ANXIETY DISORDER

Normal Anxiety
Everyone experiences anxiety. It is characterized most
commonly as a diffuse, unpleasant, vague sense of
apprehension, often accompanied by autonomic
symptoms
such
as
headache,
perspiration,
palpitations, tightness in the chest, mild stomach
discomfort, and restlessness, indicated by an inability
to sit or stand still for long.
The particular constellation of symptoms present during
anxiety tends to vary among persons
Fear versus Anxiety
Anxiety is an alerting signal; it warns of
impending danger and enables a person to take
measures to deal with a threat. A response to a threat
that is unknown, internal, vague, or conflictual.

Fear is a similar alerting signal. Fear is a

response to a known, external, definite, or
nonconflictual threat.

Is Anxiety Adaptive?
Anxiety and fear both are alerting signals and act as a
warning of an internal and external threat. Anxiety
can be conceptualized as a normal and adaptive
response that has lifesaving qualities, and
warns of threats of bodily damage, pain,
helplessness, possible punishment, or the
frustration of social or bodily needs; of
separation from loved ones; of a menace to
one's success or status; and ultimately of
threats to unity or wholeness. It prompts a
person to take the necessary steps to prevent
the threat or to lessen its consequences. This
preparation is accompanied by increased somatic and
autonomic activity controlled by the interaction of the
sympathetic and parasympathetic nervous systems.
Examples of a person warding off threats in daily life
include getting down to the hard work of preparing for
an examination, dodging a ball thrown at the head,
sneaking into the dormitory after curfew to prevent
punishment, and running to catch the last commuter
train. Thus, anxiety prevents damage by alerting
the person to carry out certain acts that
forestall the danger.
ANXIETY characterized by feeling of dread
accompanied by somatic signs that
indicate
hyperactive autonomic nervous system.

&
a

FEAR - appropriate response to a known threat

The main psychological difference between the two
emotional responses is the suddenness of fear and
the insidiousness of anxiety.
Anxiety is an alerting signal; it warns of impending
danger and enables a person to take measures to deal
with a threat. Fear is a similar alerting signal, but
should be differentiated from anxiety. Fear is a
response to a known, external, definite, or
nonconflictual threat; anxiety is a response to a threat
that is unknown, internal, vague, or conflictual.

A person whose ego is functioning properly is in

adaptive balance with both external and internal
worlds

If the ego is not functioning properly and the

resulting imbalance continues sufficiently long, the
person experiences chronic anxiety.
Whether an event is perceived as stressful depends
on the nature of the event and on the person's
resources, psychological defenses, and coping
mechanisms. All involve the ego, a collective
abstraction for the process by which a person
perceives, thinks, and acts on external events or
internal drives

Whether the imbalance is external, between the

pressures of the outside world and the person's ego,
or internal, between the person's impulses (e.g.,
aggressive, sexual, and dependent impulses) and
conscience, the imbalance produces a conflict.
Because human beings are social, their main
conflicts are usually with other persons.
The experience of anxiety has two components: the
awareness of the physiological sensations (e.g.,
palpitations and sweating) and the awareness of being
nervous or frightened. A feeling of shame may
increase anxiety. Others will recognize that I am
frightened. Many persons are astonished to
find out that others are not aware of their
anxiety or, if they are, do not appreciate its
intensity.
In addition to motor and visceral effects, anxiety
affects thinking, perception, and learning. It tends to
produce confusion and distortions of perception, not
only of time and space but also of persons and the
meanings of events. These distortions can interfere
with learning by lowering concentration, reducing
recall, and impairing the ability to relate one item to
another that is, to make associations.

Symptoms of Anxiety
The experience of anxiety has two components:
1.
Awareness of the physiological sensations (e.g.,
palpitations and sweating)
2.
Awareness of being nervous or frightened.
3.
Anxiety affects thinking, perception, and
learning.
4.
It
tends
to
produce
confusion
and
distortions of perception, not only of time and
space but also of persons and the meanings of events.
5.
These distortions can interfere with learning by
lowering concentration, reducing recall, and impairing
the ability to relate one item to anotherthat is, to
make associations.
An important aspect of emotions is their effect on the
selectivity of attention. Anxious persons likely
select certain things in their environment and
overlook others in their effort to prove that they
are justified in considering the situation
frightening. If they falsely justify their fear, they
augment their anxieties by the selective
response and set up a vicious circle of anxiety,
distorted perception, and increased anxiety. If,
alternatively, they falsely reassure themselves by
selective thinking, appropriate anxiety may be
reduced, and they may fail to take necessary
precautions.

