2. Normal anxiety
Diffuse, unpleasant, vague sense of apprehension,
often accompanied by autonomic symptoms and an
inability to sit or stand for too long
The experience of anxiety has two components: the
physiological sensations (e.g., palpitations and
sweating) and the awareness of being nervous or
frightened
3. Fear vs Anxiety
Fear is an alarm response that fires in the presence of
imminent threat or danger
Anxiety is a future-oriented mood state in which the
individual anticipates the possibility of threat and
experiences a sense of uncontrollability focused on the
upcoming negative event
Anxiety and fear both are alerting signals and act as a
warning of an internal and external threat. It prompts a
person to take the necessary steps to prevent the threat
or to lessen its consequences
4. Anxiety disorders
Among the most prevalent of mental disorders
Women affected twice as frequently as men
Often present to physician in primary care settings
Often chronic and resistant to treatment
5. Anxiety disorders
Anxiety disorders can be viewed as a family of
related but distinct mental disorders
(1) panic disorder
(2) agoraphobia
(3) generalized anxiety disorder
(4) social anxiety disorder or phobia
(5) specific phobia
6. Panic attack
Discrete period of intense fear or discomfort
Characterized by palpitations, sweating,
trembling or shaking, choking or shortness of
breath, chest pain or discomfort, nausea, feeling
of losing control
Can occur normally and also part of many
psychiatric disorders
7. Panic disorder
Acute intense attack of anxiety accompanied by
feelings of impending doom
Recurrent and spontaneous attacks of panic episode
10min duration of rapidly increasing symptoms
Crescendo and diminuendo
Lasts 20-30min in duration
Feeling of “losing control” or “I am going mad!”
Anticipatory anxiety between attacks
A significant maladaptive change in behavior related
to the attacks (avoidance/ safety behavior)
8. Etiology
Autonomic Nervous system:
exhibit increased sympathetic tone
adapt slowly to repeated stimuli
respond excessively to moderate stimuli
Neurotransmitters: Nor epinephrine, Serotonin,
GABA
9. Neuroanatomical:
the brainstem (particularly the noradrenergic neurons
of the locus ceruleus and the serotonergic neurons of the
median raphe nucleus)
the limbic system (possibly responsible for the
generation of anticipatory anxiety)
the prefrontal cortex (possibly responsible for the
generation of phobic avoidance)
10. Cognitive theories:
negative cognitions regarding self and environment
higher incidence of stressful life events (particularly
loss) in the months before the onset of panic disorder
the patients typically experience greater distress about
life events than control subjects do
11. Case vignette
Ms. S. 23yr intern seen in emergency late one evening.
Ms. S. had been evaluated three times over the
preceding 3 weeks in this emergency room.
First visit was due to a paroxysm of extreme dyspnoea
and terror that occurred while she was preparing for PG
entrance. It was accompanied by palpitations, choking
sensations, sweating, shakiness, and a strong urge to flee.
Ms. S. thought she was having a heart attack, and she
immediately went to the emergency room. She received a
full medical evaluation, including an ECG and routine
blood work, which revealed no sign of cardiovascular,
pulmonary, or other illness. Has had similar episodes on
two other occasions. Now, she continues to worry when
she will have her next attack and prefers to stay in
hostel, closer to hospital than go to library.
12. Agoraphobia
Agoraphobia- a fear of or anxiety regarding
places from which escape might be difficult.
Can significantly interfere with a person’s ability to
function in work and social situations outside the
home.
A complication in patients with panic disorder - fear
of having a panic attack in a public place from
which escape would be formidable is thought to
cause the agoraphobia.
13. The DSM-5 diagnostic criteria for agoraphobia
stipulates marked fear or anxiety about two or
more of five situation groups:
(1) using public transportation (bus, train, cars, planes)
(2) in an open space (park, shopping center, parking
lot)
(3) in an enclosed space (stores, theaters)
(4) in a crowd or standing in line
(5) alone outside of the home.
