The document provides information about anxiety disorders and their management. It defines anxiety and anxiety disorders, differentiates between normal and abnormal anxiety, and lists the components and etiology of anxiety disorders. It then describes the symptoms and types of anxiety disorders according to DSM-IV criteria. Finally, it discusses the pharmacological and non-pharmacological management of anxiety disorders, including commonly used drugs like benzodiazepines, SSRIs, and SNRIs.

2. OBJECTIVES
General Objective: At the end of teaching- learning activity, group will able to have adequate knowledge about ‘Anxiety
Disorders’ and its effect of mental health.
Specific Objectives: At the end of teaching- learning activity, group will able to;
1. define anxiety
2. differentiate between normal and abnormal anxiety
3. state the components of anxiety disorders.
4. determine the etiology of anxiety disorders.
5. enumerate the symptoms of anxiety disorders.
6. classify the types of anxiety disorders.
7. explain the diagnostic criteria for anxiety disorders.
8. elaborate the management for anxiety disorders.

3. DEFINITION
1. Anxiety: Anxiety is the mind and body's reaction to stressful, dangerous, or unfamiliar situations. It's
the sense of uneasiness, distress, or dread you feel before a significant event.
2. Anxiety disorder: The anxiety disorders are a group of mental disturbances characterized by
anxiety as a central or core symptom.
Sr. no Type ofAnxiety Description
1. State anxiety An individual’s level of anxiety at a specific time.
2. Trait anxiety
An individual’s tendency to respond to variety of situations with
more or less anxiety.

4. DIFFERENCE BETWEEN FEAR ANDANXIETY:
Sr. No Fear Anxiety
1. Basic emotion Generalized mood state
2. Response to imminent treat Response to future treat
3. External source Internal in origin
4. Alerting signal Alarming signal
5. Non- conflictual Conflictual
6. Brief/discrete Long/chronic
7. Known in origin Unknown or vague
8. Definite period Indefinite period
9. Intense autonomic arousal Intense autonomic arousal
10. Visual processing/ imagery Verbal processing/ worry/ imaginary

5. Sr.no Normal anxiety Abnormal anxiety
1.
Respond to threatening situation, and
stabilizes again to normal with time once
the problem/ thought subsides.
Respond to threatening conditions but anxiety stays
for prolonged period of time showing symptoms of
mental illness.
2.
May show fight or flight response to
stress.
Mostly shows flight response to stress.
3. It’s a beneficial response It’s a harmful response
4. It is known as ‘Eustress’ It is known as ‘Distress’

6. COMPONENTS OFANXIETY:
Sr. no Components Description
1. Physiological
Physical symptoms such as increased heart rate, shortness of breath,
tightening in chest, muscle tension, headache, nausea and sweating.
2. Cognitive
Thought and worries, which formulates the constant questions about future
problems, like what if? And how I will?
3. Behavioral
Reduced performance due to reduced focus, as focus is directed towards the
worries and not on present conditioning.
4. Emotional
The emotional component of anxiety consists fear, dread, panic state. Anxiety
can also lead to other emotions such as frustration, anger, disappointment,
sadness and depression.

7. ETIOLOGY FOR ANXIETYDISORDERS:
 There is no exact known cause for anxiety disorders.
 Like other forms of mental illness, they stem from a combination of things, including changes in your brain
and environmental stress, and even your genes. The disorders can run in families and could be linked to faulty
circuits in the brain that control fear and other emotions.

8. GABA
SEROTONIN
ACCORDING TO NEUROTRASMITTER
HYPOTHESIS ANXIETY IS CAUSED DUE TO:

9. RISK FACTORS:
Sr. no. Risk factors Description
1. Trauma
Children who endured abuse or trauma are at higher risk to develop anxiety disorders.
Adults too, can develop anxiety disorders.
2.
Stress due to an
illness
Having chronic condition or serious illness can cause significant worry about issues such
as your treatment and your future.
3. Situational crisis e.g.- death in the family, work stress or ongoing worry about finances.
4. Personality
People with certain personality types are more prone to anxiety disorders than others.
5.
Other mental
health disorders
People with other mental health disorders, such as depression, often also have an anxiety
disorder.
6. Genetic factor Anxiety disorders can run in families. Blood relatives are more prone to develop.
7. Drugs or alcohol Drug or alcohol use or misuse or withdrawal can cause or worsen anxiety.

