Anxiety Disorders

1. Anxiety disorders
Presented by : P.Harsha Vardhan Reddy

2. Anxiety : definition
• Anxiety is an emotional state commonly caused by the perception of real or
perceived danger that threatens the security of an individual. It allows a person to
prepare for or react to environmental changes. Everyone experiences a certain
amount of nervousness and apprehension when faced with a stressful situation.
• This is an adaptive response, and is transient in nature.
• Anxiety can produce uncomfortable and potentially debilitating psychological
(e.g., worry or feeling of threat) and physiological arousal (e.g., tachycardia or
shortness of breath) if it becomes excessive. Some individuals experience
persistent, severe anxiety symptoms and possess irrational fears that significantly
impair normal daily functioning. These persons often suffer from an anxiety
disorder.

3. Anxiety disorders
Reported more by women
than men.
• Anxiety disorders are among the most frequent mental disorders
encountered in clinical practice.
• Health care professionals often mistake anxiety disorders for physical
illnesses, and only 23% of patients receive appropriate treatment.
• Failure to diagnose and manage anxiety disorders results in negative
outcomes including overuse of health care resources, increased
morbidity, and mortality.

4. Fear vs Phobia
• Fear protects you from danger. Phobias have little to do with danger.
• More than 19 million Americans have a phobia -- an intense, irrational fear
when they face a certain situation, activity, or object. With a phobia, you may
know your anxiety and fear are not warranted, but you can't help the feelings.
And they can be so intense they virtually paralyze you.
• The Three Kinds of Phobia
• Hundreds of different phobias have been identified, including phobophobia or
fear of phobias. But when talking about phobias, which are a kind of anxiety
disorder, experts divide them into three categories --
• agoraphobia, an intense anxiety in public places where an escape might be
difficult;
• social phobia, a fear and avoidance of social situations; and
• specific phobia, an irrational fear of specific objects or situations.

8. Pathophysiology
• Data from biochemical and neuroimaging studies indicate that the
modulation of normal and pathologic anxiety states is associated
with multiple regions of the brain and abnormal function in several
neurotransmitter systems, including norepinephrine (NE), γ –
aminobutyric acid (GABA), and serotonin (5-HT).
• Noradrenergic model : This model suggests that the autonomic
nervous system of anxious patients is hypersensitive and overreacts
to various stimuli. The locus ceruleus may have a role in regulating
anxiety, as it activates norepinephrine release and stimulates the
sympathetic and parasympathetic nervous systems.

9. • γ-Aminobutyric acid (GABA) receptor model : GABA is the major
inhibitory neurotransmitter in the CNS. Many antianxiety drugs
target the GABAA receptor. Benzodiazepines (BZs) enhance the
inhibitory effects of GABA,which has a strong regulatory or
inhibitory effect on serotonin (5-HT), norepinephrine, and dopamine
systems.
• Anxiety symptoms may be linked to underactivity of GABA systems
or downregulated central BZ receptors. In patients with GAD, BZ
binding in the left temporal lobe is reduced Abnormal sensitivity to
antagonism of the BZ binding site and decreased binding was
demonstrated in panic disorder.
• Abnormalities of GABA inhibition may lead to increased response to
stress in PTSD patients.

10. • • 5-HT model : GAD symptoms may reflect excessive 5-HT transmission or
overactivity of the stimulatory 5-HT pathways. Patients with SAD have
greater prolactin response to buspirone challenge, indicating an
enhanced central serotonergic response. The role of 5-HT in panic
disorder is unclear, but it may have a role in development of anticipatory
anxiety. Preliminary data suggest that the 5-HT and 5-HT2 antagonist
metachlorophenylpiperazine causes increased anxiety in PTSD patients.
• In patients with SAD, there may be abnormalities in the amygdala,
hippocampus, and various cortical regions.
• Lower hippocampal volumes in patients with PTSD may be a precursor for
subsequent development of PTSD.

12. Clinical presentation :
GENERALIZED ANXIETY DISORDER
• The diagnostic criteria for GAD require
persistent symptoms for most days for at
least 6 months.
• The essential feature of GAD is unrealistic
or excessive anxiety and worry about a
number of events or activities. or other
important areas of functioning.
• The majority of patients with GAD
eventually will develop another mental
disorder.
• GAD is usually the primary disorder in
patients with comorbid anxious depression.
Presentation of Generalized Anxiety
Disorder
Psychological and cognitive symptoms :
• Excessive anxiety
• Worries that are difficult to control
• Feeling keyed up or on edge
• Poor concentration or mind going blank
Physical symptoms :
• Restlessness, Fatigue, Muscle tension,
Sleep disturbance, Irritability