14. Must be persistent and last at least 6 months
Patients with agoraphobia rigidly avoid situations in
which it would be difficult to obtain help
They prefer to be accompanied by a friend or a
family member
Or are endured with intense fear or anxiety
15. Generalized Anxiety Disorder (GAD)
Pattern of frequent, persistent worry and anxiety
that is out of proportion to the impact of the event
or circumstance that is the focus of the worry
Cause significant impairment or distress
16. Clinical features
Anxiety which is generalized and persistent and not to
any particular circumstance (free floating anxiety)
Apprehension (worries about future misfortunes, feeling
"on edge", difficulty in concentrating, etc.)
Continuous feelings of nervousness, trembling, sweating,
palpitations, epigastric discomfort (autonomic arousal)
Restless fidgeting, tension headaches, trembling,
inability to relax (motor tension)
18. Case vignette
A 27-year-old married electrician complained of dizziness,
sweating palms, heart palpitations, and ringing of the ears of
more than 18 months' duration. He also experienced dry
mouth and throat, periods of extreme muscle tension, and a
constant edgy and watchful feeling that had often interfered
with his ability to concentrate. These feelings had been
present most of the time over the previous 2 years; they had
not been limited to discrete periods. He also had many
worries. He constantly worried about the health of his parents.
His father, in fact, had a myocardial infarction 2 years
previously, but is now feeling well. He also worried about
whether he is a good father, whether his wife will ever leave
him (there is no indication that she is dissatisfied with the
marriage), and whether he is liked by co-workers on the job.
Although he recognizes that his worries are often unfounded,
he can't stop worrying.
19. Social anxiety disorder(social phobia)
Fear of social situations, including situations that
involve scrutiny or contact with strangers
Fearful of embarrassing themselves in social
situations
Specific fears about performing specific activities in
front of others (performance only)
Social situations are avoided or endured with
intense fear or anxiety
Some degree of social anxiety or self consciousness
is common
20. Specific phobia
A strong, persisting fear of an object or a situation
Requires the development of intense anxiety when
exposed to the feared object
In children - crying, tantrums, freezing or clinging
Object or situation is actively avoided or endured with
intense fear or anxiety
Classified based on the phobic stimulus as animal type,
natural environment type, blood-injection-injury type
and situational type
Etiology- classical conditioning, operant conditioning
(avoidance), learning theories and modelling
21. Types
Acrophobia fear of heights
Agoraphobia fear of open places
Ailurophobia fear of cats
Hydrophobia fear of water
Claustrophobia fear of closed spaces
Cynophobia fear of dogs
Mysophobia fear of dirt and germs
Pyrophobia fear of fire
Xenophobia fear of strangers
Zoophobia fear of animals
22. Case vignette
Mr. A. 26yr, successful software engineer, presented
following his transfer from Delhi to Singapore. While he
had formerly worked largely from an office which was on
the first floor of a building, promotion led to an office
which was situated on the 11th floor. He reported being
"deathly afraid" of heights. Even in shopping malls, he
would not go to the 2nd floor. The thought of going
upstairs would create intense anxiety. Many a time in the
past he had attempted to go to the fourth floor of his
office but he developed intense fear, palpitations,
sweating, anxiety, choking, clammy feelings, and stomach
upset, felt that he was going to die of respiratory arrest,
he had to run to the ground floor so that he can breath.
He would even avoid party or functions held on the top
floors of hotels.
