90
Anxiety Disorders New Insights Dr.R.V.S.N.Sarma., M.D., M.Sc., Consultant Physician visit : www.drsarma.in
Anxiety Disorders New Insights
DrRVSNSarma MD MSc
Consultant Physicianvisit wwwdrsarmain
What is anxiety
10487661048766It is a mood-state with
10487661048766Marked Negative effects
10487661048766Bodily symptoms of tension
10487661048766Apprehensions about future
Its consequence is lsquoworryrsquo
What is physiological worry
1048766 Worry is a normal response to stressful
situations limited to particular situations
Should not exceed the duration of event
Should not spread to other topics
1048766 Excessive worry should not be seen
as a normal response as part of onersquos
personality
What is pathological worry
10487661048766It is a component of anxiety
10487661048766Negative emotional thoughts images
10487661048766Uncontrollable and they occur in sequence
10487661048766Concern about future threats and danger
Their frequency and intensity are more
What do people worry about
10487661048766Real problems that could be potentially
solved but are not acted on
1048766 Real problems that probably cannot be
solved (at least not by the individual) but
can be coped with
1048766 ldquoImagined problemsrdquo that do not yet exist
and probably will never exist
1048766 Worry about worry and its consequences
Pathological vs normal anxiety
10487661048766 Autonomous responses
10487661048766 Greater intensity
10487661048766 Longer duration
10487661048766 Behavior significantly affected
Stressor may be minimal or absent
Origin of anxiety
10487661048766Protective response
10487661048766Normalprotective anxiety
Fear and pathological anxiety
Common underlying neuro-physiology
1048766 Two categories of fearanxiety
Acute and
Chronic
Negative effects of worry
1Unreasonable fear
2Anxiety Disorder
3Panic Disorder
4Substance abuse
5Depression
What cause Anxiety Disorders
10487661048766No single cause
1048766 Several possible causes
1048766 genetics other biological factors
physiology infection injury trauma
1048766 temperament life experiences
1048766 upbringing family school peers
society in general Doctors in particular
stress - chronic or acute
What cause Anxiety Disorders
Importance of Anxiety Disorders
10487661048766Accurate Dx and Rx of anxiety
disorders is essential
Reduction of secondary psychiatric
conditions
Depression
Substance abuse problems
1 Generalized Anxiety
Disorder (GAD)
2 Panic Disorder (PD)
with Agoraphobia (AG)
3 PD sans Agoraphobia
4 Specific Phobia (SP)
5 Social Phobia (SoP)
6 Obsessive Compulsive
Disorder (OCD)
7 Post traumatic Stress
Disorder (PTSD)
8 Acute Stress Disorder
9 SAD CAD (ASD)
10 Substance-Induced
Anxiety disorder (SIAD)
11 Anxiety disorder due
some medical illness
Anxiety Disorders - DSM-IV
Dual Diagnosis Disorders
Prevalence of Anxiety Disorders
249
14
68 57 4716
0
3
6
9
12
15
18
21
24
27
Any AnxietyDisorder
SocialAnxietyDisorder
PTSD GeneralizedAnxietyDisorder
PanicDisorder
OCD
Lif
eti
me
Pre
va
len
ce
(
)
Kessler et al Arch Gen Psychiatry 1995521048Kessler et al Arch Gen Psychiatry 1994518
Sex differences in Anxiety Disorders
Are women more lsquoNuttyrsquo
Spectrum of Anxiety Disorders
0 1 2 3 4 5
PANIC D
AGORAPH
OCD
GAD
PTSD
SocPHOB
SpecPHOB
Percent
httpwwwnimhnihgovpublicatanxietycfm
What is Gen Anxiety Disorder Anxiety Disorders are characterized by
persistent fear and anxiety that occurs too
often is too severe is triggered too easily or
lasts too long
The ldquoWhat ifrdquo disorder
Compared with others with anxiety
disorders persons with GAD have a better
ability to maintain normal work and social
relationships in spite of their distress
Domains of anxiety
10487661048766Physical
10487661048766Affective
10487661048766Cognitive
10487661048766Behavioral
Physical domain
10487661048766 Anorexia
10487661048766 Butterflies in stomach
10487661048766 Chest paintightness
10487661048766 Diaphoresis
10487661048766 Dry mouth
10487661048766 Dyspnoea
10487661048766 Faintness
10487661048766 Flushing
10487661048766 Hyperventilation
10487661048766 Light-headedness
10487661048766 Muscle tension
10487661048766 Nausea Vomiting
10487661048766 Pallor
10487661048766 Palpitations
10487661048766 Paresthesias
10487661048766 Sexual dysfunction
Physical domain contd
10487661048766 Headache
10487661048766 Shortness of breath
10487661048766 Stomach pain
10487661048766 Tachycardia
10487661048766 Tremulousness
10487661048766 Urinary frequency
10487661048766 Diarrhea
Affective domain
10487661048766 Edginess
10487661048766 Uneasiness
10487661048766 Terror
10487661048766 Panic
Behavioral domain
10487661048766 Triggers many responses
10487661048766 Behavioral in nature
10487661048766 Concerned with diminishing
10487661048766 And even avoiding the distress
Regulation of locus ceruleus
10487661048766Alpha-noradrenergic auto receptors
10487661048766Serotonin receptors
10487661048766GABA-benzodiazepine receptors
10487661048766Opiate receptors
Dopamine receptors
The amygdala and locus ceruleus
Generalized Anxiety Disorder -GADPathological anxiety which
is
excessive chronic and
typically interferes with their ability to function in normal daily activities
GAD is distinguished from Phobic anxiety ndash as it is not triggered by a specific object
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
Excessive anxiety and worry occurring more days than not for at least 6 months about a number of events The person finds it difficult to control the anxiety and worry and has associated three (or more) of the above six symptoms
Case 1
Ms D has a chief co ldquoworrying about
everythingrdquo for the last year She also co
frequent headaches fatigue and
insomnia secondary to the anxiety
These symptoms have worsened to the
point where she has been distracted and
making mistakes at work
Worry that is 1048766 Excessive uncontrollable 1048766 Frequent multiple topics (not only
onetime) 1048766 More than one day out of two
3 out of 6 other associated physical symptoms
1048766 Muscle tension Restlessness 1048766 Fatigued easily Irritability 1048766 Sleep disturbance Concentration
difficulty
GAD ndash Mr Fisc
Acute fear state
10487661048766Response to life-threatening danger
10487661048766Terror helplessness
Sense of impending disasterdoom
10487661048766Urgency to flee or seek safety
10487661048766SympatheticNor-adrenergic activation
10487661048766Located in locus ceruleus
1048766 Corresponds to panic attacks
Agoraphobia
Anxiety in situations where escape might be
difficult (or embarrassing) or help might not be
available in the event of having a panic attack or
panic-like symptoms
Situations are avoided or endured with marked
distress
May not leave home or may need a companion
Can occur with and without panic disorder
Agoraphobia
Social Phobia
Marked persistent fear of social or performance
situations where a person is exposed to unfamiliar
situations or people or possible scrutiny by others
The individual fears acting in an embarrassing or
humiliating way
The Person recognizes fear as excessive
Exposure causes anxiety symptoms or panic
Situations are avoided or endured with anxiety
Specific Phobias
Marked and persistent fear that is excessive or unreasonable
cued by the presence or anticipation of a specific object or
situation (eg flying heights animals receiving an injection
seeing blood)
Exposure to the phobic stimulus almost invariably provokes an
immediate anxiety response which may take the form of a
Panic Attack
The person recognizes that hisher fear is excessive or
unreasonable The phobic situation is avoided or else is
endured with intense anxiety or distress
Specific Phobias - Examples
Acrophobia fear of heights
Agoraphobia fear of open places
Claustrophobia fear of enclosed places
Ailurophobia fear of cats
Cynophobia fear of dogs
Pathophobia fear of disease
Mysophobia fear of dirt and germs
Arachnophobia fear of spiders
Hematophobia fear of blood
Xenophobia fear of strangers
Better-halfophobia fear of wife
PAN ndash The Greek God
Panic Attack ndash DSM IV
1 1048766 Palpitations
2 Sweating
3 Trembling or shaking
4 Shortness of breath
5 Feeling of choking
6 Chest pain or discomfort
7 Nausea or abd distress
8 Feeling dizzy fainty
9 Derealization (feelings of unreality)
10 Fear of going crazy
11 Fear of dying
12 Paresthesias
13 Chills or hot flushes
10487661048766A discrete period of intense fear or discomfort in which 4 (or more) of the above 13 symptoms develop abruptly and reach a peak within 10 minutes
Case 2
Mrs B co a long ho episodes of anxiety
SOB racing heart sweating CP and
fears that she is having a MI and will die
These last 30 minutes and are
unexpected She co anxiety while in
malls and traveling alone to new places
for fear of having another attack Despite
a negative wu she still worries about
having a MI during an attack
Panic Disorder with Agoraphobia
Recurrent unexpected panic attacks anxiety
associated with at least four physical andor
cognitive symptoms cognitive symptoms
At least 1 month of worry about having additional
attacks or the consequences of an attack (losing
control having a heart attack ldquogoing crazyrdquo)
Agoraphobia
Panic Disorder ndash Chest pain
Chest pain is a common symptom of panic
attacks
22 ndash 70 of panic attacks are associated with
CP
18 ndash 25 of all patients with chest pain have
PD
Rates of PD higher among cardiology
outpatients with chest pain
Such patients undergo expensive cardiac
workups but their PD remains undiagnosed amp
untreated
Obsessive Compulsive Disorder - OCD
Obsessions Recurrent and persistent thoughts impulses or
images
that are experienced during the disturbance as intrusive
and inappropriate and cause marked 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 to neutralize them with some other thought or action
The person recognizes that the obsessive thoughts
impulses or images are a product of his or her own mind
Obsessive Compulsive Disorder -OCD
Compulsions Repetitive behaviors (eg hand washing ordering
checking) or mental acts (eg praying counting repeating
words silently)
Heshe is driven to perform in response to an obsession
The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event
But these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent and are clearly excessive
Obsessive Compulsive Disorder -OCD
Putamen
Globus Pallidus
Caudate Nucleus
Thalamus
Orbital frontal
cortex
Post traumatic Stress Disorder- PTSD
Post traumatic Stress Disorder- PTSD
Experiential requirements The person has experienced a life-threatening
event and has responded with intense fear
hopelessness or horror The personrsquos response to the event occurred
more
than 4 weeks after it was experienced and lasted
more than one month The traumatic event is persistently re
experienced
in several ways eg by intrusive recollections
dreams illusions hallucinations or flashbacks
Post traumatic stress disorder PTSD
Post traumatic Stress Disorder- PTSD
Behavioral requirements Thought avoidance related-activities
andor People-avoidance behavior Feelings of detachment Blunted affect Sense of doom Insomnia Irritability Hyper vigilance Exaggerated startle response
Post traumatic Stress Disorder- PTSD
Subdivisions Acute ndash when PTSD is diagnosed between 1 and
3
months after the event occurs it is called acute Chronic - when PTSD continues longer than 3
months it is considered chronic and long term Delayed Onset PTSD-this term is used to
describe
those cases where the symptoms do not occur
immediately after the experience but rather
months or years later
Case 3
Mr A witnessed a friend die in a MVA six
weeks ago and co frequent nightmares
of the accident poor sleep fears of
driving anxiety around highways
anhedonia and decreased affection
highways towards his girlfriend His
girlfriend also notes that he has been
very irritable and startles easily since the
accident
Post traumatic Stress Disorder- PTSD
10487661048766Exposure to a traumatic event
10487661048766Response involving intense fear
Helplessness and horror
10487661048766Re-experiencing of the traumatic event
Avoidance of stimulipsychological numbing
10487661048766Increased arousal
10487661048766Symptoms greater than 1 month
Separation Anxiety Disorder - SAD
Medical conditions causing anxiety
10487661048766Endocrine conditions
10487661048766Cardiovascular conditions
10487661048766Respiratory conditions
10487661048766Metabolic conditions
10487661048766Neurological conditions
Substances causing anxiety
10487661048766Alcohol Alcohol
10487661048766Amphetamines
10487661048766Caffeine
10487661048766Cannabis
10487661048766Cocaine
10487661048766Hallucinogens
10487661048766Inhalants
10487661048766Phencyclidine
Substances that cause
anxiety (withdrawal)
10487661048766Alcohol
10487661048766Cocaine
10487661048766Sedatives
10487661048766Hypnotics
10487661048766Anxiolytics
Medications causing anxiety
Anesthetics
Analgesics
Sympathomimetics
Bronchodilators
Anti-cholinergics
1048766Insulin
Thyroid hormones
Oral contraceptives
Antihistamines
Anti-parkinsonians
1048766Corticosteroids
Antihypertensives
Cardiovascular drugs
Anticonvulsants
Anxiety Disorders
Current Management Strategies
Management of Anxiety Disorders
1048766 Pharmacotherapy (Medications)
Psycho-analytic therapy ndash PT
Behavior Therapy - BT
Cognitive Behavior Therapy ndash CBT
Computer therapy - CT
1048766 Virtual Realty ndash VR
Mood GYM
Drug Rx of Anxiety Disorders
Clonazepam
How do anxiolytics act
GABA and Glycine are inhibitory neurotransmitter
Serotonin and Noradrenaline are excitatory
Anxiety is increased excitatory transmitters
BZNs increase GABA and increase inhibition
SSRI decrease the serotonin levels and darrexcitation
TCAs act by darrboth serotonin and noradrenaline
Drug Rx of Anxiety Disorders
Disorder First Choice 2nd Choice Short (prn) Add on
GADBZN-
CZ CDZ ALZBeta-blockers Buspirone Carbamazp
Panic Disorder
Paroxetine
CitalopramTCA-
ClomipramineBZN-
ALZ CZ LZMAOI -
Phenelzine
Phobias Beta-blockers SSRIsBZN-
ALZ CZMAOI
OCD Clomipramine Fluoxetine CDZ Buspirone
PTSDTCA-
Imipra Amytrp
SSRI- FLX
Sertaline CPBZN MAOI
Comparison of Benzodiazepines
BZN Sedation Anxiolytic Half life Lipid solu Dose
Diazepam +++ + 20-80 h High 5 mg od
Alprazolam + +++ 6-20 h Low 05 mg qid
Clonazapam ++ +++ 22-50 h Low 05 mg bid
Lorazepam ++ ++ 10-20 h Med 1 mg tid
Chlordiazepx + + 7-30 h Med 15 mg bid
Different strategies of therapy
Behavior therapy
Desensitization
Behavior modification
Behavioral activation
Cognitive therapy
Rational-emotive therapy
Beckrsquos cognitive therapy
Newer approaches
Mindfulness meditation
Acceptance and commitment therapy
Dialectical Behavior Therapy (BPD)
Cognitive Behaviour Therapy - CBT
CBT is a method used to treat anxiety
Recognition of ldquodistorted thinkingrdquo
ldquoCognitive restructuringrdquo
It may also involve classical conditioning when used to treat Obsessive Compulsive Disorder
CBT ndash Obstacles - Restructuring
Hopelessness
Self-criticism
Fear of getting worse
Shame and embarrassment
Partial exposure
Blaming other people
Low motivation
Looking for complex solution
Depressing ruminations
There must be an easier way
Computer Therapy
Pts are ashamed to seek help and may fear the consequences at work and home
Therapy is expensive and beyond the reach of many patients
Computer therapy is very cheap and available by comparison
Computer Therapy ndash Softwares
Fearfighter - for phobiapanic
Cope - for depressionanxiety
Balance - for GAD
BTSteps - for OCD
These are PC based in a CD-Rom
or phone based or Web-based
MENTAL OUTSIDE
Virtual Reality - VR
VR therapy via SD (Systematic Desensitization) is becoming very popular
SD is a process of gradually introducing a disturbing stimulus (eg view from a high place) in otherwise pleasant surroundings
This process gradually suppresses the anxiety response
Virtual Reality ndash VR - Advantages
Patients often have difficulty imagining the stimulus themselves
They are often afraid of experiencing it directly ndash which may also be expensive and time-consuming
VR affords patient privacy and confidentiality during treatment
Very good for phobias
Virtual Reality ndash VR - Imagination
ldquoProjection in timerdquo ndash rationally reconstructing the future
ldquoDe-catastrophizing an imagerdquo ndash modifying a disturbing image
ldquoImage modeling and substitutionrdquo ndashinterrupting a negative train of images
ldquoCovert conditioningrdquo ndash subtle conditioning using imagined rather than real stimuli
Virtual Reality ndash VR - Hutchworld
Hutchworld is a virtual community attached to the Hutchison Cancer Research Center
Designed to provide social support for cancer patients and their families
Based on Microsoftrsquos Vworldrsquos system
Mood GYM on the Internet
Few GPs are trained in CBT
Clinical psychologists are expensive
Young people are not easily reached
They may not want them ndash embarrassment
The web is accessible convenient and popular
with young people
Deliver CBT via internet ndash 5 modules
Mood GYM Modules
5 Modules - analysis and results
1 Essentials of CBT with examples and interactive exercises
2 Warpy Thoughts Questionnaire Identifying dysfunctional thoughts Methods to contest such thoughts
3 Other methods for overcoming warpy thoughts
4 Life Event Stress Relaxation meditation music Pleasant Events Schedule parental style
5 Simple problem solving responses to relationship break-up
Web stats summary
Sessions
Take home points
10487661048766Anxiety disorders are very common
10487661048766Just as fevers these are of different types
10487661048766Accurate Dx and Rx by GP is essential
10487661048766Depression and substance abuse potential
Minimum of six weeks to see Rx effect
Prolonged Rx is necessary 6 m or more
Drug Rx is only a small part of management
SSRI TCAs BZNs MAOIs szlig-blockers etc
CBT Computer treatment VRs Mood GYM
Thank You All Visit us at
wwwdrsarmain
This is sponsored by Torrent ndash
Makers of Clonotril (Clonazepam)
What is anxiety
10487661048766It is a mood-state with
10487661048766Marked Negative effects
10487661048766Bodily symptoms of tension
10487661048766Apprehensions about future
Its consequence is lsquoworryrsquo
What is physiological worry
1048766 Worry is a normal response to stressful
situations limited to particular situations
Should not exceed the duration of event
Should not spread to other topics
1048766 Excessive worry should not be seen
as a normal response as part of onersquos
personality
What is pathological worry
10487661048766It is a component of anxiety
10487661048766Negative emotional thoughts images
10487661048766Uncontrollable and they occur in sequence
10487661048766Concern about future threats and danger
Their frequency and intensity are more
What do people worry about
10487661048766Real problems that could be potentially
solved but are not acted on
1048766 Real problems that probably cannot be
solved (at least not by the individual) but
can be coped with
1048766 ldquoImagined problemsrdquo that do not yet exist
and probably will never exist
1048766 Worry about worry and its consequences
Pathological vs normal anxiety
10487661048766 Autonomous responses
10487661048766 Greater intensity
10487661048766 Longer duration
10487661048766 Behavior significantly affected
Stressor may be minimal or absent
Origin of anxiety
10487661048766Protective response
10487661048766Normalprotective anxiety
Fear and pathological anxiety
Common underlying neuro-physiology
1048766 Two categories of fearanxiety
Acute and
Chronic
Negative effects of worry
1Unreasonable fear
2Anxiety Disorder
3Panic Disorder
4Substance abuse
5Depression
What cause Anxiety Disorders
10487661048766No single cause
1048766 Several possible causes
1048766 genetics other biological factors
physiology infection injury trauma
1048766 temperament life experiences
1048766 upbringing family school peers
society in general Doctors in particular
stress - chronic or acute
What cause Anxiety Disorders
Importance of Anxiety Disorders
10487661048766Accurate Dx and Rx of anxiety
disorders is essential
Reduction of secondary psychiatric
conditions
Depression
Substance abuse problems
1 Generalized Anxiety
Disorder (GAD)
2 Panic Disorder (PD)
with Agoraphobia (AG)
3 PD sans Agoraphobia
4 Specific Phobia (SP)
5 Social Phobia (SoP)
6 Obsessive Compulsive
Disorder (OCD)
7 Post traumatic Stress
Disorder (PTSD)
8 Acute Stress Disorder
9 SAD CAD (ASD)
10 Substance-Induced
Anxiety disorder (SIAD)
11 Anxiety disorder due
some medical illness
Anxiety Disorders - DSM-IV
Dual Diagnosis Disorders
Prevalence of Anxiety Disorders
249
14
68 57 4716
0
3
6
9
12
15
18
21
24
27
Any AnxietyDisorder
SocialAnxietyDisorder
PTSD GeneralizedAnxietyDisorder
PanicDisorder
OCD
Lif
eti
me
Pre
va
len
ce
(
)
Kessler et al Arch Gen Psychiatry 1995521048Kessler et al Arch Gen Psychiatry 1994518
Sex differences in Anxiety Disorders
Are women more lsquoNuttyrsquo
Spectrum of Anxiety Disorders
0 1 2 3 4 5
PANIC D
AGORAPH
OCD
GAD
PTSD
SocPHOB
SpecPHOB
Percent
httpwwwnimhnihgovpublicatanxietycfm
What is Gen Anxiety Disorder Anxiety Disorders are characterized by
persistent fear and anxiety that occurs too
often is too severe is triggered too easily or
lasts too long
The ldquoWhat ifrdquo disorder
Compared with others with anxiety
disorders persons with GAD have a better
ability to maintain normal work and social
relationships in spite of their distress
Domains of anxiety
10487661048766Physical
10487661048766Affective
10487661048766Cognitive
10487661048766Behavioral
Physical domain
10487661048766 Anorexia
10487661048766 Butterflies in stomach
10487661048766 Chest paintightness
10487661048766 Diaphoresis
10487661048766 Dry mouth
10487661048766 Dyspnoea
10487661048766 Faintness
10487661048766 Flushing
10487661048766 Hyperventilation
10487661048766 Light-headedness
10487661048766 Muscle tension
10487661048766 Nausea Vomiting
10487661048766 Pallor
10487661048766 Palpitations
10487661048766 Paresthesias
10487661048766 Sexual dysfunction
Physical domain contd
10487661048766 Headache
10487661048766 Shortness of breath
10487661048766 Stomach pain
10487661048766 Tachycardia
10487661048766 Tremulousness
10487661048766 Urinary frequency
10487661048766 Diarrhea
Affective domain
10487661048766 Edginess
10487661048766 Uneasiness
10487661048766 Terror
10487661048766 Panic
Behavioral domain
10487661048766 Triggers many responses
10487661048766 Behavioral in nature
10487661048766 Concerned with diminishing
10487661048766 And even avoiding the distress
Regulation of locus ceruleus
10487661048766Alpha-noradrenergic auto receptors
10487661048766Serotonin receptors
10487661048766GABA-benzodiazepine receptors
10487661048766Opiate receptors
Dopamine receptors
The amygdala and locus ceruleus
Generalized Anxiety Disorder -GADPathological anxiety which
is
excessive chronic and
typically interferes with their ability to function in normal daily activities
GAD is distinguished from Phobic anxiety ndash as it is not triggered by a specific object
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
Excessive anxiety and worry occurring more days than not for at least 6 months about a number of events The person finds it difficult to control the anxiety and worry and has associated three (or more) of the above six symptoms
Case 1
Ms D has a chief co ldquoworrying about
everythingrdquo for the last year She also co
frequent headaches fatigue and
insomnia secondary to the anxiety
These symptoms have worsened to the
point where she has been distracted and
making mistakes at work
Worry that is 1048766 Excessive uncontrollable 1048766 Frequent multiple topics (not only
onetime) 1048766 More than one day out of two
3 out of 6 other associated physical symptoms
1048766 Muscle tension Restlessness 1048766 Fatigued easily Irritability 1048766 Sleep disturbance Concentration
difficulty
GAD ndash Mr Fisc
Acute fear state
10487661048766Response to life-threatening danger
10487661048766Terror helplessness
Sense of impending disasterdoom
10487661048766Urgency to flee or seek safety
10487661048766SympatheticNor-adrenergic activation
10487661048766Located in locus ceruleus
1048766 Corresponds to panic attacks
Agoraphobia
Anxiety in situations where escape might be
difficult (or embarrassing) or help might not be
available in the event of having a panic attack or
panic-like symptoms
Situations are avoided or endured with marked
distress
May not leave home or may need a companion
Can occur with and without panic disorder
Agoraphobia
Social Phobia
Marked persistent fear of social or performance
situations where a person is exposed to unfamiliar
situations or people or possible scrutiny by others
The individual fears acting in an embarrassing or
humiliating way
The Person recognizes fear as excessive
Exposure causes anxiety symptoms or panic
Situations are avoided or endured with anxiety
Specific Phobias
Marked and persistent fear that is excessive or unreasonable
cued by the presence or anticipation of a specific object or
situation (eg flying heights animals receiving an injection
seeing blood)
Exposure to the phobic stimulus almost invariably provokes an
immediate anxiety response which may take the form of a
Panic Attack
The person recognizes that hisher fear is excessive or
unreasonable The phobic situation is avoided or else is
endured with intense anxiety or distress
Specific Phobias - Examples
Acrophobia fear of heights
Agoraphobia fear of open places
Claustrophobia fear of enclosed places
Ailurophobia fear of cats
Cynophobia fear of dogs
Pathophobia fear of disease
Mysophobia fear of dirt and germs
Arachnophobia fear of spiders
Hematophobia fear of blood
Xenophobia fear of strangers
Better-halfophobia fear of wife
PAN ndash The Greek God
Panic Attack ndash DSM IV
1 1048766 Palpitations
2 Sweating
3 Trembling or shaking
4 Shortness of breath
5 Feeling of choking
6 Chest pain or discomfort
7 Nausea or abd distress
8 Feeling dizzy fainty
9 Derealization (feelings of unreality)
10 Fear of going crazy
11 Fear of dying
12 Paresthesias
13 Chills or hot flushes
10487661048766A discrete period of intense fear or discomfort in which 4 (or more) of the above 13 symptoms develop abruptly and reach a peak within 10 minutes
Case 2
Mrs B co a long ho episodes of anxiety
SOB racing heart sweating CP and
fears that she is having a MI and will die
These last 30 minutes and are
unexpected She co anxiety while in
malls and traveling alone to new places
for fear of having another attack Despite
a negative wu she still worries about
having a MI during an attack
Panic Disorder with Agoraphobia
Recurrent unexpected panic attacks anxiety
associated with at least four physical andor
cognitive symptoms cognitive symptoms
At least 1 month of worry about having additional
attacks or the consequences of an attack (losing
control having a heart attack ldquogoing crazyrdquo)
Agoraphobia
Panic Disorder ndash Chest pain
Chest pain is a common symptom of panic
attacks
22 ndash 70 of panic attacks are associated with
CP
18 ndash 25 of all patients with chest pain have
PD
Rates of PD higher among cardiology
outpatients with chest pain
Such patients undergo expensive cardiac
workups but their PD remains undiagnosed amp
untreated
Obsessive Compulsive Disorder - OCD
Obsessions Recurrent and persistent thoughts impulses or
images
that are experienced during the disturbance as intrusive
and inappropriate and cause marked 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 to neutralize them with some other thought or action
The person recognizes that the obsessive thoughts
impulses or images are a product of his or her own mind
Obsessive Compulsive Disorder -OCD
Compulsions Repetitive behaviors (eg hand washing ordering
checking) or mental acts (eg praying counting repeating
words silently)
Heshe is driven to perform in response to an obsession
The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event
But these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent and are clearly excessive
Obsessive Compulsive Disorder -OCD
Putamen
Globus Pallidus
Caudate Nucleus
Thalamus
Orbital frontal
cortex
Post traumatic Stress Disorder- PTSD
Post traumatic Stress Disorder- PTSD
Experiential requirements The person has experienced a life-threatening
event and has responded with intense fear
hopelessness or horror The personrsquos response to the event occurred
more
than 4 weeks after it was experienced and lasted
more than one month The traumatic event is persistently re
experienced
in several ways eg by intrusive recollections
dreams illusions hallucinations or flashbacks
Post traumatic stress disorder PTSD
Post traumatic Stress Disorder- PTSD
Behavioral requirements Thought avoidance related-activities
andor People-avoidance behavior Feelings of detachment Blunted affect Sense of doom Insomnia Irritability Hyper vigilance Exaggerated startle response
Post traumatic Stress Disorder- PTSD
Subdivisions Acute ndash when PTSD is diagnosed between 1 and
3
months after the event occurs it is called acute Chronic - when PTSD continues longer than 3
months it is considered chronic and long term Delayed Onset PTSD-this term is used to
describe
those cases where the symptoms do not occur
immediately after the experience but rather
months or years later
Case 3
Mr A witnessed a friend die in a MVA six
weeks ago and co frequent nightmares
of the accident poor sleep fears of
driving anxiety around highways
anhedonia and decreased affection
highways towards his girlfriend His
girlfriend also notes that he has been
very irritable and startles easily since the
accident
Post traumatic Stress Disorder- PTSD
10487661048766Exposure to a traumatic event
10487661048766Response involving intense fear
Helplessness and horror
10487661048766Re-experiencing of the traumatic event
Avoidance of stimulipsychological numbing
10487661048766Increased arousal
10487661048766Symptoms greater than 1 month
Separation Anxiety Disorder - SAD
Medical conditions causing anxiety
10487661048766Endocrine conditions
10487661048766Cardiovascular conditions
10487661048766Respiratory conditions
10487661048766Metabolic conditions
10487661048766Neurological conditions
Substances causing anxiety
10487661048766Alcohol Alcohol
10487661048766Amphetamines
10487661048766Caffeine
10487661048766Cannabis
10487661048766Cocaine
10487661048766Hallucinogens
10487661048766Inhalants
10487661048766Phencyclidine
Substances that cause
anxiety (withdrawal)
10487661048766Alcohol
10487661048766Cocaine
10487661048766Sedatives
10487661048766Hypnotics
10487661048766Anxiolytics
Medications causing anxiety
Anesthetics
Analgesics
Sympathomimetics
Bronchodilators
Anti-cholinergics
1048766Insulin
Thyroid hormones
Oral contraceptives
Antihistamines
Anti-parkinsonians
1048766Corticosteroids
Antihypertensives
Cardiovascular drugs
Anticonvulsants
Anxiety Disorders
Current Management Strategies
Management of Anxiety Disorders
1048766 Pharmacotherapy (Medications)
Psycho-analytic therapy ndash PT
Behavior Therapy - BT
Cognitive Behavior Therapy ndash CBT
Computer therapy - CT
1048766 Virtual Realty ndash VR
Mood GYM
Drug Rx of Anxiety Disorders
Clonazepam
How do anxiolytics act
GABA and Glycine are inhibitory neurotransmitter
Serotonin and Noradrenaline are excitatory
Anxiety is increased excitatory transmitters
BZNs increase GABA and increase inhibition
SSRI decrease the serotonin levels and darrexcitation
TCAs act by darrboth serotonin and noradrenaline
Drug Rx of Anxiety Disorders
Disorder First Choice 2nd Choice Short (prn) Add on
GADBZN-
CZ CDZ ALZBeta-blockers Buspirone Carbamazp
Panic Disorder
Paroxetine
CitalopramTCA-
ClomipramineBZN-
ALZ CZ LZMAOI -
Phenelzine
Phobias Beta-blockers SSRIsBZN-
ALZ CZMAOI
OCD Clomipramine Fluoxetine CDZ Buspirone
PTSDTCA-
Imipra Amytrp
SSRI- FLX
Sertaline CPBZN MAOI
Comparison of Benzodiazepines
BZN Sedation Anxiolytic Half life Lipid solu Dose
Diazepam +++ + 20-80 h High 5 mg od
Alprazolam + +++ 6-20 h Low 05 mg qid
Clonazapam ++ +++ 22-50 h Low 05 mg bid
Lorazepam ++ ++ 10-20 h Med 1 mg tid
Chlordiazepx + + 7-30 h Med 15 mg bid
Different strategies of therapy
Behavior therapy
Desensitization
Behavior modification
Behavioral activation
Cognitive therapy
Rational-emotive therapy
Beckrsquos cognitive therapy
Newer approaches
Mindfulness meditation
Acceptance and commitment therapy
Dialectical Behavior Therapy (BPD)
Cognitive Behaviour Therapy - CBT
CBT is a method used to treat anxiety
Recognition of ldquodistorted thinkingrdquo
ldquoCognitive restructuringrdquo
It may also involve classical conditioning when used to treat Obsessive Compulsive Disorder
CBT ndash Obstacles - Restructuring
Hopelessness
Self-criticism
Fear of getting worse
Shame and embarrassment
Partial exposure
Blaming other people
Low motivation
Looking for complex solution
Depressing ruminations
There must be an easier way
Computer Therapy
Pts are ashamed to seek help and may fear the consequences at work and home
Therapy is expensive and beyond the reach of many patients
Computer therapy is very cheap and available by comparison
Computer Therapy ndash Softwares
Fearfighter - for phobiapanic
Cope - for depressionanxiety
Balance - for GAD
BTSteps - for OCD
These are PC based in a CD-Rom
or phone based or Web-based
MENTAL OUTSIDE
Virtual Reality - VR
VR therapy via SD (Systematic Desensitization) is becoming very popular
SD is a process of gradually introducing a disturbing stimulus (eg view from a high place) in otherwise pleasant surroundings
This process gradually suppresses the anxiety response
Virtual Reality ndash VR - Advantages
Patients often have difficulty imagining the stimulus themselves
They are often afraid of experiencing it directly ndash which may also be expensive and time-consuming
VR affords patient privacy and confidentiality during treatment
Very good for phobias
Virtual Reality ndash VR - Imagination
ldquoProjection in timerdquo ndash rationally reconstructing the future
ldquoDe-catastrophizing an imagerdquo ndash modifying a disturbing image
ldquoImage modeling and substitutionrdquo ndashinterrupting a negative train of images
ldquoCovert conditioningrdquo ndash subtle conditioning using imagined rather than real stimuli
Virtual Reality ndash VR - Hutchworld
Hutchworld is a virtual community attached to the Hutchison Cancer Research Center
Designed to provide social support for cancer patients and their families
Based on Microsoftrsquos Vworldrsquos system
Mood GYM on the Internet
Few GPs are trained in CBT
Clinical psychologists are expensive
Young people are not easily reached
They may not want them ndash embarrassment
The web is accessible convenient and popular
with young people
Deliver CBT via internet ndash 5 modules
Mood GYM Modules
5 Modules - analysis and results
1 Essentials of CBT with examples and interactive exercises
2 Warpy Thoughts Questionnaire Identifying dysfunctional thoughts Methods to contest such thoughts
3 Other methods for overcoming warpy thoughts
4 Life Event Stress Relaxation meditation music Pleasant Events Schedule parental style
5 Simple problem solving responses to relationship break-up
Web stats summary
Sessions
Take home points
10487661048766Anxiety disorders are very common
10487661048766Just as fevers these are of different types
10487661048766Accurate Dx and Rx by GP is essential
10487661048766Depression and substance abuse potential
Minimum of six weeks to see Rx effect
Prolonged Rx is necessary 6 m or more
Drug Rx is only a small part of management
SSRI TCAs BZNs MAOIs szlig-blockers etc
CBT Computer treatment VRs Mood GYM
Thank You All Visit us at
wwwdrsarmain
This is sponsored by Torrent ndash
Makers of Clonotril (Clonazepam)
What is physiological worry
1048766 Worry is a normal response to stressful
situations limited to particular situations
Should not exceed the duration of event
Should not spread to other topics
1048766 Excessive worry should not be seen
as a normal response as part of onersquos
personality
What is pathological worry
10487661048766It is a component of anxiety
10487661048766Negative emotional thoughts images
10487661048766Uncontrollable and they occur in sequence
10487661048766Concern about future threats and danger
Their frequency and intensity are more
What do people worry about
10487661048766Real problems that could be potentially
solved but are not acted on
1048766 Real problems that probably cannot be
solved (at least not by the individual) but
can be coped with
1048766 ldquoImagined problemsrdquo that do not yet exist
and probably will never exist
1048766 Worry about worry and its consequences
Pathological vs normal anxiety
10487661048766 Autonomous responses
10487661048766 Greater intensity
10487661048766 Longer duration
10487661048766 Behavior significantly affected
Stressor may be minimal or absent
Origin of anxiety
10487661048766Protective response
10487661048766Normalprotective anxiety
Fear and pathological anxiety
Common underlying neuro-physiology
1048766 Two categories of fearanxiety
Acute and
Chronic
Negative effects of worry
1Unreasonable fear
2Anxiety Disorder
3Panic Disorder
4Substance abuse
5Depression
What cause Anxiety Disorders
10487661048766No single cause
1048766 Several possible causes
1048766 genetics other biological factors
physiology infection injury trauma
1048766 temperament life experiences
1048766 upbringing family school peers
society in general Doctors in particular
stress - chronic or acute
What cause Anxiety Disorders
Importance of Anxiety Disorders
10487661048766Accurate Dx and Rx of anxiety
disorders is essential
Reduction of secondary psychiatric
conditions
Depression
Substance abuse problems
1 Generalized Anxiety
Disorder (GAD)
2 Panic Disorder (PD)
with Agoraphobia (AG)
3 PD sans Agoraphobia
4 Specific Phobia (SP)
5 Social Phobia (SoP)
6 Obsessive Compulsive
Disorder (OCD)
7 Post traumatic Stress
Disorder (PTSD)
8 Acute Stress Disorder
9 SAD CAD (ASD)
10 Substance-Induced
Anxiety disorder (SIAD)
11 Anxiety disorder due
some medical illness
Anxiety Disorders - DSM-IV
Dual Diagnosis Disorders
Prevalence of Anxiety Disorders
