Anxiety, Panic and Stress Disorder

Alcantara andAliguyon

Anxiety
 normal reaction to danger, the body’s automatic fight-or-flight response that is triggered when you
feel threatened, under pressure, or are facing a challenging situation, such as a job interview, exam, or
first date.
 In moderation, anxiety isn’t necessarily a bad thing. It can help you to stay alert and focused, spur you
to action, and motivate you to solve problems.
 But when anxiety is constant or overwhelming—when worries and fears interfere with your
relationships and daily life—you’ve likely crossed the line from normal anxiety into the territory of an
anxiety disorder.

a. Do I have an anxiety disorder?

If you identify with any of the following seven signs and symptoms, and they just won’t go away, you may
be suffering from an anxiety disorder:

1. Are you constantly tense, worried, or on edge?

2. Does your anxiety interfere with your work, school, or family responsibilities?

3. Are you plagued by fears that you know are irrational, but can’t shake?

4. Do you believe that something bad will happen if certain things aren’t done a certain way?

5. Do you avoid everyday situations or activities because they cause you anxiety?

6. Do you experience sudden, unexpected attacks of heart-pounding panic?

7. Do you feel like danger and catastrophe are around every corner?

Types of anxiety disorders and their symptoms

Anxiety disorders and conditions closely related to anxiety disorders include:
Types Description

1. Generalized anxiety disorder (GAD)  Constant worries and fears distract you from your day-
to-day activities (Chronic Worrywarts).
 manifests in physical symptoms like insomnia, stomach
upset, restlessness, and fatigue.

 Repeated, unexpected panic attacks, as well as fear of

2. Panic attacks and panic disorder
experiencing another episode.
 Agoraphobia, the fear of being somewhere where
escape or help would be difficult in the event of a panic
attack, may also accompany a panic disorder.
 If you have agoraphobia, you are likely to avoid public
places such as shopping malls, or confined spaces such as
an airplane.
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3. Obsessive-compulsive disorder (OCD)
4. Phobias and irrational fears
5. Social anxiety disorder
6. Post-traumatic stress disorder (PTSD)
7. Separation anxiety disorder
 Characterized by unwanted thoughts or behaviors that
seem impossible to stop or control.
 Feeling of troubled by obsessions
 uncontrollable compulsions (washing your hands over
and over)
 A phobia is an unrealistic or exaggerated fear of a
specific object, activity, or situation that in reality
presents little to no danger.
 Common phobias include fear of animals (such as snakes
and spiders), fear of flying, and fear of heights. In the
case of a severe phobia, you might go to extreme lengths
to avoid the object of your fear.
 Unfortunately, avoidance only strengthens the phobia.
 Severe cases, social situations are avoided altogether.
 Performance anxiety (better known as stage fright) is the
most common type of social phobia.
 Extreme anxiety disorder that can occur in the aftermath
of a traumatic or life-threatening event.
 Symptoms of PTSD include flashbacks or nightmares
about the incident, hypervigilance, startling easily,
withdrawing from others, and avoiding situations that
remind you of the event.
 While separation anxiety is a normal stage of
development, if anxieties intensify or are persistent
enough to get in the way of school or other activities,
your child may have separation anxiety disorder.
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Generalized Anxiety Disorder

People with generalized anxiety disorder (GAD) display excessive anxiety or worry, most days for at least 6
months, about a number of things such as personal health, work, social interactions, and everyday routine
life circumstances. The fear and anxiety can cause significant problems in areas of their life, such as social
interactions, school, and work.

Generalized anxiety disorder symptoms include:

● Feeling restless, wound-up, or on-edge

● Being easily fatigued

● Having difficulty concentrating; mind going blank

● Being irritable

● Having muscle tension

● Difficulty controlling feelings of worry

● Having sleep problems, such as difficulty falling or staying asleep, restlessness, or unsatisfying sleep

Pathogenesis

1. Biological factors 

 GAD shares a common heritability with major depression and with the personality trait of
“neuroticism”. The serotonin transporter gene-linked polymorphic region SS genotype
(short/short) has been found to be more frequent in patients with GAD
 Variations in two sub-types of the glutamic acid decarboxylase gene may increase individual
susceptibility to anxiety disorders, including GAD
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 Investigations of potential disturbances in the principal neurotransmitters norepinephrine, 5-
hydroxtryptamine (5-HT, serotonin) and gamma aminobutyric acid (GABA) in GAD have tended to
be small, inconsistent, or unreplicated.
 (increase: NE and Serotonin; Decrease: GABA)

