2nd CME

Anxiety Disorders

“The Scream”Edward Munch

Doct. Jean-louis Aillon28-10-10

Definition Anxiety

A diffuse, unpleasant, vague sense of apprehension, often accompanied by autonomic sintoms, such as headache, perspiration, palpitation, tighness in the chest, mild stomach discomfort, restless… is an ALERTING SIGNAL!

1)SOMATIC SINTOMS

2) PSYCHOLOGICAL

SINTOMS

+ Sympathetic nervous system

EMOTION: Distress, alarm, terror

COGNITIVE: evaluation of threat Fight/flight

Anxiety as a Normal and an Abnormal Response

• Some amount of anxiety is “normal” and is associated with optimal levels of functioning.

• Abnormal:

+ intensity or + duration to given stimuli

• Pathological:

Interfere with social, occupational or other important areas of functioning

like stress..

The Fear and Anxiety Response Patterns

• Fear: response to a threat: known, external, definite, non conflictual. Every people.

• Phobia: not same alarm in majority of people

• Anxiety: response to a threat: unknown, internal, vague or conflictual origin

DSM-IV Anxiety disorders

• Fear:

• Phobia:

• Anxiety:

Acute Stress Disorder Post Traumatic Stress Disorder

Specific Phobia, Social Fobia,Agorafobia

trauma

Interfere with functioning

Acute +++

Chronic -

Panic Attack/ Disorder

Generalized Anxiety Disorder

Obsessive Compulsive Disorder

avoidance

Abnormal response

General medical condition or drugs: Hypo/Hyperthyroidism, Hyperparathyroidism, deficit B12, Pheochromocytoma, brain lesion, Hypoglycemia, cardiac arhythmia. Anphetamine, cocaine, Miràa, caffeine.

Epidemiology in the world• Worldwide lifetime prevalence of anxiety disorders is 16.6%

(18.5% F; 10.4%M)

• One year prevalence: 10.6%

Somers JM et al., Evid Based Mental Health, 2006

Epidemiology in Kenya

n. 2770 (10 health facilities)

On average, anxiety neurosis and general anxiety were recorded in at least 11% of the patients and the levels ranged from 1.5% to 37.7% across all the centres.

Our data

Generalized Anxiety Disorder

Panic Disorder

Post Traumatic Stress Disorder

Obsessive Compulsive Disorder

Social PhobiaAgoraphobia

Generalized Anxiety Disorder

A) Have you worried excessively or been anxious about several things of day to day life, at work, at home, in your close circle over the past 6 months ?

Are these worries present most days ?

B) Do you find it difficult to control the worries or do they interfere with your ability to focus on what you are doing ?

C) When you were anxious over the past 6 months, did you, almost every day, 3 or more of these sintoms :

• Feel restless, keyed up or on edge ? 

• Feel tense ?

• Feel tired, weak or exhausted easily ?  

• Have difficulty concentrating or find your mind going blank ? 

•  Feel irritable ? 

• Have difficulty sleeping (difficulty falling asleep, waking up in the middle of the night, early morning wakening or sleeping excessively) ? 

D) The focus of the anxiety and worry is not confined to features of an Axis I disorder,: social phobia, obsessive-compulsive disorder, separation anxiety disorder, somatization disorder, hypochondriasis, posttraumatic stress disorder.

E)The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social or occupational functioning.

Panic DisorderA)1. Recurrent unexpected panic attacks

2. At least one of the attacks has been followed by at least 1 month of one or more of the following:

- Persistent concern about having additional panic attacks- Worry about the implications of the attack or its consequences- A significant change in behavior related to the attacks

B) Presence or absence of agoraphobia

C) The panic attacks are not due to the direct physiologic effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hyperthyroidism).

D) The panic attacks are not better accounted for by another mental disorder.

What is a panic attack?• Have you, on more than one occasion, had spells or attacks when you suddenly felt

anxious, frightened, uncomfortable or uneasy, even in situations where most people would not feel that way ? Did the spells peak within 10 minutes ?

• Requiring at least four of the following sintoms:1. Did you have skipping, racing or pounding of your heart ?

2. Did you have sweating or clammy hands ?

3. Were you trembling or shaking ?

4. Did you have shortness of breath or difficulty breathing ?

5. Did you have a choking sensation or a lump in your throat ?

6. Did you have chest pain, pressure or discomfort ?

7. Did you have nausea, stomach problems or sudden diarrhea ?

8. Did you feel dizzy, unsteady, lightheaded or faint ?

9. Did things around you feel strange, unreal, detached or unfamiliar, or did you feel outside of or detached from part or all of your body ?