249
14
68 57 4716
0
3
6
9
12
15
18
21
24
27
Any AnxietyDisorder
SocialAnxietyDisorder
PTSD GeneralizedAnxietyDisorder
PanicDisorder
OCD
Lif
eti
me
Pre
va
len
ce
(
)
Kessler et al Arch Gen Psychiatry 1995521048Kessler et al Arch Gen Psychiatry 1994518
Sex differences in Anxiety Disorders
Are women more lsquoNuttyrsquo
Spectrum of Anxiety Disorders
0 1 2 3 4 5
PANIC D
AGORAPH
OCD
GAD
PTSD
SocPHOB
SpecPHOB
Percent
httpwwwnimhnihgovpublicatanxietycfm
What is Gen Anxiety Disorder Anxiety Disorders are characterized by
persistent fear and anxiety that occurs too
often is too severe is triggered too easily or
lasts too long
The ldquoWhat ifrdquo disorder
Compared with others with anxiety
disorders persons with GAD have a better
ability to maintain normal work and social
relationships in spite of their distress
Domains of anxiety
10487661048766Physical
10487661048766Affective
10487661048766Cognitive
10487661048766Behavioral
Physical domain
10487661048766 Anorexia
10487661048766 Butterflies in stomach
10487661048766 Chest paintightness
10487661048766 Diaphoresis
10487661048766 Dry mouth
10487661048766 Dyspnoea
10487661048766 Faintness
10487661048766 Flushing
10487661048766 Hyperventilation
10487661048766 Light-headedness
10487661048766 Muscle tension
10487661048766 Nausea Vomiting
10487661048766 Pallor
10487661048766 Palpitations
10487661048766 Paresthesias
10487661048766 Sexual dysfunction
Physical domain contd
10487661048766 Headache
10487661048766 Shortness of breath
10487661048766 Stomach pain
10487661048766 Tachycardia
10487661048766 Tremulousness
10487661048766 Urinary frequency
10487661048766 Diarrhea
Affective domain
10487661048766 Edginess
10487661048766 Uneasiness
10487661048766 Terror
10487661048766 Panic
Behavioral domain
10487661048766 Triggers many responses
10487661048766 Behavioral in nature
10487661048766 Concerned with diminishing
10487661048766 And even avoiding the distress
Regulation of locus ceruleus
10487661048766Alpha-noradrenergic auto receptors
10487661048766Serotonin receptors
10487661048766GABA-benzodiazepine receptors
10487661048766Opiate receptors
Dopamine receptors
The amygdala and locus ceruleus
Generalized Anxiety Disorder -GADPathological anxiety which
is
excessive chronic and
typically interferes with their ability to function in normal daily activities
GAD is distinguished from Phobic anxiety ndash as it is not triggered by a specific object
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
Excessive anxiety and worry occurring more days than not for at least 6 months about a number of events The person finds it difficult to control the anxiety and worry and has associated three (or more) of the above six symptoms
Case 1
Ms D has a chief co ldquoworrying about
everythingrdquo for the last year She also co
frequent headaches fatigue and
insomnia secondary to the anxiety
These symptoms have worsened to the
point where she has been distracted and
making mistakes at work
Worry that is 1048766 Excessive uncontrollable 1048766 Frequent multiple topics (not only
onetime) 1048766 More than one day out of two
3 out of 6 other associated physical symptoms
1048766 Muscle tension Restlessness 1048766 Fatigued easily Irritability 1048766 Sleep disturbance Concentration
difficulty
GAD ndash Mr Fisc
Acute fear state
10487661048766Response to life-threatening danger
10487661048766Terror helplessness
Sense of impending disasterdoom
10487661048766Urgency to flee or seek safety
10487661048766SympatheticNor-adrenergic activation
10487661048766Located in locus ceruleus
1048766 Corresponds to panic attacks
Agoraphobia
Anxiety in situations where escape might be
difficult (or embarrassing) or help might not be
available in the event of having a panic attack or
panic-like symptoms
Situations are avoided or endured with marked
distress
May not leave home or may need a companion
Can occur with and without panic disorder
Agoraphobia
Social Phobia
Marked persistent fear of social or performance
situations where a person is exposed to unfamiliar
situations or people or possible scrutiny by others
The individual fears acting in an embarrassing or
humiliating way
The Person recognizes fear as excessive
Exposure causes anxiety symptoms or panic
Situations are avoided or endured with anxiety
Specific Phobias
Marked and persistent fear that is excessive or unreasonable
cued by the presence or anticipation of a specific object or
situation (eg flying heights animals receiving an injection
seeing blood)
Exposure to the phobic stimulus almost invariably provokes an
immediate anxiety response which may take the form of a
Panic Attack
The person recognizes that hisher fear is excessive or
unreasonable The phobic situation is avoided or else is
endured with intense anxiety or distress
Specific Phobias - Examples
Acrophobia fear of heights
Agoraphobia fear of open places
Claustrophobia fear of enclosed places
Ailurophobia fear of cats
Cynophobia fear of dogs
Pathophobia fear of disease
Mysophobia fear of dirt and germs
Arachnophobia fear of spiders
Hematophobia fear of blood
Xenophobia fear of strangers
Better-halfophobia fear of wife
PAN ndash The Greek God
Panic Attack ndash DSM IV
1 1048766 Palpitations
2 Sweating
3 Trembling or shaking
4 Shortness of breath
5 Feeling of choking
6 Chest pain or discomfort
7 Nausea or abd distress
8 Feeling dizzy fainty
9 Derealization (feelings of unreality)
10 Fear of going crazy
11 Fear of dying
12 Paresthesias
13 Chills or hot flushes
10487661048766A discrete period of intense fear or discomfort in which 4 (or more) of the above 13 symptoms develop abruptly and reach a peak within 10 minutes
Case 2
Mrs B co a long ho episodes of anxiety
SOB racing heart sweating CP and
fears that she is having a MI and will die
These last 30 minutes and are
unexpected She co anxiety while in
malls and traveling alone to new places
for fear of having another attack Despite
a negative wu she still worries about
having a MI during an attack
Panic Disorder with Agoraphobia
Recurrent unexpected panic attacks anxiety
associated with at least four physical andor
cognitive symptoms cognitive symptoms
At least 1 month of worry about having additional
attacks or the consequences of an attack (losing
control having a heart attack ldquogoing crazyrdquo)
Agoraphobia
Panic Disorder ndash Chest pain
Chest pain is a common symptom of panic
attacks
22 ndash 70 of panic attacks are associated with
CP
18 ndash 25 of all patients with chest pain have
PD
Rates of PD higher among cardiology
outpatients with chest pain
Such patients undergo expensive cardiac
workups but their PD remains undiagnosed amp
untreated
Obsessive Compulsive Disorder - OCD
Obsessions Recurrent and persistent thoughts impulses or
images
that are experienced during the disturbance as intrusive
and inappropriate and cause marked 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 to neutralize them with some other thought or action
The person recognizes that the obsessive thoughts
impulses or images are a product of his or her own mind
Obsessive Compulsive Disorder -OCD
Compulsions Repetitive behaviors (eg hand washing ordering
checking) or mental acts (eg praying counting repeating
words silently)
Heshe is driven to perform in response to an obsession
The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event
But these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent and are clearly excessive
Obsessive Compulsive Disorder -OCD
Putamen
Globus Pallidus
Caudate Nucleus
Thalamus
Orbital frontal
cortex
Post traumatic Stress Disorder- PTSD
Post traumatic Stress Disorder- PTSD
Experiential requirements The person has experienced a life-threatening
event and has responded with intense fear
hopelessness or horror The personrsquos response to the event occurred
more
than 4 weeks after it was experienced and lasted
more than one month The traumatic event is persistently re
experienced
in several ways eg by intrusive recollections
dreams illusions hallucinations or flashbacks
Post traumatic stress disorder PTSD
Post traumatic Stress Disorder- PTSD
Behavioral requirements Thought avoidance related-activities
andor People-avoidance behavior Feelings of detachment Blunted affect Sense of doom Insomnia Irritability Hyper vigilance Exaggerated startle response
Post traumatic Stress Disorder- PTSD
Subdivisions Acute ndash when PTSD is diagnosed between 1 and
3
months after the event occurs it is called acute Chronic - when PTSD continues longer than 3
months it is considered chronic and long term Delayed Onset PTSD-this term is used to
describe
those cases where the symptoms do not occur
immediately after the experience but rather
months or years later
Case 3
Mr A witnessed a friend die in a MVA six
weeks ago and co frequent nightmares
of the accident poor sleep fears of
driving anxiety around highways
anhedonia and decreased affection
highways towards his girlfriend His
girlfriend also notes that he has been
very irritable and startles easily since the
accident
Post traumatic Stress Disorder- PTSD
10487661048766Exposure to a traumatic event
10487661048766Response involving intense fear
Helplessness and horror
10487661048766Re-experiencing of the traumatic event
Avoidance of stimulipsychological numbing
10487661048766Increased arousal
10487661048766Symptoms greater than 1 month
Separation Anxiety Disorder - SAD
Medical conditions causing anxiety
10487661048766Endocrine conditions
10487661048766Cardiovascular conditions
10487661048766Respiratory conditions
10487661048766Metabolic conditions
10487661048766Neurological conditions
Substances causing anxiety
10487661048766Alcohol Alcohol
10487661048766Amphetamines
10487661048766Caffeine
10487661048766Cannabis
10487661048766Cocaine
10487661048766Hallucinogens
10487661048766Inhalants
10487661048766Phencyclidine
Substances that cause
anxiety (withdrawal)
10487661048766Alcohol
10487661048766Cocaine
10487661048766Sedatives
10487661048766Hypnotics
10487661048766Anxiolytics
Medications causing anxiety
Anesthetics
Analgesics
Sympathomimetics
Bronchodilators
Anti-cholinergics
1048766Insulin
Thyroid hormones
Oral contraceptives
Antihistamines
Anti-parkinsonians
1048766Corticosteroids
Antihypertensives
Cardiovascular drugs
Anticonvulsants
Anxiety Disorders
Current Management Strategies
Management of Anxiety Disorders
1048766 Pharmacotherapy (Medications)
Psycho-analytic therapy ndash PT
Behavior Therapy - BT
Cognitive Behavior Therapy ndash CBT
Computer therapy - CT
1048766 Virtual Realty ndash VR
Mood GYM
Drug Rx of Anxiety Disorders
Clonazepam
How do anxiolytics act
GABA and Glycine are inhibitory neurotransmitter
Serotonin and Noradrenaline are excitatory
Anxiety is increased excitatory transmitters
BZNs increase GABA and increase inhibition
SSRI decrease the serotonin levels and darrexcitation
TCAs act by darrboth serotonin and noradrenaline
Drug Rx of Anxiety Disorders
Disorder First Choice 2nd Choice Short (prn) Add on
GADBZN-
CZ CDZ ALZBeta-blockers Buspirone Carbamazp
Panic Disorder
Paroxetine
CitalopramTCA-
ClomipramineBZN-
ALZ CZ LZMAOI -
Phenelzine
Phobias Beta-blockers SSRIsBZN-
ALZ CZMAOI
OCD Clomipramine Fluoxetine CDZ Buspirone
PTSDTCA-
Imipra Amytrp
SSRI- FLX
Sertaline CPBZN MAOI
Comparison of Benzodiazepines
BZN Sedation Anxiolytic Half life Lipid solu Dose
Diazepam +++ + 20-80 h High 5 mg od
Alprazolam + +++ 6-20 h Low 05 mg qid
Clonazapam ++ +++ 22-50 h Low 05 mg bid
Lorazepam ++ ++ 10-20 h Med 1 mg tid
Chlordiazepx + + 7-30 h Med 15 mg bid
Different strategies of therapy
Behavior therapy
Desensitization
Behavior modification
Behavioral activation
Cognitive therapy
Rational-emotive therapy
Beckrsquos cognitive therapy
Newer approaches
Mindfulness meditation
Acceptance and commitment therapy
Dialectical Behavior Therapy (BPD)
Cognitive Behaviour Therapy - CBT
CBT is a method used to treat anxiety
Recognition of ldquodistorted thinkingrdquo
ldquoCognitive restructuringrdquo
It may also involve classical conditioning when used to treat Obsessive Compulsive Disorder
CBT ndash Obstacles - Restructuring
Hopelessness
Self-criticism
Fear of getting worse
Shame and embarrassment
Partial exposure
Blaming other people
Low motivation
Looking for complex solution
Depressing ruminations
There must be an easier way
Computer Therapy
Pts are ashamed to seek help and may fear the consequences at work and home
Therapy is expensive and beyond the reach of many patients
Computer therapy is very cheap and available by comparison
Computer Therapy ndash Softwares
Fearfighter - for phobiapanic
Cope - for depressionanxiety
Balance - for GAD
BTSteps - for OCD
These are PC based in a CD-Rom
or phone based or Web-based
MENTAL OUTSIDE
Virtual Reality - VR
VR therapy via SD (Systematic Desensitization) is becoming very popular
SD is a process of gradually introducing a disturbing stimulus (eg view from a high place) in otherwise pleasant surroundings
This process gradually suppresses the anxiety response
Virtual Reality ndash VR - Advantages
Patients often have difficulty imagining the stimulus themselves
They are often afraid of experiencing it directly ndash which may also be expensive and time-consuming
VR affords patient privacy and confidentiality during treatment
Very good for phobias
Virtual Reality ndash VR - Imagination
ldquoProjection in timerdquo ndash rationally reconstructing the future
ldquoDe-catastrophizing an imagerdquo ndash modifying a disturbing image
ldquoImage modeling and substitutionrdquo ndashinterrupting a negative train of images
ldquoCovert conditioningrdquo ndash subtle conditioning using imagined rather than real stimuli
Virtual Reality ndash VR - Hutchworld
Hutchworld is a virtual community attached to the Hutchison Cancer Research Center
Designed to provide social support for cancer patients and their families
Based on Microsoftrsquos Vworldrsquos system
Mood GYM on the Internet
Few GPs are trained in CBT
Clinical psychologists are expensive
Young people are not easily reached
They may not want them ndash embarrassment
The web is accessible convenient and popular
with young people
Deliver CBT via internet ndash 5 modules
Mood GYM Modules
5 Modules - analysis and results
1 Essentials of CBT with examples and interactive exercises
2 Warpy Thoughts Questionnaire Identifying dysfunctional thoughts Methods to contest such thoughts
3 Other methods for overcoming warpy thoughts
4 Life Event Stress Relaxation meditation music Pleasant Events Schedule parental style
5 Simple problem solving responses to relationship break-up
Web stats summary
Sessions
Take home points
10487661048766Anxiety disorders are very common
10487661048766Just as fevers these are of different types
10487661048766Accurate Dx and Rx by GP is essential
10487661048766Depression and substance abuse potential
Minimum of six weeks to see Rx effect
Prolonged Rx is necessary 6 m or more
Drug Rx is only a small part of management
SSRI TCAs BZNs MAOIs szlig-blockers etc
CBT Computer treatment VRs Mood GYM
Thank You All Visit us at
wwwdrsarmain
This is sponsored by Torrent ndash
Makers of Clonotril (Clonazepam)
What is pathological worry
10487661048766It is a component of anxiety
10487661048766Negative emotional thoughts images
10487661048766Uncontrollable and they occur in sequence
10487661048766Concern about future threats and danger
Their frequency and intensity are more
What do people worry about
10487661048766Real problems that could be potentially
solved but are not acted on
1048766 Real problems that probably cannot be
solved (at least not by the individual) but
can be coped with
1048766 ldquoImagined problemsrdquo that do not yet exist
and probably will never exist
1048766 Worry about worry and its consequences
Pathological vs normal anxiety
10487661048766 Autonomous responses
10487661048766 Greater intensity
10487661048766 Longer duration
10487661048766 Behavior significantly affected
Stressor may be minimal or absent
Origin of anxiety
10487661048766Protective response
10487661048766Normalprotective anxiety
Fear and pathological anxiety
Common underlying neuro-physiology
1048766 Two categories of fearanxiety
Acute and
Chronic
Negative effects of worry
1Unreasonable fear
2Anxiety Disorder
3Panic Disorder
4Substance abuse
5Depression
What cause Anxiety Disorders
10487661048766No single cause
1048766 Several possible causes
1048766 genetics other biological factors
physiology infection injury trauma
1048766 temperament life experiences
1048766 upbringing family school peers
society in general Doctors in particular
stress - chronic or acute
What cause Anxiety Disorders
Importance of Anxiety Disorders
10487661048766Accurate Dx and Rx of anxiety
disorders is essential
Reduction of secondary psychiatric
conditions
Depression
Substance abuse problems
1 Generalized Anxiety
Disorder (GAD)
2 Panic Disorder (PD)
with Agoraphobia (AG)
3 PD sans Agoraphobia
4 Specific Phobia (SP)
5 Social Phobia (SoP)
6 Obsessive Compulsive
Disorder (OCD)
7 Post traumatic Stress
Disorder (PTSD)
8 Acute Stress Disorder
9 SAD CAD (ASD)
10 Substance-Induced
Anxiety disorder (SIAD)
11 Anxiety disorder due
some medical illness
Anxiety Disorders - DSM-IV
Dual Diagnosis Disorders
Prevalence of Anxiety Disorders
249
14
68 57 4716
0
3
6
9
12
15
18
21
24
27
Any AnxietyDisorder
SocialAnxietyDisorder
PTSD GeneralizedAnxietyDisorder
PanicDisorder
OCD
Lif
eti
me
Pre
va
len
ce
(
)
Kessler et al Arch Gen Psychiatry 1995521048Kessler et al Arch Gen Psychiatry 1994518
Sex differences in Anxiety Disorders
Are women more lsquoNuttyrsquo
Spectrum of Anxiety Disorders
0 1 2 3 4 5
PANIC D
AGORAPH
OCD
GAD
PTSD
SocPHOB
SpecPHOB
Percent
httpwwwnimhnihgovpublicatanxietycfm
What is Gen Anxiety Disorder Anxiety Disorders are characterized by
persistent fear and anxiety that occurs too
often is too severe is triggered too easily or
lasts too long
The ldquoWhat ifrdquo disorder
Compared with others with anxiety
disorders persons with GAD have a better
ability to maintain normal work and social
relationships in spite of their distress
Domains of anxiety
10487661048766Physical
10487661048766Affective
10487661048766Cognitive
10487661048766Behavioral
Physical domain
10487661048766 Anorexia
10487661048766 Butterflies in stomach
10487661048766 Chest paintightness
10487661048766 Diaphoresis
10487661048766 Dry mouth
10487661048766 Dyspnoea
10487661048766 Faintness
10487661048766 Flushing
10487661048766 Hyperventilation
10487661048766 Light-headedness
10487661048766 Muscle tension
10487661048766 Nausea Vomiting
10487661048766 Pallor
10487661048766 Palpitations
10487661048766 Paresthesias
10487661048766 Sexual dysfunction
Physical domain contd
10487661048766 Headache
10487661048766 Shortness of breath
10487661048766 Stomach pain
10487661048766 Tachycardia
10487661048766 Tremulousness
10487661048766 Urinary frequency
10487661048766 Diarrhea
Affective domain
10487661048766 Edginess
10487661048766 Uneasiness
10487661048766 Terror
10487661048766 Panic
Behavioral domain
10487661048766 Triggers many responses
10487661048766 Behavioral in nature
10487661048766 Concerned with diminishing
10487661048766 And even avoiding the distress
Regulation of locus ceruleus
10487661048766Alpha-noradrenergic auto receptors
10487661048766Serotonin receptors
10487661048766GABA-benzodiazepine receptors
10487661048766Opiate receptors
Dopamine receptors
The amygdala and locus ceruleus
Generalized Anxiety Disorder -GADPathological anxiety which
is
excessive chronic and
typically interferes with their ability to function in normal daily activities
GAD is distinguished from Phobic anxiety ndash as it is not triggered by a specific object
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
Excessive anxiety and worry occurring more days than not for at least 6 months about a number of events The person finds it difficult to control the anxiety and worry and has associated three (or more) of the above six symptoms
Case 1
Ms D has a chief co ldquoworrying about
everythingrdquo for the last year She also co
frequent headaches fatigue and
insomnia secondary to the anxiety
These symptoms have worsened to the
point where she has been distracted and
making mistakes at work
Worry that is 1048766 Excessive uncontrollable 1048766 Frequent multiple topics (not only
onetime) 1048766 More than one day out of two
3 out of 6 other associated physical symptoms
1048766 Muscle tension Restlessness 1048766 Fatigued easily Irritability 1048766 Sleep disturbance Concentration
difficulty
GAD ndash Mr Fisc
Acute fear state
10487661048766Response to life-threatening danger
10487661048766Terror helplessness
Sense of impending disasterdoom
10487661048766Urgency to flee or seek safety
10487661048766SympatheticNor-adrenergic activation
10487661048766Located in locus ceruleus
1048766 Corresponds to panic attacks
Agoraphobia
Anxiety in situations where escape might be
difficult (or embarrassing) or help might not be
available in the event of having a panic attack or
panic-like symptoms
Situations are avoided or endured with marked
distress
May not leave home or may need a companion
Can occur with and without panic disorder
Agoraphobia
Social Phobia
Marked persistent fear of social or performance
situations where a person is exposed to unfamiliar
situations or people or possible scrutiny by others
The individual fears acting in an embarrassing or
humiliating way
The Person recognizes fear as excessive
Exposure causes anxiety symptoms or panic
Situations are avoided or endured with anxiety
Specific Phobias
Marked and persistent fear that is excessive or unreasonable
cued by the presence or anticipation of a specific object or
situation (eg flying heights animals receiving an injection
seeing blood)
Exposure to the phobic stimulus almost invariably provokes an
immediate anxiety response which may take the form of a
Panic Attack
The person recognizes that hisher fear is excessive or
unreasonable The phobic situation is avoided or else is
endured with intense anxiety or distress
Specific Phobias - Examples
Acrophobia fear of heights
Agoraphobia fear of open places
Claustrophobia fear of enclosed places
Ailurophobia fear of cats
Cynophobia fear of dogs
Pathophobia fear of disease
Mysophobia fear of dirt and germs
Arachnophobia fear of spiders
Hematophobia fear of blood
Xenophobia fear of strangers
Better-halfophobia fear of wife
PAN ndash The Greek God
Panic Attack ndash DSM IV
1 1048766 Palpitations
2 Sweating
3 Trembling or shaking
4 Shortness of breath
5 Feeling of choking
6 Chest pain or discomfort
7 Nausea or abd distress
8 Feeling dizzy fainty
9 Derealization (feelings of unreality)
10 Fear of going crazy
11 Fear of dying
12 Paresthesias
13 Chills or hot flushes
10487661048766A discrete period of intense fear or discomfort in which 4 (or more) of the above 13 symptoms develop abruptly and reach a peak within 10 minutes
Case 2
Mrs B co a long ho episodes of anxiety
SOB racing heart sweating CP and
fears that she is having a MI and will die
These last 30 minutes and are
unexpected She co anxiety while in
malls and traveling alone to new places
for fear of having another attack Despite
a negative wu she still worries about
having a MI during an attack
Panic Disorder with Agoraphobia
Recurrent unexpected panic attacks anxiety
associated with at least four physical andor
cognitive symptoms cognitive symptoms
At least 1 month of worry about having additional
attacks or the consequences of an attack (losing
control having a heart attack ldquogoing crazyrdquo)
Agoraphobia
Panic Disorder ndash Chest pain
Chest pain is a common symptom of panic
attacks
22 ndash 70 of panic attacks are associated with
CP
18 ndash 25 of all patients with chest pain have
PD
Rates of PD higher among cardiology
outpatients with chest pain
Such patients undergo expensive cardiac
workups but their PD remains undiagnosed amp
untreated
Obsessive Compulsive Disorder - OCD
Obsessions Recurrent and persistent thoughts impulses or
images
that are experienced during the disturbance as intrusive
and inappropriate and cause marked 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 to neutralize them with some other thought or action
The person recognizes that the obsessive thoughts
impulses or images are a product of his or her own mind
Obsessive Compulsive Disorder -OCD
Compulsions Repetitive behaviors (eg hand washing ordering
checking) or mental acts (eg praying counting repeating
words silently)
Heshe is driven to perform in response to an obsession
The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event
But these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent and are clearly excessive
Obsessive Compulsive Disorder -OCD
Putamen
Globus Pallidus
Caudate Nucleus
Thalamus
Orbital frontal
cortex
Post traumatic Stress Disorder- PTSD
Post traumatic Stress Disorder- PTSD
Experiential requirements The person has experienced a life-threatening
event and has responded with intense fear
hopelessness or horror The personrsquos response to the event occurred
more
than 4 weeks after it was experienced and lasted
more than one month The traumatic event is persistently re
experienced
in several ways eg by intrusive recollections
dreams illusions hallucinations or flashbacks
Post traumatic stress disorder PTSD
Post traumatic Stress Disorder- PTSD
Behavioral requirements Thought avoidance related-activities
andor People-avoidance behavior Feelings of detachment Blunted affect Sense of doom Insomnia Irritability Hyper vigilance Exaggerated startle response
Post traumatic Stress Disorder- PTSD
Subdivisions Acute ndash when PTSD is diagnosed between 1 and
3
months after the event occurs it is called acute Chronic - when PTSD continues longer than 3
months it is considered chronic and long term Delayed Onset PTSD-this term is used to
describe
those cases where the symptoms do not occur
immediately after the experience but rather
months or years later
Case 3
Mr A witnessed a friend die in a MVA six
weeks ago and co frequent nightmares
of the accident poor sleep fears of
driving anxiety around highways
anhedonia and decreased affection
highways towards his girlfriend His
girlfriend also notes that he has been
very irritable and startles easily since the
accident
Post traumatic Stress Disorder- PTSD
10487661048766Exposure to a traumatic event
10487661048766Response involving intense fear
Helplessness and horror
10487661048766Re-experiencing of the traumatic event
Avoidance of stimulipsychological numbing
10487661048766Increased arousal
10487661048766Symptoms greater than 1 month
Separation Anxiety Disorder - SAD
Medical conditions causing anxiety
10487661048766Endocrine conditions
10487661048766Cardiovascular conditions
10487661048766Respiratory conditions
10487661048766Metabolic conditions
10487661048766Neurological conditions
Substances causing anxiety
10487661048766Alcohol Alcohol
10487661048766Amphetamines
10487661048766Caffeine
10487661048766Cannabis
10487661048766Cocaine
10487661048766Hallucinogens
10487661048766Inhalants
10487661048766Phencyclidine
Substances that cause
anxiety (withdrawal)
10487661048766Alcohol
10487661048766Cocaine
10487661048766Sedatives
10487661048766Hypnotics
10487661048766Anxiolytics
Medications causing anxiety
Anesthetics
Analgesics
Sympathomimetics
Bronchodilators
Anti-cholinergics
1048766Insulin
Thyroid hormones
Oral contraceptives
Antihistamines
Anti-parkinsonians
1048766Corticosteroids
Antihypertensives
Cardiovascular drugs
Anticonvulsants
Anxiety Disorders
Current Management Strategies
Management of Anxiety Disorders
1048766 Pharmacotherapy (Medications)
Psycho-analytic therapy ndash PT
Behavior Therapy - BT
Cognitive Behavior Therapy ndash CBT
Computer therapy - CT
1048766 Virtual Realty ndash VR
Mood GYM
Drug Rx of Anxiety Disorders
Clonazepam
How do anxiolytics act
GABA and Glycine are inhibitory neurotransmitter
Serotonin and Noradrenaline are excitatory
Anxiety is increased excitatory transmitters
BZNs increase GABA and increase inhibition
SSRI decrease the serotonin levels and darrexcitation
TCAs act by darrboth serotonin and noradrenaline
Drug Rx of Anxiety Disorders
Disorder First Choice 2nd Choice Short (prn) Add on
GADBZN-
CZ CDZ ALZBeta-blockers Buspirone Carbamazp
Panic Disorder
Paroxetine
CitalopramTCA-
ClomipramineBZN-
ALZ CZ LZMAOI -
Phenelzine
Phobias Beta-blockers SSRIsBZN-
ALZ CZMAOI
OCD Clomipramine Fluoxetine CDZ Buspirone
PTSDTCA-
Imipra Amytrp
SSRI- FLX
Sertaline CPBZN MAOI
Comparison of Benzodiazepines
BZN Sedation Anxiolytic Half life Lipid solu Dose
Diazepam +++ + 20-80 h High 5 mg od
Alprazolam + +++ 6-20 h Low 05 mg qid
Clonazapam ++ +++ 22-50 h Low 05 mg bid
Lorazepam ++ ++ 10-20 h Med 1 mg tid
Chlordiazepx + + 7-30 h Med 15 mg bid
Different strategies of therapy
Behavior therapy
Desensitization
Behavior modification
Behavioral activation
Cognitive therapy
Rational-emotive therapy
Beckrsquos cognitive therapy
Newer approaches
Mindfulness meditation
Acceptance and commitment therapy
Dialectical Behavior Therapy (BPD)
Cognitive Behaviour Therapy - CBT
CBT is a method used to treat anxiety
Recognition of ldquodistorted thinkingrdquo
ldquoCognitive restructuringrdquo
It may also involve classical conditioning when used to treat Obsessive Compulsive Disorder
CBT ndash Obstacles - Restructuring
Hopelessness
Self-criticism
Fear of getting worse
Shame and embarrassment
Partial exposure
Blaming other people
Low motivation
Looking for complex solution
Depressing ruminations
There must be an easier way
Computer Therapy
Pts are ashamed to seek help and may fear the consequences at work and home
Therapy is expensive and beyond the reach of many patients
Computer therapy is very cheap and available by comparison
Computer Therapy ndash Softwares
Fearfighter - for phobiapanic
Cope - for depressionanxiety
Balance - for GAD
BTSteps - for OCD
These are PC based in a CD-Rom
or phone based or Web-based
MENTAL OUTSIDE
Virtual Reality - VR
VR therapy via SD (Systematic Desensitization) is becoming very popular
SD is a process of gradually introducing a disturbing stimulus (eg view from a high place) in otherwise pleasant surroundings
This process gradually suppresses the anxiety response
Virtual Reality ndash VR - Advantages
Patients often have difficulty imagining the stimulus themselves
They are often afraid of experiencing it directly ndash which may also be expensive and time-consuming
VR affords patient privacy and confidentiality during treatment
Very good for phobias
Virtual Reality ndash VR - Imagination
ldquoProjection in timerdquo ndash rationally reconstructing the future
ldquoDe-catastrophizing an imagerdquo ndash modifying a disturbing image
ldquoImage modeling and substitutionrdquo ndashinterrupting a negative train of images
ldquoCovert conditioningrdquo ndash subtle conditioning using imagined rather than real stimuli
Virtual Reality ndash VR - Hutchworld
Hutchworld is a virtual community attached to the Hutchison Cancer Research Center
Designed to provide social support for cancer patients and their families
Based on Microsoftrsquos Vworldrsquos system
Mood GYM on the Internet
Few GPs are trained in CBT
Clinical psychologists are expensive
Young people are not easily reached
They may not want them ndash embarrassment
The web is accessible convenient and popular
with young people
Deliver CBT via internet ndash 5 modules
Mood GYM Modules
5 Modules - analysis and results
1 Essentials of CBT with examples and interactive exercises
2 Warpy Thoughts Questionnaire Identifying dysfunctional thoughts Methods to contest such thoughts
3 Other methods for overcoming warpy thoughts
4 Life Event Stress Relaxation meditation music Pleasant Events Schedule parental style
5 Simple problem solving responses to relationship break-up
Web stats summary
Sessions
Take home points
10487661048766Anxiety disorders are very common
10487661048766Just as fevers these are of different types
10487661048766Accurate Dx and Rx by GP is essential
10487661048766Depression and substance abuse potential
Minimum of six weeks to see Rx effect
Prolonged Rx is necessary 6 m or more
Drug Rx is only a small part of management
SSRI TCAs BZNs MAOIs szlig-blockers etc
CBT Computer treatment VRs Mood GYM
Thank You All Visit us at
wwwdrsarmain
This is sponsored by Torrent ndash
Makers of Clonotril (Clonazepam)
What do people worry about
10487661048766Real problems that could be potentially
solved but are not acted on
1048766 Real problems that probably cannot be
solved (at least not by the individual) but
can be coped with
1048766 ldquoImagined problemsrdquo that do not yet exist
and probably will never exist
1048766 Worry about worry and its consequences
Pathological vs normal anxiety
10487661048766 Autonomous responses
10487661048766 Greater intensity
10487661048766 Longer duration
10487661048766 Behavior significantly affected
Stressor may be minimal or absent
Origin of anxiety
10487661048766Protective response
10487661048766Normalprotective anxiety
Fear and pathological anxiety
Common underlying neuro-physiology
1048766 Two categories of fearanxiety
Acute and
Chronic
Negative effects of worry
1Unreasonable fear
2Anxiety Disorder
3Panic Disorder
4Substance abuse
5Depression
What cause Anxiety Disorders
10487661048766No single cause
1048766 Several possible causes
1048766 genetics other biological factors
physiology infection injury trauma
1048766 temperament life experiences
1048766 upbringing family school peers
society in general Doctors in particular
stress - chronic or acute
What cause Anxiety Disorders
Importance of Anxiety Disorders
10487661048766Accurate Dx and Rx of anxiety
disorders is essential
Reduction of secondary psychiatric
conditions
Depression
Substance abuse problems
1 Generalized Anxiety
Disorder (GAD)
2 Panic Disorder (PD)
with Agoraphobia (AG)
3 PD sans Agoraphobia
4 Specific Phobia (SP)
5 Social Phobia (SoP)
6 Obsessive Compulsive
Disorder (OCD)
7 Post traumatic Stress
Disorder (PTSD)
8 Acute Stress Disorder
9 SAD CAD (ASD)
10 Substance-Induced
Anxiety disorder (SIAD)
11 Anxiety disorder due
some medical illness
Anxiety Disorders - DSM-IV
Dual Diagnosis Disorders
Prevalence of Anxiety Disorders
249
14
68 57 4716
0
3
6
9
12
15
18
21
24
27
Any AnxietyDisorder
SocialAnxietyDisorder
PTSD GeneralizedAnxietyDisorder
PanicDisorder
OCD
Lif
eti
me
Pre
va
len
ce
(
)
Kessler et al Arch Gen Psychiatry 1995521048Kessler et al Arch Gen Psychiatry 1994518
Sex differences in Anxiety Disorders
Are women more lsquoNuttyrsquo
Spectrum of Anxiety Disorders
0 1 2 3 4 5
PANIC D
AGORAPH
OCD
GAD
PTSD
SocPHOB
SpecPHOB
Percent
httpwwwnimhnihgovpublicatanxietycfm
What is Gen Anxiety Disorder Anxiety Disorders are characterized by
persistent fear and anxiety that occurs too
often is too severe is triggered too easily or
lasts too long
The ldquoWhat ifrdquo disorder
Compared with others with anxiety
disorders persons with GAD have a better
ability to maintain normal work and social
relationships in spite of their distress
Domains of anxiety
10487661048766Physical
10487661048766Affective
10487661048766Cognitive
10487661048766Behavioral
Physical domain
10487661048766 Anorexia
10487661048766 Butterflies in stomach
10487661048766 Chest paintightness
10487661048766 Diaphoresis
10487661048766 Dry mouth
10487661048766 Dyspnoea
10487661048766 Faintness
10487661048766 Flushing
10487661048766 Hyperventilation
10487661048766 Light-headedness
10487661048766 Muscle tension
10487661048766 Nausea Vomiting
10487661048766 Pallor
10487661048766 Palpitations
10487661048766 Paresthesias
10487661048766 Sexual dysfunction
Physical domain contd
10487661048766 Headache
10487661048766 Shortness of breath
10487661048766 Stomach pain
10487661048766 Tachycardia
10487661048766 Tremulousness
10487661048766 Urinary frequency
10487661048766 Diarrhea
Affective domain
10487661048766 Edginess
10487661048766 Uneasiness
10487661048766 Terror
10487661048766 Panic
Behavioral domain
10487661048766 Triggers many responses
10487661048766 Behavioral in nature
10487661048766 Concerned with diminishing
10487661048766 And even avoiding the distress
Regulation of locus ceruleus
10487661048766Alpha-noradrenergic auto receptors
10487661048766Serotonin receptors
10487661048766GABA-benzodiazepine receptors
10487661048766Opiate receptors
Dopamine receptors
The amygdala and locus ceruleus
Generalized Anxiety Disorder -GADPathological anxiety which
is
excessive chronic and
typically interferes with their ability to function in normal daily activities
GAD is distinguished from Phobic anxiety ndash as it is not triggered by a specific object
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
Excessive anxiety and worry occurring more days than not for at least 6 months about a number of events The person finds it difficult to control the anxiety and worry and has associated three (or more) of the above six symptoms
Case 1
Ms D has a chief co ldquoworrying about
everythingrdquo for the last year She also co
frequent headaches fatigue and
insomnia secondary to the anxiety
These symptoms have worsened to the
point where she has been distracted and
making mistakes at work
Worry that is 1048766 Excessive uncontrollable 1048766 Frequent multiple topics (not only
onetime) 1048766 More than one day out of two
3 out of 6 other associated physical symptoms
1048766 Muscle tension Restlessness 1048766 Fatigued easily Irritability 1048766 Sleep disturbance Concentration
difficulty
GAD ndash Mr Fisc
Acute fear state
10487661048766Response to life-threatening danger
10487661048766Terror helplessness
Sense of impending disasterdoom
10487661048766Urgency to flee or seek safety
10487661048766SympatheticNor-adrenergic activation
10487661048766Located in locus ceruleus
1048766 Corresponds to panic attacks
Agoraphobia
Anxiety in situations where escape might be
difficult (or embarrassing) or help might not be
available in the event of having a panic attack or
panic-like symptoms
Situations are avoided or endured with marked
distress
May not leave home or may need a companion
