Anxiety Disorders
Back to Basics 2012
Dr. Holly Dornan
PGY-4 Psychiatry Resident
University of Ottawa
Anxiety
LMCC Objectives
Key Objectives
 In patients with many other medical complaints and/or excessive
utilisation of medical health care, determine whether anxiety co-exists.
 Differentiate situational stress from true anxiety disorder and from
drug and physical causes of anxiety.
Objectives
 Through efficient, focused, data gathering:
 Review various physical symptoms briefly; elicit history of other nonpsychiatric illness, intake of alcohol and caffeine, and a brief history of
any major life stresses.
 Elicit a history of excessive worry about events which is out of
proportion to the impact of the event; history present for at least six
months (anxiety).
LMCC Objectives

Determine whether there is restlessness, fatigue, inability to
concentrate, irritability, muscle tension, sleep disturbance.

Determine whether social, occupational, or function in general has
been affected.
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Determine whether co-morbid psychiatric disorders exist, stress,
substance abuse, past sexual, physical and emotional abuse, or
neglect.
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Determine whether there is a discrete period of intense fear,
recurrent panic attacks,>1 month of concern about more attacks,
change in behavior in relation to attacks, along with
cardiopulmonary, neurologic, psychiatric or other medical
symptoms ± agoraphobia.
LMCC Objectives

List and interpret critical clinical and laboratory findings which
were key in the processes of exclusion, differentiation, and
diagnosis.
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Conduct an effective initial plan of management for a patient
with anxiety or panic:
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Outline supportive therapy (e.g., psychosocial interventions) and
counseling and list indications for drug therapy (e.g., selective
serotonin re-uptake inhibitors).
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Select patients in need of specialized care.
LMCC Objectives
Applied Scientific Concepts
1. Explain that although the pathophysiology of panic
disorder/attacks is incompletely understood, the
amygdala, locus ceruleus, and hippocampus along with
several neurotransmitters have been the focus of
attention.
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LMCC Objectives
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Causal Conditions
1. Panic attack
a. Cardiopulmonary symptoms - 40%
b. Neurologic symptoms - 40%
c. Gastrointestinal symptoms - 30%
d. Psychiatric symptoms
e. Autonomic symptoms
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2.
Panic disorder
a. With agoraphobia/Without agoraphobia
b. With social/Specific phobia
c. Trauma/Stress related/Post traumatic stress disorder

3.
Associated with other conditions
a. Depression
b. Obsessive compulsive disorder
c. Substance abuse

4.
Generalized anxiety disorder
What is anxiety?

A feeling state consisting of physical, emotional
and behavioural responses to perceived threats1

Diffuse, unpleasant sense of apprehension
accompanied by physical symptoms such as
headache, sweating, palpitations, chest tightness,
stomach upset, restlessness
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Normal and necessary part of everyday life
1
Can J Psychiatry Clinical Practice Guidelines for the Management of Anxiety
Disorders July 2006
Anxiety vs. Fear
Anxiety
Fear
Threat
Threat
Response to a threat that is unknown,
internal, vague or conflictual
Response to a known,
external, definite threat
Anxiety as a Disorder
When does anxiety become a disorder?
1) Greater intensity and/or duration than
expected given the circumstances
2) Leads to impairment or disability
3) Daily activities are disrupted by avoidance of
certain situations or objects to decrease
anxiety
4) Includes clinically significant unexplained physical
symptoms, obsessions, compulsions, or intrusive
recollections of trauma
Can J Psychiatry Clinical Practice Guidelines for the Management of Anxiety Disorders July 2006
Anxiety
Overestimated
Anxiety =
Likelihood x Harm
Ability to cope
Underestimated
Beck et al. 1985
Pathophysiology of Anxiety
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Caudate nucleus has been implicated in OCD
fMRI studies have found increased activity in
the amygdala in PTSD
Abnormalities in parahippocampal gyrus in
Panic Disorder
3 major neurotransmitters involved are
norepinephrine, serotonin, and GABA
Kaplan and Sadock’s Synopsis of Psychiatry 10th edition
* Slide courtesy of Dr. Elliott Lee
Limbic cortex
Nucleus
accumbens
Periaqueductal
Gray matter
Orbitofrontal
cortex
Amygdala
Locus
coeruleus
Brain Stem
Hippocampus
Ventral
Tegmental Area
Anxiety

