Anxiety DisordersAnxiety Disorders((General FeaturesGeneral Features))

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ASHRAF TANTAWY

Professor of Psychiatry.Suez Canal University, Egypt.

Everybody must be aware of Anxiety Everybody must be aware of Anxiety Disorders. Disorders. WHY?WHY?

Anxiety disorders are very common Anxiety disorders are very common ~30% ~30% of of any population. any population. They are the most They are the most common mental illnesscommon mental illness..Anxiety disorders have symptoms that mimic Anxiety disorders have symptoms that mimic physical diseasesphysical diseases..Anxiety disorders can lead to many problems Anxiety disorders can lead to many problems ranging from ranging from losing jobslosing jobs (due to many missed (due to many missed days of work) to days of work) to disabilitydisability as in PTSD. as in PTSD.Anxiety disorders are Anxiety disorders are treatabletreatable..All medical personnel All medical personnel must have knowledge must have knowledge and skills to deal with anxious patients and skills to deal with anxious patients regardless of their specialties. regardless of their specialties. 04/12/2304/12/23 22

STRESSSTRESS

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• Definition: Experiencing events that are perceived as endangering one’s physical, social or psychological well-being.

• Response to stressors is influenced by Controllability, predictability & challenge to our limits.

• Psychological Responses To Stress: - Anxiety. - Anger & Aggression. - Apathy & Depression. - Cognitive Impairment.

FEARFEARA normal response.A normal response.

A realistic response to an identifiable stimulus.A realistic response to an identifiable stimulus.

Imagine that you are facing a wild animal, Imagine that you are facing a wild animal,

What is your normal response? What is your normal response? Fear is normal.Fear is normal.

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FEAR? FEAR? PHOBIA? PHOBIA? WORRY?WORRY?Fear:Fear:

RealisticRealistic response to response to an identifiablean identifiable stimulus. stimulus.

Phobia:Phobia: UnrealisticUnrealistic response to response to an identifiablean identifiable stimulus. stimulus.

Worry:Worry: UnrealisticUnrealistic (Pervasive) (Pervasive) fear to fear to indefinableindefinable

stimulus stimulus (Future Oriented)(Future Oriented)..04/12/2304/12/23 55

Justifiable Fears vs. Justifiable Fears vs. Anxiety DisorderAnxiety Disorder

What make fears pathological? What make fears pathological? If fears are: If fears are: Excessive. Excessive. Out of proportion with the actual Out of proportion with the actual

threat.threat. Difficult to be controlled.Difficult to be controlled. Interfering with daily activities.Interfering with daily activities.04/12/2304/12/23 66

Primary vs. Secondary Primary vs. Secondary AnxietyAnxiety

Anxiety may be due to Anxiety may be due to

A primary psychiatric disorder. A primary psychiatric disorder.

A secondary psychiatric disorder: A secondary psychiatric disorder:

- Substance abuse. - Substance abuse.

- Substance-Induced Anxiety Disorder.- Substance-Induced Anxiety Disorder.

- A medical condition. - A medical condition.

- Another psychiatric condition. - Another psychiatric condition.

- Psychosocial Stressors. - Psychosocial Stressors.

- Adjustment Disorder with Anxiety.- Adjustment Disorder with Anxiety.04/12/2304/12/23 77

General Features of General Features of Anxiety DisordersAnxiety Disorders

Anxiety disorders are psychiatric disorders Anxiety disorders are psychiatric disorders characterized by:characterized by:

1- Fears.1- Fears.2- Tension.2- Tension.3- Autonomic Over-Activity. 3- Autonomic Over-Activity. 4- Apprehension. 4- Apprehension. 5- Continuous vigilance for danger.5- Continuous vigilance for danger.

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Shared Features of Anxiety Shared Features of Anxiety DisordersDisorders

Substantial proportion of etiology is Substantial proportion of etiology is stress related.stress related.

Reality testing is intact.Reality testing is intact.

Symptoms are ego dystonic (distressing).Symptoms are ego dystonic (distressing).

Disorders are enduring or recurrent.Disorders are enduring or recurrent.

Demonstrable organic factors are absent.Demonstrable organic factors are absent.04/12/2304/12/23 99

Symptoms of Anxiety DisordersSymptoms of Anxiety Disorders

Cognitive symptoms.Cognitive symptoms.

