Anxiety 

Fear 

• is generally regarded as a normal emotional response that prepares us for realistic, anticipated dangers and so has survival value 
• In contrast, Anxiety feels like fear but occurs in the absence of immediate or obvious threat 
• or if there is a threat, it is out of proportion  to the emotion it evokes
• Anxiety becomes a clinical problem:
  • if it appears unrelated to any obvious threat
  • if its level is disproportionate to any threat that may be present 
  •  if it is prolonged 

Anxiety

• is universally experienced
• diffuse, unpleasant vague sense of apprehension with physical discomfort/somatic complaints (↑ ANS activity) which can affect any part of the body

DSM-IV Anxiety Disorders 

ANXIETY DISORDER TYPE	CLINICAL FEATURES	MANAGEMENT
1. PANIC ATTACK •Abrupt onset •A discrete period of intense fear of discomfort •Rapid onset <10mins •last no more than 15mins	STUDENTS FEAR the 3 C’s S – Sweating T – Trembling U – Unsteadiness, dizziness D – Depersonalization, derealization E – Excessive heart rate, palpitations N – Nausea T – Tingling S – Shortness of breath FEAR of dying FEAR of losing control FEAR of going crazy C – Chest pain C – Chills C – Choking	•can occur in the context of anxiety disorders, other mental disorders, and medical conditions •Panic attacks in and of themselves are not pathological, and do not require treatment.
1. PANIC DISORDER •F>M •Episodic •Transient Sx •Unpredictable timing •Inexplicable trigger •Average age 20-24 years •Youth with panic attacks may go on to develop mood disorders such as bipolar disorder and major depressive disorder, other anxiety disorders, eating disorder, psychotic disorders, personality disorders •can have a negative impact on physical and psychological function and on the individual’s interpersonal functioning •has a chronic waxing and waning course over the individual’s lifetime •Individuals with panic disorder are at a higher risk for suicidiilty	recurrent unexpected panic attacks in the absence of triggers marked by persistent concern about additional panic attacks – losing control – having a heart attack – “going crazy” maladaptive change in behaviour related to the attacks: – behaviors designed to avoid having panic attacks – avoidance of exercise or unfamiliar situations – restricting usual activities – avoiding agoraphobia-type situations – reorganizing routines to ensure that help is available in the event of a panic attack – severe restrictions on food intake or medications for fear it may trigger attacks	CBT (problem solving based on pt’s cognitive processes to Δbehaviour) Relaxation & breathing exercises to avoid hyperventilation (show that it’s that which causes the Sx, not catastrophe like MI, etc!) Medication: SHORT term anxiolytics, antidepressants
2. PHOBIC DISORDERS •F>M for all 3 F>M for all 3 subtypes •onset: mid 20s (80% < 30 yrs) – but can being at any age •usually no precipitating event •some pts will report onset after significant life event •initial attack – most pts v alarmed → present to ED	Specific phobias (specific object) Agoraphobia (open spaces where can’t escape) Social phobia (social humiliation & meeting unfamiliar ppl)+ avoidance	behavioural – exposure & desensitisation CBT, assertiveness & social skills training, gradual exposure medication: SHORT term anxiolytics, SSRIs & MAOIs (mono-amine oxidase inhibitors), β-blockers for social
3. GENERALISED ANXIETY •F>M •Aetiology? Genetics, childhood •separations, current stressors •Onset: early 20s – can dvlp at any age •Chronic condition •Sx fluctuate in severity ¼ of pts with GAD → panic disorder	•excessive anxiety and worry majority of days over at least months about multiple events or activities (e.g. – school or work difficulties, relationships, finances) BE-SKIM  B – Blank mind  E – Easily fatigued  S – Sleep disturbance K – Keyed Up/Restless/On-edge I – Irritability  M – Muscle tension	•Reassurance •Structured problem solving CBT •Rx: avoid if possible, SHORT term anxiolytics, Antidepressants, β-blockers (eg propranolol) •Complications: – major depression – substance abuse
4. OBSESSIVE COMPULSIVE DISORDER •M=F Peak incidence 15-30yo ?genetic? 5-HT underactivity?	Distressing, time consuming & life-interfering obsessions & compulsions Obsession: in the mind (cognitive) Compulsion: resulting behaviour (acting on obsession to alleviate anxiety)	Rx has well established role 🡪 SSRIs & clomipramine (TCA) but can take 12/52 for onset, doses are higher than for depression, high relapse with cessation CBT + Rx combination is better Response prevention Thought stopping (CBT) = 2/3 respond to Tx OCD = Increased risk of suicide
5. POST-TRAUMATIC STRESS DISORDER •traumatic events like RAPE, TRAUMA, WAR memories, etconset after weeks/months	•flashbacks (re-experience) •avoidance •anxiety •autonomic arousal •emotional numbness (reduced emotions)	•debriefing & deconstructing event •CBT •Antidepressants •use BZ with extreme caution (lots of comorbid substance abuse) •EMDR (eye movement desensitisation & reprogramming)