Patients try to alleviate the
unpleasant feeling of anxiety
by:
1)
Avoiding the trigger
Developing a safety behaviour
(i.e. having someone else
accompany them)
Using a substance or
medication
2)
3)
Anxiety Disorders in DSM-IV TR
Panic Disorder with and without agoraphobia
Agoraphobia without history of Panic Disorder
Social Phobia
Specific Phobia
Obsessive Compulsive Disorder
Generalized Anxiety Disorder
Post Traumatic Stress Disorder
Acute Stress Disorder
Anxiety Disorder due to a General Medical Condition
Substance-Induced Anxiety Disorder
Anxiety Disorder NOS
Epidemiology
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Lifetime prevalence for any anxiety disorder
ranges from 10% to 29%
12 month prevalence 18%
Common presentation in primary care
1:5 to 1:12 patients presenting to primary care
will have an anxiety disorder
Suicide rate 10 x higher than general population
Can J Psychiatry Clinical Practice Guidelines for the Management of Anxiety Disorders July 2006
Initial Assessment of Patients with
Anxiety

Four scenarios:
1) Anxiety disorder is primary and there is no physical
disorder present (any physical symptoms present are
due to the anxiety)
2) The anxiety is secondary to a physical illness (e.g.
hyperthyroidism)
3) The anxiety is secondary to a medication or
substance
4) Both an anxiety and physical disorder are present by
not causally related
Can J Psychiatry Clinical Practice Guidelines for the Management of Anxiety Disorders July 2006
Medical conditions that mimic or
worsen anxiety symptoms
Endocrine conditions
Cardiovascular
Hyperthyroidism
Hypothyroidism
Pheochromocytoma
Cushing’s disease
Addison’s disease
Menopause
Acute Coronary Syndrome
Arrhythmia
CHF
Hypertension
Hypertension
Mitral Valve Prolapse
Medical conditions that mimic or
worsen anxiety symptoms (con’t)
Neurological
Epilepsy
Cerebrovascular disease
Meniere’s disease
Multiple Sclerosis
Migraine
Encephalitis
Early dementia
Metabolic
Porphyria
Diabetes
Pulmonary
Asthma
COPD
Pulmonary Embolism
Pneumonia
Medical conditions that mimic or worsen
anxiety symptoms (con’t)
Other
Medications
Anemia
UTI (in elderly)
Irritable Bowel Syndrome
Heavy metal poisoning
B12 deficiency
Electrolyte disturbances
Anti-cholinergics
Steroids
Stimulants (methylphenidate and
amphetamine based)
Theophylline
Ventolin
Nasal decongestants
SSRIs
Substance Abuse and Anxiety
Substance abuse is often co-morbid with anxiety
disorders as patients often try to self-medicate to cope
with anxiety
 37% of patients with GAD and 20-40% of patients with
Panic Disorder have alcohol abuse/dependence
 Drug intoxication can mimic anxiety:
- Amphetamines
- Marijuana

-
Caffeine
Nicotine
Cocaine
Phencyclidine
- Hallucinogens
- Ecstasy
- Excessive alcohol consumption
Substance Abuse and Anxiety (con’t)

