2.1.4 Anxiety and Phobic Disorders

Anxiety and Phobic Disorders

Anxiety and phobic disorders are the most common psychiatric disorders, with a lifetime prevalence estimated to be 28.8% worldwide. The incidence of anxiety and phobic disorders varies depending on the specific disorder.

Disorder	Prevalence (Lifetime %)	Prevalence (12-month %)
Total Anxiety Disorders	14.0	61.5
Panic Disorder	1.8	7.9
Agoraphobia	2.0	8.8
Social Anxiety Disorder	2.3	10.1
Specific Phobias	6.4	22.7
Generalized Anxiety Disorder	2.6	8.9
Post-Traumatic Stress Disorder	2.0	7.7

Panic Disorder

Prevalence/Incidence:

The National Comorbidity Survey-Replication (2001-2002) indicates a lifetime prevalence of 1.5-3.7% for panic disorder and 7-9% for panic attacks. Prevalence rates are significantly higher in medical clinics such as those specializing in dizziness (15%), cardiology (16-65%), and hyperventilation (25-35%). Women have a 2-3 times higher likelihood of being affected compared to men. Panic disorders typically manifest in two age groups, with the highest occurrence between 15-24 years and a secondary peak at 45-54 years. Instances are rare after the age of 65 (0.1%). Additional risk factors encompass marital status (widowed, divorced, or separated), urban living, lower education levels, early loss of parents, and a history of physical or sexual abuse.

Aetiology:

Multiple theories exist for the aetiology of panic disorder and the majority exist based upon successful pharmacological treatments of laboratory experiments:

Presentation:

Panic attacks are characterized by sudden episodes of intense fear or discomfort, often accompanied by physical symptoms such as palpitations, shortness of breath, and trembling. Panic disorder, on the other hand, involves recurrent panic attacks and persistent concern or worry about future attacks, which can significantly impact an individual’s daily life and functioning.

The following table are the symptoms associated with a panic attack in the order of most frequent:

Rank	Symptom
1	Palpitations, pounding heart, or accelerated heart rate
2	Sweating
3	Trembling or shaking
4	Sense of shortness of breath or smothering
5	The feeling of choking or difficulty swallowing (globus hystericus)
6	Chest pain or discomfort
7	Nausea or abdominal distress
8	Feeling dizzy, unsteady, light-headed, or faint
9	Derealization or depersonalization
10	Fear of losing control or going crazy
11	Fear of dying (angor animus)
12	Numbness or tingling sensations (paraesthesiae)
13	Chills or hot flashes

Treatment:

Emergency acute treatment: When addressing an acute panic attack, adopt a composed and comforting demeanour, as most attacks resolve on their own within 30 minutes. For extreme and distressing symptoms, consider administering benzodiazepines to alleviate anxiety quickly, which may reassure the patient and decrease future emergency visits.

Pharmacological treatment: Current evidence indicates no significant difference in efficacy between SSRIs, SNRIs, BDZs, TCAs, and monoamine oxidase inhibitors (MAOIs) for panic disorder treatment. Factors such as side effects and personal preference may influence the choice of medication. SSRIs are often recommended as the first-line treatment in the UK. Alternative antidepressants, such as SNRIs, TCAs, and MAOIs, may also be used, but some are unlicensed. BDZs are not recommended by NICE due to potential abuse or dependence risks, but they may be useful for severe cases. There is limited evidence supporting the use of buspirone, bupropion, mirtazapine, and others. Second-line treatment may involve changing the medication class or adding a BDZ. Successful treatment should continue for 12-18 months before attempting to discontinue.

