Wait, is it my

​

Heart or my

​

Head?

Dr. Aini Laili binti Romali

Family Medicine Specialist

Klinik Kesihatan Paka

Presented by:

NORMAL ANXIETY VS. ANXIETY DISORDERS

NORMAL ANXIETY

CLINICAL ANXIETY DISORDERS

Key Differentiating Factors: Duration, intensity, appropriateness to�situation, and level of interference with functioning.

• Adaptive response to stress that is�proportionate to triggers and�temporary in nature.

• Has a clear start and ending point.

• Can be helpful or motivational.

• Lessens significantly or disappears�away from stressful situations.

• Rarely impairs daily functioning.

• Persistent, excessive worry that causes�significant distress.

• Intense or disproportionate emotional�response to the situation.

• Ongoing and lasts for weeks or months.

• Significantly disrupts work,�relationships, and self-care.

• Feels impossible to control or manage.

CASE SCENARIO:�Presentation of Symptoms

• Case: Sarah, a 34-year-old corporate lawyer, presents with complaints about work deadlines

and family responsibilities.

• Key Symptoms: She experiences difficulty concentrating, and excessive worry

about child's safety and career performance.

• Duration and Impact: These symptoms have been persistent for significantly affecting her work productivity and family relationships.

• Social Media Influence: Sarah professional networks, constantly comparing herself to

colleagues and feeling inadequate despite her objective achievements.

• Self-Determination Factors: Her situation reflects a negatively impacting her psychological�wellbeing.

Mental Status Examination Findings

• Anxious Affect: Patient displays visible nervousness,�restlessness and tension during examination.

• Psychomotor Agitation: Observed fidgeting, nail�biting, and inability to remain seated for extended�periods.

• Catastrophic Thinking: Thought process reveals�preoccupation with worst-case scenarios and�negative outcomes.

• Intact Reality Testing: No evidence of hallucinations�or delusions despite heightened anxiety state.

Classification of Anxiety Disorders

• Separation Anxiety Disorder: Excessive fear of separation from�attachment figures, causing significant distress and impairment.

• Specific Phobias: Intense, irrational fear of specific�objects or situations leading to avoidance behaviors.

• Social Anxiety Disorder: Marked fear of social situations�where scrutiny by others may occur, causing avoidance.

• Panic Disorder: Recurrent unexpected panic attacks with�persistent concern about future attacks.

• Generalized Anxiety Disorder: Excessive, uncontrollable worry�about multiple events occurring most days for 6+ months.

Introduction and Malaysian Epidemiology

• Anxiety Prevalence in Malaysia: National health�survey reported prevalence of GAD in�Malaysian population.

• Gender Distribution: prevalence among�females compared to males in Malaysia.

• Age Group Analysis: Younger age groups show� trends in anxiety disorders.

• Regional Comparisons: Malaysian prevalence rates�compared with global and regional statistics.

• Urban vs Rural Distribution: Different patterns of�anxiety disorders between and �populations.

General Risk Factors for Anxiety

• Family history of major depressive disorder, disturbed family environment, childhood sexual abuse,
• Low self-esteem, among those with low education level
• Heavy alcohol consumption, smoking,
• Lower socio-economic status,
• Previous use of psychotherapy,
• Previous diagnoses of psychological disorder,
• History of addiction problem and gastrointestinal disorders were found to be associated with anxiety
• Associated with chronic diseases, smoking, physical inactivity, obesity and heavy drinking
• Being single
• Unemployed

Literature Review: GAD in Primary Care

• GAD is highly prevalent in primary care

• Studies show GAD affects 5-8% of primary care patients globally

• Often occurs without psychiatric comorbidities

• Up to 40% of GAD cases present as standalone conditions in�primary care settings

• Recognition challenges in clinical practice

• GAD is underdiagnosed, with only 30-40% of cases properly�identified in primary care

• Impact on healthcare utilization

• GAD patients have 2-3 times higher utilization of primary care�services

W. Maier et al., November 2009, Generalized anxiety disorder (ICD-10) in primary care from a cross-cultural perspective: a valid diagnostic entity?

Progression and Frequency of GAD

• GAD as a Precursor to Depression: Research shows 67% of�GAD patients develop depression, making early intervention�crucial in primary care.

• Most Common Anxiety Disorder in Primary Care: GAD�represents 22% of all anxiety cases seen by PCPs, with�prevalence rates of 1.6-5% in general population.

• Chronic Course and Fluctuating Severity: GAD typically�follows a chronic course with periods of exacerbation often�triggered by stress or life transitions.

• Impact on Healthcare Utilization: GAD patients visit primary�care 5x more frequently than non-anxious patients, often�presenting with somatic complaints.

Challenges in Clinical Recognition

• Recognition gap in primary care: often identify general mental�distress but struggle to diagnose specific anxiety disorders accurately.

• Diagnostic challenges: Symptoms often overlap with other conditions,�making precise identification difficult without specialized training.

• Time constraints: Limited consultation time prevents the thorough�assessment needed for proper diagnosis.

• Patient presentation barriers: Many patients present with physical�symptoms (somatization) rather than psychological concerns,�complicating recognition.

Epidemiology: Age and Gender Trends

• Global Prevalence: Anxiety disorders affect 359.2 million people�worldwide (as of 2021), with an 8.0% 12-month prevalence rate.

• Age of Onset: Most anxiety disorders begin in childhood or�adolescence; onset is rare after age 40.

• Gender Differences: Women are approximately twice as likely as�men to be diagnosed with anxiety disorders.

• Increasing Trends: There has been a 52% increase in anxiety�disorders among ages 10-24 from 1990 to 2021.

