Anxiety disorders

Summary

Anxiety disorders cover a broad spectrum of conditions characterized by excessive and persistent
fear (an emotional response to imminent threats), anxiety (the anticipation of a future threat), worry
(apprehensive expectation), and/or avoidance behavior. The etiology of anxiety disorders is
multifactorial and may involve genetic, developmental, environmental, neurobiological, cognitive,
and psychosocial factors. Therapy typically consists of a combination of pharmacotherapy,
especially selective serotonin reuptake inhibitors (SSRIs), and psychotherapy, especially cognitive-
behavioral therapy (CBT).

For separation anxiety disorder and selective mutism, see the learning card on emotional and
behavioral disorders in children and adolescents

Risk and prognostic factors

 Higher rates of anxiety disorders are reported in women.

 Neurobiological factors

 Disruption of the serotonin system

 Dysfunction of GABAergic inhibitory transmission

 Substance use (leading to substance/medication-induced anxiety disorder)

 Environmental and developmental factors

 Stress

 Smoking (risk factor for panic disorder and panic attacks)

  Psychological trauma, esp. during childhood

 Other medical conditions

 Conditions that may lead to anxiety and/or panic attacks include endocrine disease

(e.g., hyperthyroidism), cardiovascular disorders (e.g., congestive heart failure),
respiratory illness (e.g., asthma), metabolic disorders (e.g., porphyria), and
neurological diseases (e.g., encephalitis).

Generalized anxiety disorder

 Definition: prolonged and excessive anxiety that is either unspecific or revolves around

certain themes (e.g., health, work); not focused on a single specific fear

 Epidemiology

 Most common anxiety disorder among the elderly population

 Lifetime prevalence: 5–10%

 ♀ > ♂(2:1)

 Symptoms

 Prolonged (≥ 6 months, occurring more days than not) and excessive anxiety

 Anxiety causes clinically significant distress

 Not caused by substance use, medication, or underlying medical condition

 Fatigue and muscle tension

 Restlessness and irritability

 Sleep disturbances and difficulty concentrating

 Treatment [1][2]

 First-line: psychotherapy, pharmacotherapy, or both 

 Psychotherapy: CBT, applied relaxation therapy, biofeedback

 Pharmacotherapy: SSRIs/SNRI

 Second-line

 Benzodiazepines can be used until SSRIs take effect but should never be

used for long-term management, as they increase the risk of benzodiazepine
dependence.

 Buspirone: requires consistent, daily intake for at least two weeks because
of its delayed onset of action
  Antipsychotics only for refractory cases

 Differential diagnosis

 Panic disorder: Panic attacks may also occur in GAD.

 Panic symptoms in GAD are generally precipitated by the uncontrolled

escalation of anxiety/worry rather than occurring spontaneously or acutely
in specific situations as in panic disorder.

 Depressive disorders

 Individuals with GAD tend to be more concerned with the future; individuals

with depressive disorders are more past-oriented.

 Mood swings and suicidal ideation are uncommon in GAD.

 SAD: Patients with GAD are usually comfortable in social situations and not

particularly disturbed by the evaluation by others.

References:[3][4][1][5][6]

Panic disorder

 Definition: recurrent spontaneous and unexpected panic attacks that often occur without a

known trigger

 Epidemiology [7]

 Lifetime prevalence: approx. 5% of the population

 Most common in patients aged 26–34 years

 ♀ > ♂ (2:1)

 Associations

 Agoraphobia

 Substance use

 Depression

 Bipolar disorder

 Symptoms

 Recurrent panic attacks

 Episodes of intense fear and discomfort that last for several minutes

  Fear of dying

 Overstimulation of the sympathetic system

 Sweating, palpitations

 Paresthesias, abdominal pain, nausea, light-headedness, chest

pain, shortness of breath, choking sensation

 There is a concern about future attacks and their consequences, and/or a significant
change in behavior related to the attacks, for at least one month.

 Treatment

 Acute panic attack

 Short-acting benzodiazepine (e.g. alprazolam)

 If hyperventilation: breathing in a paper bag 

 Long-term management

 CBT

 Antidepressants: SSRIs, SNRIs, TCAs

 Benzodiazepines may be used until antidepressants take effect.

To remember the symptoms of a panic attack, think of “STUDENTS FEAR the

3Cs”: Sweating, Trembling, Unsteadiness (dizziness), Derealization, Elevated heart
rate (palpitations), Nausea, Tingling, and Shortness of breath; FEAR of dying or going
crazy; Chest pain, Choking, and Chills.