10. Did you fear that you were losing control or going crazy ?

11. Did you fear that you were dying ?

12. Did you have tingling or numbness in parts of your body ?

13. Did you have hot flashes or chills ?

Post Traumatic Stress Disorder

A) The person has been exposed to a traumatic event in which both of the following were present:

• The person experienced, witnessed, or was confronted with an event that involved actual or threatened death or serious injury or a threat to the physical integrity of others.

• The person's response involved intense fear, helplessness, or horror.

EXEMPLE: SERIOUS ACCIDENT, SEXUAL OR PHYSICAL ASSAULT, A TERRORIST ATTACK, BEING HELD HOSTAGE, KIDNAPPING, HOLD-UP, FIRE, DISCOVERNG A BODY, UNEXPECTED DEATH, WAR, NATURAL DISASTER...

• B) The traumatic event is persistently re-experienced in at least one of the following ways:

- Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions

- Recurrent distressing dreams of the event.

- Acting or feeling as if the traumatic event were recurring, including a sense of reliving the experience, illusions, hallucinations, and flashback episodes.

- Intense psychological distress at exposure to cues that symbolize an aspect of the traumatic event.

- Physiologic reactivity on exposure to cues that symbolize or resemble an aspect of the traumatic event.

C) The person persistently avoids stimuli associated with the trauma and has numbing of general responsiveness including at least three of the following:

-Efforts to avoid thoughts, feelings, or conversations associated with the trauma

- Efforts to avoid activities, places, or people that arouse recollections of the trauma

- Inability to recall an important aspect of the trauma

- Markedly diminished interest or participation in significant activities

- Feeling of detachment or estrangement from others

- Restricted range of affect

D) Persistent symptoms of increased arousal are indicated by at least two of the following:

-Difficulty falling or staying asleep- Irritability or outbursts of anger- Difficulty concentrating- Hypervigilance- Exaggerated startle response

E) Duration of the disturbance is more than 1 month.

F) The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Less: Acute Stress disorder

Post Traumatic Stress Disorder

a) Extreme traumatic event

b) Re-experience

c) Avoidance

d) Increased Arousal

e) More than 1 month

f) Significant Distress

Obsession Anxiety Compulsion

Obsessive Compulsive Disorder

Thoughts, impulses, or images:Recurrent Persistent IntrusiveInnapropriateDistressing

Repetitive behaviors or mental actsto reduce anxiety related to obsessions

+ + +

Fearing act on some impulse-Fear of harming someone even though you didn’t want to -Sexual thoughts, images or impulses - Fear or superstitions that you would be responsible for things going wrong - Religious obsessions-hoarding, collecting-To be dirty, contaminated or had germs - Fear of contaminating others,

Superstitious rituals Counting or checking - Repeating-Collecting Arranging things-Washing or cleaning excessively

• A) Either obsession or compusion

Obsession• Recurrent and persistent thoughts, impulses, or images that are experienced as intrusive and

inappropriate, causing anxiety or distress.• The thoughts, impulses, or images are not simply excessive worries about real-life problems.• The person attempts to ignore or suppress such thoughts, impulses, or images or to neutralize them

with some other thought or action.• The person recognizes that the obsessional thoughts, impulses, or images are a product of his or

her own mind.

Compulsions• Repetitive behaviors or mental acts that the person feels driven to perform in response to an

obsession or according to rules that must be applied rigidly.• The behaviors or mental acts are aimed at preventing or reducing distress or preventing some

dreaded event or situation.• These behaviors or mental acts either are not connected in a realistic way with what they are

designed to neutralize or prevent, or they are clearly excessive.

• At some point during the course of the disorder, the person has recognized that the obsessions or compulsions are excessive or unreasonable.

• The obsessions or compulsions cause marked distress, take up more than 1 hour a day, or significantly interfere with the person's normal routine, occupation, or usual social activities

Agoraphobia

Fear of being in places or situations from which escape might be difficult (or embarrassing) or in which help might not be available in the event of having unexpected panic-like symptoms.

The situations are typically avoided or require the presence of a companion.

Often associated with Panic Disorder

Social Phobia• A fear of one or more social or performance situations in

which the person is exposed to unfamiliar people or to possible scrutiny by others and feels he or she will act in an embarrassing manner.

• Exposure to the feared social situation provokes anxiety, which can take the form of a panic attack. The person recognizes that the fear is excessive or unreasonable.

• The feared social or performance situations are avoided or are endured with distress.The avoidance, anxious anticipation, or distress in the feared situation interferes significantly with the person's normal routine, occupational functioning, or social activities or relationships

etiology• Psychological Theories:- Psychoanalitic: conflict

- Behavioural: faulty, distorted thinking pattern - Existential: awareness ot nothingness of life.

