Generalized anxiety disorder is characterized by excessive, uncontrollable worry about everyday life events for at least 6 months. It affects around 3-8% of people, with higher rates in women. Common comorbid disorders include social phobia, panic disorder, and OCD. Both biological and psychosocial factors contribute to its development, such as abnormalities in neurotransmitter systems like GABA and serotonin, and incorrectly perceiving threats. Treatment involves psychotherapy and medication to regulate neurotransmitter activity.

1. ANXIETY DISORDERS

2. NORMAL ANXIETY
• Everyone experiences it.
• Characterized most commonly as a diffuse, unpleasant, vague
sense of apprehension, often accompanied by autonomic
symptoms such as headache, perspiration, palpitations,
tightness in the chest, mild stomach discomfort, and
restlessness, indicated by an inability to sit or stand still for long.
• The particular constellation of symptoms vary among persons.

3. Fear Vs Anxiety
• Anxiety is an alerting signal
• It warns of impending danger and
enables a person to take measures to deal with a threat
• Fear-a response to a known, external, definite, or nonconflictual
threat
• Anxiety -a response to a threat that is unknown,internal, vague, or
conflictual

4. Peripheral symptoms of anxiety
• Diarrhoea
• Dizziness, light headedness
• Hyperhidrosis
• Hyperreflexia
• Palpitations
• Pupillary mydriasis
• Restlessness (e.g., pacing)
• Syncope
• Tachycardia
• Tingling in the extremities
• Tremors
• Upset stomach ("butterflies")
• Urinary frequency, hesitancy,
urgency

5. Is Anxiety Adaptive?
• Anxiety and fear both are alerting signals and act as a warning
of an internal and external threat.
• Anxiety can be conceptualized as a normal and adaptive
response that has lifesaving qualities and warns of threats.
• It prompts a person to take the necessary steps to prevent the
threat or to lessen its consequences.
• This preparation is accompanied by increased somatic and
autonomic activity controlled by the interaction of the
sympathetic and parasympathetic nervous systems.
• Thus, anxiety prevents damage by alerting the person to carry
out certain acts that forestall the danger.

6. Stress and Anxiety
• Whether an event is perceived as stressful depends on the
nature of the event and on the person's resources,
psychological defenses, and coping mechanisms.
• All involve the ego, a collective abstraction for the process by
which a person perceives, thinks, and acts on external events
or internal drives.
• A person whose ego is functioning properly is in adaptive
balance with both external and internal worlds.
• If the ego is not functioning properly  Anxiety

7. PATHOLOGICAL ANXIETY

8. Symptoms of Anxiety
• The awareness of the physiological sensations(e.g. palpitations &
sweating)
• The awareness of being nervous or frightened
• Motor and visceral effects
• Affects thinking, perception
• Interfere with learning by lowering concentration, reducing recall,
and impairing the ability to relate one item to another that is, to
make associations.
• Confusion and distortions of perception- Not only of time & space
but also of persons and meaning of events.
• It causes significant subjective distress and /or impairment in
functioning of an impairment.

9. ANXIETY DISORDERS

10. Epidemiology
• The anxiety disorders make up one of the most common groups
of psychiatric disorders.
• One of four persons met the diagnostic criteria for at least one
anxiety disorder
• 12-month prevalence rate of 17.7 %.
• Women > Men
(19.2 percent lifetime prevalence).
• Prevalence of anxiety disorders decreases with higher
socioeconomic status.

11. Psychological Aspects of Anxiety
disorders
• Three major schools of psychological theory:
• Psychoanalytic Theories: Anxiety was viewed as the result of
psychic conflict between unconscious sexual or aggressive
wishes and corresponding threats from the superego or external
reality.
• Behavioural Theories: Anxiety is a conditioned response to a
specific environmental stimulus.
• Existential Theories: Persons experience feelings of living in a
purposeless universe.

