ANXIETY DISORDER

Elmeida Effendy
Psychiatric Department
Medical Faculty
USU
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Anxiety disorders : abnormal states in which
the most striking features are mental &
physical symptoms of anxiety which are not
caused by organic brain disease or another
psychiatric disorder
Anxiety disorders are divided as follows :
Generalized anxiety disorder; which anxiety is
unvarying & persistent
Phobic anxiety disorder; anxiety is intermittent
& arises in particular circumstances
Panic disorder : anxiety is intermittent &
unrelated to particular circumstances
Classification of Anxiety
Disorders
ICD 10 DSM IV
F 4. Anxiety disorders Anxiety disorders
F 40 Phobic anxiety
disorders Agoraphobia without a
Agoraphobia
history of panic
disorder
Panic disorder with
Social phobia
agoraphobia
Specific phobia
Social phobia
F 41 Other anxiety Specific phobia
disorders
Panic disorder
Panic disorder without
Generalized anxiety
disorder agoraphobia
Mixed anxiety & Generalized anxiety
depressive disorder disorder
 DSM- IV-TR
1. Panic disorder with or without
agoraphobia
2. Agoraphobia with or without panic
disorder
3. Specific phobia
4. Social phobia
5. Obsessive-compulsive disorder
6. Posttraumatic stress disorder
7. Acute stress disorder
8. Generalized anxiety disorder

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 Panic Disorder &
Agoraphobia
An acute intense attack of anxiety
accompanied by feelings of impending
doom is known as panic disorder
The anxiety is characterized by discrete
periods of intense fear that can vary
from several attacks during one day to
only a few attacks during a year
Patients with panic disorder present
with a number of comorbid conditions,
most commonly agoraphobia, which
refers to a fear of or anxiety regarding
places from which escape might be
difficult

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 DSM-IV-TR Criteria for Panic
Attack
A discrete period of intense fear or
discomfort,in which four (or more) of
the following symptoms developed
abruptly & reached a peak within 10
minutes :
1.palpitations, pounding heart, or
accelerated heart beat
2. sweating
3. trembling or shaking
4. sensations of shortness of breath
or smothering
5. feeling of choking
6.chest pain or discomfort
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 7. nausea or abdominal distress
8. feeling dizzy, unsteady,
lightheaded or faint
9. derealization (feelings of
unreality) or depersonalization
( being detached from one self)
10. fear of losing control or going
crazy
11. fear of dying
12. paresthesias ( numbness or
tingling sensations)
13. chills or hot flushes
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 The DSM-IV-TR contains 2 diagnostic criteria
for panic disorder, one without agoraphobia
and the other with agoraphobia, but both
require the presence of panic attacks
Panic attacks can occur in mental disorders
other than panic disorder, particularly in
specific phobia, social phobia & PTSD
Unexpected panic attacks occur at any time &
are not associated with any identifiable
situational stimulus, but panic attacks need
not be unexpected
Attacks in patients with social & specific
phobias are usually expected or cued to a
recognized or specific stimulus

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 Some panic attacks do not fit easily
into the distinction between
unexpected & expected, and these
attacks are referred to as
situationally predisposed panic
attacks

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 DSM- IV- TR Criteria for
Agoraphobia
A. Anxiety about being in places or
situations from which escape might be
difficult(or embarassing)or in which
help may not be available in the event
of having an unexpected or situationally
predisposed panic attack or panic-like
symptoms. Agoraphobic fears typically
involve characteristic clusters of
situations that include being outside
the home alone; being in a crowd or
standing in a line; being on a bridge &
traveling in a bus, train or automobile

