PROF. MUHAMMAD RIAZ BHATTIMBBS(K.E.), DPM., RCP&RCS(Dublin), MCCEE (Canada)

FRSH(Lond), MRCPsych,(Lond) FRCPsych.,(Lond)

Chairperson Academic Department of Psychiatry & Behavioural Sciences,

Continental Medical College, Lahore

President,Psychiatric Welfare Association

Ex-President, Pakistan Psychiatric SocietyAdvisor on Mental Health Government of the Punjab

Former Chairperson Academic Department of Psychiatry & Behavioral Sciences,

King Edward Medical University/Mayo Hospital, Lahore.

Types of Anxiety Disorders

Generalized Anxiety Disorder

Panic Disorder

Obsessive-Compulsive Disorder

Post-Traumatic Stress Disorder

Phobias

Definition of Anxiety Anxiety is a feeling of apprehension or fear.

The source of this uneasiness is not always

known or recognized, which can add to the

distress you feel.

Anxiety disorders are a group of psychiatric

conditions that involve excessive anxiety.

Anxiety as a Normal & An Abnormal Response

Some amount of anxiety is“normal” and is associated withoptimal levels of functioning.

Only when anxiety begins tointerfere with social oroccupational functioning is itconsidered “abnormal.”

An Important Law-The Yerkes Dodson Law

Three Components of Anxiety

Physical symptoms

Cognitive component

Behavioral component

Cardiovascular Effects Increase in heart rate and strength of heartbeat to

speed up blood flow.

Blood is redirected from places it is not needed (skin,

fingers and toes) to places where it is more needed

(large muscle groups like thighs and biceps).

Respiratory Effects-increase in speed and dept of

breathing.

Sweat Gland Effects-increased sweating.

Behavioral System

Fight/flight response prepares the

body for action-to attack or run.

When not possible behaviors such

as foot tapping, pacing, or snapping

at people.

Cognitive System Shift in attention to search surroundings for

potential threat.

Can’t concentrate on daily tasks.

Anxious people complain that they are easily

distracted from daily chores, cannot

concentrate, and have trouble with memory.

Introduction

Generalized anxiety disorder (GAD) is

a chronic disturbance characterized

by excessive worry and apprehension

accompanied by psychic and somatic

symptoms of stress and anxiety.

Generalized Anxiety Disorder: Neurotransmitters

Finding that benzodiazepines provide relief

from anxiety (e.g. valium).

Benzodiazepine receptors ordinarily receive

GABA (gamma-aminobutyric acid).

GABA causes neuron to stop firing (calms

things down).

Symptoms of GAD Worry and apprehension

Muscle tension

Autonomic over activity

Psychological arousal

Sleep disturbance

OTHER FEATURES

Depression

Obsessions

depersonalization

Clinical signs Face appears strained, the brow is furrowed, and

posture is tense.

Person is restless and may tremble.

The skin is pale and sweating is common.

Readiness to tears which reflects the generallyapprehensive state.

Important messages to share with people with Generalized Anxiety Disorder

Anxiety disorders are common chronic the cause of considerable distress and disability often unrecognized and untreated

If left untreated they are costly to both the individual and society.

A range of effective interventions is available to treat anxiety disorders, including medication, psychological therapies and self-help.

NICE: Clinical Guidelines for the Management of Anxiety. Management of anxiety (panic disorder, with or without agoraphobia, and generalised

anxiety disorder) in adults in primary, secondary and community care

Treatment

The most effective treatment of GAD isprobably one that combinepsychotherapeutic, pharmacotherapeutic,and supportive approaches.

Psychotherapy:

The major approaches to GAD are CBT,supportive therapy and insight orientedtherapy

Cognitive Behavioral Therapy This treatment combines relaxation with

cognitive procedures designed to helppatient to control worrying thoughts.

CBT in the optimal range of duration (16–20 hours in total) should be offered.

It has following stages:

1. Ask patient to keep a diary record of:

The frequency and severity of symptoms

The situations in which they occur

Avoidance behavior

CBT cont:2. Provide information about the physiology of anxiety

and other matters that correct misconceptions.

3. Explanation of the various vicious circles of anxiety.

4. Relaxation training as a means of controlling of anxiety.

5. Graded exposure to situations that provoke anxiety

6. Distraction to reduce the impact of anxiety provoking thoughts.

Psychotherapy cont:

Supportive therapy offers patients reassurance

and comfort, although its long term efficacy is

doubtful.

Insight-orientated psychotherapy focuses on

uncovering unconscious conflicts and identify

ego strengths

Pharmacotherapy Placebo response rate with GAD is about 40%

(Fossey and Lydiard, 1990).

Because of the long term nature of the disorder, a treatment plan must be carefully thought out.

Drug treatment of GAD is sometimes seen as a 6 to 12 months treatment, some evidence indicates that treatment should be long term, perhaps life long.

About 25% of patients relapse in the first month after the discontinuation of therapy and 60 to 80% relapse over the course of next year.

Pharmacotherapy cont:

Three major drug groups to be considered for the treatment of GAD

Benzodiazepines

Antidepressants

Buspirone

Others e.g. beta blockers

What is Phobia?

