PHA 535: Anxiety Disorders and Phobias

• Anxiety disorders and phobias are covered in Human Behavior and Psychiatry, PHA 535, Spring 2025, with Professor Renee Levy.

Anxiety vs. "Normal" Anxiety

• Anxiety becomes a disorder when worry preoccupies an individual's thoughts, impeding psychosocial function.
• "Normal" anxiety relates to living life and can be associated with medical or psychiatric conditions.

State vs. Trait Anxiety

• State anxiety depends on stressors which increase awareness, vigilance, and appropriate fear to ensure safety.
• Trait anxiety involves pervasive worry based on a perception of threat, not necessarily an actual threat.

Anxiety Disorders Generally

• Anxiety disorders are the most common psychiatric disorders.
• An estimated 15% of the population experiences them.
• The median age of onset is in the mid-20s, although anxiety disorders can emerge in childhood.
• Women are twice as likely as men to be affected.

Pathology of Anxiety

• Genetics contribute about 50% to the correlation of anxiety disorders.
• Chemical imbalances, trauma, poor parenting, state of the world, and neuroinflammation theories are all elements of the pathology.

DDX for Anxiety: Cardiac

• Angina, arrhythmias- specifically supraventricular tachycardia- congestive heart failure, infarction, and mitral valve prolapse can be on the differential.

DDX for Anxiety: Endocrine

• Hyperthyroidism and premenstrual dysphoric disorder can be on the differential.
• Hypothyroidism is less likely to present with anxiety-like symptoms, typically causing fatigue, depression, and decreased metabolism instead.

DDX for Anxiety: Neoplastic

• Carcinoid tumors secrete serotonin, histamine, tachykinins, kallikrein, and prostaglandins.
• Insulinoma
• Pheochromocytoma, displaying paroxysmal HTN, sweating, tachycardia, and anxiety, requires diagnosis via 24-hour urine collection for metanephrines and catecholamines.

DDX for Anxiety: Pulmonary

• Asthma, embolism (thrombotic vs. fat), and COPD should be considered.

DDX for Anxiety: Medications/Drugs

• Alcohol, sedative, or nicotine withdrawal
• Antidepressants
• Caffeine
• Hallucinogens
• Psychostimulants (e.g., methylphenidate, amphetamine)
• Steroids (corticosteroids, anabolic steroids)
• Stimulant abuse (e.g., cocaine)
• Sympathomimetics (e.g., pseudoephedrine)
• It is essential to ask about medication and drug use.

Autonomic Nervous System

• The parasympathetic system calms, while the sympathetic system stimulates with epinephrine during "fight or flight" responses creating increased heart rate, sweating, and heightened alertness.

Screening

• The USPSTF suggests screening individuals aged 8 years and older for anxiety.

Generalized Anxiety Disorder (GAD) Epidemiology

• Women are 2-3 times more likely than men to have GAD.
• GAD is common in the elderly population.

GAD Diagnostic Criteria

• Diagnostic criteria include excessive anxiety and worry (apprehensive expectation), occurring most days for at least 6 months, about events or activities (such as work or school performance); difficulty controlling the worry; and the presence of 3 or more symptoms
• Only one item is required for children.

Mnemonic

• AND I CREST is a mnemonic for anxiety.
• A: Anxious, nervous, or worried on most days about a number of events or activities
• N: No control over the worry
• D: Duration of 6 months
• I: Irritability
• C: Concentration impairment
• R: Restlessness
• E: Energy decreased
• S: Sleep impairment
• T: Tension in muscles

Evaluation

• GAD 2: 2 question screen for generalized anxiety.
• If positive, GAD 7: 7 question screen with Likert scale.
• Using a cut-off of 8 the GAD-7 has a sensitivity of 92% and specificity of 76% for diagnosis of generalized anxiety disorder.

