Anxiety Disorder

Silas Henry Ismanto

Departement of Psychiatry
Faculty of Medicine GMU
What is an anxiety
Anxiety is the apprehensive anticipation
of future danger or misfortune
accompanied by somatic symptoms of
tension
Sensation of anxiety is commonly
experienced by virtually all humans
Anxiety is an alerting signal it enables
a person to take measure to dealth with a
threat

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Normal & pathological
anxiety
Anxiety is normal for the infant who is
threatened by separation from parents or
by loss of love,
for the children on their first day in school,
for adolescents on their first date
for adults when they think about old age
and death
for anyone who is faced with ilness

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 Anxiety is a normal accompaniment of
growth, of change, of experiencing
something new an untried, and of
finding one`s own identity and
meaning in life
Pathological anxiety is an appropriate
response to given stimulus based on
its intensity or its duration

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 Wheter an event is perceived as
stressfull depends on the nature of the
event and on the person`s resources,
psychological defenses, and coping
mechanisms
All involve the ego the part of psychic
apparatus that is the mediator between
the person and external events and
internal drives (aggressive, sexual,
dependent impuls)
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 Ifthe ego is not functioning properly
the person experiences anxiety

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Signs and symptoms
Anxiety consists of a somatic side
( such as disturbed breathing, increased
heart activity, vasomotor changes,
musculoscletal disturbances) and
psychological side
Anxiety produces confusion and
distortion that can interfere with
learning by lowering concentration,
reducing recall, impairing the ability to
relate one item to another
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Theories of the etiology of
anxiety
There are 3 major schools of
psychological theory
1. Psychoanalytic
Anxiety is a result of the failure of the
ego as mediator between the person
and external or internal world
Anxiety is seen as a signal for the
ego to take defensive action against
the pressures
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 The defensive action (defense
mechanism) are repression,
conversion, displacement, regression
They may cause symptom formations,
such as hysteria, phobia, obsessive-
compulsive

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2. Behavioral / Learning
Anxiety is a conditioned response to
specific environmental stimuli; for example
A person who doesn`t have any food allergies
may become sick after eating contaminated
shelfish in a restaurant
Subsequent exposures to shelfish may cause
the person to feel sick
Through generalization the person may come
to distrust all food prepared by others

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 Persons may learn to have an
response of anxiety by imitating the
anxiety responses of their parents
(social learning theory)

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Cognitive theory
Anxiety is a result of overestimating
the degree of danger and the
probability of harm in a given situation
and of underestimating of the
abilities to cope with perceived threats

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Existensial
Anxiety is a result of awareness of a
profound nothingness in person`s live
(Existensial concerns may have
increased since the development of
nuclear weapons)

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Biological
Noradrenalin
Stimulation of the locus ceruleus (the
cell body of noradrenergic system)
produces a fear response (animal)
adrenergic agonist (isoproterenol)
and 2 adrenergic antagonist
(yohimbin) provoke panic attacks
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 2adrenergic agonist reduces
anxiety symptoms

Serotonin
Sertonergic antidepressants
(clomipramine), serotonergic type 5
HT1A have therapeutic effects in
some anxiety disorders
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 m-chlorphenylpiperazine(m CPP) and
fenfluramine cause the release of
serotonin cause increased anxiety

GABA
Patients with anxiety disorders may
have abnormal functioning of their
GABA receptors
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 Benzodiazepines, which enhance
GABA at the GABA receptor release
anxiety
A benzodiazepine invers agonist (-
carboline-3-carboxyclic acid) causes
anxiety

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DSM-IV list of anxiety disorders
1. Panic disoder with/without agoraphobia
2. Agoraphobia without a history of panic disorder
3. Specific and social phobia
4. Obsessive-compulsive disorder
5. Posttraumatic stress disorder
6. Acute stress disorder
7. Generalized anxiety disorder
8. Anxiety disorder due to a general medical condition
9. Substance-induced anxiety disorder
10. Anxiety diorder NOS (including mixed anxiety-
depressive diorder)

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Panic disorder and
agoraphobia
Panic disorder is characterized by the
spontaneous, unexpected occurrence of
panic attacks
Panic attack is relatively short-lived (less
than 1 hour) period of intense anxiety,
accopmpanied by such somatic symptoms:
palpitation and tachycardia
The frequency of panic attacks in patients
with panic disorder varies from multiple
attacks during a single day to only a few
attacks during the course of year
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 Panic disorder is often acompanied by
agoraphobia, the fear of being alone in
public places
Some experts hypotheside that
agoraphobia is caused by the
development of the fear that the person
will experience a panic attack in a
public place from which escape would
be difficult
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 The first panic attack is often spontaneous,
but there are some activities that commonly
precede attacks such as the use of coffein,
alcohol, nicotine, unusual patterns of
sleeping / eating; specific environmental
setting (harsh lighting at work)
The attack often begin with a 10-minute
period of rapidily increasing symptoms (the
major symptoms are extreme fear & sense
of impending death and doom)
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 The patients may feel confused and
have trouble in concentrating
The physical signs often include
tachicardia, palpitations, dyspnea, and
sweating
Patients often try to leave whatever
situation they are in to seek help
The attack generally lasts 20-30
minutes, rarely more than 1 hour
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A mental status examination during a panic
attack may reveal rumination, difficulty in
speaking (stammering) and impaired
memory, depression, and depersonalization
The symptoms may disappear quickly or
gradually
Between attacks patients may have
anticipatory anxiety about having another
attack

