Anxiety guidelines

• Anxiety is unpleasant emotional state ,
that is typically associated with feeling of
tension , fear , worried thoughts and
physical symptoms.
• It is a normal phenomena which occurs in
response to stress, and with optimum level
can be beneficial. Most people experience it
at some point, but if anxiety starts interfering
with your life, sleep, ability to form
relationships, or productivity at work or school,
you might have an anxiety disorder.
• Research shows that if it’s left untreated, anxiety
can lead to depression, early death and suicide.
• Major depression is the most
common psychiatric illness seen by
family physician but anxiety is
associated with high utilization of
services. The most common co
morbidity with anxiety is major
Fear versus anxiety
- Anxiety is response to threat that is
unknown and vague, a future threat.
-it is different from fear (Response to
an immediate threat which is
appropriate emotional response to
real known threat.
Both involve physiological arousal
Sympathetic nervous system
Is Anxiety a Mood Disorder?
“No, anxiety is a feeling. All people experience
anxiety at some time in their life during events
like car accidents, weddings and new jobs.
There are things that create anxiety, but are
short lived and not an actual disorder. There
are several qualifications before anxiety is
diagnosed as an anxiety disorder,”. Anxiety is a
subjective feeling of tension unrelated to an
external threat.
What are Mood Disorders?
• Mood disorders defined as disorders that are
characterized by extreme highs and lows
mood or energy. The most common types of
mood disorders include depression and
bipolar disorder.
• It was found that half of people with an
anxiety disorder also develop depression (a
mood disorder), if the anxiety is left
Risk factors
• Illness. Having a chronic health condition or serious
illness, such as cancer, can lead to constant worry
about the future, your treatment and your finances.
• Personality. People with some personality types are
more prone to anxiety disorders than are others. In
addition, some personality disorders, such as
borderline personality disorder, also may be linked to
generalized anxiety disorder
• Stress. environmental stressors, such as difficulties at
work, relationship problems, or family issues
• Substance abuse. withdrawal from an illicit
substance, the effects of which might intensify
the impact of other possible causes
• Sex: Female are more than twice as many
women as men are diagnosed with generalized
anxiety disorder.
• Childhood trauma. Children who endured abuse
or trauma, including witnessing traumatic events,
are at higher risk of developing generalized
anxiety disorder at some point in life.
• Genetics. genetics, as people who have family
members with an anxiety disorder are more likely
to experience one themselves
Why family doctor treating anxiety not by a
specialist in psychiatry ?
- Having such diseases are a stigma that most
of patients or their families do not want
anyone to know so going to a psychiatrist is
very obvious that he has a mental problem
- Family doctor is accessible
all the time.
- The prevalence of the disease
is very high and he is the
first contact.
Signs and symptoms of anxiety
Physical signs
Moist sweaty
palms and cold
Palpitation and chest
Short rapid breath
Dry mouth ,diarrhea
Difficulty swallowing and
Muscle tension facial muscles
twitching or tics , moves most of
the time
Psychological signs
Uncontrollable feeling of worry
Feeling of dread and the
need to escape
Difficulty in concentration
a feeling of being
Feeling lump in
throat , feeling of
Differential diagnosis:
These condition may mimic symptoms of
 Drug dependence
 Benzodiazepine
 Heart attack
 Hyperthyroidism
 Hypoglycemia
 Phaeochromocytoma
 There are no
investigations that
confirm a diagnosis of
anxiety .
Management of anxiety
Talk therapy or psychotherapy, medications or a
combination are standard treatments for anxiety
The following measures can help:
Stress management: Learning to manage stress can help
limit potential triggers.
Organize any upcoming pressures and
 Make lists to make tasks more
 Give yourself time off from study or
• Relaxation techniques: Simple activities
can help soothe the mental and physical
signs of anxiety. These techniques
 meditation,
 deep breathing exercises,
 long baths,
resting in the dark, and
 yoga.