• Social Media Impact: Digital connectivity contributes to�anxiety through social comparison and fear of missing out.

Classification of Anxiety Severity

Mild Anxiety

Moderate Anxiety

Severe Anxiety

Symptoms present but�individual can still function in�daily activities with minimal�disruption.

Individual experiences�significant distress and some�impairment in daily functioning�for several days per week.

Symptoms severely impact�daily functioning, preventing�normal activities most days of�the week.

• Functional Assessment: Evaluation based on ability to perform work, academic, social, and self-care responsibilities.�• Clinical Significance: Severity classification guides treatment approach, from self-help strategies to intensive�interventions.

Comorbidity with Depressive Disorders�

• High comorbidity rates: Up to 50% of patients with an depressive disorder�(Andrews et al., 2002; Brown et al., 2001; Comer et al., 2011).

• Increased symptom severity: Comorbidity leads to more severe symptoms,�greater functional impairment, and higher economic costs than either�condition alone.�(Andrews et al., 2002; Moffitt et al., 2007; Tyrer et al., 2004; Zhu et al., 2009).

• Treatment challenges: Patients with both conditions often require integrated�treatment approaches targeting both disorders simultaneously.

• Slower recovery trajectory: Associated with a slower rate of recovery, longer�treatment durations, and higher relapse rates.�(Newby et al., 2014, 2015).

PANIC DISORDER OVERVIEW

• Definition of Panic Disorder: Characterized by�recurrent unexpected panic attacks with intense fear�and physical symptoms.

• Diagnostic Criteria: Requires at least one attack�followed by persistent concern or behavioral change�for one month or more.

• Physical Manifestations: Heart palpitations, sweating,�trembling, shortness of breath, and feelings of choking�or dying.

• Psychological Impact: Fear of losing control, going�crazy, or experiencing future attacks, leading to�avoidance behaviors.

• Prevalence Statistics: Affects approximately 2-3% of�adults annually with higher rates in women than men.

DSM-5 Diagnostic Criteria: Panic Disorder

• Recurrent unexpected panic attacks:

• Persistent concern about additional attacks:

• Significant maladaptive change in behavior:

• Not attributable to physiological effects or other medical conditions:

• Significant distress or impairment:

– An abrupt surge of intense fear or intense discomfort that reaches a peak within�minutes.

– Characterized by physical symptoms such�Characterized by physical symptoms such as palpitations, pounding heart,�accelerated heart rate, sweating, trembling, sensations of shortness of breath or�smothering, and feelings of choking.

– At least one of the attacks has been followed by 1 month or more of persistent�worry about having additional panic attacks or their consequences (e.g., losing�control, having a heart attack, "going crazy").

– A significant change in behavior related to the attacks, such as behaviors designed�to avoid having panic attacks (e.g., avoidance of exercise or unfamiliar situations).

– The disturbance is not attributable to the physiological effects of a substance (e.g.,�a drug of abuse, a medication) or another medical condition (e.g.,�hyperthyroidism, cardiopulmonary disorders).

– The symptoms cause clinically significant distress or impairment in social,�occupational, or other important areas of functioning.

Diagnostic Features of Panic Attacks

• Definition of Panic Attack: A discrete period of intense fear with�abrupt onset that reaches a peak within minutes.

• Physical Symptoms: Includes palpitations, sweating, trembling,�shortness of breath, and feelings of choking.

• Cognitive Symptoms: Fear of losing control, going crazy, or�dying; derealization or depersonalization.

• Nocturnal Panic Attacks: Can occur during sleep, waking the�individual with intense fear and physical symptoms.

• Catastrophizing Tendencies: Patients often misinterpret minor�physical sensations as signs of serious medical conditions.

Prevalence and Demographics of Panic Disorder

• Panic Disorder Prevalence: Affects approximately 2-3%

�of adults globally according to recent epidemiological studies.

• Gender Distribution: Women are twice as likely as men

�to develop panic disorder in their lifetime.

• Age of Onset: Typically begins in late adolescence or

�early adulthood, with median age of onset around 24 years.

• Comorbidity Patterns: Often co-occurs with other anxiety disorders,

​

depression, and substance use disorders.

• Impact on Daily Functioning

Risk and Prognostic Factors for Panic

• Temperamental Factors

• Environmental Influences

• Genetic Predisposition

• Behavioral Inhibition

• Prognostic Indicators

○ Negative affectivity traits strongly predict development of panic�disorder, increasing vulnerability to anxiety.

○ Childhood physical/sexual abuse history significantly increases�risk for panic disorder development.

○ Family history of anxiety disorders suggests 30-40% heritability�for panic disorder.

○ Early childhood behavioral inhibition traits correlate with higher�panic disorder risk in adulthood.

○ Early intervention and treatment adherence significantly improve�long-term outcomes for panic disorder.

Suicide Risk in Panic Disorder

• Higher suicide risk in panic disorder: Research�shows patients with panic disorder have 2-3 times�higher rates of suicide attempts than the general�population.

• Independent risk factor: Panic disorder increases�suicide risk even after controlling for comorbid�depression and substance use disorders.

• Panic attacks and suicidality: Frequency and�intensity of panic attacks correlate with increased�suicidal ideation and behavior.

• Early intervention importance: Identifying and�treating panic disorder in primary care settings can�significantly reduce suicide risk.

Source: Medical Literature Review (2026)

GENERALIZED ANXIETY DISORDER (GAD)

• Persistent excessive worry

• Physical and psychological symptoms

• Impact on daily functioning

• Prevalence statistics

• Treatment approaches

Chronic anxiety about multiple events or activities lasting at least 6 months.