Drug withdrawal also associated with anxiety
 Alcohol
 Benzodiazepines
 Opiate
 Barbiturate
 Anti-hypertensives
Key features
Panic
Disorder
Fear of losing control, dying or going crazy
• Avoid situations in which attacks may occur
Agoraphobia • Fear of situations from which escape may be
difficult or help unavailable (crowds, bus,
bridge etc.)
OCD
• Intrusive, unwanted thoughts or urges
(obsessions) and/or repetitive behaviours or
mental acts (compulsions)
• Fear of harm, uncertainty, uncontrollable
actions
•
Key features
Generalized • Anxiety regarding a number of everyday
events
Anxiety
• Future and uncertainty difficult to accept
Social
• Fear of humiliation, embarrassment or
Anxiety
scrutiny by others
PTSD
Specific
phobia
Re-experiencing of trauma through
flashbacks, dreams, recollections
• Fear of a specific object, animal or situation
•
Generalized Anxiety Disorder – DSM
IV TR
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Excessive anxiety and worry about a number of
events or activities, occurring more days than not for
at least 6 months
Difficult to control the worry
Associated with three of the following

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Restlessness, difficulty concentrating, muscle tension, fatigue, sleep
disturbances, irritability
Not due to a substance, medical condition or other
mental disorder
Causes clinically significant distress or impairment in
functioning
Generalized Anxiety Disorder
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1Can
Lifetime prevalence 6%1
68 % comorbidity with other psychiatric illness
(depression, substance abuse, other anxiety
disorder)
Female to male ratio 2:11
25% of 1st degree relatives also have GAD2
Twin studies show concordance rate of 50%2
J Psychiatry Clinical Practice Guidelines for the Management of Anxiety Disorders July 2006
2Kaplan and Sadock’s Synopsis of Psychiatry 10th edition
Generalized Anxiety Disorder
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Chronic condition, usually lifelong
Screening questions
Do others call you a worry-wort?
 What kinds of things do you worry about?
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Usually seek treatment for somatic symptoms
rather than anxiety
Only 1/3 seek psychiatric treatment
Often see specialists (GI, cardiology, internists)
Can J Psychiatry Clinical Practice Guidelines for the Management of Anxiety Disorders July 2006
GAD - treatment

Pharmacotherapy:
 1st line SSRI or SNRI
 2nd line Benzodiazepine
 Only
recommended for short term use due
to side effects (cognitive impairment,
ataxia, sedation) and dependence and
withdrawal)
 Avoid in substance abuse and the elderly
 3rd line Adjunctive olanzapine or risperidone
Mirtazapine
Can J Psychiatry Clinical Practice Guidelines for the Management of Anxiety Disorders July 2006
GAD - treatment

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An optimal trial involves 8-12 weeks
If there is not an adequate response, switch to
another 1st line agent
Reasonable to try another 1st line agent with a
different mechanism of action
Treatment resistant patients should be assessed
for comorbid medical and psychiatric conditions
Can J Psychiatry Clinical Practice Guidelines for the Management of Anxiety Disorders July 2006
GAD - treatment
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Psychological treatment:
CBT as effective as medication (also 1st line)
CBT involves:
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Psychoeducation
Cognitive interventions (addressing cognitive distortions,
unrealistic beliefs)
Exposure
Relaxation strategies
Problem Solving
Assertiveness training
Relapse Prevention
Panic Attack – DSM-IV criteria

A discrete period of intense fear or discomfort, in which 4 or
more develop abruptly and reach a peak within ten minutes:
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Palpitations, increased heart rate
Sweating
Tremor or shaking
Shortness of breath or smothering sensation
Feeling of choking
Chest pain
Nausea or abdominal distress
Feeling dizzy, lightheaded, or faint
Derealization
Depersonalization
Parasthesias
Chills or hot flushes
Fear of losing control or going crazy
Fear of dying
Panic Disorder with or without
agoraphobia – DSM-IV criteria

The person has experienced both :
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Recurrent, unexpected panic attacks
One or more of the attacks has been followed by either
1) Persistent concern about having another attack
2) Worry about the implications of the attack
3) Significant change in behaviour
The presence (or absence of agoraphobia)
Not due to a substance, medication or medical condition
Not better accounted for by another mental disorder
Panic Disorder
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Lifetime prevalence of Panic Disorder is 4.7%
Lifetime prevalence of having a panic attack is
15%
1/3 to 1/2 of patients also have agoraphobia
More common in women than in men
Generally begins in late adolescence or early
adulthood
Can J Psychiatry Clinical Practice Guidelines for the Management of Anxiety Disorders July 2006
Panic Disorder

