This document discusses different types of anxiety disorders including generalized anxiety disorder, panic disorder, and phobic disorders. It covers the epidemiology, symptoms, differential diagnosis, and treatment options for these conditions. The treatment section notes that benzodiazepines, antidepressants like SSRIs, CBT, and other therapies can be used to treat anxiety disorders. The document also explores proposed biological and neurological factors that may contribute to the development of anxiety.

1. Dr. Aftab Asif Associate Professor Department of Psychiatry Anxiety Disorders

2. NORMAL ANXIETY & PATHOLOGICAL TYPES OF ANXIETY Behavior Ability to function Assessment by patient, friend & clinician Neuropsychiatric Evaluation

3. ANXIETY DISORDER Panic disorder (with or with out agoraphobia) Specific phobia Special phobia Generalized anxiety disorder Obsessive-compulsive disorder Acute stress disorder Posttraumatic stress disorder Anxiety disorder due to medical condition Substance-induced anxiety disorder

4. PSYCHOANALYTIC THEORIES: “ Anxiety around ego to take defensive action against the pressure from within”

5. MAJOR CATEGORIES: Depending on the nature of the feared consequences Id or impulse anxiety Separation anxiety Castration anxiety Superego anxiety

6. BEHAVIOURAL THEORIES: Conditioned response to a specific environmental stimuli. Regular food Contaminated food Allergy Desensitization

7. BIOLOGICAL THEORIES: Biological events precede the psychological conflict  Autonomic nervous system Stimulation of ANS- like Cardiovascular – tachycardia Muscular – headache Gastrointestinal – diarrhoea Respiratory – tachypnea

8. NEUROTRANSMITTER: Norepinephrine Serotonin GABA

9. Norepinephrine: Locus Ceruleus Pons Limbic system Cerebral cortex Brainstem Spinal cord Stimulation Fear

10.  - Adrenergic agonist (Isoproternol)  2 - Adrenergic antagonist (yohimbine) = Increased pain attacks Clonidine (catapres) = Reduced pain attacks

11. SEROTONIN: Raphe nuclei in rostral brainstem Cerebral cortex Limbic system Amygdala Hippocampus Hypothalamus Some drug involved with serotonin reduce the anxiety level.

12. GABA Benzodiazepine inhance The level of GABA reduced anxiety Benzodiazepine severe panic attacks antogonist (flumazenil)

13. BRAIN – IMAGING STUDY: CT/MRI --- some increase in the size of cerebral ventricles. MRI – specific defect in the tight temporal lobe. PET/SPECT/EEG – Abnormalities in frontal cortex.

14. GENETIC STUDIES: 50% relatives have panic attacks

15. NEUROANATOMICAL CONSIDERATIONS: Limbic system Increased concentration of GABA Cerebral cortex Frontal cerebral cortex Connected with Parahippocampal cingulated gyrus hypothalamus Production of anxiety

16. DIFFERENT DISORDER VARIES Wide range of medical conditioning: Hyperthyroidism Hypothyroidism Hypoparathyroidism Vit B12 deficiency Cardiac arrythmias Hypoglycemia 83 % of cardiomyopathy patient awaiting cardiac transplantation have panic disorder. 25 % Parkinson’s disease hare panic attacks 25 % of chronic obstructive pulmonary disease (COPD) have panic attacks

17. Amphetamine Cocaine Caffeine Substance Induced Anxiety Disorder

18. Mixed anxiety/depression disorder A D D A A D A D

19. PANIC DISORDER Epidemiology: Life time prevalence 1.5 to 3 % - panic disorder 4 % - panic attacks Women Men 2-3 1 Mitral valve prolapse  Mid systolic dick on cardiac auscultation  Prolapse of one of the mitral valve leaflets  Heterogenous

20. DRUGS USED FOR THE TREATMENT OF PANIC DIAORDER. Nausea, diarrhea, anxiety/nervousness, sexual dysfunction somnolence 60 mg 20-40 mg 10 mg Paroxetine Nausea, diarrhea, anxiety/nervousness, sexual dysfunction 60 mg 20-40 mg 10 mg Fluoxetine Dry mouth, drowsiness, nausea, anxiety/nervousness, othostatic hypotension, myoclonus, hypotension, myoclonus, hypertensive 90 mg 30-90 mg 15 mg twice daily Pheneizine Dry mouth, blurred vision, constipation, urinary hesitancy, othostasis, somnolence, anxiety, sexual dysfunction 150 mg 50-100 mg 25 mg at bedtime Imipramine CommonS. Effect Max. Dosage Daily Dosing Range Starting Dosage Drug

21. Somnolence, ataxia, memory problems, physical dependence, withdrawal reactions 6 mg/day 1.5-4.0 mg 0.25-0.5 mg twice daily Clonazepam Nausea, diarrhea, anxiety/nervousness, sexual dysfunction 6 mg/day 1.5-4.0 mg 0.25-0.5 mg 3times daily Alprazolam Nausea, diarrhea, anxiety/nervousness, sexual dysfunction 60 mg 25-150 mg 25 mg Sertraline

22. PHOBIC DISORDERS “ A marked and persistent fear that is excessive at unreasonable, cued by the presence or anticipation of a specific object or situation.”

23. SPECIFIC TYPES: Animal type if the fear is cued by : Animals or insects Natural environment type: Storms, heights or water Blood-injection - injury type: Situational type : Public transportation, tunnels, bridges, elevatos, flying, driving, peak in childhood or in mid 20s

24. SOCIAL PHOBIA: Exposed to unfamiliar people or to possible scrutiny by others. EPIDIMIOLOGY: Phobic disorder – 5-10 % in general population Social phobia – 3 %

25. TREATMENT: Pharmacological Treatment: Benzodiazepine  -blockers Antidepressants. Psychotherapy: Behavior or Cognitive behavior therapy

26. GENERALIZED ANXIETY DISORDER (GAD) Excessive anxiety and worry for at least 6months. SYMPTOMS: Restlessness or feeling keyed up, on edge Difficulty concentration or mind going blank Irritability Muscle tension Sleep disturbance

27. EPIDIMIOLOGY: Early adult life. Commonly in women More frequently in general Medical practice than in Psychiatry High rate of comorbidity Symptoms of hyperarousal Do not recognize themselves as having psychiatric illness

28. DIFFERENTIAL DIAGNOSIS: Major depression OCD Panic disorder Somatoform disorder Paranoid Eating disorder Hyper thyroidism Hypothyroidism Diabetes Drugs Mitral valve prolapse

29. TREATMENT: Pharmacological treatment: Benzodiazepine Buspirone(serotonin 1 A receptor partial agonist) TCA SSRI Psychotherapy: Cognitive – behavior therapy .