Anxiety and Other Related Disorders

Anxiety is derived from a Latin word - Anxietas, which means to choke, throttle, or upset. It encompasses the behavioral, affective, and cognitive responses to the perception of danger.

It’s a future-oriented mood state in which the individual anticipates the possibility of a threat and experiences a sense of uncontrollability focused on the upcoming negative events.

It may be beneficial and adaptive in many situations.

It may become maladaptive and excessive, affecting people negatively in their day-to-day lives. It is pathological when it persists even after the threat is over, when excessive and unrealistic, affecting functioning.

It causes significant distress and impairment in social, occupational, and other aspects of functioning in daily living.

Anxiety involves anticipation, future concern, and is more associated with muscle tension and avoidance behavior. The focus of anticipated danger may be internal or external.

Fear – a present-oriented emotional reaction to a perceived immediate threat, is more associated with a fight or flight reaction.

The fear or anxiety must:

• Be out of proportion to the situation or age-inappropriate
• Hinder the ability to function normally

Anxiety disorders are among the most prevalent mental disorders.

An estimated 284 million people in the year 2017 were affected.

They usually occur along with other mental or physical illnesses, including depression, alcohol, and psychoactive substances.

These disorders are often chronic and may be resistant to treatment. Women are affected nearly twice as much as males.

There is an interplay of nature and nurture in its etiology.

Highly underrecognized and undertreated.

It’s always important to screen for other psychiatric diagnoses once a diagnosis of anxiety disorder is made because of co-morbidity and its impact on treatment and prognosis.

DSM-5

• Separation anxiety disorder
• Selective mutism
• Specific phobia
• Social anxiety disorder
• Panic disorder
• Agoraphobia
• Generalized anxiety disorder (GAD)
• Substance-induced anxiety disorder
• Anxiety disorder due to another medical condition
• Other specified anxiety disorders
• Unspecified anxiety disorder

Note: OCD and stress disorders have been removed as separate entities.

ICD 11

Anxiety and Fear Related Disorders

• Obsessive-Compulsive and Related Disorders
• Disorders Specifically Associated with Stress
• Dissociative Disorders
• Disorders of Bodily Stress and Bodily Experience

ICD 11 Anxiety and Fear Related Disorders 6B:

• Generalized Anxiety Disorder (GAD)
• Panic Disorder
• Agoraphobia
• Specific Phobia
• Social Anxiety Disorder
• Separation Anxiety Disorder
• Selective Mutism
• Other Specified Anxiety or Fear-Related Disorders
• Anxiety or Fear-Related Disorders, Unspecified

Physical

• Motor: Tremors, muscle tension, muscle twitches
• ANS: Palpitations, tachypnea, tachycardia, dry mouth, etc.

Psychological

• Cognitive: Poor concentration, distractibility, hyperarousal
• Perceptual problems: Derealization, depersonalization
• Affective symptoms: Fearfulness, apprehension
• Other symptoms: Poor sleep

Although anxiety disorders share similar clinical features, they also differ significantly in the following:

• Their typical focus of fear and anxiety
• The form, type, and severity of the psychophysiological fear response and the associated cognitions
• Their onset and patterns of course
• The clinical and neurobiological correlates
• Associated risk factors

Anxieties are common during childhood and adolescence. Common examples include:

• Separation anxiety
• Test anxiety
• Excessive concern about competence
• Excessive need for reassurance
• Anxiety about harm to a parent

Girls display more anxiety than boys, but symptoms are similar.

Some specific anxieties decrease with age.

Nervous and anxious symptoms may remain stable over time.

Anxiety disorders in children present with more intense symptoms than seen in normal anxiety.

Anxiety disorders are a common psychiatric disorder.

• 12-month prevalence is 17% (Almost 1 in 5 adults between 15-54 yrs).
• 25% of the general population would suffer at some stage in their lifetime.
• Most begin in childhood, early adolescence, or early adulthood, with a median age of onset at 11 years.
• Anxiety disorders are the commonest form of mental disorders in children and adolescents.
• More prevalent in females than males (2:1).
• Common in people of lower socio-economic status, unemployed, and divorced individuals.
• Cultural variation in presentation occurs.
• Specific phobia is the commonest, followed by social anxiety disorder.

It appears to be due to interactions of biopsychosocial factors, including genetic vulnerability, which interact with situations, stress, or trauma to produce clinically significant syndromes.

