Anxiety disorders are a family of mental disorders characterized by excessive and persistent fear, anxiety, worry and avoidance behaviors. They include panic disorder, agoraphobia, specific phobia, social anxiety disorder, generalized anxiety disorder and obsessive compulsive disorder. Anxiety disorders are highly prevalent, affecting around 1 in 4 people at some point in their lives. They are more common in women and often have an early age of onset. Biological, genetic, psychological and environmental factors all contribute to the development of anxiety disorders.

1. ANXIETY DISORDERS
Presenter: Gilbert
Facilitator: Dr. Kinyanjui

2. DEFINITION
• Anxiety is a psychological and physiological state
characterized by cognitive, somatic, emotional
and behavioral components
• A response to a threat that’s unknown, internal,
vague or conflictual
• Fear is a response to a known, external, definite
or non conflictual threat
• Anxiety disorders are a family of related but
distinct mental disorders xtized by excessive and
persistent fear, anxiety, worry and/or avoidance
behavior

3. CLASSIFICATION (DSM-IV-TR)
1. Panic disorder with agoraphobia
2. Panic disorder without agoraphobia
3. Agoraphobia without panic disorder
4. Specific phobia
5. Social phobia
6. Obsessive-compulsive disorder (OCD)
7. Post-traumatic stress disorder (PTSD)
8. Acute stress disorder
9. Generalized anxiety disorder

4. EPIDEMIOLOGY
• Among the most prevalent mental disorders in the general public
• F:M 2:1
• Significant morbidity and often are chronic and resistant to treatment
• The National Comorbidity Study report
 one of four persons met the diagnostic criteria for at least one anxiety
disorder
 12-month prevalence rate of 17.7 percent.
• Women with 30.5% lifetime prevalence and men 19.2%
• Prevalence of anxiety disorders decreases with higher socioeconomic
status

5. Etiology
Theories that try to explain anxiety disorders
I. Psychological theories
II. Genetic theory
III.Biochemical theory
IV.Neuroanatomial

6. I. Psychological theories
A. Psychoanalytic theory & psychodynamic theory
 According to Freud, anxiety is a result of psychic conflict
between unconscious sexual or aggressive wishes by ID and
corresponding threats from the superego or external reality.
 In response to this signal, the ego mobilized defense
mechanisms to prevent unacceptable thoughts and feelings
from emerging into conscious awareness
Psychodynamic theory
 Superego anxiety is related to guilt feelings about not living up
to internalized standards of moral behavior derived from the
parents.

7. B) Behavioral Theory
Anxiety is a conditioned response to a specific
environmental stimulus explained by a model of classic
conditioning
A girl raised by an abusive father may become anxious
as soon as she sees the abusive father and may develop
to distrust men
A child may also develop anxiety response by imitating
the anxiety in the environment, as in anxious parents

8. C) Existential Theory
This provides a model for generalized anxiety
where no specific identifiable stimulus exist for
a chronically anxious feeling
persons experience feelings of living in a
purposeless universe.
 Anxiety is their response to the perceived void
in existence and meaning

9. II. Genetic Theory
Heredity recognized as a predisposing factor in the
development of anxiety disorders.
Almost half of all patients with panic disorder have at
least one affected relative.
One report attributed about 4% of the intrinsic variability
of anxiety within the general population to a
polymorphic variant of the gene for the serotonin
transporter, which is the site of action of many
serotonergic drugs
Persons with the variant produce less transporter and
have higher levels of anxiety

10. III. Biochemical Theories
Major NTs implicated; serotonin, norepinephrine,
GABA
GABA
Role most strongly supported by the undisputed
efficacy of benzodiazepines, which enhance the
activity of GABA at the GABA type A receptor, in the
treatment of some types of anxiety disorders
Norepinephrine
Affected patients may have a poorly regulated
noradrenergic system with occasional bursts of
activity

