Overview
The second anxiety lecture works through the individual anxiety disorders and two anxiety-related disorders that DSM-5 moved out of the anxiety chapter. It covers panic disorder, agoraphobia, specific phobia, separation anxiety disorder, social anxiety disorder and generalised anxiety disorder, then post-traumatic stress disorder, acute stress disorder and obsessive compulsive disorder. The organising principle throughout is differential diagnosis: the disorders share the same physiological arousal, so what separates them is the object or situation that is feared or avoided, and whether another mental or physical disorder explains the picture better.
Differential diagnosis: the organising question
- The question to hold throughout is how you tell one anxiety disorder from another.
- The key discriminator is what object or situation is feared or avoided.
- Always consider whether the presentation could be another mental disorder, or explained by a physical disorder.
- The two-person contrast on the plane makes the point: both men have identical anxiety symptoms in flight (sweating, rapid heart rate, trembling, tingling), but the first thinks “the plane is going to crash” (fear of the situation, pointing to specific phobia) and the second thinks “I must be having a heart attack” (fear of the bodily symptoms themselves, pointing to panic).
Panic attacks and Panic Disorder
A panic attack is not a disorder in itself. It is a symptom that can occur across disorders.
Panic attack, defined: an intense abrupt surge of fear that includes 4 or more of the following symptoms and peaks within 10 minutes.
- Palpitations, pounding heart, accelerated heart rate
- Sweating
- Trembling or shaking
- Shortness of breath or smothering
- Feelings of choking
- Chest pain or discomfort
- Nausea or abdominal distress
- Dizzy, unsteady, lightheaded, faint
- Chills or heat sensations
- Numbness or tingling sensations
- Derealization or depersonalisation
- Fear of losing control or going crazy
- Fear of dying
Panic disorder criteria:
- A. Recurrent unexpected panic attacks, and
- B. At least one attack has been followed by 1 month or more of one or both of: (1) persistent concern or worry about having additional attacks or their consequences (heart attack, going crazy); (2) a significant maladaptive change in behaviour related to the attacks (avoidance).
- C. The disturbance is not attributable to the physiological effects of a substance or another medical condition.
- D. Not better explained by another mental disorder.
- Lifetime prevalence 4.7%, median age 20 to 24 years.
Things to note:
- Attacks may be full symptom or limited symptom attacks.
- Attacks may be expected (cued: where they have typically occurred, worries, stress) or unexpected (no obvious cue, the person may even be relaxed).
- Criterion A requires recurrent, meaning more than one, unexpected attacks.
- Comorbidity is frequent, especially with agoraphobia.
Important
Criterion C means panic disorder is a diagnosis of exclusion for medical and substance causes. Conditions that may produce panic-like symptoms: anaemia, angina, arrhythmia, chronic obstructive pulmonary disease, Cushing’s disease, electrolyte disturbance, epilepsy, hyperthyroidism, hypoglycaemia, parathyroid disorders, phaeochromocytoma, pulmonary embolus and transient ischaemic attacks (Ballenger, 1997). Substance causes: marijuana, caffeine and general anaesthetics can cause panic attack symptoms, as can withdrawal from substance use and effects from medication.
Agoraphobia
- A. Marked fear or anxiety about two or more of: (1) using public transport (cars, buses, trains); (2) being in open spaces (parking lots, market places); (3) being in enclosed spaces (shops, cinema); (4) standing in line or being in a crowd; (5) being outside of the home alone.
- B. The individual fears or avoids these situations because of concerns about not being able to escape, help not being available, or embarrassing symptoms.
- C. The situations almost always provoke fear or anxiety.
- D. They are avoided, need a companion, or are endured with intense fear.
- E. The fear is out of proportion to the actual danger posed.
- F. Persistent, typically 6 months or more.
- G. Causes significant distress or impairment in functioning.
- H and I. Not better explained by another disorder.
- Debilitating, and may affect all areas of functioning (social, occupational, routines).
- Lifetime prevalence 1.4%.
Specific Phobia
- Marked fear or anxiety about a specific object or situation (flying, animals, injections, blood).
- The object or situation almost always provokes immediate fear or anxiety.
- It is avoided, or else endured with intense anxiety.
