2. Anxiety Disorders
• Anxiety is a normal response to stressors
• It is considered pathological if it becomes so exaggerated,
frequent and chronic that it impairs function
• Anxiety is the main feature of anxiety disorders, but also
seen in other psychiatric and mental disorders
• Anxiety = a state consisting of psychological and physical
symptoms brought about by a sense of apprehension at a
perceived threat
• Perceived threat can be many external like agoraphobia
(wide spaces), social phobia and specific phobias OR internal
as in panic disorder, generalised anxiety disorder and OCD
• In each of these conditions there is a characteristic pattern
of psychological and physical symptoms
ICD 10: F40-48
3. Normal Anxiety
• Known problem e.g. Exam, football match
• Definable
• External threat of some sort
• Lasts a short period of time
• If mild: helpful, If severe: harmful
What is Pathological/clinical Anxiety?
•Sense of fear
•Not well defined
•Threat not immediate/ unknown
•May be an “internal” threat
•Often chronic
4. Symptoms of Anxiety
Psychological symptoms:
• feelings of fear or impending
doom, apprehension
• Dizziness and faintness
• Restlessness
• Exaggerated startle response
• Poor concentration
• Irritability
• Insomnia
• Night terrors
• Depersonalisation
• Derealisation
• Globus hystericus (lump in
throat&gulp)
• Themes of misfortune
• Belief of inability to cope with
stress
• Unrealistic ideas of danger
Physical Symptoms
•Cardiovascular: palpitations,
tachycardia, chest discomfort
•GI: dry mouth, lump in throat,
nausea, abdominal discomfort,
diarrhoea
•Resp: hyperventilation, difficulty
catching breath, chest tightness
•GU: urinary frequency, failure of
erection, amenorrhoea
•Other: hot flushes/cold chills,
tremor, sweating, headache and
muscle pains, numbness and tingling
sensations around the mouth and in
the extremities, dizziness and
faintness
5. Symptoms
• Behaviour:
– reduced purposeful activity
– Increased purposeless activity
– Avoidance of some situations
• Somatic:
– Hyperventilation
– Retro-sternal constriction (chest pain)
– Muscle tension
– Autonomic over-activity
• Associated symptoms
– Depersonalisation (feel they are not real/watching themselves/in a
dream)
– Derealisation (feel the world isn’t real)
– Irritability
– Low mood
6. Pathological Anxiety
• Secondary to other psychiatric illnesses e.g. Psychotic and
worried about being stabbed
• Secondary to physical conditions e.g. Thyrotoxicosis, drug use
(inc caffeine), drug withdrawal (BDZs), phaeochromocytoma,
hypoglycaemia and alcohol
• High trait anxiety (personality), worrier from childhood
• Anxiety disorders
– Personality traits
– Childhood factors (loss/separation, abuse)
– Stress: relationships
– Social supports: families, less social support = more anxiety
– Genetic/biological factors
7. Sleep Hygiene
• Routine
• Wind down
• Exercise
• Reading
• Avoid caffeine
• Warm, but not too warm room
8. Anxiety Disorders
• Onset early adulthood generally, rarely middle age
• May be misdiagnosed as a depressive or medical disorder
• Female 2:1 Male
• Social phobia and OCD, closer to 1:1 ratio
• Depressive symptoms are common in anxiety disorders and vice versa
• If the diagnostic criteria for depressive disorder and generalised
anxiety disorder(GAD) are fulfilled a diagnosis of MIXED ANXIETY AND
DEPRESSIVE DISORDER is made
• Other psychiatric disorders are also common in anxiety disorders,
including other anxiety disorders, personality disorders and substance
misuse
• Anxiety disorders:
– Phobic anxiety disorders:
agoraphobia, social phobias, specific phobias
– Panic disorder
– GAD
– OCD
– PTSD
9. Aetiology
• Psychiatric and medical conditions: psychiatric - mood
disorders, psychotic disorders, somatoform disorders and eating
disorders. Medical: hyperthyroidism, Cushings,
phaeochromocytoma, hypoglycaemia and drug/alcohol
intoxication/withdrawal
• Genetic Factors: predispose to anxiety disorders, may manifest
as “neurotic” traits or neurotic clucter (cluster C) personality
disorders
• Neurochemical abnormalities: noradrenergic and serotonergic
neurons act on limbic system to increase anxiety
• Environmental factors: triggered/perpetuated by stressful
events, especially those involving a threat. Can result from
stressful/traumatic events in childhood
• Psychological theories: inappropriate though processes.
Psychoanalytical theory – loss or separation in childhood.
