This document provides an overview of anxiety and anxiety disorders presented by Dr. Joseph Jacob Panikulam. It defines anxiety as a normal biological response to threats and distinguishes this from pathological anxiety. Several common anxiety disorders are described such as generalized anxiety disorder, panic disorder, social anxiety disorder, post-traumatic stress disorder, obsessive-compulsive disorder, and specific phobias. The epidemiology, clinical features, diagnosis, treatment and prognosis of each disorder are summarized. The physiological mechanisms of the anxiety response and strategies for managing anxiety are also discussed.

1. ANXIETY AND ANXIETY
DISORDERS
Dr Joseph Jacob Panikulam
Taylor’s University School of Medicine

2. Learning objectives
 Understand the concept of anxiety as normal
biological response
 Understand the physiological basis and
features of the fight-or-flee response
 Distinguish pathological from normal anxiety

3. Learning objectives
 Identify clinical features of common anxiety
and stress related disorders
 Know the epidemiology of common anxiety
and stress related disorders
 Be able to correctly diagnose common
anxiety and stress related disorders

4. Learning objectives
 Be aware of the principles of managing
common anxiety disorders
 Know when, what and to whom to refer cases
of anxiety disorder

5. In this lecture …
 The concept of anxiety/stress
 Physiology of anxiety
 Differentiate physiological from pathological
anxiety

6. This lecture …
 Signs and symptoms of anxiety
 Medical consequences of unresolved stress
 Various anxiety disorders
 Description, clinical features, epidemiology,
differential diagnosis, comorbidities and principles
of treatment

12. Anxiety
 Normal, natural, biological built-in protective
mechanism
 Under threat of danger, real or expected
 Stress response, fight or flight response

13. Anxiety
 Fear or worry
 Physical features (biological mechanism)
 Recovers after the danger

14. Fight or Flee
Muscles
Eyes
Pupils
Heart
Breathing
Blood flow
Fainting
Sweating
Bladder
Bowel
Tremors
Energy

15. Response to Stress
• Long time -- adapt or cope
• Too long or too much--failure to adapt
• Physical and psychological stress related
diseases

16. Signs of Stress
Headache
Giddiness
Appetite
Palpitations
Chest discomfort
Abdominal discomfort
Diarrhoea
Constipation
Tremors

17. Signs of stress
Insomnia
Anxiety
Depression
Crying spells
Loss of interest
Poor concentration
Poor memory
Unable to make
decisions
Unable to solve
problems
Irritability

18. Stress related diseases
Heart diseases
Hypertension
Stroke
Asthma
Gastritis
Stomach ulcers
Skin problems
Tension headache
Migraine
Reduced immunity
Impotence

19. Stress Related Diseases
• Menstrual disorders
• Anxiety disorders
• Depressive disorders
• Emotional disturbances
• Social disturbances

20. Consequences - Unable to Cope
• Poor performance
• Absenteeism
• Stalled promotion
• Tension, anger, frustration
• Physical illness
• Drug and alcohol abuse

21. Consequences - Unable to Cope
• Marital discord
• Physical abuse

22. Anxiety
 When is it pathological?
 Inappropriate in amount or duration
 Present without cause
 Other associated features
 Sadness, somatic, avoidance, sleep, social …
physical disorders

23. Anxiety disorders
 Phobias
 Simple
 Agarophobia
 Social phobia
 Generalised anxiety disorder
 Adjustment disorders
 Stress reactions
 OCD
 Panic disorder

24. • The term “phobia” refers to an excessive fear
of a specific object, circumstance, or situation
• Phobias are classified based on the nature of
the feared object or situation
 1. Agoraphobia
 2. Specific (Limited to one/ few objects or situation)
 3. Social (limited to social situations)
Phobia

25. Simple phobias
 Fear of specific objects or animals
 Avoidance and anticipatory anxiety
 Panic attacks

26. Specific phobia/Simple
phobia
 Strong, persisting fear of specific object or
situation
 Arachnophobia
 Haemophobia
 Phonophobia
 Hydrophobia
 Dog phobia
 Computer phobia

27. Clinical Features
Component Prominent features
Emotion/mood Anxiety, irritability
Cognitions Exaggerated worries and fears
Behaviour Avoidance of feared situations/objects
Somatic Tight chest, hyperventilation,
palpitations, ‘butterflies’, tremor,
tingling of fingers, aches and pains,
poor sleep, fequent desire to pass
urine and motion

