Anxiety disorders are the most prevalent psychiatric disorders. They are characterized by feelings of fear, apprehension and worry that interfere with daily functioning. Common types include panic disorder, generalized anxiety disorder, post-traumatic stress disorder, social phobia and specific phobia. Symptoms are often somatic in nature and patients frequently seek treatment in primary care settings. Effective treatments include cognitive behavioral therapy and antidepressant medications.

1. Anxiety Disorders
Samantha Meltzer-Brody, M.D., M.P.H.
Assistant Professor
UNC Department of Psychiatry

2. Anxiety
 Nervousness and fear are common
human emotions.
 Adaptive at lower levels; disabling at
high levels.
 Physicians must recognize the
difference between pathological anxiety
and anxiety as a normal or adaptive
response.

3. Features of Pathologic Anxiety
 Autonomy: no or minimal environmental
trigger
 Intensity: exceeds patient’s capacity to
bear the discomfort
 Duration: symptoms are persistent
 Behavior: anxiety impairs coping and
results in disabling behaviors

4. Definition of Anxiety
 Diffuse, unpleasant, vague sense of
apprehension
 Often accompanied by autonomic symptoms
such as headache, perspiration, heart
palpitations, chest tightness, stomach
discomfort and restlessness
 Presentation depends on perception of
stress, personal resources, psychological
defenses, and coping mechanisms

5. Etiology
 Neurophysiology
 Central noradrenergic systems– in particular, the
locus coeruleus is the major source of adrenergic
innervation
 GABA neurons from the limbic system
 Serotoninergic systems and neuropeptides
 Cognitive-Behavioral Formulations
 Developmental (Psychodynamic)
Formulations

6. Anxiety Disorders
 The most prevalent psychiatric disorders
 One-quarter of the U.S. population
experiences pathologic anxiety in their
lifetime
 Presenting problem for 11% of patients
visiting primary care physicians
 90% of patients with anxiety present with
somatic complaints

7. Common Medical Conditions
Associated with Anxiety Disorders
 Endocrine: thyroid
dysfunction, hyper
adrenalism
 Drug Intoxication:
caffeine, cocaine
 Drug Withdrawal:
alcohol, narcotics
 Hypoxia: CHF,
angina, anemia,
COPD
 Metabolic: acidosis,
hyperthermia
 Neurological:
seizures, vestibular
dysfxn

8. Major Anxiety Disorders
 Panic Disorder
 Generalized Anxiety Disorder
 Post Traumatic Stress Disorder
 Social Phobia
 Specific Phobia
 Obsessive Compulsive Disorder (OCD)
 Substance Induced Anxiety Disorder

9. Panic Attack
 Discrete episodes of intense anxiety
 Sudden onset
 Peak within 10 minutes
 Associated with at least 4 of the 13
other somatic or cognitive symptoms of
autonomic arousal

10. Panic Attack Symptoms
 Cardiac: palpitations, tachycardia, chest
pain or discomfort
 Pulmonary: shortness of breath, a
feeling of choking
 GI: nausea or abdominal distress
 Neurological: trembling and shaking,
dizziness, lightheadedness or faintness,
paresthesias

11. Panic Attack Symptoms
 Autonomic Arousal: sweating, chills or
hot flashes
 Psychological:
 Derealization (feeling of unreality)
 Depersonalization (feeling detached from
oneself)
 Fear of losing control or going crazy
 Fear of dying

12. Panic Disorder
 A syndrome characterized by recurrent
unexpected panic attacks (at least 4 in
one month)
 Attacks are followed for at least one
month with:
 Concern about having another attack
 Worry about implications of the attack
 Behavior changes because of the attacks

13. Agoraphobia
 Complication of panic disorder
 Means “ fear of the market”
 Anxiety or avoidance of places or
situations from which escape might be
difficult, embarrassing, or help may be
unavailable.
 Restricts daily activities

14. Agoraphobia
 Agoraphobia
 The patient may avoid crowds, restaurants,
highways, bridges, movie theaters etc.
 In its most severe form, the patient may
become dependent on companions to face
situations outside the home.
 Some individuals become homebound.