Peripheral Manifestations of Anxiety

Pupillary mydriasis

Diarrhea
Restlessness (e.g., pacing)

Dizziness,
Syncope
lightTachycardia
headedness
Tingling in the extremities,

Hyperhidrosis
Tremors

Hyperreflexia
Upset stomach (butterflies)

Hypertension
Urinary frequency, hesitancy,

Palpitations
urgency
Signs & Symptoms of Anxiety Disorder
Physical signs
Psychological
symptoms
Trembling
Feeling of dread
Backaches
Shortness of breath
Fatigability

Difficulty concentrating
Hypervigilance

Startle response
Autonomic activities

Insomnia
Decreased libido

Paresthesia
Difficulty in swallowing

lump in the throat

Upset stomach

Autonomic Hyperactivity
o flushing/pallor, tachycardia/palpitation, sweating, cold
hands, dry mouth (xerostomia)
o diarrhea,
urinary frequency

Upset stomach (butterflies)

Most prevalent psychiatric condition in the United States
and in most other populations studied.
Recent studies, suggest that chronic anxiety
o disorder may increase the rate of
o cardiovascular-related mortality.
Hence, clinicians in psychiatry and other specialties
must make the proper anxiety disorder diagnosis
rapidly and initiate treatment.
DSM TR Classification of Anxiety Disorder
Panic disorder with or without agoraphobia
Agoraphobia with or without panic disorder
Specific phobia
Social phobia
Obsessive-compulsive disorder (OCD)
Posttraumatic stress disorder (PTSD)
Acute stress disorder
Generalized anxiety disorder
Epidemiology

Most common group of psychiatric disorder

Women more affected than men

Phobia most common anxiety disorder 10% of

the population

Psychological theory
Psychoanalytic
Behavioral
Existential

PSYCHODYNAMIC ASPECTS
Freud - conceptualized anxiety as both a
symptomatic manifestation of neurotic conflict and an
adaptive signal to avoid awareness of neurotic
conflict.

Anxiety as a signal of internal distress and conflict

that may require some reflection and introspection.

the goal of therapy is not necessary to

eliminate all anxiety but to increase anxiety
tolerance, that is, the capacity to experience
anxiety and use it as a signal to investigate the
underlying conflict that has created it. Anxiety
appears in response to various situations during the
life cycle and, although psychopharmacological agents
may ameliorate symptoms, they may do nothing to
address the life situation or its internal correlates that
have induced the state of anxiety. In the following
case a disturbing fantasy precipitated an anxiety
attack.
To understand fully a particular patient's anxiety
from a psychodynamic view, it is often useful to relate
the anxiety to developmental issues. At the earliest
level, disintegration anxiety may be present. This
anxiety derives from the fear that the self will
fragment because others are not responding with
needed affirmation and validation. Persecutory anxiety
can be connected with the perception that the self is
being invaded and annihilated by an outside
malevolent force. Another source of anxiety
involves the child who fears losing the love or
approval of a parent or loved object. Freud's
theory of castration anxiety is linked to the oedipal
phase of development in boys, in which a powerful
parental figure, usually the father, may damage the
little boy's genitals or otherwise cause bodily harm.
(See Section 6.1 for a discussion of Freud's theories.)
At the most mature level, superego anxiety is
related to guilt feelings about not living up to
internalized standards of moral behavior
derived from the parents. Often, a psychodynamic
interview can elucidate the principal level of anxiety
with which a patient is dealing. Some anxiety is
obviously related to multiple conflicts at various
developmental levels

Existential Theories
No specifically identifiable stimulus exists for a
chronically anxious feeling.

The central concept - persons experience feelings

of living in a purposeless universe.

Anxiety is their response to the perceived void in

existence and meaning. (Nuclear / bioterrorism)

1.
2.
3.
4.

