risk of alcohol abuse or
dependence and suicidality than the general population.
- Etiology has both Genetic and Psychological factors:
- Genetic factors: Greater risk of panic disorder if a
fi
rst-degree relative is a
ff
ected.
- Psychosocial factors: ↑ incidence of stressors (especially loss) prior to onset of
disorder; history of childhood physical or sexual abuse.
- Females are more likely to have panic disorder in a 2:1 ratio.
PANICDISORDER-OVERVIEW/ETIOLOGY

13. - Recurrent, unexpected panic attacks.
- Attacks followed by 1 mo of one of the following: concerns about having additional
attacks or worry about the consequences of attacks, and/or a maladaptive change in
behavior related to the attacks.
- Attacks are not caused by the physiological e
ff
ects of a substance, a medication, or a
medical condition.
- Attacks are not better accounted for by another mental disorder.
PANICDISORDER-DIAGNOSIS/DSM-5CRITERION

15. - History, collateral information, and
physical examination, as well as a mental
status examination remain the diagnostic
cornerstones for panic disorder.
- It is crucial to assess the speci
fi
c
features of the individual patient’s panic
disorder, such as whether agoraphobia
is present, the extent of situational fear
and avoidance, and whether there are
comorbid psychiatric conditions, all of
which can a
ff
ect the course, treatment,
and prognosis of panic disorder
- Additionally, it is important to screen for
medical illnesses that could be causing
the panic attacks.
CLINICALMANIFESTATION-HISTORY
- History should be elicited about the following:
- Onset of symptoms
- Panic attack features, duration, frequency, and severity
- Triggers for the panic attacks or if they occur
unexpectedly
- Persistent worry about additional attacks or their
consequences
- Avoidance behaviors or other behavioral changes as a
result of the panic attacks
- How the symptoms are a
ff
ecting the patient’s daily life,
including work and relationships
- Recent stressors
- Beliefs about the reason for the symptoms
- Previous periods of having panic attacks, the duration
of these periods, and treatment
- Medication and substance use
- Coping skills used

16. - No results on the mental status examination (MSE) are speci
fi
c for panic disorder.
- The patient may or may not appear anxious at the time of interview,
- During a panic attack, a MSE may reveal extreme anxiety, fear, and a sense of impending death or
doom.
- The patient may have di
ffi
culty speaking as well as appear sweaty and confused. The patient’s
speech may re
fl
ect anxiety or urgency, or it may sound normal, and the individual’s mood may be
described as similar to "anxious," with congruent a
ff
ect.
- Incongruent a
ff
ect should raise consideration of other diagnostic possibilities.
- The patient’s thought processes should be logical, linear, and goal directed.
- Thought content is particularly important to speci
fi
cally assess in order to ensure that a patient has
no suicidal or homicidal thoughts.
- Acute anxiety, as a form of acute mental anguish, can lead to unsafe or self-injurious behavior.
- Abnormalities in thought process or thought content (aside from impulsive suicidal thoughts) should
prompt reconsideration of other etiologies. Insight and judgment are usually present and intact.
CLINICALMANIFESTATION-MENTALSTATUSEXAMINATION

17. - Anxiety disorder due to another medical condition: Panic disorder is not diagnosed if the
panic attacks are judged to be a direct physiological consequence of another medical
condition.
- Appropriate laboratory tests (e.g., serum calcium levels for hyperparathyroidism; Holter
monitor for arrhythmias) or physical examinations (e.g., for cardiac conditions) may be
helpful in determining the etiological role of another medical condition.
- Substance/medication-induced anxiety disorder: Panic disorder is not diagnosed if the
panic attacks are judged to be a direct physiological consequence of a substance.
Intoxication with central nervous system stimulants (e.g., cocaine, amphetamines, ca
ff
eine)
or cannabis and withdrawal from central nervous system depressants (e.g., alcohol,
barbiturates) can precipitate a panic attack.
- Other speci
fi
ed anxiety disorder or unspeci
fi
ed anxiety disorder: Panic disorder should
not be diagnosed if full-symptom (unexpected) panic attacks have never been
experienced.
DIFFERENTIALDIAGNOSIS

19. - Other mental disorders with panic attacks as an associated feature (e.g., other anxiety
disorders and psychotic disorders): Panic attacks that occur as a symptom of other
anxiety disorders are expected (e.g., triggered by social situations in social anxiety
disorder, by phobic objects or situations in speci
fi
c phobia) and thus would not meet
criteria for panic disorder.
- The hallmark of panic disorder is unexpected panic attacks not provoked by any
particular stimulus; this is in contrast to other anxiety disorders, where panic attacks
occur because of exposure to a certain cue.
DIFFERENTIALDIAGNOSIS