Emotional & Behavioral symptoms.Emotional & Behavioral symptoms.

Somatic symptoms.Somatic symptoms.

Impairment of social or Impairment of social or occupational function.occupational function.

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Cognitive SymptomsCognitive Symptoms Difficulty Concentrating.Difficulty Concentrating. Marked Distress.Marked Distress. Obsessions (Time-Consuming).Obsessions (Time-Consuming). Helplessness.Helplessness. Intrusive Thoughts and Images.Intrusive Thoughts and Images. Distressing Dreams.Distressing Dreams. Flashbacks.Flashbacks. Feared Stimulus (Phobia).Feared Stimulus (Phobia).04/12/2304/12/23 1111

Emotional & Behavioral Emotional & Behavioral SymptomsSymptoms

Excessive Worry.Excessive Worry.

Difficulty Controlling The Worry.Difficulty Controlling The Worry.

Restlessness and Irritability.Restlessness and Irritability.

De-Realization.De-Realization.

Fear of Losing Control or Dying.Fear of Losing Control or Dying.

Avoidance Behavior.Avoidance Behavior.

Compulsive Acts.Compulsive Acts.04/12/2304/12/23 1212

Somatic SymptomsSomatic Symptoms Muscle Tension.Muscle Tension.

Sleep Disturbances.Sleep Disturbances.

Fatigue. Fatigue.

Accelerated Heart Rate.Accelerated Heart Rate.

Sweating.Sweating.

Feeling of Choking or Chest Pain.Feeling of Choking or Chest Pain.

Nausea.Nausea.

Feeling Dizzy.Feeling Dizzy.

Chills or Hot Flashes.Chills or Hot Flashes.

Numbness or Tingling Sensations.Numbness or Tingling Sensations.04/12/2304/12/23 1313

Performance-Anxiety Performance-Anxiety CurveCurve

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Impairment of Social or Impairment of Social or Occupational FunctionOccupational Function

Anxiety Disorders SubtypesAnxiety Disorders Subtypes• Generalized Anxiety disorder (GAD).

• Panic disorder (PD).

• Obsessive-Compulsive disorder (OCD).

• Post-traumatic Stress disorder (PTSD).

• Social Anxiety Disorder (SAD).

• Specific Phobias (SPh).

• Acute Stress Reaction (ASR).

• Adjustment Disorder with Anxious Mood.04/12/2304/12/23 1515

Prevalence of ADsPrevalence of ADsPsychiatric Disorders: Psychiatric Disorders: (30 - 50%).(30 - 50%).

Anxiety Disorders: Anxiety Disorders: (15% - 30%).(15% - 30%).

SAD and SPh: SAD and SPh: (10%).(10%).

PTSD: PTSD: (7.5%).(7.5%).

GAD: GAD: (5%).(5%).

PD: PD: (1-2%); lifetime prevalence (3.5%).(1-2%); lifetime prevalence (3.5%).

OCD: OCD: (2.5%). (2.5%). 04/12/2304/12/23 1616

Gender & Anxiety DisordersGender & Anxiety DisordersFemaleFemale is at higher risk than Male for all anxiety is at higher risk than Male for all anxiety disorders.disorders.GAD, PD , PTSD and SPh: GAD, PD , PTSD and SPh: F:M ratio (2:1).F:M ratio (2:1).OCD: OCD: F:M ratio (3:2).F:M ratio (3:2).PTSD:PTSD:

- - 60% M 60% M && 50% F 50% F report exposure to at least one life-report exposure to at least one life-threatening situation during their life. threatening situation during their life.

- - ~ 10% F ~ 10% F && 5% M 5% M will develop PTSD at some time in will develop PTSD at some time in their life.their life.

- - 10% F 10% F & & 8% M 8% M of the exposed persons.of the exposed persons.These data emphasize These data emphasize the role of female reproductive the role of female reproductive

hormones and activities hormones and activities in producing Anxiety in producing Anxiety disorders.disorders.

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Generalized Anxiety Disorder Generalized Anxiety Disorder (GAD)(GAD)

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• A very important disorder as it mimics many chronic medical conditions.

• Most of the patient are referred from GP, Family Physician or Internist.