11. Increased noradrenergic function -chronic symptoms
experienced by patients, such as panic attacks, insomnia,
startle, and autonomic hyperarousal
Serotonin
Different types of acute stress result in increased 5-
hydroxytryptamine (5-HT) turnover in the prefrontal
cortex, nucleus accumbens, amygdala, and lateral
hypothalamus
The effectiveness of buspirone, a 5-HT1A receptor agonist,
in the treatment of anxiety disorders
Clinical studies of 5-HT function in anxiety disorders have
had mixed results

12. IV. NEUROANATOMICAL
 Locus coereleus and raphe nuclei project to limbic system and cerebral cortex.
Limbic System
 Receives noradrenergic and serotonergic innervation and also contains a high
concentration of GABA receptors.
 Ablation and stimulation studies in nonhuman primates have implicated the
limbic system in the generation of anxiety and fear responses.
 Increased activity in the septohippocampal pathway may lead to anxiety
 The cingulate gyrus has been implicated in the pathophysiology of OCD
Cerebral Cortex
 The frontal cerebral cortex is connected with the parahippocampal region, the
cingulate gyrus, and the hypothalamus and may be involved in the production
of anxiety disorders

13. PANIC DISORDER
 Panic disorder is recurrent unexpected panic attacks with or without agoraphobia
 Panic attack is discrete period of intense fear or discomfort, in which four (or more) of
the following symptoms developed abruptly and reached a peak within 10 minutes:
STUDENTS Fear the 3Cs
1. Sweating
2. Trembling or shaking
3. Unsteadiness (dizziness), lightheaded
4. Derealization or depersonalization
5. Elevated heart rate (palpitations)
6. Nausea or abdominal distress
7. Tingling or numbness- paresthesia
8. Shortness of breath or smothering
9. Fear of dying
10. Fear of losing control or going
crazy
11. Chest pain or discomfort
12. Choking
13. Chills or hot flushes

14. Epidemiology
Lifetime prevalence is 1-4%
Women are 2-3times more likely to have panic
disorder
The only social factor is a recent history of
divorce or separation.
Most commonly develops in young adulthood the
mean age of presentation is about 25yrs though
can start at any age
It is associated with a lot of cormobidity;91%
have at least one other psychiatric disorder.

15. ETIOLOGY
1. Biological factors- major neurotransmitter systems
involved and also the importance of dysregulated CNS
2. Pain inducing substances
3. Genetic factors
4. Psychosocial factors
Psychoanalytic theory
Cognitive-behavioral theory
5. Brain imaging has shown panic attacks are associated with
cerebral vasoconstriction, which may result in CNS
symptoms, such as dizziness, and in peripheral nervous
system symptoms

16. CLINICAL FEATURES
 1st attack often spontaneous although may follow excitement, physical
exertion, sexual activity or emotional trauma.
 Preceding activities: use of caffeine, alcohol, nicotine, unusual sleeping or
eating habits
 Begins with 10 minute period of rapidly increasing symptoms lasting 20-30
minutes rarely more than 1 hour
 Physical symptoms include tachycardia, palpitations, dyspnea, sweating
 MSE: impaired memory, stammering, depression, depersonalization,
rumination
 Anticipatory fear between attacks
 Somatic concerns of death from cardiorespiratory problems during attack
 Syncopal episodes in 20%
 Others: other phobias, marital discord, financial difficulties, alcohol and
substance use

17. DSM-IV-TR Diagnostic Criteria for Panic Disorder without Agoraphobia
A)Both (1) and (2):
1) recurrent unexpected panic attacks
2)at least one of the attacks has been followed by 1 month (or more) of one
(or more) of the following:
 Persistent concern about having additional attacks
 Worry about the implications of the attack or its consequences (e.g., losing
control, having a heart attack, or going crazy)
 A significant change in behavior related to the attacks
B) Absence of agoraphobia
C) The panic attacks are not due to the direct physiological effects of a substance
(e.g., a drug of abuse, a medication) or a general medical condition (e.g.,
hyperthyroidism).
D) The panic attacks are not better accounted for by another mental disorder,
such as social phobia, specific phobia , OCD, PTSD, or separation anxiety disorder