Etiology
Biological
Psychoanalytic
Learning theory
Genetic Studies

1. BIOLOGICAL
Excessive
autonomic
reaction
with
increased
sympathetic tone
Increased release of catecholamines
Increased production of NE metabolites
Increased activity in the temporal cortex
Experimental infusion of lactate increases NE levels &
produces anxiety in patient with panic disorder
Serotonin decreases anxiety; increased dopaminergic
activity associated with anxiety
Locus ceruleus brain center for noradrenergic neurons,
hyperactive in anxiety states (panic attacks)
Decreased levels of (GABA) G-aminobutyric acid, cause
CNS hyperactivity (GABA inhibits CNS irritability)

Autonomic Nervous System

Stimulation of the autonomic nervous system causes
certain symptoms cardiovascular (e.g., tachycardia),
muscular (e.g., headache), gastrointestinal (e.g.,
diarrhea), and respiratory (e.g., tachypnea). The
autonomic nervous systems of some patients with
anxiety disorder, especially those with panic disorder,
exhibit increased sympathetic tone, adapt slowly to
repeated stimuli, and respond excessively to
moderate stimuli.
2. PSYCHOANALYTIC
FREUD:
Unconscious impulses (sex/aggression)threaten to burst
into the consciousness & produce anxiety.
Related
developmentally
to
childhood
fear
of
Disintegration that derive from the fear of loss of a
loved object or fear of castration.
3. LEARNING THEORY
Anxiety produced by continued/severe frustration or
stress.
becomes a conditioned response to other situations
that are less frustrating or stressful
may be learned through identification & imitation of
anxiety patterns in parents
associated
with naturally frightening stimulus
(accidents),
with
subsequent
displacement
or
transference to another stimulus through conditioning
produces phobia to anew & different object or
situation.

DSM-IV Criteria for Panic Attack

A discrete period of intense fear or discomfort, in which
four (or more) of the following symptoms developed
abruptly and reached a peak within 10 minutes
(1) palpitations, pounding heart, or accelerated heart
rate
(2) sweating
(3) trembling or shaking
(4) sensations of shortness of breath or smothering
(5) feeling of choking
(6) chest pain or discomfort
(7) nausea or abdominal distress
(8) feeling dizzy, unsteady, lightheaded, or faint
(9)
derealization
(feelings
of
unreality)
or
depersonalization (being detached from oneself)
(10) fear of losing control or going crazy
(11) fear of dying
(12) paresthesias (numbness or tingling sensations)
(13) chills or hot flushes

ANXIETY DISORDER
involve faulty, distorted or counterproductive
patterns of cognitive thinking
Social learning theory identification & imitation of
anxiety patterns
4. GENETIC STUDIES
Half of patient with panic disorder have one affected
relative
5% have a variant of the gene associated with serotonin
metabolism & have high levels of anxiety

MEDICAL & NEUROLOGICAL CAUSES OF ANXIETY

Neurological disorder cerebral neoplasms/trauma &
post
concussive
syndromes, cerebral syphilis,
subarachnoid bleed, encephalitis. Multiple sclerosis,
Wilsons disease, epilepsy
Systemic conditions hypoxia (cardiovascular ds,
pulmonary insufficiency, anemia)
Endocrine
disturbancetyroid/pituitary/parathyroid/adrenal
dysfunction,
pheochromocytoma
Inflammatory disorder SLE, RA
Deficiency states Vit B12 deficiency, pellagra
Toxic
conditions

alcohol/drug
withdrawal,
sulfonamides, penicillin, aspirin intolerance, mercury,
arsenic,phosphorus, organophosphates, benzene
Intoxications: Amphetamines, anticholinergics, caffeine,
cannabis, coccaine, theophylline, hallucinogens
Withdrawal:
opiods,
sedative-hypnotics,
antihypertensive
Others: hypogly
Others