Excessive constant uncontrollable worryExcessive constant uncontrollable worry about about many everyday events and issues. many everyday events and issues.

The focus of GAD worry The focus of GAD worry can shift, usually can shift, usually focusing on issues like job, finances, health of focusing on issues like job, finances, health of self and family; but it can also include more self and family; but it can also include more mundane issues such as, chores, car repairs mundane issues such as, chores, car repairs and being late for appointments.and being late for appointments.

GADGAD can occur with other anxiety disorders, can occur with other anxiety disorders, depressive disorders, or substance abuse. depressive disorders, or substance abuse.

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Over concern regarding the future.The worry seriously interferes with The worry seriously interferes with functioningfunctioning..The intensity, duration and

frequency of the worry are disproportionate to the issue.

The disturbance occurs most of the days for at least 6 months.Prevalence Prevalence ~3-6% ~3-6% of population.of population.

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Panic Disorder (PD)Panic Disorder (PD)

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• A very important disorder as it mimics acute cardiac conditions.

• Most of the patients are referred by Emergency or cardiology departments.

Recurrent, unexpected, rapid onset Recurrent, unexpected, rapid onset attacks of attacks of intense and severe autonomic intense and severe autonomic manifestations: accelerated heart rate, manifestations: accelerated heart rate, sweating, trembling, feeling of choking or sweating, trembling, feeling of choking or chest pain, nausea, dizziness, chills or hot chest pain, nausea, dizziness, chills or hot flashes, numbness or tingling sensations.flashes, numbness or tingling sensations.

In-between: In-between: Persistent concern of having Persistent concern of having an attack and avoidance of situations.an attack and avoidance of situations.

Must be differentiated from: Must be differentiated from: substance substance abuse: caffeine and amphetamines.abuse: caffeine and amphetamines.

Classify: Classify: with or without agoraphobia.with or without agoraphobia.04/12/2304/12/23 2222

Three types of Panic Attacks:Three types of Panic Attacks:1. Unexpected: 1. Unexpected: the attack comes without the attack comes without

warning and for no discernable reason.warning and for no discernable reason.2. Situational: 2. Situational: situations in which an situations in which an individual always has an attack, for individual always has an attack, for example (Always, he has attack upon example (Always, he has attack upon entering a tunnel).entering a tunnel).3. Situational Predisposed: 3. Situational Predisposed: situations in situations in which an individual is likely to have a which an individual is likely to have a Panic Attack but does not always have one. Panic Attack but does not always have one.

(Sometimes, he has attacks while driving).(Sometimes, he has attacks while driving).04/12/2304/12/23 2323

AgoraphobiaAgoraphobiaFear of Fear of open placesopen places..

Fear of being in places or Fear of being in places or situations where something situations where something terrible could happen and terrible could happen and escape might be difficultescape might be difficult..

AvoidanceAvoidance of the of the situations with marked situations with marked distress.distress.Usually associated with Usually associated with panic disorderpanic disorder..04/12/2304/12/23 2424

Obsessive-Compulsive Disorder Obsessive-Compulsive Disorder (OCD)(OCD)

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• A disorder of superego.

• It can be complicated by skin lesions.

• Most patients are referred by a dermatologist.

Obsessive Subtype: Obsessive Subtype:

Intrusive and inappropriate thoughts, images or urges, Intrusive and inappropriate thoughts, images or urges, causing anxiety or distress such as: Contamination, causing anxiety or distress such as: Contamination, pathological doubt, need for symmetry, somatic, sexual pathological doubt, need for symmetry, somatic, sexual and aggressive.and aggressive.

Compulsive Subtype: Compulsive Subtype:

Repetitive behaviors/ mental acts performed in Repetitive behaviors/ mental acts performed in response to obsession to reduce anxiety & distress.response to obsession to reduce anxiety & distress.

Obsessive Compulsive Subtype.Obsessive Compulsive Subtype. Hoarding Subtype: (DSM-V & ICD-11)Hoarding Subtype: (DSM-V & ICD-11)

Unable to throw away useless items, such as old Unable to throw away useless items, such as old

newspapers, junk mail & even broken appliances.newspapers, junk mail & even broken appliances.04/12/2304/12/23 2626

Marked distress/ time-consuming/ Marked distress/ time-consuming/ interferes with ability to function.interferes with ability to function.