Includes restlessness, fatigue, difficulty concentrating, irritability, and muscle�tension.

• Significantly impairs social, occupational, and other important areas of life.

• Among the most common anxiety disorders, affecting approxi-�ately 3% of the global population.

• Combination of cognitive-behavioral therapy, medication, and lifestyle�modifications shows best outcomes.

DSM-5 Diagnostic Criteria: GAD

Generalized Anxiety Disorder

A. Excessive anxiety and worry (apprehensive expectation), occurring more days than not�for at least 6 months, about a number of events or activities (such as work or school�performance).

B. The person finds it difficult to control the worry.

C. The anxiety and worry are associated with three (or more) of the following six symptoms�(with at least some symptoms present for more days than not for the past 6 months).�Note: Only one item is required in children.

(1) restlessness or feeling keyed up or on edge

(2) being easily fatigued

(3) difficulty concentrating or mind going blank

(4) irritability

(5) muscle tension

(6) sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep)

Generalized Anxiety Disorder (GAD)�Symptoms

Persistent Worry

Fatigue

Restlessness and Irritability

Concentration Problems

Physical Symptoms

Sleep Disturbances

Excessive concern about multiple life�areas that is difficult to control and�lasts for at least 6 months.

Persistent tiredness and lack of�energy even without physical�exertion, often worsening�symptoms.

Feeling on edge, easily annoyed, and�having difficulty relaxing even in�calm situations.

Inability to focus, mind going�blank, and decreased productivity�in work or school settings.

Muscle tension, headaches,�stomachaches, and other somatic�complaints without clear medical�cause.

Difficulty falling asleep, staying�asleep, or experiencing restful�sleep due to racing thoughts.

Physical and Somatic Manifestations

• The worries are excessive and typically interfere significantly with psychosocial functioning�• More pervasive, pronounced and distressing�• Physically

• muscle tension�• trembling�• twitching�• feeling shaky�• muscle aches, sores�• somatic symptoms (sweating, nausea, diarrhea)�• Autonomic hyperarousal (accelerated heart rate,SOB., dizziness)�• IBS�• headache

• Muscle tension manifestations: Chronic muscle tension, headaches, body aches�diarrhea, and digestive issues commonly associated with anxiety.

• Gastrointestinal disturbances: IBS-like symptoms including stomachachnes, nausea,�diarrhea, and digestive issues commonly associated with anxiety.

• Sleep disturbances:�• Impact on daily functioning: How these physical symptoms can significantly impair work�performance, social interactions, and quality of life.

Prevalence and Developmental Course of GAD

• GAD Prevalence in Adults: Affects approximately 5.7% of adults�globally, with women twice as likely to be diagnosed as men

• Adolescent Prevalence: 3.5% of adolescents experience GAD,�with rates increasing during transition to adulthood

• Median Age of Onset: Typically begins around 30 years of age,�though can develop at any point in the lifespan

• Developmental Worry Patterns: Adolescents tend to worry about�school and social acceptance; adults focus on family, finances�and health concerns

Risk and Prognostic Factors for GAD

Temperamental factors

Genetic vulnerability

Environmental stressors

Neurobiological factors

Harm avoidance traits predispose individuals to�excessive worry and anxiety reactions

First-degree relatives of GAD patients have�higher risk of developing the disorder

Childhood adversity and recent life stressors can�trigger GAD in vulnerable individuals

Dysregulation in brain areas controlling fear and�emotional responses contribute to GAD�development

Screening Tools: The GAD-7 Scale

• What is GAD-7?

• A 7-item self-report questionnaire designed to screen for and measure�severity of generalized anxiety disorder

• Scoring System

• 0-4 minimal anxiety, 5-9 mild, 10-14 moderate, 15-21 severe anxiety

• Score of ≥10 indicates a probable diagnosis of generalized anxiety disorder

• Clinical Application

• Recommended for initial screening and monitoring treatment response in�primary care settings

• Validity and Reliability

• High sensitivity (89%) and specificity (82%) for GAD at cutoff�score of 10

• Validated across diverse populations

Screening

Monitoring

Reliability of Diagnostic Instruments

• High Diagnostic Accuracy

• Validated Screening Tool

• Cultural Adaptation Success

• Implementation Benefits

Composite International Diagnostic Interview (CIDI) – 95% sensitivity and 91% specificity when standards.

The Malay version of the GAD-7 had good sensitivity and excellent specificity compared to the CIDI as the�reference standard.

• Brief 7-question format allows efficient screening in time-constrained�primary care settings.

• The Malay version maintains diagnostic integrity across cultural contexts while being easily�administered.

• an instrument developed by the WHO

• It has been evaluated for test–retest reliability and compared with schedules for clinical assessment in�neuropsychiatry, and has excellent test characteristics in primary care, with moderate to excellent�concordance

SCAS-Malay Items for Pediatric Anxiety

Assessment tool adaptations for Malaysian pediatric context.

• SCAS-Malay Validation: Psychometric validation of the�Malay version of Spence Children's Anxiety Scale for�pediatric assessment.

• Separation Anxiety Items: Questions assessing fear of�being alone, worry about caregivers, and reluctance to�sleep away from home.

• Social Phobia Assessment: Items measuring fear of�negative evaluation, public speaking anxiety, and social�interaction concerns.

• Panic Disorder Screening: Questions identifying physical�symptoms like heart racing, breathing difficulties, and fear�of losing control.

• Cultural Adaptations: Modifications made to ensure�cultural relevance while maintaining diagnostic validity in�Malaysian context.