Can occur with and without panic disorder
Agoraphobia
Social Phobia
Marked persistent fear of social or performance
situations where a person is exposed to unfamiliar
situations or people or possible scrutiny by others
The individual fears acting in an embarrassing or
humiliating way
The Person recognizes fear as excessive
Exposure causes anxiety symptoms or panic
Situations are avoided or endured with anxiety
Specific Phobias
Marked and persistent fear that is excessive or unreasonable
cued by the presence or anticipation of a specific object or
situation (eg flying heights animals receiving an injection
seeing blood)
Exposure to the phobic stimulus almost invariably provokes an
immediate anxiety response which may take the form of a
Panic Attack
The person recognizes that hisher fear is excessive or
unreasonable The phobic situation is avoided or else is
endured with intense anxiety or distress
Specific Phobias - Examples
Acrophobia fear of heights
Agoraphobia fear of open places
Claustrophobia fear of enclosed places
Ailurophobia fear of cats
Cynophobia fear of dogs
Pathophobia fear of disease
Mysophobia fear of dirt and germs
Arachnophobia fear of spiders
Hematophobia fear of blood
Xenophobia fear of strangers
Better-halfophobia fear of wife
PAN ndash The Greek God
Panic Attack ndash DSM IV
1 1048766 Palpitations
2 Sweating
3 Trembling or shaking
4 Shortness of breath
5 Feeling of choking
6 Chest pain or discomfort
7 Nausea or abd distress
8 Feeling dizzy fainty
9 Derealization (feelings of unreality)
10 Fear of going crazy
11 Fear of dying
12 Paresthesias
13 Chills or hot flushes
10487661048766A discrete period of intense fear or discomfort in which 4 (or more) of the above 13 symptoms develop abruptly and reach a peak within 10 minutes
Case 2
Mrs B co a long ho episodes of anxiety
SOB racing heart sweating CP and
fears that she is having a MI and will die
These last 30 minutes and are
unexpected She co anxiety while in
malls and traveling alone to new places
for fear of having another attack Despite
a negative wu she still worries about
having a MI during an attack
Panic Disorder with Agoraphobia
Recurrent unexpected panic attacks anxiety
associated with at least four physical andor
cognitive symptoms cognitive symptoms
At least 1 month of worry about having additional
attacks or the consequences of an attack (losing
control having a heart attack ldquogoing crazyrdquo)
Agoraphobia
Panic Disorder ndash Chest pain
Chest pain is a common symptom of panic
attacks
22 ndash 70 of panic attacks are associated with
CP
18 ndash 25 of all patients with chest pain have
PD
Rates of PD higher among cardiology
outpatients with chest pain
Such patients undergo expensive cardiac
workups but their PD remains undiagnosed amp
untreated
Obsessive Compulsive Disorder - OCD
Obsessions Recurrent and persistent thoughts impulses or
images
that are experienced during the disturbance as intrusive
and inappropriate and cause marked 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 to neutralize them with some other thought or action
The person recognizes that the obsessive thoughts
impulses or images are a product of his or her own mind
Obsessive Compulsive Disorder -OCD
Compulsions Repetitive behaviors (eg hand washing ordering
checking) or mental acts (eg praying counting repeating
words silently)
Heshe is driven to perform in response to an obsession
The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event
But these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent and are clearly excessive
Obsessive Compulsive Disorder -OCD
Putamen
Globus Pallidus
Caudate Nucleus
Thalamus
Orbital frontal
cortex
Post traumatic Stress Disorder- PTSD
Post traumatic Stress Disorder- PTSD
Experiential requirements The person has experienced a life-threatening
event and has responded with intense fear
hopelessness or horror The personrsquos response to the event occurred
more
than 4 weeks after it was experienced and lasted
more than one month The traumatic event is persistently re
experienced
in several ways eg by intrusive recollections
dreams illusions hallucinations or flashbacks
Post traumatic stress disorder PTSD
Post traumatic Stress Disorder- PTSD
Behavioral requirements Thought avoidance related-activities
andor People-avoidance behavior Feelings of detachment Blunted affect Sense of doom Insomnia Irritability Hyper vigilance Exaggerated startle response
Post traumatic Stress Disorder- PTSD
Subdivisions Acute ndash when PTSD is diagnosed between 1 and
3
months after the event occurs it is called acute Chronic - when PTSD continues longer than 3
months it is considered chronic and long term Delayed Onset PTSD-this term is used to
describe
those cases where the symptoms do not occur
immediately after the experience but rather
months or years later
Case 3
Mr A witnessed a friend die in a MVA six
weeks ago and co frequent nightmares
of the accident poor sleep fears of
driving anxiety around highways
anhedonia and decreased affection
highways towards his girlfriend His
girlfriend also notes that he has been
very irritable and startles easily since the
accident
Post traumatic Stress Disorder- PTSD
10487661048766Exposure to a traumatic event
10487661048766Response involving intense fear
Helplessness and horror
10487661048766Re-experiencing of the traumatic event
Avoidance of stimulipsychological numbing
10487661048766Increased arousal
10487661048766Symptoms greater than 1 month
Separation Anxiety Disorder - SAD
Medical conditions causing anxiety
10487661048766Endocrine conditions
10487661048766Cardiovascular conditions
10487661048766Respiratory conditions
10487661048766Metabolic conditions
10487661048766Neurological conditions
Substances causing anxiety
10487661048766Alcohol Alcohol
10487661048766Amphetamines
10487661048766Caffeine
10487661048766Cannabis
10487661048766Cocaine
10487661048766Hallucinogens
10487661048766Inhalants
10487661048766Phencyclidine
Substances that cause
anxiety (withdrawal)
10487661048766Alcohol
10487661048766Cocaine
10487661048766Sedatives
10487661048766Hypnotics
10487661048766Anxiolytics
Medications causing anxiety
Anesthetics
Analgesics
Sympathomimetics
Bronchodilators
Anti-cholinergics
1048766Insulin
Thyroid hormones
Oral contraceptives
Antihistamines
Anti-parkinsonians
1048766Corticosteroids
Antihypertensives
Cardiovascular drugs
Anticonvulsants
Anxiety Disorders
Current Management Strategies
Management of Anxiety Disorders
1048766 Pharmacotherapy (Medications)
Psycho-analytic therapy ndash PT
Behavior Therapy - BT
Cognitive Behavior Therapy ndash CBT
Computer therapy - CT
1048766 Virtual Realty ndash VR
Mood GYM
Drug Rx of Anxiety Disorders
Clonazepam
How do anxiolytics act
GABA and Glycine are inhibitory neurotransmitter
Serotonin and Noradrenaline are excitatory
Anxiety is increased excitatory transmitters
BZNs increase GABA and increase inhibition
SSRI decrease the serotonin levels and darrexcitation
TCAs act by darrboth serotonin and noradrenaline
Drug Rx of Anxiety Disorders
Disorder First Choice 2nd Choice Short (prn) Add on
GADBZN-
CZ CDZ ALZBeta-blockers Buspirone Carbamazp
Panic Disorder
Paroxetine
CitalopramTCA-
ClomipramineBZN-
ALZ CZ LZMAOI -
Phenelzine
Phobias Beta-blockers SSRIsBZN-
ALZ CZMAOI
OCD Clomipramine Fluoxetine CDZ Buspirone
PTSDTCA-
Imipra Amytrp
SSRI- FLX
Sertaline CPBZN MAOI
Comparison of Benzodiazepines
BZN Sedation Anxiolytic Half life Lipid solu Dose
Diazepam +++ + 20-80 h High 5 mg od
Alprazolam + +++ 6-20 h Low 05 mg qid
Clonazapam ++ +++ 22-50 h Low 05 mg bid
Lorazepam ++ ++ 10-20 h Med 1 mg tid
Chlordiazepx + + 7-30 h Med 15 mg bid
Different strategies of therapy
Behavior therapy
Desensitization
Behavior modification
Behavioral activation
Cognitive therapy
Rational-emotive therapy
Beckrsquos cognitive therapy
Newer approaches
Mindfulness meditation
Acceptance and commitment therapy
Dialectical Behavior Therapy (BPD)
Cognitive Behaviour Therapy - CBT
CBT is a method used to treat anxiety
Recognition of ldquodistorted thinkingrdquo
ldquoCognitive restructuringrdquo
It may also involve classical conditioning when used to treat Obsessive Compulsive Disorder
CBT ndash Obstacles - Restructuring
Hopelessness
Self-criticism
Fear of getting worse
Shame and embarrassment
Partial exposure
Blaming other people
Low motivation
Looking for complex solution
Depressing ruminations
There must be an easier way
Computer Therapy
Pts are ashamed to seek help and may fear the consequences at work and home
Therapy is expensive and beyond the reach of many patients
Computer therapy is very cheap and available by comparison
Computer Therapy ndash Softwares
Fearfighter - for phobiapanic
Cope - for depressionanxiety
Balance - for GAD
BTSteps - for OCD
These are PC based in a CD-Rom
or phone based or Web-based
MENTAL OUTSIDE
Virtual Reality - VR
VR therapy via SD (Systematic Desensitization) is becoming very popular
SD is a process of gradually introducing a disturbing stimulus (eg view from a high place) in otherwise pleasant surroundings
This process gradually suppresses the anxiety response
Virtual Reality ndash VR - Advantages
Patients often have difficulty imagining the stimulus themselves
They are often afraid of experiencing it directly ndash which may also be expensive and time-consuming
VR affords patient privacy and confidentiality during treatment
Very good for phobias
Virtual Reality ndash VR - Imagination
ldquoProjection in timerdquo ndash rationally reconstructing the future
ldquoDe-catastrophizing an imagerdquo ndash modifying a disturbing image
ldquoImage modeling and substitutionrdquo ndashinterrupting a negative train of images
ldquoCovert conditioningrdquo ndash subtle conditioning using imagined rather than real stimuli
Virtual Reality ndash VR - Hutchworld
Hutchworld is a virtual community attached to the Hutchison Cancer Research Center
Designed to provide social support for cancer patients and their families
Based on Microsoftrsquos Vworldrsquos system
Mood GYM on the Internet
Few GPs are trained in CBT
Clinical psychologists are expensive
Young people are not easily reached
They may not want them ndash embarrassment
The web is accessible convenient and popular
with young people
Deliver CBT via internet ndash 5 modules
Mood GYM Modules
5 Modules - analysis and results
1 Essentials of CBT with examples and interactive exercises
2 Warpy Thoughts Questionnaire Identifying dysfunctional thoughts Methods to contest such thoughts
3 Other methods for overcoming warpy thoughts
4 Life Event Stress Relaxation meditation music Pleasant Events Schedule parental style
5 Simple problem solving responses to relationship break-up
Web stats summary
Sessions
Take home points
10487661048766Anxiety disorders are very common
10487661048766Just as fevers these are of different types
10487661048766Accurate Dx and Rx by GP is essential
10487661048766Depression and substance abuse potential
Minimum of six weeks to see Rx effect
Prolonged Rx is necessary 6 m or more
Drug Rx is only a small part of management
SSRI TCAs BZNs MAOIs szlig-blockers etc
CBT Computer treatment VRs Mood GYM
Thank You All Visit us at
wwwdrsarmain
This is sponsored by Torrent ndash
Makers of Clonotril (Clonazepam)
Pathological vs normal anxiety
10487661048766 Autonomous responses
10487661048766 Greater intensity
10487661048766 Longer duration
10487661048766 Behavior significantly affected
Stressor may be minimal or absent
Origin of anxiety
10487661048766Protective response
10487661048766Normalprotective anxiety
Fear and pathological anxiety
Common underlying neuro-physiology
1048766 Two categories of fearanxiety
Acute and
Chronic
Negative effects of worry
1Unreasonable fear
2Anxiety Disorder
3Panic Disorder
4Substance abuse
5Depression
What cause Anxiety Disorders
10487661048766No single cause
1048766 Several possible causes
1048766 genetics other biological factors
physiology infection injury trauma
1048766 temperament life experiences
1048766 upbringing family school peers
society in general Doctors in particular
stress - chronic or acute
What cause Anxiety Disorders
Importance of Anxiety Disorders
10487661048766Accurate Dx and Rx of anxiety
disorders is essential
Reduction of secondary psychiatric
conditions
Depression
Substance abuse problems
1 Generalized Anxiety
Disorder (GAD)
2 Panic Disorder (PD)
with Agoraphobia (AG)
3 PD sans Agoraphobia
4 Specific Phobia (SP)
5 Social Phobia (SoP)
6 Obsessive Compulsive
Disorder (OCD)
7 Post traumatic Stress
Disorder (PTSD)
8 Acute Stress Disorder
9 SAD CAD (ASD)
10 Substance-Induced
Anxiety disorder (SIAD)
11 Anxiety disorder due
some medical illness
Anxiety Disorders - DSM-IV
Dual Diagnosis Disorders
Prevalence of Anxiety Disorders
249
14
68 57 4716
0
3
6
9
12
15
18
21
24
27
Any AnxietyDisorder
SocialAnxietyDisorder
PTSD GeneralizedAnxietyDisorder
PanicDisorder
OCD
Lif
eti
me
Pre
va
len
ce
(
)
Kessler et al Arch Gen Psychiatry 1995521048Kessler et al Arch Gen Psychiatry 1994518
Sex differences in Anxiety Disorders
Are women more lsquoNuttyrsquo
Spectrum of Anxiety Disorders
0 1 2 3 4 5
PANIC D
AGORAPH
OCD
GAD
PTSD
SocPHOB
SpecPHOB
Percent
httpwwwnimhnihgovpublicatanxietycfm
What is Gen Anxiety Disorder Anxiety Disorders are characterized by
persistent fear and anxiety that occurs too
often is too severe is triggered too easily or
lasts too long
The ldquoWhat ifrdquo disorder
Compared with others with anxiety
disorders persons with GAD have a better
ability to maintain normal work and social
relationships in spite of their distress
Domains of anxiety
10487661048766Physical
10487661048766Affective
10487661048766Cognitive
10487661048766Behavioral
Physical domain
10487661048766 Anorexia
10487661048766 Butterflies in stomach
10487661048766 Chest paintightness
10487661048766 Diaphoresis
10487661048766 Dry mouth
10487661048766 Dyspnoea
10487661048766 Faintness
10487661048766 Flushing
10487661048766 Hyperventilation
10487661048766 Light-headedness
10487661048766 Muscle tension
10487661048766 Nausea Vomiting
10487661048766 Pallor
10487661048766 Palpitations
10487661048766 Paresthesias
10487661048766 Sexual dysfunction
Physical domain contd
10487661048766 Headache
10487661048766 Shortness of breath
10487661048766 Stomach pain
10487661048766 Tachycardia
10487661048766 Tremulousness
10487661048766 Urinary frequency
10487661048766 Diarrhea
Affective domain
10487661048766 Edginess
10487661048766 Uneasiness
10487661048766 Terror
10487661048766 Panic
Behavioral domain
10487661048766 Triggers many responses
10487661048766 Behavioral in nature
10487661048766 Concerned with diminishing
10487661048766 And even avoiding the distress
Regulation of locus ceruleus
10487661048766Alpha-noradrenergic auto receptors
10487661048766Serotonin receptors
10487661048766GABA-benzodiazepine receptors
10487661048766Opiate receptors
Dopamine receptors
The amygdala and locus ceruleus
Generalized Anxiety Disorder -GADPathological anxiety which
is
excessive chronic and
typically interferes with their ability to function in normal daily activities
GAD is distinguished from Phobic anxiety ndash as it is not triggered by a specific object
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
Excessive anxiety and worry occurring more days than not for at least 6 months about a number of events The person finds it difficult to control the anxiety and worry and has associated three (or more) of the above six symptoms
Case 1
Ms D has a chief co ldquoworrying about
everythingrdquo for the last year She also co
frequent headaches fatigue and
insomnia secondary to the anxiety
These symptoms have worsened to the
point where she has been distracted and
making mistakes at work
Worry that is 1048766 Excessive uncontrollable 1048766 Frequent multiple topics (not only
onetime) 1048766 More than one day out of two
3 out of 6 other associated physical symptoms
1048766 Muscle tension Restlessness 1048766 Fatigued easily Irritability 1048766 Sleep disturbance Concentration
difficulty
GAD ndash Mr Fisc
Acute fear state
10487661048766Response to life-threatening danger
10487661048766Terror helplessness
Sense of impending disasterdoom
10487661048766Urgency to flee or seek safety
10487661048766SympatheticNor-adrenergic activation
10487661048766Located in locus ceruleus
1048766 Corresponds to panic attacks
Agoraphobia
Anxiety in situations where escape might be
difficult (or embarrassing) or help might not be
available in the event of having a panic attack or
panic-like symptoms
Situations are avoided or endured with marked
distress
May not leave home or may need a companion
Can occur with and without panic disorder
Agoraphobia
Social Phobia
Marked persistent fear of social or performance
situations where a person is exposed to unfamiliar
situations or people or possible scrutiny by others
The individual fears acting in an embarrassing or
humiliating way
The Person recognizes fear as excessive
Exposure causes anxiety symptoms or panic
Situations are avoided or endured with anxiety
Specific Phobias
Marked and persistent fear that is excessive or unreasonable
cued by the presence or anticipation of a specific object or
situation (eg flying heights animals receiving an injection
seeing blood)
Exposure to the phobic stimulus almost invariably provokes an
immediate anxiety response which may take the form of a
Panic Attack
The person recognizes that hisher fear is excessive or
unreasonable The phobic situation is avoided or else is
endured with intense anxiety or distress
Specific Phobias - Examples
Acrophobia fear of heights
Agoraphobia fear of open places
Claustrophobia fear of enclosed places
Ailurophobia fear of cats
Cynophobia fear of dogs
Pathophobia fear of disease
Mysophobia fear of dirt and germs
Arachnophobia fear of spiders
Hematophobia fear of blood
Xenophobia fear of strangers
Better-halfophobia fear of wife
PAN ndash The Greek God
Panic Attack ndash DSM IV
1 1048766 Palpitations
2 Sweating
3 Trembling or shaking
4 Shortness of breath
5 Feeling of choking
6 Chest pain or discomfort
7 Nausea or abd distress
8 Feeling dizzy fainty
9 Derealization (feelings of unreality)
10 Fear of going crazy
11 Fear of dying
12 Paresthesias
13 Chills or hot flushes
10487661048766A discrete period of intense fear or discomfort in which 4 (or more) of the above 13 symptoms develop abruptly and reach a peak within 10 minutes
Case 2
Mrs B co a long ho episodes of anxiety
SOB racing heart sweating CP and
fears that she is having a MI and will die
These last 30 minutes and are
unexpected She co anxiety while in
malls and traveling alone to new places
for fear of having another attack Despite
a negative wu she still worries about
having a MI during an attack
Panic Disorder with Agoraphobia
Recurrent unexpected panic attacks anxiety
associated with at least four physical andor
cognitive symptoms cognitive symptoms
At least 1 month of worry about having additional
attacks or the consequences of an attack (losing
control having a heart attack ldquogoing crazyrdquo)
Agoraphobia
Panic Disorder ndash Chest pain
Chest pain is a common symptom of panic
attacks
22 ndash 70 of panic attacks are associated with
CP
18 ndash 25 of all patients with chest pain have
PD
Rates of PD higher among cardiology
outpatients with chest pain
Such patients undergo expensive cardiac
workups but their PD remains undiagnosed amp
untreated
Obsessive Compulsive Disorder - OCD
Obsessions Recurrent and persistent thoughts impulses or
images
that are experienced during the disturbance as intrusive
and inappropriate and cause marked 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 to neutralize them with some other thought or action
The person recognizes that the obsessive thoughts
impulses or images are a product of his or her own mind
Obsessive Compulsive Disorder -OCD
Compulsions Repetitive behaviors (eg hand washing ordering
checking) or mental acts (eg praying counting repeating
words silently)
Heshe is driven to perform in response to an obsession
The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event
But these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent and are clearly excessive
Obsessive Compulsive Disorder -OCD
Putamen
Globus Pallidus
Caudate Nucleus
Thalamus
Orbital frontal
cortex
Post traumatic Stress Disorder- PTSD
Post traumatic Stress Disorder- PTSD
Experiential requirements The person has experienced a life-threatening
event and has responded with intense fear
hopelessness or horror The personrsquos response to the event occurred
more
than 4 weeks after it was experienced and lasted
more than one month The traumatic event is persistently re
experienced
in several ways eg by intrusive recollections
dreams illusions hallucinations or flashbacks
Post traumatic stress disorder PTSD
Post traumatic Stress Disorder- PTSD
Behavioral requirements Thought avoidance related-activities
andor People-avoidance behavior Feelings of detachment Blunted affect Sense of doom Insomnia Irritability Hyper vigilance Exaggerated startle response
Post traumatic Stress Disorder- PTSD
Subdivisions Acute ndash when PTSD is diagnosed between 1 and
3
months after the event occurs it is called acute Chronic - when PTSD continues longer than 3
months it is considered chronic and long term Delayed Onset PTSD-this term is used to
describe
those cases where the symptoms do not occur
immediately after the experience but rather
months or years later
Case 3
Mr A witnessed a friend die in a MVA six
weeks ago and co frequent nightmares
of the accident poor sleep fears of
driving anxiety around highways
anhedonia and decreased affection
highways towards his girlfriend His
girlfriend also notes that he has been
very irritable and startles easily since the
accident
Post traumatic Stress Disorder- PTSD
10487661048766Exposure to a traumatic event
10487661048766Response involving intense fear
Helplessness and horror
10487661048766Re-experiencing of the traumatic event
Avoidance of stimulipsychological numbing
10487661048766Increased arousal
10487661048766Symptoms greater than 1 month
Separation Anxiety Disorder - SAD
Medical conditions causing anxiety
10487661048766Endocrine conditions
10487661048766Cardiovascular conditions
10487661048766Respiratory conditions
10487661048766Metabolic conditions
10487661048766Neurological conditions
Substances causing anxiety
10487661048766Alcohol Alcohol
10487661048766Amphetamines
10487661048766Caffeine
10487661048766Cannabis
10487661048766Cocaine
10487661048766Hallucinogens
10487661048766Inhalants
10487661048766Phencyclidine
Substances that cause
anxiety (withdrawal)
10487661048766Alcohol
10487661048766Cocaine
10487661048766Sedatives
10487661048766Hypnotics
10487661048766Anxiolytics
Medications causing anxiety
Anesthetics
Analgesics
Sympathomimetics
Bronchodilators
Anti-cholinergics
1048766Insulin
Thyroid hormones
Oral contraceptives
Antihistamines
Anti-parkinsonians
1048766Corticosteroids
Antihypertensives
Cardiovascular drugs
Anticonvulsants
Anxiety Disorders
Current Management Strategies
Management of Anxiety Disorders
1048766 Pharmacotherapy (Medications)
Psycho-analytic therapy ndash PT
Behavior Therapy - BT
Cognitive Behavior Therapy ndash CBT
Computer therapy - CT
1048766 Virtual Realty ndash VR
Mood GYM
Drug Rx of Anxiety Disorders
Clonazepam
How do anxiolytics act
GABA and Glycine are inhibitory neurotransmitter
Serotonin and Noradrenaline are excitatory
Anxiety is increased excitatory transmitters
BZNs increase GABA and increase inhibition
SSRI decrease the serotonin levels and darrexcitation
TCAs act by darrboth serotonin and noradrenaline
Drug Rx of Anxiety Disorders
Disorder First Choice 2nd Choice Short (prn) Add on
GADBZN-
CZ CDZ ALZBeta-blockers Buspirone Carbamazp
Panic Disorder
Paroxetine
CitalopramTCA-
ClomipramineBZN-
ALZ CZ LZMAOI -
Phenelzine
Phobias Beta-blockers SSRIsBZN-
ALZ CZMAOI
OCD Clomipramine Fluoxetine CDZ Buspirone
PTSDTCA-
Imipra Amytrp
SSRI- FLX
Sertaline CPBZN MAOI
Comparison of Benzodiazepines
BZN Sedation Anxiolytic Half life Lipid solu Dose
Diazepam +++ + 20-80 h High 5 mg od
Alprazolam + +++ 6-20 h Low 05 mg qid
Clonazapam ++ +++ 22-50 h Low 05 mg bid
Lorazepam ++ ++ 10-20 h Med 1 mg tid
Chlordiazepx + + 7-30 h Med 15 mg bid
Different strategies of therapy
Behavior therapy
Desensitization
Behavior modification
Behavioral activation
Cognitive therapy
Rational-emotive therapy
Beckrsquos cognitive therapy
Newer approaches
Mindfulness meditation
Acceptance and commitment therapy
Dialectical Behavior Therapy (BPD)
Cognitive Behaviour Therapy - CBT
CBT is a method used to treat anxiety
Recognition of ldquodistorted thinkingrdquo
ldquoCognitive restructuringrdquo
It may also involve classical conditioning when used to treat Obsessive Compulsive Disorder
CBT ndash Obstacles - Restructuring
Hopelessness
Self-criticism
Fear of getting worse
Shame and embarrassment
Partial exposure
Blaming other people
Low motivation
Looking for complex solution
Depressing ruminations
There must be an easier way
Computer Therapy
Pts are ashamed to seek help and may fear the consequences at work and home
Therapy is expensive and beyond the reach of many patients
Computer therapy is very cheap and available by comparison
Computer Therapy ndash Softwares
Fearfighter - for phobiapanic
Cope - for depressionanxiety
Balance - for GAD
BTSteps - for OCD
These are PC based in a CD-Rom
or phone based or Web-based
MENTAL OUTSIDE
Virtual Reality - VR
VR therapy via SD (Systematic Desensitization) is becoming very popular
SD is a process of gradually introducing a disturbing stimulus (eg view from a high place) in otherwise pleasant surroundings
This process gradually suppresses the anxiety response
Virtual Reality ndash VR - Advantages
Patients often have difficulty imagining the stimulus themselves
They are often afraid of experiencing it directly ndash which may also be expensive and time-consuming
VR affords patient privacy and confidentiality during treatment
Very good for phobias
Virtual Reality ndash VR - Imagination
ldquoProjection in timerdquo ndash rationally reconstructing the future
ldquoDe-catastrophizing an imagerdquo ndash modifying a disturbing image
ldquoImage modeling and substitutionrdquo ndashinterrupting a negative train of images
ldquoCovert conditioningrdquo ndash subtle conditioning using imagined rather than real stimuli
Virtual Reality ndash VR - Hutchworld
Hutchworld is a virtual community attached to the Hutchison Cancer Research Center
Designed to provide social support for cancer patients and their families
Based on Microsoftrsquos Vworldrsquos system
Mood GYM on the Internet
Few GPs are trained in CBT
Clinical psychologists are expensive
Young people are not easily reached
They may not want them ndash embarrassment
The web is accessible convenient and popular
with young people
Deliver CBT via internet ndash 5 modules
Mood GYM Modules
5 Modules - analysis and results
1 Essentials of CBT with examples and interactive exercises
2 Warpy Thoughts Questionnaire Identifying dysfunctional thoughts Methods to contest such thoughts
3 Other methods for overcoming warpy thoughts
4 Life Event Stress Relaxation meditation music Pleasant Events Schedule parental style
5 Simple problem solving responses to relationship break-up
Web stats summary
Sessions
Take home points
10487661048766Anxiety disorders are very common
10487661048766Just as fevers these are of different types
10487661048766Accurate Dx and Rx by GP is essential
10487661048766Depression and substance abuse potential
Minimum of six weeks to see Rx effect
Prolonged Rx is necessary 6 m or more
Drug Rx is only a small part of management
SSRI TCAs BZNs MAOIs szlig-blockers etc
CBT Computer treatment VRs Mood GYM
Thank You All Visit us at
wwwdrsarmain
This is sponsored by Torrent ndash
Makers of Clonotril (Clonazepam)
Origin of anxiety
10487661048766Protective response
10487661048766Normalprotective anxiety
Fear and pathological anxiety
Common underlying neuro-physiology
1048766 Two categories of fearanxiety
Acute and
Chronic
Negative effects of worry
1Unreasonable fear
2Anxiety Disorder
3Panic Disorder
4Substance abuse
5Depression
What cause Anxiety Disorders
10487661048766No single cause
1048766 Several possible causes
1048766 genetics other biological factors
physiology infection injury trauma
1048766 temperament life experiences
1048766 upbringing family school peers
society in general Doctors in particular
stress - chronic or acute
What cause Anxiety Disorders
Importance of Anxiety Disorders
10487661048766Accurate Dx and Rx of anxiety
disorders is essential
Reduction of secondary psychiatric
conditions
Depression
Substance abuse problems
1 Generalized Anxiety
Disorder (GAD)
2 Panic Disorder (PD)
with Agoraphobia (AG)
3 PD sans Agoraphobia
4 Specific Phobia (SP)
5 Social Phobia (SoP)
6 Obsessive Compulsive
Disorder (OCD)
7 Post traumatic Stress
Disorder (PTSD)
8 Acute Stress Disorder
9 SAD CAD (ASD)
10 Substance-Induced
Anxiety disorder (SIAD)
11 Anxiety disorder due
some medical illness
Anxiety Disorders - DSM-IV
Dual Diagnosis Disorders
Prevalence of Anxiety Disorders
249
14
68 57 4716
0
3
6
9
12
15
18
21
24
27
Any AnxietyDisorder
SocialAnxietyDisorder
PTSD GeneralizedAnxietyDisorder
PanicDisorder
OCD
Lif
eti
me
Pre
va
len
ce
(
)
Kessler et al Arch Gen Psychiatry 1995521048Kessler et al Arch Gen Psychiatry 1994518
Sex differences in Anxiety Disorders
Are women more lsquoNuttyrsquo
Spectrum of Anxiety Disorders
0 1 2 3 4 5
PANIC D
AGORAPH
OCD
GAD
PTSD
SocPHOB
SpecPHOB
Percent
httpwwwnimhnihgovpublicatanxietycfm
What is Gen Anxiety Disorder Anxiety Disorders are characterized by
persistent fear and anxiety that occurs too
often is too severe is triggered too easily or
lasts too long
The ldquoWhat ifrdquo disorder
Compared with others with anxiety
disorders persons with GAD have a better
ability to maintain normal work and social
relationships in spite of their distress
Domains of anxiety
10487661048766Physical
10487661048766Affective
10487661048766Cognitive
10487661048766Behavioral
Physical domain
10487661048766 Anorexia
10487661048766 Butterflies in stomach
10487661048766 Chest paintightness
10487661048766 Diaphoresis
10487661048766 Dry mouth
10487661048766 Dyspnoea
10487661048766 Faintness
10487661048766 Flushing
10487661048766 Hyperventilation
10487661048766 Light-headedness
10487661048766 Muscle tension
10487661048766 Nausea Vomiting
10487661048766 Pallor
10487661048766 Palpitations
10487661048766 Paresthesias
10487661048766 Sexual dysfunction
Physical domain contd
10487661048766 Headache
10487661048766 Shortness of breath
10487661048766 Stomach pain
10487661048766 Tachycardia
10487661048766 Tremulousness
10487661048766 Urinary frequency
10487661048766 Diarrhea
Affective domain
10487661048766 Edginess
10487661048766 Uneasiness
10487661048766 Terror
10487661048766 Panic
Behavioral domain
10487661048766 Triggers many responses
10487661048766 Behavioral in nature
10487661048766 Concerned with diminishing
10487661048766 And even avoiding the distress
Regulation of locus ceruleus
10487661048766Alpha-noradrenergic auto receptors
10487661048766Serotonin receptors
10487661048766GABA-benzodiazepine receptors
10487661048766Opiate receptors
Dopamine receptors
The amygdala and locus ceruleus
Generalized Anxiety Disorder -GADPathological anxiety which
is
excessive chronic and
typically interferes with their ability to function in normal daily activities
GAD is distinguished from Phobic anxiety ndash as it is not triggered by a specific object
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
Excessive anxiety and worry occurring more days than not for at least 6 months about a number of events The person finds it difficult to control the anxiety and worry and has associated three (or more) of the above six symptoms
Case 1
Ms D has a chief co ldquoworrying about
everythingrdquo for the last year She also co
frequent headaches fatigue and
insomnia secondary to the anxiety
These symptoms have worsened to the
point where she has been distracted and
making mistakes at work
Worry that is 1048766 Excessive uncontrollable 1048766 Frequent multiple topics (not only
onetime) 1048766 More than one day out of two
3 out of 6 other associated physical symptoms
1048766 Muscle tension Restlessness 1048766 Fatigued easily Irritability 1048766 Sleep disturbance Concentration
difficulty
GAD ndash Mr Fisc
Acute fear state
10487661048766Response to life-threatening danger
10487661048766Terror helplessness
Sense of impending disasterdoom
10487661048766Urgency to flee or seek safety
10487661048766SympatheticNor-adrenergic activation
10487661048766Located in locus ceruleus
1048766 Corresponds to panic attacks
Agoraphobia
Anxiety in situations where escape might be
difficult (or embarrassing) or help might not be
available in the event of having a panic attack or
panic-like symptoms
Situations are avoided or endured with marked
distress
May not leave home or may need a companion
Can occur with and without panic disorder
Agoraphobia
Social Phobia
Marked persistent fear of social or performance
situations where a person is exposed to unfamiliar
situations or people or possible scrutiny by others
The individual fears acting in an embarrassing or
humiliating way
The Person recognizes fear as excessive
Exposure causes anxiety symptoms or panic
Situations are avoided or endured with anxiety
Specific Phobias
Marked and persistent fear that is excessive or unreasonable
cued by the presence or anticipation of a specific object or
situation (eg flying heights animals receiving an injection
seeing blood)
Exposure to the phobic stimulus almost invariably provokes an
immediate anxiety response which may take the form of a
Panic Attack
The person recognizes that hisher fear is excessive or
unreasonable The phobic situation is avoided or else is
endured with intense anxiety or distress
Specific Phobias - Examples
Acrophobia fear of heights
Agoraphobia fear of open places
Claustrophobia fear of enclosed places
Ailurophobia fear of cats
Cynophobia fear of dogs
Pathophobia fear of disease
Mysophobia fear of dirt and germs
Arachnophobia fear of spiders
Hematophobia fear of blood
Xenophobia fear of strangers
Better-halfophobia fear of wife
PAN ndash The Greek God
Panic Attack ndash DSM IV
1 1048766 Palpitations
2 Sweating
3 Trembling or shaking
4 Shortness of breath
5 Feeling of choking
6 Chest pain or discomfort
7 Nausea or abd distress
8 Feeling dizzy fainty
9 Derealization (feelings of unreality)
10 Fear of going crazy
11 Fear of dying
12 Paresthesias
13 Chills or hot flushes
10487661048766A discrete period of intense fear or discomfort in which 4 (or more) of the above 13 symptoms develop abruptly and reach a peak within 10 minutes
Case 2
Mrs B co a long ho episodes of anxiety
SOB racing heart sweating CP and
fears that she is having a MI and will die
These last 30 minutes and are
unexpected She co anxiety while in
malls and traveling alone to new places
for fear of having another attack Despite
a negative wu she still worries about
having a MI during an attack
Panic Disorder with Agoraphobia
Recurrent unexpected panic attacks anxiety
associated with at least four physical andor
cognitive symptoms cognitive symptoms
At least 1 month of worry about having additional
attacks or the consequences of an attack (losing
control having a heart attack ldquogoing crazyrdquo)
Agoraphobia
Panic Disorder ndash Chest pain
Chest pain is a common symptom of panic
attacks
22 ndash 70 of panic attacks are associated with
CP
18 ndash 25 of all patients with chest pain have
PD
Rates of PD higher among cardiology
outpatients with chest pain
Such patients undergo expensive cardiac
workups but their PD remains undiagnosed amp
untreated
Obsessive Compulsive Disorder - OCD
Obsessions Recurrent and persistent thoughts impulses or
images
that are experienced during the disturbance as intrusive
and inappropriate and cause marked 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 to neutralize them with some other thought or action
The person recognizes that the obsessive thoughts
impulses or images are a product of his or her own mind
Obsessive Compulsive Disorder -OCD
Compulsions Repetitive behaviors (eg hand washing ordering
checking) or mental acts (eg praying counting repeating
words silently)
Heshe is driven to perform in response to an obsession
The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event
But these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent and are clearly excessive
Obsessive Compulsive Disorder -OCD
Putamen
Globus Pallidus
Caudate Nucleus
Thalamus
Orbital frontal
cortex
Post traumatic Stress Disorder- PTSD
Post traumatic Stress Disorder- PTSD
Experiential requirements The person has experienced a life-threatening
event and has responded with intense fear
hopelessness or horror The personrsquos response to the event occurred
more
than 4 weeks after it was experienced and lasted
more than one month The traumatic event is persistently re
experienced
in several ways eg by intrusive recollections
dreams illusions hallucinations or flashbacks
Post traumatic stress disorder PTSD
Post traumatic Stress Disorder- PTSD
Behavioral requirements Thought avoidance related-activities
andor People-avoidance behavior Feelings of detachment Blunted affect Sense of doom Insomnia Irritability Hyper vigilance Exaggerated startle response
Post traumatic Stress Disorder- PTSD
Subdivisions Acute ndash when PTSD is diagnosed between 1 and
3
months after the event occurs it is called acute Chronic - when PTSD continues longer than 3
months it is considered chronic and long term Delayed Onset PTSD-this term is used to
describe
those cases where the symptoms do not occur
immediately after the experience but rather
months or years later
Case 3
Mr A witnessed a friend die in a MVA six
weeks ago and co frequent nightmares
of the accident poor sleep fears of
driving anxiety around highways
anhedonia and decreased affection
highways towards his girlfriend His