23. Differential diagnosis
Endocrinological disorders- both hypo- and
hyperthyroid states, hyperparathyroidism, and
pheochromocytomas, episodic hypoglycemia
associated with insulinomas
Neurological- seizure disorders, vestibular
dysfunction, neoplasms, or the effects of both
prescribed and illicit substances on the CNS
Disorders of the cardiac and pulmonary systems-
arrhythmias, chronic obstructive pulmonary disease,
and asthma
Others- anemia, infections, anaphylaxis, SLE
24. Psychiatric disorders- other anxiety disorders, PTSD
and OCD, psychoses and affective disorders,
substance use disorders
25. Treatment
Pharmacological:
Antidepressants: SSRIs the mainstay of treatment, others
also like SNRIs
Benzodiazepines: both fast acting and intermediate
acting (clonazepam, lorazepam)
Beta- blockers: propranolol to control autonomic
symptoms
Others: carbamazepine, valproate, calcium channel
inhibitors, buspirone
26. Non pharmacological:
Psychoeducation
Cognitive behavioral therapy (desensitization)
Behavioral therapy- relaxation and biofeedback
Supportive therapy
27. OCD
Diverse group of symptoms that include intrusive
thoughts, rituals, preoccupations, and compulsions
Cause severe distress to the person
Are time consuming and interfere significantly with
the persons normal routine, occupational functioning,
usual social activities or relationships
28. Obsessions
Repetitive thoughts, images or impulses recognized as
one’s own, intrusive, distressing, irrational but unable to
control and relieved by motor or mental compulsions
Compulsions
Conscious, standardized, repetitive behavior, either
observable or mental, that are intended to reduce the
anxiety engendered by obsessions
29. Clinical features
Obsessions-
1. Contamination
2. Pathological doubt
3. Need for symmetry
4. Somatic obsessions
5. Aggressive and sexual obsessions
Most common is fear of contamination, followed by
pathological doubt, need for symmetry
30. Compulsions-
1. Checking
2. Washing
3. Counting
4. Need to ask or confess
5. Mental compulsions
Most common is checking, followed by washing,
mental compulsions, need to ask or confess
31. Contamination-
Characterized by fear of germs or dirt; may also
involve toxins, environmental hazards, bodily waste
or secretions
Described as feared consequence of contact with
contaminated object or fear of sensory experience
of not being clean
Excessive washing is the compulsion associated;
many use avoidance
32. Pathological doubt-
Plagued by concern that as a result of their
carelessness, they will be responsible for a dire
event
Excessive doubt and associated feelings of
excessive responsibility leads to checking
Strategies- counting the number of times they check;
making a family member observe so that he can be
reassured later
33. Need for symmetry-
Drive to order or arrange things perfectly or to
perform certain behaviors symmetrically or in a
balanced way
Primarily magical thinking- worries about feared
consequences to their loved ones
34. Somatic obsessions-
Worry that they have or will contract an illness or
disease- cancer, venereal disease, AIDS
Checking and rechecking the body part of concern;
reassurance seeking
Sexual and aggressive obsessions-
Fear that they have or might harm others or commit
a sexually unacceptable act
Checking, reassurance seeking and confession
35. Mental compulsions/rituals-
Neutralizing thoughts such as mental counting or praying,
which decrease anxiety caused by obsessions
Insight-
Awareness of senselessness of obsessions
Insight and resistance are fundamental to the diagnosis
Continuum- good insight to obsessive compulsive
psychosis
36. Etiology
Biological theories
1. Genetic factors-
Relatives have 3-5 fold higher possibility of having
OCD
2. Neuro-biochemical theories-
Serotonin- dysregulation
Altered function in orbitofrontal cortex, basal
ganglia (especially caudate) and cingulate gyrus
37. Behavioral theories
Obsessions- previously neutral thoughts and objects
become conditioned stimuli capable of provoking
anxiety or discomfort
Compulsions- actions that reduce anxiety attached to
obsessions become fixed as learned patterns of
compulsions
Psychosocial theories
Personality factors- 15-35% of patients have had
premorbid obsessional traits
38. Treatment
Pharmacological management
Antidepressants- SSRIs
o Fluoxetine
o Fluvoxamine
o Sertraline and Paroxetine
o Clomipramine- TCA
Antipsychotics-HPL, risperidone, olanzapine
Benzodiazepines- clonazepam
Lithium, buspirone, pindolol
40. Case vignette
C/C- 28yr old man presents to the OPD worried that his
chapped hands may have become infected.
HOPI- Patient has been obsessed with thoughts of
infection and spends several hours each day scrubbing
his hands. His persistent and intrusive thoughts
regarding infections are quite distressing, making it
difficult for him to leave his home. He also admits to
being afraid that he will accidently leave his stove on,
and he checks his stove exactly 29 times before leaving
the house or going to bed. He acknowledges that his
behavior is senseless but is unable to control it.
PE- Severely desquamated skin with mild bleeding over
both hands