SEPARATION ANXIETY DISORDER

• DEFINITION: Excessive fear about separation from�attachment figures, beyond what is developmentally�appropriate.

• KEY SYMPTOMS: Persistent distress when separated,�excessive worry about losing attachment figures,�reluctance to be alone.

• DEVELOPMENTAL CONTEXT: Normal in early childhood�but becomes pathological when persisting into later�developmental stages.

• IMPACT ON FUNCTIONING: Causes significant distress�in social, academic or occupational settings.

• DIGITAL AGE INFLUENCE: Exacerbated by always-on�culture where separation anxiety manifests through�digital connections.

DSM-5 Criteria: Separation Anxiety

• Developmentally inappropriate fear: Excessive fear when�○ separated from attachment figures, beyond what is�expected for developmental stage.

• Persistent distress about separation: Recurrent excessive

​

​

�○ distress when anticipating or experiencing separation

​

​

​

�from home or major attachment figures.

• Worry about harm to attachment figures: Persistent and

​

�○ excessive worry that harm will come to attachment figures

​

​

or that they will not return.

• Reluctance to be alone: Persistent reluctance or refusal to�○ be alone without major attachment figures at home or�elsewhere.

• Physical symptoms during separation: Somatic complaints�○ like headaches, stomachaches, or nausea when separated�or anticipating separation.

Clinical Breakdown of Diagnostic Criteria

Separation Anxiety Diagnostic Criteria

• Persistent fear of separation from�attachment figures, beyond developmentally�appropriate levels for at least 4 weeks (Red�accent: at least 4 weeks).�○ Physical Manifestations: Recurrent�physical symptoms like headaches,�stomachaches, nausea, or vomiting when�separation occurs or is anticipated.�○ Sleep Disturbances: Reluctance to sleep�away from attachment figures or�experiencing nightmares about separation�themes (Red accent: nightmares, sleep�away).

• Functional Impairment: Clinically�significant distress affecting social,�academic, or occupational functioning�requiring intervention.�• Differential Diagnosis: Must�distinguish from other anxiety�disorders, particularly Generalized�Anxiety Disorder (GAD), and rule out�medical conditions causing similar�symptoms.

Diagnostic Features Across Age Groups

Developmental Considerations: Symptoms must be inappropriate�for the individual's developmental level.

Excessive fear or anxiety concerning separation from home or attachment figures.�Children

• unable to stay or go in a room by themselves�• clinging behaviour, staying close to or shadowing the parents�• may exhibit social withdrawal, sadness, apathy, difficulty concentrating on work or play

• Symptom Duration: Needs > 4 weeks�of symptoms (red accent).�• Behavioral Manifestations:�- Clinging behavior, staying close to�parents.�- Reluctance to sleep alone.�- School refusal.�- May exhibit social withdrawal, sadness,�apathy.

Adults (> 18 years)�• Symptom Duration: Requires > 6�months for diagnosis (red accent).�• Behavioral Manifestations:�- Excessive worry about harm to�attachment figures.�- Difficulty being alone.�- Reluctance to travel independently.

Prevalence and Developmental Context

• Global Prevalence of Separation Anxiety: Affects 4-5% of children and�adolescents worldwide, with onset typically between ages 7-9.

• Impact on Development: Separation anxiety represents a critical�developmental milestone in secure attachment formation.

• Risk Factors in Children: Family history, overprotective parenting,�and traumatic separation experiences increase vulnerability.

• Long-term Outcomes: Untreated childhood separation anxiety�may persist into adulthood, affecting 1-2% of adults.

Environmental and Genetic Risk Factors

• Childhood Trauma

• Parental Overprotection

• Genetic Predisposition

• Neurobiological Factors

• Early life stressors and adverse childhood experiences significantly increase risk�for anxiety disorders

• Overprotective parenting styles limit autonomy and can contribute to anxiety�development in children

• Twin studies show 30-40% heritability rates for anxiety disorders across different�populations

• Dysregulation in brain regions like the amygdala and prefrontal cortex contribute�to anxiety vulnerability

SUBSTANCE/MEDICATION-INDUCED�ANXIETY DISORDER

• Definition:

• Common substances:

• Diagnostic criteria:

• Treatment approach:

○ Anxiety symptoms directly caused by substance use,�medication side effects, or withdrawal.

○ Caffeine, alcohol, cannabis, stimulants, and certain�prescription medications can trigger anxiety.

○ Symptoms must develop during or shortly after�substance use or withdrawal.

○ Focuses on substance cessation, medication�adjustment, and addressing underlying anxiety.

Diagnostic Criteria for Induced Anxiety

• Substance/Medication-Induced Anxiety: Anxiety�symptoms are directly caused by substance intoxication�or withdrawal.

• Temporal Relationship: Symptoms must develop during�or shortly after substance use or withdrawal, or after�medication exposure.

• Symptom Severity: The anxiety exceeds what would be�expected from typical withdrawal or intoxication effects.

• Differential Diagnosis: Symptoms cannot be better�explained by an independent, non-substance-induced�anxiety disorder.

• Clinical Significance: The disturbance causes clinically�significant distress or functional impairment in social,�occupational, or other important areas.

Diagnostic Features and Timing

• Temporal Relationship: Anxiety symptoms must occur�during or shortly after substance use or withdrawal.

• Substance-Induced vs. Primary Disorder: Careful�assessment of timeline helps distinguish between�substance-induced and primary anxiety disorders.

• Duration Criteria: Symptoms persisting long after�substance clearance suggest primary anxiety disorder�rather than substance-induced.

• Clinical Evaluation: Medical history, substance use�patterns, and symptom onset timing are critical�diagnostic elements.