2. Neuropsychological factors

 A study of positron emission tomography (PET) scans in patients with GAD demonstrated a relative
increase in glucose metabolism in parts of the occipital, right posterior temporal lobe, inferior
gyrus, cerebellum and right frontal gyrus, and an absolute decrease in the basal ganglia:
benzodiazepine administration was associated with decreases in absolute metabolic rates for
cortical surface, limbic system and basal ganglia, but was not associated with normalization of
patterns of glucose metabolism

3. Developmental and personality factors

 GAD in adult life is associated with a higher-than-average number of traumatic experiences and
other undesirable life events in childhood, compared to individuals without GAD

4. Cognitive origins of excessive worrying — Many explanations of the origin and persistence of the
excessive and pervasive worrying that characterize GAD have been proposed. As examples, affected
individuals may:

●Constantly scan the environment for cues of threat

●Develop worrying in an attempt to solve problems

●Use worrying to avoid the fear response

●Have intolerance of uncertainty or ambiguity

●Worry about the uncontrollability and presumed dangerous consequences of worrying

Panic Disorder
People with panic disorder have recurrent unexpected panic attacks. Panic attacks are sudden periods of
intense fear that come on quickly and reach their peak within minutes. Attacks can occur unexpectedly or
can be brought on by a trigger, such as a feared object or situation.

During a panic attack, people may experience:

● Heart palpitations, a pounding heartbeat, or an accelerated heartrate

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● Sweating

● Trembling or shaking

● Sensations of shortness of breath, smothering, or choking

● Feelings of impending doom

● Feelings of being out of control

People with panic disorder often worry about when the next attack will happen and actively try to prevent
future attacks by avoiding places, situations, or behaviors they associate with panic attacks. Worry about
panic attacks, and the effort spent trying to avoid attacks, cause significant problems in various areas of the
person’s life, including the development of agoraphobia.

Phobia-related disorders

A phobia is an intense fear of—or aversion to—specific objects or situations. Although it can be realistic to
be anxious in some circumstances, the fear people with phobias feel is out of proportion to the actual
danger caused by the situation or object.

People with a phobia:

● May have an irrational or excessive worry about encountering the feared object or situation

● Take active steps to avoid the feared object or situation

● Experience immediate intense anxiety upon encountering the feared object or situation

● Endure unavoidable objects and situations with intense anxiety

There are several types of phobias and phobia-related disorders:

Specific Phobias (sometimes called simple phobias): As the name suggests, people who have a specific
phobia have an intense fear of, or feel intense anxiety about, specific types of objects or situations. Some
examples of specific phobias include the fear of:

● Flying

● Heights

● Specific animals, such as spiders, dogs, or snakes

● Receiving injections

● Blood

Social anxiety disorder (previously called social phobia): People with social anxiety disorder have a
general intense fear of, or anxiety toward, social or performance situations. This worry often causes
people with social anxiety to avoid social situations. Social anxiety disorder can manifest in a range of
situations, such as within the workplace or the school environment.

Agoraphobia: People with agoraphobia have an intense fear of two or more of the following situations:
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● Using public transportation

● Being in open spaces

● Being in enclosed spaces

● Standing in line or being in a crowd

● Being outside of the home alone

In the most severe form of agoraphobia, an individual can become housebound.

Separation anxiety disorder: Separation anxiety is often thought of as something that only children deal
with; however, adults can also be diagnosed with separation anxiety disorder. People who have separation
anxiety disorder have fears about being parted from people to whom they are attached. People with
separation anxiety may have nightmares about being separated from attachment figures or experience
physical symptoms when separation occurs or is anticipated.