- The fear is recognised as excessive or unreasonable.
- Persistent, typically 6 months or more.
- The avoidance, fear or anxiety causes significant distress or impairs functioning (social, occupational, routines).
- Not better explained by another mental disorder.
- Lifetime prevalence 7.2% to 11.3%.
In children: children may not always identify the physiology or the thoughts (they say things like “feel funny”, report no thoughts, or call it annoying). Therefore:
- Avoidance is often the key identifier.
- Look for somatic symptoms (feeling sick, sore tummy).
- Look for crying, tantrums and clinging.
Separation Anxiety Disorder
Developmentally inappropriate and excessive fear concerning separation from those to whom the individual is attached, evidenced by 3 or more of:
- Recurrent excessive distress when anticipating or experiencing separation from home or attachment figures
- Persistent or excessive worry about losing an attachment figure, or about possible harm to them
- Persistent worry about an event that causes separation (getting lost, illness, accident, kidnap)
- Reluctance or refusal to go out (school, friends) due to fear of separation
- Reluctance to be alone or without attachment figures, at home or in other settings
- Reluctance or refusal to sleep away from home, or without the attachment person there
- Nightmares involving separation
- Repeated complaints of physical symptoms when separated or anticipating separation (headache, stomach ache, nausea, vomiting)
Additional requirements:
- Persistent: at least 4 weeks for a child or adolescent, 6 months for an adult.
- Causes significant distress or impairment in functioning (social, occupational, routines).
- Not better accounted for by another mental disorder.
Typical presentation:
- Avoidance of school, going to friends’ houses, staying away from home
- Somatic symptoms (sick, sore tummy, headache)
- Extreme reaction to forced separation, verbal and behavioural
- Most common in middle childhood, 6 to 9 years
- Check for other factors, such as bullying or concerns about academic ability
Social Anxiety Disorder
- A. Marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny of others (conversing, meeting new people, eating in front of others, speeches).
- B. Fear that he or she will act in a way, or show anxiety symptoms, that will be negatively evaluated (humiliating, embarrassing, rejection).
- C. The social situations almost always provoke fear or anxiety.
- D. They are avoided or else endured with intense anxiety.
- E. The fear is recognised as excessive, unreasonable, or out of proportion to the actual threat posed.
- F. Persistent, typically 6 months or more.
- G. The avoidance, fear or anxiety causes significant distress or impairs functioning (social, occupational).
- Rule out other diagnoses.
The paradox of social anxiety: the actual fear is of being nervous, inhibited and looking anxious, and that has a reasonable probability of being realised. The distortion is in overestimating the threat: one rejection, one poor performance, or others noticing does not usually ruin a person’s life. The person is hypervigilant to cues from others about their acceptability.
Descriptive characteristics:
- Lifetime prevalence 3% to 13% in the community, or 10% to 20% in clinics.
- Frequently develops in late childhood and adolescence, often with a history of shyness. In 75% of cases the age of onset is between 8 and 15 years.
- If untreated it can become chronic and lifelong.
- Often not recognised by general practitioners.
Generalised Anxiety Disorder
- A. Excessive anxiety and worry occurring more days than not for at least 6 months, about a number of events or activities.
- B. The individual finds it difficult to control the worry.
- C. 3 or more of: on edge, restless, keyed up; easily fatigued; can’t concentrate or mind going blank; irritability; muscle tension; sleep disturbance.
- D. The anxiety or worry causes clinically significant distress or impairment in social, occupational or other important areas of functioning.
- E. Not attributable to the physiological effects of a substance or another medical condition.
- F. Not better explained by another mental disorder.
The main feature is chronic worry about a number of life matters, with the worries judged to be excessive and uncontrollable. Typical domains: school or work performance, finances, family and other relationships, health (self and others), community and world affairs, and minor matters. Patients often say they have worried all their life.
GAD versus non-pathological worry:
| GAD | Non-pathological worry |
|---|---|
| Excessive, interferes with psychosocial functioning | Not excessive |
| More pervasive, more distressing, longer duration | Perceived as manageable |
| Frequently without a precipitant | Can be put off when more pressing matters arise |
| Impairs functioning and the ability to do things quickly and efficiently | Less likely to be accompanied by physical symptoms (on edge, tension) |
Theoretical work on worry:
- Type 1 worry (positive elements): worries about external events.