Treatment Option	Recommendation
SSRIs	First-line treatment, licensed in the UK for panic disorder
SNRIs, TCAs, MAOIs	Alternative antidepressants, unlicensed in the UK
BDZs	Not recommended by NICE, the potential for abuse or dependence, may be effective for severe cases
Limited benefit	Buspirone, bupropion, mirtazapine, inositol, reboxetine, antipsychotics, anticonvulsants, propranolol
Second-line	Change medication class, the addition of BDZ, a trial of bupropion, or SGA for severe symptoms

Psychological treatment: Psychological treatment of panic disorder includes cognitive-behavioural therapy (CBT) and psychodynamic psychotherapy. CBT utilizes behavioural methods, such as exposure therapy, relaxation techniques, and hyperventilation control, while also incorporating cognitive methods to educate patients about anxiety-related bodily responses and modify thinking errors. Psychodynamic psychotherapy, particularly brief dynamic and emotion-focused therapies like panic-focused psychodynamic psychotherapy, explores fears of abandonment or entrapment and has shown some evidence of effectiveness.

Outcome:

With appropriate treatment, most people with anxiety disorders can achieve significant symptom improvement and functional recovery.

A majority of patients seeking help for panic disorder have typically endured chronic symptoms for 10-15 years. Left untreated, this condition follows a persistent trajectory. Treatment, however, results in functional recovery for 25-75% of patients within the first 1-2 years, declining to 10-30% after 5 years. In the long term, about half will have only mild symptoms. Factors linked to poor treatment response include severe initial symptoms, significant agoraphobia, low socio-economic status, limited education, prolonged untreated symptoms, a narrow social network, and the presence of a personality disorder.

Agoraphobia

Anxiety and panic symptoms are often connected to locations or situations where escape may be challenging or humiliating, such as crowded areas, public places, or travelling alone, leading to avoidance behaviours. In the DSM-5, agoraphobia is diagnosed independently of panic disorder, and if both conditions are present, both diagnoses should be given. The ICD-10 allows for specifying the presence or absence of panic disorder in agoraphobic situations, and if panic disorder occurs in other situations, both diagnoses should be applied. The ICD-11 proposals are expected to follow a similar approach.

Prevalence/Incidence:

The six-month prevalence of agoraphobia ranges between 2.8% and 5.8% (ECA) with a male-to-female ratio of 1:3. Similar to panic disorder, agoraphobia exhibits a bimodal distribution, with the first peak spanning from 15 to 35 years of age. In later life, agoraphobic symptoms may emerge due to physical frailty and related fears of worsening medical issues or experiencing accidents.

Aetiology:

Presentation:

Agoraphobia typically presents as an intense fear or anxiety associated with places or situations where escape may be difficult or embarrassing, such as crowds, public places, or travelling alone or away from home. This fear often leads to avoidance of such locations or situations, which can significantly impact an individual’s daily functioning and quality of life. In some cases, agoraphobia may develop alongside panic disorder, resulting in a complex interplay of anxiety, panic attacks, and avoidance behaviours (APA, 2013).

Treatment:

Management of agoraphobia involves both pharmacological and psychological approaches. Antidepressants, such as citalopram, escitalopram, and paroxetine, are licensed in the UK for treating panic disorder symptoms, with or without agoraphobia. Clomipramine, though unlicensed, has some evidence of effectiveness at high doses. Benzodiazepines should be used only short-term, as they may reinforce avoidance behaviours, with alprazolam, clonazepam, and diazepam having the most evidence. Psychological treatments include behavioural methods like exposure techniques for specific situations or locations, relaxation training, and anxiety management. Cognitive methods focus on education about anxiety-related bodily responses and panic attacks, as well as modifying thinking errors.

Management Approach	Description
Pharmacological	Antidepressants (citalopram, escitalopram, paroxetine) licensed in the UK for panic disorder with/without agoraphobia
	Unlicensed: clomipramine (high dose)
	Benzodiazepines: short-term use only (e.g., alprazolam, clonazepam, diazepam)
Psychological	Behavioural methods: exposure techniques, relaxation training, anxiety management
	Cognitive methods: education about anxiety-related bodily responses and panic attacks, modification of thinking errors

Outcome:

The prognosis for agoraphobia in the UK varies based on factors like severity, treatment response, and treatment quality. Early intervention and combined therapies can improve outcomes. Some individuals may achieve significant recovery, while others experience mild symptoms or relapses. Outcomes are also influenced by co-existing mental health conditions and social support networks.