GAD Other Physical Symptoms

• Weight loss: requires work up
• Headaches
• Nausea
• Numbness in hands and feet
• Muscle aches
• Difficulty swallowing: work up, consider globus hystericus

Psychiatric Diagnoses That Preclude Anxiety Disorders

• Major depression
• Developmental disorders (e.g., autism spectrum)
• Dissociative disorders
• Personality disorders
• Somatoform disorders
• Schizophrenia (and other psychotic disorders)

Diagnoses That Preclude Generalized Anxiety Disorder (GAD)

• Obsessions in obsessive-compulsive disorder
• Separation anxiety disorder (children)
• Posttraumatic stress disorder (PTSD)
• Anxiety about gaining weight in anorexia nervosa
• Body dysmorphic disorder
• Illness anxiety disorder
• Social anxiety disorder
• Phobic objects or situations

GAD Treatment

• Cognitive Behavioral Therapy (CBT) is more effective in the long term than medication.

GAD Tx: CBT

• CBT goals shift negative thought patterns to positive, realistic ones.
• Includes exposure strategies for gradual confrontation with anxieties.
• Approximately 1/3 of patients respond substantially, while another 1/3 do not respond to treatment.

GAD Treament: Address Specific Stressors

• Assertiveness training, rehearsal, financial planning, relationship counseling
• Exercise to release tension, improve fitness, enable manage of tasks/ studying
• Stop or reduce caffeine intake.

GAD Medications

• SSRIs; escitalopram (Lexapro) and paroxetine (Paxil) are FDA-approved, but other SSRIs can work.
• SSRIs are first-line medications due to effectiveness and tolerability.
• SNRIs: venlafaxine (Effexor, Effexor XR) and duloxetine (Cymbalta)
• Tricyclics (off-label): imipramine (Tofranil)
• Beta-blockers (off-label): Low-dose propranolol (Inderal), also for performance anxiety.

GAD Medications: Benzodiazepines

– FDA approved for anxiety, not GAD.

• Alprazolam (Xanax, Xanax XR)
• Chlordiazepoxide (Librium)
• Clonazepam (Klonopin)
• Clorazepate (Tranxene)
• Diazepam (Valium)
• Lorazepam (Ativan)
• Be mindful of binding to gamma-aminobutyric acid type A receptors and enhancing GABA
• It is effective and quick acting, being a depressant relaxant.
• Used for short-term treatment, if at all.
• Not recommended for long-term use, can cause 2º tolerance, psychomotor impairment, cognitive and memory impairments, physical dependence and withdrawal syndrome.

GAD Medications: Azaspirodecanedione

• FDA approved for anxiety, not GAD.
• Buspirone (Buspar) is not as effective as SSRIs or benzodiazepines.
• It acts as a serotonin 1A receptor partial agonist.
• Buspirone has minimal abuse potential and is specifically approved for anxiety (but not GAD); it's often used as an adjunct treatment.
• Produces fewer motor, memory, or concentration impairment than benzodiazepines.
• There is no abuse potential; it does not cause dependency or withdrawal, even after long periods of exposure.
• It is mostly used as "add on" treatment.
• Fewer drug interactions; avoid grapefruit juice.
• Requires at least 3 weeks to mitigate anxiety.
• Stimulates the locus coeruleus, which may be associated with a paradoxical increase in anxiety in some patients.

Panic Attacks

• At least 50% of patients with panic disorder have a family history.
• Characterized by sudden episodes of intense fear accompanied by physical symptoms such as dizziness, tingling sensations, chest discomfort, or shortness of breath.

Panic Attack DSM 5 TR Diagnostic Criteria

• Recurrent unexpected episodes that include 4 or more:
  • Palpitations, sweating, shaking, SOB, choking feeling, chest pain, nausea, dizziness, chills or heat sensations, paresthesia, derealization or depersonalization, fear of going crazy, fear of dying, uncontrollable fear, and hyperventilation.
• Symptoms reach maximum severity within 10 minutes but can peak within a few seconds.
• Symptoms often last less than 1 hour and diminish within 30 minutes.