girlfriend also notes that he has been
very irritable and startles easily since the
accident
Post traumatic Stress Disorder- PTSD
10487661048766Exposure to a traumatic event
10487661048766Response involving intense fear
Helplessness and horror
10487661048766Re-experiencing of the traumatic event
Avoidance of stimulipsychological numbing
10487661048766Increased arousal
10487661048766Symptoms greater than 1 month
Separation Anxiety Disorder - SAD
Medical conditions causing anxiety
10487661048766Endocrine conditions
10487661048766Cardiovascular conditions
10487661048766Respiratory conditions
10487661048766Metabolic conditions
10487661048766Neurological conditions
Substances causing anxiety
10487661048766Alcohol Alcohol
10487661048766Amphetamines
10487661048766Caffeine
10487661048766Cannabis
10487661048766Cocaine
10487661048766Hallucinogens
10487661048766Inhalants
10487661048766Phencyclidine
Substances that cause
anxiety (withdrawal)
10487661048766Alcohol
10487661048766Cocaine
10487661048766Sedatives
10487661048766Hypnotics
10487661048766Anxiolytics
Medications causing anxiety
Anesthetics
Analgesics
Sympathomimetics
Bronchodilators
Anti-cholinergics
1048766Insulin
Thyroid hormones
Oral contraceptives
Antihistamines
Anti-parkinsonians
1048766Corticosteroids
Antihypertensives
Cardiovascular drugs
Anticonvulsants
Anxiety Disorders
Current Management Strategies
Management of Anxiety Disorders
1048766 Pharmacotherapy (Medications)
Psycho-analytic therapy ndash PT
Behavior Therapy - BT
Cognitive Behavior Therapy ndash CBT
Computer therapy - CT
1048766 Virtual Realty ndash VR
Mood GYM
Drug Rx of Anxiety Disorders
Clonazepam
How do anxiolytics act
GABA and Glycine are inhibitory neurotransmitter
Serotonin and Noradrenaline are excitatory
Anxiety is increased excitatory transmitters
BZNs increase GABA and increase inhibition
SSRI decrease the serotonin levels and darrexcitation
TCAs act by darrboth serotonin and noradrenaline
Drug Rx of Anxiety Disorders
Disorder First Choice 2nd Choice Short (prn) Add on
GADBZN-
CZ CDZ ALZBeta-blockers Buspirone Carbamazp
Panic Disorder
Paroxetine
CitalopramTCA-
ClomipramineBZN-
ALZ CZ LZMAOI -
Phenelzine
Phobias Beta-blockers SSRIsBZN-
ALZ CZMAOI
OCD Clomipramine Fluoxetine CDZ Buspirone
PTSDTCA-
Imipra Amytrp
SSRI- FLX
Sertaline CPBZN MAOI
Comparison of Benzodiazepines
BZN Sedation Anxiolytic Half life Lipid solu Dose
Diazepam +++ + 20-80 h High 5 mg od
Alprazolam + +++ 6-20 h Low 05 mg qid
Clonazapam ++ +++ 22-50 h Low 05 mg bid
Lorazepam ++ ++ 10-20 h Med 1 mg tid
Chlordiazepx + + 7-30 h Med 15 mg bid
Different strategies of therapy
Behavior therapy
Desensitization
Behavior modification
Behavioral activation
Cognitive therapy
Rational-emotive therapy
Beckrsquos cognitive therapy
Newer approaches
Mindfulness meditation
Acceptance and commitment therapy
Dialectical Behavior Therapy (BPD)
Cognitive Behaviour Therapy - CBT
CBT is a method used to treat anxiety
Recognition of ldquodistorted thinkingrdquo
ldquoCognitive restructuringrdquo
It may also involve classical conditioning when used to treat Obsessive Compulsive Disorder
CBT ndash Obstacles - Restructuring
Hopelessness
Self-criticism
Fear of getting worse
Shame and embarrassment
Partial exposure
Blaming other people
Low motivation
Looking for complex solution
Depressing ruminations
There must be an easier way
Computer Therapy
Pts are ashamed to seek help and may fear the consequences at work and home
Therapy is expensive and beyond the reach of many patients
Computer therapy is very cheap and available by comparison
Computer Therapy ndash Softwares
Fearfighter - for phobiapanic
Cope - for depressionanxiety
Balance - for GAD
BTSteps - for OCD
These are PC based in a CD-Rom
or phone based or Web-based
MENTAL OUTSIDE
Virtual Reality - VR
VR therapy via SD (Systematic Desensitization) is becoming very popular
SD is a process of gradually introducing a disturbing stimulus (eg view from a high place) in otherwise pleasant surroundings
This process gradually suppresses the anxiety response
Virtual Reality ndash VR - Advantages
Patients often have difficulty imagining the stimulus themselves
They are often afraid of experiencing it directly ndash which may also be expensive and time-consuming
VR affords patient privacy and confidentiality during treatment
Very good for phobias
Virtual Reality ndash VR - Imagination
ldquoProjection in timerdquo ndash rationally reconstructing the future
ldquoDe-catastrophizing an imagerdquo ndash modifying a disturbing image
ldquoImage modeling and substitutionrdquo ndashinterrupting a negative train of images
ldquoCovert conditioningrdquo ndash subtle conditioning using imagined rather than real stimuli
Virtual Reality ndash VR - Hutchworld
Hutchworld is a virtual community attached to the Hutchison Cancer Research Center
Designed to provide social support for cancer patients and their families
Based on Microsoftrsquos Vworldrsquos system
Mood GYM on the Internet
Few GPs are trained in CBT
Clinical psychologists are expensive
Young people are not easily reached
They may not want them ndash embarrassment
The web is accessible convenient and popular
with young people
Deliver CBT via internet ndash 5 modules
Mood GYM Modules
5 Modules - analysis and results
1 Essentials of CBT with examples and interactive exercises
2 Warpy Thoughts Questionnaire Identifying dysfunctional thoughts Methods to contest such thoughts
3 Other methods for overcoming warpy thoughts
4 Life Event Stress Relaxation meditation music Pleasant Events Schedule parental style
5 Simple problem solving responses to relationship break-up
Web stats summary
Sessions
Take home points
10487661048766Anxiety disorders are very common
10487661048766Just as fevers these are of different types
10487661048766Accurate Dx and Rx by GP is essential
10487661048766Depression and substance abuse potential
Minimum of six weeks to see Rx effect
Prolonged Rx is necessary 6 m or more
Drug Rx is only a small part of management
SSRI TCAs BZNs MAOIs szlig-blockers etc
CBT Computer treatment VRs Mood GYM
Thank You All Visit us at
wwwdrsarmain
This is sponsored by Torrent ndash
Makers of Clonotril (Clonazepam)
Negative effects of worry
1Unreasonable fear
2Anxiety Disorder
3Panic Disorder
4Substance abuse
5Depression
What cause Anxiety Disorders
10487661048766No single cause
1048766 Several possible causes
1048766 genetics other biological factors
physiology infection injury trauma
1048766 temperament life experiences
1048766 upbringing family school peers
society in general Doctors in particular
stress - chronic or acute
What cause Anxiety Disorders
Importance of Anxiety Disorders
10487661048766Accurate Dx and Rx of anxiety
disorders is essential
Reduction of secondary psychiatric
conditions
Depression
Substance abuse problems
1 Generalized Anxiety
Disorder (GAD)
2 Panic Disorder (PD)
with Agoraphobia (AG)
3 PD sans Agoraphobia
4 Specific Phobia (SP)
5 Social Phobia (SoP)
6 Obsessive Compulsive
Disorder (OCD)
7 Post traumatic Stress
Disorder (PTSD)
8 Acute Stress Disorder
9 SAD CAD (ASD)
10 Substance-Induced
Anxiety disorder (SIAD)
11 Anxiety disorder due
some medical illness
Anxiety Disorders - DSM-IV
Dual Diagnosis Disorders
Prevalence of Anxiety Disorders
249
14
68 57 4716
0
3
6
9
12
15
18
21
24
27
Any AnxietyDisorder
SocialAnxietyDisorder
PTSD GeneralizedAnxietyDisorder
PanicDisorder
OCD
Lif
eti
me
Pre
va
len
ce
(
)
Kessler et al Arch Gen Psychiatry 1995521048Kessler et al Arch Gen Psychiatry 1994518
Sex differences in Anxiety Disorders
Are women more lsquoNuttyrsquo
Spectrum of Anxiety Disorders
0 1 2 3 4 5
PANIC D
AGORAPH
OCD
GAD
PTSD
SocPHOB
SpecPHOB
Percent
httpwwwnimhnihgovpublicatanxietycfm
What is Gen Anxiety Disorder Anxiety Disorders are characterized by
persistent fear and anxiety that occurs too
often is too severe is triggered too easily or
lasts too long
The ldquoWhat ifrdquo disorder
Compared with others with anxiety
disorders persons with GAD have a better
ability to maintain normal work and social
relationships in spite of their distress
Domains of anxiety
10487661048766Physical
10487661048766Affective
10487661048766Cognitive
10487661048766Behavioral
Physical domain
10487661048766 Anorexia
10487661048766 Butterflies in stomach
10487661048766 Chest paintightness
10487661048766 Diaphoresis
10487661048766 Dry mouth
10487661048766 Dyspnoea
10487661048766 Faintness
10487661048766 Flushing
10487661048766 Hyperventilation
10487661048766 Light-headedness
10487661048766 Muscle tension
10487661048766 Nausea Vomiting
10487661048766 Pallor
10487661048766 Palpitations
10487661048766 Paresthesias
10487661048766 Sexual dysfunction
Physical domain contd
10487661048766 Headache
10487661048766 Shortness of breath
10487661048766 Stomach pain
10487661048766 Tachycardia
10487661048766 Tremulousness
10487661048766 Urinary frequency
10487661048766 Diarrhea
Affective domain
10487661048766 Edginess
10487661048766 Uneasiness
10487661048766 Terror
10487661048766 Panic
Behavioral domain
10487661048766 Triggers many responses
10487661048766 Behavioral in nature
10487661048766 Concerned with diminishing
10487661048766 And even avoiding the distress
Regulation of locus ceruleus
10487661048766Alpha-noradrenergic auto receptors
10487661048766Serotonin receptors
10487661048766GABA-benzodiazepine receptors
10487661048766Opiate receptors
Dopamine receptors
The amygdala and locus ceruleus
Generalized Anxiety Disorder -GADPathological anxiety which
is
excessive chronic and
typically interferes with their ability to function in normal daily activities
GAD is distinguished from Phobic anxiety ndash as it is not triggered by a specific object
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
Excessive anxiety and worry occurring more days than not for at least 6 months about a number of events The person finds it difficult to control the anxiety and worry and has associated three (or more) of the above six symptoms
Case 1
Ms D has a chief co ldquoworrying about
everythingrdquo for the last year She also co
frequent headaches fatigue and
insomnia secondary to the anxiety
These symptoms have worsened to the
point where she has been distracted and
making mistakes at work
Worry that is 1048766 Excessive uncontrollable 1048766 Frequent multiple topics (not only
onetime) 1048766 More than one day out of two
3 out of 6 other associated physical symptoms
1048766 Muscle tension Restlessness 1048766 Fatigued easily Irritability 1048766 Sleep disturbance Concentration
difficulty
GAD ndash Mr Fisc
Acute fear state
10487661048766Response to life-threatening danger
10487661048766Terror helplessness
Sense of impending disasterdoom
10487661048766Urgency to flee or seek safety
10487661048766SympatheticNor-adrenergic activation
10487661048766Located in locus ceruleus
1048766 Corresponds to panic attacks
Agoraphobia
Anxiety in situations where escape might be
difficult (or embarrassing) or help might not be
available in the event of having a panic attack or
panic-like symptoms
Situations are avoided or endured with marked
distress
May not leave home or may need a companion
Can occur with and without panic disorder
Agoraphobia
Social Phobia
Marked persistent fear of social or performance
situations where a person is exposed to unfamiliar
situations or people or possible scrutiny by others
The individual fears acting in an embarrassing or
humiliating way
The Person recognizes fear as excessive
Exposure causes anxiety symptoms or panic
Situations are avoided or endured with anxiety
Specific Phobias
Marked and persistent fear that is excessive or unreasonable
cued by the presence or anticipation of a specific object or
situation (eg flying heights animals receiving an injection
seeing blood)
Exposure to the phobic stimulus almost invariably provokes an
immediate anxiety response which may take the form of a
Panic Attack
The person recognizes that hisher fear is excessive or
unreasonable The phobic situation is avoided or else is
endured with intense anxiety or distress
Specific Phobias - Examples
Acrophobia fear of heights
Agoraphobia fear of open places
Claustrophobia fear of enclosed places
Ailurophobia fear of cats
Cynophobia fear of dogs
Pathophobia fear of disease
Mysophobia fear of dirt and germs
Arachnophobia fear of spiders
Hematophobia fear of blood
Xenophobia fear of strangers
Better-halfophobia fear of wife
PAN ndash The Greek God
Panic Attack ndash DSM IV
1 1048766 Palpitations
2 Sweating
3 Trembling or shaking
4 Shortness of breath
5 Feeling of choking
6 Chest pain or discomfort
7 Nausea or abd distress
8 Feeling dizzy fainty
9 Derealization (feelings of unreality)
10 Fear of going crazy
11 Fear of dying
12 Paresthesias
13 Chills or hot flushes
10487661048766A discrete period of intense fear or discomfort in which 4 (or more) of the above 13 symptoms develop abruptly and reach a peak within 10 minutes
Case 2
Mrs B co a long ho episodes of anxiety
SOB racing heart sweating CP and
fears that she is having a MI and will die
These last 30 minutes and are
unexpected She co anxiety while in
malls and traveling alone to new places
for fear of having another attack Despite
a negative wu she still worries about
having a MI during an attack
Panic Disorder with Agoraphobia
Recurrent unexpected panic attacks anxiety
associated with at least four physical andor
cognitive symptoms cognitive symptoms
At least 1 month of worry about having additional
attacks or the consequences of an attack (losing
control having a heart attack ldquogoing crazyrdquo)
Agoraphobia
Panic Disorder ndash Chest pain
Chest pain is a common symptom of panic
attacks
22 ndash 70 of panic attacks are associated with
CP
18 ndash 25 of all patients with chest pain have
PD
Rates of PD higher among cardiology
outpatients with chest pain
Such patients undergo expensive cardiac
workups but their PD remains undiagnosed amp
untreated
Obsessive Compulsive Disorder - OCD
Obsessions Recurrent and persistent thoughts impulses or
images
that are experienced during the disturbance as intrusive
and inappropriate and cause marked 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 to neutralize them with some other thought or action
The person recognizes that the obsessive thoughts
impulses or images are a product of his or her own mind
Obsessive Compulsive Disorder -OCD
Compulsions Repetitive behaviors (eg hand washing ordering
checking) or mental acts (eg praying counting repeating
words silently)
Heshe is driven to perform in response to an obsession
The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event
But these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent and are clearly excessive
Obsessive Compulsive Disorder -OCD
Putamen
Globus Pallidus
Caudate Nucleus
Thalamus
Orbital frontal
cortex
Post traumatic Stress Disorder- PTSD
Post traumatic Stress Disorder- PTSD
Experiential requirements The person has experienced a life-threatening
event and has responded with intense fear
hopelessness or horror The personrsquos response to the event occurred
more
than 4 weeks after it was experienced and lasted
more than one month The traumatic event is persistently re
experienced
in several ways eg by intrusive recollections
dreams illusions hallucinations or flashbacks
Post traumatic stress disorder PTSD
Post traumatic Stress Disorder- PTSD
Behavioral requirements Thought avoidance related-activities
andor People-avoidance behavior Feelings of detachment Blunted affect Sense of doom Insomnia Irritability Hyper vigilance Exaggerated startle response
Post traumatic Stress Disorder- PTSD
Subdivisions Acute ndash when PTSD is diagnosed between 1 and
3
months after the event occurs it is called acute Chronic - when PTSD continues longer than 3
months it is considered chronic and long term Delayed Onset PTSD-this term is used to
describe
those cases where the symptoms do not occur
immediately after the experience but rather
months or years later
Case 3
Mr A witnessed a friend die in a MVA six
weeks ago and co frequent nightmares
of the accident poor sleep fears of
driving anxiety around highways
anhedonia and decreased affection
highways towards his girlfriend His
girlfriend also notes that he has been
very irritable and startles easily since the
accident
Post traumatic Stress Disorder- PTSD
10487661048766Exposure to a traumatic event
10487661048766Response involving intense fear
Helplessness and horror
10487661048766Re-experiencing of the traumatic event
Avoidance of stimulipsychological numbing
10487661048766Increased arousal
10487661048766Symptoms greater than 1 month
Separation Anxiety Disorder - SAD
Medical conditions causing anxiety
10487661048766Endocrine conditions
10487661048766Cardiovascular conditions
10487661048766Respiratory conditions
10487661048766Metabolic conditions
10487661048766Neurological conditions
Substances causing anxiety
10487661048766Alcohol Alcohol
10487661048766Amphetamines
10487661048766Caffeine
10487661048766Cannabis
10487661048766Cocaine
10487661048766Hallucinogens
10487661048766Inhalants
10487661048766Phencyclidine
Substances that cause
anxiety (withdrawal)
10487661048766Alcohol
10487661048766Cocaine
10487661048766Sedatives
10487661048766Hypnotics
10487661048766Anxiolytics
Medications causing anxiety
Anesthetics
Analgesics
Sympathomimetics
Bronchodilators
Anti-cholinergics
1048766Insulin
Thyroid hormones
Oral contraceptives
Antihistamines
Anti-parkinsonians
1048766Corticosteroids
Antihypertensives
Cardiovascular drugs
Anticonvulsants
Anxiety Disorders
Current Management Strategies
Management of Anxiety Disorders
1048766 Pharmacotherapy (Medications)
Psycho-analytic therapy ndash PT
Behavior Therapy - BT
Cognitive Behavior Therapy ndash CBT
Computer therapy - CT
1048766 Virtual Realty ndash VR
Mood GYM
Drug Rx of Anxiety Disorders
Clonazepam
How do anxiolytics act
GABA and Glycine are inhibitory neurotransmitter
Serotonin and Noradrenaline are excitatory
Anxiety is increased excitatory transmitters
BZNs increase GABA and increase inhibition
SSRI decrease the serotonin levels and darrexcitation
TCAs act by darrboth serotonin and noradrenaline
Drug Rx of Anxiety Disorders
Disorder First Choice 2nd Choice Short (prn) Add on
GADBZN-
CZ CDZ ALZBeta-blockers Buspirone Carbamazp
Panic Disorder
Paroxetine
CitalopramTCA-
ClomipramineBZN-
ALZ CZ LZMAOI -
Phenelzine
Phobias Beta-blockers SSRIsBZN-
ALZ CZMAOI
OCD Clomipramine Fluoxetine CDZ Buspirone
PTSDTCA-
Imipra Amytrp
SSRI- FLX
Sertaline CPBZN MAOI
Comparison of Benzodiazepines
BZN Sedation Anxiolytic Half life Lipid solu Dose
Diazepam +++ + 20-80 h High 5 mg od
Alprazolam + +++ 6-20 h Low 05 mg qid
Clonazapam ++ +++ 22-50 h Low 05 mg bid
Lorazepam ++ ++ 10-20 h Med 1 mg tid
Chlordiazepx + + 7-30 h Med 15 mg bid
Different strategies of therapy
Behavior therapy
Desensitization
Behavior modification
Behavioral activation
Cognitive therapy
Rational-emotive therapy
Beckrsquos cognitive therapy
Newer approaches
Mindfulness meditation
Acceptance and commitment therapy
Dialectical Behavior Therapy (BPD)
Cognitive Behaviour Therapy - CBT
CBT is a method used to treat anxiety
Recognition of ldquodistorted thinkingrdquo
ldquoCognitive restructuringrdquo
It may also involve classical conditioning when used to treat Obsessive Compulsive Disorder
CBT ndash Obstacles - Restructuring
Hopelessness
Self-criticism
Fear of getting worse
Shame and embarrassment
Partial exposure
Blaming other people
Low motivation
Looking for complex solution
Depressing ruminations
There must be an easier way
Computer Therapy
Pts are ashamed to seek help and may fear the consequences at work and home
Therapy is expensive and beyond the reach of many patients
Computer therapy is very cheap and available by comparison
Computer Therapy ndash Softwares
Fearfighter - for phobiapanic
Cope - for depressionanxiety
Balance - for GAD
BTSteps - for OCD
These are PC based in a CD-Rom
or phone based or Web-based
MENTAL OUTSIDE
Virtual Reality - VR
VR therapy via SD (Systematic Desensitization) is becoming very popular
SD is a process of gradually introducing a disturbing stimulus (eg view from a high place) in otherwise pleasant surroundings
This process gradually suppresses the anxiety response
Virtual Reality ndash VR - Advantages
Patients often have difficulty imagining the stimulus themselves
They are often afraid of experiencing it directly ndash which may also be expensive and time-consuming
VR affords patient privacy and confidentiality during treatment
Very good for phobias
Virtual Reality ndash VR - Imagination
ldquoProjection in timerdquo ndash rationally reconstructing the future
ldquoDe-catastrophizing an imagerdquo ndash modifying a disturbing image
ldquoImage modeling and substitutionrdquo ndashinterrupting a negative train of images
ldquoCovert conditioningrdquo ndash subtle conditioning using imagined rather than real stimuli
Virtual Reality ndash VR - Hutchworld
Hutchworld is a virtual community attached to the Hutchison Cancer Research Center
Designed to provide social support for cancer patients and their families
Based on Microsoftrsquos Vworldrsquos system
Mood GYM on the Internet
Few GPs are trained in CBT
Clinical psychologists are expensive
Young people are not easily reached
They may not want them ndash embarrassment
The web is accessible convenient and popular
with young people
Deliver CBT via internet ndash 5 modules
Mood GYM Modules
5 Modules - analysis and results
1 Essentials of CBT with examples and interactive exercises
2 Warpy Thoughts Questionnaire Identifying dysfunctional thoughts Methods to contest such thoughts
3 Other methods for overcoming warpy thoughts
4 Life Event Stress Relaxation meditation music Pleasant Events Schedule parental style
5 Simple problem solving responses to relationship break-up
Web stats summary
Sessions
Take home points
10487661048766Anxiety disorders are very common
10487661048766Just as fevers these are of different types
10487661048766Accurate Dx and Rx by GP is essential
10487661048766Depression and substance abuse potential
Minimum of six weeks to see Rx effect
Prolonged Rx is necessary 6 m or more
Drug Rx is only a small part of management
SSRI TCAs BZNs MAOIs szlig-blockers etc
CBT Computer treatment VRs Mood GYM
Thank You All Visit us at
wwwdrsarmain
This is sponsored by Torrent ndash
Makers of Clonotril (Clonazepam)
What cause Anxiety Disorders
10487661048766No single cause
1048766 Several possible causes
1048766 genetics other biological factors
physiology infection injury trauma
1048766 temperament life experiences
1048766 upbringing family school peers
society in general Doctors in particular
stress - chronic or acute
What cause Anxiety Disorders
Importance of Anxiety Disorders
10487661048766Accurate Dx and Rx of anxiety
disorders is essential
Reduction of secondary psychiatric
conditions
Depression
Substance abuse problems
1 Generalized Anxiety
Disorder (GAD)
2 Panic Disorder (PD)
with Agoraphobia (AG)
3 PD sans Agoraphobia
4 Specific Phobia (SP)
5 Social Phobia (SoP)
6 Obsessive Compulsive
Disorder (OCD)
7 Post traumatic Stress
Disorder (PTSD)
8 Acute Stress Disorder
9 SAD CAD (ASD)
10 Substance-Induced
Anxiety disorder (SIAD)
11 Anxiety disorder due
some medical illness
Anxiety Disorders - DSM-IV
Dual Diagnosis Disorders
Prevalence of Anxiety Disorders
249
14
68 57 4716
0
3
6
9
12
15
18
21
24
27
Any AnxietyDisorder
SocialAnxietyDisorder
PTSD GeneralizedAnxietyDisorder
PanicDisorder
OCD
Lif
eti
me
Pre
va
len
ce
(
)
Kessler et al Arch Gen Psychiatry 1995521048Kessler et al Arch Gen Psychiatry 1994518
Sex differences in Anxiety Disorders
Are women more lsquoNuttyrsquo
Spectrum of Anxiety Disorders
0 1 2 3 4 5
PANIC D
AGORAPH
OCD
GAD
PTSD
SocPHOB
SpecPHOB
Percent
httpwwwnimhnihgovpublicatanxietycfm
What is Gen Anxiety Disorder Anxiety Disorders are characterized by
persistent fear and anxiety that occurs too
often is too severe is triggered too easily or
lasts too long
The ldquoWhat ifrdquo disorder
Compared with others with anxiety
disorders persons with GAD have a better
ability to maintain normal work and social
relationships in spite of their distress
Domains of anxiety
10487661048766Physical
10487661048766Affective
10487661048766Cognitive
10487661048766Behavioral
Physical domain
10487661048766 Anorexia
10487661048766 Butterflies in stomach
10487661048766 Chest paintightness
10487661048766 Diaphoresis
10487661048766 Dry mouth
10487661048766 Dyspnoea
10487661048766 Faintness
10487661048766 Flushing
10487661048766 Hyperventilation
10487661048766 Light-headedness
10487661048766 Muscle tension
10487661048766 Nausea Vomiting
10487661048766 Pallor
10487661048766 Palpitations
10487661048766 Paresthesias
10487661048766 Sexual dysfunction
Physical domain contd
10487661048766 Headache
10487661048766 Shortness of breath
10487661048766 Stomach pain
10487661048766 Tachycardia
10487661048766 Tremulousness
10487661048766 Urinary frequency
10487661048766 Diarrhea
Affective domain
10487661048766 Edginess
10487661048766 Uneasiness
10487661048766 Terror
10487661048766 Panic
Behavioral domain
10487661048766 Triggers many responses
10487661048766 Behavioral in nature
10487661048766 Concerned with diminishing
10487661048766 And even avoiding the distress
Regulation of locus ceruleus
10487661048766Alpha-noradrenergic auto receptors
10487661048766Serotonin receptors
10487661048766GABA-benzodiazepine receptors
10487661048766Opiate receptors
Dopamine receptors
The amygdala and locus ceruleus
Generalized Anxiety Disorder -GADPathological anxiety which
is
excessive chronic and
typically interferes with their ability to function in normal daily activities
GAD is distinguished from Phobic anxiety ndash as it is not triggered by a specific object
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
Excessive anxiety and worry occurring more days than not for at least 6 months about a number of events The person finds it difficult to control the anxiety and worry and has associated three (or more) of the above six symptoms
Case 1
Ms D has a chief co ldquoworrying about
everythingrdquo for the last year She also co
frequent headaches fatigue and
insomnia secondary to the anxiety
These symptoms have worsened to the
point where she has been distracted and
making mistakes at work
Worry that is 1048766 Excessive uncontrollable 1048766 Frequent multiple topics (not only
onetime) 1048766 More than one day out of two
3 out of 6 other associated physical symptoms
1048766 Muscle tension Restlessness 1048766 Fatigued easily Irritability 1048766 Sleep disturbance Concentration
difficulty
GAD ndash Mr Fisc
Acute fear state
10487661048766Response to life-threatening danger
10487661048766Terror helplessness
Sense of impending disasterdoom
10487661048766Urgency to flee or seek safety
10487661048766SympatheticNor-adrenergic activation
10487661048766Located in locus ceruleus
1048766 Corresponds to panic attacks
Agoraphobia
Anxiety in situations where escape might be
difficult (or embarrassing) or help might not be
available in the event of having a panic attack or
panic-like symptoms
Situations are avoided or endured with marked
distress
May not leave home or may need a companion
Can occur with and without panic disorder
Agoraphobia
Social Phobia
Marked persistent fear of social or performance
situations where a person is exposed to unfamiliar
situations or people or possible scrutiny by others
The individual fears acting in an embarrassing or
humiliating way
The Person recognizes fear as excessive
Exposure causes anxiety symptoms or panic
Situations are avoided or endured with anxiety
Specific Phobias
Marked and persistent fear that is excessive or unreasonable
cued by the presence or anticipation of a specific object or
situation (eg flying heights animals receiving an injection
seeing blood)
Exposure to the phobic stimulus almost invariably provokes an
immediate anxiety response which may take the form of a
Panic Attack
The person recognizes that hisher fear is excessive or
unreasonable The phobic situation is avoided or else is
endured with intense anxiety or distress
Specific Phobias - Examples
Acrophobia fear of heights
Agoraphobia fear of open places
Claustrophobia fear of enclosed places
Ailurophobia fear of cats
Cynophobia fear of dogs
Pathophobia fear of disease
Mysophobia fear of dirt and germs
Arachnophobia fear of spiders
Hematophobia fear of blood
Xenophobia fear of strangers
Better-halfophobia fear of wife
PAN ndash The Greek God
Panic Attack ndash DSM IV
1 1048766 Palpitations
2 Sweating
3 Trembling or shaking
4 Shortness of breath
5 Feeling of choking
6 Chest pain or discomfort
7 Nausea or abd distress
8 Feeling dizzy fainty
9 Derealization (feelings of unreality)
10 Fear of going crazy
11 Fear of dying
12 Paresthesias
13 Chills or hot flushes
10487661048766A discrete period of intense fear or discomfort in which 4 (or more) of the above 13 symptoms develop abruptly and reach a peak within 10 minutes
Case 2
Mrs B co a long ho episodes of anxiety
SOB racing heart sweating CP and
fears that she is having a MI and will die
These last 30 minutes and are
unexpected She co anxiety while in
malls and traveling alone to new places
for fear of having another attack Despite
a negative wu she still worries about
having a MI during an attack
Panic Disorder with Agoraphobia
Recurrent unexpected panic attacks anxiety
associated with at least four physical andor
cognitive symptoms cognitive symptoms
At least 1 month of worry about having additional
attacks or the consequences of an attack (losing
control having a heart attack ldquogoing crazyrdquo)
Agoraphobia
Panic Disorder ndash Chest pain
Chest pain is a common symptom of panic
attacks
22 ndash 70 of panic attacks are associated with
CP
18 ndash 25 of all patients with chest pain have
PD
Rates of PD higher among cardiology
outpatients with chest pain
Such patients undergo expensive cardiac
workups but their PD remains undiagnosed amp
untreated
Obsessive Compulsive Disorder - OCD
Obsessions Recurrent and persistent thoughts impulses or
images
that are experienced during the disturbance as intrusive
and inappropriate and cause marked 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 to neutralize them with some other thought or action
The person recognizes that the obsessive thoughts
impulses or images are a product of his or her own mind
Obsessive Compulsive Disorder -OCD
Compulsions Repetitive behaviors (eg hand washing ordering
checking) or mental acts (eg praying counting repeating
words silently)
Heshe is driven to perform in response to an obsession
The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event
But these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent and are clearly excessive
Obsessive Compulsive Disorder -OCD
Putamen
Globus Pallidus
Caudate Nucleus
Thalamus
Orbital frontal
cortex
Post traumatic Stress Disorder- PTSD
Post traumatic Stress Disorder- PTSD
Experiential requirements The person has experienced a life-threatening
event and has responded with intense fear
hopelessness or horror The personrsquos response to the event occurred
more
than 4 weeks after it was experienced and lasted
more than one month The traumatic event is persistently re
experienced
in several ways eg by intrusive recollections
dreams illusions hallucinations or flashbacks
Post traumatic stress disorder PTSD
Post traumatic Stress Disorder- PTSD
Behavioral requirements Thought avoidance related-activities
andor People-avoidance behavior Feelings of detachment Blunted affect Sense of doom Insomnia Irritability Hyper vigilance Exaggerated startle response
Post traumatic Stress Disorder- PTSD
Subdivisions Acute ndash when PTSD is diagnosed between 1 and
3
months after the event occurs it is called acute Chronic - when PTSD continues longer than 3
months it is considered chronic and long term Delayed Onset PTSD-this term is used to
describe
those cases where the symptoms do not occur
immediately after the experience but rather
months or years later
Case 3
Mr A witnessed a friend die in a MVA six
weeks ago and co frequent nightmares
of the accident poor sleep fears of
driving anxiety around highways
anhedonia and decreased affection
highways towards his girlfriend His
girlfriend also notes that he has been
very irritable and startles easily since the
accident
Post traumatic Stress Disorder- PTSD
10487661048766Exposure to a traumatic event
10487661048766Response involving intense fear
Helplessness and horror
10487661048766Re-experiencing of the traumatic event
Avoidance of stimulipsychological numbing
10487661048766Increased arousal
10487661048766Symptoms greater than 1 month
Separation Anxiety Disorder - SAD
Medical conditions causing anxiety
10487661048766Endocrine conditions
10487661048766Cardiovascular conditions
10487661048766Respiratory conditions
10487661048766Metabolic conditions
10487661048766Neurological conditions
Substances causing anxiety
10487661048766Alcohol Alcohol
10487661048766Amphetamines
10487661048766Caffeine
10487661048766Cannabis
10487661048766Cocaine
10487661048766Hallucinogens
10487661048766Inhalants
10487661048766Phencyclidine
Substances that cause
anxiety (withdrawal)
10487661048766Alcohol
10487661048766Cocaine
10487661048766Sedatives
10487661048766Hypnotics
10487661048766Anxiolytics
Medications causing anxiety
Anesthetics
Analgesics
Sympathomimetics
Bronchodilators
Anti-cholinergics
1048766Insulin
Thyroid hormones
Oral contraceptives
Antihistamines
Anti-parkinsonians
1048766Corticosteroids
Antihypertensives
Cardiovascular drugs
Anticonvulsants
Anxiety Disorders
Current Management Strategies
Management of Anxiety Disorders
1048766 Pharmacotherapy (Medications)
Psycho-analytic therapy ndash PT
Behavior Therapy - BT
Cognitive Behavior Therapy ndash CBT
Computer therapy - CT
1048766 Virtual Realty ndash VR
Mood GYM
Drug Rx of Anxiety Disorders
Clonazepam
How do anxiolytics act
GABA and Glycine are inhibitory neurotransmitter
Serotonin and Noradrenaline are excitatory
Anxiety is increased excitatory transmitters
BZNs increase GABA and increase inhibition
SSRI decrease the serotonin levels and darrexcitation
TCAs act by darrboth serotonin and noradrenaline
Drug Rx of Anxiety Disorders
Disorder First Choice 2nd Choice Short (prn) Add on
GADBZN-
CZ CDZ ALZBeta-blockers Buspirone Carbamazp
Panic Disorder
Paroxetine
CitalopramTCA-
ClomipramineBZN-
ALZ CZ LZMAOI -
Phenelzine
Phobias Beta-blockers SSRIsBZN-
ALZ CZMAOI
OCD Clomipramine Fluoxetine CDZ Buspirone
PTSDTCA-
Imipra Amytrp
SSRI- FLX
Sertaline CPBZN MAOI
Comparison of Benzodiazepines
BZN Sedation Anxiolytic Half life Lipid solu Dose
Diazepam +++ + 20-80 h High 5 mg od
Alprazolam + +++ 6-20 h Low 05 mg qid
Clonazapam ++ +++ 22-50 h Low 05 mg bid
Lorazepam ++ ++ 10-20 h Med 1 mg tid
Chlordiazepx + + 7-30 h Med 15 mg bid
Different strategies of therapy
Behavior therapy
Desensitization
Behavior modification
Behavioral activation
Cognitive therapy
Rational-emotive therapy
Beckrsquos cognitive therapy
Newer approaches
Mindfulness meditation
Acceptance and commitment therapy
Dialectical Behavior Therapy (BPD)
Cognitive Behaviour Therapy - CBT
CBT is a method used to treat anxiety
Recognition of ldquodistorted thinkingrdquo
ldquoCognitive restructuringrdquo
It may also involve classical conditioning when used to treat Obsessive Compulsive Disorder
CBT ndash Obstacles - Restructuring
Hopelessness
Self-criticism
Fear of getting worse
Shame and embarrassment
Partial exposure
Blaming other people
Low motivation
Looking for complex solution
Depressing ruminations
There must be an easier way
Computer Therapy
Pts are ashamed to seek help and may fear the consequences at work and home
Therapy is expensive and beyond the reach of many patients
Computer therapy is very cheap and available by comparison
Computer Therapy ndash Softwares
Fearfighter - for phobiapanic
Cope - for depressionanxiety
Balance - for GAD
BTSteps - for OCD
These are PC based in a CD-Rom
or phone based or Web-based
MENTAL OUTSIDE
Virtual Reality - VR
VR therapy via SD (Systematic Desensitization) is becoming very popular
SD is a process of gradually introducing a disturbing stimulus (eg view from a high place) in otherwise pleasant surroundings
This process gradually suppresses the anxiety response
Virtual Reality ndash VR - Advantages
Patients often have difficulty imagining the stimulus themselves
They are often afraid of experiencing it directly ndash which may also be expensive and time-consuming
VR affords patient privacy and confidentiality during treatment
Very good for phobias
Virtual Reality ndash VR - Imagination
ldquoProjection in timerdquo ndash rationally reconstructing the future
ldquoDe-catastrophizing an imagerdquo ndash modifying a disturbing image
ldquoImage modeling and substitutionrdquo ndashinterrupting a negative train of images
ldquoCovert conditioningrdquo ndash subtle conditioning using imagined rather than real stimuli
Virtual Reality ndash VR - Hutchworld
Hutchworld is a virtual community attached to the Hutchison Cancer Research Center
Designed to provide social support for cancer patients and their families
Based on Microsoftrsquos Vworldrsquos system
Mood GYM on the Internet
Few GPs are trained in CBT
Clinical psychologists are expensive
Young people are not easily reached
They may not want them ndash embarrassment
The web is accessible convenient and popular
with young people
Deliver CBT via internet ndash 5 modules
Mood GYM Modules
5 Modules - analysis and results
1 Essentials of CBT with examples and interactive exercises
2 Warpy Thoughts Questionnaire Identifying dysfunctional thoughts Methods to contest such thoughts
3 Other methods for overcoming warpy thoughts
4 Life Event Stress Relaxation meditation music Pleasant Events Schedule parental style
5 Simple problem solving responses to relationship break-up
Web stats summary
Sessions
Take home points
10487661048766Anxiety disorders are very common
10487661048766Just as fevers these are of different types