10.  SYMPTOMS OFANXIETY DISORDERS:
Sr. no Psychological Physiological
1. Feeling of fear and apprehensive Cardiovascular: Palpitation, tachycardia, chest pain
2. Dizziness and fainting
Gastro- Intestinal: Dry mouth, lump in throat, nausea,
abdominal discomfort, diarrhoea.
3. Poor concentration and high irritability
Respiratory: Hyperventilation, difficulty catching
breath,
chest tightening
4. Insomnia
Genito- Urinary: Increased urine frequency, failure of
erection, amenorrhea.
5. Depersonalization and derealization Other:
• hot flushes/ cold chills,
• tremors,
• sweating,
• muscle tension,
• headaches,
• numbness and tingling sensations in extremities.
6. Night terrors
7. Themes of misfortune
8. Globus hystericus/ Globus pharyngeus
9. Exaggerated startle response
10. Unrealistic ideas of danger

11.  CLASSIFICATION OFANXIETY DISORDERS (ACCORDING TO DSM- 4)
1) Phobias:
a) Social Anxiety Disorder (Social phobia): With social anxiety disorder, people have an intense fear of others
judging them in social or performance situations. They are terrified of potential embarrassment or humiliation.
The anxiety can be extreme to the point of inhibiting the ability to socialize, date, or travel. (Judgemental)
b) Agoraphobia: Despite misconceptions the media perpetuates, agoraphobia does not necessarily involve a fear
of leaving home. Agoraphobia is a type of anxiety disorder in which people fear and avoid places or situations
that might cause them to panic or feel trapped, helpless, or embarrassed. Agoraphobia often occurs with panic
disorder. (Diff. betw claustrophobia and agoraphobia)
c) Specific Phobias: People with specific phobias avoid places, situations, objects, and even types of people -
clowns, for example - even if there is no threat or danger. Phobias do not necessarily stem from trauma
involving the object in question. They usually develop suddenly and without obvious explanation. Simply
thinking about a phobia can cause anxiety.

12.  List of specific phobias:
 Achluophobia - Fear of darkness
 Acrophobia - Fear of heights
 Autophobia - Fear of being alone
 Belonephobia - Fear of pins and needles
 Catoptrophobia - Fear of mirrors
 Claustrophobia - Fear of confined spaces
 Coulrophobia - Fear of clowns
 Gamophobia - Fear of marriage
 Hemophobia - Fear of blood
 Herpetophobia - Fear of reptiles Hydrophobia - Fear of water
 Insectophobia - Fear of insects
 Nosocomephobia - Fear of hospitals
 Coasterphobia – The fear of roller coasters.
 Ophidiophobia - Fear of snakes

13.  Trypanophobia - Fear of needles/injections
 Venustraphobia - Fear of beautiful women
 Mysophobia – The fear of germs.
 Thanatophobia – The fear of death.
 Atychiphobia – The fear of failure.
 Vehophobia – The fear of driving.
 Basiphobia – The fear of falling.
 Pyrophobia – The fear of fire.
 Pediophobia – The fear of dolls.
 Phasmophobia – The fear of ghosts.
 Pseudodysphagia – The fear of choking
 Chronophobia – The fear of the future.
 Scoleciphobia – The fear of worms.
 Philematophobia - Fear of Kissing