Irrational Fear

Avoidance

Anticipatory Anxiety

Phobic Disorders:

Phobias

1. Specific phobias

2. Social phobia

3. Agoraphobia

Phobias: Disruptive fear of a particular object or

situation Fear out of proportion to actual threat

Awareness that fear is excessive

Must be severe enough to cause distress or interfere with job or social life Avoidance

Two types: Specific

Social

25

Specific Phobia: Social and Cultural Factors

Predominantly female

Unacceptable in cultures around the

world for men to express fears.

Specific Phobia: Treatment

Exposure Treatment

Systematic Desensitization

Social Phobia

Fearful Apprehension

Social Situations

Social Phobia General characteristics:

Fear of being in social situations inwhich one will be embarrassed or humiliated.

Social Phobia/Anxiety

Common anxiety provoking social situations include: public speaking talking with people in authority dating and developing close relationships making a phone call or answering the phone interviewing attending and participating in class speaking with strangers meeting new people eating, drinking, or writing in public using public bathrooms driving shopping

Social Phobia Interaction of psychosocial and biological causal

factors

Genetic and temperamental factors

Perceptions of uncontrollability

Cognitive variables

Social Phobia Persistent, intense fear of social situations. Fear of negative evaluation or scrutiny.

More intense and extensive than shynessMore appropriate diagnostic label?

Social anxiety disorder

Exposure to trigger leads to anxiety about beinghumiliated or embarrassed socially.

Onset often adolescence.

Diagnosed as either generalized or specific.

33% also diagnosed with Avoidant PersonalityDisorder.Overlap in genetic vulnerability for both disorders.

Social Phobia: Prevalence

13% of the general population.

About equally distributed in males and females,

however, males more often seek treatment .

Usually begins around age 15.

Equally distributed among ethnic groups.

Social Phobia: TreatmentCognitive-Behavioral Therapy

Assess which social situations

are problematic.

Assess their behavior in these

situations.

Assess their thoughts in these

situations.

Teaches more effective

strategies.

Rehearse or role play feared

social situations in a group

setting.

Medication

Tricyclic antidepressants

Monoamine oxidase inhibitors

SSRI (Paxil) approved for

treatment.

Relapse is common with

medications are discontinued.

Panic Disorder With and Without Agoraphobia

Panic Disorder

Panic versus Anxiety

Agoraphobia

Agoraphobia without Panic

Panic Disorder The abrupt onset of an episode of intense fear or

discomfort, which peaks in approximately 10 minutes, and

includes at least four of the following symptoms:

• A feeling of imminent danger

or doom

• The need to escape

• Palpitations

• Sweating

• Trembling

• Shortness of breath or a

smothering

feeling

• A feeling of choking

• Chest pain or discomfort

• Nausea or abdominal

discomfort

• Dizziness or lightheadedness

• A sense of things being

unreal,

depersonalization

• A fear of losing control or

"going crazy"

• A fear of dying

• Tingling sensations

• Chills or hot flushes

TREATMENTS

Drugs:(Davison & Neale, 1998)

Benzodiazepines:

example: alprazolam

these have been found to have some success, but must becontinued otherwise symptoms will return if stopped

However, studies show that these have less long lastingeffects on patients than cognitive-behavioral treatments(Brown & Barlow, 1995).

TREATMENTS- continued Tricyclic antidepressants:(Chambless & Goldstein,

1982)

antidepressants block spontaneous panic attacks.

as of 1982, the FDA had not accepted panic attacks as anindication for antidepressants

Example: imipramine (Mavissakalian, 1992).

dosage should be carefully monitored since panic disorderpatients are sometimes very sensitive to drug use (Swinson,1992).

Along with use of this drug, persuasion, support, or minortranquilizers are often required to help extinguishanticipatory anxiety.

TREATMENTS- continued Systematic desensitization: (Chambless &

Goldstein, 1982)

patients are trained in muscular relaxation

they gradually move up a hierarchy of anxiety arousingsituations while remaining relaxed.

Either imagination or in vivo can be used.

in vivo tends to be most successful.

Flooding:(Chambless & Goldstein, 1982)

maximize anxiety throughout treatment.

this leads to extinction.

TREATMENTS- continued Self-management Procedure: (Jacobson and

Hollon, 1996)

a combination of flooding followed by self-observation.

this is more effective than any single treatment.

a viable alternative to drugs.

Relaxation Training (Barlow, 1988)

combination of cognitive and behavioral intervention andexposure to internal cues that trigger panic.

After two years, this was shown to have great success.

