2. Anxiety
It includes;
• Separation anxiety disorder
• Selective mutism
• Specific Phobia
• Social Anxiety Disorder
• Panic Disorder
• Agoraphobia
• GAD
• Substance/Medication induced Anxiety disorder
• OCD, Stress disorder and PTSD has not been included in the Anxiety disorder in the DSM-5
3. • Anxiety disorder shares the features of fear and anxiety and related behavioral
disturbances.
• Fear: is an autonomic response to real or perceived threat.
• Anxiety is muscle tension and vigilance in preparation of future danger.
• Separation Anxiety: it is characterized as fear or anxiety concerning separation
from an attachment figure.
• Selective Mutism: It is consistent failure to speak in social situations where
speaking is expected.
• Substance/Medication-induced Anxiety disorder: Heavy coffee consumption with
severe anxiety (Caffeine induced Anxiety disorder). Panic attack during or after
use of a stimulant such as cocaine.
4. • Generalized anxiety disorder, commonly referred to as GAD, is a disorder
characterized by an underlying excessive worry related to a wide range of events
or activities.
• While many individuals experience some levels of worry throughout the day,
individuals with GAD experience worry of greater intensity and for longer periods
than the average person (APA, 2013).
• Additionally, they are often unable to control their worry through various coping
strategies, which directly interferes with their ability to engage in daily social and
occupational tasks.
• Individuals with GAD will also experience somatic symptoms during intensive
periods of anxiety.
• These somatic symptoms may include sweating, dizziness, shortness of breath,
insomnia, restlessness, or muscle aches (Gelenberg, 2000).
5. • While it is not unusual for anyone to occasionally worry about things such as
family problems, health or money, people with generalized anxiety disorder
(GAD) find themselves extremely worried about these sorts of things, as well as
many other issues, even when there may be little or no reason to worry.
• Patients with GAD may be anxious just trying to get through an average day,
always believing that things will go badly.
• The constant worrying, can at times, keep patients with GAD from being able to
perform everyday tasks.
6.
7. • Generalized anxiety disorder (GAD) can be a challenge to diagnose. People
consider panic attacks a hallmark of all anxiety disorders, but GAD is different in
that there are generally no panic attacks associated with the condition.
• As a result of this misconception, without the experience of panic attacks, a person
may think they are "just worrying too much." Their struggles with constant worry
may be minimized or dismissed and, in turn, not properly diagnosed or treated.
• Generalized anxiety disorder is common. It affects about 3% of the adult
population.
• Childhood anxiety occurs in about 1 in 4 children at some time between the ages
of 13 years and 18 years. However, the lifetime prevalence of a severe anxiety
disorder in children ages 13 to 18 is approximately 6%.
8. Diagnostic Criteria DSM-5
• Factors like excessive, hindering worry paired with a variety of physical
symptoms, then use proven diagnostic assessments to make a diagnosis and rule
out other possibilities.
• All of the below features must be present in order to make a proper diagnosis of
GAD:
• Excessive anxiety and worry, occurring more days than not for at least 6 months,
concerning a number of events;
• The individual finds it difficult to control the worry;
9. • The anxiety and worry are associated with at least three of the following six
symptoms (only one item required in children):
• Restlessness, feeling keyed up or on edge.
• Being easily fatigued
• Difficulty concentrating
• Irritability
• Muscle tension
• Sleep disturbance
• The anxiety, worry or physical symptoms cause clinically significant
distress or impairment in important areas of functioning;
• The disturbance is not due to the physiological effects of a substance or
medical condition;
• The disturbance is not better explained by another medical disorder
(American Psychiatric Association, 2013).
10. • Generalized anxiety disorder (Co-morbidity)
• There is a high comorbidity between generalized anxiety disorder and the other anxiety related
disorders, as well as major depressive disorder, suggesting they all share common vulnerabilities,
both biological and psychological.
• GAD tends to coexist with a number of other psychiatric disorders, including, but not limited to
major depression, bipolar disorder, other anxieties and substance abuse problems.
• So many similarities exist between depression and GAD that many experts have even suggested re-
categorizing GAD as a mood disorder. In cases where GAD does coexist with other psychiatric
disorders, there is a heightened risk of impairment, suicide and disability.
• Unfortunately, most clinical trials evaluating GAD along with other most likely disorders do not
take comorbidity into account, resulting in a paucity of data available to help guide treatment
selection.
• As a result, there is a strong current need to push for additional research examining the
comorbidities of GAD.