14. 2) Selective Mutism in Children: Social anxiety disorder is related to selective mutism in children, an anxiety disorder where a
child experiences an inability to speak in certain social settings such as school. More than 90% of children with selective mutism
also have social anxiety- according to the Selective Mutism, Anxiety and Related Disorders TreatmentCenter.
3) Panic Disorder: Panic disorder involves experiencing panic attacks that appear out of nowhere and occur unexpectedly, at least
for 1 month. The attacks are so intense they create anxiety about experiencing them in the future.
 In panic disorder, the attacks are triggered randomly and are followed by:
 At least 1 month of persistent concern about the possibility of additional panic attacks, AND/OR Worry about the
consequences of the attacks.
 Significant behavioral changes related to the attacks.
 The frequency and severity of panic attacks vary widely, with some persons having
 Moderately frequent attacks (e.g., once weekly for months at a time)
 Others reporting short bursts of attacks (e.g., daily for a week) • and still others reporting infrequent attacks (e.g., two
per month over many years.

15.  Panic attacks:
 Clinical presentation of panic attacks
 Depersonalization: It is described as a feeling disconnected or detached from one’s self.
 Derealization: It is a feeling that one’s surroundings are not real, especially as a symptom of mental
disturbance.
 Physical symptoms includes:
a) Abdominal distress & chest tightness with palpitation.
b) Chest pain or discomfort
c) Trembling or shaking
 During an attack, there must be at least four physical symptoms in addition to intense fear or discomfort.
 Symptoms reach a peak within 10 minutes and usually last no more than 20 or 30 minutes.
 Up to 70% of patients eventually develop agoraphobia, which is avoidance of specific situations (e g, being
in crowded places or crossing bridges) where they fear a panic attack might occur. Patients may become
homebound.

16. 4) Separation Anxiety Disorder: Someone has separation anxiety disorder when he or she experiences high
levels of distress when separated from a caregiver. This distress is so extreme it interferes with functioning
and social interactions. Most of the people who have the disorder are children and adolescents. There are,
however, some rare cases where adults developit.
5) Illness Anxiety Disorder [Hypochondria, Health Anxiety Disorder]: People with illness anxiety disorder
worry excessively about becoming ill or severely ill. Even after medical tests indicate health as optimim,
they sometimes believe normal sensations or minor symptoms are signs of severe illnesses. Ironically, their
anxiety regarding illness can often make them feel physicallysick.
6) Generalized anxiety disorder (GAD): Generalized anxiety disorder (GAD) is an anxiety disorder
characterized by excessive, uncontrollable and often irrational worry about events or activities. The person
gets anxious about everything in day to day life, due to compromised self esteem, defense mechanism and
problem solving skills.

17. 7) Obsessive Compulsive Disorder [OCD]: OCD is a disorder in which a person has uncontrollable recurring
thoughts [obsessions] and behaviors [compulsions] they feel the urge to repeat excessively. Rather than
anxiety, during their compulsions some people with OCD experience a feeling of disgust or something not
being right. Nonetheless, anxiety can sometimes be a crucial factor in the development of OCD. For
example, someone with OCD might have an intense anxiety that something bad will happen if they do not
perform their compulsive behaviors such as switching a light switch on and off. (So only obsession can
there, but only compulsion cant be there, compulsion always will be after obsession), But again showing
Activity is termed as illness, thinking in not- that’s why having only obsession cant be termed as illness, but
when it accompanies with compulsion it becomes illness).
8) Post Traumatic Stress Disorder [PTSD]: PTSD involves an extended period of extreme stress and fight-
or-flight responses that occur repeatedly despite there being no stressor. People develop PTSD after
experiencing trauma such as sexual assault or nearly people losing their lives. PTSD can also develop
without any significant trauma.