10. Phobic Anxiety Disorders
• Phobia: persistent, irrational fear that is usually recognised
as such which produces anticipatory anxiety for and
avoidance of the feared object, activity or situation
• Exposure to the feared thing induces intense anxiety and
even panic attack
• 3 types
• Agoraphobia
• Social phobia
• Specific phobias: fear of a specific object/location. Commonly enclosed spaces
(claustro-), heights (acro-), darkness (achluo-), blood (haemato-). Begin in early
childhood. Thought to be passed on to help future generations survive! Leads
to avoidance. Rx: behavioural, SSRIs.
11. Agoraphobia
• Fear of places that are difficult/embarrassing to escape from
e.g. Crowd, alone at home, public transport
• Linked to poor spatial orientation
• Suffer acute anxiety attacks when in, or anticipate being in
these situations
• Actively avoid situation
• Autonomic symptoms (at least 2 of GAD)
• May respond to CBT e.g. Graded exposure and
Antidepressants:SSRIs. BDZs short term. Self help groups
• Behavioural therapy much better than drugs but normally both
used
• Relapse is common
• 60% of all phobias
• Onset 15-35. F2:1M.
12. Social Phobia
• Extreme persistent fear of being judged and embarrassed/ humiliated in
all/specific social situations.
• Either
– marked fear of being the focus of attention or fear of behaving in an
embarrassing/humiliating way
– Marked avoidance of being the focus of attention or situations that have
the potential to be embarrassing/humiliating
– Plus 2 of GAD
– Plus blushing/shaking, fear of vomiting, urgency/fear of micturition or
defaecation
• Exposure provokes extreme anxiety
• Fear recognised as unreasonable
• Onset adolescence/childhood. CHRONIC COURSE.
• Majority never get married
• ?genetic predisposition
• May respond to CBT e.g. Graded exposure and anxiety management
and Ads - SSRIs. Alcohol/BDZ abuse more common.
13. Panic Disorder
• Panic attack = Rapid onset of severe anxiety lasting 20-30mins.
Recurrent, unexpected panic attacks (no specific stimulus)
• Can occur in panic disorder, phobic anxiety disorder, GAD, OCD,
PTSD, separation anxiety disorder, depressive disorders and organic
disorders (drugs, hyperthyroidism)
• In panic disorder, panic attacks occur RECURRENTLY AND
UNEXPECTEDLY
• F2:1M in younger group, equalises with age
• Onset 30’s. >45 – investigate other causes!!!
• There is fear of the implications of a panic attack
• VICOUS cycle develops. Fear of attack triggers more!
• Can develop 2ary agoraphobia to reduce risk of PAs
• May respond to CBT, drugs: SSRIs, TCAs and BDZs
• Must exclude epilepsy, drug/alchol use/withdrawal
14. Panic attack
• A discrete episode of intense fear, characterised by acute
development of several of the following symptoms,
reaching peak severity within 10mins
– Escalating subjective tension
– Sweating/ chills
– Chest pain/discomfort
– Palpitations, tachycardia
– Tremor, nausea
– Dry mouth
– Dizziness/feeling faint
– Depersonalisation/derealisation
– Feeling of choking
– Fear of dying, loss of control
15. Generalised Anxiety Disorder
• Characterised by long standing (more days than not for
6m), free-floating anxiety that may fluctuate but is neither
situational (phobic anx disorders) nor episodic (panic
disorder)
• Apprehension about events very unlikely to occur
• Onset early adulthood. F2:1M
• Often co-morbid with other disorders e.g. OCD, dysthymia
• May respond to counselling, cognitive and behavioural
therapies, drugs: SSRIs, SNRIs, sedative Ads (amitriptyline
and trazodone) and BDZs
**drugs best as a short term thing in conjunction with
psychological treatment
- AD (SSRIs) and/or BDZ and/or busprione (relaxant) and/or
Bblocker
16. Symptoms of GAD
• At least four of:
– Palpitations -poor concentration
– Sweating -disturbed sleep
– Trembling -muscle tension
– Dry mouth -restlessness
– Difficulty breathing -numbness
– Feelings of choking -tingling
– Chest pain -difficulty swallowing
– Nausea -irritability
– Dizziness -hot flushes
– Derealisation -cold chills
– Depersonalisation
– Fear of losing control
– Fear of dying
17. Features
distinguishing 3
anxiety disorders
Phobic anxiety Panic disorder Generalised
Anxiety
Disorder
Occurrence of
anxiety
Situational Episodic Free-floating
Associated
cognitions
Fear of situation Fear of symptoms Fear of future