Specific Phobias

Specific phobias involve recurrent, extreme, and irrational anxiety symptoms, either psychological or autonomic, triggered by the presence or anticipation of a particular feared object or situation. DSM-5 categorizes these phobias into subtypes, including animals, natural environment, blood, injection, injury, situational, and ‘other.’ These phobias often lead to avoidance behaviours when possible.

Prevalence/Incidence:

Specific phobias have a lifetime prevalence of 12.5%, a 12-month prevalence of 8.7%, and a 6-month prevalence ranging from 4.5% to 11.9%. The male-to-female ratio is 1:3, with animal and situational phobias more common in females. The average onset age is 15 years, with animal phobias starting around 7 years, blood/injection/injury phobias at 8 years, and situational phobias at 20 years.

Aetiology:

Presentation:

Treatment:

Various treatments are available for specific phobias, focusing on psychological and pharmacological approaches. Psychological treatments primarily involve behavioural and cognitive methods, while pharmacological interventions are typically used in severe cases to facilitate exposure therapy.

Treatment Type	Method	Details
Psychological	Behavioural Therapy	Exposure techniques (e.g., systematic desensitization, in vivo exposure, virtual reality exposure)
	Other Techniques	Reciprocal inhibition, flooding, modelling
	Cognitive Methods	Education/anxiety management, coping skills/strategies, cognitive restructuring
Pharmacological	Anxiety Reduction	BDZs (e.g., diazepam) – used in severe cases to enable engagement in exposure
	β-blockers	Reduce sympathetic arousal, not subjective fear
	SSRIs	Limited evidence (e.g., escitalopram, paroxetine); used for secondary depression

Outcome:

In the absence of treatment, specific phobias generally follow a persistent, recurring pattern. Nonetheless, people may not seek help until life circumstances compel them to face the object or situation they fear.

Generalized Anxiety Disorder

Persistent and pervasive anxiety, characterized by excessive concern and uneasiness about daily events or issues, results in both mental and physical tension, leading to considerable distress and hindering normal functioning.

Prevalence/Incidence:

The prevalence of the condition varies, with a 6-month prevalence of 2-6% and a 12-month prevalence of 3%. Lifetime prevalence is estimated at 6%. The rates are lowest among individuals aged 18-29 years (4%) and 60+ years (4%), and highest among those aged 45-59 years (8%). Women are more affected than men, particularly in cases of early onset, which is linked to childhood fears and marital or sexual disturbances. Late-onset cases often follow a stressful event. The condition is more common among single individuals (~30% never marry) and the unemployed.

Age Group	Prevalence
18-29 years	4%
45-59 years	8%
60+ years	4%

Factor	Association
Gender	Women more affected than men
Early-onset	Childhood fears, marital/sexual disturbance
Late-onset	Stressful event
Marital status	30% of single individuals never marry
Employment status	Unemployed

Aetiology:

The aetiology of a generalized anxiety disorder (GAD) involves a combination of biological and psychological factors. Biological factors include a modest genetic role shared with depression, and neurobiological aspects involving the noradrenergic system, hypothalamic-pituitary-adrenal axis, amygdala, stria terminalis, septohippocampal system, and neurotransmitter dysregulation. Psychological vulnerabilities include a diminished sense of control due to trauma or insecure attachment, parenting styles that are overprotective or lack warmth, and specific vulnerabilities related to stressful life events, such as early parental death, traumatic experiences, and dysfunctional relationships.

Factor	Association
Genetic	The modest role, shared with depression
Neurobiological	NA system, HPA axis, amygdala & stria terminalis, septohippocampal system, BDZ-GABA system, other neurotransmitter systems
Psychological	A diminished sense of control, trauma, insecure attachment
Parenting	Overprotective, lacking warmth, low perceived control
Specific vulnerability	Stressful life events, trauma, dysfunctional relationships

Presentation:

GAD symptoms include a history of excessive anxiety and worry for at least 6 months, with tension and apprehension about everyday events. DSM-5 requires at least three symptoms (or one in children), while ICD-10 requires at least four symptoms with at least one from ‘autonomic arousal’.