Associated Substances and Medications

• Caffeine: Stimulant that can worsen anxiety symptoms by increasing�heart rate and causing jitteriness.

• Alcohol: Initially calming but can worsen anxiety as effects wear off�and disrupt sleep patterns.

• Prescription Medications: Bronchodilators, steroids, thyroid�medications, and certain antidepressants may trigger anxiety.

• Recreational Drugs: Cannabis, cocaine, amphetamines, and opioids�can induce or exacerbate anxiety symptoms.

• Dietary Supplements: Some weight loss products and energy�supplements contain stimulants that may trigger anxiety.

ANXIETY DISORDER DUE TO MEDICAL CONDITION

Understanding the Physiological Link and Diagnostic Approach

Definition

Medical Causes

Differential Diagnosis

Treatment Approach

Anxiety that occurs specifically as�a physiological response to an�underlying medical condition.

• Endocrine disorders (e.g., hyperthyroidism)�• Cardiovascular conditions (e.g., arrhythmia)�• Respiratory issues (e.g., COPD, asthma)�• Neurological problems (e.g., epilepsy,�tumors)

Requires careful assessment to�distinguish from primary anxiety�disorders through�comprehensive medical history,�physical examination, and�laboratory testing.

Focus on addressing the underlying medical condition�while concurrently managing anxiety symptoms.

Diagnostic Criteria for Medical-Related Anxiety

Diagnostic criteria

• Medical condition as direct cause: Evidence must show the anxiety is�a direct physiological consequence of the medical condition.

• Temporal relationship: Anxiety symptoms develop during or shortly�after onset of the medical condition.

• Severity disproportionate: Anxiety exceeds what would be�expected from the normal reaction to the condition.

• Not better explained: Symptoms cannot be better attributed to�another mental disorder or substance use.

Related medical conditions

Endocrine Disorders

Cardiovascular Conditions

Respiratory Diseases

Neurological Disorders

Substance-Related Issues

Conditions like hyperthyroidism, Cushing's�syndrome, and pheochromocytoma can�manifest with anxiety-like symptoms.

Heart arrhythmias, angina, and mitral valve�prolapse may present with symptoms that�mimic anxiety disorders.

Conditions such as COPD, asthma, and�pulmonary embolism can cause�breathlessness that resembles panic attacks.

Seizure disorders, vestibular dysfunction,�and early dementia may present with�anxiety as an early symptom.

Stimulant use, medication side effects,�and withdrawal from substances can�trigger anxiety symptoms.

Comprehensive Suicide Risk Assessment

• Suicide Risk in Anxiety Disorders

• Comorbidity Dangers

• Required Screening

• Warning Signs

• Assessment Tools

• Anxiety disorders increase suicide risk by 2-3 times compared to�general population

• When anxiety co-occurs with depression, suicide risk increases�significantly more

• All patients with anxiety disorders should undergo routine suicide�risk assessment

• Monitor for hopelessness, social withdrawal, and increased�substance use

• Use validated tools like Columbia-Suicide Severity Rating Scale�(C-SSRS)

General Approach to Anxiety Management

Systematic Assessment

Functional Impact Analysis

Behavioral Response Identification

Stepped Care Approach

Evaluate anxiety symptoms using validated screening tools like GAD-7 or�HAM-A to quantify severity.

Assess how anxiety affects daily activities, work performance, and social�relationships.

Recognize avoidance behaviors, safety behaviors, and maladaptive coping�mechanisms.

Match intervention intensity to symptom severity, from self-help to�specialist referral.

"Always On" Culture and Social Media

Social Media and Constant Connectivity: 24/7 digital�presence creates pressure to always be available,�increasing anxiety levels and stress responses.

Social Comparison and Self-Worth: Viewing curated,�idealized lives online leads to negative self-comparison�and feelings of inadequacy.

Thwarting Self-Determination Needs: Social media�undermines autonomy, competence, and relatedness�needs essential for psychological wellbeing.

Fear of Missing Out (FOMO): Continuous exposure to�others' activities creates anxiety about being excluded�from experiences or opportunities.

Digital Boundaries for Mental Health: Setting limits on�social media use is increasingly recognized as�essential for anxiety management in primary care.

Management Strategies Overview

• Psychological Interventions: Evidence-based�therapies including CBT, exposure therapy, and�mindfulness techniques for anxiety management.

• Pharmacological Approaches: Overview of�medication options including SSRIs, SNRIs,�benzodiazepines, and their appropriate applications.

• Stepped Care Model: Implementing a graduated�approach to treatment based on symptom severity�and patient response.

• Lifestyle Modifications: Recommendations for sleep�hygiene, physical activity, and reducing digital media�consumption.

• Social Support Integration: Leveraging community�resources and support networks to enhance�treatment outcomes.

General Principles of Treatment

• Collaborative Treatment Approach:

• Psychoeducation as Foundation: Provide clear information�about anxiety disorders, normalizing experiences while�emphasizing treatability.

• Lifestyle Modifications: Recommend regular exercise, balanced�nutrition, sleep hygiene, and stress management techniques.

• Self-monitoring Tools: Teach patients to track anxiety symptoms,�triggers, and response patterns using journals or mobile�applications.

• Regular Follow-up Schedule: Establish consistent check-ins to� assess treatment efficacy and adjust interventions as needed.

Establish partnership with patients to develop treatment plans�tailored to their specific needs and preferences.

Cognitive Behavioral Therapy (CBT)

• Core Components: Includes cognitive restructuring, behavioral�activation, and skills training to address maladaptive thoughts�and behaviors.