Panic Disorder Diagnostic Criteria

• Panic disorder is marked by recurring, unexpected panic attacks.
• Significant behavioral changes may occur for at least a month.
• At least one of the attacks has been followed by 1 month (or more) of one or both of:
  • Worry about additional panic attacks or their consequences.
  • Maladaptive behaviors to avoid having panic attacks, such as avoidance of exercise or unfamiliar situations.

Agoraphobia

• A fear of situations where escape might be difficult.
• A fear of being trapped, helpless, or embarrassed.
• Agoraphobia is the marked fear of situations where escape might be difficult or help unavailable.

Agoraphobia DSM 5 TR Diagnostic Criteria

• A marked fear or anxiety in ≥ 2 of the following five situations: using public transportation, being in open spaces, being in enclosed spaces (e.g., shops, theaters, cinemas), standing in line or being in a crowd, and being outside the home alone.

Panic Disorder Treatment

• CBT is the treatment of choice.
• Biofeedback, guided imagery, and relaxation techniques assist in treatment
• Supportive family and friends can help increase the rate of recovery.
• Support Groups for "terminal uniqueness" are also beneficial

Interoceptive (Inoculation) Exposure

• This reproduces anxiety attack symptoms for one minute.
• Intentional hyperventilation: creates lightheadedness, blurred vision, dizziness.
• Spinning in a chair: creates dizziness, disorientation.
• Straw breathing: creates dyspnea, airway constriction.
• Breath-holding: creates the sensation of being out of breath.
• Running in place: creates increased heart rate, respiration, and perspiration.
• Body tensing: addresses agoraphobia.
• Interoceptive exposure therapy intentionally reproduces anxiety symptoms to help patients tolerate and diminish their fear of these sensations.

Panic Disorder Medication Treatment

• First-line pharmacological treatments are SSRIs or venlafaxine (Effexor XR).
• Consider tricyclic antidepressants like imipramine (off-label).
• Alprazolam (Xanax) and clonazepam (Klonopin) have specific anti-panic effects.

Panic Disorder Prognosis

• Usually chronic, the long-term prognosis is good.
• Treat as early as recognized.

Specific Phobia

• Involves an unreasonable/irrational fear of specific objects or situations.
• Actively avoid direct contact with the objects or situations.
• Severe cases may incite a panic attack by any suggestion, anticipation, or depiction of them.
• DSM-5 categorizes specific phobias into distinct types.

Phobias Types

• Animal type includes fear of spiders (arachnophobia) and snakes (ophidiophobia).
• Natural environment type includes a fear of heights (acrophobia), lightning and thunderstorms (astraphobia), and aging (gerascophobia).
• Situational type includes fear of small confined spaces (claustrophobia) and being "afraid of the dark" (nyctophobia).
• The blood/injection/injury type involves a fear of medical procedures, including needles and injections (trypanophobia).
• Other phobias include a fear of the number 13 (triskaidekaphobia) and clowns (coulrophobia).

Social Anxiety

• The patient has a fear of scrutiny by others lasting 6 months or more.
• Examples: having a conversation, meeting unfamiliar people, being observed (e.g., eating or drinking), and performing in front of others (e.g., giving a concert).

Specific Social Phobias

• Anxiety occurs only in a specific situation, such as a fear of public speaking.

Treatment of Phobias

• Exposure therapy
• Inoculation Therapy: Relaxation, self-soothing talk, breathing; rehearsing, role-playing, visualizing with exposure; diversion techniques
• Desensitization
• CBT
• SSRIs
• Beta-blocker: Propranolol for performance anxiety

Obsessive-Compulsive Disorder (OCD)

• The 4th most common diagnosed disorder that's nearly as common as asthma and DM.
• In the United States, one in 50 adults has OCD.
• Differentiated from obsessive-compulsive personality disorder (OCPD), the autism spectrum disorder, or some other condition: someone who is meticulous, perfectionistic, absorbed in a cause, or otherwise fixated on something or someone is NOT OCD.