20 X the risk of suicidal ideation and suicide attempts
as the general population

Felt to be related to dysregulation of brain
noradrenergic systems

Abnormalities have been found in the autonomic
nervous system of some patients (increased
sympathetic tone, less adaptive to repeated stimulit)
Kaplan and Sadock’s Synopsis of Psychiatry 10th edition
Panic Disorder

Initially, panic attacks are unexpected

Can occur any time (even night)

Can also develop panic attacks that have triggers
(situationally-predisposed panic attacks)

Patients begin to have anticipatory anxiety about having
another panic attack

This can lead to avoidance of situations where escape or
help may not be readily available (agoraphobia)
Panic Disorder - Treatment

Pharmacotherapy:
 1st
line SSRI or SNRI
 2nd line Benzodiazepines
 Only recommended for short term use due to side
effects (cognitive impairment, ataxia, sedation)
and dependence and withdrawal
 Avoid in substance abuse and the elderly
** Often clinically, a small dose of long acting benzodiazepine is
started along with SSRI/SNRI to provide more immediate relief
from distressing symptoms
i.e. 0.5 mg clonazepam BID for 2-3 weeks, then tapered until it is
stopped
Can J Psychiatry Clinical Practice Guidelines for the Management of Anxiety Disorders July 2006
Panic Disorder - Treatment
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Psychological treatment:
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CBT most consistently efficacious psychotherapy for Panic
Disorder, according to the literature
Individual or group therapy, bibliotherapy
CBT for Panic Disorder includes same CBT concepts of
psychoeducation, cognitive approaches, relaxation, problem
solving
Also incorporates interoceptive exposure (exposure to feared
symptoms  therapist may ask patient to hyperventilate or
spin to make themselves dizzy)
Exposure to avoided situations is important
Obsessive Compulsive Disorder –
DSM IV criteria

Either obsessions or compulsions
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Obsessions are defined as:
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Recurrent and persistent thoughts, images or impulses that are
experienced as intrusive and inappropriate and cause marked
anxiety/distress
Not simply excessive worries about real-life problems
Person attempts to ignore or suppress the obsessions, or neutralize them
with other thoughts or actions
Recognized as a product of the patient’s own mind
Compulsions are defined as:
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Repetitive behaviours or mental acts that the person feels driven to
perform in response to an obsession, or according to rigid rules
Compulsions are aimed at reducing distress or preventing some dreaded
event, however they are not connected in a realistic way to what they are
meant to neutralize, or are clearly excessive
Obsessive Compulsive Disorder –
DSM IV criteria (con’t)

At some point during the course of the disorder, the
person recognizes that the obsessions and/or
compulsions are excessive or unreasonable

The obsessions and/or compulsions cause marked
distress, are time consuming (> 1 h/day), or
significantly interfere with functioning

Not due to substance, or another medical or mental
disorder
Obsessive-Compulsive Disorder
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Estimated lifetime prevalence of 1.6%
Median age of onset 19 years (range 14 – 30
years)
60% are female
High psychiatric co-morbidity rate (56% -83%)
Common co-morbidities include substance abuse,
depression, social phobia, generalized anxiety
disorder, panic disorder
Can J Psychiatry Clinical Practice Guidelines for the Management of Anxiety Disorders July 2006
Obsessive-Compulsive Disorder
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In 50-70% of patients, onset of symptoms is
following a stressful event (i.e. pregnancy, death)
Course is usually long, can be constant or
fluctuating
20-30 % have significant improvement
40-50% have moderate improvement
20-30% have no improvement or worsening
Kaplan and Sadock’s Synopsis of Psychiatry 10th edition
Obsessive-Compulsive Disorder

