ANXIETY DISORDER

Elmeida Effendy
Psychiatric Department
Medical Faculty
USU

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
F 4. Anxiety

disorders
F 40 Phobic anxiety
disorders
Agoraphobia

Social phobia
Specific phobia

F 41 Other anxiety

disorders

Panic disorder
Generalized anxiety

disorder
Mixed anxiety &
depressive disorder

DSM IV
Anxiety disorders
Agoraphobia without a

history of panic
disorder
Panic disorder with
agoraphobia
Social phobia
Specific phobia

Panic disorder without

agoraphobia
Generalized anxiety
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
7

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

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.,

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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),

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
12

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

13

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

14

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 egodystonic (unwanted behavior)

16

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

21

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

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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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Obsessive-Compulsive and Related

Disorders (235)
The following specifier applies to

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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

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
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Other Specified Obsessive-Compulsive and

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 StressorRelated Disorders (265)

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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

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 Traumaand Stressor-Related Disorder (289)
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