An acute intense attack of anxiety accompanied by

feelings of impending doom is known as panic
disorder.
The anxiety is characterized by discrete periods of
intense fear that can vary from several attacks during
one day to only a few attacks during a year.
Patients with panic disorder present with a
number of comorbid conditions, most commonly
agoraphobia, which refers to a fear of or anxiety
regarding places from which escape might be
difficult.
Somatic concerns of death from a cardiac or
respiratory problem may be the major focus of
patients' attention during panic attacks.
20 % of patients - syncopal episodes
Seen in ER young , physically healthy persons insist
that they are about to die from a heart attack.
Avoid immediately diagnosing hypochondriasis vs
panic disorder.
Hyperventilation produce respiratory alkalosis and
thersymptoms,breathing into a paper bag sometimes
helps.
Patients with panic disorder have a higher
incidence of stressful life events (particularly loss)
Moreover, the patients typically experience
greater distress about life events than control subjects
do.

Behavioral theories
Anxiety is a response learned either from parental
behavior or through the process of classic
conditioning.

Classic conditioning approach to panic disorder and

agoraphobia, a noxious stimulus (e.g., a panic attack)
that occurs with a neutral stimulus (e.g., a bus ride)
can result in the avoidance of the neutral stimulus.

Psychodynamic Themes in Panic Disorder

1. Difficulty tolerating anger.
2. Physical or emotional separations from significant
person both in childhood and in adult life.
3. May be triggered by situations of increased work
responsibilities.
4. Perception of parents as controlling, frightening,
critical, and demanding.
5. Internal representations of relationships involving
sexual or physical abuse.

6. A chronic sense of feeling trapped.

7. Vicious cycle of anger at parental-rejecting behavior
followed by anxiety that the fantasy will destroy the
tie to parents.
8. Failure of signal anxiety function in ego related to self
fragmentation and self-other boundary confusion.
9. Typical defense mechanisms: reaction formation,
undoing, somatization, and externalization.

Patients with panic disorder present with a

number of comorbid conditions, most commonly
agoraphobia, (a fear of or anxiety regarding places
from which escape might be difficult)

DSM-IV Criteria for Agoraphobia

A.Anxiety about being in places or situations from which
escape might be difficult (or embarrassing) or in which
help may not be available . Agoraphobic 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.
B.The situations are avoided (e.g., travel is restricted) or
else are endured with marked distress or with anxiety
about having a panic attack or panic-like symptoms,
or require the presence of a companion.
C.The anxiety or phobic avoidance is not better accounted
for by another mental disorder, such as social phobia
(e.g., avoidance limited to social situations because of
fear of embarrassment), specific phobia (e.g.,
avoidance limited to a single situation like elevators),
obsessive-compulsive disorder (e.g., avoidance of dirt
in someone with an obsession about contamination),
posttraumatic stress disorder (e.g., avoidance of
stimuli associated with a severe stressor), or
separation anxiety disorder (e.g., avoidance of leaving
home or relatives).
PHOBIAS most common anxiety
three categories:
(1) agoraphobia without history of panic disorder,
(2) specific phobia,
(3) social phobia.
Social phobia, most common of all phobias,
subdivided into two subtypes:
a. The nongeneralized type - fear of public situations
such as public speaking or performing on stage.
b. The generalized type which almost all social
interactions are feared. This variant may be difficult to
differentiate from avoidant personality disorder.

Phobia - an excessive fear of a specific object,

circumstance, or situation.
Specific phobia is a strong, persisting fear of an
object or situation
Social phobia is a strong, persisting fear of
situations in which embarrassment can occur
Freud viewed phobia as a result of conflicts on
unresolved childhood situation.
Primary defenses DISPLACEMENT
SYMBOLIZATION
AVOIDANCE
Psychodynamic Themes in Phobias
Principle
defense
mechanisms
displacement, projection, and avoidance.

include:

Environmental stressors, including humiliation and

criticism from an older sibling, parental fights, or loss
and separation from parents, interact with a genetic
constitutional diathesis.
A characteristic pattern of internal object relations
is externalized in social situations in the case of social
phobia.
Anticipation of humiliation, criticism, and ridicule is
projected onto individuals in the environment.
Shame and embarrassment are the principal affect
states.
Family members may encourage phobic behavior
and serve as obstacles to any treatment plan.
Self-exposure to the feared situation is a basic
principle of all treatment.

