Anxiety Disorders

Eleonor E. Sanchez, M.D.,D.P.B.P.

Child and Adult Psychiatry
Anxiety

- a diffuse, unpleasant, vague sense of

apprehension
- accompanied by autonomic symptoms
- symptom presentation vary among
individuals
Anxiety vs Fear

Similarity
- Both are alerting signals to an
impending danger
Differences
Fear – sudden response to a known,
external, definite or nonconflictual
threat
Anxiety – insidious response to an
unknown, internal, vague or
conflictual threat
Is Anxiety Adaptive?

As a warning of internal or external threat

 anxiety is adaptive and is life-saving
Etiology and Management of
Mood Disorders
 Tachycardia,
L. Hypothalamus paleness, inc BP

Nucleus Ambiguus GI ulcers, urination

V. Tegmental Area Arousal, vigilance

Amygdala
N. Reticularis pontis Inc. startle

Trigeminal Facial expression

of fear

Paraventricular Corticosteroid
Hypothalamus release
Biological Theory
Cerebral Cortex

Thalamus Amygdala

Sensory System Brainstem

Sensory Stimuli
Anatomical Target Amygdala Effect Anxiety signs

Lat.Hypothalamus Sympathetc Inc HR,BP,pallor

actvatn
Vagus, N.ambiguus Parasympathetic Urination,defecatn

Parabrachial N. Inc respiration Respiratory distrss

Locus Coerulus, Dopamine, NE & Arousal (also in

Ventral Tegmental, Ach activation EEG), vigilance
Dorsl Lat Tegmentl
N.Reticularis pontis Inc reflexes Inc startle response

Trigeminal,Facial N Mouth & jaw movt Facial expression

Paraventricular N. ACTH release Corticosteroid

Hypothalamus release
 Maladaptive
Defense Mechanisms Mental Disorder

Repression,
Displacement,
Phobia
Symbolization,
Avoidance

Regression,
ANXIETY reaction OCD
formation,
undoing

Repression,
denial, splitting, PTSD
dissociation

Introjection Depression
Psychoanalytic Theory: Treatment

Insight-Oriented Psychotherapy

Superego

Conflict ANXIETY
Mature & Adaptive
Defense
Mechanism
Id Ego
Anxiety Disorders
Anxiety Disorders

1. Panic Disorder and Agoraphobia

2. Specific and Social Phobia
3. Obsessive-Compulsive Disorder
4. Posttraumatic Stress Disorder and
Acute Stress Disorder
5. Generalized Anxiety Disorder
Anxiety Disorders

6. Anxiety Disorder Due to General Medical

Condition
7. Substance-Induced Anxiety Disorder
8. Anxiety Disorder Not Otherwise
Specified (NOS)
9. Mixed Anxiety-Depressive Disorder
10. Adjustment Disorder with Anxiety
Panic Disorder
Panic Attack: DSM-IV-TR Criteria

A discrete period of intense fear or discomfort,

4 or more of the ff developed abruptly
reaching a peak within 10 minutes:
3. Palpitations or accelerated heart rate
4. Sweating
5. Trembling or shaking
6. Sensations of shortness of breath or smothering
7. Feeling of choking
8. Chest pain or discomfort
*Panic Attack: DSM-IV-TR Criteria

7. Nausea or abdominal distress

8. Feeling dizzy, unsteady, lightheaded or faint
9. Paresthesia (numbness or tingling sensations)
10. Chills or hot flushes
11. Derealization or depersonalization
12. Fear of losing control or going crazy
13. Fear of dying

*not a codable disorder

Panic Disorder with (or without) Agoraphobia
DSM-IV-TR Diagnostic Criteria

A. Both (1) and (2)

 Recurrent and unexpected panic attacks
 At least one of the attacks has been followed by
1 month (or more) of one (or more) of the ff:
 Persistent concern: additional attacks
 Worry: implications of the attack and its
consequences
 Significant change in behavior related to the
attack
Panic Disorder with (or without) Agoraphobia
DSM-IV-TR Diagnostic Criteria

B. Absence (or Presence) of Agoraphobia

C. NOT due to the direct physiological
effects of a substance or a general
medical condition
D. NOT better accounted for by another
mental disorder (social or specific
phobia, obsessive-compulsive do, PTSD
or separation anxiety)
Agoraphobia
DSM-IV-TR Diagnostic Criteria

 Anxiety about being in places or situations

from which escape might be difficult (or
embarrassing) or in which help may not be
available in the event of having a panic
attack
 Situations are avoided or endured with
marked distress or anxiety of having a panic
attack, or having a companion
 Not accounted for by another mental
disorder
Specific Phobia
DSM-IV-TR Diagnostic Criteria

