Anxiety Disoders 1

8/9/2019 Anxiety Disoders 1

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Anxiety DisorderAnxiety DisorderTazeen Arif


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Anxiety Disorders

AnxietyDiffuse, unpleasant, sense of apprehensionaccompanied by autonomic symptoms to athreat that is unknown, vague and conflictual

Normal if Less severe, shorter duration, adaptive

response, no suffering, improve performanceand needs no treatment

Fear

As anxiety, alerting symptom but to known,external threat


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Anxiety Disorders

- Most prevalent psychiatric disorder

- Produce inordinate morbidity

- Use health services

- Produce impairment

- Must be treated


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Anxiety Disorders

1- Panic disorder and agoraphobia

2- Social and specific phobia

3- Obsessive compulsive disorder

4- Posttraumatic stress disorder and

Acute stress reaction

5- Generalized anxiety disorder

6- Other anxiety disorders


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Anxiety Disorders( Etiology )

1- Psychoanalytical theoriesAnxiety result from psychic conflict betweensexual or aggressive wishes and threats fromexternal reality

2- Behavioral theories

- Classical conditioning

- Social learning theory: patients learn to respondexcessively to stress e.g through modeling

3- Cognitive theories

- Patients misperceive situations as dangerouswhen they are not.

- Overestimation of danger or harm andunderestimation of their abilities


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4- Biological

A- Autonomic nervous system

Increased Sympathetic tone

B- Neurotransmitters

Dysregulation of monoamines e.g nor

epinephrine and serotonin.

- GABA

C- +ve link between streptococcalinfections and OCD


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D- Brain imaging studies

- CT ,MRI

Cerebral asymmetries

-PE

T,S

PECT

,EEG

Abnormalities in frontal, temporal and

occipital lobes

E- Genetics

Higher incidence in relatives indicate

positive genetic factors


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1- Panic disorderand agoraphobia

Definitions

Panic disorder

Spontaneous, unexpected occurrence of panicattacks

Panic attacks

Discrete periods of intense fear or discomfort,occurring over a short period develop abruptlyand reach a peak within 10 minutes not related tospecific situation or object that can vary fromonce/ day to few attacks / year

Agoraphobia

Fear of being alone in public places especially inplaces in which rapid exit is difficult


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Life time prevalence: 1-5%

Sex: Female: male = 3:1

Age: young adulthood( before 30 years)

Co morbidity = 90%

- Agoraphobia

- Depression

- Other anxiety disorders

- Other psychiatric disorders asHypochondriasis, personality disorders,substance abuse especially alcohol

Epidemiology


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- Commonly presents to the Emergency room

complain of somatic concern of death fromcardiac or respiratory problem

- 1st attack usually spontaneous, may be

precipitated by caffeine, alcohol, nicotine,

sleep exertion, unusual sleep pattern

- Onset: sudden

- Course: rapidly progress within 10 minutes

- In-between attacks : patient has anticipatory

anxiety

- +/- Associated symptoms: Depression, suicide,

substance intake, other anxiety disorder

Clinical picture ofpanic attack


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A discrete period of intense fear or discomfort inwhich 4 or more symptoms are present

Mental Symptoms

1- Fear of dying ( can't name source of fear )

2- Fear of losing control or going crazy

3- Depersonalization( detachment from self) andderealization (feeling of unreality)

Neurological symptoms

4- Parasthesia ( numbness or tingling sensation)5- Feeling dizzy, unsteady, or faint

6- Trembling or shaking

DSM IV Criteria ofpanic attack


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Physical symptoms

7- Palpitation, pounding heart, accelerated heartrate

8- Dyspnea and chest pain9- Chills or hot flushes

10- Sweating

11- Nausea or abdominal distress

12- feeling of choking

DSM IV Criteria ofpanic attack


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A- Both 1 and 2

1- Recurrent unexpected panic attacks

2- at least one attack followed 1 month by at least

1 of the following ( anticipatory anxiety)i- Concern about having additional attacks

ii- Worry about the consequences

iii- a significant change in behavior related to theattacks

B- +/- Agoraphobia

DSM IV Criteria ofpanic disorder

with or without agoraphobia


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C- The panic attacks are not due to direct

physiological effect of substance or

general medical condition

D- The panic attacks are not due to other

mental disorder

E- Frequency

Moderate = 3 attacks/ 3 weeks

Severe = 4 attacks/4 weeks

DSM IV Criteria ofpanic disorder

with or without agoraphobia


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A- Anxiety about being in place or situation ( busystreets, closed spaces, crowded stores ) fromwhich escape may be difficult or in which helpmay not be available