Biological factors

• Excessive autonomic reaction
• Increased noradrenaline
• Decreased GABA
• Reduced serotonin activity
• Increased activity in the temporal lobes
• Increased activity in the locus ceruleus
• Hyperactivity and dysregulation in the amygdala
• Prefrontal cortex deficits
• Corticostriatal-thalamocortical (CSTC) circuit (fear-specific circuit) is implicated in panic disorders

Psychodynamic Theory

• Unconscious impulses threatening to burst into consciousness

Learning Theory

• Generalization of anxiety resulting from frustration or stress
• Imitation and identification of anxiety patterns in parents
• Individual develops neurotic responses to avoid or end exposure to the threatening stimulus to reduce anxiety

Genetic Factors

• Higher concordance rates in monozygotic twins
• 50% of patients with panic disorder have one affected relative

Social Factors and Life Events

• Childhood experiences (adversity): child abuse
• Parental separation or death, traumatic events
• Use of recreational drugs
• Use of some medicines (side effects or withdrawal)

• CVS: Arrhythmias, IHD, mitral valve disease, cardiac failure.
• Respiratory: Asthma, COPD, HVS, PE, hypoxia.
• Neurological: TLE, vestibular nerve disease.
• Endocrine: Hyperthyroidism, hypoparathyroidism, hypoglycemia, phaeochromocytoma.
• Miscellaneous: Anaemia, porphyria, SLE, carcinoid tumor, pellagra.

Complications or Co-morbidity Development

• Other Anxiety Disorders
• Depression
• Substance Abuse
• Suicidality

• CVS: Antihypertensives, anti-arrhythmics.
• RS: Bronchodilators, A1/B-adrenergic agonists.
• CNS: Anaesthetics, anticholinergics, anticonvulsants, anti-Parkinsonian agents, antidepressants, antipsychotics, disulfiram reactions, withdrawal from BDZs and other sedatives.
• Miscellaneous: Levothyroxine, NSAIDs, antibiotics, chemotherapy.

Pharmacologic Approach:

• Antidepressants (SSRI, SNRI) - first-line drugs
• Benzodiazepines
• Beta Blockers
• Buspirone
• Antipsychotics

Psychological Approach:

• Psychoeducation
• Behavior Modification
• CBT (Cognitive Behavioral Therapy)
• Psychodynamic Psychotherapy
• Biofeedback
• Exposure Treatments
• Cognitive Restructuring
• Mindfulness and Contemplative Therapy
• Bibliotherapy

Social Approach:

• Coping Skills
• Social Skills Training
• Social Prescribing
• Nature Therapy

Complementary & Alternative Treatments

• Acupuncture
• Aromatherapy
• Breathing Exercises & Relaxation Training
• Exercise
• Meditation
• Nutrition and Diet Therapy
• Vitamins
• Self-Love/Self-Monitoring
• Art/Movement Therapy

Persistent, uncontrollable & excessive anxiety and worry for at least several months.

Anxiety is free-floating.

No realistic reasons to worry.

Fear out of proportion to circumstances.

Fear causing disruption to everyday functioning.

Difficulty to control worry.

Associated with:

• ANS arousal
• Restlessness
• Poor concentration
• Insomnia
• Muscle tension
• Easy fatigability
• Irritability

Somatic & ANS Symptoms of GAD

• Dry mouth
• Nausea
• Diarrhea
• Sweating
• Urinary frequency
• Headache
• Dysphagia
• Loss of appetite
• Muscle tension

ICD 11

• Marked symptoms of anxiety manifested by general apprehensiveness not restricted to any particular environmental circumstance (free-floating anxiety).
• Excessive worry about negative events occurring in several different aspects of everyday life.
• Anxiety accompanied by muscle tension, ANS activity (GIT like nausea, abdominal distress, CVS like palpitations, sweating, trembling, shaking, or dry mouth).
• Subjective experience of nervousness, restlessness, or being on edge.
• Difficulty concentrating.
• Sleep disturbance.
• Irritability.
• Symptoms are not transient.
• Onset usually early to mid-30s.
• Common in childhood and adolescence.