20. - Hyperventilation syndrome (HVS) presents with acute onset of deep breathing and/or
tachypnea often accompanied by neurologic symptoms. Lung examination is normal.
- Patients with acute HVS) may present with agitation and anxiety. Most commonly, the
history is one of sudden onset of dyspnea, chest pain, or neurologic symptoms (eg,
dizziness, weakness, paresthesias, or near-syncope) after a stressful event.
- There is an overlap between hyperventilation syndrome and panic disorders; however,
panic attacks are characterized by an acute onset of intense fear accompanied by 4 out of
13 symptoms that may not necessarily include respiratory symptoms.
- Education and reassurance are key comments of treatment. Patients should be taught
abdominal (diaphragmatic) breathing, a retraining maneuver that involves trying to keep
the chest still.
- Rebreathing into a paper bag is no longer a recommended technique, because of
signi
fi
cant hypoxia and death.
HYPERVENTILATIONSYNDROME

21. - A biopsychosocial model can be used and it proposes there are multiple, and inter-related
causes of pathological anxiety. These causes can be roughly categorized into three main
groups: biological causes, psychological causes, and environmental or social causes.
- Pharmacotherapy, cognitive- behavioral therapy (CBT), and other psychological
treatment modalities are used to manage panic disorder.
- The American Psychiatric Association (APA) recommends treating patients with panic
disorder when symptoms cause dysfunction (e.g., work, family, social, leisure activities) or
signi
fi
cant distress.
PANICDISORDER-MANAGEMENT

22. - Cognitive-behavioral therapy (CBT) helps patients to
understand how automatic thoughts and false beliefs/
distortions lead to exaggerated emotional responses,
such as anxiety, and how they can lead to secondary
behavioral consequences.
- CBT is an evidence-based therapy for many psychiatric
conditions. It focuses on identifying and changing
maladaptive thoughts, feelings, and behaviors.
- The typical treatment course is 12 weeks, with sessions
usually occurring once per week.
- For panic disorder, some elements of CBT are relaxation
training, mindfulness training, cognitive restructuring
(identifying anxiety-provoking thoughts and replacing
them with calm ones).
PANICDISORDER-COGNITIVEBEHAVIORTHERAPY

23. - First line therapy is with SSRIs (
fl
uoxetine, paroxetine, and sertraline).
- While SNRIs (venlafaxine), and TCAs (imipramine and clomipramine) are also highly
e
ff
ective in treating panic disorder and are FDA approved.
- Treatment with a benzodiazepine may be needed on a short- term basis to provide more
immediate relief. In fact, alprazolam and clonazepam are not only e
ff
ective but also FDA
approved for the treatment of panic disorder.
- Small doses of atypical antipsychotics in combination with an SSRI or SSNRI can also be
used for treatment of resistant panic disorder.
- Beta-blockers like propranolol in low doses can be used to treat the physical symptoms of
panic attacks (tachycardia, tremor).
PANICDISORDER-PHARMACOTHERAPY

24. AGORAPHOBIA

25. - Agoraphobia literally means ‘fear of the marketplace’ (i.e. fear of public places).
- There is a close relationship between agoraphobia and panic disorder that occurs when
patients develop a fear of being in a place from where escape would be di
ffi
cult in the
event of having a panic attack.
- In fact, studies have shown that in a clinical setting, up to 95% of patients presenting
with agoraphobia have a current or past diagnosis of panic disorder. Therefore in the
ICD-10 you can code agoraphobia as occurring with or without panic disorder.
- The pathogenesis of agoraphobia is not known; however, an evolving body of research
has led to conceptual models suggesting that the etiology of the disorder involves a
complex interaction of biological, psychological, and environmental factors.
AGORAPHOBIA-OVERVIEW/ETIOLOGY

26. - Onset is usually before age 35.
- Course is persistent and chronic, with rare full remission.
- Comorbid diagnoses include other anxiety disorders, depressive disorders, and substance
use disorders.
- In its most severe forms, agoraphobia can cause individuals to become completely home-
bound, unable to leave their home and dependent on others for services or assistance to
provide even for basic needs.
- Demoralization and depressive symptoms, as well as abuse of alcohol and sedative
medication as inappropriate self-medication strategies, are common.
AGORAPHOBIA-OVERVIEW/ETIOLOGY

27. - Intense fear/anxiety about more than two situations due to concerns of di
ffi
culty escaping or obtaining help
in case of panic or other humiliating symptoms:
- Outside of the home alone.
- Open spaces (e.g., bridges).
- Enclosed places (e.g., stores).
- Public transportation (e.g., trains).
- Crowds/lines.
- The triggering situations cause fear/anxiety out of proportion to the potential danger posed, leading to
endurance of intense anxiety, avoidance, or requiring a companion. This holds true even if the patient
su
ff
ers from another medical condition such as in
fl
ammatory bowel disease (IBS) which may lead to
embarrassing public scenarios.
- Symptoms cause signi
fi
cant social or occupational dysfunction.
- Symptoms last ≥6 months.
- Symptoms not better explained by another mental disorder.
AGORAPHOBIA-DIAGNOSIS