• Exercises to replace negative thoughts with
positive ones: Make a list of the negative
thoughts that might be cycling as a result of
anxiety, and write down another list next to it
containing positive, believable thoughts to
replace them. Creating a mental image of
successfully facing and conquering a specific
fear can also provide benefits if anxiety
symptoms relate to a specific cause, such as in
a phobia.
• Support network: Talk with familiar people who are
supportive, such as a family member or friend. Support
group services may also be available in the local area and
• Exercise: Physical exertion can improve self-image and
release chemicals in the brain that trigger positive feelings.
• Exposure therapy can be particularly helpful for phobias.
For instance, people with iatrophobia, or fear of doctors,
can benefit from exposure therapy. In that case, patients
are gradually confronted with medically related images,
items. Patients can learn to overcome deep-seated fears by
facing them head-on.
• Counseling
A standard way of treating anxiety is
psychological counseling. This can include
cognitive-behavioral therapy (CBT),
psychotherapy, or a combination of therapies.
Cognitive behavioral therapy is a first-line,
evidence-based approach for anxiety. CBT helps
you identify distorted or negative thinking
patterns, and find more positive, effective ways
to respond.
Cognitive behavioral therapy (CBT)
Engaging with CBT can help people reduce stress, cope
with complicated relationships, deal with grief, and
face many other common life challenges.
• CBT is a structured psychological treatment which
recognizes that the way we think (cognition) and act
(behaviour) affects the way we feel.
• For example, a psychotherapist providing CBT for panic
disorder will try to reinforce the fact that panic attacks
are not really heart attacks.
• Exposure to fears and triggers can be a part of CBT. This
encourages people to confront their fears and helps
reduce sensitivity to their usual triggers of anxiety.
• Cognitive-behavioral therapy helps people with
mental illness to identify and change inaccurate
perceptions that they may have of themselves
and the world around them. The therapist helps
the patient establish new ways of thinking by
directing attention to both the "wrong" and
"right" assumptions they make about themselves
and others.
• Some forms of psychotherapy focus on looking
into the past to gain an understanding of current
feelings. In contrast, CBT focuses on present
thoughts and beliefs and challenges .
Changing distortions and perceptions
CBT can help people to find new ways of looking
at things by changing:
a negative mindset
jumping to conclusions
mistakenly seeing situations as catastrophic
seeing things as either good or bad with nothing
in between
distinguish between facts and irrational thoughts
better understand other people's actions and
avoid generalizations and all-or-nothing thinking
establish attainable goals
Medicines that might control some of the physical and
mental symptoms include antidepressants,
benzodiazepines, tricyclics, and beta-blockers.
• Benzodiazepines : A doctor may prescribe these for
certain people with anxiety, but they can be highly
addictive. These drugs tend to have few side effects
except for drowsiness and possible dependence.
Diazepam, or Valium, is an example of a commonly
prescribed benzodiazepine. It should be withdraw
slowly because some patient have difficulty in stopping
the drug.
• Tricyclics: This is a class of drugs older than
SSRIs that provide benefits for most anxiety
disorders other than OCD. These drugs might
cause side effects, including dizziness,
drowsiness, dry mouth, and weight gain.
• Antidepressants (serotonin reuptake
inhibitors (SSRI): These commonly help with
anxiety, even though they also target
Sexual side
side effects
begin with 20mg in the morning and gradually increase to 40 mg
• With SSRIs treatment should start at a very low
dose. Doubling of the initial dose should occur
every 5 days as tolerated. Explain to the patient
that they will have jerky (jumpy) or nervous
actions , nausea and headache but these
symptoms will usually resolve within 1 to 2 weeks
of starting the treatment. Also it can make sexual
dysfunction which will occur in 20 to 35% of
patients . If it occurs the dosage may have to be
decreased or the medication changed.