Disorder	Key features
Panic disorder	• Recurrent unexpected panic attacks, in the absence of triggers • Persistent concern about additional panic attacks and/or maladaptive change in behavior related to the attacks
Agoraphobia	• Marked, unreasonable fear or anxiety about a situation • Active avoidance of feared situation due to thoughts that escape might be difficult or help unavailable if panic-like symptoms occur
Specific phobia	• Marked, unreasonable fear or anxiety about a specific object or situation, which is actively avoided (e.g., flying, heights, animals, receiving an injection, seeing blood)
Social anxiety disorder (SAD)	• Marked, excessive or unrealistic fear or anxiety about social situations in which there is possible exposure to scrutiny by others • Active avoidance of feared situation
Generalized anxiety disorder (GAD)	• Excessive, difficult to control anxiety and worry (apprehensive expectation) about multiple events or activities (e.g., school/work difficulties) • Accompanied by symptoms such as restlessness/feeling on edge or muscle tension
Obsessive–compulsive disorder (OCD)	• Obsessions: recurrent and persistent thoughts, urges, or images that are experienced as intrusive and unwanted and that cause marked anxiety or distress • Compulsions: repetitive behaviors (e.g., hand washing) or mental acts (e.g., counting) that the individual feels driven to perform to reduce the anxiety generated by the obsessions
Posttraumatic stress disorder (PTSD)	• Exposure to actual or threatened death, serious injury, or sexual violation • Intrusion symptoms (e.g., distressing memories or dreams, flashbacks, intense distress) and avoidance of stimuli associated with the event • Negative alterations in cognitions and mood (e.g., negative beliefs and emotions, detachment), as well as marked alterations in arousal and reactivity (e.g., irritable behavior, hypervigilance)

Separation anxiety disorder
Average age	11 years
Range	6 to 14
Specific phobia
Average age	11 years
Range	8 to 14
Social anxiety disorder (social phobia)
Average age	14 years
Range	13 to 15
Agoraphobia without panic disorder
Average age	21 years
Range	17 to 25
Obsessive-compulsive disorder
Average age	24 years
Range	19 to 29
Posttraumatic stress disorder
Average age	27 years
Range	22 to 31
Panic disorder
Average age	30 years
Range	26 to 35
Generalized anxiety disorder
Average age	35 years
Range	31 to 39

Average Age of Onset

• Older Adults
  • Late onset anxiety disorders are relatively unusual.
  • older patients with new onset anxiety symptoms should always have a thorough investigation for other etiologies including physical illness and medication side 