OC spectrum Disorders: OC spectrum Disorders:

Impulse control disorders- Tourette’s Impulse control disorders- Tourette’s Syndrome (Tics)- Body dysmorphic Syndrome (Tics)- Body dysmorphic disorder- Self injury- OC personality.disorder- Self injury- OC personality.

OCD: OCD: Recurrent absurd ideas. The Recurrent absurd ideas. The patient knows that they are absurd. He patient knows that they are absurd. He tries to resist them but he fails. So, he gets tries to resist them but he fails. So, he gets anxiety. Then compulsive acts start to anxiety. Then compulsive acts start to relief anxiety.relief anxiety.04/12/2304/12/23 2727

Posttraumatic Stress Disorder Posttraumatic Stress Disorder (PTSD)(PTSD)

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Disasters Sep 11th, 2001

• A very important disorder as it leads to disability.

• It needs unusual stress (extraordinary) to happen.

Exposure to an unusual stress (Exposure to an unusual stress (Extra-ordinary TraumasTraumas) such as a serious ) such as a serious accident, a natural disaster, or criminal accident, a natural disaster, or criminal assault. assault. A response to an event involving A response to an event involving panic panic like attacks like attacks with persistent avoidance of with persistent avoidance of associated stimuli.associated stimuli.Re-experienceRe-experience of the event, such as: of the event, such as: intrusive thoughts and images, distressing intrusive thoughts and images, distressing dreams and flashbacks.dreams and flashbacks.Acute onset Acute onset (within 3 months).(within 3 months).Chronic onset Chronic onset (from 3 to 6 months).(from 3 to 6 months).04/12/2304/12/23 2929

Social Anxiety Disorder Social Anxiety Disorder (SAD)(SAD)

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Box ManSelf TTT

It was called Social Phobia but it is better to call it Social Anxiety Disorder. (Why?)

It is It is inappropriate public behavior inappropriate public behavior due due to exposure to unfamiliar people.to exposure to unfamiliar people.Subtypes:Subtypes:

1- 1- Generalized Social Anxiety Generalized Social Anxiety ((GSPGSP): ): Multiple fears, some of which are non-Multiple fears, some of which are non-

speaking fears. speaking fears. (95%)(95%) (You Must Treat).(You Must Treat). 2- 2- Specific Social Anxiety Specific Social Anxiety ((SSPSSP): ): Fears to specific situation, similar to Fears to specific situation, similar to

specific phobias. specific phobias. (5%) (5%) (You May Not Treat).(You May Not Treat).04/12/2304/12/23 3131

Common Anxiety Provoking Situations Common Anxiety Provoking Situations Public speaking. Public speaking.

Talking with people in authority. Talking with people in authority.

Developing close relationships. Developing close relationships.

Making or answering a phone call. Making or answering a phone call.

Interviewing. Interviewing.

Attending and participating in class. Attending and participating in class.

Speaking with strangers. Speaking with strangers.

Meeting new people. Meeting new people.

Eating, drinking or writing in public. Eating, drinking or writing in public.

Using public bathrooms. Using public bathrooms.

Driving. Driving.

Shopping. Shopping. 04/12/2304/12/23

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Specific Phobias (SPh)Specific Phobias (SPh)Intense, irrational fear that is out of Intense, irrational fear that is out of proportion to the threat.proportion to the threat.Avoidance of the feared stimulus.Avoidance of the feared stimulus.Immediate anxiety upon encountering the Immediate anxiety upon encountering the stimulus.stimulus.

It is called by the stimulus name e.g.,It is called by the stimulus name e.g.,Animals and Insects.Animals and Insects.Natural Environment (e.g., Water).Natural Environment (e.g., Water).Blood, Injection, Injury.Blood, Injection, Injury.Situational (Planes & Elevators).Situational (Planes & Elevators).

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Co-Morbidity of Anxiety DisordersCo-Morbidity of Anxiety Disorders

1- Other Psychiatric Disorders:1- Other Psychiatric Disorders:

Major Depressive Disorders: Major Depressive Disorders: GAD GAD 60%, PD 50% & OCD 25%.60%, PD 50% & OCD 25%.

OCD:OCD: with SAD (40%). with SAD (40%).