10487661048766Accurate Dx and Rx by GP is essential
10487661048766Depression and substance abuse potential
Minimum of six weeks to see Rx effect
Prolonged Rx is necessary 6 m or more
Drug Rx is only a small part of management
SSRI TCAs BZNs MAOIs szlig-blockers etc
CBT Computer treatment VRs Mood GYM
Thank You All Visit us at
wwwdrsarmain
This is sponsored by Torrent ndash
Makers of Clonotril (Clonazepam)
What cause Anxiety Disorders
Importance of Anxiety Disorders
10487661048766Accurate Dx and Rx of anxiety
disorders is essential
Reduction of secondary psychiatric
conditions
Depression
Substance abuse problems
1 Generalized Anxiety
Disorder (GAD)
2 Panic Disorder (PD)
with Agoraphobia (AG)
3 PD sans Agoraphobia
4 Specific Phobia (SP)
5 Social Phobia (SoP)
6 Obsessive Compulsive
Disorder (OCD)
7 Post traumatic Stress
Disorder (PTSD)
8 Acute Stress Disorder
9 SAD CAD (ASD)
10 Substance-Induced
Anxiety disorder (SIAD)
11 Anxiety disorder due
some medical illness
Anxiety Disorders - DSM-IV
Dual Diagnosis Disorders
Prevalence of Anxiety Disorders
249
14
68 57 4716
0
3
6
9
12
15
18
21
24
27
Any AnxietyDisorder
SocialAnxietyDisorder
PTSD GeneralizedAnxietyDisorder
PanicDisorder
OCD
Lif
eti
me
Pre
va
len
ce
(
)
Kessler et al Arch Gen Psychiatry 1995521048Kessler et al Arch Gen Psychiatry 1994518
Sex differences in Anxiety Disorders
Are women more lsquoNuttyrsquo
Spectrum of Anxiety Disorders
0 1 2 3 4 5
PANIC D
AGORAPH
OCD
GAD
PTSD
SocPHOB
SpecPHOB
Percent
httpwwwnimhnihgovpublicatanxietycfm
What is Gen Anxiety Disorder Anxiety Disorders are characterized by
persistent fear and anxiety that occurs too
often is too severe is triggered too easily or
lasts too long
The ldquoWhat ifrdquo disorder
Compared with others with anxiety
disorders persons with GAD have a better
ability to maintain normal work and social
relationships in spite of their distress
Domains of anxiety
10487661048766Physical
10487661048766Affective
10487661048766Cognitive
10487661048766Behavioral
Physical domain
10487661048766 Anorexia
10487661048766 Butterflies in stomach
10487661048766 Chest paintightness
10487661048766 Diaphoresis
10487661048766 Dry mouth
10487661048766 Dyspnoea
10487661048766 Faintness
10487661048766 Flushing
10487661048766 Hyperventilation
10487661048766 Light-headedness
10487661048766 Muscle tension
10487661048766 Nausea Vomiting
10487661048766 Pallor
10487661048766 Palpitations
10487661048766 Paresthesias
10487661048766 Sexual dysfunction
Physical domain contd
10487661048766 Headache
10487661048766 Shortness of breath
10487661048766 Stomach pain
10487661048766 Tachycardia
10487661048766 Tremulousness
10487661048766 Urinary frequency
10487661048766 Diarrhea
Affective domain
10487661048766 Edginess
10487661048766 Uneasiness
10487661048766 Terror
10487661048766 Panic
Behavioral domain
10487661048766 Triggers many responses
10487661048766 Behavioral in nature
10487661048766 Concerned with diminishing
10487661048766 And even avoiding the distress
Regulation of locus ceruleus
10487661048766Alpha-noradrenergic auto receptors
10487661048766Serotonin receptors
10487661048766GABA-benzodiazepine receptors
10487661048766Opiate receptors
Dopamine receptors
The amygdala and locus ceruleus
Generalized Anxiety Disorder -GADPathological anxiety which
is
excessive chronic and
typically interferes with their ability to function in normal daily activities
GAD is distinguished from Phobic anxiety ndash as it is not triggered by a specific object
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
Excessive anxiety and worry occurring more days than not for at least 6 months about a number of events The person finds it difficult to control the anxiety and worry and has associated three (or more) of the above six symptoms
Case 1
Ms D has a chief co ldquoworrying about
everythingrdquo for the last year She also co
frequent headaches fatigue and
insomnia secondary to the anxiety
These symptoms have worsened to the
point where she has been distracted and
making mistakes at work
Worry that is 1048766 Excessive uncontrollable 1048766 Frequent multiple topics (not only
onetime) 1048766 More than one day out of two
3 out of 6 other associated physical symptoms
1048766 Muscle tension Restlessness 1048766 Fatigued easily Irritability 1048766 Sleep disturbance Concentration
difficulty
GAD ndash Mr Fisc
Acute fear state
10487661048766Response to life-threatening danger
10487661048766Terror helplessness
Sense of impending disasterdoom
10487661048766Urgency to flee or seek safety
10487661048766SympatheticNor-adrenergic activation
10487661048766Located in locus ceruleus
1048766 Corresponds to panic attacks
Agoraphobia
Anxiety in situations where escape might be
difficult (or embarrassing) or help might not be
available in the event of having a panic attack or
panic-like symptoms
Situations are avoided or endured with marked
distress
May not leave home or may need a companion
Can occur with and without panic disorder
Agoraphobia
Social Phobia
Marked persistent fear of social or performance
situations where a person is exposed to unfamiliar
situations or people or possible scrutiny by others
The individual fears acting in an embarrassing or
humiliating way
The Person recognizes fear as excessive
Exposure causes anxiety symptoms or panic
Situations are avoided or endured with anxiety
Specific Phobias
Marked and persistent fear that is excessive or unreasonable
cued by the presence or anticipation of a specific object or
situation (eg flying heights animals receiving an injection
seeing blood)
Exposure to the phobic stimulus almost invariably provokes an
immediate anxiety response which may take the form of a
Panic Attack
The person recognizes that hisher fear is excessive or
unreasonable The phobic situation is avoided or else is
endured with intense anxiety or distress
Specific Phobias - Examples
Acrophobia fear of heights
Agoraphobia fear of open places
Claustrophobia fear of enclosed places
Ailurophobia fear of cats
Cynophobia fear of dogs
Pathophobia fear of disease
Mysophobia fear of dirt and germs
Arachnophobia fear of spiders
Hematophobia fear of blood
Xenophobia fear of strangers
Better-halfophobia fear of wife
PAN ndash The Greek God
Panic Attack ndash DSM IV
1 1048766 Palpitations
2 Sweating
3 Trembling or shaking
4 Shortness of breath
5 Feeling of choking
6 Chest pain or discomfort
7 Nausea or abd distress
8 Feeling dizzy fainty
9 Derealization (feelings of unreality)
10 Fear of going crazy
11 Fear of dying
12 Paresthesias
13 Chills or hot flushes
10487661048766A discrete period of intense fear or discomfort in which 4 (or more) of the above 13 symptoms develop abruptly and reach a peak within 10 minutes
Case 2
Mrs B co a long ho episodes of anxiety
SOB racing heart sweating CP and
fears that she is having a MI and will die
These last 30 minutes and are
unexpected She co anxiety while in
malls and traveling alone to new places
for fear of having another attack Despite
a negative wu she still worries about
having a MI during an attack
Panic Disorder with Agoraphobia
Recurrent unexpected panic attacks anxiety
associated with at least four physical andor
cognitive symptoms cognitive symptoms
At least 1 month of worry about having additional
attacks or the consequences of an attack (losing
control having a heart attack ldquogoing crazyrdquo)
Agoraphobia
Panic Disorder ndash Chest pain
Chest pain is a common symptom of panic
attacks
22 ndash 70 of panic attacks are associated with
CP
18 ndash 25 of all patients with chest pain have
PD
Rates of PD higher among cardiology
outpatients with chest pain
Such patients undergo expensive cardiac
workups but their PD remains undiagnosed amp
untreated
Obsessive Compulsive Disorder - OCD
Obsessions Recurrent and persistent thoughts impulses or
images
that are experienced during the disturbance as intrusive
and inappropriate and cause marked 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 to neutralize them with some other thought or action
The person recognizes that the obsessive thoughts
impulses or images are a product of his or her own mind
Obsessive Compulsive Disorder -OCD
Compulsions Repetitive behaviors (eg hand washing ordering
checking) or mental acts (eg praying counting repeating
words silently)
Heshe is driven to perform in response to an obsession
The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event
But these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent and are clearly excessive
Obsessive Compulsive Disorder -OCD
Putamen
Globus Pallidus
Caudate Nucleus
Thalamus
Orbital frontal
cortex
Post traumatic Stress Disorder- PTSD
Post traumatic Stress Disorder- PTSD
Experiential requirements The person has experienced a life-threatening
event and has responded with intense fear
hopelessness or horror The personrsquos response to the event occurred
more
than 4 weeks after it was experienced and lasted
more than one month The traumatic event is persistently re
experienced
in several ways eg by intrusive recollections
dreams illusions hallucinations or flashbacks
Post traumatic stress disorder PTSD
Post traumatic Stress Disorder- PTSD
Behavioral requirements Thought avoidance related-activities
andor People-avoidance behavior Feelings of detachment Blunted affect Sense of doom Insomnia Irritability Hyper vigilance Exaggerated startle response
Post traumatic Stress Disorder- PTSD
Subdivisions Acute ndash when PTSD is diagnosed between 1 and
3
months after the event occurs it is called acute Chronic - when PTSD continues longer than 3
months it is considered chronic and long term Delayed Onset PTSD-this term is used to
describe
those cases where the symptoms do not occur
immediately after the experience but rather
months or years later
Case 3
Mr A witnessed a friend die in a MVA six
weeks ago and co frequent nightmares
of the accident poor sleep fears of
driving anxiety around highways
anhedonia and decreased affection
highways towards his girlfriend His
girlfriend also notes that he has been
very irritable and startles easily since the
accident
Post traumatic Stress Disorder- PTSD
10487661048766Exposure to a traumatic event
10487661048766Response involving intense fear
Helplessness and horror
10487661048766Re-experiencing of the traumatic event
Avoidance of stimulipsychological numbing
10487661048766Increased arousal
10487661048766Symptoms greater than 1 month
Separation Anxiety Disorder - SAD
Medical conditions causing anxiety
10487661048766Endocrine conditions
10487661048766Cardiovascular conditions
10487661048766Respiratory conditions
10487661048766Metabolic conditions
10487661048766Neurological conditions
Substances causing anxiety
10487661048766Alcohol Alcohol
10487661048766Amphetamines
10487661048766Caffeine
10487661048766Cannabis
10487661048766Cocaine
10487661048766Hallucinogens
10487661048766Inhalants
10487661048766Phencyclidine
Substances that cause
anxiety (withdrawal)
10487661048766Alcohol
10487661048766Cocaine
10487661048766Sedatives
10487661048766Hypnotics
10487661048766Anxiolytics
Medications causing anxiety
Anesthetics
Analgesics
Sympathomimetics
Bronchodilators
Anti-cholinergics
1048766Insulin
Thyroid hormones
Oral contraceptives
Antihistamines
Anti-parkinsonians
1048766Corticosteroids
Antihypertensives
Cardiovascular drugs
Anticonvulsants
Anxiety Disorders
Current Management Strategies
Management of Anxiety Disorders
1048766 Pharmacotherapy (Medications)
Psycho-analytic therapy ndash PT
Behavior Therapy - BT
Cognitive Behavior Therapy ndash CBT
Computer therapy - CT
1048766 Virtual Realty ndash VR
Mood GYM
Drug Rx of Anxiety Disorders
Clonazepam
How do anxiolytics act
GABA and Glycine are inhibitory neurotransmitter
Serotonin and Noradrenaline are excitatory
Anxiety is increased excitatory transmitters
BZNs increase GABA and increase inhibition
SSRI decrease the serotonin levels and darrexcitation
TCAs act by darrboth serotonin and noradrenaline
Drug Rx of Anxiety Disorders
Disorder First Choice 2nd Choice Short (prn) Add on
GADBZN-
CZ CDZ ALZBeta-blockers Buspirone Carbamazp
Panic Disorder
Paroxetine
CitalopramTCA-
ClomipramineBZN-
ALZ CZ LZMAOI -
Phenelzine
Phobias Beta-blockers SSRIsBZN-
ALZ CZMAOI
OCD Clomipramine Fluoxetine CDZ Buspirone
PTSDTCA-
Imipra Amytrp
SSRI- FLX
Sertaline CPBZN MAOI
Comparison of Benzodiazepines
BZN Sedation Anxiolytic Half life Lipid solu Dose
Diazepam +++ + 20-80 h High 5 mg od
Alprazolam + +++ 6-20 h Low 05 mg qid
Clonazapam ++ +++ 22-50 h Low 05 mg bid
Lorazepam ++ ++ 10-20 h Med 1 mg tid
Chlordiazepx + + 7-30 h Med 15 mg bid
Different strategies of therapy
Behavior therapy
Desensitization
Behavior modification
Behavioral activation
Cognitive therapy
Rational-emotive therapy
Beckrsquos cognitive therapy
Newer approaches
Mindfulness meditation
Acceptance and commitment therapy
Dialectical Behavior Therapy (BPD)
Cognitive Behaviour Therapy - CBT
CBT is a method used to treat anxiety
Recognition of ldquodistorted thinkingrdquo
ldquoCognitive restructuringrdquo
It may also involve classical conditioning when used to treat Obsessive Compulsive Disorder
CBT ndash Obstacles - Restructuring
Hopelessness
Self-criticism
Fear of getting worse
Shame and embarrassment
Partial exposure
Blaming other people
Low motivation
Looking for complex solution
Depressing ruminations
There must be an easier way
Computer Therapy
Pts are ashamed to seek help and may fear the consequences at work and home
Therapy is expensive and beyond the reach of many patients
Computer therapy is very cheap and available by comparison
Computer Therapy ndash Softwares
Fearfighter - for phobiapanic
Cope - for depressionanxiety
Balance - for GAD
BTSteps - for OCD
These are PC based in a CD-Rom
or phone based or Web-based
MENTAL OUTSIDE
Virtual Reality - VR
VR therapy via SD (Systematic Desensitization) is becoming very popular
SD is a process of gradually introducing a disturbing stimulus (eg view from a high place) in otherwise pleasant surroundings
This process gradually suppresses the anxiety response
Virtual Reality ndash VR - Advantages
Patients often have difficulty imagining the stimulus themselves
They are often afraid of experiencing it directly ndash which may also be expensive and time-consuming
VR affords patient privacy and confidentiality during treatment
Very good for phobias
Virtual Reality ndash VR - Imagination
ldquoProjection in timerdquo ndash rationally reconstructing the future
ldquoDe-catastrophizing an imagerdquo ndash modifying a disturbing image
ldquoImage modeling and substitutionrdquo ndashinterrupting a negative train of images
ldquoCovert conditioningrdquo ndash subtle conditioning using imagined rather than real stimuli
Virtual Reality ndash VR - Hutchworld
Hutchworld is a virtual community attached to the Hutchison Cancer Research Center
Designed to provide social support for cancer patients and their families
Based on Microsoftrsquos Vworldrsquos system
Mood GYM on the Internet
Few GPs are trained in CBT
Clinical psychologists are expensive
Young people are not easily reached
They may not want them ndash embarrassment
The web is accessible convenient and popular
with young people
Deliver CBT via internet ndash 5 modules
Mood GYM Modules
5 Modules - analysis and results
1 Essentials of CBT with examples and interactive exercises
2 Warpy Thoughts Questionnaire Identifying dysfunctional thoughts Methods to contest such thoughts
3 Other methods for overcoming warpy thoughts
4 Life Event Stress Relaxation meditation music Pleasant Events Schedule parental style
5 Simple problem solving responses to relationship break-up
Web stats summary
Sessions
Take home points
10487661048766Anxiety disorders are very common
10487661048766Just as fevers these are of different types
10487661048766Accurate Dx and Rx by GP is essential
10487661048766Depression and substance abuse potential
Minimum of six weeks to see Rx effect
Prolonged Rx is necessary 6 m or more
Drug Rx is only a small part of management
SSRI TCAs BZNs MAOIs szlig-blockers etc
CBT Computer treatment VRs Mood GYM
Thank You All Visit us at
wwwdrsarmain
This is sponsored by Torrent ndash
Makers of Clonotril (Clonazepam)
Importance of Anxiety Disorders
10487661048766Accurate Dx and Rx of anxiety
disorders is essential
Reduction of secondary psychiatric
conditions
Depression
Substance abuse problems
1 Generalized Anxiety
Disorder (GAD)
2 Panic Disorder (PD)
with Agoraphobia (AG)
3 PD sans Agoraphobia
4 Specific Phobia (SP)
5 Social Phobia (SoP)
6 Obsessive Compulsive
Disorder (OCD)
7 Post traumatic Stress
Disorder (PTSD)
8 Acute Stress Disorder
9 SAD CAD (ASD)
10 Substance-Induced
Anxiety disorder (SIAD)
11 Anxiety disorder due
some medical illness
Anxiety Disorders - DSM-IV
Dual Diagnosis Disorders
Prevalence of Anxiety Disorders
249
14
68 57 4716
0
3
6
9
12
15
18
21
24
27
Any AnxietyDisorder
SocialAnxietyDisorder
PTSD GeneralizedAnxietyDisorder
PanicDisorder
OCD
Lif
eti
me
Pre
va
len
ce
(
)
Kessler et al Arch Gen Psychiatry 1995521048Kessler et al Arch Gen Psychiatry 1994518
Sex differences in Anxiety Disorders
Are women more lsquoNuttyrsquo
Spectrum of Anxiety Disorders
0 1 2 3 4 5
PANIC D
AGORAPH
OCD
GAD
PTSD
SocPHOB
SpecPHOB
Percent
httpwwwnimhnihgovpublicatanxietycfm
What is Gen Anxiety Disorder Anxiety Disorders are characterized by
persistent fear and anxiety that occurs too
often is too severe is triggered too easily or
lasts too long
The ldquoWhat ifrdquo disorder
Compared with others with anxiety
disorders persons with GAD have a better
ability to maintain normal work and social
relationships in spite of their distress
Domains of anxiety
10487661048766Physical
10487661048766Affective
10487661048766Cognitive
10487661048766Behavioral
Physical domain
10487661048766 Anorexia
10487661048766 Butterflies in stomach
10487661048766 Chest paintightness
10487661048766 Diaphoresis
10487661048766 Dry mouth
10487661048766 Dyspnoea
10487661048766 Faintness
10487661048766 Flushing
10487661048766 Hyperventilation
10487661048766 Light-headedness
10487661048766 Muscle tension
10487661048766 Nausea Vomiting
10487661048766 Pallor
10487661048766 Palpitations
10487661048766 Paresthesias
10487661048766 Sexual dysfunction
Physical domain contd
10487661048766 Headache
10487661048766 Shortness of breath
10487661048766 Stomach pain
10487661048766 Tachycardia
10487661048766 Tremulousness
10487661048766 Urinary frequency
10487661048766 Diarrhea
Affective domain
10487661048766 Edginess
10487661048766 Uneasiness
10487661048766 Terror
10487661048766 Panic
Behavioral domain
10487661048766 Triggers many responses
10487661048766 Behavioral in nature
10487661048766 Concerned with diminishing
10487661048766 And even avoiding the distress
Regulation of locus ceruleus
10487661048766Alpha-noradrenergic auto receptors
10487661048766Serotonin receptors
10487661048766GABA-benzodiazepine receptors
10487661048766Opiate receptors
Dopamine receptors
The amygdala and locus ceruleus
Generalized Anxiety Disorder -GADPathological anxiety which
is
excessive chronic and
typically interferes with their ability to function in normal daily activities
GAD is distinguished from Phobic anxiety ndash as it is not triggered by a specific object
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
Excessive anxiety and worry occurring more days than not for at least 6 months about a number of events The person finds it difficult to control the anxiety and worry and has associated three (or more) of the above six symptoms
Case 1
Ms D has a chief co ldquoworrying about
everythingrdquo for the last year She also co
frequent headaches fatigue and
insomnia secondary to the anxiety
These symptoms have worsened to the
point where she has been distracted and
making mistakes at work
Worry that is 1048766 Excessive uncontrollable 1048766 Frequent multiple topics (not only
onetime) 1048766 More than one day out of two
3 out of 6 other associated physical symptoms
1048766 Muscle tension Restlessness 1048766 Fatigued easily Irritability 1048766 Sleep disturbance Concentration
difficulty
GAD ndash Mr Fisc
Acute fear state
10487661048766Response to life-threatening danger
10487661048766Terror helplessness
Sense of impending disasterdoom
10487661048766Urgency to flee or seek safety
10487661048766SympatheticNor-adrenergic activation
10487661048766Located in locus ceruleus
1048766 Corresponds to panic attacks
Agoraphobia
Anxiety in situations where escape might be
difficult (or embarrassing) or help might not be
available in the event of having a panic attack or
panic-like symptoms
Situations are avoided or endured with marked
distress
May not leave home or may need a companion
Can occur with and without panic disorder
Agoraphobia
Social Phobia
Marked persistent fear of social or performance
situations where a person is exposed to unfamiliar
situations or people or possible scrutiny by others
The individual fears acting in an embarrassing or
humiliating way
The Person recognizes fear as excessive
Exposure causes anxiety symptoms or panic
Situations are avoided or endured with anxiety
Specific Phobias
Marked and persistent fear that is excessive or unreasonable
cued by the presence or anticipation of a specific object or
situation (eg flying heights animals receiving an injection
seeing blood)
Exposure to the phobic stimulus almost invariably provokes an
immediate anxiety response which may take the form of a
Panic Attack
The person recognizes that hisher fear is excessive or
unreasonable The phobic situation is avoided or else is
endured with intense anxiety or distress
Specific Phobias - Examples
Acrophobia fear of heights
Agoraphobia fear of open places
Claustrophobia fear of enclosed places
Ailurophobia fear of cats
Cynophobia fear of dogs
Pathophobia fear of disease
Mysophobia fear of dirt and germs
Arachnophobia fear of spiders
Hematophobia fear of blood
Xenophobia fear of strangers
Better-halfophobia fear of wife
PAN ndash The Greek God
Panic Attack ndash DSM IV
1 1048766 Palpitations
2 Sweating
3 Trembling or shaking
4 Shortness of breath
5 Feeling of choking
6 Chest pain or discomfort
7 Nausea or abd distress
8 Feeling dizzy fainty
9 Derealization (feelings of unreality)
10 Fear of going crazy
11 Fear of dying
12 Paresthesias
13 Chills or hot flushes
10487661048766A discrete period of intense fear or discomfort in which 4 (or more) of the above 13 symptoms develop abruptly and reach a peak within 10 minutes
Case 2
Mrs B co a long ho episodes of anxiety
SOB racing heart sweating CP and
fears that she is having a MI and will die
These last 30 minutes and are
unexpected She co anxiety while in
malls and traveling alone to new places
for fear of having another attack Despite
a negative wu she still worries about
having a MI during an attack
Panic Disorder with Agoraphobia
Recurrent unexpected panic attacks anxiety
associated with at least four physical andor
cognitive symptoms cognitive symptoms
At least 1 month of worry about having additional
attacks or the consequences of an attack (losing
control having a heart attack ldquogoing crazyrdquo)
Agoraphobia
Panic Disorder ndash Chest pain
Chest pain is a common symptom of panic
attacks
22 ndash 70 of panic attacks are associated with
CP
18 ndash 25 of all patients with chest pain have
PD
Rates of PD higher among cardiology
outpatients with chest pain
Such patients undergo expensive cardiac
workups but their PD remains undiagnosed amp
untreated
Obsessive Compulsive Disorder - OCD
Obsessions Recurrent and persistent thoughts impulses or
images
that are experienced during the disturbance as intrusive
and inappropriate and cause marked 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 to neutralize them with some other thought or action
The person recognizes that the obsessive thoughts
impulses or images are a product of his or her own mind
Obsessive Compulsive Disorder -OCD
Compulsions Repetitive behaviors (eg hand washing ordering
checking) or mental acts (eg praying counting repeating
words silently)
Heshe is driven to perform in response to an obsession
The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event
But these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent and are clearly excessive
Obsessive Compulsive Disorder -OCD
Putamen
Globus Pallidus
Caudate Nucleus
Thalamus
Orbital frontal
cortex
Post traumatic Stress Disorder- PTSD
Post traumatic Stress Disorder- PTSD
Experiential requirements The person has experienced a life-threatening
event and has responded with intense fear
hopelessness or horror The personrsquos response to the event occurred
more
than 4 weeks after it was experienced and lasted
more than one month The traumatic event is persistently re
experienced
in several ways eg by intrusive recollections
dreams illusions hallucinations or flashbacks
Post traumatic stress disorder PTSD
Post traumatic Stress Disorder- PTSD
Behavioral requirements Thought avoidance related-activities
andor People-avoidance behavior Feelings of detachment Blunted affect Sense of doom Insomnia Irritability Hyper vigilance Exaggerated startle response
Post traumatic Stress Disorder- PTSD
Subdivisions Acute ndash when PTSD is diagnosed between 1 and
3
months after the event occurs it is called acute Chronic - when PTSD continues longer than 3
months it is considered chronic and long term Delayed Onset PTSD-this term is used to
describe
those cases where the symptoms do not occur
immediately after the experience but rather
months or years later
Case 3
Mr A witnessed a friend die in a MVA six
weeks ago and co frequent nightmares
of the accident poor sleep fears of
driving anxiety around highways
anhedonia and decreased affection
highways towards his girlfriend His
girlfriend also notes that he has been
very irritable and startles easily since the
accident
Post traumatic Stress Disorder- PTSD
10487661048766Exposure to a traumatic event
10487661048766Response involving intense fear
Helplessness and horror
10487661048766Re-experiencing of the traumatic event
Avoidance of stimulipsychological numbing
10487661048766Increased arousal
10487661048766Symptoms greater than 1 month
Separation Anxiety Disorder - SAD
Medical conditions causing anxiety
10487661048766Endocrine conditions
10487661048766Cardiovascular conditions
10487661048766Respiratory conditions
10487661048766Metabolic conditions
10487661048766Neurological conditions
Substances causing anxiety
10487661048766Alcohol Alcohol
10487661048766Amphetamines
10487661048766Caffeine
10487661048766Cannabis
10487661048766Cocaine
10487661048766Hallucinogens
10487661048766Inhalants
10487661048766Phencyclidine
Substances that cause
anxiety (withdrawal)
10487661048766Alcohol
10487661048766Cocaine
10487661048766Sedatives
10487661048766Hypnotics
10487661048766Anxiolytics
Medications causing anxiety
Anesthetics
Analgesics
Sympathomimetics
Bronchodilators
Anti-cholinergics
1048766Insulin
Thyroid hormones
Oral contraceptives
Antihistamines
Anti-parkinsonians
1048766Corticosteroids
Antihypertensives
Cardiovascular drugs
Anticonvulsants
Anxiety Disorders
Current Management Strategies
Management of Anxiety Disorders
1048766 Pharmacotherapy (Medications)
Psycho-analytic therapy ndash PT
Behavior Therapy - BT
Cognitive Behavior Therapy ndash CBT
Computer therapy - CT
1048766 Virtual Realty ndash VR
Mood GYM
Drug Rx of Anxiety Disorders
Clonazepam
How do anxiolytics act
GABA and Glycine are inhibitory neurotransmitter
Serotonin and Noradrenaline are excitatory
Anxiety is increased excitatory transmitters
BZNs increase GABA and increase inhibition
SSRI decrease the serotonin levels and darrexcitation
TCAs act by darrboth serotonin and noradrenaline
Drug Rx of Anxiety Disorders
Disorder First Choice 2nd Choice Short (prn) Add on
GADBZN-
CZ CDZ ALZBeta-blockers Buspirone Carbamazp
Panic Disorder
Paroxetine
CitalopramTCA-
ClomipramineBZN-
ALZ CZ LZMAOI -
Phenelzine
Phobias Beta-blockers SSRIsBZN-
ALZ CZMAOI
OCD Clomipramine Fluoxetine CDZ Buspirone
PTSDTCA-
Imipra Amytrp
SSRI- FLX
Sertaline CPBZN MAOI
Comparison of Benzodiazepines
BZN Sedation Anxiolytic Half life Lipid solu Dose
Diazepam +++ + 20-80 h High 5 mg od
Alprazolam + +++ 6-20 h Low 05 mg qid
Clonazapam ++ +++ 22-50 h Low 05 mg bid
Lorazepam ++ ++ 10-20 h Med 1 mg tid
Chlordiazepx + + 7-30 h Med 15 mg bid
Different strategies of therapy
Behavior therapy
Desensitization
Behavior modification
Behavioral activation
Cognitive therapy
Rational-emotive therapy
Beckrsquos cognitive therapy
Newer approaches
Mindfulness meditation
Acceptance and commitment therapy
Dialectical Behavior Therapy (BPD)
Cognitive Behaviour Therapy - CBT
CBT is a method used to treat anxiety
Recognition of ldquodistorted thinkingrdquo
ldquoCognitive restructuringrdquo
It may also involve classical conditioning when used to treat Obsessive Compulsive Disorder
CBT ndash Obstacles - Restructuring
Hopelessness
Self-criticism
Fear of getting worse
Shame and embarrassment
Partial exposure
Blaming other people
Low motivation
Looking for complex solution
Depressing ruminations
There must be an easier way
Computer Therapy
Pts are ashamed to seek help and may fear the consequences at work and home
Therapy is expensive and beyond the reach of many patients
Computer therapy is very cheap and available by comparison
Computer Therapy ndash Softwares
Fearfighter - for phobiapanic
Cope - for depressionanxiety
Balance - for GAD
BTSteps - for OCD
These are PC based in a CD-Rom
or phone based or Web-based
MENTAL OUTSIDE
Virtual Reality - VR
VR therapy via SD (Systematic Desensitization) is becoming very popular
SD is a process of gradually introducing a disturbing stimulus (eg view from a high place) in otherwise pleasant surroundings
This process gradually suppresses the anxiety response
Virtual Reality ndash VR - Advantages
Patients often have difficulty imagining the stimulus themselves
They are often afraid of experiencing it directly ndash which may also be expensive and time-consuming
VR affords patient privacy and confidentiality during treatment
Very good for phobias
Virtual Reality ndash VR - Imagination
ldquoProjection in timerdquo ndash rationally reconstructing the future
ldquoDe-catastrophizing an imagerdquo ndash modifying a disturbing image
ldquoImage modeling and substitutionrdquo ndashinterrupting a negative train of images
ldquoCovert conditioningrdquo ndash subtle conditioning using imagined rather than real stimuli
Virtual Reality ndash VR - Hutchworld
Hutchworld is a virtual community attached to the Hutchison Cancer Research Center
Designed to provide social support for cancer patients and their families
Based on Microsoftrsquos Vworldrsquos system
Mood GYM on the Internet
Few GPs are trained in CBT
Clinical psychologists are expensive
Young people are not easily reached
They may not want them ndash embarrassment
The web is accessible convenient and popular
with young people
Deliver CBT via internet ndash 5 modules
Mood GYM Modules
5 Modules - analysis and results
1 Essentials of CBT with examples and interactive exercises
2 Warpy Thoughts Questionnaire Identifying dysfunctional thoughts Methods to contest such thoughts
3 Other methods for overcoming warpy thoughts
4 Life Event Stress Relaxation meditation music Pleasant Events Schedule parental style
5 Simple problem solving responses to relationship break-up
Web stats summary
Sessions
Take home points
10487661048766Anxiety disorders are very common
10487661048766Just as fevers these are of different types
10487661048766Accurate Dx and Rx by GP is essential
10487661048766Depression and substance abuse potential
Minimum of six weeks to see Rx effect
Prolonged Rx is necessary 6 m or more
Drug Rx is only a small part of management
SSRI TCAs BZNs MAOIs szlig-blockers etc
CBT Computer treatment VRs Mood GYM
Thank You All Visit us at
wwwdrsarmain
This is sponsored by Torrent ndash
Makers of Clonotril (Clonazepam)
1 Generalized Anxiety
Disorder (GAD)
2 Panic Disorder (PD)
with Agoraphobia (AG)
3 PD sans Agoraphobia
4 Specific Phobia (SP)
5 Social Phobia (SoP)
6 Obsessive Compulsive
Disorder (OCD)
7 Post traumatic Stress
Disorder (PTSD)
8 Acute Stress Disorder
9 SAD CAD (ASD)
10 Substance-Induced
Anxiety disorder (SIAD)
11 Anxiety disorder due
some medical illness
Anxiety Disorders - DSM-IV
Dual Diagnosis Disorders
Prevalence of Anxiety Disorders
249
14
68 57 4716
0
3
6
9
12
15
18
21
24
27
Any AnxietyDisorder
SocialAnxietyDisorder
PTSD GeneralizedAnxietyDisorder
PanicDisorder
OCD
Lif
eti
me
Pre
va
len
ce
(
)
Kessler et al Arch Gen Psychiatry 1995521048Kessler et al Arch Gen Psychiatry 1994518
Sex differences in Anxiety Disorders
Are women more lsquoNuttyrsquo
Spectrum of Anxiety Disorders
0 1 2 3 4 5
PANIC D
AGORAPH
OCD
GAD
PTSD
SocPHOB
SpecPHOB
Percent
httpwwwnimhnihgovpublicatanxietycfm
What is Gen Anxiety Disorder Anxiety Disorders are characterized by
persistent fear and anxiety that occurs too
often is too severe is triggered too easily or
lasts too long
The ldquoWhat ifrdquo disorder
Compared with others with anxiety
disorders persons with GAD have a better
ability to maintain normal work and social
relationships in spite of their distress
Domains of anxiety
10487661048766Physical
10487661048766Affective
10487661048766Cognitive
10487661048766Behavioral
Physical domain
10487661048766 Anorexia
10487661048766 Butterflies in stomach
10487661048766 Chest paintightness
10487661048766 Diaphoresis
10487661048766 Dry mouth
10487661048766 Dyspnoea
10487661048766 Faintness
10487661048766 Flushing
10487661048766 Hyperventilation
10487661048766 Light-headedness
10487661048766 Muscle tension
10487661048766 Nausea Vomiting
10487661048766 Pallor
10487661048766 Palpitations
10487661048766 Paresthesias
10487661048766 Sexual dysfunction
Physical domain contd
10487661048766 Headache
10487661048766 Shortness of breath
10487661048766 Stomach pain
10487661048766 Tachycardia
10487661048766 Tremulousness
10487661048766 Urinary frequency
10487661048766 Diarrhea
Affective domain
10487661048766 Edginess
10487661048766 Uneasiness
10487661048766 Terror
10487661048766 Panic
Behavioral domain
10487661048766 Triggers many responses
10487661048766 Behavioral in nature
10487661048766 Concerned with diminishing
10487661048766 And even avoiding the distress
Regulation of locus ceruleus
10487661048766Alpha-noradrenergic auto receptors
10487661048766Serotonin receptors
10487661048766GABA-benzodiazepine receptors
10487661048766Opiate receptors
Dopamine receptors
The amygdala and locus ceruleus
Generalized Anxiety Disorder -GADPathological anxiety which
is
excessive chronic and
typically interferes with their ability to function in normal daily activities
GAD is distinguished from Phobic anxiety ndash as it is not triggered by a specific object
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
Excessive anxiety and worry occurring more days than not for at least 6 months about a number of events The person finds it difficult to control the anxiety and worry and has associated three (or more) of the above six symptoms
Case 1
Ms D has a chief co ldquoworrying about
everythingrdquo for the last year She also co
frequent headaches fatigue and
insomnia secondary to the anxiety
These symptoms have worsened to the
point where she has been distracted and
making mistakes at work
Worry that is 1048766 Excessive uncontrollable 1048766 Frequent multiple topics (not only
onetime) 1048766 More than one day out of two
3 out of 6 other associated physical symptoms
1048766 Muscle tension Restlessness 1048766 Fatigued easily Irritability 1048766 Sleep disturbance Concentration
difficulty
GAD ndash Mr Fisc
Acute fear state
10487661048766Response to life-threatening danger
10487661048766Terror helplessness
Sense of impending disasterdoom
10487661048766Urgency to flee or seek safety
10487661048766SympatheticNor-adrenergic activation
10487661048766Located in locus ceruleus
1048766 Corresponds to panic attacks
Agoraphobia
Anxiety in situations where escape might be
difficult (or embarrassing) or help might not be
available in the event of having a panic attack or
panic-like symptoms
Situations are avoided or endured with marked
distress
May not leave home or may need a companion
Can occur with and without panic disorder
Agoraphobia
Social Phobia
Marked persistent fear of social or performance
situations where a person is exposed to unfamiliar
situations or people or possible scrutiny by others
The individual fears acting in an embarrassing or
humiliating way
The Person recognizes fear as excessive
Exposure causes anxiety symptoms or panic
Situations are avoided or endured with anxiety
Specific Phobias
Marked and persistent fear that is excessive or unreasonable
cued by the presence or anticipation of a specific object or
situation (eg flying heights animals receiving an injection
seeing blood)
Exposure to the phobic stimulus almost invariably provokes an
immediate anxiety response which may take the form of a
Panic Attack
The person recognizes that hisher fear is excessive or
unreasonable The phobic situation is avoided or else is
endured with intense anxiety or distress
Specific Phobias - Examples
Acrophobia fear of heights
Agoraphobia fear of open places
Claustrophobia fear of enclosed places
Ailurophobia fear of cats
Cynophobia fear of dogs
Pathophobia fear of disease
Mysophobia fear of dirt and germs
Arachnophobia fear of spiders
Hematophobia fear of blood
Xenophobia fear of strangers
Better-halfophobia fear of wife
PAN ndash The Greek God
Panic Attack ndash DSM IV
1 1048766 Palpitations
2 Sweating
3 Trembling or shaking
4 Shortness of breath
5 Feeling of choking
6 Chest pain or discomfort
7 Nausea or abd distress
8 Feeling dizzy fainty
9 Derealization (feelings of unreality)
10 Fear of going crazy
11 Fear of dying
12 Paresthesias
13 Chills or hot flushes
10487661048766A discrete period of intense fear or discomfort in which 4 (or more) of the above 13 symptoms develop abruptly and reach a peak within 10 minutes
Case 2
Mrs B co a long ho episodes of anxiety
SOB racing heart sweating CP and