DSM-IV Diagnostic Criteria for Specific Phobia

A.Marked and persistent fear that is excessive or
unreasonable, cued by the presence or anticipation of
a specific object or situation (e.g., flying, heights,
animals, receiving an injection, seeing blood).
B.Exposure to the phobic stimulus almost invariably
provokes an immediate anxiety response.
C.The person recognizes that the fear is excessive or
unreasonable.
D. The phobic situation(s) is avoided.
E. The avoidance, anxious anticipation, or distress in the
feared situation(s) interferes significantly with the
person's normal routine, occupational (or academic)
functioning, or social activities or relationships with
others, or there is marked distress about having the
phobia.
F. In individuals under age 18 years, the duration is at
least 6 months.
G. The anxiety, panic attacks, or phobic avoidance
associated with the specific object or situation are not
better accounted for by another mental disorder
The development of specific phobia may result from the
pairing of a specific object or situation with the
emotions of fear and panic.

The feared objects and situations in specific

phobias :
Animals, storms, heights, illness, injury, and death.

Acrophobia fear of heights

Agoraphobia fear of open places

Hydrophobia fear of water

Claustrophobia fear of closed spaces

Mysophobia fear of dirt and germs Pyrophobia fear

of fire

Xenophobia fear of strangers

Zoophobia fear of animals

Persons seek out situations of danger and rush

enthusiastically toward them.

Devotees of potentially dangerous sports, such as

parachute jumping and rock climbing, may be
exhibiting counterphobic behavior.
DSM-IV Diagnostic Criteria for Social Phobia
A.marked and persistent fear of one or more social or
performance situations in which the person is exposed
to unfamiliar people or to possible scrutiny by others.
The individual fears that he or she will act in a way (or
show anxiety symptoms) that will be humiliating or
embarrassing.

B.Exposure to the feared social situation almost invariably

provokes anxiety, which may take the form of a
situationally bound or situationally predisposed panic
attack.
C.The person recognizes that the fear is excessive or
unreasonable.
D. The feared social or performance situations are
avoided.
E. The avoidance, anxious anticipation, or distress in the
feared social or performance situation(s) interferes
significantly with the person's normal routine,
occupational (academic) functioning, or social
activities or relationships with others, or there is
marked distress about having the phobia.
F. In individuals under age 18 years, the duration is at
least 6 months.
G. The fear or avoidance is not due to the direct
physiological effects of a substance (e.g., a drug of
abuse, a medication) or a general medical condition,
and is not better accounted for by another mental
disorder (e.g., panic disorder with or without
agoraphobia, separation anxiety disorder, body
dysmorphic disorder, a pervasive developmental
disorder, or schizoid personality disorder).
H.If a general medical condition or other mental disorder is
present, the fear in criterion A is unrelated to it, e.g.,
the fear is not of stuttering, trembling in Parkinson's
disease, or exhibiting abnormal eating behavior in
anorexia nervosa or bulimia nervosa.

(1)

(2)

(3)

(4)

Behavioral treatment techniques

Systematic
desensitization,
a
method
pioneered by Joseph Wolpe.
the patient is exposed
serially to a predetermined list of anxiety-provoking
stimuli graded in a hierarchy from the least to the
most frightening.

DSM-IV
Diagnostic
Criteria
for
ObsessiveCompulsive Disorder
A.A. Either obsessions or compulsions (or both) are
present on most days for
a period of at least 2
weeks.
B.Obsessions
(thoughts,
ideas,
or
images)
and
compulsions (acts) share the following features, all of
which must be present:
They are acknowledged as originating in the mind of the
patient and are not imposed by outside persons or
influences.
They are repetitive and unpleasant, and at least one
obsession or compulsion that is acknowledged as
excessive or unreasonable must be present.
The patient tries to resist them (but resistance to very
long-standing obsessions or compulsions may be
minimal). At least one obsession or compulsion that
is unsuccessfully resisted must be present.
Experiencing the obsessive thought or carrying out the
compulsive act is not in itself pleasurable.
C. The obsessions or compulsions cause distress or
interfere with the patient's social or individual
functioning, usually by wasting time.
D. Most commonly used exclusion clause. The
obsessions or compulsions are not the result of
other mental disorders, such as schizophrenia and
related disorders or mood [affective] disorders.
Obsessive-Compulsive Disorder

Obsessions is recurrent & intrusive thoughts,

rituals, preoccupations
Compulsion is a conscious, standardized,
recurrent behavior, such as counting, checking, or
avoiding
Anxiety is also increased when a person resists
carrying out a compulsion.