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 B. The situations are avoided (e.g., travel is
restricted) or else are endured with marked
distress or with anxiety about having a panic
attack or panic like symptoms, or require the
presence of a companion
C. The anxiety or phobic avoidance is not better
accounted for by another mental disorder , such
as social phobia (e.g., avoidance limited to
social situations because of fear of
embarassment), specific phobia (e.g., avoidance
limited to a single situation like elevators),
obsessive compulsive disorder ( avoidance of
dirt), posttraumatic stress disorder ( avoidance
of stimuli associated with a severe stressor) or
separation anxiety disorder (e.g., avoidance of
leaving home or relatives)
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 Specific Phobia & Social
Phobia
Phobia : an excessive fear of a specific
object, circumstance or situation
Specific phobia : strong, persisting fear of
an object or situation
Social phobia :strong, persisting fear of
situations in which embarassment can occur
The diagnosis of both specific & social
phobia requires the development of intense
anxiety, even to the point of panic, when
exposed to the feared situations

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 Specific Phobia
More common than social phobia
May anticipate harm, such as being bitten by a dog,
may panic at thought of losing control if they fear
being in an elevator
The peak age of onset for the natural environment
type & blood-injection-injury-type : 5-9 years
Onset for situational type (except fear of heights):
mid 20s
The feared objects & situations in specific phobia
(listed in descending frequency of appearance) are
animals, storms, heights, illness, injury & death

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 Social Phobia= Social Anxiety
Disorder
Have excessive fears of humiliation or
embarassment in various social settings,
such as speaking in public, urinating in
public rest room (shy bladder) &speaking
to a date

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 Obsessive Compulsive Disorder
(OCD)
Represented by a diverse group of symptoms
that include intrusive thoughts, rituals,
preoccupation & compulsions
These recurrent obsessions or compulsions
cause severe distress to the person
The obsessions or compulsions are time
consuming & interfere significantly with the
persons normal routine, occupational
functioning, usual social activities or
relationships
A patient with OCD may have an obsession, a
compulsion or both

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 Obsession : a recurrent & intrusive
thought, feeling, idea or sensation
Compulsion : a behavior
Specifically, a compulsion is a conscious,
standardized, recurrent behavior, such as
counting, checking, or avoiding
A patient with OCD realizes the irrationality
of the obsession & experiences both the
obsession & the compulsion as ego-
dystonic (unwanted behavior)

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 OCD has 4 major symptom
pattern :
1. Contamination
2. Pathological doubt
3. Intrusive thoughts
4. Symmetry

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 Obsessions
Contamination
Pathological doubt
Somatic
Need for symmetry
Aggressive
Sexual
Other
Multiple obsessions

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 Compulsions
Checking
Washing
Counting
Need to ask or confess
Symmetry and precision
Hoarding
Multiple comparisons

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 Treatment
Pharmacotherapy : SSRI, clomipramine
Behavior therapy : desensitization,thought
stopping,flooding,implosion therapy &
aversive conditioning
Psychotherapy

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 Posttraumatic Stress Disorder
(PTSD)& Acute Stress Disorder
Condition marked by the development of
symptoms after exposure to traumatic life events
The person reacts to this experience with fear &
helplessness, persistently relives the event, & tries
to avoid being reminded of it
PTSD :The symptom must last for more than a
month after the event & must significantly affect
important areas of life, such as family & work
Acute stress disorder : occurs earlier than PTSD;
within 4 weeks of the event, & remits within 2days
to 4 weeks

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 The stressors causing both acute stress
disorder & PTSD are sufficiently
overwhelming to affect almost anyone
They can arise from experiences in war,
torture, natural catatstrophes, assault, rape
& serious accidents, for example, in cars &
in burning buildings
The DSM-IV-TR diagnostic criteria for PTSD
specify that the symptoms of experiencing,
avoidance & hyperarousal must have lasted
more than 1 month ;acute : if the symptoms
have lasted less than 3 months, chronic : if
the symptoms have lasted than 3 months or
more
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 Clinical Features of PTSD
Painful reexperiencing of the event, a
pattern of avoidance & emotional numbing,
fairly constant hyperarousal
The disorder may not develop until months
or even years after the event
The mental status examination often reveals
feelings of guilt, rejection & humiliation
Patients may also describe dissociative
states & panic attacks, illusions &
hallucinations may be present

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 Treatment
Pharmacotherapy : SSRI : sertraline,
paroxetine
Psychotherapy : psychodynamic
psychotherapy, crisis intervention with
support, education & development of
coping mechanism & acceptance of the
event

