Anxiety Disorders
Anxiety disorders are common psychiatric disorders. Many patients with anxiety disorders
experience physical symptoms related to anxiety and subsequently visit their primary care
providers.
Despite the high prevalence rates of these anxiety disorders, they often are
underrecognized and undertreated clinical problems.
Panic disorder
Acute stress disorder
Posttraumatic stress disorder (PTSD)
Phobic illness
Adjustment disorder with anxious features
Obsessive-compulsive disorder (OCD)
Anxiety due to a general medical condition
Substance-induced anxiety disorder
Generalized anxiety
Pathophysiology
Anxiety disorders appear to be caused by an interaction of biopsychosocial factors, including
genetic vulnerability, which interact with situations, stress, or trauma to produce clinically
significant syndromes.
In the central nervous system, the major mediators of the symptoms of anxiety disorders
appear to be norepinephrine and serotonin.
Peripherally, the autonomic nervous system, especially the sympathetic nervous system,
mediates many of the symptoms.
Frequency
lifetime prevalence rates for individual anxiety disorders are panic disorder (2.3-2.7%),
generalized anxiety disorder (4.1-6.6%) ,OCD (2.3-2.6%), PTSD (1-9.3%) social phobia (2.6-
13.3%).
Mortality/Morbidity :Anxiety disorders may contribute to morbidity and mortality through
neuroendocrine and neuroimmune mechanisms or by direct neural stimulation, eg,
increased risk for cardiovascular morbidity and mortality) ( hypertension or cardiac
arrhythmia.
Severe anxiety disorders may be complicated by suicide, with or without secondary mood
disorders (eg, depression).
Anxiety disorders have high rates of comorbidity with major depression and alcohol and
drug abuse. Some of the increased morbidity and mortality associated with anxiety
disorders may be related to this high rate of comorbidity.
Race
Some studies have found higher rates of PTSD in minority populations. Some of this
association may be due to higher rates of specific traumatic events (ie, assault) in minority
populations.
Sex
The female to male ratio for any lifetime anxiety disorder is 3:2
Age
Most anxiety disorders begin in childhood, adolescence, and early adulthood. Separation
anxiety is an anxiety disorder of childhood that often includes anxiety related to going to
school. This disorder may be a precursor for adult anxiety disorders.
Panic disorder demonstrates a bimodal age of onset in the study in the age groups of 15-24
years and 45-54 years.
The median age of onset of social phobia in the study was 16 years.
The age of onset for OCD appears to be in the mid 20s to early 30s.
New onset anxiety symptoms in older adults should prompt a search for an unrecognized
general medical condition, a substance abuse disorder, or major depression with secondary
anxiety symptoms.
Clinical : History AND Symptoms vary depending on the specific anxiety disorder. To rule out
anxiety disorders secondary to general medical or substance abuse conditions, a detailed
history and review of symptoms is essential.
Review use of caffeine-containing beverages (coffee, tea, colas), over-the-counter
medications (aspirin with caffeine, sympathomimetics), herbal "medications,"
Ask the patient's sleep patterned . Concurrent depressive symptoms are common in all of
the anxiety disorders.
Severe anxiety disorders may produce agitation, suicidal ideation, and increased risk of
completed suicide. Always ask about suicidal ideation or suicidal intent.
Generalised anxiety disorder
Persistent and generalized anxiety about everyday events, not restricted to a particular
situation or phobic stimulus. Present for at least 6 months for diagnosis.
Causes:
Biological
1:genetic predisposition
2:autonomic nervous system abnormalities (increased sympathetic tone)
Psychosocial
1:current stress
2:life events
3:Childhood experiences characterized by separations, demands for high achievement and
excess conformity.
Lifetime prevalence 5%. F>M.
Onset adolescence to early adulthood.
Symptoms:
Fears which are excessive, disproportionate and unfocused.
Increased vigilance, restless, on edge.
Insomnia/middle insomnia/fatigue on waking.
Motor tension – tremors, headache.
Autonomic hyperactivity (arousal, sweating, increased HR, RR, dilated pupils).
Prolonged course, relapses and remissions, may or may not be a reaction to external events.
Increased HR, increased skin conductance, increased forearm blood flow and muscular
tension. Hyperactive deep reflexes.
Diagnosis
is characterized by excessive anxiety and worry. Worrying is difficult to control. Anxiety and
worry are associated with at least 3 of the following symptoms:
Restlessness or feeling keyed-up or on edge, Being easily fatigued
Difficulty concentrating or mind going blank ,Irritability ,Muscle tension ,Sleep disturbance
EEG may show reduced alpha rhythm.
Treatment:
(1) Reassurance, counseling and psychotherapy.
(2) CBT to identify anticipatory anxieties and replace them with realistic cognitions.
(3) Anxiety management training, e.g. relaxation therapy.
(4) Treat comorbid conditions, e.g.depression, somatoform disorders.
(5) Drug therapies: short-term benzodiazepines, TCAs, beta blockers.
Complication: Secondary agoraphobia, depression, alcohol/drug abuse.
Prognosis: Course may be chronic, worse at times of stress.
Panic disorder is characterized by recurrent panic attacks (ie, periods of intense fear of
abrupt onset peaking in intensity within 10 min). Four of the following must be present for a
panic attack: Palpitations, pounding heart, or accelerated heart rate ,Sweating ,Trembling or
shaking ,of breath or dyspnea ,Sensation of choking ,Chest pain or discomfort ,Nausea or
abdominal distress ,Feeling dizzy, unsteady, lightheaded, or faint ,Derealization or
depersonalization ,Fear of losing control or going crazy ,Fear of dying ,Paresthesias ,Chills or
hot flashes.
Although not a diagnostic feature, suicidal ideation and completed suicide have been
associated with panic disorder.
If the panic attacks are recurrent and cannot be explained by other psychological or physical
illness, panic disorder is diagnosed.
The circumstances of the attack need to be clarified to exclude other disorders.
In a panic attack, the anxiety starts abruptly in the absence of any objective danger and
reaches a peak within a few minutes. The anxiety is very intense, but has a limited duration
(usually 10–40 minutes).
Behavioral &Cognitive
Urge to get away from the current situation (flight),Restlessness,Perception of difficulty in
breathing/choking sensation,Unpleasant feeling of anticipation/threat,Fear of losing control,
dying, Derealisation/depersonalization
