Anxiety Disorders

• A discrete period of intense fear or discomfort w >4 of:
• palpitations, pounding heart or accelerated HR
• sweating
• trembling or shaking
• sensations of SOB or smotherng
• feeling of choking
• CP or discomfort
• nausea or Abdominal Distress
• feeling dizzy, unsteady, lightheaded or faint
• derealisation or depersonalisation
• fear of losing control or going crazy
• fear of dying
• paraesthesias
• chills or hot flushes

• Recurrent unexpected panic attacks
• at least one attack followed by 1 month or more of one of the following:
• - persistent concern about having additional attacks
• - worry about the implications of the attack or its consequences
• - significant change in behaviour related to the attacks
• Absence of Agoraphobia
• Panic attacks not due to substance abuse or a general medical condition
• Panic attacks not better accounted for by another mental disorder

• Excessive anxiety and worry, occuring more days than not for at least 6 months, about a number of events or activities
• The person finds it difficult to control the worry
• The anxiety and worry are associated with 3 or more of the following
• 1. restlessness or feeling keyed up on edge
• 2.being easity fatigued
• 3. difficulty concentrating or mind going blank
• 4. irritability
• 5. muscle tension
• 6. sleep disturbance
• The focus of the anxiety and worry is not confined to features of an Axis 1 disorder
• 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 substance abuse or a general medical condition

• Feeling of dread
• difficulty concentrating
• hypervigilance
• insomnia
• decreased libido
• 'lump in the throat'
• upset stomach

• Trembling, twitching, feeling shaky
• Backache, headache
• muscle tension
• SOB, Hyperventilation
• Fatigability
• Startle response
• Autonomic hyperactivity (flushing, pallor, tachycardia, palpitations, sweating, cold hands, diarrhoea, dry mouth, urinary frequency)
• Paraesthesia
• Difficulty swallowing

• Marked and persistent fear that is excessive or unreasonable, cued by the presence or anticipation of a specific object or situation
• exposure to the phobic stimulus almost invariably provokes an immediate anxiety response, which may take the forma of a situationally bound or situationally predisposed panic attack
• The person recognises that teh fear is excessive or unreasonable
• The phobic situation is avoided or else is endured with intense anxiety or distress
• The avoidance, anxious anticipation, or distress in the feared situation interferes significantly with the person's normal routine, occupational (or academic) functioning, or social activities or relationships, or there is marked distress about having a phobia
• In individuals <18yo the duration is at least 6 months
• Not better accounted for by another mental disorder (OCD, PTSD, social phobia, Panic disorder w agoraphobia or agoraphobia)

• Animal type
• Natural environmental type (heights, storms, water)
• Blood-injection-injury type
• Situational Type (airplanes, elevators, enclosed spaces)
• Other types

• A. Marked and persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others. The individual fears that he or she will act in a way that will be humiliating and embarrassing
• B. Exposure to the feared social situation almost invariably provokes anxiety, which may take the form of a situationally bound or situationally perdisposed panic attack
• C. The person recognises that the fear is excessive or unreasonable
• D. The feared social or performance situations are avoided or else endured with intense anxiety or distress
• E. The avoidance, anxious anticipation or distress interferes significantly with the person't normal routine, occupational functioning or social activities or relationships, or there is marked distress about the phobia
• F. In individuals under 18yo duration is at least 6 months
• G. Not due to substance abuse or a general medical condition or better accounted for by another mental disorder
• H. If a gneral medical condition or another mental disorder is present, the fear in criterion A is unrelated to it.

Can be 'generalised' if the fear includes most social situations

• 1. recurrent and persistent thoughts, impulses, or images that are experienced, at some time during the disturbance, as intrusive and inappropriate and that cause marked anxiety or distress
• 2. The thoughts, impulses or images are not simply excessive worries about real life problems
• 3. The person attempts to ignore or suppress such thoughts, impulses or images, or to neutralise them with some other thought or action
• 4. The person recognises the obsessions are a product of his or her own mind

• 1. repetitive behaviours or mental acts that the person feels driven to perform in response to an obsession, or according to rules that must be applied regidly
• 2. The behaviours or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation; however thense behaviours or mental acts either are not connected in a realistic way with what they are designed to neutralise or prevent or are clearly excessive

• A. Other obsessions or compulsions
• B. At some point during the course of the disorder, the person has recognised that the obsesssions or compulsions are excessive or unreasonable
• C. The O or C cause marked distress, are time consuming (>1hr/day), or significantly interfere with the person's normal routine, occupational functioning or usual social activities or relationships
• D. If another Axis 1 disorder is present, the content of the O or C is not restricted to it
• E. The disturbance is not due to substance abuse or a general medical condition

Specify if 'with poor insight' - if for most of the time during the current episode, the person does not recognise that the O and C are excessive or unreasonable.