Substance Abuse: Substance Abuse: most probably as a most probably as a self medication to relief anxiety and self medication to relief anxiety and tension.tension.

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2- Medical Diseases:2- Medical Diseases:–Endocrine and Metabolic Diseases: Endocrine and Metabolic Diseases: Thyroid Dysfunction, Hyper Adrenalism, Vitamin Thyroid Dysfunction, Hyper Adrenalism, Vitamin B12 Deficiency, Acidosis & Hyperthermia.B12 Deficiency, Acidosis & Hyperthermia.–Drug Intoxication: Drug Intoxication: Caffeine, Amph., & Cocaine.Caffeine, Amph., & Cocaine.–Drug Withdrawal: Drug Withdrawal: Alcohol & Narcotics.Alcohol & Narcotics.–Neurological Diseases: Neurological Diseases: Delirium, Fits & Temporal Lobe Epilepsy.Delirium, Fits & Temporal Lobe Epilepsy.–Cardio-Vascular Diseases: Cardio-Vascular Diseases: Angina, Arrhythmias, CHF & Hypotension.Angina, Arrhythmias, CHF & Hypotension.–Respiratory Diseases: Respiratory Diseases: COPD, Asthma & Pulmonary Embolism.COPD, Asthma & Pulmonary Embolism.–Blood Diseases: Blood Diseases: Anemia.Anemia.

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SOME DISEASES THAT MAY BE CAUSED SOME DISEASES THAT MAY BE CAUSED BY OR MADE WORSE BY ANXIETY BY OR MADE WORSE BY ANXIETY

((PsychosomaticsPsychosomatics))

Chest: Chest: BRONCHIAL ASTHMA.BRONCHIAL ASTHMA.

Cardiac: Cardiac: ANGINA & HEART CONDITIONS.ANGINA & HEART CONDITIONS.

GIT: GIT: STOMACH OR DUODENAL ULCERS, STOMACH OR DUODENAL ULCERS, ULCERATIVE COLITIS; IBS.ULCERATIVE COLITIS; IBS.

Skin: Skin: ECZEMA, PSORIASIS & HAIR LOSS.ECZEMA, PSORIASIS & HAIR LOSS.

Gyne: Gyne: MENSTRUAL DISTURBANCES.MENSTRUAL DISTURBANCES.

Dental: Dental: MOUTH ULCERS.MOUTH ULCERS.

Developmental: Developmental: STUTTERING.STUTTERING.04/12/2304/12/23 3636

General Causal FactorsGeneral Causal Factors

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Biological Psychological

Genetic

NTs & H

Brain Circuits

Learning: Conditioning

Preparedness

Cognitive

Social Stressors

Genetic FactorsGenetic FactorsGenetic Tendency:Genetic Tendency:–Higher concordance in MZ than DZ Higher concordance in MZ than DZ

twins (All anxiety disorders).twins (All anxiety disorders).

–Adoption studies (GAD).Adoption studies (GAD).

–Family studies (PD).Family studies (PD).

Gene Studies: Gene Studies: (OCD).(OCD).

Gene-Environment Interaction: Gene-Environment Interaction: (PTSD).(PTSD).04/12/2304/12/23 3838

Anatomical FactorsAnatomical Factors

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Limbic System and Hypothalamus

[GAD, PD, ASR, PTSD]

Amygdala

[PD]Autonomic N S [GAD, PD, SAD, SPh]Basal Ganglia: [OCD and its spectrum]

NeurotransmittersNeurotransmittersGABAa: GABAa:

GAD, PD.GAD, PD.Norepinephrine: Norepinephrine:

PD.PD.Dopamine: Dopamine:

OCD.OCD.MAOI: MAOI:

SAD.SAD.CO2: CO2:

GAD, PD.GAD, PD.Serotonin (5-HT): Serotonin (5-HT):

GAD, PD, OCD, SAD, ASR, PTSD.GAD, PD, OCD, SAD, ASR, PTSD.04/12/2304/12/23 4040

Hormones: The HPA AxisHormones: The HPA Axis

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Adrenal cortex

CRH

ACTH

-

-

PTSD, Acute stress, chronic stress and GAD

GlucocorticoidReceptors areresponsive

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A Biological Model for Panic and Social Anxiety Disorders

hypothalamus

thalamusamygdala

Sensory cortex

serotonin

-

-

SSRI04/12/2304/12/23 4343

Psychological FactorsPsychological FactorsPsychoanalytical Theory: Psychoanalytical Theory:

- - GAD:GAD: Conflict between Conflict between Id & Ego.Id & Ego. - - OCD: OCD: Personality arrest at Personality arrest at Anal Stage.Anal Stage. - - Phobia: Phobia: Anxiety due to repressed Anxiety due to repressed Id Impulses.Id Impulses.