12. Biological Aspects of Anxiety disorders
A) Autonomic Nervous System
Stimulation of the autonomic nervous system causes certain
symptoms  cardiovascular( e.g. Tachycardia), muscular(e.g.
headache), gastrointestinal(e.g. diarrhea), and respiratory(e.g.
Tachypnea).

13. B) Neurotransmitters
• Three major neurotransmitters norepinephrine (NE), serotonin
(5HT), gamma-aminobutyric acid (GABA) are associated with
anxiety.
i)NOREPINEPHRINE (area – locus ceruleus):
• Patients may have a poorly regulated noradrenergic system with
occasional bursts of activity.

14. • Beta-adrenergic receptor agonists (e.g., isoproterenol ) and
alpha adrenergic receptor antagonists (e.g., yohimbine ) can
provoke frequent and severe panic attacks.
• Conversely, clonidine, and alpha2-receptor agonist, reduces
anxiety symptoms in some experimental and therapeutic
situations.

15. ii)Serotonin/5HT (area – locus ceruleus)
• Different types of acute stress result in increased 5-hydroxytryptamine (5-
HT) turnover in the prefrontal cortex, nucleus accumbens, amygdala, and
lateral hypothalamus.
• Effectiveness of buspirone , a serotonin 5-HT1a receptor agonist, in the
treatment of anxiety disorders also suggests the possibility of an
association between serotonin and anxiety..
• Serotonergic hallucinogens and stimulants-for example, lysergic acid
diethylamide (LSD) and 3,4-methylenedioxymethamphetamine (MDMA)---
are associated with the development of both acute and chronic anxiety
disorders.

16. iii) GABA:
• A role of GABA is supported by the undisputed efficacy of
benzodiazepines, which enhance the activity of GABA at the
GABA type A (GABA A) receptor, in the treatment of some
types of anxiety disorders.

17. C) HYPOTHALAMIC-PITUITARY-ADRENAL AXIS
• Consistent evidence indicates that many forms of psychological stress
increase the synthesis and release of cortisol.
• Excessive and sustained cortisol secretion can have serious adverse
effects, including hypertension, osteoporosis, immunosuppression,
insulin resistance, dyslipidemia, dyscoagulation, and, ultimately,
atherosclerosis and cardiovascular disease.
• Alteration of HPA axis function have been demonstrated in PTSD.
• Blunted ACTH responses to CRF have been reported in some studies
in Panic disorder.

18. D) Corticotropin-releasing hormone (CRH):
• CRH coordinates the adaptive behavioral and physiological changes
that occur
during stress.
• Hypothalamic levels of CRH are increased by stress, resulting in
activation of the HPA axis and increased release of cortisol and
dehydroepiandrosterone (DHEA)
• CRH also inhibits a variety of neurovegetative functions, such as food
intake, sexual activity, and endocrine programs for growth and
reproduction.

19. E)NEUROPEPTIDE Y:
• Evidence suggesting the involvement of the amygdala in the
anxiolytic effects of NPY via the NPY-Y1receptor.
• NPY has counterregulatory effects on (CRH) and LC-NE
systems at brain sites that are important in the expression of
anxiety, fear, and depression
• Preliminary studies in special operations soldiers under extreme
training stress indicate that high NPY levels are associated with
better performance.

20. F)GALANIN:
• It has been demonstrated to be involved in a number of physiological
and behavioral functions, including learning and memory, pain control,
food intake, neuroendocrine control, cardiovascular regulation, and,
most recently anxiety.
• galanin  LC  Various Cortical structures
• Hence, Galanin and NPY receptor agonists may be novel
targets for antianxiety drug development.

21. Brain Imaging Studies
• CT and MRI: occasionally show some increase in the size of cerebral
ventricles.
• fMRI studies like, PET, SPECT, and EEG - reported abnormalities in
the frontal cortex; the occipital and temporal areas; and, in a study of
panic disorder, the Parahippocampal gyrus.