Discontinuation syndrome
• When coming off of antidepressants (cessation),
individuals can experience withdrawal syndrome. This
can highly resemble the symptoms of depression, such
as low mood and feeling suicidal. This can
make people feel that they are relapsing and become
depressed again, which can in turn lead to them
starting back on their antidepressants when actually
they are not needed.
• Guidelines recommend short tapers, of between 2
weeks and 4 weeks, down to therapeutic minimum
doses, or half-minimum doses, before complete
Take the following steps to help moderate anxious
Reduce intake of caffeine, tea, cola, and chocolate.
Before using over-the-counter (OTC) or herbal
remedies, check with a doctor or pharmacist for any
chemicals that may make anxiety symptoms worse.
Maintain a healthy diet.
Keep a regular sleep pattern.
Avoid alcohol, cannabis, and other recreational drugs.
Types of anxiety
1-Panic disorder
2- Social phobia.
3- Specific phobia
4-Obsessive compulsive disorder (OCD).
5-Post-traumatic stress disorder (PTSD)
6-Generalized anxiety disorder (GAD).
Panic Attack
Panic disorder is the term used to describe when panic
attacks are recurrent and disabling.
Panic disorder can be characterized by:
• The presence of recurring and unexpected („out of the
blue‟) panic attacks.
• Worrying for at least a month after having a panic attack
that you will have another one.
• Worrying about the implications or consequences of a panic
attack (such as thinking that the panic attack is a sign of an
undiagnosed medical problem). For example, some people
have repeated medical tests due to these worries and,
despite reassurance, still have fears of being unwell.
• Significant changes in behaviour that relate to the panic
attacks (such as avoiding activities like exercise because it
increases the heart rate).
• Panic attacks reach a peak within about 10
minutes and usually last for up to half an hour,
leaving you feeling tired or exhausted. They
can occur several times a day or may happen
only once every few years. They can even
occur while people are asleep, waking them
up. Many people experience a panic attack
once or twice in their lives; this is common
and is not panic disorder. The attack must be
followed by at least a one month persistent
concern about having additional attacks and
worry about the implication of the attack.
Panic attack symptoms
 A sense of overwhelming panic or fear
 Sudden, intense episode of apprehension
‫رعب‬, terror, feelings, of impending doom
and dread ( ‫ ) فزع‬. The need to escape.
Symptoms reach peak intensity within 10
 Accompanied by at least 4 other symptoms:
Heart palpitations, sweating, nausea, shortness
of breath, , dizziness, upset stomach,
lightheadedness, etc.
 Other symptoms may include:
• Depersonalization
• Derealization ; a sense that you or the
world around you is not real (Feeling of
unreality or being detached from one’s
• Fear of going crazy, losing control, or
People having panic attacks
sometimes believe they are
having heart attacks, losing their
minds, or on the verge of death.
Causes of panic disorder
• Panic disorders usually occur after
frightening experiences or prolonged
stress but may also occur without a
trigger. An individual experiencing a panic
attack may misinterpret it as a lifethreatening illness, and may make drastic
changes in behavior to avoid future
Management of panic attack
• Cognitive behavioral therapy can help him
learn, through his own experience, that panic
symptoms are not dangerous.
• Medications:
- B blocker
- SSRI’s
Specific Phobias
• Fear is a rational response to situations that can
pose a threat to our safety.
• However, some people react to objects, activities
or situations (the phobic stimulus) by imagining
or irrationally exaggerating the danger. Their
feelings of panic, fear or terror are completely
out of proportion to the actual threat. Sometimes
the thought of the phobic stimulus, or the sight
of it on TV, is enough to cause a reaction. These
types of excessive reactions may be indicative of
a specific phobia.
• People with specific phobias are often
well aware that their fears are
exaggerated or irrational, but feel that
their anxious reaction is automatic or
uncontrollable. Specific phobias are often
associated with panic attacks, during
which the person experiences
overwhelming physical sensations that
may include a pounding heart, choking,
nausea, faintness, dizziness, chest pain,
hot or cold flushes and perspiration.