18. DIFFERENTIAL DIAGNOSIS
• Medical disorders
• Specific and social phobias
• Mental disorders like GAD
• Agoraphobia without panic disorder

19. TREATMENT
A. Pharmacotherapy
• Benzodiazepines (alprazolam) and antidepressants
(paroxetine) are used
 Experience is showing superiority of SSRIs and
clomipramine over the benzodiazepines and other
antidepressants
 Treatment should generally continue for 8 to 12 months.
 Panic disorder is a chronic condition and studies have
reported that 30 to 90% of patients who have had
successful treatment have a relapse when their medication
is discontinued
B. Cognitive and behavioral therapies

20. PROGNOSIS
 30-40% of patients are symptom free on long term
follow up
 50% have very mild symptoms and 10-20% have
significant symptoms
 There is increased risk of suicide
 Alcohol and substance dependency may occur in 20-40%
of patients while 40-80% may have depression
 Patients with good premorbid functioning and symptoms
of brief duration tend to have good prognoses

21. AGORAPHOBIA
 Phobia refers to marked and persistent fear that is
excessive or unreasonable cued by the presence or
anticipation of a specific object or situation
 Agoraphobia- fear of or anxiety regarding places or
situations from which escape might be difficult
 Interferes with a person's ability to function in work
and social situations outside the home-most disabling

22. EPIDEMIOLOGY
 Prevalence varies between 2-6%
 Can occur with or without panic disorder
 The onset of agoraphobia mostly follows a
traumatic event.
 84% of those with agoraphobia have at least
one other psychiatric condition

23. DSM-IV-TR Criteria for diagnosis of agoraphobia
A. Anxiety about being in places or situations from which escape
might be difficult (or embarrassing) or in which help may not be
available in the event of having an unexpected or situationally
predisposed panic attack or panic-like symptoms.
B. The situations are avoided (e.g., travel is restricted) or else are
endured with marked distress or with anxiety about having a
panic attack or panic-like symptoms, or require the presence of a
companion.
C. The anxiety or phobic avoidance is not better accounted for by
another mental disorder, such as social phobia, specific phobia,
OCD, PTSD, or separation anxiety

24. CLINICAL FEATURES
• Rigidly avoiding situations in which it would
be difficult to obtain help.
• Prefer to be accompanied by friend or family
member in busy streets, crowded stores,
closed in spaces or closed in vehicles.
• Severely affected patients may refuse to
leave the house

25. OBSESSIVE-COMPULSIVE DISORDER
An obsession is a recurrent and intrusive
thought, feeling, idea, or sensation while a
compulsion is a repetitive, conscious,
standardized, recurrent behavior that a person
feels driven to perform in response to an
obsession e.g. counting, checking, or avoiding.
A patient with OCD may have an obsession, a
compulsion, or both.

27. EPIDEMIOLOGY
 Life time prevalence of 2-3% ,
 Affects both men and women equally (adults) but affecting
boys more than girls (adolescents).
 Mean age of onset is 20 years
 Occurs more commonly in single people and whites
compared to married and black people.
 Commonly affected by other mental disorders:
• Major depressive disorder 67%
• Social phobia 25%
• Others like specific phobia, generalized anxiety
• 20-30% have history of tics

28. ETIOLOGY
• Biological
• Genetics
• Behavioral
• Brain imaging studies
• Psychosocial factors (psychodynamic,
psychoanalytic and personality)

29. CLINICAL FEATURES
 Patients often take their complaints to physicians other than
psychiatrists like to dermatologist, pediatricians, obstetricians
 Most patients(up to 75% ) have both obsessions and
compulsions
 No matter how vivid and compelling the obsession or
compulsion, the person usually recognizes it as absurd and
irrational.
 Feels a strong desire to resist them
 Obsessive thoughts or ideas, images, ruminations, doubts,
convictions and compulsive rituals

30.  OCD has four major symptom patterns though the symptom of
an individual patient may overlap or change with time.
1. Contamination
2. Pathological doubt
3. Intrusive thoughts
4. Symmetry
 On MSE the patients may show symptoms of depressive
disorders(50%), character traits suggesting obsessive compulsive
personality disorder
 Men especially have higher than average celibacy rates
 Others: hoarding, trichotillomania, nail biting and masturbation

