This document discusses anxiety disorders in African Americans. It provides statistics on the prevalence and costs of various anxiety disorders like panic disorder, social phobia, PTSD, and GAD. While lifetime rates of anxiety disorders are lower in African Americans compared to whites, African Americans are more likely to be misdiagnosed or experience higher rates of certain disorders like phobias and PTSD. The document reviews diagnostic criteria, epidemiology, symptoms, course, and treatment options for various anxiety disorders and highlights some differences observed in the African American population.

1. Anxiety Disorders in African
Americans
Tanya N. Alim, M.D.
Assistant Professor of Psychiatry
Howard University
Mini-Medical School
Tuesday, April 18, 2006

2. 1990 Annual Costs of Anxiety
Disorders (Billions)
42.3
23
13.3
20.4
1.2
0.8
0 10 20 30 40 50
Total
Non-psy
Psy Tx
Work
Mort.
Rx
Greenberg et al., J of Clin Psychiatry 60 (7), ‘99 Estimated $63 billion in 1998
2%
3%
10%
31%
54%

3. Importance of Recognition of
Anxiety Disorders
• Accurate Dx and Tx of
anxiety disorders
• Reduction of secondary
psychiatric conditions
– Depression
– Substance use problems

4. Percentage of Anxiety Disorders in
Adults in a given year
0 1 2 3 4 5
PANIC D
AGORAPH
OCD
GAD
PTSD
SocPHOB
SpecPHOB
Percent
http://www.nimh.nih.gov/publicat/anxiety.cfm

5. Definition of Fear and Anxiety

6. Difference between Fear
and Anxiety
• Fear is sense of dread and
foreboding that is in response
to an imminent, external
threatening event
• Anxiety is expected response
to stress; or feelings of
apprehension or dread to
nonspecific stimuli

7. Difference between Normal and
Pathological Anxiety
• Normal anxiety is expected response to
stress or threat
• Pathologic anxiety
– Autonomy
– Intensity
– Duration
– Behavior: avoidance or withdrawal

8. Anxiety Manifestations
• Physical symptoms and signs
• Facial Expression
• Behavior
• Thoughts

9. Brain Anatomy of Anxiety
• Locus coeruleus
– Important in vigilance, attention and
anxiety or fear
– Stimulation: ↑ panic attacks
– Blockade: ↓panic attacks
• Amygdala
– Major mediator of stress response
(fear/anxiety)

10. Amygdala connections
• Fear, cognitive misappraisal
• Escape and freezing
• Hyperventilation or fast breathing
• Sympathetic activation: ↑ heart rate, sweating
• ↑ stress hormone i.e. cortisol
• Nausea, queasy stomach, diarrhea
• ↑ startle
• Motor activation

11. Hypotheses-
Psychological
• Psychodynamic
– Freud: anxiety as a signal of threat to the
ego
– Symbolic or current events are similar to
threatening developmental events
• Cognitive-Behavioral
– Negative thoughts and beliefs activate
anxiety
– Overprediction & Castastrophic thinking

12. Hypotheses-
Genetic
• First degree relatives of patients with anxiety
disorders have a Significantly ↑↑ risk for
anxiety
• First degree relatives of panic disorder
patients have a 4- 10x risk
• ↑ risk in social phobia for relatives
• ↑rates of OCD, Tourette’s d/o and chronic
motor tics in relatives of Tourette’s

13. Anxiety Disorders
• Panic disorder- PD
• Agoraphobia- AG
• Social phobia**- SoP
• Specific phobias- SP
• Generalized Anxiety Disorder**- GAD or GD
• Posttraumatic Stress Disorder**- PTSD or PTD
• Acute Stress Disorder**-ASD
• Obsessive Compulsive Disorder**-OCD
• Separation Anxiety Disorder*-SAD
*children only **both children & adults

14. Panic attack overwhelming
sense of fear with :
• Shortness of breath
• Heart pounding
• Chest pain
• Smothering/choking
• Dizziness
• Loss of sense of
reality or oneself
• Numbing and/or
weakness
• Hot & cold flashes
• Sweating
• Faintness
• Trembling
• Losing control or
going crazy
• Nausea/upset
stomach

15. Panic disorder –
PD
• Persistent worry about ANOTHER
ATTACK
• Change in behavior because of the
attacks
• Peak in 10 min
• Associated with at least 4 other
symptoms

16. Panic Disorder - Epidemiology
• Prevalence (NCS) up to 3.5%
• Sex - More females than males (2:1)
• Age of onset – 20’s (bimodal – 45-64)
• Race – 45-54 yr range African-
Americans and Hispanics were lower
• Can occur with major depression and
agoraphobia