- Type 2 worry, worry about the worry (negative): “my worry is uncontrollable”, “I could go crazy with worrying”, “my worries will take over and control me”.
Where PTSD and OCD sit in DSM-5
The next two disorders are no longer grouped under anxiety disorders:
- Post-traumatic stress disorder is now under Trauma- and Stressor-Related Disorders.
- Obsessive compulsive disorder is now under Obsessive-Compulsive and Related Disorders.
Anxiety is nevertheless a large component in both, and they remain relevant to clinicians for treatment.
Post-traumatic Stress Disorder and acute stress disorder
Exposure to trauma comes first. A potentially traumatising event (PTE) is unpredictable, uncontrollable, severe, and a catastrophic violation of fundamental beliefs and expectations about safety, physical integrity, trust and justice. PTEs are not uncommon: population studies report 50% to 89% exposure. Examples include life threat, physical injury, exposure to violence, sexual assault, child sexual abuse and earthquake.
Immediate stress reaction: normal reactions to an abnormal event. Feelings of fear, sadness, anger, being overwhelmed, tearful or unsafe; feeling detached or withdrawn; difficulty with attention, concentration and planning; unwanted or recurring memories and bad dreams; sleep problems; replaying the event and “what if” thinking; wanting to avoid the feelings that arise from it; avoiding situations or cues that remind them of the experience.
PTSD criteria (for age 6 and over, adult):
- A. Exposure to actual or threatened death, serious injury or sexual violence by: directly experiencing the traumatic event; witnessing it in person as it occurred to others; learning the event occurred to a close family member or friend; or repeated or extreme exposure to aversive details of traumatic events.
- B. One or more intrusive symptoms associated with the event: intrusive distressing memories, dreams, flashbacks, intense distress or physiological reactions to internal or external cues.
- C. Persistent avoidance of stimuli associated with the event, external or internal.
- D. Negative alterations in cognition or mood: can’t remember, negative beliefs about self or world, self blame, horror, anger, fear, guilt, shame, feeling detached, not interested, unable to feel positive emotions, not trusting.
- E. Physiological arousal or reactivity: reckless, irritable, anger, can’t sleep, startle, hypervigilance.
- F. Duration of disturbance more than one month.
- G. Causes significant distress or impairment in functioning.
- Not attributable to substance use or another medical condition.
Acute stress disorder is similar, but occurs at least 3 days to one month after trauma exposure.
Epidemiology: lifetime prevalence of PTSD is 8%. Groups at risk include soldiers, people in war zones, emergency medical technicians, police, firefighters and people in disaster areas.
Obsessive Compulsive Disorder
- A. Characterised by the presence of obsessions, compulsions, or both.
Obsessions: recurrent and persistent thoughts (for example contamination), urges (for example to stab someone) or images (for example violent, horrific or sexual) that are experienced as intrusive and unwanted and cause marked distress or anxiety. The individual attempts to ignore or suppress such thoughts, urges or images, or to neutralise them with a thought or an act, that is, a compulsion.
Compulsions: repetitive behaviours (hand washing, checking, ordering) or mental acts (counting, repeating words silently) that the person feels driven to perform in relation to an obsession, or to rules that must be applied. The behaviours or mental acts are aimed at preventing or reducing anxiety, or preventing some dreaded event or situation.
Remaining criteria:
- B. Time consuming (more than one hour a day) or causing distress or impairment in functioning. Mild to moderate is 1 to 3 hours per day; severe is constant intrusive thoughts or compulsions.
- C and D. Not attributable to substance use or another medical or mental condition, and not better explained by another mental disorder.
- Lifetime prevalence 2.3%.
Common themes:
- Cleaning: contamination obsessions with cleaning compulsions
- Symmetry: symmetry obsessions with repeating, ordering and counting compulsions
- Taboo thoughts: aggressive, sexual or religious
- Harm: fear of harm to self or others, with checking compulsions
Worked cases
Knowledge check vignettes (hypotheses based on the information given):
- Susan, 20, a student who experiences anxiety when birds come near her; walking around campus and seeing birds land on the grass gives her a rapid heart rate, shaking and an urge to flee, and it is now affecting her ability to attend lectures on campus.