28. - Speci
fi
c phobia, situational type: Requiring fears from two or more of the agoraphobic
situations is a robust means for di
ff
erentiating agoraphobia form speci
fi
c phobias.
- Panic disorder
- Separation anxiety disorder: Separation anxiety disorder can be best di
ff
erentiated from
agoraphobia by examining cognitive ideation. In separation anxiety disorder, the thoughts
are about detachment from signi
fi
cant others and the home environment.
- Social anxiety disorder (social phobia): In social anxiety disorder, the focus is on fear of
being negatively evaluated.
- Acute stress disorder and posttraumatic stress disorder: If the fear, anxiety, or avoidance
is restricted to trauma reminders
- Major depressive disorder: Individual may avoid leav ing home because of apathy, loss of
energy, low self-esteem, and anhedonia.
DIFFERENTIALDIAGNOSIS

29. - Although with the revision of DSM-IV to DSM-5, agoraphobia is diagnosed independently
of panic disorder, there has been little study of treatment for agoraphobia outside of trials
in patients with both panic disorder and agoraphobia.
- Based on current evidence, treatment of agoraphobia independent of panic disorder
should follow recommendations for agoraphobia in the context of panic disorder.
AGORAPHOBIA-MANAGEMENT

30. GENERALIZEDANXIETYDISORDER(GAD)

31. - Patients with GAD worry about everything (e.g., career, family, future, relationships, and
money) at the same time. Symptoms are not as dramatic as in panic disorder. The patient is
simply a severe worrier.
- The key element of generalized anxiety disorder is long-standing, free-
fl
oating anxiety.
- Many individuals with generalized anxiety disorder report that they have felt anxious and
nervous all of their lives. The median age at onset for generalized anxiety disorder is 30
years.
- GAD symptoms cause signi
fi
cant distress and/or impairment in the patient’s social life,
academics, or career. GAD typically is a chronic condition that can worsen with life
stressors. Like most anxiety disorders, GAD occurs more frequently in women than in men
(2:1 ratio).
- Course is chronic, with waxing and waning symptoms.
GENERALIZEDANXIETYDISORDER-OVERVIEW/ETIOLOGY

32. - Persistent, excessive, uncontrollable anxiety/worry ≥ 6 mo.
The person struggles to control the worry.
- At least three of these symptoms:
- Disrupted sleep
- Fatigue
- Impaired concentration
- Irritability
- Muscle tension
- Restlessness
- Symptoms are not better accounted for by another
psychiatric disorder.
- Not caused by the direct e
ff
ects of a substance or
medication or medical illness. Clinically signi
fi
cant distress
or impairment of psychosocial functioning.
GENERALIZEDANXIETYDISORDER-DIAGNOSIS

33. - Anxiety due to Medications/Substances or Medical Condition: Prior to diagnosing a primary
anxiety disorder, one must rule out substance intoxication/withdrawal, a substance/medication-
induced anxiety disorder, and an anxiety disorder due to another medical condition.
- A candid history regarding substances, current medications, the temporal relationship
between symptoms and use, collateral information, vital signs, physical examination, blood
alcohol level, and urine drug screen will help to determine if substances contribute to or
cause the patient’s anxiety.
- Other Anxiety Disorders: When establishing a diagnosis of GAD versus other anxiety
disorders, look for a broad base of anxiety (eg, free-
fl
oating) generalized across various
domains.
- Other anxiety disorders typically have a speci
fi
c focus or trigger, such as social anxiety
disorder, in which the worry stems from the judgment of others. GAD patients will worry
regardless of social evaluation.
- Anxiety commonly occurs with other disorders such as PTSD, obsessive-compulsive
disorder (OCD), adjustment disorders, mood disorders, and psychotic disorders.
DIFFERENTIALDIAGNOSIS

34. - The most e
ff
ective treatment for GAD entails a two-pronged approach combining both
pharmacotherapy and psychotherapy.
- Psychotherapy, in particular CBT, as mono-therapy or combined with medications, may
be considered as initial treatment for patients with mild-to-moderate symptoms.
- Psychodynamic psychotherapy can be helpful in understanding the maladaptive
patterns and unconscious reasons for the anxiety and working through those to
ultimately attain mastery over the symptoms. Psychotherapy helps patients develop
coping skills for life with longer-lasting treatment gains compared to medications.
- SSRIs are a
fi
rst-line medication for many disorders, including GAD. If there is no response
after an adequate trial, then switch to another SSRI.
- If symptoms continue without abating, SNRIs or TCAs can be tried.
- Other second-line medications often used as augmentation include benzodiazepines,
hydroxyzine, buspirone, and mirtazapine.
GENERALIZEDANXIETYDISORDER-MANAGEMENT

35. THANKYOU😄