2. Often have an early onset on early twenties.
Show 2:1 female predominance, Except OCD.
OCD is the only anxiety disorder without a
significant gender difference.
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3. Panic Disorder 3.5%
GAD 5%
Social phobia 8%
OCD 2.5%
PTSD 9%
Chronic anxiety disorder may increase the
rate of cardiovascular-related mortality.
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4. Normal anxiety is adaptive.
Pathologic anxiety is anxiety that is excessive,
impairs function.
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5. Everyone experiences anxiety.
It is characterized most commonly as:
- a diffuse, unpleasant, vague sense of
apprehension
- often accompanied by autonomic symptoms
and restlessness like inability to sit or stand
still for long.
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6. Anxiety is an alerting signal;
-it warns of impending danger and enables a
person to take measures to deal with a
threat.
Fear is a similar alerting signal, but it should
be differentiated from anxiety.
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7. Fear is a response to a known, external,
definite, or nonconflictual threat. prepared
the body for fight-flight response.
Whereas anxiety is a response to a threat
that is unknown, internal, vague, or
conflictual.
Fight-flight responses are ineffective.
- Instead the mechanisms of defense are
recruited. 7
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8. Anxiety may be due to one of the primary
anxiety disorders OR secondary to substance
abuse and a medical condition.
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9. What constitutes danger?
It depends on:
1. nature of an event.
2. a person’s resources
-psychological defenses and
available coping mechanisms.
Psychodynamic theories
- anxiety as a signal about danger in the
unconscious resulting from psychic
conflict.
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10. A psychic conflict can arise:
- between a wish and defense against the
wish.
- between the different intrapsychic
agencies.
- as the result of an impulse in opposition
to an internalized awareness of the
demands of external reality.
There is evidence from neurobiology that
the amygdala subserves fear response
with out any reference to the conscious
memory.
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11. In psychodynamic psychiatry anxiety is a
symptom whose underlying sources should
be uncovered.
A developmental hierarchy of anxiety
- Super-ego anxiety=mature form
- Castration anxiety.
- Fear of loss of love.
- Persecutory
- Disintegration anxiety=at childhood
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12. Cognitive-Behavioral theories
Behavioral- anxiety is a conditioned response to
specific environmental stimuli.
- Social learning theories posit that children learn
anxiety by imitating the anxiety responses of
their parents.
Cognitive – anxiety disorders are accompanied by
faulty, distorted or counter productive thinking
patterns.
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13. Some of these are:
- Overestimation of danger and probability of
harm in a given situation.
- Underestimation of their abilities to cope with
perceived threats to their physical or
psychological well-being.
- Selective attention (items which reinforce
anxiety are given much attention while others
are overlooked).
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14. The biology of anxiety
- Peripheral signs of anxiety are thought to be the
results of central nervous system anxiety.
- The autonomic nervous system (ANS) of panic
disorder patients shows:
a) Increased sympathetic tone.
b) Slow adaptation to repeated stimuli.
c) Excessive response to moderate stimuli
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15. Neurotransmitter systems
Norepinephrine: most of noradrenergic neurons
in the CNS originate from the locus ceruleus.
- Destruction of these neurons leads to abolition
of the anxiety-fear response.
- B-agonist drugs and alpha 2 blockers provoke
panic attacks in patients with panic disorders.
- Clonidine (alpha 2 agonist) reduces anxiety
symptoms.
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16. In panic disorder patients, there is an
elevated level in the CSF and urine of
norepinephrine metabolite.
Serotonin: Positive response of anxiety
symptoms to serotonergic antidepressants.
Eg. Clomipramine,Buspirone.
-The raphe nucleus: drugs which increase
release of serotonin cause increased anxiety
in patients with anxiety disorders.
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17. GABA
- Its role in anxiety disorders is suggested by the
efficacy of benzodiazepines (BDZ).
- BDZ antagonists induce symptoms of anxiety and
can even induce panic attacks.
- It is postulated that abnormal functioning of
GABA receptors may lead to anxiety d/o.
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18. Genetic Studies
- anxiety disorders are complex genetic disorders.
- Inherited vulnerabilities + traumatic
events result in the disorder.
- There is increased incidence of anxiety disorders in 1st
degree relatives of affected individuals as compared to 1st
degree relatives of non-affected individuals.
Eg. 50% of all panic d/o patients have at least one affected
relative.
-4% of intrinsic variability in the level of anxiety with in the
general population is attributed to a variant of the gene
for serotonin transporter protein.
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20. Somatic and autonomic
Palpitations
Difficulty in breathing
Dry mouth
Nausea
Frequency of micturition
Dizziness
Muscular tension**
Sweating
Abdominal churning
Tremor
Cold skin
Psychic (Psychological)
Feelings of dread and threat
Irritability
Panic
Anxious anticipation
Inner (psychic) terror
Worrying over trivial things
Difficulty in concentrating
Initial insomnia
Inability to relax**
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22. Cornerstone of treatment for anxiety
disorders is increasing serotonin
Any of the SSRIs or SNRIs can be used
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23. Marked or persistent fear (>6 months) 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).
The phobic object or situation almost always provokes
immediate fear or anxiety.
The phobic object or situation is actively avoided or endured
with intense fear or anxiety.
The fear or anxiety is out of proportion to the actual danger
posed by the specific object or situation and to the sociocultural
context
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28. E.g of specific phobia cont…
Siderodromophobia =Railroads or train travel
Taphophobia =Being buried alive
Thanatophobia =Death
Trichophobia =Hair
Triskaidekaphobia =The number 13
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29. Specific phobia sometimes develops
Following a traumatic event (e.g., being attacked by an
animal or stuck in an elevator),
Observation of others going through a traumatic event
(e.g., watching someone drown),
An unexpected panic attack in the to be feared
situation (e.g., an unexpected panic attack while on
the subway),
Informational transmission (e.g., extensive media
coverage of a plane crash).