- Dave, 28, who suddenly experienced heart palpitations, sweating, trembling, unsteadiness and an intense feeling that he was going to die or collapse. His doctor found no medical explanation. He is now worried it will happen again.
- Margaret, 70, with severe anxiety symptoms (nausea, feeling of collapsing, tingling in fingers, shaking, rapid heart rate) when shopping at supermarkets, when driving further from home than she could walk, when trying to shop in the mall, and now beginning when she walks down the street.
- Two men in their mid thirties, both anxious on a plane with sweating, rapid heart rate, trembling and tingling, but with different cognitions: “the plane is going to crash” versus “I must be having a heart attack”.
Example exam question. Mark, a 9 year old boy, is seen at the GP with ongoing constipation to the point of stool leakage around the constipated mass and soiling in his pants. He is diagnosed with encopresis (voluntary or involuntary faecal soiling in children who have already been toilet trained) and referred for treatment. History: he was toilet trained without problems, but the problem began when he started school. He said the school toilets were really scary, with big pipes and funny noises, and he was afraid they would suck him in. When he went to the school toilets his heart would race and he would feel sick. He would use them for urinating because it was quick and he did not have to flush, but would not defecate at school because of having to flush, sit on the toilet, and stay there longer. He is now becoming scared of the toilet at home.
Question 1: give a psychological diagnosis, and the key diagnostic symptoms (physiological, cognitive, affective, behavioural) from the scenario.
- Diagnosis: specific phobia (2 points); anxiety disorder (1 point).
- Physiological: heart rate increase and feeling sick on exposure to the feared place.
- Cognitive: “the pipes will suck me in”, and thinking he cannot stay there for long.
- Affective: afraid, scared.
- Behavioural: avoidance of toilets, avoidance of flushing.
Question 2: what are the key diagnostic criteria from the scenario?
- There is marked anxiety about a specific situation, the toilets at school.
- The situation almost always provokes the fear.
- The situation is avoided if he can (he will not defecate at school, will not flush) or endured with anxiety (he uses it for urinating but experiences racing heart, nausea and fear).
- It causes him significant distress and impairment (constipation, holding, encopresis, soiling in pants, social problems due to smelling, routines) due to the avoidance.
- The problem is persistent: it began when he was 5 and he is now 9.
Summary points
- Anxiety is a common disorder.
- It can have a huge impact on functioning: occupational, social, educational and on daily routines.
- You need to recognise it, which means differential diagnosis, assessment, treatment and referral, and it is something to consider when medically treating patients.
Self-test
- What is the single key feature that distinguishes one anxiety disorder from another, and what two alternative explanations must always be considered?
- Define a panic attack, including the symptom threshold and the time course.
- List eight of the thirteen panic attack symptoms.
- State criteria A and B of panic disorder.
- Distinguish an expected from an unexpected panic attack, and explain why the distinction matters for diagnosing panic disorder.
- List five medical conditions and three substance-related causes that may produce panic-like symptoms.
- List the five situation categories in criterion A of agoraphobia, and state how many are required.
- Explain why a person with agoraphobia fears or avoids those situations.
- Describe the diagnostic features of specific phobia, including the duration requirement and prevalence.
- Explain why avoidance is the key identifier of specific phobia in children, and list the other features to look for.
- List six of the eight symptom criteria for separation anxiety disorder, and state the symptom count and duration required for a child and for an adult.
- State criteria A and B of social anxiety disorder.
- Explain the paradox of social anxiety.
- Describe the onset pattern and prevalence of social anxiety disorder.
- State the duration, frequency and associated-symptom requirements for GAD.
- Distinguish GAD from non-pathological worry on four points.
- Distinguish type 1 from type 2 worry, with examples.
- Where do PTSD and OCD now sit in DSM-5, and why are they still taught alongside the anxiety disorders?
- Define a potentially traumatising event and state how common exposure is.
- Describe criteria B to E of PTSD.
- Distinguish PTSD from acute stress disorder.