20-30% have tics, 6-7% Tourette’s
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Possible link between a subset of OCD and tics
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PET studies have shown increased activity in the frontal lobes,
basal ganglia (caudate), and cingulum in patients with OCD
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PANDAS – Pediatric Autoimmune Neuropsychiatric Disorders
associated with Streptococcal infections

Streptococcus infection may trigger an autoimmune response
which causes acute onset OCD symptoms and tics in children
Kaplan and Sadock’s Synopsis of Psychiatry 10th edition
Obsessive-Compulsive Disorder
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Most common obsessions include:
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Contamination (#1)
Doubt/safety (idea that stove was left on, door unlocked etc.) (#2)
Sexual and aggressive impulses (#3)
Symmetry and exactness (#4)
Somatic and religious preoccupations
Most common compulsions include:
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Checking
Washing
Repeating
Ordering
Counting
Hoarding
OCD - treatment
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Pharmacotherapy:
 1st line SSRI (serotonergic response needed)
 2nd line : Clomipramine (2nd line due to side
effects –
cardiotoxicity, anticholinergic, drug interactions and lethality
in overdose)
Effexor XR, Mirtazapine
Adjunctive Risperidone

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Dosages of meds e.g. SSRIs may need to be higher than
in mood disorders
Response may take 6 wks or longer (Guidelines state
adequate trial 6-8 weeks)
Can J Psychiatry Clinical Practice Guidelines for the Management of Anxiety Disorders July 2006
OCD - treatment

Psychological
1) Exposure with Response Prevention
(ERP) – form of behavioural therapy
2) CBT which combines Exposure and
Response Prevention with cognitive
interventions
Posttraumatic Stress Disorder DSMIV criteria

The person has been exposed to a traumatic event which
included both:
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1) The person experienced or witnessed an event involving
actual or threatened death or serious injury, or a threat to
personal integrity of self or others
2) Response was fear, horror, or helplessness
The traumatic event is re-experienced including at least
one of:

Distressing memories, dreams, acting or feeling as if event is
recurring (illusions, dissociative flashbacks, hallucinations),
intense psychological or physiological distress when exposed
to cues that symbolize the trauma
Posttraumatic Stress Disorder DSMIV criteria
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Persistent avoiding of stimuli associated with the
trauma and numbing of responsiveness including at
least 3 of:
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Efforts to avoid thoughts, feelings, conversations associated
with the trauma
Efforts to avoid people, places and activities associated with
the trauma
Inability to recall an important aspect of the trauma
Feeling of detachment or estrangement from others
Restricted range of affect
Sense of foreshortened future
Posttraumatic Stress Disorder DSMIV criteria

Persistent symptoms of increased arousal including at
least two of:
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Difficulty falling or staying asleep
Irritability or outbursts of anger
Difficulty concentrating
Hypervigilance
Exaggerated startle reflex

Duration is more than 1 month

Causes clinically significant distress or impairment in
functioning
Posttraumatic Stress Disorder

Key features include exposure to trauma, reexperiencing of the trauma, avoidance and emotional
numbing, and hyperarousal

Examples of traumas include exposure to war, terrorist
attacks, natural disasters, accidents involving serious
injury or death, rape, torture

If symptoms are present for less than one month, then
the diagnosis may be Acute Stress Disorder
Posttraumatic Stress Disorder
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Prevalence in Canada 2.4% (1 month
prevalence) and 9.2% (lifetime prevalence)
Higher among women than men
Lifetime prevalence estimates 16-37% in areas
of the world where conflict has occurred
Frequent co-morbidity with depression,
substance abuse, other anxiety disorders
Can J Psychiatry Clinical Practice Guidelines for the Management of Anxiety Disorders July 2006
Posttraumatic Stress Disorder
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6X increased risk of suicide attempts
Predisposing factors include:
Childhood trauma
 Inadequate support system
 Female
 Genetic vulnerability to psychiatric illness
 Excessive alcohol use (recent)
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Posttraumatic Stress Disorder Treatment
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1Can
Guidelines recommend SSRI/SNRI as first line
treatment1
Recommended that patients with PTSD should
continue medication for at least 1 year1
In practice, agents to help with insomnia are
often added (i.e. Trazadone)
J Psychiatry Clinical Practice Guidelines for the Management of Anxiety Disorders July 2006
Posttraumatic Stress Disorder Treatment