• A. The person has been exposed to a traumatic event in which both of the following were present
• 1. the person experienced, witnessed, or was confronted with an event or events that invlved acutal or threatened death or serious injury or a threat to the physical integrity of self or others
• 2. the person's response involved intense fear, helplessness, or horror
• B. The traumatic event is persistently reexperienced in on or more of the following ways:
• 1. recurrent and intrusive distressing recollections of the event, including images, thoughts or perceptions
• 2. recurrent distressing dreams of the event
• 3. acting or feeling as if the traumatic event were recurring
• 4. intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event
• 5. physiologic reactivity on exposure to internal or external cues that symbolise or resemble an aspect of the traumatic event
• C. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness, as indicated by three of more of:
• 1. efforts to avoid thoughts, feelings, or conversations associated with the trauma
• 2. efforts to avoid activities, places, or people that arose recollections of trauma
• 3. inability to recall an important aspect of the trauma
• 4. markedly diminished interest or participation in significant activities
• 5. feeling of detachment or estrangement from others
• 6. restricted range of affect
• 7. sense of foreshortened future
• D. Persistent symptoms of increased arousal as indicated by 2 or more of:
• 1. difficulty falling asleep or staying asleep
• 2. irritability or outbursts of anger
• 3. difficulty concentrating
• 4. hypervigilance
• 5. exaggerated startle response
• E. Duration of the disturbance (symptoms in B,C and D) is more than 1 month.
• F. The disturbance causes clinically significant distress or impairment in social, occupational or other important areas of functioning

• Specify if acute - Sx less than 3 months
• Chronic - Sx greater than 3 months
• Delayed onset - Sx begin at least 6 months after stressor

• Intoxication:
• amphetamines and other sympathomimetics
• amyl nitrate
• anticholinergics
• caffeine
• cannabis
• sedative-hypnotics
• cocaine
• hallucinogens
• theophylline
• yohimbine

• Withdrawal:
• alcohol
• antihypertensives
• caffeine
• opiods

• Cerebral neoplasms
• cerebral trauma and postconcussive syndromes
• cerebrovascular disease
• subarachnoid haemorrhage
• migraine
• encephalitis
• cerebral syphilis
• MS
• Wilson's disease
• Huntington's disease
• Epilepsy

• Hypoxia
• CV disease
• Pulmonary insufficiency
• Anaemia

• pituitary dysfunction
• thyroid dysfunction
• parathyroid dysfunction
• adrenal dysfunction
• pheochromocytoma
• female virilisation disorders

• Lupus erythematosus
• Rheumatoid Arthritis
• Polyarteritis nodosa
• Temporal Arteritits

• A state that has many effects - it influences cognition and tends to produce distortions of perception.
• Effects tend to be dread accompanied by somatic complaints that indicate a hyperactive autonomic nervous system
• Fear - an appropriate response to a known threat
• Anxiety - response to a threat that is unknown, vague, or conflictual

• 1. Panic Disorder with and with or without agoraphobia
• 2. Agoraphobia without history of panic disorder
• 3. Generalised Anxiety Disorder
• 4. Specific Phobia
• 5. Social Phobia
• 6. Obsessive Compulsive Disorder
• 7. PTSD
• 8. Anxiety Disorder due to a medical Condition
• 9. Substance induced anxiety disorder
• 10 Mixed anxiety-depressive disorder
• 11. Anxiety disorder not otherwise specified

• 1. Adjustment Disorder with Anxiety - pt with an obvious stressor in whom excessive anxiety develops within 3 months and lasts no longer than 6 months
• 2. Anxiety secondary to another psychiatric disorder - 70% of depressed pts experience anxiety. Also seen in psychoses, schizophrenia, mania or brief psychotic disorder, delerium and dementia
• 3. Situational Anxiety - effects of a stressful situation temporarily overwhelm the ability to cope
• 4. Existential anxiety - Involves fears of helplessness, aging, loss of control, and loss of others in addition to the fear of death and dying.
• 5. Separation anxiety and stranger anxiety - regressed adults can manifest w anxiety when separated from loved ones. Common in children until 2.5yrs of age
• 6. Anxiety related to loss of self control - eg loss of autonomy can preceed anxiety
• 7. Anxiety related to dependence or intimacy
• 8. Anxiety related to guilt and punishment