22. Genetic Studies
Almost half of all patients with panic disorder have at least one affected
relative.

23. Neuroanatomical Basis
• The locus ceruleus(NE) and the raphe nuclei(5HT) project primarily to
the limbic system and the cerebral cortex.
i) LIMBIC SYSTEM:
• Animal studies shows involvement of the limbic system in the
generation of anxiety and fear responses.
• Two areas of the limbic system:
a)Increased activity in the septohippocampal pathway Anxiety
b)The cingulate gyrus OCD.

24. ii) CEREBRAL CORTEX
The frontal cerebral cortex and temporal cortex is connected
with the Parahippocampal region, the cingulate gyrus, and the
hypothalamus and thus may be involved in the production of
anxiety disorders.

25. Generalised Anxiety Disorder

26. • Generalized anxiety disorder is defined as excessive anxiety and worry
about several events or activities for most days during at least a 6-
month period.
• The anxiety is difficult to control, is subjectively distressing, and
produces impairment in important areas of a person's life.

27. EPIDEMIOLOGY
• 1-year prevalence 3 to 8 %.
• Women > men
• Lifetime prevalence is close to 5 % (maximum up to 8%)

28. Comorbid illnesses
• 50 to 90 % of patients with generalized anxiety disorder have
another mental disorder.
• 25 % of patients eventually experience panic disorder.
• Co morbidities viz.: social phobia, specific phobia, panic
disorder, OCD

29. ETIOLOGY
• Cause of generalized anxiety disorder is not known
• Biological and psychological factors probably work together
• Biological factors:
• Focused biological research efforts on the gamma-aminobutyric acid
and serotonin neurotransmitter systems.
• Other neurotransmitter systems in generalized anxiety disorder include
the norepinephrine, glutamate, and cholecystokinin systems.
• .

30. • Psychosocial factors
• Patients with generalized anxiety disorder respond to incorrectly and
inaccurately perceived dangers.
• Psychoanalytic school hypothesizes that anxiety is a symptom of
unresolved, unconscious conflicts.

31. DSM-5 Diagnostic Criteria for Generalized
Anxiety Disorder
A. Excessive anxiety and worry
(apprehensive expectation), occurring
more days than not for at least 6
months, about a number of events or
activities (such as work or school
performance).
B. The individual finds it difficult to
control the worry.
C.The anxiety and worry are associated
with three (or more) of the following
Restlessix symptoms (with at least
some symptoms having been present
for more days than not for the past 6
months):
Note: Only one item is required in
children.
1. Restlessness or feeling keyed up or on
edge.
2. Being easily fatigued.
3. Difficulty concentrating or mind going blank.
4. Irritability.
5. Muscle tension.
6. Sleep disturbance (difficulty falling or
staying asleep, or restless, unsatisfying
sleep).
D.The anxiety, worry, or physical
symptoms cause clinically
significant distress or impairment in
social, occupational, or
other areas of functioning.

32. DIFFERENTIAL DIAGNOSIS
Medical Disorders

33. DIFFERENTIAL DIAGNOSIS
Psychiatric disorders
• Common co-occurring anxiety disorders also must be
considered, including panic disorder, phobias, OCD, and PTSD.

34. COURSE AND PROGNOSIS
• Patients usually come to a clinician's attention in their 20s
• High incidence of comorbid mental disorders the clinical course
and prognosis of the disorder are difficult to predict
• Generalized anxiety disorder is a chronic condition that may
well be lifelong.