OCD Etiology

• Genetics (10-20%) which includes possible Tourette syndrome gene associations
• Head trauma
• Poor correlation with psychological trauma
• Abnormal brain "circuitry"
• Nero autoimmune diseases
• Note an upward of a 43% increase in those with autoimmune disorders that have OCD

Red Flags: Potential Autoimmune/Obsessive-Compulsive Disorder

• Subacute onset of OCD (< 3 months)
• Treatment resistance despite guideline-based therapy
• Atypical age of onset (early childhood or later adulthood)
• Atypical presentation of OCD
• Accompanying neurological signs and new seizures
• New headache
• Anatomic dysfunction
• Suspect adverse response to antipsychotics (especially if malignant neuroleptic syndrome is suspected)
• Temporal association* of OCD onset with infections (such as Group A streptococcal infection)
• Comorbid autoimmune diseases and malignancies
• Suspicious alterations in diagnostic investigations

Two Types of OCD Thoughts

1. Pathologic doubt, e.g., dread and uncertainty
2. Incompletion, or "not-just-right" perceptions

Intrusive Thoughts

• Inappropriate, obsessive thoughts occur at inappropriate moments and fit into common categories:
  • Aggressive
  • Sexual
  • Blasphemous religious
  • Fear of harm

OCD Compulsions

• The patient has compulsive behaviors to alleviate the obsession.
• These behaviors are highly secretive due to embarrassment.

OCD Characteristics

• Symptoms can be alienating and time-consuming and cause severe emotional and economic loss.
• Ego dystonic
• May be mental (counting, phrase repetition)
• May involve avoidance

Other Diagnoses with OCD-Like Symptoms

• Anorexia and bulimia nervous
• Tourette syndrome
• Autism spectrum disorder/ "Asperger syndrome"
• Compulsive skin picking
• Body dysmorphic disorder
• Trichotillomania
• Obsessive-compulsive personality disorder

OCD Relationships: Dysfunctional Facilitation

• In "co-dependency," the facilitator may perform rituals or permit the patient to control the environment or common time.
• Co-dependent behavior occurs when a partner or family member allows or facilitates obsessive-compulsive rituals, effectively supporting or enabling the OCD behaviors, thereby maintaining the disorder.
• Allows behavior without normal constraints.
• Gives into pleading, nagging, demanding, or threats.

OCD Relationships: Adversarial

• The patient has an antagonistic-defensive dyad.
• The Antagonistic partner of "patient” acts in a caustic, demeaning manner and does not understand or accept the illness.
• Instability, loss of self-esteem, and stress exacerbate the patient's OCD and lead to further antagonism.

OCD Healthier Interacting

• Talk openly about behaviors that impact household routines and time.
• Gradually reduce participation in the person's rituals and explain the reasons for doing this.
• Encourage the person with OCD to be a part of the decision.
• Set realistic goals together and talk about ways to ensure that everyone will abide by the plan.
• If the person with OCD is in treatment, offer to attend a session.
• Try to maintain normal household routines, connections, and events whenever possible.
• Reinforce positive communication and behaviors (such as sharing, hugs and helping each other)

ODC Treatment: Exposure and Ritual Prevention

• Also known as "exposure and response prevention" or ERP.
• This involves gradually learning to tolerate the anxiety associated with not performing the ritual/ behavior.
• ERP therapy involves exposing patients to anxiety-provoking situations or triggers while preventing them from engaging in compulsive rituals.
• Over time, patients learn to tolerate anxiety without resorting to compulsions, significantly reducing OCD symptoms.
• It is the most effective treatment for OCD (70% in one study).
• With ERP alone, one can become completely symptom-free.
• Must be highly motivated and consistent.