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 Somatic concerns of death from a cardiac or
respiratory problem may be the major focus
of patients` attention during panic attacks
Agoraphobic patients rigidly avoid situations
in which it would be difficult to obtain help
They prefer to be accompanied by a friend or
a family member in such places as a busy
streets, crowded store, closed-in spaces
(elevator, bridges), closed-in vehicles
(airplane, buses)
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 Before a correct diagnosis is made, patients
may be terrified that they are going crazy
The most effective treatments are
pharmacotherapy and cognitive-behavioral
therapy
Pharmacotherapy: tricyclic & tetracyclic
drugs, monoamine oxidase inhibitors
(MAOIs), serotonin-specific reuptake
inhibitors (SSRIs), benzodiazepines

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 Cognitve therapy consists of instruction
regarding the patient`s false beliefs and
information regarding panic attacks
The instruction centers on the patient`s
tendency to misinterpret mild bodily
sensations as indicative of impending death
or doom
The information about panic attacks include
explanations that panic attacks are time-
limitted and not life threatening
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 Behaviortherapy includes 1)
techniques for muscle relaxation and
imagining of relaxing situation helps
the patients through panic attacks 2)
exposure to the feared stimulus

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Specific phobia and social
phobia
A phobia is an irrational fear resulting
in a conscious avoidance of the feared
object, activity, or situation
Specific phobia is a marked and
persisting fear that is excessive or
unreasonable, cued by the presence of
anticipation of specific object or
situation (animals, heights, flying,
receiving an injection, seeing blood)

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 Exposure to the phobic stimulus almost
always provokes an immediate anxiety
response, which may causes panic
attack
The person recognizes that the fear is
excessive or unreasonable
The phobic situation is avoided, or
endured with intense anxiety or distress

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 In social phobia, there is marked and
persistent fear of one or more social
situations in which the person is
expossured to unfamiliar people or to
possible scrutiny by others.
The individual fears that he/she will
show anxiety symptoms that will be
humiliating or embarrassing

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 Depression is commonly found in phobic
patients
The most commonly used treament for specific
phobia is exposure therapy, by which the
therapist desensitizes the patient
The therapist teaches the patient techniques to
deal with the anxiety (relaxation, breathing
control, cognitive approach to the situaton)
The cognitive approach include reinforcing the
realization that the situation is, infact, safe

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 -adrenergic antagonist can be useful in
the treatment of specific phobia
The treatment of social phobia uses both
pharmacotherapy and psychotherapy
Monoamine oxidase inhibitor,
alprazolam, clonazepam, serotonin-
specific reauptake inhibitors are
effective in treatment of social phobia

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 The administration of -adrenergic
rerceptor antagonist before exposure to
social phobic situation is usefull
atenolol 50-100 mg every morning or
one hour before the performance, or
propanolol 20-40 mg
Psychotherapy for social phobia
includes behavioral and cognitive
methods
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Obsessive-compulsive
disorder
An obsession is a recurrent and intensive
thought, feeling, idea, or sensation
A compulsion is a conscious,
standardized, reccurent thought and
behavior such as counting, checking or
avoiding
Obsessions increase a person`s anxiety,
whereas carrying out compulsions
reduces the anxiety

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 When a person resists carrying out a
compulsion, anxiety is increased
A person with obsessive and compulsive
disorder realizes the irrationality of the
obsessions
Obsessive-compulsive disorder can be disabling
disorder because the obsessions can be time
consuming and can interfere significantly with
the person`s normal routine (occupational
functioning, usual social activities or
relationships with friends and family members

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 Obsessions and compulsions have certain
features in common:
1. An idea or an impulse intrudes itself
insistently and persistently into the
person`s conscious awareness
2. An anxious feeling accompanies the
central manifestation and frequently leads
the person to take countermeasures
against the initial idea or impulse

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3. The obsession or the compulsion is
ego- dystonic (something that is
unacceptable to the ego)
4. The person usually recognizes the
obsession and the compulsion as
absurd and irrational
5. The person usually feels a strong
desire to resist them