13. Panic disorder :
• Panic disorder begins as a series of
unexpected (spontaneous) panic attacks
involving an intense, terrifying fear
similar to that caused by life-
threatening danger.
• During an attack, patients often
describe an overwhelming sense of
doom, a fear of dying or losing control,
and at least four physical symptoms.
• Panic attacks usually last no more than
20 to 30 minutes,
• With the peak intensity of symptoms
within the first 10 minutes.
• Secondary to the panic attacks, many
patients eventually develop
agoraphobia.
Symptoms of a Panic Attack
Psychological symptoms :
• Depersonalization, Derealization, Fear of
losing control, Fear of going crazy, Fear of
dying.
Physical symptoms :
• Abdominal distress, Chest pain or
discomfort, Chills, Dizziness or light-
headedness, Feeling of choking, Hot
flushes, Palpitations, Nausea, Shortness
of breath, Sweating, Tachycardia,
Trembling or shaking.

14. SOCIAL ANXIETY DISORDER :
• SAD is characterized by an intense, irrational, and persistent fear of being
negatively evaluated or scrutinized in at least one social or performance
situation. Exposure to the feared circumstance usually provokes an
immediate situation-related panic attack.
• Blushing is the principal physical indicator and distinguishes SAD from other
anxiety disorders.
• Adults with SAD usually recognize their fear is excessive and unreasonable;
however, they are unable to overcome it without treatment.
• In individuals under 18 years of age, the duration of symptoms is at least 6
months. The fear or avoidance is not caused by a drug or other substance
(e.g., cocaine), or a general medical or psychiatric Disorder.
• The mean age of onset of SAD is during the mid-teens. Rates of SAD are
slightly higher among women than men and more frequent in younger
cohorts. It is a chronic disorder with a mean duration of 20 years.

15. Presentation of Social Anxiety Disorder
Fears
• Being scrutinized by others, Being embarrassed, Being humiliated
Some feared situations
• Addressing a group of people, Eating or writing in front of others, Interacting with
authority figures, Speaking in public, Talking with strangers, Use of public toilets
Physical symptoms
• Blushing, Butterflies in the stomach, Diarrhea, Sweating, Tachycardia, Trembling
Types
• Generalized type: fear and avoidance extend to a wide range of social situations
• Nongeneralized type: fear is limited to one or two situations.
• SPECIFIC PHOBIA

16. POSTTRAUMATIC STRESS DISORDER
• In PTSD, exposure to a traumatic event causes immediate intense fear, helplessness, or
horror.
• PTSD can occur at any age, and the course is variable.
• One-third of patients with PTSD have a poor prognosis, and about 80% have a
concurrent depression or anxiety disorder.
• Over half of men with PTSD have comorbid alcohol abuse or dependence, and about
20% of patients attempt suicide.
Presentation of Posttraumatic Stress Disorder
Re-experiencing symptoms
• Recurrent, intrusive distressing memories of the trauma, Recurrent, disturbing dreams
of the event, Feeling that the traumatic event is recurring (e.g., dissociative flashbacks),
Physiologic reaction to reminders of the trauma

17. Avoidance symptoms
• Avoidance of conversations about the trauma, Avoidance of thoughts or feelings
about the trauma, Avoidance of activities that are reminders of the event, Avoidance of
people or places that arouse recollections of the trauma, Inability to recall an important
aspect of the trauma, Anhedonia, Restricted affect, Sense of a foreshortened future
(e.g., does not expect to have a career, marriage)
Hyper-arousal symptoms
• Decreased concentration, Easily startled, Hypervigilance, Insomnia, Irritability or
angry outbursts
Subtypes
• Acute: duration of symptoms is less than 3 months
• Chronic: symptoms last for longer than 3 months
• With delayed onset: onset of symptoms is at least 6 months posttrauma

18. Obsessive-compulsive disorder (OCD)
• Obsessive-compulsive disorder (OCD) is one of the ten leading causes of
disability.
• Patients with OCD experience significant impairment in their quality of life
(QOL), with reductions in social, family, and occupational functioning.
• OCD affects far more individuals than was thought in the past.
• Because of the nature and potential severity of signs and symptoms and the
resultant negative effects on QOL, OCD is considered a major medical condition.
• Clinicians should be able to identify OCD and understand the current treatment
options.
• There is no exact cause for this condition.