31. DSM-IV-TR Criteria for diagnosis of OCD
A. Either obsessions or compulsions:
Obsessions as defined by (1), (2), (3), and (4):
1. recurrent and persistent thoughts, impulses, or images that are experienced, at some time during
the disturbance, as intrusive and inappropriate and that cause marked anxiety or distress
2. the thoughts, impulses, or images are not simply excessive worries about real-life problems
3. the person attempts to ignore or suppress such thoughts, impulses, or images, or to neutralize
them with some other thought or action
4. the person recognizes that the obsessional thoughts, impulses, or images are a product of his or
her own mind (not imposed from without as in thought insertion)
Compulsions as defined by (1) and (2):
1. repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting,
repeating words silently) that the person feels driven to perform in response to an obsession, or
according to rules that must be applied rigidly
2. the behaviors or mental acts are aimed at preventing or reducing distress or preventing some
dreaded event or situation; however, these behaviors or mental acts either are not connected in a
realistic way with what they are designed to neutralize or prevent or are clearly excessive

32. B. At some point during the course of the disorder, the person has recognized that
the obsessions or compulsions are excessive or unreasonable.
Note: This does not apply to children.
C. The obsessions or compulsions cause marked distress, are time-consuming
(take more than 1 hour a day), or significantly interfere with the person's normal
routine, occupational (or academic) functioning, or usual social activities or
relationships.
D. If another Axis I disorder is present, the content of the obsessions or
compulsions is not restricted to it (e.g., preoccupation with food in the presence
of an eating disorder;
E. The disturbance is not due to the direct physiological effects of a substance
(e.g., a drug of abuse, a medication) or a general medical condition.
• Specify if: With poor insight: if, for most of the time during the current
episode, the person does not recognize that the obsessions and compulsions
are excessive or unreasonable

33. DIFFERENTIAL DIAGNOSIS
• Medical conditions such as Sydenham's
chorea and Huntington's disease that affect
primarily the basal ganglia
• Tourette's Disorder
• Other Psychiatric Conditions like obsessive
compulsive personality disorder, depression,
psychotic episode

34. COURSE AND PROGNOSIS
• 20-30 % of patients have significant
improvement in their symptoms
• 40-50% have moderate improvement.
• The remaining 20-40% of patients either
remain ill or their symptoms worsen.
• One third of patients with OCD have major
depressive disorder
• Suicide is a risk for all patients with OCD.

35. Indications of Poor Prognosis
• Yielding to compulsions
• Childhood onset
• Bizarre compulsions,
• The need for hospitalization,
• A coexisting major depressive
disorder,
• Delusional beliefs,
• The presence of overvalued ideas
(i.E., Some acceptance of
obsessions and compulsions),
• Presence of a personality disorder
(especially schizotypal personality
disorder)
Indications of a Good Prognosis
• Good social and occupational
adjustment,
• The presence of a
precipitating event
• Episodic nature of the
symptoms.

36. Treatment
Pharmacotherapy
 Start treatment with an SSRI or clomipramine and
then move to other pharmacological strategies if the
SSRIs drugs are not effective
 Initial effects are generally seen after 4 to 6 weeks of
treatment
Behavior Therapy
 Desensitization, thought stopping, flooding,
implosion therapy, and aversive conditioning
Psychotherapy

37. Posttraumatic Stress Disorder and Acute
Stress Disorder
• Posttraumatic stress disorder (PTSD) is a condition
marked by the development of symptoms after
exposure to traumatic life events with the symptoms
lasting more than a month significantly affecting daily
functioning
• Acute stress disorder occurs earlier than PTSD (within 4
weeks of the event) and remits within 2 days to 4 weeks
• The stressors are sufficiently overwhelming to affect
almost anyone and can arise from experiences in war,
torture, natural catastrophes, assault, rape, and
serious accidents.