Treating Panic Disorder and Agoraphobia

Medications

Behavioral and cognitive-

behavioral treatments

Range of Mood and Emotion

severe mania

mild to moderate mania (hypomania)

normal-balanced mood

mild to moderate depression

severe depression

Depressive Disorders

Major Depressive Disorder (single, recurrent)

Dysthymic Disorder

Double Depression

Major Depressive Disorder: Diagnostic Criteria

5 of following symptoms, must include one of first

two, occurred almost every day for two weeks:

• Depressed mood

• Pleasure or interest/ Loss

• Appetite

• Sleep disturbance, too much or too little

• Agitation or retardation

• Fatigue

• Feelings of worthlessness or guilt

• Difficulty concentrating or deciding

• Recurrent thoughts of death

Dysthymic Disorder: SymptomsA. Depressed/irritable mood

B. Presence of two of the following:

• Appetite disturbance

• Sleep disturbance

• Low energy/fatigue

• Poor concentration of difficulties making decision

• Feelings of hopelessness

C. Present for two year period (one year in children and adolescents)

D. No evidence of a Major Depressive Episode during the first two years (one year for

children)

E. No manic or hypomanic episode

F. No chronic psychotic disorder

G. Not related to organic factors

Manic Episode: Diagnostic CriteriaA. A distinct period of abnormally and persistently elevated, expansive,

or irritable mood.B. Mood disturbance plus three of the following symptoms (four if the

mood is only irritable): Inflated self esteem or grandiosity Decreased need for sleep More talkative than usual or pressure to keep talking Flight of ideas, or racing thoughts Distractibility Increase in goal directed activity Excessive involvement in pleasurable activitiesC. Marked impairmentD. No psychosisE. Not organic

Mood Disorders: Summary

Depressive Disorders

Major Depressive Disorder

(single, recurrent)

[Major Depressive

Disorder: Postpartum

onset]**

Dysthymic Disorder

Bipolar Disorders

Bipolar I Disorder

Bipolar II Disorder

Cyclothymic Disorder

Mood Disorders: Prevalence

Disorders

Major Depression

Dysthymia

Bipolar I

Biploar II

MDD (Postpartum)

Prevalence

4.9%

3.2%

0.8%

0.5

13%

Major Depressive Disorder: Etiological Theories

Biological

(genetic, brain structures, neurotransmitters)

Personality

Early Environment

Behavior and cognition

Emotion

Social and cultural factors

Cognitive Model(Early) experience

Formation of dysfunctional assumptions

Critical incident(s)

Assumptions activated

Negative automatic thoughts

Symptoms of depression

Behavioral motivational Affective cognitive somatic

Major Depression: Social and Cultural Factors

1. Stressful life events

2. Social support (marital relationship) (see chart)

3. Gender

4. Culture (see chart)

Marital Status and MDDPercentage w/MDD

2.1 2.1

2.8

6.3

0

1

2

3

4

5

6

7

Married Widowed Never M. M/D/W

Married

Widowed

Never M.

M/D/W

Ethnicity and Prevalence of MDDPercentage by Ethnicity

3.1

4.4

5.1 4.9

0

1

2

3

4

5

6

Af. Am Latina White Average

Af. Am

Latina

White

Average

Treatment Major Depression: OverviewBiological Treatments Medication ECT Special note about antidepressants and children

Psychological Treatments Cognitive Therapies Interpersonal Psychotherapy (IPT)

NIMH Collaborative Treatment Study

Biological TreatmentMedications

Tricyclic antidepressants

Monoamine oxidase (MAO) inhibitors

Selective serotonin uptake inhibitors

St. John’s Wort

ECT

Suicide 8th leading cause of death in the U.S.

Overwhelmingly white phenomena

Suicide rates also quite high in Native American

Rate of suicide is increasing in adolescents and elderly

Males are more likely to commit suicide

Females are more likely to attempt suicide (except China)

Suicide: A Sociological TypologyEmile Durkeim

Formalized or altruistic suicide

Egoistic suicide

Anomic suicides

Fatalistic suicide

Sanctioned suicide

Disintegration of social support

Major disruption

Loss of control of one’s destiny (mass suicide’s)

5 Myths and Facts About Suicide

Myth #1:

People who talk about killing themselves rarely commit suicide.

Fact:

Most people who commit suicide have given some verbal clues or warnings of their intentions

5 Myths and Facts About SuicideMyth #2:

The suicidal person wants to die and feels there is no turning back.

Fact:

Suicidal people are usually ambivalent about dying; they may desperately want to live but can not see alternatives to problems.

5 Myths and Facts About SuicideMyth # 3:

If you ask someone about their suicidal intentions, you will only encourage them to kill themselves.

Fact:

The opposite is true. Asking lowers their anxiety and helps deter suicidal behavior. Discussion of suicidal feelings allow for accurate risk assessment.

5 Myths and Facts About SuicideMyth # 4:

All suicidal people are deeply depressed.

Fact:

Although depression is usually associated with depression, not all suicidal people are obviously depressed. Once they make the decision, they may appear happier/carefree.

5 Myths and Facts About Suicide

Myths # 5:

Suicidal people rarely seek medical attention.

Fact:

75% of suicidal individuals will visit a physician within the month before they kill themselves.

Clinical Risk Factors Previous Attempts

Clinical depression or schizophrenia

Substance Abuse

Feelings of hopelessness

Severe anxiety, particularly with depression

Severe loss of interest in usual activities

Impaired thought process

Impulsivity

Suicide:Treatment Problem-solving

Cognitive behavioral therapy

Coping skills

Stress reduction