- Distinguish an obsession from a compulsion, giving examples of each.
- List the four common OCD themes, pairing the obsession with its typical compulsion.
- What is the time threshold in OCD criterion B, and what daily duration counts as mild to moderate?
- Predict the likely diagnosis for Margaret, the 70 year old with anxiety symptoms in supermarkets, when driving beyond walking distance from home, in the mall and now in the street, and justify it from the criteria.
- Two men have identical physical anxiety symptoms on a plane, but one thinks “the plane is going to crash” and the other thinks “I must be having a heart attack”. Explain what this contrast demonstrates about differential diagnosis.
- Integrative: Mark, aged 9, has encopresis and avoids the school toilets, which he believes will suck him in. Give the diagnosis and map his presenting features onto the physiological, cognitive, affective and behavioural domains.
Answers
Reveal answers
- The key is what object or situation is feared or avoided. Always also consider whether it could be another mental disorder, or whether it is explained by a physical disorder.
- An intense abrupt surge of fear that includes 4 or more of the listed 13 symptoms and peaks within 10 minutes. It is not itself a disorder.
- Any eight of: palpitations, pounding heart or accelerated heart rate; sweating; trembling or shaking; shortness of breath or smothering; feelings of choking; chest pain or discomfort; nausea or abdominal distress; dizzy, unsteady, lightheaded or faint; chills or heat sensations; numbness or tingling; derealization or depersonalisation; fear of losing control or going crazy; fear of dying.
- A. Recurrent unexpected panic attacks. B. At least one attack followed by 1 month or more of persistent concern or worry about further attacks or their consequences (heart attack, going crazy), and/or a significant maladaptive change in behaviour related to the attacks such as avoidance.
- Expected attacks are cued, for example by places where they have typically occurred, by worries or by stress. Unexpected attacks have no obvious cue and the person may even be relaxed. It matters because criterion A of panic disorder requires recurrent, that is more than one, unexpected attacks.
- Medical: any five of anaemia, angina, arrhythmia, COPD, Cushing’s disease, electrolyte disturbance, epilepsy, hyperthyroidism, hypoglycaemia, parathyroid disorders, phaeochromocytoma, pulmonary embolus, transient ischaemic attacks. Substance: marijuana, caffeine and general anaesthetics, plus withdrawal from substance use and medication effects.
- Using public transport; being in open spaces; being in enclosed spaces; standing in line or being in a crowd; being outside of the home alone. Two or more are required.
- Because of concerns about not being able to escape, about help not being available, or about embarrassing symptoms.
- Marked fear or anxiety about a specific object or situation (flying, animals, injections, blood); it almost always provokes immediate fear or anxiety; it is avoided or endured with intense anxiety; the fear is recognised as excessive or unreasonable; persistent, typically 6 months or more; causes significant distress or impairs functioning; not better explained by another mental disorder. Lifetime prevalence 7.2% to 11.3%.
- Children may not identify the physiology or the thoughts, saying things like “feel funny”, reporting no thoughts, or calling it annoying, so avoidance becomes the key identifier. Also look for somatic symptoms such as feeling sick or sore tummy, and for crying, tantrums and clinging.
- Any six of: recurrent excessive distress on anticipating or experiencing separation; persistent excessive worry about losing an attachment figure or harm coming to them; persistent worry about an event causing separation (lost, ill, accident, kidnap); reluctance or refusal to go out due to fear of separation; reluctance to be alone or without attachment figures; reluctance or refusal to sleep away from home or without the attachment person; nightmares about separation; repeated physical complaints when separated or anticipating separation. Three or more are required, persisting at least 4 weeks in a child or adolescent and 6 months in an adult.
- A. Marked fear or anxiety about one or more social situations involving possible scrutiny by others, such as conversing, meeting new people, eating in front of others or giving speeches. B. Fear of acting in a way, or showing anxiety symptoms, that will be negatively evaluated as humiliating or embarrassing or leading to rejection.
- The feared outcome, being nervous, inhibited and looking anxious, has a reasonable probability of actually happening. The distortion lies in overestimating the threat: one rejection, one poor performance, or others noticing does not usually ruin a person’s life. The person is hypervigilant to cues from others about their acceptability.