fears that she is having a MI and will die
These last 30 minutes and are
unexpected She co anxiety while in
malls and traveling alone to new places
for fear of having another attack Despite
a negative wu she still worries about
having a MI during an attack
Panic Disorder with Agoraphobia
Recurrent unexpected panic attacks anxiety
associated with at least four physical andor
cognitive symptoms cognitive symptoms
At least 1 month of worry about having additional
attacks or the consequences of an attack (losing
control having a heart attack ldquogoing crazyrdquo)
Agoraphobia
Panic Disorder ndash Chest pain
Chest pain is a common symptom of panic
attacks
22 ndash 70 of panic attacks are associated with
CP
18 ndash 25 of all patients with chest pain have
PD
Rates of PD higher among cardiology
outpatients with chest pain
Such patients undergo expensive cardiac
workups but their PD remains undiagnosed amp
untreated
Obsessive Compulsive Disorder - OCD
Obsessions Recurrent and persistent thoughts impulses or
images
that are experienced during the disturbance as intrusive
and inappropriate and cause marked 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 to neutralize them with some other thought or action
The person recognizes that the obsessive thoughts
impulses or images are a product of his or her own mind
Obsessive Compulsive Disorder -OCD
Compulsions Repetitive behaviors (eg hand washing ordering
checking) or mental acts (eg praying counting repeating
words silently)
Heshe is driven to perform in response to an obsession
The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event
But these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent and are clearly excessive
Obsessive Compulsive Disorder -OCD
Putamen
Globus Pallidus
Caudate Nucleus
Thalamus
Orbital frontal
cortex
Post traumatic Stress Disorder- PTSD
Post traumatic Stress Disorder- PTSD
Experiential requirements The person has experienced a life-threatening
event and has responded with intense fear
hopelessness or horror The personrsquos response to the event occurred
more
than 4 weeks after it was experienced and lasted
more than one month The traumatic event is persistently re
experienced
in several ways eg by intrusive recollections
dreams illusions hallucinations or flashbacks
Post traumatic stress disorder PTSD
Post traumatic Stress Disorder- PTSD
Behavioral requirements Thought avoidance related-activities
andor People-avoidance behavior Feelings of detachment Blunted affect Sense of doom Insomnia Irritability Hyper vigilance Exaggerated startle response
Post traumatic Stress Disorder- PTSD
Subdivisions Acute ndash when PTSD is diagnosed between 1 and
3
months after the event occurs it is called acute Chronic - when PTSD continues longer than 3
months it is considered chronic and long term Delayed Onset PTSD-this term is used to
describe
those cases where the symptoms do not occur
immediately after the experience but rather
months or years later
Case 3
Mr A witnessed a friend die in a MVA six
weeks ago and co frequent nightmares
of the accident poor sleep fears of
driving anxiety around highways
anhedonia and decreased affection
highways towards his girlfriend His
girlfriend also notes that he has been
very irritable and startles easily since the
accident
Post traumatic Stress Disorder- PTSD
10487661048766Exposure to a traumatic event
10487661048766Response involving intense fear
Helplessness and horror
10487661048766Re-experiencing of the traumatic event
Avoidance of stimulipsychological numbing
10487661048766Increased arousal
10487661048766Symptoms greater than 1 month
Separation Anxiety Disorder - SAD
Medical conditions causing anxiety
10487661048766Endocrine conditions
10487661048766Cardiovascular conditions
10487661048766Respiratory conditions
10487661048766Metabolic conditions
10487661048766Neurological conditions
Substances causing anxiety
10487661048766Alcohol Alcohol
10487661048766Amphetamines
10487661048766Caffeine
10487661048766Cannabis
10487661048766Cocaine
10487661048766Hallucinogens
10487661048766Inhalants
10487661048766Phencyclidine
Substances that cause
anxiety (withdrawal)
10487661048766Alcohol
10487661048766Cocaine
10487661048766Sedatives
10487661048766Hypnotics
10487661048766Anxiolytics
Medications causing anxiety
Anesthetics
Analgesics
Sympathomimetics
Bronchodilators
Anti-cholinergics
1048766Insulin
Thyroid hormones
Oral contraceptives
Antihistamines
Anti-parkinsonians
1048766Corticosteroids
Antihypertensives
Cardiovascular drugs
Anticonvulsants
Anxiety Disorders
Current Management Strategies
Management of Anxiety Disorders
1048766 Pharmacotherapy (Medications)
Psycho-analytic therapy ndash PT
Behavior Therapy - BT
Cognitive Behavior Therapy ndash CBT
Computer therapy - CT
1048766 Virtual Realty ndash VR
Mood GYM
Drug Rx of Anxiety Disorders
Clonazepam
How do anxiolytics act
GABA and Glycine are inhibitory neurotransmitter
Serotonin and Noradrenaline are excitatory
Anxiety is increased excitatory transmitters
BZNs increase GABA and increase inhibition
SSRI decrease the serotonin levels and darrexcitation
TCAs act by darrboth serotonin and noradrenaline
Drug Rx of Anxiety Disorders
Disorder First Choice 2nd Choice Short (prn) Add on
GADBZN-
CZ CDZ ALZBeta-blockers Buspirone Carbamazp
Panic Disorder
Paroxetine
CitalopramTCA-
ClomipramineBZN-
ALZ CZ LZMAOI -
Phenelzine
Phobias Beta-blockers SSRIsBZN-
ALZ CZMAOI
OCD Clomipramine Fluoxetine CDZ Buspirone
PTSDTCA-
Imipra Amytrp
SSRI- FLX
Sertaline CPBZN MAOI
Comparison of Benzodiazepines
BZN Sedation Anxiolytic Half life Lipid solu Dose
Diazepam +++ + 20-80 h High 5 mg od
Alprazolam + +++ 6-20 h Low 05 mg qid
Clonazapam ++ +++ 22-50 h Low 05 mg bid
Lorazepam ++ ++ 10-20 h Med 1 mg tid
Chlordiazepx + + 7-30 h Med 15 mg bid
Different strategies of therapy
Behavior therapy
Desensitization
Behavior modification
Behavioral activation
Cognitive therapy
Rational-emotive therapy
Beckrsquos cognitive therapy
Newer approaches
Mindfulness meditation
Acceptance and commitment therapy
Dialectical Behavior Therapy (BPD)
Cognitive Behaviour Therapy - CBT
CBT is a method used to treat anxiety
Recognition of ldquodistorted thinkingrdquo
ldquoCognitive restructuringrdquo
It may also involve classical conditioning when used to treat Obsessive Compulsive Disorder
CBT ndash Obstacles - Restructuring
Hopelessness
Self-criticism
Fear of getting worse
Shame and embarrassment
Partial exposure
Blaming other people
Low motivation
Looking for complex solution
Depressing ruminations
There must be an easier way
Computer Therapy
Pts are ashamed to seek help and may fear the consequences at work and home
Therapy is expensive and beyond the reach of many patients
Computer therapy is very cheap and available by comparison
Computer Therapy ndash Softwares
Fearfighter - for phobiapanic
Cope - for depressionanxiety
Balance - for GAD
BTSteps - for OCD
These are PC based in a CD-Rom
or phone based or Web-based
MENTAL OUTSIDE
Virtual Reality - VR
VR therapy via SD (Systematic Desensitization) is becoming very popular
SD is a process of gradually introducing a disturbing stimulus (eg view from a high place) in otherwise pleasant surroundings
This process gradually suppresses the anxiety response
Virtual Reality ndash VR - Advantages
Patients often have difficulty imagining the stimulus themselves
They are often afraid of experiencing it directly ndash which may also be expensive and time-consuming
VR affords patient privacy and confidentiality during treatment
Very good for phobias
Virtual Reality ndash VR - Imagination
ldquoProjection in timerdquo ndash rationally reconstructing the future
ldquoDe-catastrophizing an imagerdquo ndash modifying a disturbing image
ldquoImage modeling and substitutionrdquo ndashinterrupting a negative train of images
ldquoCovert conditioningrdquo ndash subtle conditioning using imagined rather than real stimuli
Virtual Reality ndash VR - Hutchworld
Hutchworld is a virtual community attached to the Hutchison Cancer Research Center
Designed to provide social support for cancer patients and their families
Based on Microsoftrsquos Vworldrsquos system
Mood GYM on the Internet
Few GPs are trained in CBT
Clinical psychologists are expensive
Young people are not easily reached
They may not want them ndash embarrassment
The web is accessible convenient and popular
with young people
Deliver CBT via internet ndash 5 modules
Mood GYM Modules
5 Modules - analysis and results
1 Essentials of CBT with examples and interactive exercises
2 Warpy Thoughts Questionnaire Identifying dysfunctional thoughts Methods to contest such thoughts
3 Other methods for overcoming warpy thoughts
4 Life Event Stress Relaxation meditation music Pleasant Events Schedule parental style
5 Simple problem solving responses to relationship break-up
Web stats summary
Sessions
Take home points
10487661048766Anxiety disorders are very common
10487661048766Just as fevers these are of different types
10487661048766Accurate Dx and Rx by GP is essential
10487661048766Depression and substance abuse potential
Minimum of six weeks to see Rx effect
Prolonged Rx is necessary 6 m or more
Drug Rx is only a small part of management
SSRI TCAs BZNs MAOIs szlig-blockers etc
CBT Computer treatment VRs Mood GYM
Thank You All Visit us at
wwwdrsarmain
This is sponsored by Torrent ndash
Makers of Clonotril (Clonazepam)
Prevalence of Anxiety Disorders
249
14
68 57 4716
0
3
6
9
12
15
18
21
24
27
Any AnxietyDisorder
SocialAnxietyDisorder
PTSD GeneralizedAnxietyDisorder
PanicDisorder
OCD
Lif
eti
me
Pre
va
len
ce
(
)
Kessler et al Arch Gen Psychiatry 1995521048Kessler et al Arch Gen Psychiatry 1994518
Sex differences in Anxiety Disorders
Are women more lsquoNuttyrsquo
Spectrum of Anxiety Disorders
0 1 2 3 4 5
PANIC D
AGORAPH
OCD
GAD
PTSD
SocPHOB
SpecPHOB
Percent
httpwwwnimhnihgovpublicatanxietycfm
What is Gen Anxiety Disorder Anxiety Disorders are characterized by
persistent fear and anxiety that occurs too
often is too severe is triggered too easily or
lasts too long
The ldquoWhat ifrdquo disorder
Compared with others with anxiety
disorders persons with GAD have a better
ability to maintain normal work and social
relationships in spite of their distress
Domains of anxiety
10487661048766Physical
10487661048766Affective
10487661048766Cognitive
10487661048766Behavioral
Physical domain
10487661048766 Anorexia
10487661048766 Butterflies in stomach
10487661048766 Chest paintightness
10487661048766 Diaphoresis
10487661048766 Dry mouth
10487661048766 Dyspnoea
10487661048766 Faintness
10487661048766 Flushing
10487661048766 Hyperventilation
10487661048766 Light-headedness
10487661048766 Muscle tension
10487661048766 Nausea Vomiting
10487661048766 Pallor
10487661048766 Palpitations
10487661048766 Paresthesias
10487661048766 Sexual dysfunction
Physical domain contd
10487661048766 Headache
10487661048766 Shortness of breath
10487661048766 Stomach pain
10487661048766 Tachycardia
10487661048766 Tremulousness
10487661048766 Urinary frequency
10487661048766 Diarrhea
Affective domain
10487661048766 Edginess
10487661048766 Uneasiness
10487661048766 Terror
10487661048766 Panic
Behavioral domain
10487661048766 Triggers many responses
10487661048766 Behavioral in nature
10487661048766 Concerned with diminishing
10487661048766 And even avoiding the distress
Regulation of locus ceruleus
10487661048766Alpha-noradrenergic auto receptors
10487661048766Serotonin receptors
10487661048766GABA-benzodiazepine receptors
10487661048766Opiate receptors
Dopamine receptors
The amygdala and locus ceruleus
Generalized Anxiety Disorder -GADPathological anxiety which
is
excessive chronic and
typically interferes with their ability to function in normal daily activities
GAD is distinguished from Phobic anxiety ndash as it is not triggered by a specific object
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
Excessive anxiety and worry occurring more days than not for at least 6 months about a number of events The person finds it difficult to control the anxiety and worry and has associated three (or more) of the above six symptoms
Case 1
Ms D has a chief co ldquoworrying about
everythingrdquo for the last year She also co
frequent headaches fatigue and
insomnia secondary to the anxiety
These symptoms have worsened to the
point where she has been distracted and
making mistakes at work
Worry that is 1048766 Excessive uncontrollable 1048766 Frequent multiple topics (not only
onetime) 1048766 More than one day out of two
3 out of 6 other associated physical symptoms
1048766 Muscle tension Restlessness 1048766 Fatigued easily Irritability 1048766 Sleep disturbance Concentration
difficulty
GAD ndash Mr Fisc
Acute fear state
10487661048766Response to life-threatening danger
10487661048766Terror helplessness
Sense of impending disasterdoom
10487661048766Urgency to flee or seek safety
10487661048766SympatheticNor-adrenergic activation
10487661048766Located in locus ceruleus
1048766 Corresponds to panic attacks
Agoraphobia
Anxiety in situations where escape might be
difficult (or embarrassing) or help might not be
available in the event of having a panic attack or
panic-like symptoms
Situations are avoided or endured with marked
distress
May not leave home or may need a companion
Can occur with and without panic disorder
Agoraphobia
Social Phobia
Marked persistent fear of social or performance
situations where a person is exposed to unfamiliar
situations or people or possible scrutiny by others
The individual fears acting in an embarrassing or
humiliating way
The Person recognizes fear as excessive
Exposure causes anxiety symptoms or panic
Situations are avoided or endured with anxiety
Specific Phobias
Marked and persistent fear that is excessive or unreasonable
cued by the presence or anticipation of a specific object or
situation (eg flying heights animals receiving an injection
seeing blood)
Exposure to the phobic stimulus almost invariably provokes an
immediate anxiety response which may take the form of a
Panic Attack
The person recognizes that hisher fear is excessive or
unreasonable The phobic situation is avoided or else is
endured with intense anxiety or distress
Specific Phobias - Examples
Acrophobia fear of heights
Agoraphobia fear of open places
Claustrophobia fear of enclosed places
Ailurophobia fear of cats
Cynophobia fear of dogs
Pathophobia fear of disease
Mysophobia fear of dirt and germs
Arachnophobia fear of spiders
Hematophobia fear of blood
Xenophobia fear of strangers
Better-halfophobia fear of wife
PAN ndash The Greek God
Panic Attack ndash DSM IV
1 1048766 Palpitations
2 Sweating
3 Trembling or shaking
4 Shortness of breath
5 Feeling of choking
6 Chest pain or discomfort
7 Nausea or abd distress
8 Feeling dizzy fainty
9 Derealization (feelings of unreality)
10 Fear of going crazy
11 Fear of dying
12 Paresthesias
13 Chills or hot flushes
10487661048766A discrete period of intense fear or discomfort in which 4 (or more) of the above 13 symptoms develop abruptly and reach a peak within 10 minutes
Case 2
Mrs B co a long ho episodes of anxiety
SOB racing heart sweating CP and
fears that she is having a MI and will die
These last 30 minutes and are
unexpected She co anxiety while in
malls and traveling alone to new places
for fear of having another attack Despite
a negative wu she still worries about
having a MI during an attack
Panic Disorder with Agoraphobia
Recurrent unexpected panic attacks anxiety
associated with at least four physical andor
cognitive symptoms cognitive symptoms
At least 1 month of worry about having additional
attacks or the consequences of an attack (losing
control having a heart attack ldquogoing crazyrdquo)
Agoraphobia
Panic Disorder ndash Chest pain
Chest pain is a common symptom of panic
attacks
22 ndash 70 of panic attacks are associated with
CP
18 ndash 25 of all patients with chest pain have
PD
Rates of PD higher among cardiology
outpatients with chest pain
Such patients undergo expensive cardiac
workups but their PD remains undiagnosed amp
untreated
Obsessive Compulsive Disorder - OCD
Obsessions Recurrent and persistent thoughts impulses or
images
that are experienced during the disturbance as intrusive
and inappropriate and cause marked 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 to neutralize them with some other thought or action
The person recognizes that the obsessive thoughts
impulses or images are a product of his or her own mind
Obsessive Compulsive Disorder -OCD
Compulsions Repetitive behaviors (eg hand washing ordering
checking) or mental acts (eg praying counting repeating
words silently)
Heshe is driven to perform in response to an obsession
The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event
But these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent and are clearly excessive
Obsessive Compulsive Disorder -OCD
Putamen
Globus Pallidus
Caudate Nucleus
Thalamus
Orbital frontal
cortex
Post traumatic Stress Disorder- PTSD
Post traumatic Stress Disorder- PTSD
Experiential requirements The person has experienced a life-threatening
event and has responded with intense fear
hopelessness or horror The personrsquos response to the event occurred
more
than 4 weeks after it was experienced and lasted
more than one month The traumatic event is persistently re
experienced
in several ways eg by intrusive recollections
dreams illusions hallucinations or flashbacks
Post traumatic stress disorder PTSD
Post traumatic Stress Disorder- PTSD
Behavioral requirements Thought avoidance related-activities
andor People-avoidance behavior Feelings of detachment Blunted affect Sense of doom Insomnia Irritability Hyper vigilance Exaggerated startle response
Post traumatic Stress Disorder- PTSD
Subdivisions Acute ndash when PTSD is diagnosed between 1 and
3
months after the event occurs it is called acute Chronic - when PTSD continues longer than 3
months it is considered chronic and long term Delayed Onset PTSD-this term is used to
describe
those cases where the symptoms do not occur
immediately after the experience but rather
months or years later
Case 3
Mr A witnessed a friend die in a MVA six
weeks ago and co frequent nightmares
of the accident poor sleep fears of
driving anxiety around highways
anhedonia and decreased affection
highways towards his girlfriend His
girlfriend also notes that he has been
very irritable and startles easily since the
accident
Post traumatic Stress Disorder- PTSD
10487661048766Exposure to a traumatic event
10487661048766Response involving intense fear
Helplessness and horror
10487661048766Re-experiencing of the traumatic event
Avoidance of stimulipsychological numbing
10487661048766Increased arousal
10487661048766Symptoms greater than 1 month
Separation Anxiety Disorder - SAD
Medical conditions causing anxiety
10487661048766Endocrine conditions
10487661048766Cardiovascular conditions
10487661048766Respiratory conditions
10487661048766Metabolic conditions
10487661048766Neurological conditions
Substances causing anxiety
10487661048766Alcohol Alcohol
10487661048766Amphetamines
10487661048766Caffeine
10487661048766Cannabis
10487661048766Cocaine
10487661048766Hallucinogens
10487661048766Inhalants
10487661048766Phencyclidine
Substances that cause
anxiety (withdrawal)
10487661048766Alcohol
10487661048766Cocaine
10487661048766Sedatives
10487661048766Hypnotics
10487661048766Anxiolytics
Medications causing anxiety
Anesthetics
Analgesics
Sympathomimetics
Bronchodilators
Anti-cholinergics
1048766Insulin
Thyroid hormones
Oral contraceptives
Antihistamines
Anti-parkinsonians
1048766Corticosteroids
Antihypertensives
Cardiovascular drugs
Anticonvulsants
Anxiety Disorders
Current Management Strategies
Management of Anxiety Disorders
1048766 Pharmacotherapy (Medications)
Psycho-analytic therapy ndash PT
Behavior Therapy - BT
Cognitive Behavior Therapy ndash CBT
Computer therapy - CT
1048766 Virtual Realty ndash VR
Mood GYM
Drug Rx of Anxiety Disorders
Clonazepam
How do anxiolytics act
GABA and Glycine are inhibitory neurotransmitter
Serotonin and Noradrenaline are excitatory
Anxiety is increased excitatory transmitters
BZNs increase GABA and increase inhibition
SSRI decrease the serotonin levels and darrexcitation
TCAs act by darrboth serotonin and noradrenaline
Drug Rx of Anxiety Disorders
Disorder First Choice 2nd Choice Short (prn) Add on
GADBZN-
CZ CDZ ALZBeta-blockers Buspirone Carbamazp
Panic Disorder
Paroxetine
CitalopramTCA-
ClomipramineBZN-
ALZ CZ LZMAOI -
Phenelzine
Phobias Beta-blockers SSRIsBZN-
ALZ CZMAOI
OCD Clomipramine Fluoxetine CDZ Buspirone
PTSDTCA-
Imipra Amytrp
SSRI- FLX
Sertaline CPBZN MAOI
Comparison of Benzodiazepines
BZN Sedation Anxiolytic Half life Lipid solu Dose
Diazepam +++ + 20-80 h High 5 mg od
Alprazolam + +++ 6-20 h Low 05 mg qid
Clonazapam ++ +++ 22-50 h Low 05 mg bid
Lorazepam ++ ++ 10-20 h Med 1 mg tid
Chlordiazepx + + 7-30 h Med 15 mg bid
Different strategies of therapy
Behavior therapy
Desensitization
Behavior modification
Behavioral activation
Cognitive therapy
Rational-emotive therapy
Beckrsquos cognitive therapy
Newer approaches
Mindfulness meditation
Acceptance and commitment therapy
Dialectical Behavior Therapy (BPD)
Cognitive Behaviour Therapy - CBT
CBT is a method used to treat anxiety
Recognition of ldquodistorted thinkingrdquo
ldquoCognitive restructuringrdquo
It may also involve classical conditioning when used to treat Obsessive Compulsive Disorder
CBT ndash Obstacles - Restructuring
Hopelessness
Self-criticism
Fear of getting worse
Shame and embarrassment
Partial exposure
Blaming other people
Low motivation
Looking for complex solution
Depressing ruminations
There must be an easier way
Computer Therapy
Pts are ashamed to seek help and may fear the consequences at work and home
Therapy is expensive and beyond the reach of many patients
Computer therapy is very cheap and available by comparison
Computer Therapy ndash Softwares
Fearfighter - for phobiapanic
Cope - for depressionanxiety
Balance - for GAD
BTSteps - for OCD
These are PC based in a CD-Rom
or phone based or Web-based
MENTAL OUTSIDE
Virtual Reality - VR
VR therapy via SD (Systematic Desensitization) is becoming very popular
SD is a process of gradually introducing a disturbing stimulus (eg view from a high place) in otherwise pleasant surroundings
This process gradually suppresses the anxiety response
Virtual Reality ndash VR - Advantages
Patients often have difficulty imagining the stimulus themselves
They are often afraid of experiencing it directly ndash which may also be expensive and time-consuming
VR affords patient privacy and confidentiality during treatment
Very good for phobias
Virtual Reality ndash VR - Imagination
ldquoProjection in timerdquo ndash rationally reconstructing the future
ldquoDe-catastrophizing an imagerdquo ndash modifying a disturbing image
ldquoImage modeling and substitutionrdquo ndashinterrupting a negative train of images
ldquoCovert conditioningrdquo ndash subtle conditioning using imagined rather than real stimuli
Virtual Reality ndash VR - Hutchworld
Hutchworld is a virtual community attached to the Hutchison Cancer Research Center
Designed to provide social support for cancer patients and their families
Based on Microsoftrsquos Vworldrsquos system
Mood GYM on the Internet
Few GPs are trained in CBT
Clinical psychologists are expensive
Young people are not easily reached
They may not want them ndash embarrassment
The web is accessible convenient and popular
with young people
Deliver CBT via internet ndash 5 modules
Mood GYM Modules
5 Modules - analysis and results
1 Essentials of CBT with examples and interactive exercises
2 Warpy Thoughts Questionnaire Identifying dysfunctional thoughts Methods to contest such thoughts
3 Other methods for overcoming warpy thoughts
4 Life Event Stress Relaxation meditation music Pleasant Events Schedule parental style
5 Simple problem solving responses to relationship break-up
Web stats summary
Sessions
Take home points
10487661048766Anxiety disorders are very common
10487661048766Just as fevers these are of different types
10487661048766Accurate Dx and Rx by GP is essential
10487661048766Depression and substance abuse potential
Minimum of six weeks to see Rx effect
Prolonged Rx is necessary 6 m or more
Drug Rx is only a small part of management
SSRI TCAs BZNs MAOIs szlig-blockers etc
CBT Computer treatment VRs Mood GYM
Thank You All Visit us at
wwwdrsarmain
This is sponsored by Torrent ndash
Makers of Clonotril (Clonazepam)
Sex differences in Anxiety Disorders
Are women more lsquoNuttyrsquo
Spectrum of Anxiety Disorders
0 1 2 3 4 5
PANIC D
AGORAPH
OCD
GAD
PTSD
SocPHOB
SpecPHOB
Percent
httpwwwnimhnihgovpublicatanxietycfm
What is Gen Anxiety Disorder Anxiety Disorders are characterized by
persistent fear and anxiety that occurs too
often is too severe is triggered too easily or
lasts too long
The ldquoWhat ifrdquo disorder
Compared with others with anxiety
disorders persons with GAD have a better
ability to maintain normal work and social
relationships in spite of their distress
Domains of anxiety
10487661048766Physical
10487661048766Affective
10487661048766Cognitive
10487661048766Behavioral
Physical domain
10487661048766 Anorexia
10487661048766 Butterflies in stomach
10487661048766 Chest paintightness
10487661048766 Diaphoresis
10487661048766 Dry mouth
10487661048766 Dyspnoea
10487661048766 Faintness
10487661048766 Flushing
10487661048766 Hyperventilation
10487661048766 Light-headedness
10487661048766 Muscle tension
10487661048766 Nausea Vomiting
10487661048766 Pallor
10487661048766 Palpitations
10487661048766 Paresthesias
10487661048766 Sexual dysfunction
Physical domain contd
10487661048766 Headache
10487661048766 Shortness of breath
10487661048766 Stomach pain
10487661048766 Tachycardia
10487661048766 Tremulousness
10487661048766 Urinary frequency
10487661048766 Diarrhea
Affective domain
10487661048766 Edginess
10487661048766 Uneasiness
10487661048766 Terror
10487661048766 Panic
Behavioral domain
10487661048766 Triggers many responses
10487661048766 Behavioral in nature
10487661048766 Concerned with diminishing
10487661048766 And even avoiding the distress
Regulation of locus ceruleus
10487661048766Alpha-noradrenergic auto receptors
10487661048766Serotonin receptors
10487661048766GABA-benzodiazepine receptors
10487661048766Opiate receptors
Dopamine receptors
The amygdala and locus ceruleus
Generalized Anxiety Disorder -GADPathological anxiety which
is
excessive chronic and
typically interferes with their ability to function in normal daily activities
GAD is distinguished from Phobic anxiety ndash as it is not triggered by a specific object
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
Excessive anxiety and worry occurring more days than not for at least 6 months about a number of events The person finds it difficult to control the anxiety and worry and has associated three (or more) of the above six symptoms
Case 1
Ms D has a chief co ldquoworrying about
everythingrdquo for the last year She also co
frequent headaches fatigue and
insomnia secondary to the anxiety
These symptoms have worsened to the
point where she has been distracted and
making mistakes at work
Worry that is 1048766 Excessive uncontrollable 1048766 Frequent multiple topics (not only
onetime) 1048766 More than one day out of two
3 out of 6 other associated physical symptoms
1048766 Muscle tension Restlessness 1048766 Fatigued easily Irritability 1048766 Sleep disturbance Concentration
difficulty
GAD ndash Mr Fisc
Acute fear state
10487661048766Response to life-threatening danger
10487661048766Terror helplessness
Sense of impending disasterdoom
10487661048766Urgency to flee or seek safety
10487661048766SympatheticNor-adrenergic activation
10487661048766Located in locus ceruleus
1048766 Corresponds to panic attacks
Agoraphobia
Anxiety in situations where escape might be
difficult (or embarrassing) or help might not be
available in the event of having a panic attack or
panic-like symptoms
Situations are avoided or endured with marked
distress
May not leave home or may need a companion
Can occur with and without panic disorder
Agoraphobia
Social Phobia
Marked persistent fear of social or performance
situations where a person is exposed to unfamiliar
situations or people or possible scrutiny by others
The individual fears acting in an embarrassing or
humiliating way
The Person recognizes fear as excessive
Exposure causes anxiety symptoms or panic
Situations are avoided or endured with anxiety
Specific Phobias
Marked and persistent fear that is excessive or unreasonable
cued by the presence or anticipation of a specific object or
situation (eg flying heights animals receiving an injection
seeing blood)
Exposure to the phobic stimulus almost invariably provokes an
immediate anxiety response which may take the form of a
Panic Attack
The person recognizes that hisher fear is excessive or
unreasonable The phobic situation is avoided or else is
endured with intense anxiety or distress
Specific Phobias - Examples
Acrophobia fear of heights
Agoraphobia fear of open places
Claustrophobia fear of enclosed places
Ailurophobia fear of cats
Cynophobia fear of dogs
Pathophobia fear of disease
Mysophobia fear of dirt and germs
Arachnophobia fear of spiders
Hematophobia fear of blood
Xenophobia fear of strangers
Better-halfophobia fear of wife
PAN ndash The Greek God
Panic Attack ndash DSM IV
1 1048766 Palpitations
2 Sweating
3 Trembling or shaking
4 Shortness of breath
5 Feeling of choking
6 Chest pain or discomfort
7 Nausea or abd distress
8 Feeling dizzy fainty
9 Derealization (feelings of unreality)
10 Fear of going crazy
11 Fear of dying
12 Paresthesias
13 Chills or hot flushes
10487661048766A discrete period of intense fear or discomfort in which 4 (or more) of the above 13 symptoms develop abruptly and reach a peak within 10 minutes
Case 2
Mrs B co a long ho episodes of anxiety
SOB racing heart sweating CP and
fears that she is having a MI and will die
These last 30 minutes and are
unexpected She co anxiety while in
malls and traveling alone to new places
for fear of having another attack Despite
a negative wu she still worries about
having a MI during an attack
Panic Disorder with Agoraphobia
Recurrent unexpected panic attacks anxiety
associated with at least four physical andor
cognitive symptoms cognitive symptoms
At least 1 month of worry about having additional
attacks or the consequences of an attack (losing
control having a heart attack ldquogoing crazyrdquo)
Agoraphobia
Panic Disorder ndash Chest pain
Chest pain is a common symptom of panic
attacks
22 ndash 70 of panic attacks are associated with
CP
18 ndash 25 of all patients with chest pain have
PD
Rates of PD higher among cardiology
outpatients with chest pain
Such patients undergo expensive cardiac
workups but their PD remains undiagnosed amp
untreated
Obsessive Compulsive Disorder - OCD
Obsessions Recurrent and persistent thoughts impulses or
images
that are experienced during the disturbance as intrusive
and inappropriate and cause marked 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 to neutralize them with some other thought or action
The person recognizes that the obsessive thoughts
impulses or images are a product of his or her own mind
Obsessive Compulsive Disorder -OCD
Compulsions Repetitive behaviors (eg hand washing ordering
checking) or mental acts (eg praying counting repeating
words silently)
Heshe is driven to perform in response to an obsession
The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event
But these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent and are clearly excessive
Obsessive Compulsive Disorder -OCD
Putamen
Globus Pallidus
Caudate Nucleus
Thalamus
Orbital frontal
cortex
Post traumatic Stress Disorder- PTSD
Post traumatic Stress Disorder- PTSD
Experiential requirements The person has experienced a life-threatening
event and has responded with intense fear
hopelessness or horror The personrsquos response to the event occurred
more
than 4 weeks after it was experienced and lasted
more than one month The traumatic event is persistently re
experienced
in several ways eg by intrusive recollections
dreams illusions hallucinations or flashbacks
Post traumatic stress disorder PTSD
Post traumatic Stress Disorder- PTSD
Behavioral requirements Thought avoidance related-activities
andor People-avoidance behavior Feelings of detachment Blunted affect Sense of doom Insomnia Irritability Hyper vigilance Exaggerated startle response
Post traumatic Stress Disorder- PTSD
Subdivisions Acute ndash when PTSD is diagnosed between 1 and
3
months after the event occurs it is called acute Chronic - when PTSD continues longer than 3
months it is considered chronic and long term Delayed Onset PTSD-this term is used to
describe
those cases where the symptoms do not occur
immediately after the experience but rather
months or years later
Case 3
Mr A witnessed a friend die in a MVA six
weeks ago and co frequent nightmares
of the accident poor sleep fears of
driving anxiety around highways
anhedonia and decreased affection
highways towards his girlfriend His
girlfriend also notes that he has been
very irritable and startles easily since the
accident
Post traumatic Stress Disorder- PTSD
10487661048766Exposure to a traumatic event
10487661048766Response involving intense fear
Helplessness and horror
10487661048766Re-experiencing of the traumatic event
Avoidance of stimulipsychological numbing
10487661048766Increased arousal
10487661048766Symptoms greater than 1 month
Separation Anxiety Disorder - SAD
Medical conditions causing anxiety
10487661048766Endocrine conditions
10487661048766Cardiovascular conditions
10487661048766Respiratory conditions
10487661048766Metabolic conditions
10487661048766Neurological conditions
Substances causing anxiety
10487661048766Alcohol Alcohol
10487661048766Amphetamines
10487661048766Caffeine
10487661048766Cannabis
10487661048766Cocaine
10487661048766Hallucinogens
10487661048766Inhalants
10487661048766Phencyclidine
Substances that cause
anxiety (withdrawal)
10487661048766Alcohol
10487661048766Cocaine
10487661048766Sedatives
10487661048766Hypnotics
10487661048766Anxiolytics
Medications causing anxiety
Anesthetics
Analgesics
Sympathomimetics
Bronchodilators
Anti-cholinergics
1048766Insulin
Thyroid hormones
Oral contraceptives
Antihistamines
Anti-parkinsonians
1048766Corticosteroids
Antihypertensives
Cardiovascular drugs
Anticonvulsants
Anxiety Disorders
Current Management Strategies
Management of Anxiety Disorders
1048766 Pharmacotherapy (Medications)
Psycho-analytic therapy ndash PT
Behavior Therapy - BT
Cognitive Behavior Therapy ndash CBT
Computer therapy - CT
1048766 Virtual Realty ndash VR
Mood GYM
Drug Rx of Anxiety Disorders
Clonazepam
How do anxiolytics act
GABA and Glycine are inhibitory neurotransmitter
Serotonin and Noradrenaline are excitatory
Anxiety is increased excitatory transmitters
BZNs increase GABA and increase inhibition
SSRI decrease the serotonin levels and darrexcitation
TCAs act by darrboth serotonin and noradrenaline
Drug Rx of Anxiety Disorders
Disorder First Choice 2nd Choice Short (prn) Add on
GADBZN-
CZ CDZ ALZBeta-blockers Buspirone Carbamazp
Panic Disorder
Paroxetine
CitalopramTCA-
ClomipramineBZN-
ALZ CZ LZMAOI -
Phenelzine
Phobias Beta-blockers SSRIsBZN-
ALZ CZMAOI
OCD Clomipramine Fluoxetine CDZ Buspirone
PTSDTCA-
Imipra Amytrp
SSRI- FLX
Sertaline CPBZN MAOI
Comparison of Benzodiazepines
BZN Sedation Anxiolytic Half life Lipid solu Dose
Diazepam +++ + 20-80 h High 5 mg od
Alprazolam + +++ 6-20 h Low 05 mg qid
Clonazapam ++ +++ 22-50 h Low 05 mg bid
Lorazepam ++ ++ 10-20 h Med 1 mg tid
Chlordiazepx + + 7-30 h Med 15 mg bid
Different strategies of therapy
Behavior therapy
Desensitization
Behavior modification
Behavioral activation
Cognitive therapy
Rational-emotive therapy
Beckrsquos cognitive therapy
Newer approaches
Mindfulness meditation
Acceptance and commitment therapy
Dialectical Behavior Therapy (BPD)
Cognitive Behaviour Therapy - CBT
CBT is a method used to treat anxiety
Recognition of ldquodistorted thinkingrdquo
ldquoCognitive restructuringrdquo
It may also involve classical conditioning when used to treat Obsessive Compulsive Disorder
CBT ndash Obstacles - Restructuring
Hopelessness
Self-criticism
Fear of getting worse
Shame and embarrassment
Partial exposure
Blaming other people
Low motivation
Looking for complex solution
Depressing ruminations
There must be an easier way
Computer Therapy
Pts are ashamed to seek help and may fear the consequences at work and home
Therapy is expensive and beyond the reach of many patients
Computer therapy is very cheap and available by comparison
Computer Therapy ndash Softwares
Fearfighter - for phobiapanic
Cope - for depressionanxiety
Balance - for GAD
BTSteps - for OCD
These are PC based in a CD-Rom
or phone based or Web-based
MENTAL OUTSIDE
Virtual Reality - VR
VR therapy via SD (Systematic Desensitization) is becoming very popular
SD is a process of gradually introducing a disturbing stimulus (eg view from a high place) in otherwise pleasant surroundings
This process gradually suppresses the anxiety response
Virtual Reality ndash VR - Advantages
Patients often have difficulty imagining the stimulus themselves
They are often afraid of experiencing it directly ndash which may also be expensive and time-consuming
VR affords patient privacy and confidentiality during treatment
Very good for phobias
Virtual Reality ndash VR - Imagination
ldquoProjection in timerdquo ndash rationally reconstructing the future
ldquoDe-catastrophizing an imagerdquo ndash modifying a disturbing image
ldquoImage modeling and substitutionrdquo ndashinterrupting a negative train of images
ldquoCovert conditioningrdquo ndash subtle conditioning using imagined rather than real stimuli
Virtual Reality ndash VR - Hutchworld
Hutchworld is a virtual community attached to the Hutchison Cancer Research Center