11. Diagnostic Criteria of ICD-11 for Anxiety Disorder
• Description
• Anxiety and fear-related disorders are characterized by excessive fear and anxiety and related
behavioral disturbances, with symptoms that are severe enough to result in significant distress or
significant impairment in personal, family, social, educational, occupational, or other important
areas of functioning.
• Fear and anxiety are closely related phenomena; fear represents a reaction to perceived imminent
threat in the present, whereas anxiety is more future-oriented, referring to perceived anticipated
threat.
• A key differentiating feature among the Anxiety and fear-related disorders are disorder-specific
focus of apprehension, that is, the stimulus or situation that triggers the fear or anxiety.
• The clinical presentation of Anxiety and fear-related disorders typically includes specific
associated cognitions that can assist in differentiating among the disorders by clarifying the focus
of apprehension.
12. • 6B00 Generalized Anxiety Disorder
• 6B01 Panic Disorder
• 6B02 Agoraphobia
• 6B03 Specific Phobia
• 6B04 Social Anxiety Disorder
• 6B05 Separation Anxiety Disorder
• 6B06 Selective Mutism
• 6B0Y Other Specified Anxiety or Fear-Related Disorders
13. • Etiology of GAD
• 1. Biological - Genetic influences. While genetics have been known to contribute
to the presentation of anxiety symptoms, the interaction between genetics and
stressful environmental influences appears to account for more anxiety disorders
than genetics alone (Bienvenu, Davydow, & Kendler, 2011).
• The quest to identify specific genes that may predispose individuals to develop
anxiety disorders has led researchers to the serotonin transporter gene (5-
HTTLPR).
• Mutation of the 5-HTTLPR gene is related to a reduction in serotonin activity and
an increase in anxiety-related personality traits (Munafo, Brown, & Hairiri, 2008).
14. • Biological - Neurobiological structures. Researchers have identified several brain
structures and pathways that are likely responsible for anxiety responses.
• Among those structures is the amygdala, the area of the brain that is responsible for storing
memories related to emotional events (Gorman, Kent, Sullivan, & Coplan, 2000).
• When presented with a fearful situation, the amygdala initiates a reaction to ready the body for a
response. First, the amygdala triggers the hypothalamic-pituitary-adrenal (HPA) axis to prepare for
immediate action— either to fight or flight.
• The second pathway is activated by the feared stimulus itself, by sending a sensory signal to the
hippocampus and prefrontal cortex, for determination if threat is real or imagined.
• If it is determined that no threat is present, the amygdala sends a calming response to the HPA
axis, thus reducing the level of fear. If there is a threat present, the amygdala is activated,
producing a fear response.
15. • Risk and Prognostic Factors
• Temperamental. Behavioral inhibition, negative affectivity (neuroticism), and harm
• avoidance have been associated with generalized anxiety disorder.
• Environmental. Although childhood adversities and parental overprotection have been
• associated with generalized anxiety disorder, no environmental factors have been
identified
• as specific to generalized anxiety disorder or necessary or sufficient for making the
diagnosis.
• Genetic and physiological. One-third of the risk of experiencing generalized anxiety
• disorder is genetic, and these genetic factors overlap with the risk of neuroticism and are
• shared with other anxiety and mood disorders, particularly major depressive disorder.
16. • Gender-Related Diagnostic Issues
• In clinical settings, generalized anxiety disorder is diagnosed somewhat more frequently in females
than in males (about 55%-60% of those presenting with the disorder are female). In
epidemiological studies, approximately two-thirds are female.
• Females and males who experience generalized anxiety disorder appear to have similar symptoms
but demonstrate different patterns of comorbidity consistent with gender differences in the
prevalence of disorders.
• In females, comorbidity is largely confined to the anxiety disorders and unipolar depression,
whereas in males, comorbidity is more likely to extend to the substance use disorders as well.
17. • Functional Consequences of Generalized Anxiety Disorder
• Excessive worrying impairs the individual's capacity to do things quickly and efficiently whether at
home or at work. The worrying takes time and energy; the associated symptoms of muscle tension
and feeling keyed up or on edge, tiredness, difficulty concentrating, and disturbed sleep contribute
to the impairment.
• Importantly the excessive worrying may impair the ability of individuals with generalized anxiety
disorder to encourage confidence in their children.
• Generalized anxiety disorder is associated with significant disability and distress that is
independent of comorbid disorders, and most non-institutionalized adults with the disorder are
moderately to seriously disabled. Generalized anxiety disorder accounts for 110 million disability
days per annum in the U.S. population.