 Marked & persistent fear (excessive or

unrealistic) in the presence or anticipation of
a specific object or situation
 Exposure  immediate anxiety response:
may be situationally-bound or situationally-
predisposed panic attack.
In children: crying tantrums, freezing or
clinging
 Recognizes that the fear is excessive (may
be absent in children)
Specific Phobia
DSM-IV-TR Diagnostic Criteria

D. Phobic situation is avoided or is endured with

marked anxiety
E. Avoidance, anxious anticipation or distress
 significantly affect normal routine, social
or occupational functioning OR marked
distress of having the phobia
F. Under age 18 years, duration at least 6 mos
G. Not better accounted for by another mental
disorder
Specific Phobia
DSM-IV-TR Diagnostic Criteria

Specify type:
Animal type
Natural environment type
Blood-injection-injury type
Situational type
Other type (e.g. fear of choking, vomiting
or contracting an illness; in children, fear
of loud sound or costumed characters)
Social Phobia
DSM-IV-TR Diagnostic Criteria

 Fear  1 or more social or performance

situations in which the person is exposed to
unfamiliar people or to possible scrutiny by
others.
Fears that he will act in a way (or show
anxiety sxs) that will be humiliating or
embarrassing
In children: must be evidence of the
capacity for age-appropriate social
relationships w/ familiar people (peer
setting)
Social Phobia
DSM-IV-TR Diagnostic Criteria

Criteria B, C, D, E, F, G – same as Specific

Phobia
B. If a general medical condition or another
mental disorder is present, the fear in
Criterion A is unrelated to it, e.g. the fear is
not of stuttering, trembling in Parkinson’s
Dis
Specify if:
Generalized: includes most social situations
(consider addtl dx of Avoidant Personality
DO)
Obsessive-Compulsive Disorder
DSM-IV-TR Diagnostic Criteria

A. Either obsessions or compulsions:

Obsessions as defined by (1),(2),(3)&(4):
 Recurrent & persistent thoughts,
impulses or images; experienced at
some time as intrusive & inappropriate
& that caused marked anxiety or
distress
 …not simply excessive worries about
real-life problems
Obsessive-Compulsive Disorder
DSM-IV-TR Diagnostic Criteria

3. Attempts to ignore or suppress such

thought, etc., or to neutralize them with
some other thought or action
4. Recognizes that the obsessional
thoughts, etc., are a product of his own
mind (not thought insertion)
Obsessive-Compulsive Disorder
DSM-IV-TR Diagnostic Criteria

Compulsions as defined by (1) and (2):

 Repetitive behaviors or mental acts that
he feels driven to perform in response to
an obsession, or accdg to rules that
must be applied rigidly
 Acts: aimed at preventing or reducing
stress or preventing some dreaded
event but are NOT connected in a
realistic way with what they are designed
to neutralize or prevent or are clearly
excessive
Obsessive-Compulsive Disorder
DSM-IV-TR Diagnostic Criteria

B. At some point, the persons recognizes

that the obsessions or compulsions are
excessive or unreasonable (does NOT
apply in children)
C. Obsessions or compulsions caused
marked distress, time-consuming (> 1
hour/day) and significantly interfere with
functioning
Obsessive-Compulsive Disorder
DSM-IV-TR Diagnostic Criteria

D. If another Axis I Disorder is present, the content

of the obsessions or compulsions is not
restricted to it (e.g., preoccupation with physical
appearance in Body Dysmorphic Disorder, etc.)
E. NOT due to effects of a substance or GMC
Specify if:
With poor insight: person does not recognize that
obsession & compulsion are excessive or
unreasonable
Posttraumatic Stress Disorder
DSM-IV-TR Diagnostic Criteria

A. Exposure to a traumatic event in which both of

the ff are present:
1. person experienced, witnessed or was
confronted with an event that involved
actual or threatened death or serious
injury, or a threat to the physical integrity of
self or others
2. response: intense fear, helplessness, or
horror (in children: disorganized or agitated
behavior)
Posttraumatic Stress Disorder
DSM-IV-TR Diagnostic Criteria

B. Traumatic event is persistently

reexperienced in 1 or more of the ff
ways:
 Recurrent and intrusive recollections
(in children: repetitive play)
2. Recurrent & distressing dreams
(in children: no recognizable content)
Posttraumatic Stress Disorder
DSM-IV-TR Diagnostic Criteria

3. Acting or feeling as if the event was recurring (a

sense of reliving, illusions, hallucinations, &
dissociative flashbacks including during
awakening or when intoxicated)
In children: trauma-specific reenactment
4. Exposure to cues that symbolize or resemble the
event  intense psychological distress
5. Exposure to cues..  physiological reactivity
Posttraumatic Stress Disorder
DSM-IV-TR Diagnostic Criteria