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 Generalized Anxiety Disorder
Excessive anxiety & worry about several events or
activities for most days during at least 6- month
period
The worry is difficult to control and is associated with
somatic symptoms, such as muscle tension,
irritability, difficulty sleeping & restlessness
Anxiety is not focused on features of another axis I
disorder, not caused by substance use or a general
medical condition& does not occur only during a
mood or psychiatric disorder
Anxiety is difficult to control, is subjectively
distressing & produces impairment in important
areas of a persons life

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Generalized anxiety disorder
3 characteristic features
Worry & apprehension :worries are
widespread & not focused on a specific
issue
Motor tension : restlessness, trembling,
inability to relax, headache
Autonomic hyperactivity :sweating,
palpitations, dry mouth, epigastric
discomfort, dizziness
Other psychological symptoms of GAD
:irritability, poor concentration, sensitivity to
noise, poor memory
Other motor symptoms of GAD :aching &
stiffness in muscles
Autonomic symptoms can be grouped
according to systems of the body as follows :
Gastrointestinal :dry mouth, difficulty in
swallowing, epigastric discomfort, excessive
wind, borborygmi, frequent loose motions
Respiratory : feeling of construction in the
chest,difficulty in inhaling, & the consequences
of hyperventilation
Cardiovascular :feeling of discomfort over the
heart, palpitations, awareness of missed beats &
throbbing in the neck
Genitourinary : frequency & urgency of
micturition, failure of erection, lack of libido,
menstrual discomfort
Nervous system :tinnitus, feeling of blurring of
vision, dizziness, prickling sensations
 Etiology
Stressful events; involving threat
Genetic causes
Personality ;a persistent tendency to anxiety
Psychoanalytic theories by a particular way of
dealing with painful emotions intrapsychic
conflicts which generate anxiety when the ego
is overwhelmed by excitation from any of 3
sources :i) outside the world (realistic anxiety);
ii) the instinctual level of id : love,
anger & sex (neurotic anxiety)
iii) the superego
(moral anxiety)
Psychological responses to stressful events
Conditioning theories
Cognitive theories
 DSM-IV_TR Diagnostic Criteria
for Generalized Anxiety Disorder
A. Excessive anxiety & worry occurring
more days than not for at least 6 months,
about a number of events or activities
(such as work or school performance)
B. The person finds it difficult to control the
worry

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 C. The anxiety & worry are associated with
3 or more of the following 6 symptoms
(with at least some symptoms present for
more days than not for the past 6 months)
1. restlessness or feeling keyed up or on
edge
2. being easily fatigue
3. difficulty concentrating or mind going
blank
4. irritability
5. muscle tension
6. sleep disturbance ( difficulty falling or
staying asleep, or restless unsatisfying sleep)

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 D. The focus of the anxiety & worry is not
confined to features of an axis I disorder
E. The anxiety, worry or physical symptoms
cause clinically significant distress or
impairment in social, occupational or other
important areas of functioning
The disturbance is not due to the direct
physiological effects of a substance or a
general medical condition and does not
occur exclusively during a mood disorder, a
psychotic disorder or a pervasive
developmental disorder

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Diagnostic conventions
DSM- IV & ICD 10 require the presence of
similar symptoms for diagnosis of GAD
but they require different durations for
these symptoms.
DSM-IV requires that symptoms have
been present for 6 months
ICD 10 has the less stringent requirement
that symptoms should have been present
for most days for at least several weeks
at a time & usually several months
Treatment
Counselling
Cognitive behavioral therapy
Drugs
 DSM 5
Separation Anxiety Disorder (190)
Selective Mutism (195)
Specific Phobia (197)
Specify if:
Animal
Natural environment
Blood-injection-injury
Fear of blood
Fear of injections and transfusions
Fear of other medical care
Fear of injury
Situational
Social Anxiety Disorder (Social Phobia) (202)
Specify if: Performance only
Panic Disorder (208)
Panic Attack Specifier (214)
Agoraphobia (217)
Generalized Anxiety Disorder (222)
Substance/Medication-Induced Anxiety Disorder (226)
Note: See the criteria set and corresponding recording procedures for
substance-specific codes and ICD-9-CM and ICD-IO-CM coding.
Specify if: With onset during intoxication. With onset during withdrawal.
36With onset after medication use
293.84 (F06.4) Anxiety Disorder Due to Another Medical
 Social Anxiety Disorder (Social Phobia) (202)
Specify if: Performance only
Panic Disorder (208)
Panic Attack Specifier (214)
Agoraphobia (217)
Generalized Anxiety Disorder (222)