15. Epidemiology of Panic Disorder
 Panic disorder has a lifetime prevalence
of 1.5-3.5%
 2:1 female/male ratio
 ? Of true gender difference versus men
tend to self-medicate with alcohol and
are less likely to seek treatment.
 Onset is late teens through third decade
of life.

16. Differential Diagnosis of Panic
Disorder
 Not due to another anxiety disorder
 Not due to effects of a general medical
condition
 Cardiovascular disease
 Pulmonary disease
 Neurological disease
 Endocrine disease
 Drug intoxication or withdrawal
 Other (lupus, infections, heavy metal poisoning,
uremia, temporal arteritis)

17. Panic Disorder: Costs
 200,000 normal coronary angiograms/yr in
the U.S. at a cost of 600 million dollars: 1/3
of these patients have panic disorder
 ½ of patients referred for non-invasive testing
for atypical chest pain and who have normal
tests have panic disorder
 1/3 patients undergoing work-up for vestibular
disorder with c/o dizziness have panic
disorder

18. Panic Disorder: Comorbidity
 Panic disorder patients have an increased
personal and family history of other
anxiety, mood and substance abuse
disorders.
 Major depression is a co-morbid diagnosis
in 1/3 of cases presenting for treatment
 Untreated patients have high risk of suicide

19. Panic Disorder: Treatment
 About 80% of patients will respond to
treatment
 Antidepressant medications are
effective
 Serotonin reuptake inhibitors (SSRI) are
first line therapy
 Tricyclic antidepressants (TCA) and
monoamine oxidase inhibitors (MAOI’s) are
also used.

20. Panic Disorder: Treatment
 Sedative-Hypnotics: benzodiazepines
are ideally used in the short term before
an antidepressant has had time to work
 Cognitive Behavioral Therapy (CBT):
helps patients overcome a learned
pattern of catastrophically
misinterpreting the physical symptoms
associated with panic attacks.

21. Generalized Anxiety Disorder
(GAD)
 Patients with GAD suffer from severe
worry or anxiety that is out of proportion
to situational factors.
 Must last most days for at least 6
months
 Described as “worriers” or “nervous”

22. GAD
 Symptoms include:
 Muscle tension
 Restlessness
 Insomnia
 Difficulty concentrating
 Easy fatigability
 Irritability
 Persistent anxiety (rather than discrete
panic attacks)

23. GAD Diagnostic Criteria
 Excessive anxiety and worry that
occurs more days than not for 6 months
 Difficult to control the worry
 3 out of 6 symptoms
 Anxiety caused significant distress or
impairment in function
 Not attributed to another organic cause

24. GAD Epidemiology
 5% prevalence in community samples
 2:1 female/male ratio
 Age of onset is frequently in childhood
or adolescence
 Chronic but fluctuating course of illness
(worsened during stressful periods)

25. GAD Treatment
 Cognitive Behavioral Therapy
 Other Psychotherapies
 Pharmacotherapy
 Antidepressants
 Benzodiazepines
 Buspirone

26. Post Traumatic Stress
Disorder (PTSD)
 Patients with PTSD have experienced a
trauma and develop disabling
symptoms in response to the event.
 Symptoms usually begin within 3
months of the trauma
 Syndrome can occur at any age

27. Definition of Trauma
 The person experienced, witnessed or
learned of an event that involved actual
or threatened death, serious injury, or
threat of harm to self or others
 The person’s response involved intense
fear, helplessness or horror

28. Types of Trauma
 Sexual abuse
 Rape
 Physical abuse
 Severe motor vehicle
accidents
 Robbery/mugging
 Terrorist attack
 Combat veteran
 Natural disasters
 Being diagnosed with a
life threatening illness
 Sudden unexpected
death of family/friend
 Witnessing violence
(including domestic
violence)
 Learning one’s child has
life threatening illness