References:[8][9]

Social anxiety disorder

 Definition: pronounced anxiety lasting ≥ 6 months of social situations that might involve

scrutiny by others

 Epidemiology

 One of the most common mental disorders

 Lifetime prevalence: approx. 5–10% of the population

 Peak incidence: adolescence and early adulthood

 ♀ > ♂ (2:1)

 Types
  Social anxiety disorder (SAD): fear/anxiety out of proportion to a social situation
where one may be scrutinized by others (e.g., meeting new people at a party, eating
in public, using public restrooms)

 Performance-only SAD: symptoms of fear/anxiety restricted only to public

speaking or performing in front of crowds

 Symptoms

 Blushing, palpitations, sweating during a social interaction

 Anticipatory anxiety (e.g., worrying weeks in advance about attending a social

event)

 Anxiety driven by fear of embarrassment and others noticing the reaction

 Avoidance of the aforementioned triggers (e.g., not attending parties, refusing to

attend school)

 In children: refusing to speak at social events, crying/throwing a tantrum, clinging to

their caregiver

 Treatment

 CBT for SAD and performance-only SAD 

 Pharmacotherapy for SAD

 First-line pharmacotherapy: SSRIs/SNRIs

 No/partial response to SSRIs/SNRIs and no history of a substance

use disorder: clonazepam (long-acting benzodiazepine)

 No/partial response to SSRIs/SNRIs and a history of a substance use

disorder: phenelzine (monoamine-oxidase inhibitors) 

 Pharmacotherapy for performance-only SAD: propranolol (beta-blockers)

or clonazepam on an as-needed basis; taken 30–60 minutes before an anxiety-
causing event

References:[3][10][11][12]

Specific phobias

 Definition: persistent and intense fears of one or more specific situations or

objects (phobic stimuli); always occurs during encounters with the phobic stimulus but may
already surge in anticipation of an encounter

 Epidemiology
  Lifetime prevalence: approx. 5–10% of the population

 The average age of onset depends on the specific phobia (e.g., animal phobias more

commonly develop in early childhood).

 ♀ > ♂ (2:1) 

 Common phobias

 Animal: spiders (arachnophobia), insects (entomophobia), dogs (cynophobia)

 Natural environment: heights (acrophobia), storms (astraphobia)

 Blood-injection-injury: blood (hematophobia), needles (blenophobia), dental

procedures (odontophobia), fear of injury (traumatophobia)

 Situational: enclosed places (claustrophobia), flying (aviophobia)

 Other: fear of vomiting (emetophobia), the number 13 (triskaidekaphobia),

costumed characters (masklophobia), fear of clowns (coulrophobia)

 Treatment

 First-line: CBT

 Alternative: benzodiazepine or SSRIs 

References:[13][14][15]

Agoraphobia

 Definition: pronounced fear or anxiety of being in situations that are perceived as difficult to

escape from or situations in which it might be difficult to seek help

 Epidemiology

 ♀ > ♂ (2:1)

 Age of onset: < 35 years (60–70% of cases)

 Clinical features

 Fear, anxiety, or even panic attacks over a period of ≥ 6 months in ≥ 2 of the

following 5 situations:

 Using public transportation

 Being in open spaces

 Being in enclosed places

  Standing in line or being in a crowd

 Being outside of the home alone

 Active avoidance of these settings unless a companion is present

 Some patients can have comorbid panic disorder.

 Treatment

 CBT

 SSRIs

If a patient meets the criteria for panic disorder and agoraphobia, both conditions should be

diagnosed.

References:[16][17][18][18][18]

Substance/medication-induced anxiety disorder

 Definition: prominent anxiety or panic attacks within 1 month of use of, or withdrawal from,
a substance/medication that is capable of inducing anxiety symptoms [19]

 Causes [20][21]

 Alcohol

 Caffeine

 Anticonvulsants, opioids, and sedatives

 Anticholinergics

 Bronchodilators

 Corticosteroids

 Amphetamines, cocaine, cannabis, phencyclidine, hallucinogens, and inhalants

 Clinical features

 Fear, anxiety, or panic attacks over a period of 1 month after taking or stopping the
substance/medication

 Physical symptoms such as palpitation, dizziness, shaking, shortness of breath, and

sweating

 Generalized anxiety or phobia may accompany the substance-induced anxiety

 Treatment

 Discontinuation of the substance/medication 

 CBT

 Antidepressants (e.g., SSRIs, SNRIs, TCAs, buspirone)