Anxiety = A Generalised, Pervasive fear
Anxiety can be a normal, physiological response (flight or fight
response) to a threatening situation – which is of benefit in
escaping or taking on the threat.
Threatening situation Excess Adrenaline release Over
activity of the Sympathetic Nervous System
o HR↑ / BP↑ / RR↑ / ↑Muscle Tension / Tremor /
Sweating / Polyuria and Diarrohea.
o Attention and Concentration are focused on
However, it can also be abnormal. A similar physiological response takes place, but one that
focuses on the symptoms of anxiety, as opposed to the threat itself, leading to a vicious cycle of:
Feelings of anxiety Physiological response Individual focusing on symptoms e.g.
Palpitations Concern about symptoms Feelings of anxiety
This results in the generation of abnormal responses which are:
Out of proportion to the threat
More prolonged than necessary
Occurring in the absence of a threat
Increasing the risk of developing an Anxiety Disorder = Marked, persistent
mental and physical symptoms of Anxiety, impacting negatively on an
There are two patterns of Pathological Anxiety:
1. Generalised (Continuous): No discrete episodes, lasts from hours weeks and is of a
mild or moderate severity. It is not associated with an external threat, rather an excessive
worry or apprehension about many life events e.g. Relationships and Responsibilities
2. Paroxysmal (Episodic): Discrete episodes, usually short lived (<1hr) of intense severity.
Strong autonomic symptoms occur, which may lead to the patient believing that they are
dying and perpetuate the anxiety.
Generalised Anxiety Disorder (GAD)
Epidemiology: Lifetime risk is 4-5% and there is a 3% prevalence in the general population
o Predisposing: FH / Twin Studies / Personality / Childhood upbringing
o Precipitating: Relationships / Unemployment / Financial Problems / Ill health
o Perpetuating: Continuing Stressful Events / Depression / Cycle of Anxiety
DSM IV Criteria:
o Excessive anxiety and worry about various ordinary events – more days than not
<6months = Stress or Adjustment Disorder
o 3/6 of the following associated symptoms:
Restlessness / Fatigue / Irritability / Muscle Tension / cannot get to sleep or
unsatisfying sleep / Poor concentration
Other Symptoms: Palpitations / Hyperventilation / Nausea / Vomiting / Tremor /
Erectile Dysfunction / Menstural discomfort and chronic stomach aches
o Symptoms cause clinically significant distress or impairment in:
Social / Occupational / other important areas of functioning
o Exclusion of direct physiological effects of substances or general medical conditions.
Simple phobias are restricted to clearly specific objects or
situations – other than those described in Agoraphobia.
Epidemiology: Lifetime prevalence of 12.5%:
o Mean onset of Animal phobia = 7 years
o Situational phobias usually develop in early adulthood.
Aeitiology: Most likely due to bad experiences classical
conditioning, there is also robust evidence that there is a genetic
component – as 1 in 3 first degree relatives suffer too.
Clinically, they can be:
o Situational = Public transportation / Flying / Driving / Tunnels / Bridges / Elevators
o Natural = Heights (Acrophobia) / Storms / Water / Darkness (Scotophobia)
o Blood- Injection = Seeing blood (Haematophobia) or injury, fear of needles
(Trypanophobia) or invasive medical procedures
o Animals: Spiders (Arachnophobia), Snakes, Mice, Dogs.
o Others: Vomiting (Emetophobia), contracting illness e.g. AIDS or Clowns.
Prognosis: Those that begin in childhood persist for many years, but those starting in adult life
may improve with time.
Social phobia = Fear of social situations where the individual may
be exposed to scrutiny by others, which may lead to humiliation or
Epidemiology: The lifetime risk of developing it is12.1%
o This may be linked with an isolated fear of:
Public Speaking / Eating in Public / Interacting with the
o Or it may involve almost all social activities outside of the
Agoraphobia = ‘Fear of the Marketplace’ – a fear of entering crowded spaces e.g.:
o Shops / Trains / Buses / Elevators, where immediate escape is difficult and/or
immediate help may not be available if the individual suffers a panic attack.
Epidemiology: Lifetime risk if 1-2%, Two peaks: 15-30 years and 70-80 years
o At worst patients become housebound or refuse to
leave the house without a friend or relative
o There is a close relationship with panic disorder- up
to 95% of patients with agoraphobia have a current or
past history of panic disorder. Therefore it has its own
classification too – of ‘Agoraphobia with Panic
Attack’ (Episodic anxiety in multiple situations).
Pan = Greek god, able to inspire fear in people and animals, whilst in lonely places.
A Panic disorder = the presence of Panic attacks, that occur unpredictably and are not
restricted to any particular situation or objective danger.
Epidemiology: Prevalence of 7-9%, more common in Women, two peaks: 15-24 years and
Risk Factors: Urban living / Divorce / Limited Education / Physical or Sexual abuse
o Symptoms: Palpitations / Tachycardia / Sweating and
Flushing / Trembling / Dyspnoea / Chest Discomfort / Nausea
/ Dizziness / Fainting / Depersonalisation
o Panic attacks are particularly distressing, so much so that
patient’s develop a fear of having further attacks =
o NB: Always ask about Agoraphobia as 95% of patients with
Panic Disorder have it.
DDx of Anxiety:
o Continuous: Generalised Anxiety Disorder (GAD)
Defined Situation: Simple Phobia / Agoraphobia / Social Phobia
Multiple Situations: Agoraphobia + Panic Disorder
Any Situation: Panic Disorder
o Stress Reactions:
o Acute Stress Reactions
o Post-Traumatic Stress Disorder
o Adjustment Disorder
o Obsessive Compulsive Disorder
o Psychiatric disorders:
o Substance misuse or Withdrawal:
o Caffeine / Cocaine / Cannabis / Theophylline / Amphetamines / Steroids
o Organic Medical Conditions:
o Thyrotoxicosis / Hypoparathyroidism / Phaeochromocytoma / Hypoglycaemia /
Arrythmias / Meniere’s disease / Temporal Lobe Epilepsy / Respiratory disease /
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Edition Oxford University Press; 2012
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Bourke, Castle and Cameron. Crash Course Psychiatry. 3rd
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