28. Agoraphobia
 Anxiety in situations where escape or help
may not be easily available.
 Crowded places
 Enclosed places
 Underwater
 Panic attacks

29. Epidemiology
 Lifetime prevalence 2-6%
 It begins mainly in the early or middle
twenties, with a second peak in the mid
thirties.
 Women 2-3x than men
 75% have panic disorder

30. MENTAL STATE EXAMINATION
•Behavior: psychomotor agitation, tremor/ fidgety/ hyper-vigilant, with
fear, intense eye contact, limited cooperation
•Speech: often pressured but interruptible, difficulty speaking
•Mood/Affect: likely congruent with mood, anxious, scared, labile,
irritable, angry.
•Thought Process: perseverative, ruminative, circumstantial
•Thought Content: obsessions, worries, concerns regarding danger
•Cognition: generally intact apart from concentration and attention
•Insight/Judgment: anxiety is often fear out of proportion to the realistic
level of threat, so insight not necessarily that great.Therefore, judgment
may also be impaired

31. Differential Diagnosis
Mental
Panic disorder, depressive disorder, obsessive
compulsive disorder, post traumatic stress disorder,
social phobia, generalized anxiety disorder.
Medical
Congestive heart failure, angina, myocardial
infarction, thyrotoxicosis, phaechromocytoma.
Medication/Drugs
Amphetamine, caffeine, nicotine, cocaine, alcohol
or opiate withdrawal

32. Treatment
• When coexisting panic disorder is treated, it
usually resolved
• Teach coping skills and relaxation
• Anxiolytic- benzodiazepine, (short term)
• alprazolam and clonazepam
• Antidepressants for panic symptoms
• Behavioral therapy

33. Panic disorder
 Attacks of short-lived anxiety in relation to
specific situations
 Or spontaneous panic attacks with no
apparent cause
 Often take action to avoid recurrence- may
develop into agoraphobia

34. Epidemiology
 Lifetime prevalence is 1-4%
 2 to 3 times more common in females than
males
 It has strong genetic component, 4 to 8 times
greater risk if first degree relative is affected
 Age of onset is usually late teens to early
thirties, average age is 25 but may occur at any
age

35. Clinical features
 First panic attack is usually unexpected and is
accompanied by feelings of extreme fear and
impending doom
 It may follow a period of stress or physical
exertion
 Spontaneous recurrent panic attack without
obvious precipitant
 Anticipatory anxiety about having another
attack between episodes.

36. Differential Diagnosis
• Medical
 Congestive heart failure, angina, myocardial
infarction, thyrotoxicosis, phaechromocytoma,
carcinoid syndrome, chronic obstructive
pulmonary disease
• Medication/Drugs
 Amphetamine, caffeine, nicotine, cocaine, alcohol
or opiate withdrawal
• Mental
 Phobic disorder, depressive disorder, obsessive
compulsive disorder, post traumatic stress
disorder

37. Treatment
 Psychotherapy(Non pharmacological)
 cognitive behavior therapy - teaches a person different
ways of thinking, behaving, and reacting to situations
that help him or her feel less anxious and fearful.
 Interoceptive therapy - simulates the symptoms of
panic to allow patients to experience them in a controlled
environment. Symptom inductions should be repeated
three to five times per day until the patient has little to
no anxiety in relation to the symptoms that were induced

38. Prognosis
 Panic disorder is a chronic disorder, although its course is
variable.
 30 to 40 % - remain symptom free after treatment;
 50 % continue to have mild symptoms
 10 to 20 % continue to have significant symptoms.
 Depression can complicate the symptom from 40 to 80 %
of all patients. Alcohol and other substance dependence
occurs in about 20 to 40% of all patients, and OCD may
also develop.
 Patients with good premorbid functioning and symptoms
of brief duration tend to have good prognoses.

39. Generalised Anxiety Disorder
 Excessive anxiety & worry almost all the time;
free floating anxiety
 Accompanied by restlessness, fatigue, poor
concentration, irritability, muscle tension &
reduced sleep
 Often co-morbid with depression when it
greatly increases the suicide risk

40. Epidemiology
 GAD is very common in the general
population.
 3-8% of general population.
 Lifetime prevalence: 45%
 M:W= 1 : 2
 Onset is usually before 20 y.o; many
patients report lifetime of “feeling anxious.”