18. 11. Substance induced anxiety disorder:. People with this type of anxiety feel restless or nervous due to consuming substances or
stopping the intake. This is not limited just to drugs, it can also be generated by consuming alcohol, caffeine, phencyclidine, inhalants,
cocaine, amphetamines or other hallucinogens.
➢ Known medications that can cause substance-induced anxietyinclude:
• Analgesic
• bronchodilators
• Anticholinergics
• Anaesthetics
• Insulin
• Oral contraceptives
• Antiparkinsonian
• Anticonvulsants
• Lithium
• Antipsychotic
• Antidepressants
• Corticosteroids

19.  DIAGNOSTIC CRITERIA FOR ANXIETY DISORDERS (ACCORDING TO DSM- 4):
Sr.
no. Criteria
1. Excessive anxiety and worry (apprehensive expectation), occurring for at least for 6 months.
2. The individual finds it difficult to control the worry.
3. The anxiety and worry are associated with at least 3 or more from 6 symptoms, for at least 6 months.
a. Restlessness, feeling keyed up or on edge
b. Being easily fatigued
c. Difficulty in concentrating or mind going blank
d. Irritability
e. Muscle tension
f. Sleep disturbances (difficulty in falling or staying asleep).
4. The anxiety, worry and physical symptoms cause significant distress or impairment in social, occupational or
or other area of functioning.
5. The disturbance is not attributable to physiological effect of substance or another medical condition.
6. The disturbance is not explained by any another mental disorder.

20. MANAGEMENT FOR ANXIETYDISORDERS:
 Pharmacological management:
→ 3 major neurotransmitters are targeted in pharmacological treatment of anxiety.
Sr. no. Neurotransmitters Drug used
1. Gamma aminobutyric acid (GABA) Benzodiazepines
2. Serotonin
Selective Serotonin Reuptake Inhibitor
(SSRI’s)
3. Norepinephrine
Serotonin and Norepinephrine
Reuptake inhibitors (SNRI’s)

21. COMMONLY USED DRUGS FOR ANXIETY DISORDERS:
❖ Benzodiazepines
 Lorazepam
 Clonazepam
 Diazepam
 Chlordiazepoxide
 Clobazam
❖ SSRI’s
 Fluoxetine
 Paroxetine
 Escitalopram
 Sertraline
 Fluvoxamine
❖ SNRI’s
 Venlafaxine or desvenlafaxine
 Duloxetine
 Atomoxetine
 Reboxetine
 Milnacipran

23. HOW ANTI-ANXIETY DRUGS COMMONLY ACTS?
Anxiolytic drugs acts specifically on Central Nervous System to produce the calm and
sedative effect, in irder to control the symptoms of anxiety.

24. 1.BENZODIAZEPINES
Mechanism of action to reduce anxiety:
Benzodiazepines acts by binding to GABA-A
receptor in the brain.
Opens up the chloride channel.
Reduction of neuronal excitability.

25. WHERE ALL BENZODIAZEPINES ARE USED?
1. Anxiety disorders
2. Sleep disorders
3. To treat Epilepsy
4. In anesthesia

26. 2. BARBITURATES
What are Barbiturates?
 Barbiturates are a kind of depressant or sedative drug. They are an old
class of drug used to relax the body and help people sleep.
 Barbiturates are a class of drugs derived from barbituric acid that act as
depressants to the central nervous system. These drugs are used as
sedatives or anesthetics and have the potential to become addictive.

27. How Barbiturates works on anxiety?
 Barbiturates INCREASES the level of GABA in brain.
 GABA is responsible to control the neuronal excitability.
 Increase in GABA, Reduces the anxiety but generating calming
effect due to sedation.

28. 3.AZAPIRONES (BUSPIRONE)
FIRST DRUG OF CHOICE FOR ANXIETY
(Known as classical drug in treatment of anxiety disorders)
MECHANISM OF ACTION OF BUSPIRONE:
 Selective agonistic action on 5HT-1A receptor
 That means selective serotonin agonist receptor. Acts on specific receptor of serotonin and
not on all serotonin receptors.
Weak D2 blocking action
No antipsychotic
No risk for Extrapyramidal syndrome

29. Advantages of Buspirone over other anti –anxiety drugs. Why it is first
drug of choice for anxiety?
Because other groups of anti-anxiety drugs does not only acts on anxiety specifically. Where as
Buspirone does.
Buspirone Advantages:
 No Sedative effect
 No hypnotic effect
 No muscle relaxant effect
 No Anti- convulsive effect
 No CNS Depressant effect
 Does not affect driving skills
 No or minimal Dependency
 No Tolerance
 No Withdrawal symptoms