- It frequently develops in late childhood and adolescence, often on a background of shyness, with onset between 8 and 15 years in 75% of cases. Untreated it can become chronic and lifelong, and it is often not recognised by general practitioners. Lifetime prevalence is 3% to 13% in the community and 10% to 20% in clinics.
- Excessive anxiety and worry occurring more days than not for at least 6 months, about a number of events or activities, that the person finds difficult to control, with 3 or more of: on edge, restless or keyed up; easily fatigued; poor concentration or mind going blank; irritability; muscle tension; sleep disturbance.
- GAD is excessive and interferes with psychosocial functioning, is more pervasive, more distressing and of longer duration, is frequently without a precipitant, and impairs the ability to do things quickly and efficiently. Non-pathological worry is not excessive, is perceived as manageable, can be put off when more pressing matters arise, and is less likely to be accompanied by physical symptoms such as feeling on edge or tension.
- Type 1 worry has positive elements and concerns external events. Type 2 worry is worry about the worry and is negative, for example “my worry is uncontrollable”, “I could go crazy with worrying”, “my worries will take over and control me”.
- PTSD is now under Trauma- and Stressor-Related Disorders and OCD under Obsessive-Compulsive and Related Disorders. Anxiety is a large component in both, and they remain relevant to clinicians for treatment.
- A potentially traumatising event is unpredictable, uncontrollable, severe, and a catastrophic violation of fundamental beliefs and expectations about safety, physical integrity, trust and justice. Exposure is not uncommon, with population studies reporting 50% to 89%.
- B. One or more intrusive symptoms: intrusive distressing memories, dreams, flashbacks, intense distress or physiological reactions to internal or external cues. C. Persistent avoidance of stimuli associated with the event, external or internal. D. Negative alterations in cognition or mood: inability to remember, negative beliefs about self or world, self blame, horror, anger, fear, guilt, shame, detachment, loss of interest, inability to feel positive emotions, loss of trust. E. Physiological arousal or reactivity: recklessness, irritability, anger, insomnia, exaggerated startle, hypervigilance.
- PTSD requires a duration of disturbance of more than one month. Acute stress disorder is similar but occurs at least 3 days to one month after trauma exposure.
- An obsession is a recurrent, persistent, intrusive and unwanted thought (contamination), urge (to stab someone) or image (violent, horrific, sexual) causing marked distress or anxiety, which the person tries to ignore, suppress or neutralise. A compulsion is a repetitive behaviour (hand washing, checking, ordering) or mental act (counting, repeating words silently) the person feels driven to perform in response to an obsession or to rules that must be applied, aimed at preventing or reducing anxiety or preventing a dreaded event.
- Cleaning: contamination obsessions with cleaning compulsions. Symmetry: symmetry obsessions with repeating, ordering and counting compulsions. Taboo thoughts: aggressive, sexual or religious. Harm: fear of harm to self or others with checking compulsions.
- More than one hour a day, or causing distress or impairment in functioning. Mild to moderate is 1 to 3 hours per day; severe is constant intrusive thoughts or compulsions.
- Agoraphobia. She has marked anxiety in more than two of the criterion A situations (open spaces and market places in the form of supermarkets and the mall, being outside the home alone, and travel away from home), the situations provoke severe symptoms, and the fear is spreading and impairing her functioning.
- The physiological symptoms are identical, so they do not discriminate. What separates the diagnoses is the object of the fear as revealed by the cognition: fear of the situation itself (the plane crashing) points to a specific phobia, whereas fear of the bodily symptoms and their consequences (a heart attack) points to panic. This is the lecture’s key differential-diagnosis principle in action.
- Specific phobia (an anxiety disorder). Physiological: heart rate increase and feeling sick on exposure to the feared place. Cognitive: “the pipes will suck me in” and thinking he cannot stay there for long. Affective: afraid, scared. Behavioural: avoidance of toilets and of flushing. The criteria are met: marked anxiety about a specific situation (school toilets), which almost always provokes fear, is avoided where possible or endured with anxiety, causes significant distress and impairment (constipation, holding, encopresis, soiling, social problems from smelling, disrupted routines), and is persistent, having begun at age 5 with him now 9.