38. • Persons re-experience the traumatic event in their
dreams and their daily thoughts;
• They are determined to evade anything that would bring
the event to mind and they undergo a numbing of
responsiveness along with a state of hyperarousal.
• Other symptoms are depression, anxiety, and cognitive
difficulties, such as poor concentration
• The term PTSD was introduced in the 1980s following
the psychiatric morbidity associated with Vietnam War
veterans
• Previously known as irritable heart, shell shock, combat
neurosis or operational fatigue

39. EPIDEMIOLOGY
 Lifetime prevalence: 10 to 12% in women, 5 to 6% in men
and 5 to 75% in high-risk groups
 Onset at any age but it is most prevalent in young adults,
as they tend be more exposed to precipitating situations
 Comorbidity rates are high with about two thirds having
at least two other disorders which make persons more
vulnerable to developing PTSD
 Common comorbid conditions: depressive disorders,
substance-related disorders, other anxiety disorders, and
bipolar disorders

40. ETIOLOGY
Stressor
Risk factors
Psychodynamic
Factors
Cognitive-Behavioral
Factors
Biological Factors
• Presence of childhood trauma
• Borderline, paranoid, dependent, or
antisocial personality disorder traits
• Inadequate family or peer support system
• Being female
• Genetic vulnerability to psychiatric illness
• Recent stressful life changes
• Perception of an external locus of control
(natural) rather than an internal one (human)
• Recent excessive alcohol intake

41. DSM-IV-TR Diagnostic Criteria for Posttraumatic Stress Disorder
A)The person has been exposed to a traumatic event in which both of the following were
present:
– the person experienced, witnessed, or was confronted with an event or events that involved
actual or threatened death or serious injury, or a threat to the physical integrity of self or others
– the person's response involved intense fear, helplessness, or horror. a2
B)The traumatic event is persistently re-experienced in one (or more) of the following ways:
– recurrent and intrusive distressing recollections of the event, including images, thoughts, or
perceptions.
– recurrent distressing dreams of the event
– acting or feeling as if the traumatic event were recurring (includes a sense of reliving the
experience, illusions, hallucinations, and dissociative flashback episodes, including those that
occur on awakening or when intoxicated).
– intense psychological distress at exposure to internal or external cues that symbolize or
resemble an aspect of the traumatic event
– physiological reactivity on exposure to internal or external cues that symbolize or resemble an
aspect of the traumatic event

42. C) Persistent avoidance of stimuli associated with the trauma and numbing of general
responsiveness (not present before the trauma), as indicated by three (or more) of the
following:
– efforts to avoid thoughts, feelings, or conversations associated with the trauma
– efforts to avoid activities, places, or people that arouse recollections of the trauma
– inability to recall an important aspect of the trauma
– markedly diminished interest or participation in significant activities
– feeling of detachment or estrangement from others
– restricted range of affect (e.g., unable to have loving feelings)
– sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life
span)
D) Persistent symptoms of increased arousal (not present before the trauma), as indicated by
two (or more) of the following:
– difficulty falling or staying asleep
– irritability or outbursts of anger
– difficulty concentrating
– hypervigilance
– exaggerated startle response

43. E) Duration of the disturbance (symptoms in Criteria B, C,
and D) is more than 1 month.
F) The disturbance causes clinically significant distress or
impairment in social, occupational, or other important
areas of functioning.
Specify if:
Acute: if duration of symptoms is less than 3 months
Chronic: if duration of symptoms is 3 months or more
Specify if:
With delayed onset: if onset of symptoms is at least 6
months after the stressor

44. DSM-IV-TR Diagnostic Criteria for Acute Stress Disorder
A. The person has been exposed to a traumatic event in which both of the following were
present:
 the person experienced, witnessed, or was confronted with an event or events that
involved actual or threatened death or serious injury, or a threat to the physical
integrity of self or others
 the person's response involved intense fear, helplessness, or horror
B. Either while experiencing or after experiencing the distressing event, the individual has
three (or more) of the following dissociative symptoms:
 a subjective sense of numbing, detachment, or absence of emotional responsiveness
 a reduction in awareness of his or her surroundings
 derealization
 depersonalization
 dissociative amnesia (i.e., inability to recall an important aspect of the trauma)