Examples of Co-morbid Conditions with GAD

• Somatoform Disorders
• Depression
• Adjustment Disorders
• Panic Disorders
• Social/Other Phobias
• Substance-Related Disorders
• OCD (Obsessive-Compulsive Disorder)

• Autonomic Arousal
• Numbness, tingling
• Tremor or shaking
• Hot flashes or chills
• Choking/Difficulty Swallowing
• Fear of dying
• Chest pain or pressure
• Fear of going crazy
• Nausea, Inability to Control Bowels
• Dizziness/Light-headedness

Panic Attack

A panic attack is characterized by abrupt onset of intense fear, terror, or discomfort in the absence of real danger that lasts at least several minutes, peaks within 10-20 mins and is accompanied by ANS arousal and at least 3 of the following:

• Tremor or shaking
• Choking or difficulty swallowing
• Chest pain or pressure
• Nausea/abdominal distress
• Inability to control bowels
• Dizziness, light-headedness
• Numbness, tingling sensations
• Hot flashes or chills
• Fear of dying
• Fear of going crazy or losing control
• Derealization/depersonalization

Some Differentials of Panic Attack

Psychiatric Disorders:

• Panic Disorder
• Phobic Disorder
• OCD (Obsessive-Compulsive Disorder)
• Temporal Lobe Epilepsy

Medical Disorders:

• Hyperthyroidism
• Hyperparathyroidism
• Phaeochromocytoma
• Chronic Obstructive Pulmonary Disorder
• Hypoglycemia

Panic Disorder (Episodic Paroxysmal Anxiety Disorder)

Is characterized by recurrent, unexpected/unpredictable panic attacks.

The attack is accompanied by:

• One month or more of persistent concern about the significance of the attack
• Persistent concern about recurrence

The attacks are associated with avoidance of situations in which the attacks occurred.

Some patients may develop agoraphobia.

Panics are not restricted to particular stimuli or situations.

Synonym: Episodic Paroxysmal Anxiety Disorders

Attacks are followed by persistent worry of recurrence.

• Panic Attacks: Common
• Panic Disorder: Less common
• Usually first attack around 15-19 years
• Can affect any age group
• Female twice as likely as males
• Co-occurring disorders include other AFRDs, depression, disorders due to substance use, agoraphobia
• Runs a waxing and waning course

Education, reassurance, elimination of psychoactive drugs such as caffeine and alcohol make better treatment outcomes.

Also

• Psychotherapy/Talk Therapy
• Anxiolytics

Excessive and persistent fear in specific well-defined situations, of clearly identifiable object, in interactive or performance situations in which they are exposed to scrutiny of others.

The fear is:

• Out of proportion to the inherent danger
• Cannot be explained or reasoned away
• Uncontrollable
• Associated with avoidance of the situation
• Persistent fear in the specific situation

Types of Phobic Disorders

Specific Phobia

• An irrational fear due to the presence or anticipation of a specific object or situation.
• Avoidance of anxiety-provoking object.
• Anxious anticipation of the feared situation.
• Interferes significantly with the person’s normal routine and socio-occupational functioning.

Agoraphobia

• Anxiety about being in places or situations such as in a crowd or in open spaces, outside the home, from which escape is feared to be impossible.
• The situation is avoided or endured with marked distress, sometimes including the fear of having a panic attack.
• Active avoidance of the situations occurs and can be behavioral, such as changing daily routines or using delivery to avoid entering a restaurant, or cognitive, such as using distraction to bear with agoraphobia.
• Avoidance may make the patient become housebound and may never leave the home or go outside only with a companion.

Phobias

• Algophobia: Pain
• Astraphobia: Thunderstorms
• Pathophobia: Disease
• Monophobia: Being alone
• Mysophobia: Contamination
• Nosocomephobia: Hospitals
• Trypanophobia: Injections
• Nyctophobia: Darkness
• Ochlophobia: Crowds
• Glossophobia: Fear of speaking in public
• Anthropophobia: Fear of people

Social Anxiety Disorder (Social Phobia)

• An irrational fear of public situations.
• The person fears that he/she will act in a way or show anxiety symptoms that will be humiliating or embarrassing.
• May be associated with panic disorders.
• Avoidance of feared situations.
• Interferes with normal routine functioning.
• Includes anthropophobia (fear of people).