• They have a persistent, excessive and
unreasonable fear of a specific object, activity or
situation, e.g. heights, the sight of blood or
encountering a dog.
• Avoid situations where you may have to face the
phobic stimulus, e.g. not walking down a street
where there may be a dog. If the situation is
unavoidable, you're likely to feel high levels of
• Find that the anxiety or avoidance associated
with such situations makes it difficult to go about
daily life (e.g. interferes with working, studying
or seeing friends and family).
• The anxiety and avoidance are persistent and
have been present for at least 6 months or more
Specific phobias are generally divided
into the following categories:
• Animal type: fear that relates to animals or insects (e.g.
fear of dogs or spiders).
• Natural environment type: fear associated with the
natural environment (e.g. fear of thunder or heights
storms, or water) generally has a childhood onset.
• Blood/injection/injury type: fear associated with
invasive medical procedures (e.g. injections), or with
seeing blood or injury.
• Situational type: fear of specific situations (e.g.
elevators, bridges or driving).
• Other: any other specific phobias (e.g. fear of choking,
fear of vomiting).
Blood-injury phobia or Vasovagal
• “Blood-injury phobia” is a curious type of specific
phobia with distinct clinical features. Exposure to
phobic cues induces tachycardia in most phobias.
Blood-injury phobia patients typically experience a
response of an initial tachycardia, followed by
bradycardia, hypotension, shock, vertigo, syncope.
This response is peculiar to blood phobia and is not a
characteristic of other specific phobias (fight and
• Vasovagal syncope is a common cause of fainting. The
vagus nerve is over stimulated and causes the body's
blood vessels to dilate and the heart to slow down.
This anti-adrenaline effect decreases the ability of the
heart to pump blood upward to the brain against
gravity. Without blood flow, the brain turns off. It is
familial .
• Anxiety about or avoidance of, places or
situations from which escape might be difficult
(or embarrassing) or in which be available in the
event of having a Panic Attack or panic-like
symptoms. 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; and traveling in a bus,
train, or automobile. People often misunderstand
this condition as a phobia of open spaces and the
outdoors, but it is not so simple. A person
with agoraphobia may have a fear of leaving
home or using elevators and public transport.
Nearly all patients with agoraphobia have panic
Generalized anxiety disorder (GAD)
• It is characterized by excessive and
persistent worrying that is hard to
control, causes significant distress or
impairment, and
• occurs for more than six months at least.
• It’s the worst anxiety
• Non specific fear
• People with GAD, however, feel anxious and
worried most of the time, not just in specific
stressful situations, and these worries are
intense, persistent and interfere with their
normal lives. Their worries relate to several
aspect of everyday life, including work, health,
family and/or financial issues, rather than just
one issue. Even minor things such as household
activites or being late for an appointment can
become the focus of anxiety, leading to
uncontrollable worries and a feeling that
something terrible will happen.
Signs and symptoms:
The symptoms of generalized anxiety disorder
fluctuate. You may notice better and worse times of
the day, or better and worse days in general. And
while stress doesn’t cause generalized anxiety
disorder, it can make the symptoms worse.
Not everyone with generalized anxiety disorder has
the same symptoms. But most people with GAD
experience a combination of a number of the
following emotional, behavioral, and physical
Emotional symptoms of generalized anxiety
Constant worries running through head
Feeling like anxiety is uncontrollable; there is
nothing he can do to stop the worrying
Intrusive thoughts about things that make him
anxious; he try to avoid thinking about them,
but he can’t
An inability to tolerate uncertainty; he need to
know what’s going to happen in the future
 A pervasive feeling of apprehension or dread
Behavioral symptoms of generalized anxiety disorder
• Inability to relax, enjoy quiet time, or be by yourself
• Difficulty concentrating or focusing on things
• Putting things off because you feel overwhelmed
• Avoiding situations that make you anxious
Physical symptoms of generalized anxiety disorder
• Feeling tense; having muscle tightness or body
• Having trouble falling asleep or staying asleep
because your mind won’t quit
• Feeling edgy, restless, or jumpy
• Stomach problems, nausea, diarrhea
Management of GAD
Selective serotonin re-uptake inhibitors (SSRIs):
• Selective serotonin re-uptake inhibitors are
antidepressants. They can relieve anxiety symptoms
and help reduce the symptoms of depression that
often accompany anxiety disorders.