Management

traditional CBT 

1. psychoEducation 
2. Cognitive restructuring
   • aims to reduce negative beliefs about self and others, works to reduce the excessive self-focus that is characteristic of SAD, examines and changes perfectionistic attitudes
   • Cognitive Restructuring: Helps patients identify and modify distorted thoughts about social situations.
   • Behavioral Experiments: Encourages patients to test the validity of their negative thoughts through real-life experiments.
3. Exposure Therapy
   • Hierarchical Exposure: Patients create a list of feared situations ranked by difficulty and gradually face these situations starting from the least to the most challenging.
   • In Vivo Exposure: offers imaginal exposure to situations that are difficult to practice regularly in real life, offers in-vivo exposure to situations that provoke social anxiety during treatment sessions and homework, provides exposure role-play simulations, reduces safety behaviours in social situations
4. Social skills training 
   • deals with any areas of weak social skills such as eye contact or conversation skills, addresses any interpersonal problems, including lack of social contacts and friendships, improving social life, assertiveness, managing conflict, and dealing with romantic or problematic relationships
   • Role-Playing: Practicing social interactions in a safe environment.
   • Feedback and Reinforcement: Receiving constructive feedback to improve social behavior.
   • Non-Verbal Communication: Training on eye contact, body language, and tone of voice.
5. Emotion-regulation approaches
   • offer relaxation approaches, acceptance of symptoms and anxiety
6. 4. Mindfulness and Acceptance-Based Therapies
   • These therapies help patients accept their anxious thoughts and feelings without judgment.
   • Mindfulness Meditation: Enhances present-moment awareness and reduces rumination.
   • Acceptance and Commitment Therapy (ACT): Focuses on accepting anxious thoughts while committing to values-based actions.
7. 5. Psychoeducation
   • Educating patients about SAD and its treatment can empower them and reduce feelings of isolation.
   • Understanding SAD: Providing information about the nature, causes, and maintenance of social anxiety.
   • Treatment Expectations: Setting realistic expectations for the treatment proce

Newer CBT additions

• Performance feedback
• Attention training
• Exposure to consequences and dropping safety behaviours
• Modifying core belief

Typical structure and components of CBT for anxiety disorders

Stage 1	Goals Assist patient awareness Develop formulation Provide education about the anxiety disorder and treatment rationale Monitor symptoms Address factors that facilitate or hinder therapy
Stage 2	Goals	Components	Targets and effects
	Reduce physical symptoms through relaxation and exercise	Arousalmanagement	Relaxation and breathing control to help manage increased anxiety levels
	Reduce cognitive symptoms and drivers of ongoing anxiety by challenging unhelpful thinking styles and using structured problem solving	Cognitivestrategies	Cognitive restructuring, behavioural experiments and related strategies: • Targets patient’s exaggerated perception of danger (beliefs around the likelihood and extent of feared consequences); • Provides corrective information regarding level of threat; • Can also enhance self-efficacy beliefs.
	Increase engagement in activities that represent mastery over fears including:
	– Reduce behavioural avoidance through graded exposure to avoided situations and activities, and relinquishment of safety signals;	Gradedexposure	Encouraging patient to face fears: • Patient learns corrective information through experience • Extinction of fear occurs through repeated exposure • Successful coping enhances self-efficacy.
	Restrict anxiety reducing behaviours	Safety response inhibition	Patient restricts anxiety-reducing behaviours (e.g. escape,need for reassurance) that maintain anxiety cycles: • Restriction of these behaviours decreases negative reinforcement; • Coping with anxiety without using anxiety-reducing behaviours enhances self-efficacy.
	Relinquish safety signals	Surrender of safety signals	Patient relinquishes safety signals (e.g. presence of a companion or mobile phone, or knowledge of the location of the nearest toilet: • Patients learn adaptive self-efficacy.
Stage 3	Goal Relapse prevention

Medications:

Drug	GAD		Panic disorder	Social anxiety disorder
Benzodiazepines
Alprazolam			1.5–8
Clonazepam			1–4	1.5–8
Diazepam	5–15		5–20
Lorazepam	2–8		2–8
Calcium channel modulators
Pregabalin	150–600
Monoamine oxidase inhibitors (MAOIs)
Moclobemide				300–600
Tranylcypromine
Norepinephrine-dopamine-reuptake inhibitors (NDRIs)
Bupropion
Norepinephrine-reuptake inhibitors (NARIs)
Reboxetine
Noradrenergic and specific serotonergic antidepressants (NaSSAs)
Mirtazapine
Other antidepressants
Tianeptine
vortioxetine
Selective serotonin reuptake inhibitors (SSRIs)
Citalopram			20–60	20–40
Escitalopram	10–20		10–20	10–20
Fluoxetine			20–40	20–40
Fluvoxamine	50		100–300	100–300
Paroxetine	20–50		20–60	20–50
Sertraline	50–150		50–150	50–150
Serotonin antagonist and reuptake inhibitors (SARIs)
Trazodone
Duloxetine	60–120
Milnacipran
venlafaxine	75–225	75–225		75–225
Tricyclic antidepressants (TCAs)
Amitriptyline
Clomipramine		75–250