• Arousal Management Techniques: Progressive muscle�relaxation, deep breathing, and mindfulness meditation to�reduce physiological symptoms of anxiety.

• Graded Exposure Therapy: Systematic approach to facing�feared situations in a controlled manner, reducing avoidance�behaviors over time.

• Delivery Formats: Available as individual therapy, group sessions,�or digital interventions through apps and online platforms.

• Evidence-Based Effectiveness: Strong research support for CBT�in treating various anxiety disorders with sustainable long-term�outcomes.

Self-Determination Theory (SDT) in Therapy�Diagram

Developing Competence:

Understanding Autonomy in SDT:

Fostering Relatedness:

Teaching skills that help�patients effectively manage�anxiety symptoms builds�self-efficacy and resilience.

Supporting patient choice and control�in therapeutic decisions enhances�treatment engagement and outcomes.

Creating therapeutic alliance�and encouraging healthy�social connections counteracts�isolation common in anxiety.

Pharmacotherapy: SSRIs and SNRIs

SSRI and SNRI antidepressant

SSRIs as First-line Treatment: Selective Serotonin Reuptake Inhibitors offer�effective symptom control with better tolerability than older medications.

SNRIs as Alternative Option: Serotonin-Norepinephrine Reuptake Inhibitors�effective when SSRIs fail or for patients with comorbid pain conditions.

Efficacy in Anxiety Disorders: Both medication classes show 50-70% response�rates across various anxiety disorders, with full remission in 20-40% of cases.

Common Side Effects: Initial exacerbation of anxiety (particularly where there�is a history of panic attacks), nausea, sexual dysfunction, and sleep�disturbances typically improve after 2-4 weeks.

Treatment Duration Considerations: Minimum 6-12 month treatment after�symptom remission with gradual tapering to prevent�discontinuation syndrome.

SSRI Medications: Types and Overview

• Mechanism of Action: How SSRIs work by blocking serotonin reuptake to�increase availability

• FDA-Approved SSRIs with generic and brand names:

• Primary Indications: Depression, anxiety disorders, panic disorder, OCD

• General Characteristics: Well-tolerated, fewer side effects than older�antidepressants

• Fluoxetine (Prozac)�• Sertraline (Zoloft)�• Paroxetine (Paxil)�• Citalopram (Celexa)�• Escitalopram (Lexapro)�• Fluvoxamine (Luvox)

Individual SSRI Profiles:

�Fluoxetine (Prozac)

�Sertaline (Zoloft)

�Paroxetine (Paxil)

Starting dose: 20mg daily

Common side effects:�Nausea, insomnia, sexual�dysfunction, weight loss

Special considerations: Long�half-life, activating, good for�morning dosing

Starting dose: 25-50mg daily

Common side effects:�Nausea, diarrhea, sexual�dysfunction, drowsiness

Special considerations:�Well-tolerated, good first-line�choice

Starting dose: 10-20mg daily

Common side effects:�Sedation, weight gain, sexual�dysfunction, withdrawn�symptoms

Special considerations: Most�sedating SSRI, higher�discontinuation syndrome risk

Individual SSRI Profiles: Part 2

Citalopram (Celexa)

Escitalopram (Lexapro)

Fluvoxamine (Luvox)

• Starting dose: 10-20mg daily

• Common side effects:�Nausea, dry mouth,�drowsiness, sexual dysfunction

• Special considerations: QT�prolongation risk, max 20mg�for elderly/hepatic impairment

• Starting dose: 5-10mg daily

• Common side effects:�Nausea, insomnia, sexual�dysfunction, fatigue

• Special considerations:�Often better tolerated, S-�enantiomer of citalopram

• Starting dose: 25-50mg daily

• Common side effects:�Nausea, sedation, sexual�dysfunction, drug interactions

• Special considerations:�Strong CYP1A2 inhibitor,�primarily used for OCD

SNRI Medications: Types and Overview

• Mechanism of Action�• How SNRIs work by blocking both serotonin and norepinephrine reuptake

• FDA-Approved SNRIs (Generic & Brand)�• Venlafaxine (Effexor XR)�• Duloxetine (Cymbalta)�• Desvenlafaxine (Pristiq)�• Levomilnacipran (Fetzima)

• Primary Indications�Depression, generalized anxiety disorder, social anxiety, panic disorder,�fibromyalgia, neuropathic pain

• General Characteristics�• Dual mechanism, may be more effective for severe depression�• Can treat pain conditions

Individual SNRI Profiles

Venlafaxine (Effexor XR)

Duloxetine (Cymbalta)

Desvenlafaxine (Pristiq)

Levomilnacipran (Fetzima)

• Starting dose: 37.5-75mg daily�• Common side effects: Nausea, dizziness,�sexual dysfunction, hypertension�• Special considerations: Dose-dependent�effects, monitor blood pressure

• Starting dose: 30-60mg daily�• Common side effects: Nausea, dry mouth,�constipation, fatigue�• Special considerations: Good for pain�conditions, hepatic metabolism

• Starting dose: 50mg daily�• Common side effects: Nausea, dizziness,�insomnia, hyperhidrosis�• Special considerations: Active metabolite�of venlafaxine, renal elimination

• Starting dose: 20mg daily�• Common side effects: Nausea,�constipation, hyperhidrosis, erectile�dysfunction�• Special considerations: More�norepinephrine selective, activating

SSRI vs SNRI: Key Comparisons

Mechanism of Action

Side Effect Profile

Efficacy

Clinical Considerations

• SSRIs: Target serotonin only�• SNRIs: Target both serotonin and�norepinephrine

• SSRIs: Generally better tolerated, less�blood pressure effects

• SNRIs: Higher risk of hypertension,�dizziness, withdrawal symptoms

• SSRIs: Better for anxiety disorders,�first-line choice�• SNRIs: May be more effective for�severe depression, good for comorbid�pain