 Persistent avoidance of stimuli assoc with trauma

or numbing of general responsiveness, as
indicated by 3 or more of the ff:
1. efforts to avoid thoughts, feelings or
conversations associated with the trauma
2. efforts to avoid activities, places or people
that arouse recollections of the trauma
3. inability to recall important aspect of trauma
Posttraumatic Stress Disorder
DSM-IV-TR Diagnostic Criteria

4. Markedly diminished interest or

participation in significant activities.
5. Feeling of detachment or estrangement
from others
6. Restricted range of affect (e.g. unable to
have loving feelings)
7. Sense of foreshortened future
Posttraumatic Stress Disorder
DSM-IV-TR Diagnostic Criteria

D. Persistent symptoms of increased arousal as

indicated by 2 or more of the ff:
2. Difficulty falling or staying asleep

3. Irritability or outbursts of anger

4. Difficulty concentrating

5. Hypervigilance

6. Exaggerated startle response

Posttraumatic Stress Disorder
DSM-IV-TR Diagnostic Criteria

E. Duration of symptoms in Criteria B,C and D is

more than 1 month
F. Cause significant impairment in functioning
Specify if:
Acute: duration of sxs is less than 3 months
Chronic: duration is 3 months or more
Specify if:
With delayed onset: if onset is at least 6
months after the stressor
Generalized Anxiety Disorder
DSM-IV-TR Diagnostic Criteria

 Excessive anxiety and worry (apprehensive

expectation), occurring more days than not for
at least 6 months, about a number of events or
activities (e.g. work or school performance)
 The person finds it difficult to control the worry
Generalized Anxiety Disorder
DSM-IV-TR Diagnostic Criteria

 The anxiety and worry are associated with 3 or more

of the ff 6 sxs (w/ at least some sxs present for more
days than not for the past 6 months) For children:
only 1 item is required
2. Restlessness or feeling keyed up or on edge
3. Being easily fatigued
4. Difficulty concentrating or mind going blank
5. Irritability
6. Muscle tension
7. Sleep disturbance
Generalized Anxiety Disorder
DSM-IV-TR Diagnostic Criteria

D. Focus of the anxiety & worry is not confined to

features of an Axis I Disorder, e.g. anxiety not
about having a panic attack as in Panic DO
E. Causes significant impairment in functioning
F. NOT due to direct physiological effects of a
substance or a GMC & does not occur
exclusively during a mood d/o, psychotic d/o or
pervasive developmental d/o
Adjustment Disorder
DSM-IV-TR Diagnostic Criteria

 Emotional or behavioral symptoms in

response to a stressor occurring within
3 months of the onset of the stressor
 Symptoms are marked by the ff:
1. marked distress that is in excess of what is
expected from exposure to the stressor
2. impairment in functioning
c. Does NOT meet criteria for another Axis I,
NOT mere exacerbation of Axis I or II
diagnosis
Adjustment Disorder
DSM-IV-TR Diagnostic Criteria

D. Do NOT represent Bereavement

E. Stressor (or its consequences) terminated 
symptoms do NOT persist beyond an additional
6 months
Specify if:
with depressed mood
with anxiety
with mixed anxiety & depressed mood
with disturbance in conduct
with mixed disturbance of emotion and conduct
Anxiety Disorder Due to General Medical
Condition (GMC)
DSM-IV-TR Diagnostic Criteria

 Prominent anxiety, panic attacks or obsessions or

compulsions
 Evidence from the history, PE and lab findings:
direct physiological effects of GMC
 Not better accounted for by another mental d/o
 Does not occur exclusively during delirium
 Significant impairment in functioning
Anxiety Disorder Due to General Medical
Condition (GMC)
DSM-IV-TR Diagnostic Criteria

Specify if:
With generalized anxiety
With panic attacks
With obsessive-compulsive symptoms
Coding: Example
Axis I: Anxiety D/O Due to Pheochromocytoma, with
generalized anxiety
Axis III: Pheochromocytoma
Substance-Induced Anxiety Disorder
DSM-IV-TR Diagnostic Criteria

B. Evidence from the history, PE, lab of either (1) or (2):

 symptoms developed during or w/in 1 month of
substance intoxication or withdrawal
 Meds use is etiologically related to the disturbance
Substance-Induced Anxiety Disorder
DSM-IV-TR Diagnostic Criteria

C. Not better accounted for anxiety d/o that is NOT

substance-induced. Evidences include:
 sxs precede onset of substance use
 Sxs persist for a substantial period of time (e.g.
about a month) after the cessation of acute
withdrawal or severe intoxication or in excess of
expected
 Suggestion of an independent non-substance-
related episodes
Substance-Induced Anxiety Disorder
DSM-IV-TR Diagnostic Criteria