29. Diagnosis of PTSD
 Symptoms must be > one month
duration and include:
 Re-experiencing symptoms
 Avoidance symptoms
 Emotional numbing
 Hyperarousal symptoms

30. Re-experiencing Symptoms
 There are recurrent, intrusive thoughts
of the event (can’t not think about it)
 Dreams (nightmares) about the event
 Acting or feeling the event is recurring,
or sense of living the event (flashbacks)
 Psychological or Physiological Distress
upon exposure to reminders or cues of
the event.

31. Avoidance/Numbing
Symptoms
 Avoid thoughts, feelings, places or people
that arouse memories of the event
 Being unable to recall important parts of the
event
 Decrease interest in activities
 Feeling detached or estranged from others
 Decreased range of affect
 Sense of foreshortened future

32. Hyperarousal Symptoms
 Patient experiences at least two of the
following:
 Insomnia (falling or staying asleep)
 Irritability or outbursts of anger
 Decreased concentration
 Hypervigilance
 Increased/exaggerated startle response

33. Epidemiology of PTSD
 Prevalence is 1% in the general
population, and can be as high as 25%
in those who have experienced trauma
 In combat veterans, prevalence is 20%
 Very high prevalence in women who
are victims of sexual trauma

34. PTSD Costs
 Patients with PTSD are frequent users
of the health care system
 Patients usually present to primary care
physicians with somatic complaints
 After panic disorder, PTSD is the most
costly anxiety disorder

35. PTSD Treatment
 Psychotherapies
 Exposure-based cognitive behavioral therapy
 Psychotherapy aimed at survivor anger, guilt and
helplessness (victimization)
 Pharmacological treatment targets the
reduction of prominent symptoms
 SSRI’s are first line therapy
 Atypical antipsychotics are being increasingly
used

36. Social Phobia
 Fear of being exposed to public scrutiny
 Fear of behaving in a way which will be
humiliating or embarrassing
 Symptomatic resemblance to panic
disorder with anticipatory anxiety
(person may be anxious/worrying far in
advance of the event)
 Extensive phobic avoidance

37. Social Phobia
 Distinction: anxiety only occurs when
the patient is subject to the scrutiny of
others (public speaking, oral exam,
eating in the cafeteria)
 Phobic stimulus is avoided or endured
with intense anxiety
 Fear and avoidant behaviors interfere
with person’s normal routine or cause
marked distress

38. Epidemiology: Social Phobia
 Prevalence rates vary depending on
study; overall range is 3 –13% of the
population
 Onset in adolescence
 Prevalence greater in females, but
greater for males in clinical samples
 Frequent comorbidity with depression
and substance abuse

39. Social Phobia: Treatment
 Antidepressants, SSRI’s and MAOI’s
 High potency benzodiazepines
 Low doses of beta blockers are helpful
for public speaking (if only an
occasional event); this alleviates the
autonomic symptoms
 Psychotherapy-cognitive restructuring

40. Specific Phobia
 Marked and persistent fear that is
excessive and unreasonable of a
specific object or situation
 Exposure to the phobic stimulus will
provoke an anxiety response

41. Phobia Subtypes
 Animals or insects
 Natural environment– storms, water, heights
 Blood, injury, injection, medical procedure
 Situational flying, driving, enclosed places
 Having a phobia of a specific subtype
increased the chances of having another
phobia within that subtype

42. Epidemiology of Specific Phobias
 Lifetime prevalence is 10% of the
population
 Age of onset varies with subtype
 Childhood onset for phobias of animals,
natural environments blood and injections
 Bimodal distribution (childhood and mid-
twenties for situational phobias

43. Specific Phobia Treatments
 Flooding-exposing the person to the
feared stimulus
 Exposure therapy works to desensitize
the patient using a series of gradual,
self-paced exposures to the phobic
stimulus; uses relaxation, hypnosis,
breathing control and other cognitive
approaches
 Benzodiazepines or Beta blockers are
useful acutely

44. Specific Phobia: Treatment
 Example: Fear of Flying
 Visualize a plane. Look at a plane in the
sky. Drive by an airport. Go to a museum
that has planes. Same museum—visualize
going inside. Go inside. Go to airport and
watch planes take off and land. Visualize
yourself on a plane flying. Omnimax
theater experience. The real thing.