Designed to provide social support for cancer patients and their families
Based on Microsoftrsquos Vworldrsquos system
Mood GYM on the Internet
Few GPs are trained in CBT
Clinical psychologists are expensive
Young people are not easily reached
They may not want them ndash embarrassment
The web is accessible convenient and popular
with young people
Deliver CBT via internet ndash 5 modules
Mood GYM Modules
5 Modules - analysis and results
1 Essentials of CBT with examples and interactive exercises
2 Warpy Thoughts Questionnaire Identifying dysfunctional thoughts Methods to contest such thoughts
3 Other methods for overcoming warpy thoughts
4 Life Event Stress Relaxation meditation music Pleasant Events Schedule parental style
5 Simple problem solving responses to relationship break-up
Web stats summary
Sessions
Take home points
10487661048766Anxiety disorders are very common
10487661048766Just as fevers these are of different types
10487661048766Accurate Dx and Rx by GP is essential
10487661048766Depression and substance abuse potential
Minimum of six weeks to see Rx effect
Prolonged Rx is necessary 6 m or more
Drug Rx is only a small part of management
SSRI TCAs BZNs MAOIs szlig-blockers etc
CBT Computer treatment VRs Mood GYM
Thank You All Visit us at
wwwdrsarmain
This is sponsored by Torrent ndash
Makers of Clonotril (Clonazepam)
Spectrum of Anxiety Disorders
0 1 2 3 4 5
PANIC D
AGORAPH
OCD
GAD
PTSD
SocPHOB
SpecPHOB
Percent
httpwwwnimhnihgovpublicatanxietycfm
What is Gen Anxiety Disorder Anxiety Disorders are characterized by
persistent fear and anxiety that occurs too
often is too severe is triggered too easily or
lasts too long
The ldquoWhat ifrdquo disorder
Compared with others with anxiety
disorders persons with GAD have a better
ability to maintain normal work and social
relationships in spite of their distress
Domains of anxiety
10487661048766Physical
10487661048766Affective
10487661048766Cognitive
10487661048766Behavioral
Physical domain
10487661048766 Anorexia
10487661048766 Butterflies in stomach
10487661048766 Chest paintightness
10487661048766 Diaphoresis
10487661048766 Dry mouth
10487661048766 Dyspnoea
10487661048766 Faintness
10487661048766 Flushing
10487661048766 Hyperventilation
10487661048766 Light-headedness
10487661048766 Muscle tension
10487661048766 Nausea Vomiting
10487661048766 Pallor
10487661048766 Palpitations
10487661048766 Paresthesias
10487661048766 Sexual dysfunction
Physical domain contd
10487661048766 Headache
10487661048766 Shortness of breath
10487661048766 Stomach pain
10487661048766 Tachycardia
10487661048766 Tremulousness
10487661048766 Urinary frequency
10487661048766 Diarrhea
Affective domain
10487661048766 Edginess
10487661048766 Uneasiness
10487661048766 Terror
10487661048766 Panic
Behavioral domain
10487661048766 Triggers many responses
10487661048766 Behavioral in nature
10487661048766 Concerned with diminishing
10487661048766 And even avoiding the distress
Regulation of locus ceruleus
10487661048766Alpha-noradrenergic auto receptors
10487661048766Serotonin receptors
10487661048766GABA-benzodiazepine receptors
10487661048766Opiate receptors
Dopamine receptors
The amygdala and locus ceruleus
Generalized Anxiety Disorder -GADPathological anxiety which
is
excessive chronic and
typically interferes with their ability to function in normal daily activities
GAD is distinguished from Phobic anxiety ndash as it is not triggered by a specific object
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
Excessive anxiety and worry occurring more days than not for at least 6 months about a number of events The person finds it difficult to control the anxiety and worry and has associated three (or more) of the above six symptoms
Case 1
Ms D has a chief co ldquoworrying about
everythingrdquo for the last year She also co
frequent headaches fatigue and
insomnia secondary to the anxiety
These symptoms have worsened to the
point where she has been distracted and
making mistakes at work
Worry that is 1048766 Excessive uncontrollable 1048766 Frequent multiple topics (not only
onetime) 1048766 More than one day out of two
3 out of 6 other associated physical symptoms
1048766 Muscle tension Restlessness 1048766 Fatigued easily Irritability 1048766 Sleep disturbance Concentration
difficulty
GAD ndash Mr Fisc
Acute fear state
10487661048766Response to life-threatening danger
10487661048766Terror helplessness
Sense of impending disasterdoom
10487661048766Urgency to flee or seek safety
10487661048766SympatheticNor-adrenergic activation
10487661048766Located in locus ceruleus
1048766 Corresponds to panic attacks
Agoraphobia
Anxiety in situations where escape might be
difficult (or embarrassing) or help might not be
available in the event of having a panic attack or
panic-like symptoms
Situations are avoided or endured with marked
distress
May not leave home or may need a companion
Can occur with and without panic disorder
Agoraphobia
Social Phobia
Marked persistent fear of social or performance
situations where a person is exposed to unfamiliar
situations or people or possible scrutiny by others
The individual fears acting in an embarrassing or
humiliating way
The Person recognizes fear as excessive
Exposure causes anxiety symptoms or panic
Situations are avoided or endured with anxiety
Specific Phobias
Marked and persistent fear that is excessive or unreasonable
cued by the presence or anticipation of a specific object or
situation (eg flying heights animals receiving an injection
seeing blood)
Exposure to the phobic stimulus almost invariably provokes an
immediate anxiety response which may take the form of a
Panic Attack
The person recognizes that hisher fear is excessive or
unreasonable The phobic situation is avoided or else is
endured with intense anxiety or distress
Specific Phobias - Examples
Acrophobia fear of heights
Agoraphobia fear of open places
Claustrophobia fear of enclosed places
Ailurophobia fear of cats
Cynophobia fear of dogs
Pathophobia fear of disease
Mysophobia fear of dirt and germs
Arachnophobia fear of spiders
Hematophobia fear of blood
Xenophobia fear of strangers
Better-halfophobia fear of wife
PAN ndash The Greek God
Panic Attack ndash DSM IV
1 1048766 Palpitations
2 Sweating
3 Trembling or shaking
4 Shortness of breath
5 Feeling of choking
6 Chest pain or discomfort
7 Nausea or abd distress
8 Feeling dizzy fainty
9 Derealization (feelings of unreality)
10 Fear of going crazy
11 Fear of dying
12 Paresthesias
13 Chills or hot flushes
10487661048766A discrete period of intense fear or discomfort in which 4 (or more) of the above 13 symptoms develop abruptly and reach a peak within 10 minutes
Case 2
Mrs B co a long ho episodes of anxiety
SOB racing heart sweating CP and
fears that she is having a MI and will die
These last 30 minutes and are
unexpected She co anxiety while in
malls and traveling alone to new places
for fear of having another attack Despite
a negative wu she still worries about
having a MI during an attack
Panic Disorder with Agoraphobia
Recurrent unexpected panic attacks anxiety
associated with at least four physical andor
cognitive symptoms cognitive symptoms
At least 1 month of worry about having additional
attacks or the consequences of an attack (losing
control having a heart attack ldquogoing crazyrdquo)
Agoraphobia
Panic Disorder ndash Chest pain
Chest pain is a common symptom of panic
attacks
22 ndash 70 of panic attacks are associated with
CP
18 ndash 25 of all patients with chest pain have
PD
Rates of PD higher among cardiology
outpatients with chest pain
Such patients undergo expensive cardiac
workups but their PD remains undiagnosed amp
untreated
Obsessive Compulsive Disorder - OCD
Obsessions Recurrent and persistent thoughts impulses or
images
that are experienced during the disturbance as intrusive
and inappropriate and cause marked 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 to neutralize them with some other thought or action
The person recognizes that the obsessive thoughts
impulses or images are a product of his or her own mind
Obsessive Compulsive Disorder -OCD
Compulsions Repetitive behaviors (eg hand washing ordering
checking) or mental acts (eg praying counting repeating
words silently)
Heshe is driven to perform in response to an obsession
The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event
But these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent and are clearly excessive
Obsessive Compulsive Disorder -OCD
Putamen
Globus Pallidus
Caudate Nucleus
Thalamus
Orbital frontal
cortex
Post traumatic Stress Disorder- PTSD
Post traumatic Stress Disorder- PTSD
Experiential requirements The person has experienced a life-threatening
event and has responded with intense fear
hopelessness or horror The personrsquos response to the event occurred
more
than 4 weeks after it was experienced and lasted
more than one month The traumatic event is persistently re
experienced
in several ways eg by intrusive recollections
dreams illusions hallucinations or flashbacks
Post traumatic stress disorder PTSD
Post traumatic Stress Disorder- PTSD
Behavioral requirements Thought avoidance related-activities
andor People-avoidance behavior Feelings of detachment Blunted affect Sense of doom Insomnia Irritability Hyper vigilance Exaggerated startle response
Post traumatic Stress Disorder- PTSD
Subdivisions Acute ndash when PTSD is diagnosed between 1 and
3
months after the event occurs it is called acute Chronic - when PTSD continues longer than 3
months it is considered chronic and long term Delayed Onset PTSD-this term is used to
describe
those cases where the symptoms do not occur
immediately after the experience but rather
months or years later
Case 3
Mr A witnessed a friend die in a MVA six
weeks ago and co frequent nightmares
of the accident poor sleep fears of
driving anxiety around highways
anhedonia and decreased affection
highways towards his girlfriend His
girlfriend also notes that he has been
very irritable and startles easily since the
accident
Post traumatic Stress Disorder- PTSD
10487661048766Exposure to a traumatic event
10487661048766Response involving intense fear
Helplessness and horror
10487661048766Re-experiencing of the traumatic event
Avoidance of stimulipsychological numbing
10487661048766Increased arousal
10487661048766Symptoms greater than 1 month
Separation Anxiety Disorder - SAD
Medical conditions causing anxiety
10487661048766Endocrine conditions
10487661048766Cardiovascular conditions
10487661048766Respiratory conditions
10487661048766Metabolic conditions
10487661048766Neurological conditions
Substances causing anxiety
10487661048766Alcohol Alcohol
10487661048766Amphetamines
10487661048766Caffeine
10487661048766Cannabis
10487661048766Cocaine
10487661048766Hallucinogens
10487661048766Inhalants
10487661048766Phencyclidine
Substances that cause
anxiety (withdrawal)
10487661048766Alcohol
10487661048766Cocaine
10487661048766Sedatives
10487661048766Hypnotics
10487661048766Anxiolytics
Medications causing anxiety
Anesthetics
Analgesics
Sympathomimetics
Bronchodilators
Anti-cholinergics
1048766Insulin
Thyroid hormones
Oral contraceptives
Antihistamines
Anti-parkinsonians
1048766Corticosteroids
Antihypertensives
Cardiovascular drugs
Anticonvulsants
Anxiety Disorders
Current Management Strategies
Management of Anxiety Disorders
1048766 Pharmacotherapy (Medications)
Psycho-analytic therapy ndash PT
Behavior Therapy - BT
Cognitive Behavior Therapy ndash CBT
Computer therapy - CT
1048766 Virtual Realty ndash VR
Mood GYM
Drug Rx of Anxiety Disorders
Clonazepam
How do anxiolytics act
GABA and Glycine are inhibitory neurotransmitter
Serotonin and Noradrenaline are excitatory
Anxiety is increased excitatory transmitters
BZNs increase GABA and increase inhibition
SSRI decrease the serotonin levels and darrexcitation
TCAs act by darrboth serotonin and noradrenaline
Drug Rx of Anxiety Disorders
Disorder First Choice 2nd Choice Short (prn) Add on
GADBZN-
CZ CDZ ALZBeta-blockers Buspirone Carbamazp
Panic Disorder
Paroxetine
CitalopramTCA-
ClomipramineBZN-
ALZ CZ LZMAOI -
Phenelzine
Phobias Beta-blockers SSRIsBZN-
ALZ CZMAOI
OCD Clomipramine Fluoxetine CDZ Buspirone
PTSDTCA-
Imipra Amytrp
SSRI- FLX
Sertaline CPBZN MAOI
Comparison of Benzodiazepines
BZN Sedation Anxiolytic Half life Lipid solu Dose
Diazepam +++ + 20-80 h High 5 mg od
Alprazolam + +++ 6-20 h Low 05 mg qid
Clonazapam ++ +++ 22-50 h Low 05 mg bid
Lorazepam ++ ++ 10-20 h Med 1 mg tid
Chlordiazepx + + 7-30 h Med 15 mg bid
Different strategies of therapy
Behavior therapy
Desensitization
Behavior modification
Behavioral activation
Cognitive therapy
Rational-emotive therapy
Beckrsquos cognitive therapy
Newer approaches
Mindfulness meditation
Acceptance and commitment therapy
Dialectical Behavior Therapy (BPD)
Cognitive Behaviour Therapy - CBT
CBT is a method used to treat anxiety
Recognition of ldquodistorted thinkingrdquo
ldquoCognitive restructuringrdquo
It may also involve classical conditioning when used to treat Obsessive Compulsive Disorder
CBT ndash Obstacles - Restructuring
Hopelessness
Self-criticism
Fear of getting worse
Shame and embarrassment
Partial exposure
Blaming other people
Low motivation
Looking for complex solution
Depressing ruminations
There must be an easier way
Computer Therapy
Pts are ashamed to seek help and may fear the consequences at work and home
Therapy is expensive and beyond the reach of many patients
Computer therapy is very cheap and available by comparison
Computer Therapy ndash Softwares
Fearfighter - for phobiapanic
Cope - for depressionanxiety
Balance - for GAD
BTSteps - for OCD
These are PC based in a CD-Rom
or phone based or Web-based
MENTAL OUTSIDE
Virtual Reality - VR
VR therapy via SD (Systematic Desensitization) is becoming very popular
SD is a process of gradually introducing a disturbing stimulus (eg view from a high place) in otherwise pleasant surroundings
This process gradually suppresses the anxiety response
Virtual Reality ndash VR - Advantages
Patients often have difficulty imagining the stimulus themselves
They are often afraid of experiencing it directly ndash which may also be expensive and time-consuming
VR affords patient privacy and confidentiality during treatment
Very good for phobias
Virtual Reality ndash VR - Imagination
ldquoProjection in timerdquo ndash rationally reconstructing the future
ldquoDe-catastrophizing an imagerdquo ndash modifying a disturbing image
ldquoImage modeling and substitutionrdquo ndashinterrupting a negative train of images
ldquoCovert conditioningrdquo ndash subtle conditioning using imagined rather than real stimuli
Virtual Reality ndash VR - Hutchworld
Hutchworld is a virtual community attached to the Hutchison Cancer Research Center
Designed to provide social support for cancer patients and their families
Based on Microsoftrsquos Vworldrsquos system
Mood GYM on the Internet
Few GPs are trained in CBT
Clinical psychologists are expensive
Young people are not easily reached
They may not want them ndash embarrassment
The web is accessible convenient and popular
with young people
Deliver CBT via internet ndash 5 modules
Mood GYM Modules
5 Modules - analysis and results
1 Essentials of CBT with examples and interactive exercises
2 Warpy Thoughts Questionnaire Identifying dysfunctional thoughts Methods to contest such thoughts
3 Other methods for overcoming warpy thoughts
4 Life Event Stress Relaxation meditation music Pleasant Events Schedule parental style
5 Simple problem solving responses to relationship break-up
Web stats summary
Sessions
Take home points
10487661048766Anxiety disorders are very common
10487661048766Just as fevers these are of different types
10487661048766Accurate Dx and Rx by GP is essential
10487661048766Depression and substance abuse potential
Minimum of six weeks to see Rx effect
Prolonged Rx is necessary 6 m or more
Drug Rx is only a small part of management
SSRI TCAs BZNs MAOIs szlig-blockers etc
CBT Computer treatment VRs Mood GYM
Thank You All Visit us at
wwwdrsarmain
This is sponsored by Torrent ndash
Makers of Clonotril (Clonazepam)
What is Gen Anxiety Disorder Anxiety Disorders are characterized by
persistent fear and anxiety that occurs too
often is too severe is triggered too easily or
lasts too long
The ldquoWhat ifrdquo disorder
Compared with others with anxiety
disorders persons with GAD have a better
ability to maintain normal work and social
relationships in spite of their distress
Domains of anxiety
10487661048766Physical
10487661048766Affective
10487661048766Cognitive
10487661048766Behavioral
Physical domain
10487661048766 Anorexia
10487661048766 Butterflies in stomach
10487661048766 Chest paintightness
10487661048766 Diaphoresis
10487661048766 Dry mouth
10487661048766 Dyspnoea
10487661048766 Faintness
10487661048766 Flushing
10487661048766 Hyperventilation
10487661048766 Light-headedness
10487661048766 Muscle tension
10487661048766 Nausea Vomiting
10487661048766 Pallor
10487661048766 Palpitations
10487661048766 Paresthesias
10487661048766 Sexual dysfunction
Physical domain contd
10487661048766 Headache
10487661048766 Shortness of breath
10487661048766 Stomach pain
10487661048766 Tachycardia
10487661048766 Tremulousness
10487661048766 Urinary frequency
10487661048766 Diarrhea
Affective domain
10487661048766 Edginess
10487661048766 Uneasiness
10487661048766 Terror
10487661048766 Panic
Behavioral domain
10487661048766 Triggers many responses
10487661048766 Behavioral in nature
10487661048766 Concerned with diminishing
10487661048766 And even avoiding the distress
Regulation of locus ceruleus
10487661048766Alpha-noradrenergic auto receptors
10487661048766Serotonin receptors
10487661048766GABA-benzodiazepine receptors
10487661048766Opiate receptors
Dopamine receptors
The amygdala and locus ceruleus
Generalized Anxiety Disorder -GADPathological anxiety which
is
excessive chronic and
typically interferes with their ability to function in normal daily activities
GAD is distinguished from Phobic anxiety ndash as it is not triggered by a specific object
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
Excessive anxiety and worry occurring more days than not for at least 6 months about a number of events The person finds it difficult to control the anxiety and worry and has associated three (or more) of the above six symptoms
Case 1
Ms D has a chief co ldquoworrying about
everythingrdquo for the last year She also co
frequent headaches fatigue and
insomnia secondary to the anxiety
These symptoms have worsened to the
point where she has been distracted and
making mistakes at work
Worry that is 1048766 Excessive uncontrollable 1048766 Frequent multiple topics (not only
onetime) 1048766 More than one day out of two
3 out of 6 other associated physical symptoms
1048766 Muscle tension Restlessness 1048766 Fatigued easily Irritability 1048766 Sleep disturbance Concentration
difficulty
GAD ndash Mr Fisc
Acute fear state
10487661048766Response to life-threatening danger
10487661048766Terror helplessness
Sense of impending disasterdoom
10487661048766Urgency to flee or seek safety
10487661048766SympatheticNor-adrenergic activation
10487661048766Located in locus ceruleus
1048766 Corresponds to panic attacks
Agoraphobia
Anxiety in situations where escape might be
difficult (or embarrassing) or help might not be
available in the event of having a panic attack or
panic-like symptoms
Situations are avoided or endured with marked
distress
May not leave home or may need a companion
Can occur with and without panic disorder
Agoraphobia
Social Phobia
Marked persistent fear of social or performance
situations where a person is exposed to unfamiliar
situations or people or possible scrutiny by others
The individual fears acting in an embarrassing or
humiliating way
The Person recognizes fear as excessive
Exposure causes anxiety symptoms or panic
Situations are avoided or endured with anxiety
Specific Phobias
Marked and persistent fear that is excessive or unreasonable
cued by the presence or anticipation of a specific object or
situation (eg flying heights animals receiving an injection
seeing blood)
Exposure to the phobic stimulus almost invariably provokes an
immediate anxiety response which may take the form of a
Panic Attack
The person recognizes that hisher fear is excessive or
unreasonable The phobic situation is avoided or else is
endured with intense anxiety or distress
Specific Phobias - Examples
Acrophobia fear of heights
Agoraphobia fear of open places
Claustrophobia fear of enclosed places
Ailurophobia fear of cats
Cynophobia fear of dogs
Pathophobia fear of disease
Mysophobia fear of dirt and germs
Arachnophobia fear of spiders
Hematophobia fear of blood
Xenophobia fear of strangers
Better-halfophobia fear of wife
PAN ndash The Greek God
Panic Attack ndash DSM IV
1 1048766 Palpitations
2 Sweating
3 Trembling or shaking
4 Shortness of breath
5 Feeling of choking
6 Chest pain or discomfort
7 Nausea or abd distress
8 Feeling dizzy fainty
9 Derealization (feelings of unreality)
10 Fear of going crazy
11 Fear of dying
12 Paresthesias
13 Chills or hot flushes
10487661048766A discrete period of intense fear or discomfort in which 4 (or more) of the above 13 symptoms develop abruptly and reach a peak within 10 minutes
Case 2
Mrs B co a long ho episodes of anxiety
SOB racing heart sweating CP and
fears that she is having a MI and will die
These last 30 minutes and are
unexpected She co anxiety while in
malls and traveling alone to new places
for fear of having another attack Despite
a negative wu she still worries about
having a MI during an attack
Panic Disorder with Agoraphobia
Recurrent unexpected panic attacks anxiety
associated with at least four physical andor
cognitive symptoms cognitive symptoms
At least 1 month of worry about having additional
attacks or the consequences of an attack (losing
control having a heart attack ldquogoing crazyrdquo)
Agoraphobia
Panic Disorder ndash Chest pain
Chest pain is a common symptom of panic
attacks
22 ndash 70 of panic attacks are associated with
CP
18 ndash 25 of all patients with chest pain have
PD
Rates of PD higher among cardiology
outpatients with chest pain
Such patients undergo expensive cardiac
workups but their PD remains undiagnosed amp
untreated
Obsessive Compulsive Disorder - OCD
Obsessions Recurrent and persistent thoughts impulses or
images
that are experienced during the disturbance as intrusive
and inappropriate and cause marked 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 to neutralize them with some other thought or action
The person recognizes that the obsessive thoughts
impulses or images are a product of his or her own mind
Obsessive Compulsive Disorder -OCD
Compulsions Repetitive behaviors (eg hand washing ordering
checking) or mental acts (eg praying counting repeating
words silently)
Heshe is driven to perform in response to an obsession
The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event
But these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent and are clearly excessive
Obsessive Compulsive Disorder -OCD
Putamen
Globus Pallidus
Caudate Nucleus
Thalamus
Orbital frontal
cortex
Post traumatic Stress Disorder- PTSD
Post traumatic Stress Disorder- PTSD
Experiential requirements The person has experienced a life-threatening
event and has responded with intense fear
hopelessness or horror The personrsquos response to the event occurred
more
than 4 weeks after it was experienced and lasted
more than one month The traumatic event is persistently re
experienced
in several ways eg by intrusive recollections
dreams illusions hallucinations or flashbacks
Post traumatic stress disorder PTSD
Post traumatic Stress Disorder- PTSD
Behavioral requirements Thought avoidance related-activities
andor People-avoidance behavior Feelings of detachment Blunted affect Sense of doom Insomnia Irritability Hyper vigilance Exaggerated startle response
Post traumatic Stress Disorder- PTSD
Subdivisions Acute ndash when PTSD is diagnosed between 1 and
3
months after the event occurs it is called acute Chronic - when PTSD continues longer than 3
months it is considered chronic and long term Delayed Onset PTSD-this term is used to
describe
those cases where the symptoms do not occur
immediately after the experience but rather
months or years later
Case 3
Mr A witnessed a friend die in a MVA six
weeks ago and co frequent nightmares
of the accident poor sleep fears of
driving anxiety around highways
anhedonia and decreased affection
highways towards his girlfriend His
girlfriend also notes that he has been
very irritable and startles easily since the
accident
Post traumatic Stress Disorder- PTSD
10487661048766Exposure to a traumatic event
10487661048766Response involving intense fear
Helplessness and horror
10487661048766Re-experiencing of the traumatic event
Avoidance of stimulipsychological numbing
10487661048766Increased arousal
10487661048766Symptoms greater than 1 month
Separation Anxiety Disorder - SAD
Medical conditions causing anxiety
10487661048766Endocrine conditions
10487661048766Cardiovascular conditions
10487661048766Respiratory conditions
10487661048766Metabolic conditions
10487661048766Neurological conditions
Substances causing anxiety
10487661048766Alcohol Alcohol
10487661048766Amphetamines
10487661048766Caffeine
10487661048766Cannabis
10487661048766Cocaine
10487661048766Hallucinogens
10487661048766Inhalants
10487661048766Phencyclidine
Substances that cause
anxiety (withdrawal)
10487661048766Alcohol
10487661048766Cocaine
10487661048766Sedatives
10487661048766Hypnotics
10487661048766Anxiolytics
Medications causing anxiety
Anesthetics
Analgesics
Sympathomimetics
Bronchodilators
Anti-cholinergics
1048766Insulin
Thyroid hormones
Oral contraceptives
Antihistamines
Anti-parkinsonians
1048766Corticosteroids
Antihypertensives
Cardiovascular drugs
Anticonvulsants
Anxiety Disorders
Current Management Strategies
Management of Anxiety Disorders
1048766 Pharmacotherapy (Medications)
Psycho-analytic therapy ndash PT
Behavior Therapy - BT
Cognitive Behavior Therapy ndash CBT
Computer therapy - CT
1048766 Virtual Realty ndash VR
Mood GYM
Drug Rx of Anxiety Disorders
Clonazepam
How do anxiolytics act
GABA and Glycine are inhibitory neurotransmitter
Serotonin and Noradrenaline are excitatory
Anxiety is increased excitatory transmitters
BZNs increase GABA and increase inhibition
SSRI decrease the serotonin levels and darrexcitation
TCAs act by darrboth serotonin and noradrenaline
Drug Rx of Anxiety Disorders
Disorder First Choice 2nd Choice Short (prn) Add on
GADBZN-
CZ CDZ ALZBeta-blockers Buspirone Carbamazp
Panic Disorder
Paroxetine
CitalopramTCA-
ClomipramineBZN-
ALZ CZ LZMAOI -
Phenelzine
Phobias Beta-blockers SSRIsBZN-
ALZ CZMAOI
OCD Clomipramine Fluoxetine CDZ Buspirone
PTSDTCA-
Imipra Amytrp
SSRI- FLX
Sertaline CPBZN MAOI
Comparison of Benzodiazepines
BZN Sedation Anxiolytic Half life Lipid solu Dose
Diazepam +++ + 20-80 h High 5 mg od
Alprazolam + +++ 6-20 h Low 05 mg qid
Clonazapam ++ +++ 22-50 h Low 05 mg bid
Lorazepam ++ ++ 10-20 h Med 1 mg tid
Chlordiazepx + + 7-30 h Med 15 mg bid
Different strategies of therapy
Behavior therapy
Desensitization
Behavior modification
Behavioral activation
Cognitive therapy
Rational-emotive therapy
Beckrsquos cognitive therapy
Newer approaches
Mindfulness meditation
Acceptance and commitment therapy
Dialectical Behavior Therapy (BPD)
Cognitive Behaviour Therapy - CBT
CBT is a method used to treat anxiety
Recognition of ldquodistorted thinkingrdquo
ldquoCognitive restructuringrdquo
It may also involve classical conditioning when used to treat Obsessive Compulsive Disorder
CBT ndash Obstacles - Restructuring
Hopelessness
Self-criticism
Fear of getting worse
Shame and embarrassment
Partial exposure
Blaming other people
Low motivation
Looking for complex solution
Depressing ruminations
There must be an easier way
Computer Therapy
Pts are ashamed to seek help and may fear the consequences at work and home
Therapy is expensive and beyond the reach of many patients
Computer therapy is very cheap and available by comparison
Computer Therapy ndash Softwares
Fearfighter - for phobiapanic
Cope - for depressionanxiety
Balance - for GAD
BTSteps - for OCD
These are PC based in a CD-Rom
or phone based or Web-based
MENTAL OUTSIDE
Virtual Reality - VR
VR therapy via SD (Systematic Desensitization) is becoming very popular
SD is a process of gradually introducing a disturbing stimulus (eg view from a high place) in otherwise pleasant surroundings
This process gradually suppresses the anxiety response
Virtual Reality ndash VR - Advantages
Patients often have difficulty imagining the stimulus themselves
They are often afraid of experiencing it directly ndash which may also be expensive and time-consuming
VR affords patient privacy and confidentiality during treatment
Very good for phobias
Virtual Reality ndash VR - Imagination
ldquoProjection in timerdquo ndash rationally reconstructing the future
ldquoDe-catastrophizing an imagerdquo ndash modifying a disturbing image
ldquoImage modeling and substitutionrdquo ndashinterrupting a negative train of images
ldquoCovert conditioningrdquo ndash subtle conditioning using imagined rather than real stimuli
Virtual Reality ndash VR - Hutchworld
Hutchworld is a virtual community attached to the Hutchison Cancer Research Center
Designed to provide social support for cancer patients and their families
Based on Microsoftrsquos Vworldrsquos system
Mood GYM on the Internet
Few GPs are trained in CBT
Clinical psychologists are expensive
Young people are not easily reached
They may not want them ndash embarrassment
The web is accessible convenient and popular
with young people
Deliver CBT via internet ndash 5 modules
Mood GYM Modules
5 Modules - analysis and results
1 Essentials of CBT with examples and interactive exercises
2 Warpy Thoughts Questionnaire Identifying dysfunctional thoughts Methods to contest such thoughts
3 Other methods for overcoming warpy thoughts
4 Life Event Stress Relaxation meditation music Pleasant Events Schedule parental style
5 Simple problem solving responses to relationship break-up
Web stats summary
Sessions
Take home points
10487661048766Anxiety disorders are very common
10487661048766Just as fevers these are of different types
10487661048766Accurate Dx and Rx by GP is essential
10487661048766Depression and substance abuse potential
Minimum of six weeks to see Rx effect
Prolonged Rx is necessary 6 m or more
Drug Rx is only a small part of management
SSRI TCAs BZNs MAOIs szlig-blockers etc
CBT Computer treatment VRs Mood GYM
Thank You All Visit us at
wwwdrsarmain
This is sponsored by Torrent ndash
Makers of Clonotril (Clonazepam)
Domains of anxiety
10487661048766Physical
10487661048766Affective
10487661048766Cognitive
10487661048766Behavioral
Physical domain
10487661048766 Anorexia
10487661048766 Butterflies in stomach
10487661048766 Chest paintightness
10487661048766 Diaphoresis
10487661048766 Dry mouth
10487661048766 Dyspnoea
10487661048766 Faintness
10487661048766 Flushing
10487661048766 Hyperventilation
10487661048766 Light-headedness
10487661048766 Muscle tension
10487661048766 Nausea Vomiting
10487661048766 Pallor
10487661048766 Palpitations
10487661048766 Paresthesias
10487661048766 Sexual dysfunction
Physical domain contd
10487661048766 Headache
10487661048766 Shortness of breath
10487661048766 Stomach pain
10487661048766 Tachycardia
10487661048766 Tremulousness
10487661048766 Urinary frequency
10487661048766 Diarrhea
Affective domain
10487661048766 Edginess
10487661048766 Uneasiness
10487661048766 Terror
10487661048766 Panic
Behavioral domain
10487661048766 Triggers many responses
10487661048766 Behavioral in nature
10487661048766 Concerned with diminishing
10487661048766 And even avoiding the distress
Regulation of locus ceruleus
10487661048766Alpha-noradrenergic auto receptors
10487661048766Serotonin receptors
10487661048766GABA-benzodiazepine receptors
10487661048766Opiate receptors
Dopamine receptors
The amygdala and locus ceruleus
Generalized Anxiety Disorder -GADPathological anxiety which
is
excessive chronic and
typically interferes with their ability to function in normal daily activities
GAD is distinguished from Phobic anxiety ndash as it is not triggered by a specific object
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
Excessive anxiety and worry occurring more days than not for at least 6 months about a number of events The person finds it difficult to control the anxiety and worry and has associated three (or more) of the above six symptoms
Case 1
Ms D has a chief co ldquoworrying about
everythingrdquo for the last year She also co
frequent headaches fatigue and
insomnia secondary to the anxiety
These symptoms have worsened to the
point where she has been distracted and
making mistakes at work
Worry that is 1048766 Excessive uncontrollable 1048766 Frequent multiple topics (not only
onetime) 1048766 More than one day out of two
3 out of 6 other associated physical symptoms
1048766 Muscle tension Restlessness 1048766 Fatigued easily Irritability 1048766 Sleep disturbance Concentration
difficulty
GAD ndash Mr Fisc
Acute fear state
10487661048766Response to life-threatening danger
10487661048766Terror helplessness
Sense of impending disasterdoom
10487661048766Urgency to flee or seek safety
10487661048766SympatheticNor-adrenergic activation
10487661048766Located in locus ceruleus
1048766 Corresponds to panic attacks
Agoraphobia
Anxiety in situations where escape might be
difficult (or embarrassing) or help might not be
available in the event of having a panic attack or
panic-like symptoms
Situations are avoided or endured with marked
distress
May not leave home or may need a companion
Can occur with and without panic disorder
Agoraphobia
Social Phobia
Marked persistent fear of social or performance
situations where a person is exposed to unfamiliar
situations or people or possible scrutiny by others
The individual fears acting in an embarrassing or
humiliating way
The Person recognizes fear as excessive
Exposure causes anxiety symptoms or panic
Situations are avoided or endured with anxiety
Specific Phobias
Marked and persistent fear that is excessive or unreasonable
cued by the presence or anticipation of a specific object or
situation (eg flying heights animals receiving an injection
seeing blood)
Exposure to the phobic stimulus almost invariably provokes an
immediate anxiety response which may take the form of a
Panic Attack
The person recognizes that hisher fear is excessive or
unreasonable The phobic situation is avoided or else is
endured with intense anxiety or distress
Specific Phobias - Examples
Acrophobia fear of heights
Agoraphobia fear of open places
Claustrophobia fear of enclosed places
Ailurophobia fear of cats
Cynophobia fear of dogs
Pathophobia fear of disease
Mysophobia fear of dirt and germs
Arachnophobia fear of spiders
Hematophobia fear of blood
Xenophobia fear of strangers
Better-halfophobia fear of wife
PAN ndash The Greek God
Panic Attack ndash DSM IV
1 1048766 Palpitations
2 Sweating
3 Trembling or shaking
4 Shortness of breath
5 Feeling of choking
6 Chest pain or discomfort
7 Nausea or abd distress
8 Feeling dizzy fainty
9 Derealization (feelings of unreality)
10 Fear of going crazy
11 Fear of dying
12 Paresthesias
13 Chills or hot flushes
10487661048766A discrete period of intense fear or discomfort in which 4 (or more) of the above 13 symptoms develop abruptly and reach a peak within 10 minutes
Case 2
Mrs B co a long ho episodes of anxiety
SOB racing heart sweating CP and
fears that she is having a MI and will die
These last 30 minutes and are
unexpected She co anxiety while in
malls and traveling alone to new places
for fear of having another attack Despite
a negative wu she still worries about
having a MI during an attack
Panic Disorder with Agoraphobia
Recurrent unexpected panic attacks anxiety
associated with at least four physical andor
cognitive symptoms cognitive symptoms
At least 1 month of worry about having additional
attacks or the consequences of an attack (losing
control having a heart attack ldquogoing crazyrdquo)
Agoraphobia
Panic Disorder ndash Chest pain
Chest pain is a common symptom of panic
attacks
22 ndash 70 of panic attacks are associated with
CP
18 ndash 25 of all patients with chest pain have
PD
Rates of PD higher among cardiology
outpatients with chest pain
Such patients undergo expensive cardiac
workups but their PD remains undiagnosed amp
untreated
Obsessive Compulsive Disorder - OCD
Obsessions Recurrent and persistent thoughts impulses or
images
that are experienced during the disturbance as intrusive
and inappropriate and cause marked 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 to neutralize them with some other thought or action
The person recognizes that the obsessive thoughts
impulses or images are a product of his or her own mind
Obsessive Compulsive Disorder -OCD
Compulsions Repetitive behaviors (eg hand washing ordering
checking) or mental acts (eg praying counting repeating
words silently)
Heshe is driven to perform in response to an obsession
The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event
But these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent and are clearly excessive
Obsessive Compulsive Disorder -OCD
Putamen
Globus Pallidus
Caudate Nucleus
Thalamus
Orbital frontal
cortex
Post traumatic Stress Disorder- PTSD
Post traumatic Stress Disorder- PTSD
Experiential requirements The person has experienced a life-threatening
event and has responded with intense fear
hopelessness or horror The personrsquos response to the event occurred
more
than 4 weeks after it was experienced and lasted
more than one month The traumatic event is persistently re
experienced
in several ways eg by intrusive recollections
dreams illusions hallucinations or flashbacks
Post traumatic stress disorder PTSD
Post traumatic Stress Disorder- PTSD