Cognitive behavioral therapy
• Cognitive behavioral therapy has benefits that go
beyond just helping to reduce anxiety. It can also help
with the symptoms of depression, for example, which
may accompany generalized anxiety disorder.
Obsessive Compulsive Disorder (OCD):
Obsessive-compulsive disorder (OCD)
is characterized by unreasonable
thoughts and fears (obsessions) that
lead him to do repetitive behaviors +
rituals affects his life + repeated
• Although the person may
acknowledge these thoughts as
silly, they often try to relieve
their anxiety by carrying out
certain behaviours or rituals. For
example, a fear of germs and
contamination can lead to
constant washing of hands and
Signs and symptoms:
Most people with obsessive-compulsive disorder
(OCD) have both obsessions and compulsions, but
some people experience just one or the other.
Obsessive thoughts
Common obsessive thoughts include:
 Fear of being contaminated by germs or dirt or
contaminating others
 Fear of causing harm to himself or others
 Intrusive bad or violent thoughts and images
 Excessive focus on religious or moral ideas
 Fear of losing or not having things that might need
order and symmetry: the idea that everything must
line up “just right”
 Superstitions ‫ مشعوذ‬excessive attention to
something considered lucky or unlucky
Compulsive behaviors
Common compulsive behaviors in (OCD) include:
Excessive double-checking of things, such as
locks, appliances, and switches
Repeatedly checking in on loved ones to make
sure they‟re safe
Counting, tapping, repeating certain words, or
doing other senseless things to reduce anxiety
Spending a lot of time washing or cleaning
Ordering or arranging things “just so”
Praying excessively or engaging in rituals
triggered by religious fear
Accumulating “junk” such as old newspapers or
empty food containers
Selective serotonin re-uptake inhibitors (SSRIs):
• Selective serotonin re-uptake inhibitors are
antidepressants. They can relieve anxiety
Cognitive behavioral therapy
• Cognitive behavioral therapy has benefits that
go beyond just helping to reduce anxiety using
Exposure and Response Prevention (ERP)
which is a type of CBT.
What is Exposure and Response
• For OCD use the most important type of
CBT Exposure and Response
Prevention (ERP).
• The Exposure in ERP refers to exposing
patient to the thoughts, images, objects
and situations that make him anxious
and/or start your obsessions. While
the Response Prevention part of ERP,
refers to making a choice not to do a
compulsive behavior once the anxiety or
obsessions have been “triggered
Post-Traumatic Stress Disorder (PTSD):
What is PTSD?
• Post-traumatic stress disorder (PTSD) is a
particular set of reactions that can develop in
people who have been through a traumatic
event which threatened their life or safety, or
that of others around them. This could be a
car or other serious accident, physical or
sexual assault, war, or disasters such as
bushfires or floods. As a result, the person
experiences feelings of intense fear,
helplessness or horror.
• People with PTSD often experience feelings of
panic or extreme fear, similar to the fear they felt
during the traumatic event. A person with PTSD
experiences four main types of difficulties.
1- Re-living the traumatic event – The person
relives the event through unwanted and
upsetting memories, often in the form of vivid
images (flashbacks), frightening thoughts and
nightmares. There may be intense emotional or
physical reactions, such as sweating, heart
palpitations or panic when reminded of the
2- Being overly alert or wound up:
The person experiences sleeping difficulties,
irritability and lack of concentration,
becoming easily irritated and constantly
on the lookout for signs of danger.