17. Panic Disorder - course
• High rates of relapse with stopping treatment
• Persistent anxiety and avoidant behavior
• Social and vocational dysfunction
• Marital problems
• Alcohol and drug use
• ↑use of medical service
• ↑mortality from cardiovascular
problems/suicide

18. Agoraphobia –
AG
• Fear and avoidance in being in a
situation that escape may be difficulty
or they may not be able to get help
• May not leave home or may need a
companion
• Can occur with and without panic
disorder

19. Agoraphobia
• Prevalence (NCS) 6.7%
• Sex – Women higher than Men
2.9% in White males
12% in African American females
• Race – higher in African Americans than
in Whites or Hispanics
• 1/3 of Agoraphobics have history of
panic attacks

20. Social Phobia
Persistent, irrational fear of social situations
• Marked avoidance of situations (humiliation
or embarrassment)
• Or marked anxiety under these situations
• Recognized as not reasonable

21. Social Phobia-
SoP
• Prevalence – 13.3%
• Age of onset – mid teens to 20’s (16)
• Higher in females of less education, less
income, single never married, students, living
with parents
• Men more likely to seek treatment
• Children: Crying or staying close to familiar
adults; very shy; periphery of social situations
• Can occur with depression

22. Social Phobia - course
• Comorbid with depression
• Alcohol and drug use
• Chronic but fluctuates
• Worsened during stress
• In children and adolescents may lead to
failure to achieve and inability to
function in social activities

23. Specific Phobias
• Marked persistent fear of situation or
object
• Examples: heights, closed spaces,
animals or sight of blood
• Exposure causes intense anxiety and
avoidance causing interference

24. Specific Phobias-
SP
• Prevalence 10%
• Onset in childhood - Phobias to
animals, natural environments (hts,
storms, water) blood and injections
• Onset bimodally (childhood and mid
20’s)
– Situational phobias (airplanes, elevators
and closed places)

25. Phobia Types
• Acrophobia
• Agoraphobia
• Ailurophobia
• Hydrophobia
• Claustrophobia
• Cynophobia
• Mysophobia
• Pyrophobia
• Xenophobia
• Zoophobia
• Fear of heights
• Fear of open places
• Fear of cats
• Fear of water
• Fear of closed places
• Fear of dogs
• Fear of dirt and germs
• Fear of fire
• Fear of strangers
• Fear of animals

26. Obsessive Compulsive Disorder -
OCD
• Presence of obsessions or compulsions
causing a lot of distress or impairment
• Consume more than 1 hour a day or
• Interfere with normal
routine/occupational/social
• Unreasonable or excessive

27. OCD - Epidemiology
• Prevalence – 2.2 to 2.3% in adults; 1-
2% in children
• Age of onset – mid 20’s to 30’s
• Higher in women than men
• Can occur commonly with major
depression or another anxiety disorder

28. OCD
• Thoughts may include
– Fears of contamination
– Feelings of self-doubt/guilt
• Compulsive behaviors: Alleviate obsessions
– Checking
– Counting
– Hand-washing
– touching

29. Posttraumatic Stress Disorder -
PTSD
• “A” criteria –psychological distress in
response to stressor that is defined as
severe with threat to physical integrity,
hopelessness/helplessness, intense
fear or horror
• B criteria - Reexperiencing
• C criteria - Avoidance
• D criteria - Hyperarousal

30. PTSD – Re-experiencing
B criteria
• Intrusive recollections
• Nightmares
• Flashbacks
• Psychological distress
• Physical reactivity upon cue exposure

31. PTSD – Avoidance
C criteria
• Avoidance of thoughts or activities
assoc. with trauma
• Numbing
• Detachment or estrangement from
others
• Sense of foreshortened future

32. PTSD – Hyperarousal
D criteria
• Sleep disturbance
• Irritability and anger
• Difficulty concentrating
• Hypervigilance
• Startle response

33. PTSD
• Prevalence – 10.4 – 12.3% in women;
5 – 6% in men
• Traumatic attacks in Men
– Physical attacks – combat – threats with
weapons – held captive – kidnapped
Women
– Rape – sexual molestation – parental
neglect or abuse

34. PTSD
• Risk factors
– Higher in women than men
– Preexisting traumas
– Personality disorder
– Previous mental illness
– Usually occurs with other psychiatric
disorders

35. PTSD - course
• Course is variable occurring at any age
• Sx occur within 3 months of trauma or
• Can be delayed
• Social withdrawal
• Depression
• Suicidality
• Alcohol and drug abuse