• 1. Depressive Disorders
• 2. Schizophrenia
• 3. Bipolar 1 Disorder
• 4. Atypical psychosis
• 5. Adjustment disorder w anxiety
• 6. Medical and Neurological conditions
• 7. Substance related disorders
• 8. Cognitive Disorders

• Initial - information about anxiety disorder and education on relaxation techniques and coping skills
• CBT
• Pharmacotherapy (only if nonpharmacological in inadequate)
• 1. diazepam 2-5mg orally (single dose, repeated up to twice daily)

• Long term:
• CBT
• Pharmacological (if psychological inadequate):
• 1. if coexisting depression --> antidepressants
• Paroxetine 10mg orally, mane & increase according to tolerability and pt response to 40-60mg daily
• OR Sertraline 25mg orally, mane & increase according to tolerability and pt response to 200mg daily
• OR imipramine 25mg orally nocte increasing to 75mg nocte. (caution in risk of overdose)
• OR Venlafaxine 75mg orally, mane
• OR buspirone 5mg orally,TID, increase up to 20mg TID.
• 2. long term benzodiazepine use (consider only when both nonpharmacological and alternative pharmacological therapies have failed(
• Diazepam 2-5mg orally, single dose, can be repeated twice daily.

• Investigation for medical causes
• Explanation, support and stress management
• Deep breathing techniques

• Non pharmacological (1st line)
• Education about the disorder - explain the way the panic attack produces physical symptoms
• Breathing control strategies and relaxation strategies
• CBT (Rx of choice) - panic control treatment which involves exposure to deliberately induced sypmtoms together with techniques for controlling sx and reattribution of sx to benign causes

• Pharmacological
• SSRIs and Venlafaxine are 1st line (alphabetical order)
• 1. Citalopram 10mg orally, mane increase to max 40mg
• 2. escitalopram 5mg orally, mane increase to max 20mg
• 3. Fluoxetine 10mg mane increase to max 40mg
• 4. fluvoxamine 50mg orally, mane increase to max 300mg
• 5. paroxetine 10mg orally mane, increase to 40-60mg
• 6. sertraline 25mg orally, mane, increase to max 200mg
• 7. venlafaxine 75mg orally mane increase to max 225mg

• Second line
• - TCAs (clomipramine or imipramine - doses required for anxiety disorders higher than depressive disorders)

- Benzodiazepines clonazepam 0.25 - 2mg BD, OR alprazolam 0.25 - 1mg QID

-MAOIs

• Best Rx is a combination of pharmaco and non pharmaco therapy.
• eg. CBT - some need pharmacotherapy before being able to engage

Doses required are higher than that of depression and response may not be seen for 6-12 weeks

• Pharmaco therapy
• -continued for 6 to 12 months in first instance
• 1st line - SSRIs
• eg. citalopram 20mg - 60mg mane
• escitalopram 10mg - 20mg mane
• fluoxetine 10mg - 8mg mane
• fluvoxamine 50mg - 300mg mane
• paroxetine 10mg - 60mg mane
• sertraline 25-200mg mane

• 2nd line
• TCAs - eg clomipramine 50-75mg nocte up to 150-250mg nocte

Rx involves control of panic attacks and then behavioural therapy with graduated in vivo exposure to overcome phobic avoidance.

• Non Pharmacological:
• CBT incorporating exposure based therapy, social skills training and cognitive therapy

Combination w pharmacological often required

• Pharmacological
• SSRIs, MAOIs and benzos have shown efficacy in Sx control
• Must be continued for 6-12 months in first instance
• 1st line - SSRIs:
• Fluvoxamine 100mg - 300mg mane
• Paroxetine 10mg - 60mg mane
• Sertraline 25mg - 200mg mane
• 2nd line:
• - Benzodiazepines (if no hx of alcohol or substance abuse or co-occuring depression) CLONAZEPAM -0.25 - 2mg BD
• -MAOIs - most powerful effect but highest SE profile. eg. phenelzine 15mg BD up to 45-60mg BD

Pharmacological goal is to decrease physiological Sx

• BetaBlockers
• propranolol 10-40mg 30 to 60minutes prior to social event or performance

• Short acting Benzodiazepines
• Alprazolam 0.25mg - 0.5mg single dose OR
• Lorazepam 0.5 - 1mg single dose

Almost NO place for pharmacotherapy

• Acute
• -CBT ususally w graduated xposure therapy
• -Pharmacotherapy - used as an adjunct to psychotherapy. SSRIs

• Chronic
• -Little role for pharmacotherapy or exposure therapy
• -main aim is to cope w symptoms rather than symptom remission