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 Substance/Medication-Induced Anxiety
Disorder (226)
Note: See the criteria set and
corresponding recording procedures
for
substance-specific codes and ICD-9-CM and
ICD-IO-CM coding.
Specify if: With onset during intoxication.
With onset during withdrawal.
With onset after medication use

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 293.84 (F06.4) Anxiety Disorder Due
to Another Medical Condition (230)
300.09 (F41.8) \ Other Specified
Anxiety Disorder (233)
300.00 (F41.9) Unspecified Anxiety
Disorder (233)
Obsessive-Compulsive and Related
Disorders

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 The following specifier applies to Obsessive-Compulsive and Related Disorders where indicated:
^Specify if: With good or fair insight. With poor insight. With absent insight/delusional beliefs
Obsessive-Compulsive Disorder^ (237)
Specify if: Tic-related
Body Dysmorphic Disorder^ (242)
Specify if: With muscle dysmorphia
Hoarding Disorder^ (247)
Specify if: With excessive acquisition
Obsessive-Compulsive and Related
Trauma- and Stressor-Related Disorders (265)
313.89 (F94.1)

Disorders (235)
313.89 (F94.2)
309.81 (F43.10)
308.3 (F43.0)
Reactive Attachment Disorder (265)
Specify if: Persistent
Specify current severity: Severe
Disinhibited Social Engagement Disorder (268)
Specify if: Persistent
Specify current severity: Severe
Posttraumatic Stress Disorder (includes Posttraumatic Stress
Disorder for Children 6 Years and Younger) (271)
Specify whether:

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 Trichotillomania (Hair-Pulling Disorder) (251)
Excoriation (Skin-Picking) Disorder (254)
Substance/Medication-Induced Obsessive-Compulsive and
Related Disorder (257)
Note: See the criteria set and corresponding recording
procedures for
substance-specific codes and ICD-9-CM and ICD-IO-CM coding.
Specify if: With onset during intoxication. With onset during
withdrawal.
With onset after medication use
symptoms. With skin-picking symptoms
Other Specified Obsessive-Compulsive and Related Disorder
(263)
Unspecified Obsessive-Compulsive and Related Disorder (264)

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 Obsessive-Compulsive and Related Disorder
Due to Another
Medical Condition (260)
Specify if: With obsessive-compulsive
disorder-like symptoms. With
appearance preoccupations. With hoarding
symptoms. With hairpulling
Other Specified Obsessive-Compulsive and
Related Disorder
Unspecified Obsessive-Compulsive and
Related Disorder

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 Trauma- and Stressor-
Related Disorders (265)
Reactive Attachment Disorder (265)
Specify if: Persistent
Specify current severity: Severe
Disinhibited Social Engagement Disorder (268)
Specify if: Persistent
Specify current severity: Severe
Posttraumatic Stress Disorder (includes
Posttraumatic Stress
Disorder for Children 6 Years and Younger) (271)
Specify whether: With dissociative symptoms
Specify if: With delayed expression

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Acute Stress Disorder (280)
 Adjustment Disorders (286)
Specify whether:
309.0 (F43.21) With depressed mood
309.24 (F43.22) With anxiety
309.28 (F43.23) With mixed anxiety and
depressed mood
309.3 (F43.24) With disturbance of
conduct
309.4 (F43.25) With mixed disturbance of
emotions and conduct
309.9 (F43.20) Unspecified
309.89 (F43.8) Other Specified Trauma-
and Stressor-Related Disorder (289)
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