Psychodynamic Themes in Obsessive-Compulsive

Disorder

Classical psychoanalytic formulation was linked to

an anal-phase regression with a specific constellation
of defenses: reaction formation, doing and undoing,
and isolation of affect.

The psychodynamic meaning of psychosocial

stressors, such as pregnancy or childbirth, may help to
explain the onset or exacerbation of symptoms of
obsessive-compulsive disorder.

Psychodynamic conflicts frequently appropriate

biologically driven symptoms and use them as a
vehicle for the xpression of those conflicts.

Treatment resistance, such as poor compliance with

medication, often involves the tendency to hang on to
the symptoms because of special meanings to the
patient or because of characterological resistances to
receiving help.

Symptoms of obsessive-compulsive disorder almost

always have interpersonal meanings, including
omnipotent control of family members and others in
significant interpersonal relationships.
DSM-IV Diagnostic Criteria for Posttraumatic
Stress Disorder
A.The person has been exposed to a traumatic event in
which both of the following were present:
B.the person experienced, witnessed, or was confronted
with an event or events that involved actual or
threatened death or serious injury, or a threat to the
physical integrity of self or others
C.the
person's
response
involved
intense
fear,
helplessness, or horror. Note: in children, this may be
expressed instead by disorganized or agitated
behavior
D. The traumatic event is persistently reexperienced in
one (or more) of the following ways:
1. recurrent and intrusive distressing recollections of the
event, including images, thoughts, or perceptions.
2. recurrent distressing dreams of the event.
3. acting or feeling as if the traumatic event were
recurring (includes a sense of reliving the experience,
illusions, hallucinations, and dissociative flashback
episodes, including those that occur upon awakening
or when intoxicated)..
4. intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
5. physiologic reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
E. Persistent avoidance of stimuli associated with the
trauma and numbing of general responsiveness (not
present before the trauma), as indicated by three (or
more) of the following:
1. efforts to avoid thoughts, feelings, or conversations
associated with the trauma
2. efforts to avoid activities, places, or people that
arouse recollections of the trauma

3. inability to recall an important aspect of the trauma

4. markedly diminished interest or participation in
significant activities
5. feeling of detachment or estrangement from others
6. restricted range of affect (e.g., unable to have loving
feelings)
7. sense of a foreshortened future (e.g., does not expect
to have a career, marriage, children, or a normal life
span)
F. Persistent symptoms of increased arousal (not present
before the trauma), as indicated by two (or more) of
the following:
1. difficulty falling or staying asleep
2. irritability or outbursts of anger
3. difficulty concentrating
4. hypervigilance
5. exaggerated startle response
G. Duration of the disturbance (symptoms in criteria B, C,
and D) is more than 1 month.
H.The disturbance causes clinically significant distress or
impairment in social, occupational, or other important
areas of functioning
DSM-IV Diagnostic Criteria for Acute Stress
Disorder
A.The person has been exposed to a traumatic event in
which both of the following were present:
1. the person experienced, witnessed, or was confronted
with an event or events that involved actual or
threatened death or serious injury, or a threat to the
physical integrity of self or others.
2. The person's response involved intense fear,
helplessness, or horror
B.Either while experiencing or after experiencing the
distressing event, the individual has three (or more) of
the following dissociative symptoms:
1. a subjective sense of numbing, detachment, or
absence of emotional responsiveness
2. a reduction in awareness of his or her surroundings
(e.g., "being in a daze")
3. derealization
4. depersonalization
5. dissociative amnesia (e.g., inability to recall an
important aspect of the trauma)
C.The traumatic event is persistently reexperienced in at
least one of the following ways: recurrent images,
thoughts, dreams, illusions, flashback episodes, or a
sense of reliving the experience; or distress on
exposure to reminders of the traumatic event.
D. Marked avoidance of stimuli that arouse recollections
of the trauma (e.g., thoughts, feelings, conversations,
activities, places, people).
E. Marked symptoms of anxiety or increased arousal (e.g.,
difficulty sleeping, irritability, poor concentration,
hypervigilance, exaggerated startle response, and
motor restlessness).
F. The disturbance causes clinically significant distress or
impairment in social, occupational, or other important
areas of functioning, impairs the individual's ability to
pursue some necessary tasks, such as obtaining
necessary assistance or mobilizing personal resources
by telling family members about the traumatic
experience.
G. The disturbance lasts for a minimum of 2 days and a
maximum of 4 weeks and occurs within 4 weeks of the
traumatic event.