35. TREATMENT
• Psychotherapy
• CBT: address patients' hypothesized cognitive distortions directly
• Supportive psychotherapy: patients reassurance and comfort
• Insight oriented Therapy: uncovering unconscious conflicts and identifying
ego strengths
• Relaxation and Biofeedback

36. TREATMENT
• Behavioral approaches address somatic symptoms directly.
• Psychodynamic therapy proceeds with the assumption that anxiety can
increase with effective treatment.
• The goal of the dynamic approach may be to increase the patient's
anxiety tolerance, rather than to eliminate anxiety

37. • Pharmacotherapy
• Benzodiazepines: the drugs of choice for generalized anxiety disorder.
• Buspirone: 5-HT1A receptor partial agonist and is most likely effective in 60 to
80 percent of patients with generalized anxiety disorder.
• Disadvantage: Effect takes 2 to 3 weeks to become evident
• Venlafaxine: effective in treating the insomnia, poor concentration,
restlessness, irritability, and excessive muscle tension associated with
generalized anxiety disorder.
• Selective Serotonin Reuptake Inhibitors
• Other Drugs: Beta-adrenergic receptor antagonists may reduce the somatic
manifestations.

38. Panic Disorder

39. • An acute intense attack of anxiety accompanied by feelings of
impending doom is known as panic disorder.
• Comorbid conditions: most commonly agoraphobia
• Previously known as DaCosta's syndrome

40. EPIDEMIOLOGY
• Prevalence Panic disorder - 1 to 4 %
• Prevalence Panic attacks - 3 to 5.6 %
• Women > men.

41. Comorbid illnesses
• 91 % have at least one other psychiatric disorder.
• About 1/3rd have MDD before onset; 2/3rd experience during or after
the onset of MDD.
• Social anxiety disorder or social phobia
• Specific phobia
• Generalized anxiety disorder
• PTSD
• OCD
• Hypochondriasis or illness anxiety disorder, personality disorders,
and substance related disorders.

42. ETIOLOGY
• Biological Factors:
• Abnormal Regulation Of Brain Noradrenergic Systems
• Hypotheses Implicating Both Peripheral And Central Nervous System
Dysregulation.
• Major Neurotransmitter Systems: NE, 5HT, And GABA
• Postsynaptic Serotonin Hypersensitivity In Panic Disorder Local Inhibitory
• GABA-nergic Transmission in the Basolateral Amygdala, Midbrain, And
Hypothalamus can elicit anxiety-like Physiological Responses.
• Patients With Panic Disorder are Sensitive to The Anxiogenic Effects Of
Yohimbine.

43. Panic-Inducing Substances: Panicogens
• Carbon dioxide (5 to 35 percent mixtures)
• Sodium lactate, and bicarbonate
• Neurochemical panic-inducing substances that act through specific
neurotransmitter systems include yohimbine, an a2-adrenergic receptor
antagonist; mCPP, m-caroline drugs; GABA-B receptor inverse agonists;
flumazenil, a GABA-B receptor antagonist; cholecystokinin; and caffeine,
Isoproterenol.
• Respiratory panic-inducing substances may act initially at the
peripheral cardiovascular baroreceptors and relay their signal by vagal
afferents to the nucleus tractus solitarii and then on to the nucleus
paragigantocellularis of the medulla.

44. Brain Imaging
• MRI: Temporal lobes, particularly
the hippocampus and the amygdala.
• PET: Dysregulation of cerebral blood flow, cerebral
vasoconstriction, which may result in CNS symptoms, such as
dizziness, and in peripheral nervous system symptoms that may
be induced by hyperventilation and hypocapnia.

45. Genetic Factors
• First-degree relatives of patients with panic disorder have a
four- to eightfold higher risk for panic disorder than first-degree
relatives of other psychiatric patients.

46. Psychosocial Factors
• Psychoanalytic theories- panic attacks as arising from an unsuccessful defense
against anxiety-provoking impulses.
• Panic attacks is likely to involve the unconscious meaning of stressful events
• The pathogenesis of the panic attacks may be related to neurophysiological
factors triggered by the psychological reactions.
• Panic attacks are correlated neurophysiologically with the locus ceruleus, the
onset of panic is generally related to environmental or psychological factors.
• Stressful life events (particularly loss)
• Childhood physical and sexual abuse.
• Before the therapy, the patients responded to panic attack induction with lactate.
After successful cognitive therapy, lactate infusion no longer
produced a panic attack.