Specify if:
With generalized anxiety
With panic attacks
With obsessive compulsive symptoms
With phobic symptoms
Specify if:
With onset during intoxication
With onset during withdrawal
Biological Treatment: Anxiety Disorders
1. Catecholamine Theory
 Increased Autonomic Reactivity
Neurotransmitter: Norepinephrine
Cell Bodies: Locus Coerulus (Brainstem)
Medications:
1. Alpha-2-adrenergic receptor agonist
e.g. Clonidine
2. Benzodiazepine – inhibitory mechanism
Biological Treatment: Anxiety Disorder

2. GABA Theory
 abnormal functioning of GABAa receptors
 dec inhibition of hyperactive
noradrenergic, dopaminergic neurons
NT: Gamma Amino Butyric Acid (GABA)
Medications:
Benzodiazepine – prolongs synaptic action
of GABA
e.g. Alprazolam (Xanor),
Clonazepam (Rivotril)
Biological Treatment: Anxiety
Disorder
3. Serotonin Theory
 mechanism is unclear, some are contradictory
- 5HT1A receptor subsensitivity in Panic DO
- serotonin inhibitory effects on locus coerulus
NT: Serotonin
Medications:
1. Selective Serotonin Reuptake Inhibitor (SSRI)
e.g. Fluoxetine (Prozac), Sertraline
2. Tricyclic & Tetracyclic
e.g. Imipramine, Clomipramine
Biological Treatment: Anxiety
Disorder
4. Opioid Peptide Theory
 hyperactive endogenous opiate system in
PTSD  numbing & avoidance symptoms
NT: Endogenous opiate
Medications:
Opioid receptor antagonists
e.g. Noloxone (Narcan)
Nalmefene (Revex)
Cognitive Theory
- faulty, distorted or counterproductive
thinking patterns accompany or precede
maladaptive behaviors and emotional
disorders
- Selective attention over negative thoughts
 reinforce anxiety and/or depression
- Overestimate the danger and
underestimate their ability to cope
Cognitive-Behavioral
Therapy
1. Cognitive Approach
- to elicit, test and correct distorted
perceptions or thought
2. Behavioral Approach
- learn new strategies and ways of
dealing with issues
**Does not deal with the source of distorted
perceptions
Behavioral Techniques

1. Systematic Desensitization
 Feared object approached gradually
under a relaxed state
 Involves relaxation techniques
2. Flooding
 Exposure to anxiety-provoking
experience in vivo or using imagination
Aplysia experiment by E. Kandel 2000
Learning  changes in gene regulation
 changes in presynaptic facilitation
 inc in neurotransmitter release
 inc in number of synapses
Unlearning  reverses this process

Psychotherapy is a both a learning and

unlearning process..
Separation Anxiety
Disorder
(SAD)
SAD: Diagnostic Criteria

A. Developmentally-inappropriate and
excessive anxiety concerning separation
from home or from those to the individual
is attached, as evidenced by three (3) or
more of the following:
SAD: Diagnostic Criteria

1. Recurrent,
excessive distress
when separation from
home or major
attachment figures
(MAF) occurs or is
anticipated
SAD: Diagnostic Criteria

2. Persistent and
excessive worry about
losing, or about
possible harm
befalling MAF
SAD: Diagnostic Criteria

3. … worry that an
untoward event will
lead to separation
from MAF
SAD: Diagnostic
Criteria
4. Persistent
reluctance or refusal
to go to school or
elsewhere bec. of fear
of separation
SAD: Diagnostic
Criteria

5. …fearful or reluctant
to be alone or w/o MAF
at home or w/o
significant adults in other
settings
SAD: Diagnostic Criteria

6. …reluctance or refusal to go to sleep w/o

being near MAF or to sleep away from home
7. Repeated nightmares involving the
theme of separation
SAD: Diagnostic Criteria

8. Repeated
complaints of physical
symptoms when
separation from MAF
occurs or is
anticipated
SAD: Diagnostic Criteria

B. Duration: at least 4 weeks

C. Onset: before age 18 years
D. Causes clinically significant distress or
impairment in social, academic & other
areas of functioning
SAD: Treatment

1. Cognitive-behavioral therapy – first line

2. Family interventions
3. School liaison
4. Pharmacotherapy
a. SSRI – Paroxetine, Sertraline,
Citalopram
b. Benzodiazepine – Alprazolam,
Clonazepam
Selective Mutism
(SM)
SM: Diagnostic Criteria

A. Consistent failure to
speak in specific social
situation, despite
speaking in other
situations
SM: Diagnostic Criteria

B. Interferes with educational achievement or

with social communication
C. Duration: at least 1 month (not limited to 1st
month of school)
D. Not due to lack of knowledge of, or comfort
with, the spoken language required
SM: Treatment

1. Preschool: therapeutic nursery

2. School age: cognitive behavioral therapy –
first line
3. Family education
4. Pharmacotherapy – when psychosocial
interventions does not suffice
a. SSRI - Fluoxetine
Thank you!