Selective mutism: A somewhat rare disorder associated with anxiety is selective mutism. Selective mutism
occurs when people fail to speak in specific social situations despite having normal language skills.
Selective mutism usually occurs before the age of 5 and is often associated with extreme shyness, fear of
social embarrassment, compulsive traits, withdrawal, clinging behavior, and temper tantrums

Risk Factors/ Pathogenesis

Researchers are finding that both genetic and environmental factors contribute to the risk of developing an
anxiety disorder. Although the risk factors for each type of anxiety disorder can vary, some general risk
factors for all types of anxiety disorders include:

● Temperamental: traits of shyness or behavioral inhibition in childhood

● Childhood adversity or Life Stress: Exposure to stressful and negative life or environmental events
in early childhood or adulthood

● Genetics: A history of anxiety or other mental illnesses in biological relatives

● Some physical health conditions, such as thyroid problems or heart arrhythmias, or caffeine or
other substances/medications, can produce or aggravate anxiety symptoms; a physical health
examination is helpful in the evaluation of a possible anxiety disorder.

● Neurobiology: NT: NE, Serotonin, GABA

Stress Disorder
Acute stress disorder is a mental health condition that can occur immediately after a traumatic event. It
can cause a range of psychological symptoms and, without recognition or treatment, it can lead to post-
traumatic stress disorder.

A person with ASD experiences psychological distress immediately following a traumatic event. Unlike
PTSD, ASD is a temporary condition, and symptoms typically persist for at least 3 to 30 days after the
traumatic event.

If a person experiences symptoms for longer than a month, a doctor will usually assess them for PTSD.
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Symptoms

People who have ASD experience symptoms similar to those of PTSD and other stress disorders.

ASD symptoms fall under five broad categories:

1. Intrusion symptoms. These occur when a person is unable to stop revisiting a traumatic event
through flashbacks, memories, or dreams.

2. Negative mood. A person may experience negative thoughts, sadness, and low mood.

3. Dissociative symptoms. These can include an altered sense of reality, a lack of awareness of the
surroundings, and an inability to remember parts of the traumatic event.

4. Avoidance symptoms. People with these symptoms purposefully avoid thoughts, feelings, people,
or places that they associate with the traumatic event.

5. Arousal symptoms. These can include insomnia and other sleep disturbances, difficulty

concentrating, and irritability or aggression, which can be either verbal or physical. The person may
also feel tense or on guard and become startled very easily.

People with ASD may develop additional mental health disorders, such as anxiety anddepression.

Symptoms of depression include:

 persistent feelings of hopelessness, sadness, or numbness

 fatigue

 crying unexpectedly

 loss of interest in activities that were once pleasurable

 changes in appetite or body weight

 thoughts of suicide or self-harm

Pathogenesis

 It is not known why some people develop acute stress disorder (ASD) following a traumatic event. Nor
is it fully understood why some people with ASD develop subsequent posttraumatic stress disorder
(PTSD) and others do not.

 When ASD was initially introduced, it was largely influenced by the proposal that dissociative symptoms
(ie, impaired consciousness, memory, identity, or awareness of body, self, or environment)

Causes
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People can develop ASD after experiencing one or more traumatic events. A traumatic event can cause
significant physical, emotional, or psychological harm.

Among others, possible traumatic events can include:

 the death of a loved one

 the threat of death or serious injury

 natural disasters

 motor vehicle accidents

 sexual assault, rape, or domestic abuse

 receiving a terminal diagnosis

 surviving a traumatic brain injury

Risk factors

Factors that can increase an individual's risk of developing ASD include:

 previously experiencing, witnessing, or having knowledge of a traumatic event

 a history of other mental health disorders

 a history of dissociative reactions to past traumatic events

 being younger than 40 years old

 being female

Management
Pharmacological
Medication does not cure anxiety disorders but can help relieve symptoms. Medication for anxiety is
prescribed by doctors, such as a psychiatrist or primary care provider. Some states also allow psychologists
who have received specialized training to prescribe psychiatric medications. The most common classes of
medications used to combat anxiety disorders are anti-anxiety drugs (such as benzodiazepines),
antidepressants, and beta-blockers.