• SSRIs: Preferred for anxiety-�predominant presentations�• SNRIs: Consider when�fatigue/pain co-occur,�treatment-resistant cases

Treatment Initiation

• General Principles

• SSRI Initiation

• SNRI Initiation

• Patient Education

• “Start low and go slow” approach�• Begin with half the normal dose for elderly/sensitive patients�• Titrate upward every 14 days as tolerated

• Start at lower doses than for depression�• Monitor for initial anxiety worsening in first 1-2 weeks�• Consider morning dosing for activating SSRIs

• Monitor blood pressure regularly�• Start with lowest effective dose�• Be cautious with anxiety patients due to norepinephrine effects

• Explain delayed onset of benefits (2-6 weeks)�• Discuss common early side effects�• Emphasize importance of adherence

Expected Treatment Response Timeline

Week 1-2

Week 2-4

Week 4-6

Week 6-12

• Initial side effects�may appear (nausea,�sleep changes)

• Some patients may�experience temporary�anxiety worsening

• Early improvements�in sleep or appetite�possible

• Side effects typically�begin to diminish�• Initial therapeutic�benefits may emerge�• 20% chance of�response if no effect�by week 2

• Significant symptom�improvement�expected

• Full therapeutic�effects typically�develop

• Consider dose�adjustment if�inadequate response

• Maximum therapeutic�benefit achieved

• Continued�improvement over�several months

• Maintenance phase�begins after symptom�remission

Positive vs Negative Treatment Symptoms

Positive Treatment Response�Indicators

Negative Symptoms/Side�Effects to Monitor

Reduced anxiety and worry frequency

Improved sleep quality and duration

Enhanced mood stability

Increased energy and motivation

Better concentration and focus

Improved social functioning

Reduced physical anxiety symptoms

Persistent nausea or GI distress

Sexual dysfunction

Weight changes

Sleep disturbances (insomnia/sedation)

Increased suicidal thoughts

Hypertension

Withdrawal symptoms

Medication Choices in Primary Care

First-Line Choices for Anxiety Disorders

Special Considerations

Second-Line Options

When to Refer

Sertraline (Zoloft): Well-tolerated, good safety profile

Escitalopram (Lexapro): Often better tolerated than other�SSRIs

Fluoxetine (Prozac): Long half-life, good for adherence�issues

Start with lowest effective dose

Consider patient age, comorbidities, drug interactions

Monitor for suicidal ideation, especially in patients under�25

Plan for 12+ months of treatment after symptom�remission

Venlafaxine XR (Effexor): For treatment-resistant cases

Duloxetine (Cymbalta): When comorbid pain conditions�present

Treatment failure after 2-3 adequate trials

Complex comorbidities or severe symptoms

Suicidal ideation or self-harm behaviors

Alternative Pharmacological Options

• Tricyclic Antidepressants (TCAs) (eg; amitriptyline, clomipramine,nortriptyline)

• Monoamine Oxidase Inhibitors (MAOIs) (eg; selegiline, rasagiline)

• Dietary Restrictions with MAOIs

• Monitoring Requirements

• Risk-Benefit Assessment

• Effective for treatment-resistant anxiety but with significant anticholinergic side�effects and cardiac risks.

• Powerful option for refractory cases requiring strict dietary restrictions to prevent�hypertensive crisis.

• Patients must avoid tyramine-rich foods including aged cheese, cured meats, and�fermented products.

• Regular blood pressure checks and liver function tests necessary with these�alternative medications.

• Consider these options only after SSRI/SNRI failure, weighing efficacy against�potentially serious adverse effects.

Stopping and Switching Medications

• Gradual Discontinuation: Taper medications slowly over 2-4�weeks to minimize withdrawal symptoms and rebound anxiety.

• Cross-Tapering Approach: Gradually reduce first medication�while introducing the new one to maintain therapeutic�coverage.

• Washout Periods: Allow 2 weeks when switching from SSRIs�to MAOIs to prevent Serotonin Syndrome.

• Monitor for Discontinuation Syndrome: Watch for dizziness,�nausea, headache, and sensory disturbances when reducing doses.

• Patient Education: Inform patients about potential withdrawal�effects and the importance of adherence to the switching�schedule.

Risk Factors for Discontinuation�Syndrome

• Medication-related factors

• Duration of treatment

• Abrupt discontinuation

• Patient-specific vulnerabilities

• Antidepressants with shorter half-lives like paroxetine and venlafaxine�pose higher discontinuation risks.

• Longer treatment periods (>8 weeks) significantly increase risk of�withdrawal symptoms.

• Stopping medication suddenly rather than tapering increases�syndrome severity.

• History of anxiety disorders or previous withdrawal experiences�increases susceptibility.

Role of Benzodiazepines

• Limited role in anxiety management: Short-term relief but not�recommended as first-line or long-term treatment option

• Anxiolytic benefits: Rapid symptom relief for acute anxiety, panic�attacks, and severe insomnia

• Significant risks: Cognitive impairment, tolerance development,�physical dependence, and withdrawal symptoms

• Prescribing guidelines: Use lowest effective dose for shortest�duration with clear discontinuation plan

• Alternative approaches preferred: CBT, SSRIs, and lifestyle�modifications should be considered before benzodiazepines

Primary Indications: Management of anxiety, panic disorders, acute seizures, muscle spasms, alcohol withdrawal, and procedural sedation.