36. Acute Stress Disorder-
ASD
• Sx of PTSD
• Less than 4 weeks following trauma

37. Generalized Anxiety disorder-
GAD
• Unrealistic or excessive worry with the
following
• 3 out of 4 symptoms
– Motor tension
– Autonomic hyperactivity
– Vigilance and scanning
– Apprehensive expectation

38. GAD
• Prevalence – 4.1 to 6.6%; ↑ in females
• Age onset – children or 25 years and up
• Prior marriage, unemployed, homemaker,
Northeast
• Children: perfectionistic, redo tasks, seek
constant reassurance
• Worry about catastrophic events (eg.
hurricane); ability to perform school; sports;
• Common with agoraphobia, mood & panic
disorders

39. Separation anxiety disorder
• Excess anxiety during the time a child is
separated from home or a significant
attachment figure (parents, primary
caretaker)
• Attachment anxiety is normal at 2 years
• Disorder occurs when excessive and
occurs later

40. Separation Anxiety Disorder-
SAD
• May worry about something happening
to the major attachment person
• Prevalence: 4% in school age children
• 1% in adolescence
• Sex: equal in males and females
• Symptoms: at least 4 weeks
• Onset: occurs before 18 years old

41. Medical Causes of Anxiety
• Endocrine or hormone changes
• Neurological: including seizures
• Metabolic changes including ↑ body temp.
• Hypoxia (decreased oxygen to the body)
– Heart and lung disease: irregular heart
rhythm, chest pain, congestive heart
failure, bronchitis, blood clot (s)
• Drug Intoxication or Withdrawal

42. Anxiety disorders in African
Americans (AA)
• ↓ lifetime rates (3.2%) vs. Whites (6.3%) *
• More likely to be misdiagnosed**
• ↑ Phobias than non-Hispanic whites
• OCD- rare
• PTSD- in past, misdiagnosed for
schizophrenia; due to ↑ paranoia and
psychotic symptoms
*Turner & Lloyd, 2004; **Lawson, 2003

43. PTSD in African Americans
• Posttraumatic stress disorder- 7 -12% in
general population; 14% (in nonwhite sample)
• ↑↑rates including youth from socially
disadvantaged areas, high traumatic
exposures (eg. violence) – 7 to 50%
• The rate of lifetime PTSD (approx. 33% of
those screened) exceeds estimates for the
general population in our sample of patients
attending primary care offices at HUH

44. Lifetime treatment contact for
Anxiety disorders by African
Americans vs. Whites
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
PD AG SoP SP GD PTD SAD
Whites
Blacks
Odds
Ratio
Wang et al.

45. References
• Alim, TN, Charney, DS & Mellman, TA. An Overview of Posttraumatic Stress Disorder in African Americans.
Journal of Clinical Psychology, accepted for publication March 2006.
• Breslau, N., Kessler, R. C., Chilcoat, H. D., Schultz, L. R., Davis, G. C., & Andreski, P. (1998). Trauma and
posttraumatic stress disorder in the community: The 1996 Detroit area survey of trauma. Archives of
General Psychiatry, 55(7), 626-632.
• Lawson, W B(2003) Mental Health Issues in African Americans In: Handbook of Racial & Ethnic Minority
Psychology. Ed: Bernal, G, Trimble, JE, Burlew AK, Leong, FTL. Sage Publications, 561-9.
• Lawson, W. B. (2000). Issues in pharmacotherapy for African Americans. In P. Ruiz, J. M. Oldham & M.B.
Riba (Ed.), Ethnicity and Psychopharmacology, Review of Psychiatry, 19, (pp. 37-52). Washington, DC:
American Psychiatric Publishing, Inc.
• Turner, RJ & Lloyd, DA. (2004). Stress Burden and the Lifetime Incidence of Psychiatric Disorder in Young
Adults: Racial and Ethnic Contrasts. Archives of General Psychiatry, 61, 481-88.
• U.S. Department of Health and Human Services. (2001). Mental Health: Culture, Race, and Ethnicity – A
Supplement to Mental Health: A Report of the Surgeon General. Rockville, MD: U.S. Department of Health
and Human Services, Public Health Service, Office of the Surgeon
• Wang, PS, Berglund, P, Olfson, M, Pincus, HA, Wells, KB & Kessler, RC. (2005). Failure and Delay in Initial
Treatment Contact After First Onset of Mental Disorders in the National Comorbidity Survey Replication.
Archives of General Psychiatry, 62, 603-613.
• http://www.nimh.nih.gov/publicat/anxiety.cfm