• Can be diagnosed in adults and children.
• Focus of apprehension is separation from attachment figures with whom the individual has a deep emotional bond.
• One of the two most common childhood anxiety disorders.
• Occurs in 4-10% of children.
• More prevalent in girls than in boys.
• More than 2/3 of children with SAD have another anxiety disorder, and about half develop a depressive disorder.
• SAD has the earliest reported age of onset of anxiety disorders (7-8 years of age) and the youngest age at referral.
• Progresses from mild to severe.
• Associated with major stress.
• Examples: moving to a new neighborhood or entering a new school.
• SAD persists into adulthood for more than 1/3 of affected children and adolescents.

• Characterized by consistent selectivity in speaking, such that a child demonstrates adequate language competence in specific social situations, typically at home, but consistently fails to speak in others, typically at school.
• Estimated to occur in 0.7% of children.
• Average age of onset is 3-4 years.
• May be an extreme type of social phobia, but there are differences between the two disorders.

• Obsessive-Compulsive Disorder
• Body Dysmorphic Disorder
• Olfactory Reference Disorder
• Hypochondriasis (Health Anxiety Disorder)
• Hoarding Disorder
• Body-Focused Repetitive Behavior Disorders
• Trichotillomania (Hair Pulling Disorder)
• Excoriation (Skin Picking Disorder)

• PTSD (Post-Traumatic Stress Disorder)
• Complex PTSD
• Prolonged Grief Disorder
• Adjustment Disorder

Examples: Amnesia, Fugue, Stupor, Movement, and Sensation

Diagnosis:

• At least 1 neurological symptom.
• Psychological factors associated with initiation or exacerbation of symptoms.
• Symptoms are not intentionally produced.
• Symptoms can't be explained by medical condition or substance use.
• It causes significant distress or impairment in social and occupational functioning.
• Not accounted for by somatization disorders or other mental disorders.
• Not limited to pain or sexual symptoms.

Belle indifference is a classical sign of these disorders.

Disruption in the usually integrated functions of consciousness, memory, identity, and perception.

Characterized by symptoms or deficits affecting voluntary motor or sensory function that suggest but are not fully explained by a neurological or general medical condition or the direct effects of psychoactive substance. The symptoms are not intentionally produced or contrived.

Types of Dissociative States:

• Dissociative Amnesia: Unable to recall long periods of their life.
• Dissociative Fugue: Lose their memory and wander away from their usual surroundings, deny any memory of where they went.
• Dissociative Pseudodementia: The patient shows abnormality of intelligence suggesting dementia, but answers questions wrongly in a way that suggests they have the correct answer in mind, e.g., the Ganser question: 'how many legs does a cow have?' answer, '3' or '5'!
• Dissociative Stupor: Motionless and mute, but they are aware of their surroundings.
• Dissociative Identity Disorder (Multiple Personality Disorder): Sudden alternations between two patterns of behavior, each of which is forgotten by the patient when the other is present. Individuals use dissociation as a defense against severe trauma.
• Dissociative Anaesthesia or Sensory Loss: Often with unusual distribution of loss of sensation, e.g., hands only (includes hysterical blindness).
• Dissociative Convulsions (Pseudoseizures): Serum prolactin not elevated when sample taken 20 minutes after a ‘fit’, whereas in genuine seizures prolactin is raised.

Symptoms of Conversion Disorders:

• Shifting Paralysis
• Blindness
• Mutism
• Paresthesias
• Seizures
• Globus Hystericus

Individuals with conversion disorders may show a lack of concern out of keeping with the nature or implications of symptoms (La Belle Indifference).

Epidemiology:

• Common
• 20-25% incidence in general medical settings
• 2-5 times more common in women than men
• Onset at any age, usually adolescence or early adulthood
• Low socio-economic class
• High incidence of co-morbid schizophrenia, major depression, or anxiety disorders
• Greater incidence in 1st degree relatives (? Nature ? Nuture)

Course & Prognosis:

• 50% of patients eventually receive a medical diagnosis
• Symptoms resolve within 1 month
• 25% have future episodes, especially during times of stress
• Symptoms may spontaneously resolve after sodium amobarbital
• Interview if the psychological trigger is uncovered

Management:

• Insight-oriented psychotherapy
• Relaxation training
• Trauma-informed cognitive-behavioral therapy/cognitive restructuring
• Art and movement therapy

• Bodily symptoms that are distressing
• Excessive attention directed toward the symptoms
• Repeated contact with healthcare providers
• Degree of attention is excessive
• BDS involves multiple symptoms that may vary over time

Bodily Distress Disorders:

• Patients present with physical symptoms that have no organic cause. They truly believe that their symptoms are due to medical problems and not consciously faking symptoms
• Commoner in females
• Half of the patients have co-morbid mental disorders, especially anxiety disorders and major depression

Pain Disorder:

• Prolonged severe discomfort without adequate medical explanation
• Pain often coexists with a medical condition but is not directly caused by it
• History of multiple visits to doctors

Diagnosis:

• Main complaint is of pain at one or more anatomic sites
• The pain causes significant distress in the patient’s life
• The pain has to be related to psychological factors
• The pain is not due to a true medical disorder

Epidemiology:

• Women are two times as likely as men
• Average age of onset: 30-50
• Increased incidence in 1st degree relatives
• Increased incidence in blue-collar workers
• Higher incidence of major depression, anxiety disorders, and substance abuse

Differentials:

• Rule out underlying medical condition
• Hypochondriasis
• Malingering

Course:

• Abrupt onset
• Increase intensity for the first several months
• Chronic and disabling course

Treatment:

• Analgesics are not helpful and often patients become dependent on them
• SSRIs
• Transient nerve stimulation
• Biofeedback
• Psychotherapy

Patients are not consciously aware of gains and don’t intentionally seek them.

Primary Gain: Expression of unacceptable feelings as symptoms to avoid facing them. Produces internal motivators and provides protection from anxiety or emotional symptoms and/or conflicts.

Secondary Gain: Use of symptoms to benefit the patient (attention from others, less responsibilities, avoidance of the law, financial assistance, etc.). Produces external motivators.

• Somatization/Somatic Symptom: Persistent worry about possible disorder or sickness
• Conversion Disorder: Interpretation of bodily sensations as an indication of severe physical illness
• Pain Disorder: Fear that symptoms are dire or life-threatening
• Illness Anxiety Disorder: Mistrust of medical assessment and treatment, fear that symptoms are dire or life-threatening
• Factitious Disorder: Multiple/excessive visits to healthcare

This is not a neurotic disorder but it is included because it can be a differential diagnosis. It is a psychiatric disorder where the patient intentionally produces symptoms to fulfill and assume the role of a sick patient. It involves the deliberate falsification of medical or psychological symptoms imposed on oneself or on another, with the overall intention of deception. Primary gain is the prominent feature of this disorder.

Diagnosis:

• Patient intentionally produces signs of a physical or mental disorder to receive medical treatment.
• The symptom is voluntarily produced to assume the sick role (primary gain).
• There are no external incentives.
• May be either predominantly psychogenic complaints or predominantly physical complaints.

Commonly feigned symptoms include:

• Psychiatric - hallucinations, depression
• Medical - fever, pain, seizure, skin lesions, hematuria

Munchausen by Proxy / Factitious Disorder Imposed on Another:

Munchausen by proxy or factitious disorder imposed on another involves the production of medical or psychological symptoms targeted towards a third party who is currently under the client’s care.

Epidemiology:

• Occurs in above 5% of hospitalized patients.
• More common in males.
• Seen in hospital and health workers.
• Higher intelligence, poor sense of identity, and poor sexual adjustment are associated factors.
• In-patient hospitalization from abuse may provide a safe, comforting environment that links the sick role to a positive experience.

Definition: Fake symptoms produced to achieve personal gain (external gain). It is not a mental disorder.

External Motivations: Include avoiding police or law enforcers, lessening criminal responsibility, receiving room/shelter, obtaining narcotics, and receiving monetary compensation.

Simulation of Symptoms: Conscious. Symptoms are rarely sustained continuously for long.

Clinical Presentation of Malingering:

• Multiple vague complaints that do not conform with a known medical disorder.
• Long medical history and many hospital stays.
• Uncooperative patient.
• Refuses to accept a good prognosis even after intensive medical evaluation.
• Symptoms improve once their desired objective has been met.

• Panic: Have you ever experienced a panic attack?
• GAD (Generalized Anxiety Disorder): Do you consider yourself a worrier?
• PTSD (Post-Traumatic Stress Disorder): Have you ever had anything happen that still haunts you?
• OCD (Obsessive-Compulsive Disorder): Do you get thoughts stuck in your head that really bother you or need to do things over and over like washing your hands, checking things, or counting?
• Social Anxiety (Social Phobia): When you are in a situation where people can observe you, do you feel nervous and worry that they will judge you?