45. C. The traumatic event is persistently re-experienced in at least one of the following
ways: recurrent images, thoughts, dreams, illusions, flashback episodes, or a sense
of reliving the experience; or distress on exposure to reminders of the traumatic
event.
D. Marked avoidance of stimuli that arouse recollections of the trauma (e.g., thoughts,
feelings, conversations, activities, places, people).
E. Marked symptoms of anxiety or increased arousal (e.g., difficulty sleeping,).
F. The disturbance causes clinically significant distress or impairment in social,
occupational, or other important areas of functioning or impairs the individual's
ability to pursue some necessary task, such as obtaining necessary assistance or
mobilizing personal resources by telling family members about the traumatic
experience.
G. The disturbance lasts for a minimum of 2 days and a maximum of 4 weeks and occurs
within 4 weeks of the traumatic event.
H. The disturbance is not due to the direct physiological effects of a substance (e.g., a
drug of abuse, a medication) or a general medical condition, is not better accounted
for by brief psychotic disorder, and is not merely an exacerbation of a preexisting Axis
I or Axis II disorder.

46. DIFFERENTIAL DIAGNOSIS
• Other medical conditions
• Head injury, organic considerations that can both cause
and exacerbate the symptoms like epilepsy, alcohol-use
disorders, and other substance-related disorders
• Panic disorder and generalized anxiety disorder
• Major depression is also a frequent concomitant of
PTSD.
• Borderline personality disorder, dissociative disorders,
and factitious disorders

47. TREATMENT
• Pharmacotherapy
Selective serotonin reuptake inhibitors (SSRIs),
such as sertraline (Zoloft) and paroxetine
(Paxil), are considered first-line treatments
• Psychotherapy
behavior therapy, cognitive therapy, and
hypnosis

48. COURSE AND PROGNOSIS
• Untreated, about 30% of patients recover completely, 40%
continue to have mild symptoms, 20% continue to have
moderate symptoms, and 10% remain unchanged or
become worse
Good Prognostic Factors
• rapid onset of the symptoms,
• short duration of the symptoms (less than 6 months),
• good premorbid functioning,
• strong social supports
• absence of other psychiatric, medical or substance-related
disorders.

49. GENERALIZED ANXIETY DISORDER
GAD: excessive anxiety and worry about several
events or activities for most days during at least a
6-month period.
The worry is difficult to control and is associated
with somatic symptoms, such as muscle tension,
irritability, difficulty sleeping, and restlessness

50. EPIDEMIOLOGY
 Lifetime prevalence close to 5 percent some studies
suggesting 8%
 F:M 2:1, Inpatient treatment 1:1
 Onset in late adolescence or early adulthood, although
cases are commonly seen in older adults
 50 to 90 percent of patients with generalized anxiety
disorder have another mental disorder usually social
phobia, specific phobia, panic disorder or a depressive
disorder

51. DSM-IV-TR 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 person finds it difficult to control the worry.
C. The anxiety and worry are associated with three (or more) of the
following six symptoms (with at least some symptoms present for
more days than not for the past 6 months).
i. restlessness or feeling keyed up or on edge
ii. being easily fatigued
iii. difficulty concentrating or mind going blank
iv. irritability
v. muscle tension
vi. sleep disturbance (difficulty falling or staying asleep, or restless
unsatisfying sleep)

52. D. The focus of the anxiety and worry is not confined to features of an Axis I disorder,
e.g., the anxiety or worry is not about having a panic attack (as in panic disorder),
being embarrassed in public (as in social phobia), being contaminated (as in
obsessive-compulsive disorder), being away from home or close relatives (as in
separation anxiety disorder), gaining weight (as in anorexia nervosa), having multiple
physical complaints (as in somatization disorder), or having a serious illness (as in
hypochondriasis), and the anxiety and worry do not occur exclusively during
posttraumatic stress disorder.
E. The anxiety, worry, or physical symptoms cause clinically significant distress or
impairment in social, occupational, or other important areas of functioning.
F. The disturbance is not due to the direct physiological effects of a substance (e.g., a
drug of abuse, a medication) or a general medical condition (e.g., hyperthyroidism)
and does not occur exclusively during a mood disorder, a psychotic disorder, or a
pervasive developmental disorder