A. Anti-Anxiety Reduce the symptoms of anxiety, panic Benzodiazepines

Medications attacks, or extreme fear and worry.
a. Advantages:
Benzodiazepines Short/ as needed: first-line for any
distressing flare-ups of symptoms. ● effective in relieving anxiety and
Alprazolam take effect more quickly than
Long term: second-line treatment for antidepressant
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Clonazepam anxiety (with antidepressants being b. Disadvantages

considered a first-line treatment)y
Non- disorder ● Tolerance if taken over a long
Benzodiazepine period of

Buspirone ● Dependence

● Withdrawal (suddenly stopped)

Non- Benzodiazepine

Buspirone- chronic anxiety

B. Antidepressants Treat depression, but they can also be
helpful for treating anxiety disorders.
SSRI
They may help improve the way your
Venlafaxine brain uses certain chemicals that
control mood or stress
Sertraline
● selective serotonin reuptake
SNRI
inhibitors (SSRIs) are commonly
Duloxetine used as first-line treatments for
anxiety.
TCA
● serotonin-norepinephrine
Amitriptyline reuptake inhibitors (SNRIs): are
commonly used as first-line
MAOI treatments for anxiety.
● Withdrawal (suddenly stopped)
Please Note: In some cases, children,
teenagers, and young adults under 25
may experience an increase in suicidal
thoughts or behavior when taking
antidepressant medications, especially
in the first few weeks after starting or
when the dose is changed. Because of
this, patients of all ages taking
antidepressants should be watched
closely, especially during the first few
weeks of treatment.

Phenelzine ● Less-commonly used — but

effective —tricyclic
antidepressants and monoamine
oxidase inhibitors (MAOIs).

C. Beta-Blocekrs help relieve the physical symptoms of serious side effects:

anxiety, such as rapid heartbeat,
Propranolol shaking, trembling, and blushing.
used “as needed” to reduce acute
anxiety, including as a preventive
intervention for some predictable
forms of performance anxieties.
 blue fingers/toes
 numbness/tingling of arms/legs
 shortness of breath
 swelling ankles/feet
 unusual tiredness

D. Anticonvulsant the use of anticonvulsant drugs in

treating anxiety disorders can be found
Gabapentin in the main cerebral structures
involved in fear circuits. These reduce
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Pregabalin symptoms of anxiety by decreasing

neuronal activation within fear circuits.

The amygdala is important in

experiencing fear and its autonomic
and endocrine response

the hippocampus is important in the

re-experiencing of fear and the
cognitive aspects of fear and anxiety.

Non-Pharmaceutical Therapy
1. Psychotherapy

Psychotherapy or “talk therapy” can help people with anxiety disorders. To be effective, psychotherapy
must be directed at the person’s specific anxieties and tailored to his or her needs.

Cognitive Behavioral Therapy

Cognitive Behavioral Therapy (CBT) is an example of one type of psychotherapy that can help people
with anxiety disorders. It teaches people different ways of thinking, behaving, and reacting to anxiety-
producing and fearful objects and situations. CBT can also help people learn and practice social skills,
which is vital for treating social anxiety disorder.

2. Support Groups

3. Stress Management Techniques

Patient Counselling

Not everyone who worries a lot has an anxiety disorder. You may feel anxious because of an overly
demanding schedule, lack of exercise or sleep, pressure at home or work, or even from too much caffeine.
The bottom line is that if your lifestyle is unhealthy and stressful, you’re more likely to feel anxious—
whether or not you actually have an anxiety disorder. These tips can help to lower anxiety and manage
symptoms of a disorder:

1. Connect with others. Loneliness and isolation can trigger or worsen anxiety, while talking about
your worries face to face can often make them seem less overwhelming. If you don’t have anyone
you can reach out to, it’s never too late to build new friendships and a support network.

2. Manage stress

3. Practice relaxation techniques. When practiced regularly relaxation techniques such as

mindfulness meditation, progressive muscle relaxation, and deep breathing can reduce anxiety
symptoms and increase feelings of relaxation and emotional well-being.

4. Exercise regularly.Exercise is a natural stress buster and anxiety reliever.

5. Get enough sleep. A lack of sleep can exacerbate anxious thoughts and feelings, so try to get seven
to nine hours of quality sleep a night.
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6. Be smart about caffeine, alcohol, and nicotine.consider reducing your caffeine intake, or cutting it
out completely. Similarly alcohol can also make anxiety worse. And while it may seem like cigarettes
are calming, nicotine is actually a powerful stimulant that leads to higher, not lower, levels of
anxiety.

7. Put a stop to chronic worrying. Worrying is a mental habit you can learn how to break. Strategies
such as creating a worry period, challenging anxious thoughts, and learning to accept uncertainty
can significantly reduce worry and calm your anxious thoughts.