Other meds sometimes used include:
Clonidine (antiadrenergic agent)
 Prazosin for nightmares (alpha-1 adrenergic
antagonist)
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Psychological treatment:
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CBT recommended
Social Anxiety Disorder (Social
phobia) – DSM IV criteria

Marked and persistent fear of social or performance
situations in which the person is exposed to unfamiliar
people or possible scrutiny by others

Fear that they will embarrass or humiliate themselves

Exposure to the feared situation invariable produces
anxiety which may be in the form of a panic attack

The person recognizes that the fear is excessive or
unreasonable
Social Anxiety Disorder (Social
phobia) – DSM IV criteria (con’t)
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The feared situations are avoided or endured with
intense anxiety and distress
The avoidance, anxious anticipation or distress
interferes with functioning or causes marked distress
In individuals under 18, duration is at least 6 months
Not due to substance, medical condition or other
mental disorder
If a medical condition is present, the fear is not related
to it (i.e. trembling in Parkinson’s)
Social Phobia
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Most people in the general population experience
a degree of discomfort with certain social
situations
Generalized type vs. non-generalized (a restricted
number of situations i.e. public speaking)
Differentiate from panic disorder (panic attacks in
social phobia always occur in feared situations)
Differentiate from normal shyness (shyness should
not cause functional impairment or marked distress)
Social Phobia

Has significant impact on quality of life

Lifetime prevalence of 8-12% 1 (one of the most
common anxiety disorders)
r
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Early onset, usually in childhood
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Chronic course, usually 20 years or longer
Can J Psychiatry Clinical Practice Guidelines for the Management of Anxiety Disorders July 2006
Social Phobia
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Interferes with career, relationship, goals
“illness of missed opportunities”
Comorbid conditions include substance abuse,
depression, or another anxiety disorder
Key symptoms include blushing, sweating,
palpitations, tremor and lightheadedness, panic
attacks
Situations are often avoided as an effort to
alleviate distress
Social Phobia - treatment

Pharmacotherapy:
 1st line SSRI or SNRI
 2nd line Benzodiazepine
Only recommended for short term use due to side
effects (cognitive impairment, ataxia, sedation) and
dependence and withdrawal
 Avoid in people with substance abuse and the
elderly
 3rd line Adjunctive Abilify or Risperidone
Mirtazapine, wellbutrin

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** Although not in guidelines, in practice, beta blockers
have been used with effect for non-generalized type
performance anxiety
Can J Psychiatry Clinical Practice Guidelines for the Management of Anxiety Disorders July 2006
Social Phobia - treatment

Psychological treatment
CBT (group or individual)
 CBT for social phobia includes exposure to feared
situations and social skills training
 Similar efficacy to pharmacotherapy
 In practice, CBT and medications are often
combined
 After discontinuation of CBT or medications, gains
with CBT last longer

Specific Phobia – DSM IV criteria
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Excessive or unreasonable fear cued by the presence or
anticipation of a specific object or situation (insects,
flying, heights, blood)
Exposure provokes an immediate anxiety response
Fear is recognized as excessive or unreasonable
Situation is avoided or endured with intense distress
Marked distress or interferes with functioning
Not due to a substance, medical condition or other
mental disorder
Specific Phobia
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Lifetime prevalence of 12%
Most common mental disorder
Begins at young age, 5-12 years old
Treatment is exposure based therapy
Graded exposure helpful
Virtual reality or computer programs sometimes
used for fear of heights, flying, dentist
Can J Psychiatry Clinical Practice Guidelines for the Management of Anxiety Disorders July 2006
Questions