53. CLINICAL FEATURES
 Sustained and excessive anxiety and worry accompanied
by a number of physiological symptoms.
 The anxiety is excessive and interferes with other
aspects of a person's life occurring more days than not
for at least 6 months.
 Motor tension is most commonly manifested as
shakiness, restlessness, and headaches
 Autonomic hyperactivity is commonly manifested by
shortness of breath, excessive sweating, palpitations,
and various gastrointestinal symptoms
 Cognitive vigilance is evidenced by irritability and the
ease with which patients are startled

54. DIFFERENTIAL DIAGNOSIS
Medical conditions
• Neurological,
• endocrinological,
• metabolic, and
• medication-related disorders similar to those considered in the
differential diagnosis of panic disorder
Other anxiety conditions
• panic disorder,
• phobias,
• obsessive-compulsive disorder (OCD)
• posttraumatic stress disorder (PTSD).

55. TREATMENT
The most effective treatment of generalized anxiety disorder is probably
one that combines psychotherapeutic, pharmacotherapeutic and
supportive approaches
Psychotherapy
cognitive-behavioral, supportive, and insight oriented
Pharmacotherapy
Treatment is almost lifelong in many cases due to the observed
incidences 25%, of relapse on discontinuation of medication within the
year and 60-80% over the course of the next year
• benzodiazepines,
• SSRIs(fluoxetine),
• buspirone (BuSpar)
• venlafaxine (Effexor)

56. COURSE AND PROGNOSIS
• Clinical course and prognosis is difficult to
predict
• Most patients have early onset seeking
treatment later on (only 1/3)
• Generally a lifelong condition with fluctuating
course

57. SPECIFIC PHOBIA AND SOCIAL PHOBIA
o Phobia refers to an excessive fear of a specific object,
circumstance, or situation.
o A specific phobia is a strong, persisting fear of an object or
situation(situation type, animal type, natural environment type
or injury and blood)
o Social phobia is a strong, persisting fear of social situations in
which a person is exposed to unfamiliar people or possible
scrutiny by others .
o The individual fears that he will act in a way that will be
humiliating or embarrassment can occur.
o The diagnosis of both specific and social phobias requires the
development of intense anxiety, even to the point of panic,
when exposed to the feared object or situation

58. EPIDEMIOLOGY
o As high as 25 percent of the population affected by phobias.
o Complications including other anxiety disorders, major depressive
disorder, and substance-related disorders, especially alcohol use
disorders.
Specific phobia
o lifetime prevalence of specific phobia is about 11 percent
o most common mental disorder among women and the second most
common among men, second only to substance-related disorders
Social phobia
o Lifetime prevalence of social of 3 to 13 percent
o Females are affected more often than males
o Peak age of onset is in the teens although can start as early as five
years

59. ETIOLOGY
• Behavioral Factors
• Psychoanalytic Factors
• Genetic Factors
• Neurochemical Factors

60. DSM-IV-TR Diagnostic Criteria for Specific Phobia
A. Marked and persistent fear that is excessive or unreasonable, cued
by the presence or anticipation of a specific object or situation (e.g.,
flying, heights, animals, receiving an injection, seeing blood).
B. Exposure to the phobic stimulus almost invariably provokes an
immediate anxiety response, which may take the form of a
situationally bound or situationally predisposed panic attack.
Note: In children, the anxiety may be expressed by crying,
tantrums, freezing, or clinging.
C. The person recognizes that the fear is excessive or unreasonable.
D. The phobic situation(s) is avoided or else is endured with intense
anxiety or distress.

61. E. The avoidance, anxious anticipation, or distress in the feared situation(s)
interferes significantly with the person's normal routine, occupational functioning,
or social activities or relationships, or there is marked distress about having the
phobia.
F. In individuals under age 18 years, the duration is at least 6 months.
G. The anxiety, panic attacks, or phobic avoidance associated with the specific object
or situation are not better accounted for by another mental disorder, such as
obsessive-compulsive disorder (e.g., fear of dirt in someone with an obsession
about contamination), posttraumatic stress disorder (e.g., avoidance of stimuli
associated with a severe stressor), separation anxiety disorder (e.g., avoidance of
school), social phobia (e.g., avoidance of social situations because of fear of
embarrassment), panic disorder with agoraphobia, or agoraphobia without history
of panic disorder.
• Specify type:
Animal type
Natural environment type (e.g., heights, storms, water)
Blood-injection-injury type
Situational type (e.g., airplanes, elevators, enclosed places)
Other type (e.g., fear of choking, vomiting, or contracting an illness; in children,
fear of loud sounds or costumed characters)

62. Phobias
Acrophobia fear of heights
Agoraphobia fear of open places
Ailurophobia fear of cats
Hydrophobia fear of water
Claustrophobia fear of closed spaces
Cynophobia fear of dogs
Mysophobia fear of dirt and germs
Pyrophobia fear of fire
Xenophobia fear of strangers
Zoophobia fear of animals

63. DSM-IV-TR Diagnostic Criteria for Social Phobia
A. A marked and persistent fear of one or more social or performance
situations in which the person is exposed to unfamiliar people or to
possible scrutiny by others. The individual fears that he or she will act in
a way (or show anxiety symptoms) that will be humiliating or
embarrassing.
Note: In children, there must be evidence of the capacity for age-
appropriate social relationships with familiar people and the anxiety
must occur in peer settings, not just in interactions with adults.
B. Exposure to the feared social situation almost invariably provokes
anxiety, which may take the form of a situationally bound or
situationally predisposed panic attack.
C. The person recognizes that the fear is excessive or unreasonable.
Note: In children, this feature may be absent.
D. The feared social or performance situations are avoided or else are
endured with intense anxiety or distress.

64. E. The avoidance, anxious anticipation, or distress in the feared social or
performance situation(s) interferes significantly with the person's
normal routine, occupational (academic) functioning, or social activities
or relationships, or there is marked distress about having the phobia.
F. In individuals under age 18 years, the duration is at least 6 months.
G. The fear or avoidance is not due to the direct physiological effects of a
substance or a general medical condition and is not better accounted for
by another mental disorder (e.g., panic disorder with or without
agoraphobia, separation anxiety disorder, body dysmorphic disorder, a
pervasive developmental disorder, or schizoid personality disorder).
H. If a general medical condition or another mental disorder is present, the
fear in Criterion A is unrelated to it (e.g., the fear is not of stuttering,
trembling in Parkinson's disease, or exhibiting abnormal eating behavior in
anorexia nervosa or bulimia nervosa).
• Specify if:
Generalized: if the fears include most social situations

65. Differential diagnosis
o Appropriate fear and normal shyness
o Nonpsychiatric medical conditions that can result in the
development of a phobia include the use of substances
(hallucinogens and sympathomimetic), central nervous system
tumors and cerebrovascular diseases.
o Schizophrenia
o Panic disorder and agoraphobia
o Avoidant personality disorder
Social phobia- major depressive disorder and schizoid personality
disorder
Specific phobia- hypochondriasis, OCD and paranoid personality
disorder

66. TREATMENT
Behavior Therapy
• Insight-Oriented Psychotherapy
Specific Phobia
- Exposure therapy
- adrenergic receptor antagonists esp if associated with panic
symptoms
- Benzodiazepines
Social phobia
- Both psychotherapy and pharmacotherapy
- Effective drugs include (1) SSRIs, (2) the benzodiazepines, (3)
venlafaxine (Effexor), and (4) buspirone (BuSpar).

67. OTHER ANXIETY DISORDERS
1. Anxiety Disorder due to a General Medical
Condition
2. Substance-Induced Anxiety Disorder
3. Anxiety Disorder not Otherwise Specified
4. Mixed Anxiety-Depressive Disorder