Associated
behaviour
avoidance escape inhibition
18. PTSD
• Protracted and sometimes delayed response to a highly
threatening or catastrophic experience (within 6m)
• Commonly combat in males and sexual assault in women
• Characterised by numbing, detachment, flashbacks,
nightmares, partial or complete amnesia for the event
avoidance of and distress as reminders of the event and
prominent anxiety symptoms
• Depressive disorders common, as well as anxiety disorders
and alcohol/substance misuse
• May respond to supportive psychotherapy, CBT, group
therapy and Ads: SSRIs, TCAs
• BDZs should be avoided due to dependence risk
• Prognosis good but may persist for years
19. Obsessions
• Recurrent, persistent ideas/thoughts/images that enter the mind
again and again in a stereotyped form
• Patient regards them as alien and absurd and recognises them as
products of their own imagination
• Almost invariably distressing and attempts are made to
ignore/suppress them
Compulsions
• Voluntary, stereotyped behaviours which are reluctantly performed
again and again despite being regarded as alien or absurd
• Act is performed with a subjective sense of compulsion and desire to
resist it
• If resisting is attempted there is increasing anxiety which is only
yielded by giving in
• Function is to prevent some unlikely event (objectively) which they
fear will occur
• Usually recognised as pointless/ineffectual
• Can be normal in childhood or adulthood
20. Obsessive-Compulsive Symptoms
• Obsessive compulsive disorder
• Depression
• Anankastic (obsessional) personality disorder
• Schizophrenia
• Early dementia & other organic brain disorder
• Gilles de la Tourette’s syndrome
• Anxiety
Obsessions
•Contamination 45%
•Pathological doubt 42%
•Somatic 36%
•Need for symmetry 31%
•Aggressive impulse 28%
•Sexual impulse 26%
•Obsessional slowness 3-4%
Compulsions
•Checking 63%
•Washing 50%
•Counting 36%
•Need to ask/confess 31%
•Symmetry and precision 28%
•Hoarding 18%
21. Obsessive Compulsive Disorder
• 3 classifications:
– Predominantly obsessional thoughts
– Predominantly compulsive acts
– Mixed obsessional thoughts and acts
• Obsessional thought: recurrent idea, image or impulse that is
perceived as being senseless, that is unsuccessfully resisted amd
that results in marked anxiety and distress
• Product of ones own mind (not thought insertion)
• Commonly involve doubt, contamination, orderliness and
symmetry, safety, physical symptoms, aggression and sex
• Compulsive act: recurrent stereotypical behaviour that isn’t useful
or enjoyable but that reduces anxiety and stress
• Perceived as being senseless but unsuccessfully resisted
• Commonly washing, cleaning, arranging and ordering, checking,
counting or repeating a phrase
• Rx: SSRIs, TCAs, psychological: graded exposure etc
22. OCD
• A mental disorder characterised by recurrent obsessional
thoughts or compulsive acts (rituals)
• Frequently accompanied by depression
• Males have worse prognosis
• Aetiology:
– partly genetic
– Abnormalities of brain circuits linking pre-frontal cortex, striatum,
thalamus and back to pre-frontal cortex
– Hypersensitivity of post-synaptic serotonin receptors
Tourette’s Syndrome
•Neuropsychiatric disorder
•Multiple motor and vocal tics
•Onset 5-8
•Commoner in boys
•Up to 80% have obsessional symptoms
•Treat with dopamine blocker e.g. haloperidol
PANDAS
•Associated with Sydenham’s chorea
•B haemolytic streptococcus
•Cross immunity with basal ganglia
•OCD symptoms and motor disorder
23. Treatment
• Benzodiazepines: Diazepam (valium), temazepam,
nitrazepam, lorazepam, clonazepam
– Uses: anxiety, sleep disorders (zopiclone), muscle
spasticity, epilepsy, pre-meds before an operation,
alcohol withdrawl, myoclonus, akathisia
– A/Es: drowsiness, dizziness, psychomotor impairment.
Dry mouth, blurred vision, GIT upset, ataxia, headache,
hypotension. RARE: amnesia, restlessness and skin rash.
– Problems: active metabolites causing prolonged effects
e.g. Hangover effect. Tolerance. Psychological
dependence. Physical dependence.
– PRESCRIBED WITH CAUTION. Reserved for more severe
cases. Lowest effective dose should be used. Prescribe
for 2 weeks. 4 at most. Avoid “repeat” prescriptions.
Warn pts about risk of dependence
• SSRIs – fluoxetine