30. 4. BETA BLOCKERS
PROPRANOLOL – also called as atenolol
Mechanism of action of Propranolol:
 Non-selective beta adrenergic antagonist used to treat hypertension, angina, atrial fibrillation,
myocardial infarction, migraine, essential tremor, hypertrophic subaortic stenosis, and
pheochromocytoma.
 Act by blocking Peripheral sympathetic system.
 Reduce somatic symptoms of anxiety. (Convulsions)
 Decrease BP & slow HR.
 Used in social phobia.
 Propranolol are less effective for other forms of anxiety.

31. HYDROXYZINE
 Hydroxyzine is an H1 antihistaminic with sedative, antiemetic,
antimuscarinic and spasmolytic properties.
 Hydroxyzine used in reactive anxiety or that associated with marked
autonomic symptoms.
 It is useful in pruritus (itching diseases) and (urticaria red infection
rashes on skin).
5.SEDATIVES

32. 6. ANTI-DEPRESSANTS (SSRI’s)
 SSRI’s are been used mostly for the anti-anxiety effect too.
 As it acts selectively on serotonin receptors and has reuptake
inhibitory action. Preventing the loss of serotonin from receptors.
 Thus serotonin levels are increased and the depressive effect in
anxiety disorders are been reduced.

33. When anti-depressants are used in anxiety disorders?
 Selective serotonin anti-depressants are mostly used in PTSD.
 Tricyclic anti-depressants are widely used for panic attacks where
there is anxiety with depression.

34.  Psychotherapies:
→ Psychotherapies which are used for management of anxiety disorders are as follows:
1) Cognitive therapy:
 Cognitive therapy focuses on changing patterns of thinking and beliefs that are associated with, and trigger, anxiety. For
example, a person with a social phobia may make their anxiety worse by negative thoughts such as, ‘Everyone thinks I’m
boring’.
 The basis of cognitive therapy is that beliefs trigger thoughts, which then trigger feelings and produce behaviors. For
example, let’s say you believe (perhaps unconsciously) that you must be liked by everyone in order to feel worthwhile. If
someone turns away from you in mid- conversation, you may think, ‘This person hates me’, which makes you feel anxious.
2) Behavior therapy:
 A major component of behavior therapy is exposure. Exposure therapy involves deliberately confronting your fears in order
to desensitize yourself. Exposure allows you to train yourself to redefine the danger or fear aspect of the situation or trigger.

35. Supportive therapies:
 Mindfulness:
→ When feeling anxious, a person can spend a significant amount of time caught up in anxiety-provoking thoughts. Mindfulness
guides us to bring our attention back to the present moment and unhook from thoughts that may beunhelpful.
 Relaxation techniques:
→A person who feels anxious most of the time has trouble relaxing, but knowing how to release muscle tension can be a helpful
strategy.
→ Relaxation techniques include:
• progressive muscle relaxation
• abdominal breathing
• isometric relaxation exercises.
 Correct breathing techniques:
1) The physical symptoms of anxiety may be triggered by hyperventilation, which raises oxygen levels and reduces the amount of
carbon dioxide in the blood. Carbon dioxide assists in the regulation of the body’s reaction to anxiety and panic.

36.  RECAPTUALIZATION:
1. Define Anxiety & Anxiety disorder.
2. What do you mean by eustress and distress?
3. Write down the physiological & psychological symtoms of anxiety.
4. Write the classification of anxiety disorders according to dsm-4.
5. Elaborate the role of physiotherapist in the management of client with anxiety disorder.

37.  BIBLIOGRAPHY:
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4. “Dr. Bimla Kapoor”, ‘A textbook of Psychiatric Nursing’, ‘Volume 2’, ‘2nd edition’, ‘Kumar publication’- page no.- 144 to
152.
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