18. Panic Disorder
• Diagnostic Criteria:
• Recurrent unexpected panic attacks. A panic attack is an abrupt surge of intense fear
• or intense discomfort that reaches a peak within minutes, and during which time four
• (or more) of the following symptoms occur;
• Note: The abrupt surge can occur from a calm state or an anxious state.
• 1. Palpitations, pounding heart, or accelerated heart rate.
• 2. Sweating.
• 3. Trembling or shaking.
• 4. Sensations of shortness of breath or smothering.
• 5. Feelings of choking.
• 6. Chest pain or discomfort.
19. 7. Nausea or abdominal distress.
8. Feeling dizzy, unsteady, light-headed, or faint.
9. Chills or heat sensations.
10. Paresthesias (numbness or tingling sensations).
11. Derealization (feelings of unreality) or depersonalization (being detached from
oneself).
12. Fear of losing control or “going crazy.”
13. Fear of dying.
Note: Culture-specific symptoms (e.g., tinnitus, neck soreness, headache, uncontrollable
screaming or crying) may be seen. Such symptoms should not count as one of the four
required symptoms.
20. • B. At least one of the attacks has been followed by 1 month (or more)
of one or both of the following:
1. Persistent concern or worry about additional panic attacks or their consequences (e.g.,
losing control, having a heart attack, “going crazy”).
2. A significant maladaptive change in behavior related to the attacks (e.g., behaviors designed
to avoid having panic attacks, such as avoidance of exercise or unfamiliar situations).
• C. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug
of abuse, a medication) or another medical condition (e.g., hyperthyroidism, cardiopulmonary
disorders).
• D. The disturbance is not better explained by another mental disorder (e.g., the panic attacks
do not occur only in response to feared social situations, as in social anxiety disorder:
• in response to circumscribed phobic objects or situations, as in specific phobia: in response to
obsessions, as in obsessive-compulsive disorder:
• in response to reminders of traumatic events, as in posttraumatic stress disorder: or in
response to separation from attachment figures, as in separation anxiety disorder).
21. • Diagnostic Features
• Panic disorder refers to recurrent unexpected panic attacks (Criterion A). A panic attack is
an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes
and during which time four or more of a list of 13 physical and cognitive symptoms
occur.
• The term recurrent literally means more than one unexpected panic attack. The term
unexpected refers to a panic attack for which there is no obvious cue or trigger at the time
of occurrence— that is, the attack appears to occur from out of the blue, such as when the
individual is relaxing or emerging from sleep (nocturnal panic attack).
• In contrast, expected panic attacks are attacks for which there is an obvious cue or
trigger, such as a situation in which panic attacks typically occur.
• The determination of whether panic attacks are expected or unexpected is made by the
clinician, who makes this judgment based on a combination of careful questioning as to
the sequence of events preceding or leading up to the attack and the individual's own
judgment of whether or not the attack seemed to occur for no apparent reason.
22. Associated Features Supporting Diagnosis
• One type of unexpected panic attack is a nocturnal panic attack (i.e., waking
from sleep in a state of panic, which differs from panicking after fully waking
from sleep).
• In addition to worry about panic attacks and their consequences, many
individuals with panic disorder report constant or intermittent feelings of
anxiety that are more broadly related to health and mental health concerns.
• For example, individuals with panic disorder often anticipate a disastrous
outcome from a mild physical symptom or medication side effect (e.g., thinking
that they may have heart disease or that a headache means presence of a brain
tumor).
• Such individuals often are relatively intolerant of medication side effects. In
addition, there may be pervasive concerns about abilities to complete daily tasks
or withstand daily stressors, excessive use of drugs (e.g., alcohol, prescribed
medications or illicit drugs) to control panic attacks, or extreme behaviors
aimed at controlling panic attacks (e.g., severe restrictions on food intake or
avoidance of specific foods or medications because of concerns about physical
symptoms that provoke panic attacks).
23. • Prevalence
• In the general population, the 12-month prevalence estimate for panic disorder across the
United States and several European countries is about 2%-3% in adults and adolescents.
• Females are more frequently affected than males, at a rate of approximately 2:1. The gender
differentiation occurs in adolescence and is already observable before age 14 years.
• Although panic attacks occur in children, the overall prevalence of panic disorder is low
before age 14 years (<0.4%). The rates of panic disorder show a gradual increase during
adolescence, particularly in females, and possibly following the onset of puberty, and peak
during adulthood.