Treatment:

Psychological treatment for anxiety disorders may be less effective due to the absence of situational triggers, but combining cognitive and behavioural techniques can be beneficial. Pharmacological treatment targets specific anxiety symptoms, including somatic, psychic, depressive, cardiovascular, and autonomic symptoms. Various medications, such as benzodiazepines, buspirone, SSRIs, SNRIs, β-blockers, and others, may be used depending on the symptoms. In extremely rare cases, psychosurgery may be considered for severe, intractable anxiety.

Anxiety Symptom	Treatment	Examples	Notes
Somatic	BDZs	Lorazepam Diazepam Alprazolam
Psychic	Buspirone		Beneficial effects may take 2-4 weeks
Depressive	SSRIs, SNRIs, TCAs, Trazodone, Mirtazapine	Escitalopram (10-20mg/day) Paroxetine (20-50mg/day) Duloxetine (60-120mg/day) Venlafaxine (75-225mg/day) Imipramine Clomipramine Trazodone (75-300mg/day) Mirtazapine (30mg/day)	Varying licenses and dosages
Cardiovascular or Autonomic	β-blockers	Atenolol
Other treatments	Pregabalin, Agomelatine, Quetiapine, Trifluoperazine	Pregabalin (150-600mg/day), Agomelatine (25-50mg/day), Quetiapine (150mg/day), Trifluoperazine (2-6mg/day)	Varying licenses, dosages, and use as an adjunct to SSRI/SNRI

Outcome:

Long-lasting and debilitating, the outlook is typically unfavourable, with low rates of recovery (around 30% after 3 years, even with treatment). After 6 years, 68% experience mild ongoing symptoms and 9% suffer from severe, continuous impairment. Frequently, co-occurring conditions, particularly alcohol abuse, exacerbate the prognosis.

	Anxiety Disorders
Prevalence	12.6%
Onset	Typically in childhood or adolescence
Gender	Females are twice as likely as males to experience an anxiety disorder
Aetiology	Genetic, environmental, and psychological factors
Presentation	Excessive and persistent fear, worry, and anxiety
Treatment	CBT, medication
Outcome	Significant symptom improvement and functional recovery

Outcome Significant symptom improvement and functional recovery

	Panic disorder	Agoraphobia	Specific phobias	GAD
Prevalence	1.5-3.7%	2.8-5.8%	12.5%	6%
Onset	Typically in childhood or adolescence	Late adolescence to early adulthood	Childhood to early adulthood	Adulthood
Gender	Females are twice as likely as males to experience an anxiety disorder	More common in females	More common in females	More common in females
Aetiology	Genetic, environmental, and psychological factors	Genetic, environmental, and psychological factors	Genetic, environmental, and psychological factors	Genetic, environmental, and psychological factors
Presentation	Excessive and persistent fear, worry, and anxiety	Sudden panic attacks, fear of recurrent attacks	Fear of specific situations or places	Chronic, excessive worry about everyday events
Treatment	CBT, medication	CBT, medication	CBT, medication	CBT, medication
Outcome	Significant symptom improvement and functional recovery	Varies, better with treatment	Varies, better with treatment	Varies, better with treatment

References:

1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
2. Kessler, R.C., Berglund, P., Demler, O., Jin, R., Merikangas, K.R. and Walters, E.E., 2005. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62(6), pp.593-602.
3. Semple, D., Smyth, R., & Burns, J. (Eds.). (2013). Oxford handbook of psychiatry (3rd ed.). Oxford University Press.
4. Wittchen, H.U., et al., 2011. The size and burden of mental disorders and other disorders of the brain in Europe 2010. European Neuropsychopharmacology, 21, pp.655-679.