B- The situations are avoided, done with anxiety, orrequire the presence of a companion

C- The anxiety is not due to substance, generalmedical condition, or other mental disorder

D- Complications: Psychosocial consequences

DSM IV Criteria of agoraphobia


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Medical disorders1- Cardiovascular disorder

Angina, mitral valve prolapse, myocardialinfarction, hypertension, cardiac

dysrhythmias

2- Pulmonary diseases

Bronchial asthma, pulmonary embolus

3- Neurological disease

Migraine, temporal lobe epilepsy, multiplesclerosis, transient ischemic attack

Differential diagnosis


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4- Endocrinal disordersHypoglycemia( insulinomas),pheochromocytoma, diabetes, hyperthyroid,hypo parathyroid

5- Drug intoxication

Amphetamines, hallucinogens, theophylline,nicotine, cannabis, caffeine

6- Drug withdrawal

Alcohol, sedatives hypnotics, antihypertensive

7- Psychiatric disorders

Malingering, hypochondriasis, specific and socialphobia

Differential diagnosis


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Workup to assess

Thyroid

Parathyroid

AdrenalSubstance intake

Chest X- ray

ECG

Cardiac enzymes

EEG

MRI

Investigations


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Duration of therapy= 8-12 months

Combined pharmacotherapy+ Psychotherapy

I) Pharmacotherapy

A- Selective Serotonin Reuptake Inhibitor( SSRI)

Best approved for panic is paroxetine

Dose= 5-10 mg and titrate up to 20-60 mg/day2nd choice is fluvoxamine or sertraline

B- Tricyclic Antidepressant (TCA)

Clomipramine( anafranil) or imiprammine ( tofranil)( 100-150 mg/day)

Less widely used d.t side effects

Treatment


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C- Benzodiazepines (BDZ)Given only 4- 6 weeks

Advantage: rapid onset of action

Mostly used is Alprazolam( Xanax)

D- Non benzodiazepines

Buspirone ( 10 mg /day )

E- Beta blockers

Propranolol 10 mg tablet, up to 30 mg/day.

Treatment


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II) Psychotherapy

A- Cognitive therapyAim: Change false beliefs and information about panicattacks

- Patient's of bodily sensation as indicating impendingdeath

- Explain that when panic attack occurs it is time limitedand not life threatening

B- Behavioral therapy

- Applied relaxation

Aim: Instill in patients a sense of control over theirlevels of anxiety

- Respiratory training

Train patient to control urge to hyperventillation

C- Supportive psychotherapy to assure the patient

D- patient education

E- Environmental and societal manipulation

Treatment


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2- Specific Phobiaand Social PhobiaDefinitions

Phobia

Fear of a specific object, circumstances, or

situation that is excessive, irrational result in

avoidance of the feared object

Social Phobia (Social Anxiety Disorder)

Excessive fears of humiliation or embarrassment

in various social settings e.g Speaking in public

Specific Phobia

Marked and persistent fear that is excessive andunreasonable, cued by the presence of specific

object or situation


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Epidemiology

- Most common mental disorder = 5-10% up to

25%

- Sex: Female > Male- Age: Teenagers can occur in childhood

- In specific Phobia, most common feared object:

Animals, storms, Heights, illness, injury, and

death

Co morbidity

- Other anxiety disorder

- Mood disorders esp. depression

- Substance related disorders( i.e way to cope )- Bulimia nervosa

- Avoidant personality disorder


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Clinical picture

A- intense fear of an object or situation .The fearis:

- Out of proportion with the situation

- Cannot be reasoned or explained

- Is beyond voluntary control

- Leads to avoidance

B- Psychological symptoms

Fear, anticipatory anxiety

C- Pysiological, somatic symptoms

Autonomic manifestations on exposure to theobject, palpitation, sweating, trembling, drymouth, breathing difficulty, hot flushes,numbnessetc

D- Behavioral

Avoidance


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Other forms of specific phobia

- Agoraphobia: fear of open spaces

- Claustrophobia: fear of closed spaces

- Acrophobia : fear of heights

- Nosophobia: fear of illness

- Xantophobia: fear of death

-Zoophobia: fear of animals

- Fear of blood injection injury

- School phobia


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Clinical picture of social phobia

Fear of social situations in which:

- Fear of being the focus of attention or being

negative evaluated in social situations

- The affected patient is exposed to the gaze of

others, is being criticized by others , or has to talk

in front of others

- Fear of doing something embarrassing

- Social situations are avoided

- Patient develops intense anxiety with autonomic

manifestations on exposure to the phobic

situations


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Psychotherapy and pharmacotherapy

I- Behavioral therapy

A- Systemic desensitization

The patient is exposed serially to apredetermined list of anxiety provoking stimuliunder relaxation, hypnosis, or tranquilizingdrugs

B- Flooding ( in vivo or imaginary )

C- Relaxation techniques and breathingexercises

D- Rehearsal during sessions

E- Homework assignments

F-

social skill training in social phobia

Treatment


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II-Cognitive therapy

Correct cognitive distortion

III- social and environmental manipulations

IV- PharmacotherapyA-1st line= SSRI( fluoxetine, citalopram, sertraline,

fluvoxamine, paroxetine).

-Other approved (TCA,SNRI)

B- Initial BDZ, alprazolam ( Xanax 0.25-0.5mg) 1 to2 tab./day, then taper after 4-6 weeks

C- Beta blockers esp. if associated with panicattacks e.g propranolol( Inderal 10 mg/day): upto 30 mg/day.

Treatment


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3-Obsessive compulsive disorder

Definition

Recurrent occurrence of obsessions andcompulsions severe to cause marked distress tothe person

Obsessions is a mental event

Compulsion is a behavior

Epidemiology

- Life time prevalence:2-3 %

- 4th common psychiatric diagnosis

- Mean age:25 years

- Sex: equal

- More in single person

Co morbidity

- 2/3 has major depressive disoder, alcohol use

- Other anxiety disorders: Social phobia, GAD

- Tics


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Obsessions1- Recurrent and persistent thoughts,

impulses, or images that areexperienced as intrusive andinappropriate causing markedanxiety or distress

2- they are not simply excessiveworries

3- The person tries to neutralize themwith some thought or action

4- the person realizes that thesethoughts are the product of his mind

Clinical features


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Compulsions1- Repetitive behaviors, or mental acts that

person feels driven to perform them

2- Aimed to relieve anxiety

Obsessions and compulsions are excessive,

unreasonable, time consuming, and

significantly interferes with the patient

routine and function

Specify: if with poor insight

Clinical features


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1- Contamination

CommonestFollowed by washing or avoidance of contaminatedobject

2- Pathological doubt

Followed by compulsion of checking

3- Intrusive thoughts

Usually sexual or aggressive

May report themselves to police

4- Symmetry

Result in compulsive of slowness

5- Others

Religious obsessions

Compulsions of hoarding

Depression, psychosocial factors, insight

Symptom patterns


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1- Hospitalize

Remove external stressors, ECT, depressed, andsuicidal risk

2- Pharmacotherapy +Behavioral therapy

a- SSRI orTCA + behavioral therapy ( 12 weeks )

b- AnotherSSRI orTCA +Behavioral therapy (12weeks)

c- Combine 2 SSRI or (SSRI +TCA) +Behavioral

therapy ( 12 weeks )

d- Augment ( Valproate , Lithium , or

Carbamazepine)e- ECT

f- Surgery ( Cingulotomy )

Treatment


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3- Psychotherapy

A- Behavioral therapy

- Exposure and response prevention

- Desensitization- Thought stoppage

- Implosion therapy

- Aversion conditioning

B- Family therapy

C- Supportive therapy

D- Group therapy

Treatment


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DefinitionSyndrome occurs to person when sees ,involved in, or hears of an extreme traumaticstress

Epidemiology- Prevalence

30% in traumatic event

25 % sub clinical form

- Women > Men

- Age: young adults- High risk : Severe trauma, long duration,high proximity of person to the actualtrauma, stressful life changes, 1st degreerelatives have depression, inadequate family

support

4- Posttraumatic stress disorder ( PTSD )and acute stress reaction


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A- A person has been exposed to a traumaticevent in which both of the following werepresent

1- Experience, witnessed or confronted with anevent involved actual death or serious injurye.g torture, wars, rape, and brain washing

2- Person's has intense fear, helplessness, orhorror

B- Re-experience of the traumatic event

1- Distressing images, thoughts or perceptions

2- Distressing dreams

3- Flashbacks

4- Psychological distress on exposure to internal

or external cues5- Physiological distress on exposure to internal

or external cues

Clinical features (1 Month)


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C- Avoidance of stimuli associated with the trauma

1- Avoidance of thoughts, feelings or conversation

associated with the trauma2- Avoidance of activities, places, or people that

arouse recollection of the trauma

3- inability to recall important aspect of the trauma

4-diminished interest in activities

5- Feeling of detachment from others

6- unable to have lovely feelings7- Sense of foreshortened future

D- Hyper arousal

1- Difficulty in falling asleep

2- Irritability or outbursts of anger

3- Difficult concentration4- Hyper vigilance

5- Exaggerated startle response

Acute stress reaction = Less than one month

Clinical features ( cont. )


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I- Prophylaxis

Aim: Develop more mature copingmechanisms and acceptance of theevent through psychotherapy

- Crisis intervention

- Education and support

II- Hospitalize if

Symptoms are severe, suicide, orviolence

III- Psychotherapy ( individual or group )

A- Exposure therapy

B- Stress management ( Relaxationtechniques, cognitive approaches )

Treatment


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C- Support through relatives and friends

D- Abreaction- Experiencing the emotionsassociated with event

IV- Pharmacotherapy (duration = 1 year)

A- Induction of sleep by sedative hypnotics butno more than 1 month

B- SSRI -Sertraline, paroxetine

Or TCA as imipramine or amitriptyline

Dose = antidepressant dose

Each trial = 8 weeks

C- Others as alpha agonist and beta blockers

Treatment


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DefinitionChronic condition characterized bysubjective experience of apprehensionwithout objective reasons, excessiveanxiety and worry about several events

or activities can't be controlled for mostof the day

Epidemiology

Common = 3-8 %

Female : Male = 2:1

25% ofGAD in anxiety clinics

5- Generalized anxiety disorder


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- Somatic symptoms( cardiopulmonary

symptoms, easy fatigability, restlessness,

shakiness, GIT symptoms, tension headache,

muscle pain, parathesia and hyperreflexia)

- Psychological,anxiety difficult to control ( worry,

apprehension, fear, sense of insecurity,irritable, restless, hypersenstivity, easy loss of

temper,and breaking down in tears)

- Autonomic hyperactivity ( pallor or flushing,

blurred vision, dry mouth, sweating,palpitation)

- Cognitive symptoms ( irritable, difficult

concentration, difficult recall )

Clinical picture ( 6 months duration)


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Combined pharmacotherapy andPsychotherapy

A- Psychotherapy

- Cognitive behavioral therapy

- Environmental and social manipulation

- Biofeedback training

- Encourage patient to engage inpleasurable activities

Treatment


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B- Pharmacotherapy

Duration = 6-12 months

1- benzodiazepine

Not more than 1 month

2- Buspirone

Non BDZ anxiolytic

3- SSRI( Fluvoxamine, Sertraline,

Escitalopram, Paroxetine, Fluoxetine)

4- SNRI (Venlafaxine ) for cognitive

impairment and insomnia

Treatment

Documents

Anxiety Disoders 1