19. Presentation of Obsessive-Compulsive Disorder
Obsessions
• Repetitive thoughts (e.g., feeling contaminated after touching an
object, doubting whether the stove was turned off), Repetitive
images (e.g., recurrent sexually explicit pictures), Repetitive
impulses (e.g., need for symmetry or putting things in specific order,
impulse to shout out obscenities in a church)
• Compulsions
• Repetitive activities (e.g., hand washing, checking, ordering, need
to ask, need to confess)
• Repetitive mental acts (e.g., counting, repeating words silently,
praying)

20. DRUG-INDUCED ANXIETY
• Drugs are a common cause of anxiety symptoms. Anxiety occurs during the use
of central nervous system (CNS) stimulating drugs in a dose-dependent manner,
but ingestion of minimal amounts can result in marked anxiety, including panic
attacks, in some individuals.
• The onset of drug-induced anxiety is usually rapid after the initiation of therapy;
look for a recent drug or dosage change to rule out drug etiologies for anxiety.
• Anxiety occurs occasionally during the use of cns depressants, especially in
children and the elderly; however, anxiety complaints are more common as
complications of drug withdrawal after the abrupt discontinuation of these
agents.

21. Drugs Associated with Anxiety Symptoms
• Anticonvulsants: carbamazepine
• Antidepressants: selective serotonin
reuptake inhibitors, tricyclic
• antidepressants
• Antihypertensives: felodipine
• Antibiotics: quinolones, isoniazid
• Bronchodilators: albuterol,
theophylline
• Corticosteroids: prednisone
• Dopa agonists: levodopa
• Herbals: ma huang, ginseng, ephedra
• Nonsteroidal anti-inflammatory
drugs: ibuprofen
• Stimulants: amphetamines,
methylphenidate, caffeine, cocaine
• Sympathomimetics:
pseudoephedrine
• Thyroid hormones: levothyroxine
• Toxicity: anticholinergics,
antihistamines, digoxin
• Withdrawal: alcohol, sedatives.

22. MEDICAL DISEASES ASSOCIATED WITH ANXIETY
Common Medical Illnesses Associated with Anxiety Symptoms :
Cardiovascular :
• Angina, arrhythmias, congestive heart
failure, ischemic heart
disease, myocardial infarction
Endocrine and metabolic :
• Cushing’s
disease, hyperparathyroidism, hyperth
yroidism, hypothyroidism, hypoglyce
mia, hyponatremia, hyperkalemia, phe
ochromocytoma, vitamin B12 or
folate deficiencies
Neurologic :
• Dementia, migraine, Parkinson’s
disease, seizures, stroke, neoplasms,
poor pain control
Respiratory system :
• Asthma, chronic obstructive
pulmonary disease, pulmonary
embolus, pneumonia
Others :
• Anemias, systemic lupus
erythematosus, vestibular dysfunction

23. Treatment :
• Treatment for anxiety disorders often requires multiple
approaches.
• The patient may need short-term treatment with an anxiolytic,
such as a benzodiazepine, to help reduce the immediate
symptoms combined with psychological therapies and an
antidepressant for longer term treatment and prevention of
symptoms returning.

24. Psychotherapy :
• The specific psychotherapy with the most supporting evidence in anxiety
disorders is cognitive behavioural therapy (CBT). Cognitive behaviour
therapy focuses on the ‘here and now’ and explores how the individual feels
about themselves and others and how behaviour is related to these thoughts.
• Through individual therapy or group work the patient and therapist identify
and question maladaptive thoughts and help develop an alternative
perspective. Individual goals and strategies are developed and evaluated with
patients encouraged to practice what they have learned between sessions.
• Therapy usually lasts for around 60–90 minutes every week for 8–16 weeks,
or longer in more resistant cases.
• Specific phobias are also almost exclusively treated using exposure
techniques and most patients will respond to this treatment. Only a very few
will require additional drug therapy.

25. Pharmacotherapy :
Benzodiazepines : Benzodiazepines are commonly prescribed to provide
immediate relief of the symptoms of severe anxiety. A number of different
benzodiazepines are available. These drugs differ considerably in potency
(equivalent dosage) and in rate of elimination but only slightly in clinical
effects.
All benzodiazepines have sedative/hypnotic, anxiolytic, amnesic, muscular
relaxant and anticonvulsant actions with minor differences in the relative
potency of these effects.

27. Mechanism of action :

29. Anti-depressants :
 Selective serotonin reuptake inhibhitors
 Tricyclic antidepressants
 Monoamine oxidase inhibhitors

30. Other medications occasionally used in
anxiety :
• Hydroxyzine – sedating anti-histamine – used in GAD
dose- 50-100mg
• Anti-psychotics – has limited evidence and high side effects
• Pregabalin – only for GAD (licenced)
• Buspirone – 5HT1a partial agonist(anxiolytic-psychoactive drug)-
GAD
• Propranolol & oxprenolol- licensed to treat anxiety symptoms-
used in PTSD

31. Summary :