Anxiety disorder

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Anxiety is the commonest psychiatric symptom in clinical practice and Anxiety disorders are one of the commonest psychiatric disorders in general Population.



 Anxiety is a ‘normal’ phenomenon, which is characterized by a state of apprehension or unease arising out of anticipation of danger.

 Anxiety is an individual’s emotional and physical fear response to a perceived threat.

 Anxiety is often differentiated from fear, as fear is an apprehension in response to an external danger while in anxiety the danger is largely unknown (or Internal).

 Normal anxiety becomes pathological when it causes significant subjective distress and/or impairment in functioning of an individual.

 Pathologic anxiety occurs when symptoms are excessive, irrational, out of proportion to the trigger or are without an identifiable trigger.

 Anxiety disorders are caused by a combination of genetic, biological, environment and psychosocial factors.

 Major neurotransmitter system implicated: norepinephrine (NE), serotonin (5-HT), and gamma-aminobutyric acid (GABA).

 Anxiety disorders affect more women compared to men (2:1).

Symptoms of anxiety:

 Physical symptoms:

  •  Constitutional: fatigue, diaphoresis (sweating), shivering (trembling)
  •  Autonomic and visceral symptoms: 

1. Neurologic/musculoskeletal: dizziness, lightheadedness, 

paresthesias, tremors, insomnia, muscle tension, agitation, 

sweating, flushes, mydriasis 

2.Cardiac: Chest pain, palpitations, tachycardia, hypertension.

 3.Pulmonary: hyperventilation, shortness of breathing, dyspnea, 

4. Gastrointestinal: abdominal discomfort, dry mouth, anorexia, 

nausea, emesis, diarrhea, constipation

5. Genitourinary: frequency and hesitancy of micturition

  •  Motor symptoms: tremors, restlessness, muscle twitches, fearful facial expression

Psychological symptoms:

  1.  Cognitive symptoms: poor concentration, distractibility, hyperarousal, 
  2. vigilance or scanning, negative automatic thoughts.
  3.  Perceptual symptoms: derealization, depersonalization o Affective symptoms: diffuse, unpleasant and vague sense of apprehension, fearfulness, inability to relax, irritability, fear of loss of control, feeling of impending doom/dread (when severe)
  4.  Other symptoms: insomnia (initial), increased sensitivity to noise, exaggerated startle response obsessions and compulsions.

Risk factors for most anxiety disorders:

  1. Family history (mild).
  2. Women are at higher risk, except OCD and social anxiety disorders.
  3. Onset is usually in teens and 20s. However, may rumble on untreated for years. Exception is GAD which is commonest in 40s and 50s.
  4.  Life stressors: this can include physical illness.
  5.  Medications and substances that cause anxiety: alcohol, sedatives/hypontics, cannabis, hallucinogens (phencyclidine, lysergic acid, methylenedioxymethamphetamine), stimulants (amphetamines, cocaine), caffeine, tobacco, and opioids.

 Anxiety disorders are divided into 3 main subtypes:

  • Paroxysmal (panic) disorder
  •  Phobic anxiety
  • Generalized anxiety disorder Treatment includes pharmacological drugs and psychotherapy.

 Pharmacological drugs: drugs are used to achieve symptomatic relief and continue treatment for at least 6 months before attempting to titrate off medications.

o First-line: Selective serotonin reuptake inhibitors (SSRIs) e.g. sertraline and serotonin-norepinephrine reuptake inhibitors (SNRIs) e.g. Venlafaxine. Note: SSRIs typically take about 4-6 weeks to become fully effective and higher doses (than used in treating depression) are generally required.

Sertraline initially 25mg daily for 1 week then increased to 50mg 

daily, then increased in steps of 50mg at intervals of at least 1 

week if required, maximum dose is 200mg per day. Increase dose 

only if response is partial and if drug is tolerated.


Benzodiazepine work quickly and effectively, but they all can be 

addictive. Minimize the use, duration and dose. Benzodiazepines 

should be avoided in patients with a history of substance use disorders, Particularly alcohol. 

Note: if a patient has a comorbid depressive disorder, consider 

alternative to benzodiazepines as they may worsen depression. 

Use benzodiazepines to temporarily bridge patients until longterm medication becomes effective.

 Benzodiazepines should be avoided except for short-term relief 

during crises.

Busiprone (5-HT1a partial agonist): this is a non-benzodiazepine anxiolytic, however it is not commonly used due to mininmal efficacy and often only prescribed as augmentation.

Beta blockers (e.g. propranolol): may be used to help control autonomic Symptoms with panic attack or performance anxiety.

Tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs): May be considered if first-line agents are not effective. Their side-effect profile makes them less tolerable.



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