Behavioral requirements Thought avoidance related-activities
andor People-avoidance behavior Feelings of detachment Blunted affect Sense of doom Insomnia Irritability Hyper vigilance Exaggerated startle response
Post traumatic Stress Disorder- PTSD
Subdivisions Acute ndash when PTSD is diagnosed between 1 and
3
months after the event occurs it is called acute Chronic - when PTSD continues longer than 3
months it is considered chronic and long term Delayed Onset PTSD-this term is used to
describe
those cases where the symptoms do not occur
immediately after the experience but rather
months or years later
Case 3
Mr A witnessed a friend die in a MVA six
weeks ago and co frequent nightmares
of the accident poor sleep fears of
driving anxiety around highways
anhedonia and decreased affection
highways towards his girlfriend His
girlfriend also notes that he has been
very irritable and startles easily since the
accident
Post traumatic Stress Disorder- PTSD
10487661048766Exposure to a traumatic event
10487661048766Response involving intense fear
Helplessness and horror
10487661048766Re-experiencing of the traumatic event
Avoidance of stimulipsychological numbing
10487661048766Increased arousal
10487661048766Symptoms greater than 1 month
Separation Anxiety Disorder - SAD
Medical conditions causing anxiety
10487661048766Endocrine conditions
10487661048766Cardiovascular conditions
10487661048766Respiratory conditions
10487661048766Metabolic conditions
10487661048766Neurological conditions
Substances causing anxiety
10487661048766Alcohol Alcohol
10487661048766Amphetamines
10487661048766Caffeine
10487661048766Cannabis
10487661048766Cocaine
10487661048766Hallucinogens
10487661048766Inhalants
10487661048766Phencyclidine
Substances that cause
anxiety (withdrawal)
10487661048766Alcohol
10487661048766Cocaine
10487661048766Sedatives
10487661048766Hypnotics
10487661048766Anxiolytics
Medications causing anxiety
Anesthetics
Analgesics
Sympathomimetics
Bronchodilators
Anti-cholinergics
1048766Insulin
Thyroid hormones
Oral contraceptives
Antihistamines
Anti-parkinsonians
1048766Corticosteroids
Antihypertensives
Cardiovascular drugs
Anticonvulsants
Anxiety Disorders
Current Management Strategies
Management of Anxiety Disorders
1048766 Pharmacotherapy (Medications)
Psycho-analytic therapy ndash PT
Behavior Therapy - BT
Cognitive Behavior Therapy ndash CBT
Computer therapy - CT
1048766 Virtual Realty ndash VR
Mood GYM
Drug Rx of Anxiety Disorders
Clonazepam
How do anxiolytics act
GABA and Glycine are inhibitory neurotransmitter
Serotonin and Noradrenaline are excitatory
Anxiety is increased excitatory transmitters
BZNs increase GABA and increase inhibition
SSRI decrease the serotonin levels and darrexcitation
TCAs act by darrboth serotonin and noradrenaline
Drug Rx of Anxiety Disorders
Disorder First Choice 2nd Choice Short (prn) Add on
GADBZN-
CZ CDZ ALZBeta-blockers Buspirone Carbamazp
Panic Disorder
Paroxetine
CitalopramTCA-
ClomipramineBZN-
ALZ CZ LZMAOI -
Phenelzine
Phobias Beta-blockers SSRIsBZN-
ALZ CZMAOI
OCD Clomipramine Fluoxetine CDZ Buspirone
PTSDTCA-
Imipra Amytrp
SSRI- FLX
Sertaline CPBZN MAOI
Comparison of Benzodiazepines
BZN Sedation Anxiolytic Half life Lipid solu Dose
Diazepam +++ + 20-80 h High 5 mg od
Alprazolam + +++ 6-20 h Low 05 mg qid
Clonazapam ++ +++ 22-50 h Low 05 mg bid
Lorazepam ++ ++ 10-20 h Med 1 mg tid
Chlordiazepx + + 7-30 h Med 15 mg bid
Different strategies of therapy
Behavior therapy
Desensitization
Behavior modification
Behavioral activation
Cognitive therapy
Rational-emotive therapy
Beckrsquos cognitive therapy
Newer approaches
Mindfulness meditation
Acceptance and commitment therapy
Dialectical Behavior Therapy (BPD)
Cognitive Behaviour Therapy - CBT
CBT is a method used to treat anxiety
Recognition of ldquodistorted thinkingrdquo
ldquoCognitive restructuringrdquo
It may also involve classical conditioning when used to treat Obsessive Compulsive Disorder
CBT ndash Obstacles - Restructuring
Hopelessness
Self-criticism
Fear of getting worse
Shame and embarrassment
Partial exposure
Blaming other people
Low motivation
Looking for complex solution
Depressing ruminations
There must be an easier way
Computer Therapy
Pts are ashamed to seek help and may fear the consequences at work and home
Therapy is expensive and beyond the reach of many patients
Computer therapy is very cheap and available by comparison
Computer Therapy ndash Softwares
Fearfighter - for phobiapanic
Cope - for depressionanxiety
Balance - for GAD
BTSteps - for OCD
These are PC based in a CD-Rom
or phone based or Web-based
MENTAL OUTSIDE
Virtual Reality - VR
VR therapy via SD (Systematic Desensitization) is becoming very popular
SD is a process of gradually introducing a disturbing stimulus (eg view from a high place) in otherwise pleasant surroundings
This process gradually suppresses the anxiety response
Virtual Reality ndash VR - Advantages
Patients often have difficulty imagining the stimulus themselves
They are often afraid of experiencing it directly ndash which may also be expensive and time-consuming
VR affords patient privacy and confidentiality during treatment
Very good for phobias
Virtual Reality ndash VR - Imagination
ldquoProjection in timerdquo ndash rationally reconstructing the future
ldquoDe-catastrophizing an imagerdquo ndash modifying a disturbing image
ldquoImage modeling and substitutionrdquo ndashinterrupting a negative train of images
ldquoCovert conditioningrdquo ndash subtle conditioning using imagined rather than real stimuli
Virtual Reality ndash VR - Hutchworld
Hutchworld is a virtual community attached to the Hutchison Cancer Research Center
Designed to provide social support for cancer patients and their families
Based on Microsoftrsquos Vworldrsquos system
Mood GYM on the Internet
Few GPs are trained in CBT
Clinical psychologists are expensive
Young people are not easily reached
They may not want them ndash embarrassment
The web is accessible convenient and popular
with young people
Deliver CBT via internet ndash 5 modules
Mood GYM Modules
5 Modules - analysis and results
1 Essentials of CBT with examples and interactive exercises
2 Warpy Thoughts Questionnaire Identifying dysfunctional thoughts Methods to contest such thoughts
3 Other methods for overcoming warpy thoughts
4 Life Event Stress Relaxation meditation music Pleasant Events Schedule parental style
5 Simple problem solving responses to relationship break-up
Web stats summary
Sessions
Take home points
10487661048766Anxiety disorders are very common
10487661048766Just as fevers these are of different types
10487661048766Accurate Dx and Rx by GP is essential
10487661048766Depression and substance abuse potential
Minimum of six weeks to see Rx effect
Prolonged Rx is necessary 6 m or more
Drug Rx is only a small part of management
SSRI TCAs BZNs MAOIs szlig-blockers etc
CBT Computer treatment VRs Mood GYM
Thank You All Visit us at
wwwdrsarmain
This is sponsored by Torrent ndash
Makers of Clonotril (Clonazepam)
Physical domain
10487661048766 Anorexia
10487661048766 Butterflies in stomach
10487661048766 Chest paintightness
10487661048766 Diaphoresis
10487661048766 Dry mouth
10487661048766 Dyspnoea
10487661048766 Faintness
10487661048766 Flushing
10487661048766 Hyperventilation
10487661048766 Light-headedness
10487661048766 Muscle tension
10487661048766 Nausea Vomiting
10487661048766 Pallor
10487661048766 Palpitations
10487661048766 Paresthesias
10487661048766 Sexual dysfunction
Physical domain contd
10487661048766 Headache
10487661048766 Shortness of breath
10487661048766 Stomach pain
10487661048766 Tachycardia
10487661048766 Tremulousness
10487661048766 Urinary frequency
10487661048766 Diarrhea
Affective domain
10487661048766 Edginess
10487661048766 Uneasiness
10487661048766 Terror
10487661048766 Panic
Behavioral domain
10487661048766 Triggers many responses
10487661048766 Behavioral in nature
10487661048766 Concerned with diminishing
10487661048766 And even avoiding the distress
Regulation of locus ceruleus
10487661048766Alpha-noradrenergic auto receptors
10487661048766Serotonin receptors
10487661048766GABA-benzodiazepine receptors
10487661048766Opiate receptors
Dopamine receptors
The amygdala and locus ceruleus
Generalized Anxiety Disorder -GADPathological anxiety which
is
excessive chronic and
typically interferes with their ability to function in normal daily activities
GAD is distinguished from Phobic anxiety ndash as it is not triggered by a specific object
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
Excessive anxiety and worry occurring more days than not for at least 6 months about a number of events The person finds it difficult to control the anxiety and worry and has associated three (or more) of the above six symptoms
Case 1
Ms D has a chief co ldquoworrying about
everythingrdquo for the last year She also co
frequent headaches fatigue and
insomnia secondary to the anxiety
These symptoms have worsened to the
point where she has been distracted and
making mistakes at work
Worry that is 1048766 Excessive uncontrollable 1048766 Frequent multiple topics (not only
onetime) 1048766 More than one day out of two
3 out of 6 other associated physical symptoms
1048766 Muscle tension Restlessness 1048766 Fatigued easily Irritability 1048766 Sleep disturbance Concentration
difficulty
GAD ndash Mr Fisc
Acute fear state
10487661048766Response to life-threatening danger
10487661048766Terror helplessness
Sense of impending disasterdoom
10487661048766Urgency to flee or seek safety
10487661048766SympatheticNor-adrenergic activation
10487661048766Located in locus ceruleus
1048766 Corresponds to panic attacks
Agoraphobia
Anxiety in situations where escape might be
difficult (or embarrassing) or help might not be
available in the event of having a panic attack or
panic-like symptoms
Situations are avoided or endured with marked
distress
May not leave home or may need a companion
Can occur with and without panic disorder
Agoraphobia
Social Phobia
Marked persistent fear of social or performance
situations where a person is exposed to unfamiliar
situations or people or possible scrutiny by others
The individual fears acting in an embarrassing or
humiliating way
The Person recognizes fear as excessive
Exposure causes anxiety symptoms or panic
Situations are avoided or endured with anxiety
Specific Phobias
Marked and persistent fear that is excessive or unreasonable
cued by the presence or anticipation of a specific object or
situation (eg flying heights animals receiving an injection
seeing blood)
Exposure to the phobic stimulus almost invariably provokes an
immediate anxiety response which may take the form of a
Panic Attack
The person recognizes that hisher fear is excessive or
unreasonable The phobic situation is avoided or else is
endured with intense anxiety or distress
Specific Phobias - Examples
Acrophobia fear of heights
Agoraphobia fear of open places
Claustrophobia fear of enclosed places
Ailurophobia fear of cats
Cynophobia fear of dogs
Pathophobia fear of disease
Mysophobia fear of dirt and germs
Arachnophobia fear of spiders
Hematophobia fear of blood
Xenophobia fear of strangers
Better-halfophobia fear of wife
PAN ndash The Greek God
Panic Attack ndash DSM IV
1 1048766 Palpitations
2 Sweating
3 Trembling or shaking
4 Shortness of breath
5 Feeling of choking
6 Chest pain or discomfort
7 Nausea or abd distress
8 Feeling dizzy fainty
9 Derealization (feelings of unreality)
10 Fear of going crazy
11 Fear of dying
12 Paresthesias
13 Chills or hot flushes
10487661048766A discrete period of intense fear or discomfort in which 4 (or more) of the above 13 symptoms develop abruptly and reach a peak within 10 minutes
Case 2
Mrs B co a long ho episodes of anxiety
SOB racing heart sweating CP and
fears that she is having a MI and will die
These last 30 minutes and are
unexpected She co anxiety while in
malls and traveling alone to new places
for fear of having another attack Despite
a negative wu she still worries about
having a MI during an attack
Panic Disorder with Agoraphobia
Recurrent unexpected panic attacks anxiety
associated with at least four physical andor
cognitive symptoms cognitive symptoms
At least 1 month of worry about having additional
attacks or the consequences of an attack (losing
control having a heart attack ldquogoing crazyrdquo)
Agoraphobia
Panic Disorder ndash Chest pain
Chest pain is a common symptom of panic
attacks
22 ndash 70 of panic attacks are associated with
CP
18 ndash 25 of all patients with chest pain have
PD
Rates of PD higher among cardiology
outpatients with chest pain
Such patients undergo expensive cardiac
workups but their PD remains undiagnosed amp
untreated
Obsessive Compulsive Disorder - OCD
Obsessions Recurrent and persistent thoughts impulses or
images
that are experienced during the disturbance as intrusive
and inappropriate and cause marked 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 to neutralize them with some other thought or action
The person recognizes that the obsessive thoughts
impulses or images are a product of his or her own mind
Obsessive Compulsive Disorder -OCD
Compulsions Repetitive behaviors (eg hand washing ordering
checking) or mental acts (eg praying counting repeating
words silently)
Heshe is driven to perform in response to an obsession
The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event
But these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent and are clearly excessive
Obsessive Compulsive Disorder -OCD
Putamen
Globus Pallidus
Caudate Nucleus
Thalamus
Orbital frontal
cortex
Post traumatic Stress Disorder- PTSD
Post traumatic Stress Disorder- PTSD
Experiential requirements The person has experienced a life-threatening
event and has responded with intense fear
hopelessness or horror The personrsquos response to the event occurred
more
than 4 weeks after it was experienced and lasted
more than one month The traumatic event is persistently re
experienced
in several ways eg by intrusive recollections
dreams illusions hallucinations or flashbacks
Post traumatic stress disorder PTSD
Post traumatic Stress Disorder- PTSD
Behavioral requirements Thought avoidance related-activities
andor People-avoidance behavior Feelings of detachment Blunted affect Sense of doom Insomnia Irritability Hyper vigilance Exaggerated startle response
Post traumatic Stress Disorder- PTSD
Subdivisions Acute ndash when PTSD is diagnosed between 1 and
3
months after the event occurs it is called acute Chronic - when PTSD continues longer than 3
months it is considered chronic and long term Delayed Onset PTSD-this term is used to
describe
those cases where the symptoms do not occur
immediately after the experience but rather
months or years later
Case 3
Mr A witnessed a friend die in a MVA six
weeks ago and co frequent nightmares
of the accident poor sleep fears of
driving anxiety around highways
anhedonia and decreased affection
highways towards his girlfriend His
girlfriend also notes that he has been
very irritable and startles easily since the
accident
Post traumatic Stress Disorder- PTSD
10487661048766Exposure to a traumatic event
10487661048766Response involving intense fear
Helplessness and horror
10487661048766Re-experiencing of the traumatic event
Avoidance of stimulipsychological numbing
10487661048766Increased arousal
10487661048766Symptoms greater than 1 month
Separation Anxiety Disorder - SAD
Medical conditions causing anxiety
10487661048766Endocrine conditions
10487661048766Cardiovascular conditions
10487661048766Respiratory conditions
10487661048766Metabolic conditions
10487661048766Neurological conditions
Substances causing anxiety
10487661048766Alcohol Alcohol
10487661048766Amphetamines
10487661048766Caffeine
10487661048766Cannabis
10487661048766Cocaine
10487661048766Hallucinogens
10487661048766Inhalants
10487661048766Phencyclidine
Substances that cause
anxiety (withdrawal)
10487661048766Alcohol
10487661048766Cocaine
10487661048766Sedatives
10487661048766Hypnotics
10487661048766Anxiolytics
Medications causing anxiety
Anesthetics
Analgesics
Sympathomimetics
Bronchodilators
Anti-cholinergics
1048766Insulin
Thyroid hormones
Oral contraceptives
Antihistamines
Anti-parkinsonians
1048766Corticosteroids
Antihypertensives
Cardiovascular drugs
Anticonvulsants
Anxiety Disorders
Current Management Strategies
Management of Anxiety Disorders
1048766 Pharmacotherapy (Medications)
Psycho-analytic therapy ndash PT
Behavior Therapy - BT
Cognitive Behavior Therapy ndash CBT
Computer therapy - CT
1048766 Virtual Realty ndash VR
Mood GYM
Drug Rx of Anxiety Disorders
Clonazepam
How do anxiolytics act
GABA and Glycine are inhibitory neurotransmitter
Serotonin and Noradrenaline are excitatory
Anxiety is increased excitatory transmitters
BZNs increase GABA and increase inhibition
SSRI decrease the serotonin levels and darrexcitation
TCAs act by darrboth serotonin and noradrenaline
Drug Rx of Anxiety Disorders
Disorder First Choice 2nd Choice Short (prn) Add on
GADBZN-
CZ CDZ ALZBeta-blockers Buspirone Carbamazp
Panic Disorder
Paroxetine
CitalopramTCA-
ClomipramineBZN-
ALZ CZ LZMAOI -
Phenelzine
Phobias Beta-blockers SSRIsBZN-
ALZ CZMAOI
OCD Clomipramine Fluoxetine CDZ Buspirone
PTSDTCA-
Imipra Amytrp
SSRI- FLX
Sertaline CPBZN MAOI
Comparison of Benzodiazepines
BZN Sedation Anxiolytic Half life Lipid solu Dose
Diazepam +++ + 20-80 h High 5 mg od
Alprazolam + +++ 6-20 h Low 05 mg qid
Clonazapam ++ +++ 22-50 h Low 05 mg bid
Lorazepam ++ ++ 10-20 h Med 1 mg tid
Chlordiazepx + + 7-30 h Med 15 mg bid
Different strategies of therapy
Behavior therapy
Desensitization
Behavior modification
Behavioral activation
Cognitive therapy
Rational-emotive therapy
Beckrsquos cognitive therapy
Newer approaches
Mindfulness meditation
Acceptance and commitment therapy
Dialectical Behavior Therapy (BPD)
Cognitive Behaviour Therapy - CBT
CBT is a method used to treat anxiety
Recognition of ldquodistorted thinkingrdquo
ldquoCognitive restructuringrdquo
It may also involve classical conditioning when used to treat Obsessive Compulsive Disorder
CBT ndash Obstacles - Restructuring
Hopelessness
Self-criticism
Fear of getting worse
Shame and embarrassment
Partial exposure
Blaming other people
Low motivation
Looking for complex solution
Depressing ruminations
There must be an easier way
Computer Therapy
Pts are ashamed to seek help and may fear the consequences at work and home
Therapy is expensive and beyond the reach of many patients
Computer therapy is very cheap and available by comparison
Computer Therapy ndash Softwares
Fearfighter - for phobiapanic
Cope - for depressionanxiety
Balance - for GAD
BTSteps - for OCD
These are PC based in a CD-Rom
or phone based or Web-based
MENTAL OUTSIDE
Virtual Reality - VR
VR therapy via SD (Systematic Desensitization) is becoming very popular
SD is a process of gradually introducing a disturbing stimulus (eg view from a high place) in otherwise pleasant surroundings
This process gradually suppresses the anxiety response
Virtual Reality ndash VR - Advantages
Patients often have difficulty imagining the stimulus themselves
They are often afraid of experiencing it directly ndash which may also be expensive and time-consuming
VR affords patient privacy and confidentiality during treatment
Very good for phobias
Virtual Reality ndash VR - Imagination
ldquoProjection in timerdquo ndash rationally reconstructing the future
ldquoDe-catastrophizing an imagerdquo ndash modifying a disturbing image
ldquoImage modeling and substitutionrdquo ndashinterrupting a negative train of images
ldquoCovert conditioningrdquo ndash subtle conditioning using imagined rather than real stimuli
Virtual Reality ndash VR - Hutchworld
Hutchworld is a virtual community attached to the Hutchison Cancer Research Center
Designed to provide social support for cancer patients and their families
Based on Microsoftrsquos Vworldrsquos system
Mood GYM on the Internet
Few GPs are trained in CBT
Clinical psychologists are expensive
Young people are not easily reached
They may not want them ndash embarrassment
The web is accessible convenient and popular
with young people
Deliver CBT via internet ndash 5 modules
Mood GYM Modules
5 Modules - analysis and results
1 Essentials of CBT with examples and interactive exercises
2 Warpy Thoughts Questionnaire Identifying dysfunctional thoughts Methods to contest such thoughts
3 Other methods for overcoming warpy thoughts
4 Life Event Stress Relaxation meditation music Pleasant Events Schedule parental style
5 Simple problem solving responses to relationship break-up
Web stats summary
Sessions
Take home points
10487661048766Anxiety disorders are very common
10487661048766Just as fevers these are of different types
10487661048766Accurate Dx and Rx by GP is essential
10487661048766Depression and substance abuse potential
Minimum of six weeks to see Rx effect
Prolonged Rx is necessary 6 m or more
Drug Rx is only a small part of management
SSRI TCAs BZNs MAOIs szlig-blockers etc
CBT Computer treatment VRs Mood GYM
Thank You All Visit us at
wwwdrsarmain
This is sponsored by Torrent ndash
Makers of Clonotril (Clonazepam)
Physical domain contd
10487661048766 Headache
10487661048766 Shortness of breath
10487661048766 Stomach pain
10487661048766 Tachycardia
10487661048766 Tremulousness
10487661048766 Urinary frequency
10487661048766 Diarrhea
Affective domain
10487661048766 Edginess
10487661048766 Uneasiness
10487661048766 Terror
10487661048766 Panic
Behavioral domain
10487661048766 Triggers many responses
10487661048766 Behavioral in nature
10487661048766 Concerned with diminishing
10487661048766 And even avoiding the distress
Regulation of locus ceruleus
10487661048766Alpha-noradrenergic auto receptors
10487661048766Serotonin receptors
10487661048766GABA-benzodiazepine receptors
10487661048766Opiate receptors
Dopamine receptors
The amygdala and locus ceruleus
Generalized Anxiety Disorder -GADPathological anxiety which
is
excessive chronic and
typically interferes with their ability to function in normal daily activities
GAD is distinguished from Phobic anxiety ndash as it is not triggered by a specific object
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
Excessive anxiety and worry occurring more days than not for at least 6 months about a number of events The person finds it difficult to control the anxiety and worry and has associated three (or more) of the above six symptoms
Case 1
Ms D has a chief co ldquoworrying about
everythingrdquo for the last year She also co
frequent headaches fatigue and
insomnia secondary to the anxiety
These symptoms have worsened to the
point where she has been distracted and
making mistakes at work
Worry that is 1048766 Excessive uncontrollable 1048766 Frequent multiple topics (not only
onetime) 1048766 More than one day out of two
3 out of 6 other associated physical symptoms
1048766 Muscle tension Restlessness 1048766 Fatigued easily Irritability 1048766 Sleep disturbance Concentration
difficulty
GAD ndash Mr Fisc
Acute fear state
10487661048766Response to life-threatening danger
10487661048766Terror helplessness
Sense of impending disasterdoom
10487661048766Urgency to flee or seek safety
10487661048766SympatheticNor-adrenergic activation
10487661048766Located in locus ceruleus
1048766 Corresponds to panic attacks
Agoraphobia
Anxiety in situations where escape might be
difficult (or embarrassing) or help might not be
available in the event of having a panic attack or
panic-like symptoms
Situations are avoided or endured with marked
distress
May not leave home or may need a companion
Can occur with and without panic disorder
Agoraphobia
Social Phobia
Marked persistent fear of social or performance
situations where a person is exposed to unfamiliar
situations or people or possible scrutiny by others
The individual fears acting in an embarrassing or
humiliating way
The Person recognizes fear as excessive
Exposure causes anxiety symptoms or panic
Situations are avoided or endured with anxiety
Specific Phobias
Marked and persistent fear that is excessive or unreasonable
cued by the presence or anticipation of a specific object or
situation (eg flying heights animals receiving an injection
seeing blood)
Exposure to the phobic stimulus almost invariably provokes an
immediate anxiety response which may take the form of a
Panic Attack
The person recognizes that hisher fear is excessive or
unreasonable The phobic situation is avoided or else is
endured with intense anxiety or distress
Specific Phobias - Examples
Acrophobia fear of heights
Agoraphobia fear of open places
Claustrophobia fear of enclosed places
Ailurophobia fear of cats
Cynophobia fear of dogs
Pathophobia fear of disease
Mysophobia fear of dirt and germs
Arachnophobia fear of spiders
Hematophobia fear of blood
Xenophobia fear of strangers
Better-halfophobia fear of wife
PAN ndash The Greek God
Panic Attack ndash DSM IV
1 1048766 Palpitations
2 Sweating
3 Trembling or shaking
4 Shortness of breath
5 Feeling of choking
6 Chest pain or discomfort
7 Nausea or abd distress
8 Feeling dizzy fainty
9 Derealization (feelings of unreality)
10 Fear of going crazy
11 Fear of dying
12 Paresthesias
13 Chills or hot flushes
10487661048766A discrete period of intense fear or discomfort in which 4 (or more) of the above 13 symptoms develop abruptly and reach a peak within 10 minutes
Case 2
Mrs B co a long ho episodes of anxiety
SOB racing heart sweating CP and
fears that she is having a MI and will die
These last 30 minutes and are
unexpected She co anxiety while in
malls and traveling alone to new places
for fear of having another attack Despite
a negative wu she still worries about
having a MI during an attack
Panic Disorder with Agoraphobia
Recurrent unexpected panic attacks anxiety
associated with at least four physical andor
cognitive symptoms cognitive symptoms
At least 1 month of worry about having additional
attacks or the consequences of an attack (losing
control having a heart attack ldquogoing crazyrdquo)
Agoraphobia
Panic Disorder ndash Chest pain
Chest pain is a common symptom of panic
attacks
22 ndash 70 of panic attacks are associated with
CP
18 ndash 25 of all patients with chest pain have
PD
Rates of PD higher among cardiology
outpatients with chest pain
Such patients undergo expensive cardiac
workups but their PD remains undiagnosed amp
untreated
Obsessive Compulsive Disorder - OCD
Obsessions Recurrent and persistent thoughts impulses or
images
that are experienced during the disturbance as intrusive
and inappropriate and cause marked 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 to neutralize them with some other thought or action
The person recognizes that the obsessive thoughts
impulses or images are a product of his or her own mind
Obsessive Compulsive Disorder -OCD
Compulsions Repetitive behaviors (eg hand washing ordering
checking) or mental acts (eg praying counting repeating
words silently)
Heshe is driven to perform in response to an obsession
The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event
But these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent and are clearly excessive
Obsessive Compulsive Disorder -OCD
Putamen
Globus Pallidus
Caudate Nucleus
Thalamus
Orbital frontal
cortex
Post traumatic Stress Disorder- PTSD
Post traumatic Stress Disorder- PTSD
Experiential requirements The person has experienced a life-threatening
event and has responded with intense fear
hopelessness or horror The personrsquos response to the event occurred
more
than 4 weeks after it was experienced and lasted
more than one month The traumatic event is persistently re
experienced
in several ways eg by intrusive recollections
dreams illusions hallucinations or flashbacks
Post traumatic stress disorder PTSD
Post traumatic Stress Disorder- PTSD
Behavioral requirements Thought avoidance related-activities
andor People-avoidance behavior Feelings of detachment Blunted affect Sense of doom Insomnia Irritability Hyper vigilance Exaggerated startle response
Post traumatic Stress Disorder- PTSD
Subdivisions Acute ndash when PTSD is diagnosed between 1 and
3
months after the event occurs it is called acute Chronic - when PTSD continues longer than 3
months it is considered chronic and long term Delayed Onset PTSD-this term is used to
describe
those cases where the symptoms do not occur
immediately after the experience but rather
months or years later
Case 3
Mr A witnessed a friend die in a MVA six
weeks ago and co frequent nightmares
of the accident poor sleep fears of
driving anxiety around highways
anhedonia and decreased affection
highways towards his girlfriend His
girlfriend also notes that he has been
very irritable and startles easily since the
accident
Post traumatic Stress Disorder- PTSD
10487661048766Exposure to a traumatic event
10487661048766Response involving intense fear
Helplessness and horror
10487661048766Re-experiencing of the traumatic event
Avoidance of stimulipsychological numbing
10487661048766Increased arousal
10487661048766Symptoms greater than 1 month
Separation Anxiety Disorder - SAD
Medical conditions causing anxiety
10487661048766Endocrine conditions
10487661048766Cardiovascular conditions
10487661048766Respiratory conditions
10487661048766Metabolic conditions
10487661048766Neurological conditions
Substances causing anxiety
10487661048766Alcohol Alcohol
10487661048766Amphetamines
10487661048766Caffeine
10487661048766Cannabis
10487661048766Cocaine
10487661048766Hallucinogens
10487661048766Inhalants
10487661048766Phencyclidine
Substances that cause
anxiety (withdrawal)
10487661048766Alcohol
10487661048766Cocaine
10487661048766Sedatives
10487661048766Hypnotics
10487661048766Anxiolytics
Medications causing anxiety
Anesthetics
Analgesics
Sympathomimetics
Bronchodilators
Anti-cholinergics
1048766Insulin
Thyroid hormones
Oral contraceptives
Antihistamines
Anti-parkinsonians
1048766Corticosteroids
Antihypertensives
Cardiovascular drugs
Anticonvulsants
Anxiety Disorders
Current Management Strategies
Management of Anxiety Disorders
1048766 Pharmacotherapy (Medications)
Psycho-analytic therapy ndash PT
Behavior Therapy - BT
Cognitive Behavior Therapy ndash CBT
Computer therapy - CT
1048766 Virtual Realty ndash VR
Mood GYM
Drug Rx of Anxiety Disorders
Clonazepam
How do anxiolytics act
GABA and Glycine are inhibitory neurotransmitter
Serotonin and Noradrenaline are excitatory
Anxiety is increased excitatory transmitters
BZNs increase GABA and increase inhibition
SSRI decrease the serotonin levels and darrexcitation
TCAs act by darrboth serotonin and noradrenaline
Drug Rx of Anxiety Disorders
Disorder First Choice 2nd Choice Short (prn) Add on
GADBZN-
CZ CDZ ALZBeta-blockers Buspirone Carbamazp
Panic Disorder
Paroxetine
CitalopramTCA-
ClomipramineBZN-
ALZ CZ LZMAOI -
Phenelzine
Phobias Beta-blockers SSRIsBZN-
ALZ CZMAOI
OCD Clomipramine Fluoxetine CDZ Buspirone
PTSDTCA-
Imipra Amytrp
SSRI- FLX
Sertaline CPBZN MAOI
Comparison of Benzodiazepines
BZN Sedation Anxiolytic Half life Lipid solu Dose
Diazepam +++ + 20-80 h High 5 mg od
Alprazolam + +++ 6-20 h Low 05 mg qid
Clonazapam ++ +++ 22-50 h Low 05 mg bid
Lorazepam ++ ++ 10-20 h Med 1 mg tid
Chlordiazepx + + 7-30 h Med 15 mg bid
Different strategies of therapy
Behavior therapy
Desensitization
Behavior modification
Behavioral activation
Cognitive therapy
Rational-emotive therapy
Beckrsquos cognitive therapy
Newer approaches
Mindfulness meditation
Acceptance and commitment therapy
Dialectical Behavior Therapy (BPD)
Cognitive Behaviour Therapy - CBT
CBT is a method used to treat anxiety
Recognition of ldquodistorted thinkingrdquo
ldquoCognitive restructuringrdquo
It may also involve classical conditioning when used to treat Obsessive Compulsive Disorder
CBT ndash Obstacles - Restructuring
Hopelessness
Self-criticism
Fear of getting worse
Shame and embarrassment
Partial exposure
Blaming other people
Low motivation
Looking for complex solution
Depressing ruminations
There must be an easier way
Computer Therapy
Pts are ashamed to seek help and may fear the consequences at work and home
Therapy is expensive and beyond the reach of many patients
Computer therapy is very cheap and available by comparison
Computer Therapy ndash Softwares
Fearfighter - for phobiapanic
Cope - for depressionanxiety
Balance - for GAD
BTSteps - for OCD
These are PC based in a CD-Rom
or phone based or Web-based
MENTAL OUTSIDE
Virtual Reality - VR
VR therapy via SD (Systematic Desensitization) is becoming very popular
SD is a process of gradually introducing a disturbing stimulus (eg view from a high place) in otherwise pleasant surroundings
This process gradually suppresses the anxiety response
Virtual Reality ndash VR - Advantages
Patients often have difficulty imagining the stimulus themselves
They are often afraid of experiencing it directly ndash which may also be expensive and time-consuming
VR affords patient privacy and confidentiality during treatment
Very good for phobias
Virtual Reality ndash VR - Imagination
ldquoProjection in timerdquo ndash rationally reconstructing the future
ldquoDe-catastrophizing an imagerdquo ndash modifying a disturbing image
ldquoImage modeling and substitutionrdquo ndashinterrupting a negative train of images
ldquoCovert conditioningrdquo ndash subtle conditioning using imagined rather than real stimuli
Virtual Reality ndash VR - Hutchworld
Hutchworld is a virtual community attached to the Hutchison Cancer Research Center
Designed to provide social support for cancer patients and their families
Based on Microsoftrsquos Vworldrsquos system
Mood GYM on the Internet
Few GPs are trained in CBT
Clinical psychologists are expensive
Young people are not easily reached
They may not want them ndash embarrassment
The web is accessible convenient and popular
with young people
Deliver CBT via internet ndash 5 modules
Mood GYM Modules
5 Modules - analysis and results
1 Essentials of CBT with examples and interactive exercises
2 Warpy Thoughts Questionnaire Identifying dysfunctional thoughts Methods to contest such thoughts
3 Other methods for overcoming warpy thoughts
4 Life Event Stress Relaxation meditation music Pleasant Events Schedule parental style
5 Simple problem solving responses to relationship break-up
Web stats summary
Sessions
Take home points
10487661048766Anxiety disorders are very common
10487661048766Just as fevers these are of different types
10487661048766Accurate Dx and Rx by GP is essential
10487661048766Depression and substance abuse potential
Minimum of six weeks to see Rx effect
Prolonged Rx is necessary 6 m or more
Drug Rx is only a small part of management
SSRI TCAs BZNs MAOIs szlig-blockers etc
CBT Computer treatment VRs Mood GYM
Thank You All Visit us at
wwwdrsarmain
This is sponsored by Torrent ndash
Makers of Clonotril (Clonazepam)
Affective domain
10487661048766 Edginess
10487661048766 Uneasiness
10487661048766 Terror
10487661048766 Panic
Behavioral domain
10487661048766 Triggers many responses
10487661048766 Behavioral in nature
10487661048766 Concerned with diminishing
10487661048766 And even avoiding the distress
Regulation of locus ceruleus
10487661048766Alpha-noradrenergic auto receptors
10487661048766Serotonin receptors
10487661048766GABA-benzodiazepine receptors
10487661048766Opiate receptors
Dopamine receptors
The amygdala and locus ceruleus
Generalized Anxiety Disorder -GADPathological anxiety which
is
excessive chronic and
typically interferes with their ability to function in normal daily activities
GAD is distinguished from Phobic anxiety ndash as it is not triggered by a specific object
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
Excessive anxiety and worry occurring more days than not for at least 6 months about a number of events The person finds it difficult to control the anxiety and worry and has associated three (or more) of the above six symptoms
Case 1
Ms D has a chief co ldquoworrying about
everythingrdquo for the last year She also co
frequent headaches fatigue and
insomnia secondary to the anxiety
These symptoms have worsened to the
point where she has been distracted and
making mistakes at work
Worry that is 1048766 Excessive uncontrollable 1048766 Frequent multiple topics (not only
onetime) 1048766 More than one day out of two
3 out of 6 other associated physical symptoms
1048766 Muscle tension Restlessness 1048766 Fatigued easily Irritability 1048766 Sleep disturbance Concentration
difficulty
GAD ndash Mr Fisc
Acute fear state
10487661048766Response to life-threatening danger
10487661048766Terror helplessness
Sense of impending disasterdoom
10487661048766Urgency to flee or seek safety
10487661048766SympatheticNor-adrenergic activation
10487661048766Located in locus ceruleus
1048766 Corresponds to panic attacks
Agoraphobia
Anxiety in situations where escape might be
difficult (or embarrassing) or help might not be
available in the event of having a panic attack or
panic-like symptoms
Situations are avoided or endured with marked
distress
May not leave home or may need a companion
Can occur with and without panic disorder
Agoraphobia
Social Phobia
Marked persistent fear of social or performance
situations where a person is exposed to unfamiliar
situations or people or possible scrutiny by others
The individual fears acting in an embarrassing or
humiliating way
The Person recognizes fear as excessive
Exposure causes anxiety symptoms or panic
Situations are avoided or endured with anxiety
Specific Phobias
Marked and persistent fear that is excessive or unreasonable
cued by the presence or anticipation of a specific object or
situation (eg flying heights animals receiving an injection
seeing blood)
Exposure to the phobic stimulus almost invariably provokes an
immediate anxiety response which may take the form of a
Panic Attack
The person recognizes that hisher fear is excessive or
unreasonable The phobic situation is avoided or else is
endured with intense anxiety or distress
Specific Phobias - