This document discusses various types of anxiety disorders including generalized anxiety disorder, social phobia, panic disorder, agoraphobia, specific phobia, post-traumatic stress disorder, and obsessive-compulsive disorder. It covers the definitions, symptoms, epidemiology, pathophysiology, clinical features, investigations, management including psychotherapy and pharmacotherapy, prognosis, and references for each disorder. The management section emphasizes identification of triggers, breathing exercises, thought management, lifestyle changes, cognitive behavioral therapy, and antidepressant or benzodiazepine medication. Prognosis is generally good with proper treatment.

1. AnxietyPresented by:
Perez, Daren Nicole N.
BSPH-5A

2. OBJECTIVES
ANXIETY
– Natural response and a necessary warning adaptation in humans.
– Pathologic disorder when it is excessive and uncontrollable,
requires no specific external stimulus, and manifests with a wide
range of physical and affective symptoms as well as changes in
behavior and cognition disorder.
DEFINITION

3. OBJECTIVES
• Generalized Anxiety Disorder (GAD)
• Social Phobia
• Panic Disorder
• Agoraphobia
• Specific Phobia
• Post-Traumatic Stress Disorder (PTSD)
• Obsessive-Compulsive Disorder (OCD)
TYPES OF ANXIETY

4. OBJECTIVES
• Generalized Anxiety Disorder (GAD)
– Is characterized by at least 6 months of persistent and excessive anxiety and
worry.
• Social Phobia
– Is characterized by clinically significant anxiety provoked by exposure to
certain types of social or performance situations, often leading to avoidance
behaviors.
• Panic Disorder
– Severe feelings of doom that cause both mental and physical symptoms that
can be so intense that some people become hospitalized, worried that
something is dangerously wrong with their health.
– characterized by two things:
• Panic attacks.
• Fear of getting panic attacks.
TYPES OF ANXIETY

5. OBJECTIVES
• Agoraphobia
– Is anxiety about, or avoidance of, places or situations from which escape might
might be difficult (or embarrassing) or in which help may not be available in
the event of having a Panic Attack or panic-like symptoms
• Specific Phobia
– People with a specific phobia experience extreme anxiety and fear if exposed
to a particular feared object or situation. Common phobias include fear of
flying, spiders and other animals, heights or small spaces.
• Post-Traumatic Stress Disorder (PTSD)
– Is characterized by the re-experiencing of an extremely traumatic event
accompanied by symptoms of increased arousal and by avoidance of stimuli
associated with the trauma.
TYPES OF ANXIETY

6. OBJECTIVES
• Obsessive-Compulsive Disorder (OCD)
Compulsions and obsessions are similar, but exhibit themselves in
different ways:
• Obsessions:
– thought based
– Causes mark anxiety or distressed
• Compulsions:
– behavior based.
– Neutralizes anxiety
TYPES OF ANXIETY

7. ETIOLOGY
• Genetic factors
• Environmental factors
(early childhood trauma, traumatic social experience)
• Known or Unrecognized medical condition
• Substance-induced anxiety disorder
(over-the-counter medications, herbal medications, substances
of abuse)

8. EPIDEMIOLOGY
UNITED STATES STATISTICS
• Social phobia is the most common anxiety disorder;
• it has an early age of onset— age 11 years -50% & by age 20 years -80%
According to: Epidemiological Catchment Area (ECA) study
and National Comorbidity Survey (NCS) study
• 2.3-2.7% for panic disorder
• 4.1-6.6% for generalized anxiety disorder
• 2.3-2.6% for OCD
• 1-9.3% for PTSD
• 2.6-13.3% for social phobia.
Further, the NCS reported the following lifetime (and 30-day) prevalence estimates:
6.7% (and 2.3%) for agoraphobia, 11.3% (and 5.5%) for simple (ie, specific) phobia, and
13.3% (and 4.5%) for social phobia

9. EPIDEMIOLOGY
International statistics
• Cross-national study - prevalence of panic disorder found lifetime prevalence rates
ranging from 0.4% in Taiwan to 2.9% in Italy.
• Cross-cultural study - prevalence of OCD found lifetime prevalence rates ranging
from 0.7% in Taiwan to 2.5% in Puerto Rico.
• In some Far East cultures, individuals with social phobia may develop fears of being
offensive to others rather than fears of being embarrassed.
Prevalence of anxiety disorders by race
• The ECA study found no difference in rates of panic disorder among white, African
American, or Hispanic populations in the United States.
• Some studies have found higher rates of PTSD in minority populations.

10. EPIDEMIOLOGY
Sex ratio for anxiety disorders
Anxiety. Chart showing the female-to-male sex ratio for anxiety disorders.
Adapted from Kessler et al, 1994.

11. EPIDEMIOLOGY
Age distribution for anxiety disorders
Anxiety. Age of onset for anxiety disorders based on specific anxiety disorder type.

12. PATHOPHYSIOLOGY

13. PATHOPHYSIOLOGY

14. PATHOPHYSIOLOGY

15. PATHOPHYSIOLOGY
• Major mediators of the symptoms (CNS) of anxiety disorders:
 Norepinephrine
 Serotonin,
 Dopamine
 Gamma-aminobutyric acid (GABA)
Other neurotransmitter : Corticotropin-releasing factor *
• The most commonly considered are the serotoninergic and
noradrenergic neurotransmitter systems.
under activation
over activation

16. PATHOPHYSIOLOGY
• Disruption of the gamma-aminobutyric acid (GABA) system has also been
implicated because of the response of many of the anxiety-spectrum disorders to
treatment with benzodiazepines
GABA = Glutamate=impact anxiety response
• There has also been some interest in the role of corticosteroid regulation and its
relation to symptoms of fear and anxiety. Corticosteroids might increase or
decrease the activity of certain neural pathways, affecting not only behavior under
stress but also the brain's processing of fear-inducing stimuli.
• Although a genetic predisposition to developing an anxiety disorder is
likely, environmental stressors clearly play a role in varying degrees. All of the
disorders are affected in some way by external cues and how they are processed
and reacted to.

17. CLINICAL FEATURES

18. CLINICAL FEATURES

19. CLINICAL FEATURES

20. CLINICAL FEATURES

21. INVESTIGATIONS
No biologic markers are specific enough at this time to detect anxiety early, and
no research shows that current medications prove efficacious in preventing these
disorders.
• It is therefore important to screen for specific risk factors:
o strong family psychiatric history
o concurrent substance abuse.
Efforts since the 1990s have improved the diagnosis of these disorders, but
the overall quality of care provided to patients remains substandard and CBT
continues to be underused.

22. INVESTIGATIONS
DIFFERENTIAL DIAGNOSIS
• Other important causes in the differential include medication-induced anxiety:
• Due to epinephrine or other sympathomimetic
• Theophylline or other neurostimulant bronchodilators,
• Analgesics containing caffeine,
• Corticosteroids,
• Antivirals
• Migraine
• Seizure disorders
• other CNS-based disorders
• Sleep disorders such as restless legs syndrome, sleep apnea, and periodic
limb movement.
• Heroin abuse

23. NATURAL HISTORY
Levels of anxiety
• Mild Anxiety
• Moderate Anxiety
• Severe Anxiety
• Panic
• Anxiety Disorder
Complications
 Depression
(which often occurs with anxiety disorder)
 Substance abuse
 Trouble sleeping (insomnia)
 Digestive or bowel problems
 Headaches
 Suicide
 Poor quality of life

24. NATURAL HISTORY
Anxiety and the risk of death in older men and
women
• An association between anxiety disorders and subsequent mortality was
found for men only.
• Older men with diagnosed anxiety disorders had 87% higher risk of
mortality over 7 years of follow-up. The associations between anxiety and
mortality in men remained after adjustment for comorbid depression, the
explanatory variables (activity, smoking, drinking, body mass index) and
confounders (age, psychiatric treatment, functional limitations and chronic
diseases, including heart disease and stroke).
• In women with anxiety disorders no association was found with
subsequent mortality.
The British Journal of Psychiatry Oct 2004, 185 (5) 399-404; DOI: 10.1192/bjp.185.5.399

25. MANAGEMENT
• Identification of stress and trigger factors
– Identify the problem. When you have identified the situations that are contributing to
your anxiety, write down the problem and be very specific in your description, includin
what is happening, where, how, with whom, why, and what you would like to change
– Come up with as many options as possible for solving the problem, and consider the
likely chances that these will help you overcome your problem.
– Select your preferred option.
– Develop a plan for how to try out the option selected and then carry it out.
– If this option does not solve the problem remember that there are other options to try
– Go back to the list and select your next preferred option.
• Breathing exercises
• Thought management
• Lifestyle changes

26. MANAGEMENT
Psychological Therapies
• Cognitive behavior theraphy
• Behaviour therapy
• E-therapies

27. Treatment of Anxiety Disorders
Treatment usually consists of a combination of
pharmacotherapy and/or psychotherapy.
• DOC: Antidepressant agents are the drugs
of choice
• Benzodiazepines
• Tricyclic antidepressants (TCAs)
• Selective serotonin reuptake inhibitors (SSRIs).
• Monoamine oxidase inhibitors (MAOIs)

28. PROGNOSIS
• Today, the majority of people with panic
disorder and OCD improve significantly within
weeks or months of getting proper treatment.
The same is true for people with phobias. And
many people with PTSD and generalized anxiety
disorder also make substantial improvement
with treatment.
Source: excerpt from Anxiety Disorders Research at the National
Institute of Mental Health: NIMH

29. REFERENCES
• http://www.calmclinic.com/anxiety/types
• http://www.clevelandclinicmeded.com/medicalpubs/diseasema
nagement/psychiatry-psychology/anxiety-
disorder/Default.htm#s0055
• http://emedicine.medscape.com/article/286227-clinical
• http://www.mindfulnessmd.com/2014/08/09/the-neuroscience-
of-anxiety-disorders/
• Mayo Clinic Staff, (2010). Treatments and drugs. Mayo clinic.
Retrieved October 25, 2010, from
http://www.mayoclinic.com/health/panic-
attacks/DS00338/DSECTION=treatments-and-drugs