41. Comorbidity
 Other anxiety disorders (simple phobia,
social phobia, panic disorder)
 MDD
 Alcohol and drug problems
 Other 'physical' condition (e.g irritable
bowel, hyperventilation, atypical chest
pain)

42. Etiology
 Not clearly understood.
 Hypothesize that biological and psychosocial factor contribute to
the problem
 Genetic : heritability 30%
 :Neuro may be due to altered levels of GABA and serotonin levels in
brain
 Pet scan of brain shows reduced metabolic rate in basal ganglia
 Psychological:
o Experience of unexpected negative events (early parent death, rape,
war)
o Chronic stressors (dysfunctional family/marriage)
o Overprotective or parenting lacking warmth and responsiveness
o sensitive and insecure personality have lower threshold for
developing GAD

44. Differential diagnosis
 Normal worries
 Mixed anxiety/depression
 Other anxiety disorders
 Drug and alcohol problems
 Medical condition

45. Treatment
Biopsychosocial approach
 Pharmacological
◦ Benzodiazepines – short term, possible risk of
tolerance and dependence
◦ Buspirone- 5HT1A receptor partial agonist, more
towards cognitive symptoms vs somatic. Effect
not immediate.
◦ SNRI- for insomnia, restlesss, poor concentration,
irritability, excessive muscle tension.
◦ SSRI- especially with comorbid depression
◦ TCA

46.  Psychosocial
• cognitive-behavioral, supportive, and
insight oriented
• Psychoeducation- educate about panic
attack and modification of thinking errors
• Relaxation therapy
• Support system – family, friends, support
group.

47. Prognosis
 50% of patients - chronic, with lifelong,
fluctuating symptoms
 The other 50% fully recover within several
years of therapy.

48.  However remission rate is low
o about 30% after 3yrs of treatment
o 68% has mild residual symptoms after 6yrs of
treatment
o 9% has severe persistent impairment
 Prognosis worsen with co-morbidities e.g.
substance abuse

50.  Intense fear in social situations
 Fear of being judged, embarrassed or
humiliated
 Associated with blushing, sweating,
trembling, palpitations & nausea
 Leads to avoidance of a variety of social
situations
Social Anxiety Disorder

51. Clinical Features
Component Prominent features
Emotion/mood Situational anxiety in social gatherings
Cognitions Being judged negatively by others
Behaviour Avoidance of social occasions
Somatic Blushing, trembling, sweating,
palpitations, nausea, stammering
Associations Secondary alcohol misuse
Low self-esteem
suicide thoughts

52. Differential Diagnosis
 Other anxiety and related disorders (GAD,
agoraphobia, OCD)
 Poor social skills
 Anxious/avoidant personality traits
 Depressive disorder
 Secondary avoidance due to delusional ideas in
psychotic disorders
 General medical condition
 Substance misuse

53.  Psychological
- CBT (first line)
- relaxation training/anxiety management
- social skills training
- integrated exposure methods
 Pharmacotherapy
 SSRI : paroxetine, fluoxetine
 MAOI : phenelzine
 RIMA
 B-blockers if performance phobia

54. Prognosis
 Without treatment, may be a chronic lifelong
condition
 With treatment, response rates may be up to
90%, especially with combined approaches
 Medication best regarded as long-term, as
relapse rates are high on discontinuation

55. Post-traumatic Stress
Disorder

57. Post-traumatic Stress
Disorder
 Response to traumatic events- violence,
accidents, disasters, military action, crime
 Event is life-threatening
 Experienced or witnessed
 Overwhelming emotional response

58. PTSD
 Re-experiencing
 flashbacks, re-living, nightmares, reacting to
reminders

59. PTSD
 Persistent avoidance of stimuli
 Avoidance of people/places/situations/objects
 Avoidance of thoughts/feelings
 Amnesia

60. PTSD
 Hyperarousal
 Insomnia
 Irritability
 Hypervigilance
 Exaggerated startle response

61. OCD
 Obsessions
 Recurrent, intrusive thoughts, impulses, images
 Unwelcome/unacceptable but irresistible
 Know it is from own mind, know it is irrational
 Compulsions
 Conscious, standardized, recurring pattern of
behavior

62. OCD
 Common themes
 Contamination & cleaning
 Pathological doubt & checking
 Counting/rituals
 Obsessions alone – unacceptible
sexual/aggressive acts
 Symmetry/precision