Benzodiazepine Profiles & Indications

Safety & Adverse Profiles

FDA BLACK BOX WARNING Combined use with Opioids may result in profound sedation, respiratory depression, coma, and death.

CNS Depression: Somnolence, fatigue, and psychomotor impairment.

Ataxia: Significant risk of falls/fractures, especially in the elderly.

Cognitive: Anterograde amnesia and paradoxical agitation.

Risks: Physical dependence, tolerance, and life-threatening withdrawal.

ANXIETY MANAGEMENT IN PREGNANCY

Prenatal Anxiety Assessment:

Medication Safety Considerations:

Non-Pharmacological Approaches:

Postpartum Anxiety Management:

Impact on Maternal-Fetal Outcomes:

o Screening tools and signs specific to pregnancy- related anxiety and panic disorders.

o Guidelines for anxiolytic medications during pregnancy, including risks and benefits assessment.

o Evidence-based therapies like CBT, mindfulness, and yoga adapted for pregnant women.

o Distinguishing between normal adjustment and pathological anxiety after childbirth.

o How untreated anxiety affects pregnancy outcomes and infant development.

Clinical Guidelines for Pregnant Patients

• Pregnancy-specific considerations

• Non-pharmacologic approaches first

• SSRI safety profile

• Avoid benzodiazepines

• Regular monitoring

Anxiety disorders often worsen during pregnancy or postpartum�periods, requiring special monitoring.

CBT, mindfulness, and relaxation techniques should be employed�as first-line treatments.

When medication is necessary, select SSRIs with established�safety data at the lowest effective doses.

Associated with birth defects and neonatal withdrawal�syndrome; use only for severe, acute situations.

Assess treatment response and side effects more frequently�during pregnancy and postpartum.

Medication Discontinuation Risks in Pregnancy

• Avoid abrupt medication discontinuation

• Tapering is preferred when necessary

• Risk-benefit assessment is essential

• Monitor for withdrawal symptoms

• Sudden cessation increases risk of maternal relapse and may negatively impact�fetal development.

• Gradual reduction under medical supervision minimizes withdrawal symptoms and�stabilizes maternal mental health.

• Collaborate with healthcare providers to weigh medication risks against untreated�anxiety consequences.

• Regular assessment helps identify early signs of relapse or withdrawal requiring�intervention.

Perinatal and Withdrawal Syndromes

• Perinatal Anxiety Disorders: Anxiety disorders during pregnancy and�postpartum period can significantly impact maternal and infant�outcomes.

• Neonatal Withdrawal Syndrome: Symptoms include irritability, tremors,�feeding difficulties, and respiratory distress in newborns exposed to�medications.

• Floppy Baby Syndrome: Characterized by hypotonia, lethargy, and poor�reflexes in infants exposed to benzodiazepines in late�pregnancy.

• Management Approaches: Includes gradual�medication tapering, non-pharmacological�interventions, and specialized neonatal care.

Limitations in Primary Care Settings

• Time constraints in primary care: Limited appointment�duration (often 10-15 minutes) makes comprehensive�anxiety assessment challenging.

• Knowledge gaps: Many primary care providers lack�specialized training in psychiatric disorders and DSM-5�diagnostic criteria.

• Screening tool limitations: Brief screening tools may�miss nuanced symptoms or comorbid conditions.

• Resource constraints: Limited access to mental health�specialists for referrals, especially in rural areas.

• Patient barriers: Stigma, reluctance to discuss mental�health, and difficulty articulating symptoms accurately.

Faith & The Human Soul

Anxiety as a Natural Trial

Islam views mental distress not as a failure of faith, but as a part of the human experience (ibtilā’).

أَلَا بِذِكْرِ اللَّهِ تَطْمَئِنُّ الْقُلُوبُ

"Unquestionably, by the remembrance of Allah do hearts find rest." — Quran 13:28

•

Validation: Quran 2:155 acknowledges "fear" as a test.

•

Spiritual Anchor: Trust in Allah (Tawakkul) acts as a psychological buffer against uncertainty.

Prophetic Prescription

Dual Path to Healing

Healing in Islam combines spiritual anchoring with active medical intervention.

•

Medical Care: Seeking therapy is a Sunnah. "Make use of medical treatment, for Allah has not made a disease without a remedy."

•

Prophetic Dua: The Prophet (PBUH) sought refuge from Hamm (anxiety about the future) and Hazan (sorrow).

•

Holistic Balance: Prayer and professional clinical care work in tandem for recovery.

Conclusion: Living with Anxiety

• Anxiety as a lifelong companion: Anxiety is a natural part of�human experience that will always be present in some form.

• Management vs elimination: The goal is not to eliminate�anxiety completely but to develop effective coping�strategies.

• Self-determination in anxiety management: Fostering�autonomy, competence and relatedness helps build�resilience against anxiety.

• Digital balance for mental health: Creating boundaries with�social media and the always-on culture is essential for�wellbeing.

• Primary care as the frontline: Primary care providers play a�crucial role in early identification and management of anxiety�disorders.

REFERENCES AND CLINICAL GUIDELINES

• American Psychiatric Association (APA): DSM-5 diagnostic criteria and�treatment guidelines for anxiety disorders

• Royal Australian and New Zealand College of Psychiatry: RANZCP clinical�practice guidelines for anxiety disorders management

• World Health Organization (WHO): Global recommendations and statistics on�anxiety disorder prevalence

• Journal of Affective Disorders: Recent epidemiological data on anxiety�disorders (2021-2025)

• Self-Determination Theory resources: selfdeterminationtheory.org -�Framework for understanding psychological needs