Dr. Aftab AsifAssociate Professor

Department of Psychiatry

NORMAL ANXIETY &

PATHOLOGICAL TYPES OF ANXIETY

   Behavior Ability to function  Assessment by patient, friend &

clinician Neuropsychiatric Evaluation

ANXIETY DISORDER  Panic disorder (with or with out agoraphobia) Specific phobia Special phobia Generalized anxiety disorder Obsessive-compulsive disorder Acute stress disorder Posttraumatic stress disorder   Anxiety disorder due to medical condition Substance-induced anxiety disorder

    PSYCHOANALYTIC THEORIES:

   “Anxiety around ego to take defensive action against the pressure from

within”

MAJOR CATEGORIES:

Depending on the nature of the feared consequences

Id or impulse anxiety Separation anxiety Castration anxiety Superego anxiety

  BEHAVIOURAL THEORIES:

Conditioned response to a specific environmental stimuli.

Regular food Contaminated foodAllergy Desensitization

BIOLOGICAL THEORIES:Biological events precede the psychological conflict

Autonomic nervous system Stimulation of ANS- like

Cardiovascular – tachycardia Muscular – headache Gastrointestinal – diarrhoea Respiratory – tachypnea

NEUROTRANSMITTER:

Norepinephrine

Serotonin

GABA

Norepinephrine:

Locus Ceruleus Pons  Limbic system Cerebral cortex Brainstem Spinal cord   Stimulation Fear

- Adrenergic agonist

(Isoproternol)

 

2- Adrenergic antagonist (yohimbine)

= Increased pain attacks

  Clonidine (catapres) = Reduced pain

attacks

SEROTONIN:

Raphe nuclei in rostral brainstem Cerebral cortex Limbic system Amygdala Hippocampus Hypothalamus Some drug involved with serotonin reduce the

anxiety level.

GABA

Benzodiazepine inhance The level of GABA reduced

anxiety Benzodiazepine severe panic attacks

antogonist (flumazenil)

BRAIN – IMAGING STUDY:CT/MRI --- some

increase in the size

of cerebral ventricles.

MRI – specific defect

in the tight temporal lobe.

PET/SPECT/EEG –

Abnormalities in frontal cortex.

GENETIC STUDIES:

50% relatives

have panic

attacks

NEUROANATOMICAL CONSIDERATIONS:

Limbic system

Increased concentration of GABA

Cerebral cortex

Frontal cerebral cortex Connected with Parahippocampal

cingulated gyrus hypothalamus Production of anxiety

DIFFERENT DISORDER VARIES Wide range of medical conditioning: Hyperthyroidism Hypothyroidism Hypoparathyroidism Vit B12 deficiency Cardiac arrythmias Hypoglycemia 83 % of cardiomyopathy patient awaiting cardiac

transplantation have panic disorder. 25 % Parkinson’s disease hare panic attacks 25 % of chronic obstructive pulmonary disease

(COPD) have panic attacks

Amphetamine Cocaine Caffeine

Substance Induced Anxiety Disorder

Mixed anxiety/depression disorder

AD

DA

AD

A

D

PANIC DISORDER

Epidemiology: Life time prevalence 1.5 to 3 % - panic disorder  4 % - panic attacks  Women Men

2-3 1

Mitral valve prolapse    Mid systolic dick on cardiac auscultation

   Prolapse of one of the mitral valve leaflets

   Heterogenous

Drug Starting Dosage

Daily Dosing Range

Max. Dosage

CommonS. Effect

Imipramine

25 mg at bedtime

50-100 mg 150 mg Dry mouth, blurred vision, constipation, urinary hesitancy, othostasis, somnolence, anxiety, sexual dysfunction

Pheneizine 15 mg twice daily

30-90 mg 90 mg Dry mouth, drowsiness, nausea, anxiety/nervousness, othostatic hypotension, myoclonus, hypotension, myoclonus, hypertensive

Fluoxetine 10 mg 20-40 mg 60 mg Nausea, diarrhea, anxiety/nervousness, sexual dysfunction

Paroxetine 10 mg 20-40 mg 60 mg Nausea, diarrhea, anxiety/nervousness, sexual dysfunction somnolence

DRUGS USED FOR THE TREATMENT OF PANIC DIAORDER.

Sertraline 25 mg 25-150 mg 60 mg Nausea, diarrhea, anxiety/nervousness, sexual dysfunction

Alprazolam

0.25-0.5 mg 3times daily

1.5-4.0 mg 6 mg/day Nausea, diarrhea, anxiety/nervousness, sexual dysfunction

Clonazepam

0.25-0.5 mg twice daily

1.5-4.0 mg 6 mg/day Somnolence, ataxia, memory problems, physical dependence,

withdrawal reactions

PHOBIC DISORDERS

“A marked and persistent

fear that is excessive at

unreasonable, cued by

the presence or anticipation

of a specific object or

situation.”

SPECIFIC TYPES: Animal type if the fear is cued by : Animals or insects

Natural environment type: Storms, heights or water

Blood-injection-injury type:

Situational type: Public transportation, tunnels, bridges, elevatos,

flying, driving, peak in childhood or in mid 20s

SOCIAL PHOBIA: Exposed to unfamiliar people

or to possible scrutiny by others. EPIDIMIOLOGY: Phobic disorder – 5-10 % in

general population Social phobia – 3 %

TREATMENT:

Pharmacological Treatment: Benzodiazepine -blockers Antidepressants.

Psychotherapy: Behavior or Cognitive behavior therapy

GENERALIZEDANXIETY DISORDER (GAD)

Excessive anxiety and worry for at least 6months. SYMPTOMS: Restlessness or feeling

keyed up, on edge Difficulty concentration or mind going blank  Irritability Muscle tension  Sleep disturbance

EPIDIMIOLOGY:

 Early adult life.  Commonly in women  More frequently in general Medical practice than in Psychiatry  High rate of comorbidity  Symptoms of hyperarousal  Do not recognize themselves as having

psychiatric illness

DIFFERENTIAL DIAGNOSIS: Major depression OCD Panic disorder Somatoform disorder Paranoid Eating disorder Hyper thyroidism Hypothyroidism Diabetes Drugs Mitral valve prolapse     

TREATMENT: Pharmacological treatment: Benzodiazepine

Buspirone(serotonin 1A receptor partial agonist)

TCA SSRI

Psychotherapy:– Cognitive – behavior therapy.