Performance Anxiety

Performance anxiety, often known as stage fright, can affect individuals in various scenarios, including public speaking, sports, and artistic performances. Management strategies can be both non-pharmacological and pharmacological. Here’s an overview of both approaches along with their pros and cons:

Non-Pharmacological Management

1. Cognitive-Behavioral Therapy (CBT)
   • Pros:
     • Evidence-based and effective for long-term management.
     • Addresses underlying thought patterns contributing to anxiety.
     • Can be tailored to individual needs.
   • Cons:
     • Requires time and commitment.
     • May not provide immediate relief.
2. Exposure Therapy
   • Pros:
     • Gradual exposure helps reduce fear over time.
     • Can build confidence through repeated practice.
   • Cons:
     • Initial discomfort and anxiety during exposure sessions.
     • Requires consistent effort and time.
3. Relaxation Techniques
   • Pros:
     • Includes methods such as deep breathing, progressive muscle relaxation, and meditation.
     • Can be used immediately before performance to reduce anxiety symptoms.
   • Cons:
     • May not be sufficient for severe anxiety.
     • Requires practice to be effective.
4. Mindfulness and Meditation
   • Pros:
     • Promotes present-moment awareness and reduces rumination.
     • Can improve overall mental well-being.
   • Cons:
     • Requires regular practice to see benefits.
     • May be challenging for individuals new to mindfulness.
5. Biofeedback
   • Pros:
     • Provides real-time feedback on physiological functions (e.g., heart rate) to help manage stress responses.
     • Can be highly effective for some individuals.
   • Cons:
     • Requires specialized equipment and training.
     • Can be expensive and time-consuming.
6. Performance Coaching and Training
   • Pros:
     • Tailored strategies to improve specific performance skills.
     • Can increase confidence and competence.
   • Cons:
     • May not address underlying anxiety issues.
     • Can be expensive and requires ongoing effort.

Pharmacological Management

1. Beta-Blockers (e.g., Propranolol)
   • Pros:
     • Effective at reducing physical symptoms of anxiety (e.g., tremors, rapid heartbeat).
     • Can be used as needed before performances.
   • Cons:
     • Does not address psychological aspects of anxiety.
     • Potential side effects include fatigue, dizziness, and gastrointestinal issues.
     • Contraindicated in individuals with certain medical conditions (e.g., asthma, certain heart conditions).
2. Benzodiazepines (e.g., Lorazepam, Diazepam)
   • Pros:
     • Provides rapid relief of anxiety symptoms.
     • Can be very effective for situational use.
   • Cons:
     • Risk of dependence and tolerance with regular use.
     • Potential side effects include drowsiness, impaired coordination, and cognitive impairment.
     • Not suitable for long-term management.
3. Selective Serotonin Reuptake Inhibitors (SSRIs) (e.g., Sertraline, Fluoxetine)
   • Pros:
     • Effective for long-term management of anxiety disorders.
     • Addresses both physical and psychological symptoms of anxiety.
   • Cons:
     • Requires several weeks to achieve full therapeutic effect.
     • Potential side effects include nausea, insomnia, and sexual dysfunction.
     • May not be necessary for situational performance anxiety.
4. Gabapentin
   • Pros:
     • May help reduce anxiety and is sometimes used off-label for performance anxiety.
     • Generally well-tolerated.
   • Cons:
     • Limited evidence for use specifically in performance anxiety.
     • Potential side effects include dizziness, fatigue, and weight gain.

Pros and Cons of Each Approach

Non-Pharmacological Approaches

• Pros:
  • Address underlying causes of anxiety.
  • No risk of medication side effects or dependence.
  • Can provide long-lasting benefits and skills applicable to various situations.
• Cons:
  • Requires time, effort, and consistency.
  • May not provide immediate relief.
  • Effectiveness can vary based on individual commitment and the severity of anxiety.

Pharmacological Approaches

• Pros:
  • Can provide rapid relief of symptoms.
  • Useful for situational anxiety and when non-pharmacological methods are insufficient.
• Cons:
  • Risk of side effects, dependence, and tolerance (particularly with benzodiazepines).
  • May not address the psychological aspects of anxiety.
  • Requires careful management and monitoring by a healthcare provider.