3- Avoiding reminders of the event:
The person deliberately avoids activities,
places, people, thoughts or feelings
associated with the event because they
bring back painful memories.
4- Hyperarousal symptoms (abnormal state of
increased responsiveness to stimuli )
- Feeling tense or “on edge”
- Having difficulty sleeping, and/or having
angry outbursts.
- Feeling emotionally numb not able to feel any
emotions or to think clearly,
– The person loses interest in day-to-day
activities, feels cut off and detached from
friends and family, or feels emotionally flat
and numb.
• Hyperarousal is the abnormally heightened state of
anxiety that occurs whenever you think about a
traumatic event. Even though the threat may no
longer be present, your body will respond as if it
were. Hyperarousal symptoms are usually
constant, instead of being triggered by
things that remind one of the traumatic
event. They can make the person feel
stressed and angry. These symptoms may
make it hard to do daily tasks, such as
sleeping, eating, or concentrating.
• Short- and longterm psychotherapy and medications can work
very well. Often, the two kinds of treatment are
more effective together.
• Most PTSD therapies fall under the umbrella of
cognitive behavioral therapy (CBT). The idea is to
change the thought patterns that are disturbing
your life. This might happen through talking
about your trauma or concentrating on where
your fears come from.
• Prolonged Exposure Therapy
• If he is avoiding things that remind him of the
traumatic event, PE will help him confront them.
It involves eight to 15 sessions, usually 90
minutes each.
• Early on in treatment, therapist will teach
him breathing techniques to ease
his anxiety when he think about what happened.
• Later, he will make a list of the things he have
been avoiding and learn how to face them, one
by one.
• In another session, he will record the traumatic
experience to his therapist, then go home and
listen to a recording of him self.
• Doing this as "homework" over time may help
ease symptoms.
Social Anxiety Disorder:
• It's perfectly normal to feel nervous in social situations
where we might come under the attention of others,
whether they're strangers or people we know.
Attending a formal function, giving a speech at a
wedding, doing a presentation to work colleagues are
likely to cause nervousness and anxiety, both in the
lead-up and during the event.
• However, for people with social phobia (sometimes
known as social anxiety disorder), performing in front
of others and social situations can lead to intense
anxiety. They may fear being judged, criticised, laughed
at or humiliated in front of others, even in the most
ordinary, everyday situations.
• A person
with social
anxiety disorder
is afraid that he
or she will make
mistakes, look
bad, and be
embarrassed or
humiliated in
front of others
Signs and symptoms:
Emotional symptoms of social anxiety disorder /
social phobia
- Intense worry for days, weeks, or even months
before an upcoming social situation
- Extreme fear of being watched or judged by
others, especially people you don’t know
- Fear that you’ll act in ways that that will
embarrass or humiliate yourself
- Fear that others will notice that you’re nervous
- Physical symptoms of social anxiety disorder
/ social phobia
- Red face, or blushing
- Shortness of breath
- Upset stomach, nausea
- Trembling or shaking (including shaky voice)
- Racing heart or tightness in chest
- Sweating or hot flashes
- Feeling dizzy or faint
Terrified female speaker on the stage
• Social phobia is treatable and seeking
professional support is the first step to
recovery. There are two main types of
effective treatments for social
phobia; psychological treatments will
generally be the first line of treatment.
In some severe cases, medication can
also be effective.
• References:
• South-Paul J, Matheny S Lewis E. Current diagnosis
and treatment in Family medicine. 4th ed. Mc Grew
Hill Lange 2015. ISBN-13: 978-0071827454; ISBN10: 0071827455
• Douglas G, Nicol F, Robertson C. Macleod's Clinical
Examination, 12th Edition ChurchilLivingstone |
Elsevier © 2009, Elsevier Limited. Al rights reserved.
• American Family Physician Journal.