Many individuals with specific phobia are unable to
recall the specific reason.
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30. Agoraphobia
A. Marked fear or anxiety about two (or more) of the
following five situations:
1. Using public transportation (e.g., automobiles, buses,
trains, ships, planes).
2. Being in open spaces (e.g., parking lots, marketplaces,
bridges).
3. Being in enclosed places (e.g., shops, theaters,
cinemas).
4. Standing in line or being in a crowd.
5. Being outside of the home alone.
B. The individual fears or avoids these situations because of
thoughts that escape might be difficult or help might not
be available in the event of developing panic-like
symptoms
C. The agoraphobic situations almost always provoke fear or
anxiety.
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32. 1. 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 not just during interactions with adults.
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33. 2. 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).
3. The anxiety lasts more than 6 months
4. The feared situation is avoided.
5. The avoidance or fear significantly interferes
with their function.
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35. Pharmacotherapy
Agoraphobia
– antipanic drugs e.g. imipramine.
Social phobia
Medication – SSRIs, SNRIs, MAOIs,
benzodiazepines, gabapentin
Beta blockers – propranolol (esp. for stage
freight)
Others –buspirone
Specific phobias
no medication has been shown to be
effective in treating specific phobias.
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36. Psychotherapy
Agoraphobia
“Group in vivo exposure”
Aim – to reenter feared situation
Social phobia
Exposure treatment – imaginal or in vivo exposure
Social skill training – modeling, rehearsal,
Cognitive restructuring
Specific phobias
Treatment of choice – exposure treatment( imaginal/in
vivo)-Systematic desensitization.
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37. 1. Palpitations or
rapid heart rate
2. Sweating
3. Trembling or
shaking
4. Shortness of breath
5. Feeling of choking
6. Chest pain or
discomfort
7. Nausea
8. Chills or heat
sensations
9. Paresthesias
10. Feeling dizzy or
faint
11. Derealization or
depersonalization
12. Fear of losing
control or going
crazy
13. Fear of dying
A discrete period of intense fear in which 4 of the following
Symptoms abruptly develop and peak within 10 minutes:
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38. Recurrent unexpected panic attacks and for
a one month period or more of:
1. Persistent worry about having additional
attacks
2. Worry about the implications of the attacks
3. Significant change in behavior because of the
attacks
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42. Excessive worry more days than not for at least 6
months about a number of events and they find
it difficult to control the worry.
3 or more of the following symptoms:
1. Restlessness or feeling keyed up or on edge,
2. easily fatigued,
3. difficulty concentrating,
4. irritability,
5. muscle tension,
6. sleep disturbance
Causes significant distress or impairment
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43. Medications buspirone, benzodiazepines,
antidepressants (SSRIs, venlafaxine,
imipramine)
Cognitive-behavioral therapy
Supportive psychotherapy
Educating about the illness
Encouragement from other patients
Relaxation training – for both imaginal and real
life training
Meditation and biofeedback – Zen,Yoga, etc.
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44. Obsessions defined by:
recurrent and persistent thoughts that are intrusive
and unwanted that cause marked distress
The person attempts to ignore or suppress such
thoughts with some other thought or action (i.e.
compulsion)
Obsessions or compulsions or both defined by:
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46. Compulsions as defined by:
Repetitive behaviors or mental acts that the
person feels driven to perform in response to an
obsession.
The behaviors or acts are aimed at reducing
distress.
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50. Exposure to actual or threatened death,
serious or sexual violence in one or more of
the following ways:
Direct experiencing of traumatic event(s)
Witnessed in person the events as it occurred to
others
Learning that the traumatic events occurred to
person close to them
Experiencing repeated or extreme exposure to
aversive details of trauma
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51. Experiencing repeated or extreme exposure
to aversive details of trauma- e.g. first
responders collecting human remains,
police officers repeatedly exposed to details
of child abuse
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53. Presence of 1 or more sx after
the event
Persistent avoidance by 1 or
both:
Recurrent, involuntary
and intrusive memories
of event
Recurrent trauma-
related nightmares
Avoidance of distressing
memories or feelings of
the event(s)
Avoidance of external
reminders of that arouse
memories of event(s)
e.g. people, places,
activities
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54. Inability to remember an important aspect of the
traumatic event(s)
Feeling detached from others
Persistent inability to experience positive emotions
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55. Hypervigilance
Exaggerated startle response
Problems with concentration
Sleep disturbance
Duration of disturbance is more than one
month AND causes significant impairment in
function.
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56. Debriefing immediately following trauma is
NOT necessarily effective
EMDR
Narrative Therapy
Cognitive-behavioral therapy, exposure
Group therapy
Medications – antidepressants like paroxitine
and sedative like prazosin.
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57. Similar exposure as in PTSD
Duration of disturbance is 2 days to 1 month
after trauma
Causes significant impairment
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58. Excessive or out of proportion - Pervasive avoidance - Persistent-least 6 months
Anxiety
Disorders
Specific
phobia
Social
phobia
Panic
disorder
Generalized
anxiety
disorder
Agoraphobia
Specific
object or
situation
Social
situations
Recurrent
Unexpected
panic attacks no
obvious cue or
trigger -out of the
blue
Two (or more)
situations
Escape might
be difficult
Require
companion
Excessive anxiety and worry
Number of events
or activities- work,
school, etc.
3/6 symptoms
Treatment- Psychotherapy; Pharmacotherapy(anxiolytic,antidepressant,
propranolol).
Panic
Attack
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