45. Obsessive Compulsive
Disorder (OCD)
 Obsessions: recurrent, intrusive,
unwanted thoughts (i.e. fear of
contamination)
 Compulsions: behaviors or rituals aimed
at reducing distress or preventing a
dreaded event (i.e. compulsive
handwashing)

46. OCD Symptoms
 Recurrent obsessions and/or
compulsions are severe enough to
consume more than one hour/day
 Person recognizes the obsession as a
“product of his/her own mind”, rather
than imposed from the outside, and that
they are unreasonable or excessive

47. OCD Symptoms
 The obsessions are “ego-dystonic” (not
enjoyable for the ego), as opposed to
“ego-syntonic” (the ego likes it)

48. Common Obsessions
 Contamination
 Repeated doubts
 Order
 Aggressive or horrific images
 Sexual/pornographic imagery
 Scrupulosity

49. Obsessions and Common
Compulsive Responses
 Contamination: cleaning, hand washing,
showering
 Repeated doubts: checking, requesting or
demanding reassurances from others,
counting
 Order: checking, rituals, counting
 Aggressive or horrific images, checking,
prayers, rituals
 Sexual/Pornographic imagery: prayer/rituals

50. Epidemiology of OCD
 Lifetime prevalence is 2-3% in the
general population
 Mean age of onset is mid-twenties,
although men may develop symptoms
earlier
 Less than 5% of patients develop
disease after age of 35 years
 Chronic course, stress can exacerbate
symptoms

51. OCD Treatment
 Serotonin reuptake inhibitors
 Clomipramine, a serotonergic tricyclic
antidepressant
 Psychotherapy: exposure and response
prevention

52. OCD is not OCPD
 Obsessive-Compulsive Disorder is
different from obsessive compulsive
personality disorder (OCPD)
 OCPD: a pervasive pattern of
preoccupation with orderliness,
perfectionism and control that begins by
early adulthood

53. Substance Induced Anxiety
Disorder
 Prominent symptoms of anxiety that are
judged to be the direct physiological
consequence of a drug or abuse, a
medication or toxin exposure

54. Summary and Review of
Anxiety Disorders

55. Panic Attacks and Panic Disorder
 Panic Attacks
 Agoraphobia without a history of panic
disorder
 Panic Disorder without agoraphobia
 Panic Disorder with agoraphobia

56. Generalized Anxiety Disorder
 Characterized by at least 6 months of
persistent and excessive anxiety and
worry

57. Post Traumatic Stress
Disorder
 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
 Symptoms present for at least one month
 If event just occurred and/or symptoms
present for less than one month, a diagnosis
of Acute Stress Disorder is given

58. Social Phobia
 Clinically significant anxiety provoked
by exposure to certain types of social or
performance situations, often leading to
avoidance behavior

59. Specific Phobia
 Clinically significant anxiety provoked
by exposure to a specific feared object
or situation, often leading to avoidance
behavior

60. Obsessive Compulsive
Disorder
 Characterized by obsessions that cause
marked anxiety or distress and/or
compulsions that serve to neutralize
anxiety

61.  Substance Induced Anxiety Disorder
 Anxiety Disorder not otherwise specified

62. Anxiety Disorder Association
of American (ADAA)
 The ADAA brings together professionals
from many disciplines including
psychiatrists, psychologists, social workers,
physicians, nurses, etc. Through networks,
the ADAA increases awareness about
anxiety disorders, provides education
resources, offers access to care, and
supports research.
 www.adaa.org