24. • Risk and Prognostic Factors
• Temperamental. Negative affectivity (neuroticism) (i.e., proneness to experiencing
negative emotions) and anxiety sensitivity (i.e., the disposition to believe that symptoms of
anxiety are harmful) are risk factors for the onset of panic attacks and, separately, for worry
about panic, although their risk status for the diagnosis of panic disorder is unknown.
• History of "fearful spells" (i.e., limited-symptom attacks that do not meet full criteria for a
panic attack) may be a risk factor for later panic attacks and panic disorder.
• Although separation anxiety in childhood, especially when severe, may precede the later
development of panic disorder, it is not a consistent risk factor.
25. • Environmental. Reports of childhood experiences of sexual and physical abuse are more common
in panic disorder than in certain other anxiety disorders.
• Smoking is a risk facto for panic attacks and panic disorder. Most individuals report identifiable
stressors in the months before their first panic attack (e.g., interpersonal stressors and stressors
related to physical well-being, such as negative experiences with illicit or prescription drugs,
disease, or death in the family).
• Genetic and physiological. It is believed that multiple genes confer vulnerability to panic disorder.
However, the exact genes, gene products, or functions related to the genetic regions implicated
remain unknown.
• Current neural systems models for panic disorder emphasize the amygdala and related structures,
much as in other anxiety disorders.
• There is an increased risk for panic disorder among offspring of parents with anxiety, depressive,
and bipolar disorders. Respiratory disturbance, such as asthma, is associated with panic disorder,
in terms of past history, comorbidity, and family history.
26. • Comorbidity
• Panic disorder infrequently occurs in clinical settings in the absence of other
psychopathology.
• The prevalence of panic disorder is elevated in individuals with other disorders,
particularly other anxiety disorders (and especially agoraphobia), major depression,
bipolar disorder, and possibly mild alcohol use disorder.
• While panic disorder often has an earlier age at onset than the comorbid disorder(s), onset
sometimes occurs after the comorbid disorder and may be seen as a severity marker of the
comorbid illness.
• Reported lifetime rates of comorbidity between major depressive disorder and panic
disorder vary widely, ranging from 10% to 65% in individuals with panic disorder.
• In approximately one-third of individuals with both disorders, the depression precedes
the onset of panic disorder. In the remaining two-thirds, depression occurs coincident with
or following the onset of panic disorder.
27. ICD-11 Criteria for panic Disorder
• Panic disorder is characterized by recurrent unexpected panic attacks that are not restricted
to particular stimuli or situations.
• Panic attacks are discrete episodes of intense fear or apprehension accompanied by the
rapid and concurrent onset of several characteristic symptoms (e.g. palpitations or increased
heart rate, sweating, trembling, shortness of breath, chest pain, dizziness or lightheadedness,
chills, hot flushes, fear of imminent death).
• In addition, panic disorder is characterized by persistent concern about the recurrence or
significance of panic attacks, or behaviour intended to avoid their recurrence, that results in
significant impairment in personal, family, social, educational, occupational, or other
important areas of functioning.
• The symptoms are not a manifestation of another medical condition and are not due to the
effects of a substance or medication on the central nervous system.
28. • Panic attack (MB23.H)
• Diagnostic Requirements
• Essential (Required) Features:
• Recurrent panic attacks, which are discrete episodes of intense fear or apprehension
characterized by the rapid and concurrent onset of several characteristic symptoms. These
symptoms may include, but are not limited to, the following:
• Palpitations or increased heart rate
• Sweating
• Trembling
• Sensations of shortness of breath
• Feelings of choking
• Chest pain
• Nausea or abdominal distress
29. • Feelings of dizziness or light-headedness
• Chills or hot flushes
• Tingling or lack of sensation in extremities (i.e., paraesthesias)
• Depersonalization or derealization
• Fear of losing control or going mad
• Fear of imminent death
• At least some of the panic attacks are unexpected, that is they are not restricted to particular stimuli or
situations but rather seem to arise ‘out of the blue’.
• Panic attacks are followed by persistent concern or worry (e.g., for several weeks) about their recurrence
or their perceived negative significance (e.g., that the physiological symptoms may be those of a
myocardial infarction), or behaviors intended to avoid their recurrence (e.g., only leaving the home with
a trusted companion).
• Panic attacks are not limited to anxiety-provoking situations in the context of another mental disorder.
30. • The symptoms result in significant impairment in personal, family, social, educational,
occupational, or other important areas of functioning. If functioning is maintained, it is only
through significant additional effort.
• Note: Panic attacks can occur in other Anxiety or Fear-Related Disorders as well as other mental
disorders and therefore the presence of panic attacks is not in itself sufficient to assign a diagnosis
of Panic Disorder.
