Anxiety disorders

Dr. Layali Abbasi

Psychiatrist

Al-Balqa Applied University

5th year/Faculty of Medicine

2019-2020

• Anxiety and/or panic attacks are the core symptoms of the anxiety disorders.

Symptoms are uncontrollable, unpleasant (ego-dystonic) and impairing.

• Anxiety can involve both psychological and somatic attributes:

Psychological anxiety- includes worry and fear.

Somatic anxiety- includes restlessness, gastrointestinal complaints, headaches, muscle aches, and increases heart rate and respiration.

Fear versus anxiety

• Fear is a response to a known, external, definite threat.

• Anxiety is a response to a threat that is unknown, internal, vague.

Anxiety disorders :

Make up one of the most common groups of psychiatric disorders.

More frequent in women.

More likely to develop at an early age.

Chronic, with symptom intensity waxing and waning overtime. At times, symptoms may totally remit, only to return at a later age.

Often disabling.

Etiological formulations of anxiety symptoms

Neurological formulations:

The limbic system and locus coeruleus are implicated in the manifestations of GAD, panic disorder.

Brain imaging in persons with GAD and panic disorder may demonstrate organic pathology (e.g., lesions in the hippocampus, lesions in the frontal or temporal lobes) or functional pathology (e.g., dysregulation of cerebral blood flow).

Etiological formulations of anxiety symptoms

Biochemical formulations:

The three major neurotransmitters associated with anxiety are Gamma-aminobutyric acid (GABA), serotonin and norepinephrine (NE).

Gamma-aminobutyric acid (GABA) is a neutral inhibitory neurotransmitter that reduces anxiety by binding to GABAA receptor sites. When GABA binds to GABAA receptor sites, chloride ion channels open, resulting in reduced firing of neurons, producing a calming effect.

Etiological formulations of anxiety symptoms

Genetic formulations:

Individuals with close relatives with an anxiety disorder are at increased risk of developing anxiety disorders.

Psychoanalytic formulations:

Anxiety is related to unresolved unconscious conflicts.

Anxiety Disorders DSM-5

• Separation Anxiety Disorder

• Selective mutism

• Specific phobia

• Social anxiety disorder (Social Phobia)

• Panic Disorder

• Agoraphobia

• Generalized Anxiety Disorder

• Substance/Medication-Induced Anxiety Disorder

• Anxiety Disorder Due to Another Medical Condition

Specific phobia

• The term phobia refers to an excessive fear of a specific object, circumstance, or situation.

• A specific phobia is a strong, persisting fear of an object or situation.

• The diagnosis requires the development of intense anxiety, even to the point of panic, when exposed to the feared object.

Specific Phobia DSM-5 Diagnostic Criteria

A. Marked fear or anxiety about a specific object or situation (e.g., flying, heights, animals, receiving an injection, seeing blood).

Note: In children, the fear or anxiety may be expressed by crying, tantrums, freezing, or clinging.

• B. The phobic object or situation almost always provokes immediate fear or anxiety.

Specific Phobia DSM-5 Diagnostic Criteria C. The phobic object or situation is actively avoided or endured with intense fear or anxiety. D. The fear or anxiety is out of proportion to the actual danger posed by the specific object or situation and to the sociocultural context. E. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more. F. The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. G. The disturbance is not better explained by the symptoms of another mental disorder, including fear, anxiety, and avoidance of situations associated with panic-like symptoms or other incapacitating symptoms (as in agoraphobia); objects or situations related to obsessions (as in obsessive-compulsive disorder);

Specific Phobia Clinical issues

• Phobia is excessive fear of a specific object, circumstance, or situation.

• Individuals with specific phobia:

Have an intense and persistent fear of a specific object or situation, which maybe expressed as anxiety, fear of being harmed, fear of losing control, dizziness Or fainting spells.

Clearly recognize the specific object or situation as anxiogenic.

• Typical phobic object or situations include animals, witnessing blood, heights, flying, driving on bridges.

Specific Phobia Epidemiology

• Lifetime prevalence is 10%.

• Is the most common mental disorder among women and the second most common among men.

• Exhibits a bimodal age of onset, with a childhood peak and an early adulthood peak.

Comorbidity

• Common comorbid disorders include anxiety, mood, and substance related disorders.

Social anxiety disorder (Social Phobia)

Social anxiety disorder (Social Phobia) DSM-5 Diagnostic Criteria

A. Marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others. Examples include social interactions (e.g., having a conversation, meeting unfamiliar people), being observed (e.g., eating or drinking), and performing in front of others (e.g., giving a speech)

Note: In children, the anxiety must occur in peer settings and not just during interactions with adults.

B. The individual fears that he or she will act in a way or show anxiety symptoms that will be negatively evaluated (i.e., will be humiliating or embarrassing; will lead to rejection or offend others).

C. The social situations almost always provoke fear or anxiety.

Note: In children, the fear or anxiety may be expressed by crying, tantrums, freezing, clinging, shrinking, or failing to speak in social situations.

Social anxiety disorder (Social Phobia) DSM-5 Diagnostic Criteria

D. The social situations are avoided or endured with intense fear or anxiety.

E. The fear or anxiety is out of proportion to the actual threat posed by the social situation and to the sociocultural context.

F. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more.

G. The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

H. The fear, anxiety, or avoidance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.

l. The fear, anxiety, or avoidance is not better explained by the symptoms of another mental disorder, such as panic disorder, body dysmorphic disorder, or autism spectrum disorder.

J. if another medical condition (e.g., Parkinson’s disease, obesity, disfigurement from burns or injury) is present, the fear, anxiety, or avoidance is clearly unrelated or is excessive.

Social anxiety disorder (Social Phobia) Clinical issues • Individuals with : Avoid social interactions because of intense fear of being observed,

scrutinized, embarrassed or humiliated. Tend to be hypersensitive to criticism, have low self-esteem, have poor

social skills, and prefer not to make eye contact. Are markedly impaired in terms of social functioning. By definition, the

impairment reaches a significant level of function (e.g., unable to attend work or school, isolation, few or no friends), or there is marked distress about having the phobia.

• Typical phobias include the fear of speaking or performing in public, the fear of eating or shopping in public, the fear of being criticized for poor school or work performance, the fear of social interaction or dating

Social anxiety disorder (Social Phobia) Epidemiology

• Lifetime prevalence is 3-13% (7%)

• Is more prevalent in females.

• The peak age is in the teens.

• Is a chronic disorder that waxes and wanes in intensity. Complete remission is unusual.

Panic Disorder

Panic Disorder DSM-5 Diagnostic Criteria • A. 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.

Panic Disorder DSM-5 Diagnostic Criteria

A. 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.

Panic Disorder DSM-5 Diagnostic Criteria

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).

Panic Disorder Clinical issues • The presence of sudden, unexpected panic attacks in the absence of a medical

disorder is the main feature of panic disorder.

• An acute intense attack of anxiety accompanied by feelings of impending death and doom.

• The first panic attack is completely spontaneous.

• The attack often begins with a 10-minute period of rapidly increasing symptoms.

• The attack generally lasts 20 to 30 minutes and rarely more than an hour.

• The symptoms can disappear quickly or gradually.

• Between attacks, patients may have anticipatory anxiety about having another attack.

• Depressive symptoms are often present in panic disorder, and in some patients, a depressive disorder coexists with the panic disorder.

Panic Disorder Epidemiology

• Lifetime prevalence is 1-4%.

• F:M ratio is 2-3: 1.

• Most commonly develops in young adulthood.

• Onset after age 40 suggests an underlying medical or substance-related cause or another psychiatric diagnosis.

Agoraphobia

Agoraphobia Clinical issues

• Refers to a fear of or anxiety triggered by real or anticipated exposure to a variety of situations (e.g., using public transportation, going to open or public spaces) from which escape might be difficult.

• This disorder can be very similar to other phobias such as social anxiety disorder and specific phobia, situational type, however the focus of the fear is not the situation itself, but rather the fear that an incapacitating event may occur during the situation.

• It can be the most disabling of the phobias because it can significantly interfere with a person’s ability to function in work and social situations outside the home.

Agoraphobia Epidemiology • The lifetime prevalence of agoraphobia is somewhat controversial,

varying between 2 to 6 percent across studies.

• According to the DSM-5, persons older than age 65 years have a 0.4 percent prevalence rate of agoraphobia, but this may be a low estimate.

Generalized Anxiety Disorder

Generalized Anxiety Disorder DSM-5 Diagnostic Criteria • A. Excessive anxiety and worry (apprehensive expectation), occurring

more days than not for at least 6 months, about a number of events or activities (such as work or school performance).

• B. The individual finds it difficult to control the worry.

Generalized Anxiety Disorder DSM-5 Diagnostic Criteria • C. The anxiety and worry are associated with three (or more) of the

following six symptoms (with at least some symptoms having been present for more days than not for the past 6 months):

Note: Only one item is required in children.

1.Restlessness or feeling keyed up or on edge.

2.Being easily fatigued.

3. Difficulty concentrating or mind going blank.

4. irritability.

5. Muscle tension.

6. Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep).

Generalized Anxiety Disorder DSM-5 Diagnostic Criteria • The symptoms cause clinically significant distress or impairment in

social, occupational, or other important areas of functioning.

• The symptoms are not due to a substance or a medical condition.

Generalized Anxiety Disorder Clinical issues • Excessive anxiety and worry about several events or activities for

most days during at least a 6-month period. The worry is difficult to control and is associated with somatic symptoms, such as muscle tension, irritability, difficulty sleeping , and restlessness. The anxiety is not focused on features of another disorder, is not caused by substance use or a general medical condition, and does not occur only during a mood or psychiatric disorder. The anxiety is difficult to control, is subjectively distressing, and produces impairment in important areas of a person’s life.

Generalized Anxiety Disorder Clinical issues • Is distinguished from “normal” worrying by the higher intensity of

anxiety symptoms, the longer duration of the anxiety, and the resultant impairment in daily functioning.

• The risk of suicide increases when severe, chronic, or ruminating anxiety accompanies MDD.

Generalized Anxiety Disorder Epidemiology

• A lifetime prevalence is close to 5%.

• The disorder usually has its onset in late adolescence or early adulthood, although cases are commonly seen in older adults.

• The ratio of women to men with the disorder is about 2 to 1.

THE END