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There are 4 major symptom patterns of OCD
1. An obsession of contamination followed by
washing or accompanied by compulsive
avoidance of presumably contaminated
object (feces, urine, dust)
2. An obsession of doubt, followed by checking
3. Intrusive obsesional thought without a
compulsion (repetitious thoughts of sexual
or aggressive act)

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4. The need for symmetry or precicion, which
can lead to a compulsion of slowness
The standard drug for the treatment of OCD
is a serotonin-specific tricyclic drug
clomipramine iniated at dosages of 25-50
mg at bedtime, can be increased of 25 mg a
day every 2-3 days, up to maximum dosage
of 250 mg
SSRIs (fluoxetine, sertraline, paroxetine,
fluvoxamine) dosage of fluoxetine up to 80
mg/ day
MAOIs (phenelzine)

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 The principal behavioral therapy in OCD is
desensitisation (exposure to the object
gradually)
Supportive psychotherapy continuous and
regular contact with an interested,
sympathetic, and encouraging person
patient may be to function
Attention to family member support,
reassurance, advice on how to manage and
respond to the patient
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 Group therapy is usefull as a support
system
Psychosurgery cingulotomy

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Posttraumatic stress disorder &
acute stress disorder
For patients to be classified as having
PTSD, they must have experienced an
emotional stress that was magnitude
that would be traumatic for almost
anyone
Such traumas include combat
experience, natural catastrophes,
assault, rape, serious accidents

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 PTSD consists of
1. The reexperiencing of the trauma
through dreams and waking thoughts
2. Persistent avoidance of reminders of
the trauma and numbing of
responsiveness to such reminders
3. Persistent hyperarousal

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 Common associated symptoms of PTSD
are depression, anxiety, cognitive
difficulties (i.e poor concentration,
impairment of memory)
The disorder may not develop until
months or even years after the event
The mental status examination reveals
feelings of guilt, rejection, and
humiliation
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 Patientsis classified as having acute
stress disorder if the symptoms occur
within 4 weeks of the traumatic event
and last for 2 days to 4 weeks

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 The major approaches for patient who
has a significant trauma are support,
encouragement to discuss the event,
education regarding coping
mechanisms (for example relaxation)
The use of sedatives and hypnotics
can be also usefull
Support group is helpful for patients
with PTSD
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 When a clinician is faced with a patient
who experienced a traumatic event in
the past and now has PTSD the
emphasis should be on education
regarding the disoder and its
treatment, both pharmacological and
psychotherapeutic

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 Tricyclicdrugs (imipramine, amitrptyline)
are effective in the treatment of PTSD
Other drugs are SSRIs, MAOIs, clonidine,
propanolol
Alprazolam is effective but the longterm
use is acomplicated by drug dependency
Antipsychotic drugs (haloperidol) is
helpful for the short-term control of
severe agression and agitation

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 The therapist should overcome
patients` denial of traumatic event,
encourage them to relax, and remove
them from the source of the stress
The patient should be encouraged to
review and abreact (discharge)
emotional feelings associated with the
traumatic event and plan for future
recovery
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 Two major psychotherapeutic approaches
can be taken for patients with PTSD
1. An exposure to the traumatic event
through imaginal or in vivo exposure; it
should be graded as in systematic
desensitization
2. Teaching the patient methods of stress
management, including relaxation and
cognitive approaches to coping with
stress
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 Group therapy is effective in patients
with PTSD; the advantages of the
therapy include the sharing of multiple
traumatic experiences and support
from other group members

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Generalized Anxiety Disorder
GAD is an excessive and pervasive
worry, accompanied by a variety of
somatic symptoms, that causes
impairment in social or occupational
functioning or marked distress in the
patient
The primary symptoms of GAD are
anxiety, motor tension, autonomic
hyperactivity, and cognitive vigilance
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 The motor tension is most commonly
manifested as shakiness, restlessness,
and headaches
The autonomic hyperactivity is
commonly manifested by shortness of
breath, excessive sweating,
palpitations, and gastrointestinal
symptoms

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 The cognitive vigilance is evidenced by
patient`s irritability and the ease with
which the patient is startled
The most effective treatment of
patient with GAD is one that combines
psychoterapeutic,
pharmacotherapeutic, and supportive
approaches

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 Two major drugs to be considered for
the treatment of GAD are buspirone
and the benzodiazepines

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 Conversion
symbolic representation of psychic conflict
in terms of motor or sensory
manifestation
A loss of voluntary motor or sensory
functioning suggesting a neurological or
general medical condition; psychological
factors are judged to be associated with
the development of the symptom

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 Displacement
Transference of the emotions from the
original ideas to other ideas; by such an
arrangement the patient is spared the
pain of knowing the original source

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 Regression = the act of returning to
some earlier level of adaptation
Hysteria = the term refering to
conversion symptom
Ruminate = to think deeply about
something

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 Repression = dealing with emotional
conflicts, or stressors by expelling
them from conscious awareness

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