47. DIAGNOSIS
• Panic Attacks
• A panic attack is a sudden period of intense fear or apprehension that may
last from minutes to hours.

48. DSM-5 Diagnostic Criteria for Panic Disorder
A. Recurrent unexpected panic attacks. A panic attack is
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:
Note: The abrupt surge can occur from a calm state or
an anxious state.
1. Palpitations, pounding heart, or accelerated heart
rate.
2. Sweating.
3. Trembling or shaking.
4. Sensations of shortness of breath or smothering.
5. Feelings of choking.
6. Chest pain or discomfort.
7. Nausea or abdominal distress.
8. Feeling dizzy, unsteady, light-headed, or faint.
9. Chills or heat sensations.
10.Paresthesias (numbness or tingling sensations).
11.Derealization (feelings of unreality) or
depersonalization (being detached from one-self).
12.Fear of losing control or "going crazy.“
13.Fear of dying.
Note: Culture-specific symptoms (e.g., tinnitus, neck
soreness, headache, uncontrollable screaming or
crying) may be seen. Such symptoms should not
count as one of the four required symptoms.
B. At least one of the attacks has been followed by 1
month
(or more) of one or both of the following:
1. Persistent concern or worry about additional
panic
attacks or their consequences (e.g., losing
control, having a heart attack, "going crazy").
2. A significant maladaptive change in behavior
related
to the attacks (e.g., behaviors designed to
avoid having
panic attacks, such as avoidance of exercise
or unfamiliar situations).

49. CLINICAL FEATURES
• First panic attack is often completely spontaneous, although panic
attacks occasionally follow excitement, physical exertion, sexual
activity, or moderate emotional trauma.
• The attack often begins with a 10-minute period of rapidly increasing
symptoms. The major mental symptoms are extreme fear and a
sense of impending death and doom.
• Patients often try to leave whatever situation they are in to seek help.
The attack generally lasts 20 to 30 minutes and rarely more than an
hour.
• Between attacks, patients may have anticipatory anxiety about
having
another attack.

50. CLINICAL FEATURES
• Somatic concerns of death from a cardiac or respiratory problem may
be the major focus of patients' attention.
• Hyperventilation can produce respiratory alkalosis and other
symptoms. The age-old treatment of breathing into a paper bag
sometimes helps because it decreases alkalosis.

51. Associated Symptoms
• Depressive symptoms
• Agoraphobia, other phobias
• OCD

52. DIFFERENTIAL DIAGNOSIS
Medical Disorders

53. DIFFERENTIAL DIAGNOSIS
• Psychiatric disorders
-Anxiety disorders - social and specific phobia
-PTSD
-OCD

54. COURSE AND PROGNOSIS
• Panic disorder, in general, is a chronic disorder, although its course is
variable.
• About 30 to 40 percent - symptom free at long-term follow-up,
• About 50 percent - have symptoms that are sufficiently mild not
to affect their lives significantly,
• About 10 to 20 percent continue to have significant symptoms.

55. Treatment
1)Pharmacotherapy
• Alprazolam and paroxetine are the two drugs approved by the (FDA) for the
treatment of panic disorder.
• superiority of the SSRIs and Clomipramine over the benzodiazepines, MAOis,
and tricyclic and tetracyclic drugs
• Clonazepam can be prescribed for patients who anticipate a situation in
which panic may occur (0.5 to 1 mg as required).

56. Treatment
2) Psychotherapy
Cognitive and Behavior Therapies
a)Instruction about false belief –Pts tendency to misinterpret mild
body sensations as …
b) information about panic attacks- explanations that Panic
attacks are time limited and not life threatening

57. Treatment
• SSRI
• Benzodiazepines
• MAOI’s
• TCA’s
• CBT

58. Social Anxiety Disorder(Social Phobia)

59. • Involves the fear of social situations, including situations that
involve scrutiny or contact with strangers.
• Persons with social anxiety disorder are fearful of embarrassing
themselves in social situations (i.e. Social gatherings, oral
presentations, meeting new people).
• Social anxiety Vs Specific Phobia- Social anxiety which is the intense
and persistent fear of an Object or situation.
• May have specific fears about performing specific activities such as
eating or speaking in front of others etc..