OCD Treatments: Cognitive Restructuring

• Thoughts of the patient replace irrational beliefs with more accurate and beneficial ones.
• Cognitive restructuring therapy in OCD aims to replace irrational or harmful thoughts with more realistic and helpful beliefs, thereby reducing anxiety-driven compulsive behaviors.
• Includes relaxation techniques and family therapy.

OCD Medications

• SSRIs are the drugs of choice.
• Fluvoxamine (Luvox) SSRI with special indication
• It's known to be most effective at higher dosage ranges and often requires longer treatment durations (up to 12 weeks) to achieve maximum benefit.
• Need to achieve maximal benefit for OCD at 12 weeks.
• Most effective at higher range of dosing
• If no improvement at 8 weeks, increase dose or change
• 20% will improve with another SSRI
• After a third SSRI failure, a trial of clomipramine
• Clomipramine (Tofranil), but ↑ anticholinergic side effects
• Medication can be lifelong
• 50-60% will have a response
• Therapy and medication must be synergic.

OCD Neuro Stimulation

• Deep-brain stimulation (DBS) and vagus nerve stimulation (VNS) do not require destruction of brain tissue.
• Surgery is only an option after failing several attempts at medication (at the full dosage) with augmentation and several months of intensive cognitive-behavioral therapy with exposure and ritual/response prevention.

Other Repetitive Disorders

• Not the same as OCD, but are associated with OCD.
• Some behaviors bring some relief.
• Body dysmorphic disorder produces more anxiety.

Body Dysmorphic Disorder

• An individual has a preoccupation with one or more perceived defects/flaws that are not observable in physical appearance or appear slight to others.
• Performed repetitive behaviors (mirror checking, excessive grooming, skin picking, reassurance-seeking) or mental acts (comparing his or her appearance with that of others) with appearance concerns.
• Not better explained by an eating disorder.
• A Specifier is to consider if the patient has muscle dysmorphia: Is preoccupied that their body build or body area is too small or insufficiently muscular. -One is to Specify if: -Indicate degree of insight into body dysmorphic disorder beliefs is good, fair, poor, absent, or delusional.
• The Patient can be suicidal

Body Dysmorphic Disorder Treatment

• CBT
• SSRIs

Hoarding Disorder

• Patients struggle with discarding or parting with possessions, regardless of their value and have perceived needs to save the items and become distressed if they have to discard them
• Substantially compromises area use
• If living areas are uncluttere, it is only because of the interventions of family members, cleaners, and authorities
• Enjoys acquiring and is distressful when they need to let go
• Individuals typically gain pleasure or security from acquiring items.

Hoarding vs OCD

• OCD*
  • The patient has obsessions with compensatory compulsions.
  • Acquisition is usually not there; but if present, items are acquired due to obsession, NOT because of a genuine desire to possess items.
  • The possession of items is not pleasurable per se.
  • May contain bizarre objects like nail clippings, feces, urine
• Hoarding*
  • The patient has buying and having for pleasure/security.
  • The possessions are seen as either useful, pleasurable, or of some possible use/repair at a later date.

Hoarding Disorder Treatment

• CBT and therapy

Trichotillomania

• One is Recurrently pulling out their hair results in thinning/Alopecia
• Repeated attempts to decrease OR stop
• It is NOT related to cosmetics or body dysmorphic disorder, and can be any body area.
• Treatment should be Pysciatry and Hypnosys

Pathologic Excoriation (Skin Picking Disorder)

• One has a Recurrent skin picking which results in the lesions
• Repeated attempts to decrease/ stop
• One may use fingers, tweezers, or biting
• May be triggered by feelings of anxiety or boredom
• May be preceded by tension
• May lead to gratification, pleasure, or a sense of relief
• It is Not related to body dysmorphic disorder
• The treatment plan should include no meds or hypnosis
• The patient may be referral to Psysciatry
• Pathologic Excoriation (skin picking disorder) involves recurrent skin picking causing visible damage, associated with tension relief or gratification.
• It is distinguished from OCD due to the specific compulsive behavior of skin-picking itself.