• Biological Theories:- autonomic system- neurotrasmitters- Genetic ( + panic)

External: world pressure vs EgoInternal: impulses vs conscience

• The fundamental problem in dealing with the pharmacological treatment of anxiety doesn’t seem to be which medicine to use, but whether to use it or not-

• Altesman, Cole, 1983

• Psychotherapy: + cognitive-behavioural

• Relaxation techniques• Farmacotheraphy: Benzodiazepine: Diazepam,alprazolam

Amitriptyline

Fluoxetine (SSRIs)

Theraphy

For anxiety that is severe, disabling and causing extreme distress or associated with somatic sintoms

1° approach

“Empathic listening, reassurance and guidance should always be offered.

Additionally, specific psychotherapeutic techniques, such as cognitive-behavioural therapy, are effective measures to reduce anxiety. Relaxation techniques may additionally be offered.

WHO

Cognitive-Behavioural Psychotherapy

GAD: relaxation tecnique, biofeedback/ distorted thinking

Panic Disorder: instruction about false beliefs: tendency to misinterpret mild bodly sensation as indicative of impending panic attack. Panic attack are time limited and not life-thretening.

PTSD: reconstruction/review of traumatic event. Abreact emotional feeling associated with trauma.

DOC: exposure and response prevention, desensibilization

Relaxation technique1) Breathing And Relaxation exercise for Insomnia • Take a deep breath. Breathe in through your nose and visualize the air moving down to your stomach. Breathe out slowly through your mouth. As you breathe in again, silently

count to four. Purse your lips as you exhale slowly. This time count silently to eight.Repeat this process six to ten times.

• 2)Lay on your back on the floor with your feet slightly apart, your hands by your sides, and your palms turned upward. Close your eyes and concentrate on every part of your body.Begin at the top of your head and work your way down to your toes.Start by feeling your forehead tense, then your eyes, face, and jaw. Tense and release each muscle group, such as your shoulders and neck.Pay attention to each area of your body from the top of your head, down through the trunk of your body, along your legs, and ending at the tips of your toes.Stay in this relaxed condition for a few minutes. Concentrate on your breathing and let all worry and stress dissipate from your mind and body. Make sure that your breathing comes from deep in your stomach and flows slowly and evenly.Stretch slowly before standing up.

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Farmacotheraphy1) Benzodiazepine for short term• Diazepam: 2 mg PO OD/TID, up to oral doses

of 5-10 mg BD.

• Alprazolam: 1 mg OD/TID, up to 2 mg TIDLowest effective dose for as short a period as possible (maximum 4

weeks)

Lower doses are generally advised in children and adolescents.

“The main objective may be to reduce symptoms enough to allow the patient to engage in treatments based on cognitive-behavioural techniques.” WHO

Start: 2,5 mg bid

Start: 0,25 mg bid

Antidepressants for long term treatment

1) Amitriptiline 25 mg NOCTE: gold standard

2) Fluoxetine 20 mg OD

Contraindications

Not tollerate side effects

For Disorders that are severe, disabling and causing extreme distress, or somatic sintomsNo responding o no possibility of Psychotherapy

Amitriptyline

Start with: 25 mg NOCTE 1/12 *

+ dosage in DOC

2 weeks

Monitoring acute treatmentPsychological counseling

Light emprouvement

4-6 weeks

Evaluation of response to treatment

Remarkable emprouvement

NO emprouvement

+ 25 mg every week (max: 200 mg)

Change antidepressantRefer Psychiatrist

Long term therapy at least 6-8 months

If problem to review soon

Amitriptiline

Contraindication: : Pregnancy and breast feeding, Glaucome, hyperthyroidism, prostatic hypertrophy, Stenosis pillorica, heart failure, serious rhythm disturbances, Hypotension, treatment with thyroid ormons, liver diseases, Dementia.

Inform patients about side effects - Dosage in elders

FluoxetineStart with: 20 mg OD 1/12 *

2 weeks

Monitoring acute treatmentPsychological counseling

Light emprouvement

4-6 weeks

Evaluation of response to treatment

Remarkable emprouvement

NO emprouvement

+ 10 mg every week (max: 40-60 mg)

Change antidepressantRefer Psychiatrist

Long term therapy at least 6-8 months

*Better 10 mg 1° week 20 mg 2° week

Administer in morning or after lunch

+ dosage in DOC

Fluoxetine

Contraindication: Pregnancy and breast feeding, Hypersensibility

Utopia lies at the horizon. When I draw nearer by two steps, it retreats two steps. If I proceed ten steps forward, it swiftly slips ten steps ahead. No matter how far I go, I can never reach it. What, then, is the purpose of utopia? It is to cause us to advance.” Eduardo Hughes Galeano

Asante sana for your attention

For any suggestion: jean.84@libero.it 0735525429

http://www.who.int/mental_health/management/psychotropic/en/index.html