60. EPIDEMIOLOGY
• Lifetime prevalence- 3 to 13 %
• 6-month prevalence is about 2 to 3 per 100 persons
• Females > males
• Onset - 5 to 35 years

61. Etiology
• Children with a trait characterized by a consistent pattern of behavioral
inhibition.
• Children of parents affected with panic disorder and may develop into
severe shyness as the children grow older.
• Parents of persons with social anxiety disorder, as a group, were less
caring, more rejecting, and more overprotective of their children than
were other
parents.

62. Neurochemical factors
• Two specific neurochemical hypotheses:
i)Adrenergic theory – Performance phobias
Increased NE or Epinephrine both centrally & peripherally or
Sensitive to normal level of Adrenergic stimulation
ii)Dopaminergic activity- MAOIs more effective than TCA i.e.
suggests dopamine dysfunction
• SPECT scan –Decreased striatal dopamine reuptake site
density

63. Genetic factors
• First-degree relatives of persons with social anxiety disorder are
about three times more likely to be affected with social anxiety
disorder

64. Comorbid illnesses
• Persons with social anxiety disorder may have
-a history of other anxiety disorders
-mood disorders
-substance-related disorders
-and bulimia nervosa

65. DSM-5 Diagnostic Criteria for Social
Anxiety Disorder
A. Marked fear or anxiety about one or more
social situations in which the individual is
exposed to possible scrutiny by others.
Examples include social interactions (e.g.,
having a conversation, meeting unfamiliar
people), being observed (e.g., eating or
drinking), and performing in front of others
(e.g., giving a speech).
Note: In children, the anxiety must occur in
peer settings and just during interactions with
adults.
B. The individual fears that he or she will act in a
way or show anxiety symptoms that will be
negatively evaluated (i.e., will be humiliating
or embarrassing; will lead to rejection or
offend others).
C. The social situations almost always provoke
fear or anxiety.
Note: In children, the fear of anxiety may be
expressed by crying, tantrums, freezing,
clinging, shrinking, or failing to speak in social
situations.
D. The social situations are avoided or endured
with intense fear or anxiety.
E. The fear of anxiety is out of proportion to the
actual threat posed by the social situations
and to the sociocultural context.
F. The fear, anxiety, or avoidance is persistent,
typically lasting for 6 months or more
Specify if:
Performance only: If the fear is restricted to
speaking or performing in public

66. DIFFERENTIAL DIAGNOSIS
• Agoraphobia
• Panic Disorder
• Avoidant Personality Disorder
• Major Depressive Disorder
• Schizoid Personality Disorder.

67. COURSE AND PROGNOSIS
• Onset in late childhood or early adolescence.
• Typically chronic
• Although Pts whose symptoms do remit tend to stay well.

68. Treatment
Both psychotherapy and pharmacotherapy.
A)Pharmacotherapy
-SSRIs the first-line treatment
-Benzodiazepines
-venlafaxine
-Buspirone as add on with SSRI.
• In severe cases-Irreversible MAOIs such phenelzine
Reversible MAOIs such moclobemide &
Brofaromine

69. Treatment
• In case of performance situations
- Beta-blocker viz. atenolol & propranolol
- Short or intermediate acting BZDs viz. Lorazepam or Alprazolam
Shortly before exposure to a phobic stimulus.
B)Psychotherapy
A combination of behavioral and cognitive methods- including cognitive
retraining, desensitization, rehearsal during sessions, and a range of
homework assignments.

70. • References-
1) Kaplan & Sadock’s SYNOPSIS OF PSYCHIATRY 11th edition
Page no.387-417
2) Neeraj Ahuja Textbook of Psychiatry…

71. Thank you