Psychological Vulnerability:Psychological Vulnerability: - - Tendency to believe that unexpected bodily Tendency to believe that unexpected bodily sensations are dangerous. sensations are dangerous. -- Worry about a panic attack makes the future Worry about a panic attack makes the future attack more likely (attack more likely (Vicious circleVicious circle) () (PDPD).).04/12/2304/12/23 4444

The Cognitive Theory: PanicThe Cognitive Theory: Panic

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Cognitive Behavioral Theory:Cognitive Behavioral Theory: - - Phobia: Phobia: Conditioning of anxietyConditioning of anxiety to externalto external stimuli.stimuli.Behavioral Theory: Behavioral Theory: - - OCD: OCD: Learned behavior reinforced by fear reduction.Learned behavior reinforced by fear reduction.The Fear of Fear Hypothesis:The Fear of Fear Hypothesis: - - Some people have an overly aroused NS. Some people have an overly aroused NS. - A tendency to be upset by the sensation generated by - A tendency to be upset by the sensation generated by their NS.their NS.

Intensity of Trauma: Intensity of Trauma: ((PTSDPTSD).).Psychological Factors: Psychological Factors: ((PTSDPTSD););– Family instability.Family instability.– Less influence at high levels of trauma.Less influence at high levels of trauma.– Social support.Social support.

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Conditioning Theory: (SPh)Conditioning Theory: (SPh)

Management of Management of Anxiety DisordersAnxiety Disorders

Psychoanalytical Theory: Psychoanalytical Theory: - Reveal Source of The Conflict (- Reveal Source of The Conflict (GAD & ASRGAD & ASR).). - Free Association (- Free Association (SAD & SPhSAD & SPh).).Cognitive Behavioral Theory (CBT):Cognitive Behavioral Theory (CBT): - Relaxation.- Relaxation. - Cognitive Training. - Cognitive Training. - Graded Exposure.- Graded Exposure. - Systematic Desensitization. - Systematic Desensitization. - Flooding. - Flooding. - Altering Irrational Beliefs. - Altering Irrational Beliefs. - - Cognitive & Coping Strategies.Cognitive & Coping Strategies.Biological Theory: Biological Theory: Pharmacotherapy.Pharmacotherapy.

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PharmacotherapyPharmacotherapy1. Benzodiazepines.2. Antidepressants: SSRIs, MAOIs & Tricyclics.3. Buspirone.4. Antipsychotics.5. Mood Stabilizers.6. β-blockers.

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ConclusionsConclusionsAnxiety disorders are common Anxiety disorders are common (~ 30%)(~ 30%)..

Although there are many psychosocial Although there are many psychosocial factors that induce anxiety disorders, factors that induce anxiety disorders, biological causes biological causes are more evident.are more evident.

There are co-morbidity particularly with There are co-morbidity particularly with many many physical diseases physical diseases which necessitate which necessitate the psychiatric care for these physical the psychiatric care for these physical diseases.diseases.

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ConclusionsConclusionsAnxiety disorders have cognitive, Anxiety disorders have cognitive, behavioral & somatic symptoms & can behavioral & somatic symptoms & can lead to disability. lead to disability.

So, So, differential diagnosis differential diagnosis is very is very important.important.

So, we have to deal with them as So, we have to deal with them as A Bio-Psycho-Social A Bio-Psycho-Social approach.approach.

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There are different effective & safe There are different effective & safe medications and effective psychotherapy are medications and effective psychotherapy are available now.available now.

So, anxiety disorders are more treatable than So, anxiety disorders are more treatable than before.before.

Anxiety disorders can lead to many serious Anxiety disorders can lead to many serious condition. So, we have to fight anxiety condition. So, we have to fight anxiety disorders.disorders.

Conclusions

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