H.Not due to the direct physiological effects of a substance

(e.g., a drug of abuse, a medication) or a general
medical condition, is not better accounted for by brief
psychotic disorder, and is not merely an exacerbation
of a preexisting Axis I or Axis II disorder.

DSM-IV Diagnostic
Criteria
for Generalized
Anxiety Disorder
A. Excessive anxiety and worry (apprehensive
expectation), occurring more days than not for at least
6 months, about a number of events or activities (such
as work or school performance).
B. The person finds it difficult to control the worry.
C. The anxiety and worry are associated with three (or
more) of the following six symptoms (with at least
some symptoms present for more days than not for
the past 6 months).
(1) restlessness or feeling keyed up or on edge
(2) being easily fatigued
(3) difficulty concentrating or mind going blank
(4) irritability
(5) muscle tension
(6) sleep disturbance (difficulty falling or staying asleep,
or restless unsatisfying sleep)
D. The focus of the anxiety and worry is not confined to
features of an Axis I disorder, e.g., the anxiety or
worry is not about having a panic attack (as in panic
disorder), being embarrassed in public (as in social
phobia), being contaminated (as in obsessivecompulsive disorder), being away from home or close
relatives (as in separation anxiety disorder), gaining
weight (as in anorexia nervosa), having multiple
physical complaints (as in somatization disorder), or
having a serious illness (as in hypochondriasis), and
the anxiety and worry do not occur exclusively during
post-traumatic stress disorder.
E. The anxiety, worry, or physical symptoms cause
clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
F. The disturbance is not due to the direct physiological
effects of a substance or a general medical condition
(e.g., hyperthyroidism), and does not occur exclusively
during a mood disorder, psychotic disorder, or a
pervasive developmental disorder.
Psychodynamic Themes in Generalized Anxiety
Disorder

Worrying serves a defensive function to avoid

thinking about more disturbing issues.

Increased prevalence of past trauma is highly

characteristic.

Link with an insecure/conflicted attachment in

childhood.

The underlying conflict that creates the anxiety can

be related to any number of developmental themes.

The unconscious conflict continues to be "alive" in

self-defeating patterns in relationships.

Resistance is common in moving below the level of

symptoms to underlying sources of conflict.
Recommended Dosages for Antipanic Drugs (Daily
Unless Indicated Otherwise)
Starting (mg) Maintenance (mg)

SSRI
Paroxetine
510
2060
Fluoxetine
25
2060

Sertraline
Fluvoxamine
Citalopram

12.5
10

12.525 50200
100150
2040

Tricyclic antidepressants
Imipramine
1025 150500

Benzodiazepines
Alprazolam
0.250.5 t.i.d.
Clonazepam 0.250.5 b.i.d.
Diazepam
25 b.i.d.
Lorazepam
0.250.5 b.i.d.

0.52 t.i.d.
0.52 b.i.d.
530 b.i.d.
0.52 b.i.d.

Atypical antidepressants
Venlafaxine
6.2525 50150
Nefazodone
50 b.i.d. 100300 b.i.d.
Other agents

Valproic acid
Inositol

125 b.i.d.
500750 b.i.d.
6000 b.i.d. 6000 b.i.d.

PSYCHOSOCIAL THERAPY
Supportive and psychodynamic therapies understanding of the various elements of
psychic conflict (impulses,
conscience,
internal standards that are often excessively
harsh, psychological defense patterns, and realistic
concerns) and
reintegration of these elements
in a more realistic and adaptive way resolution and
fewer relapses.

Group therapy

Patient support group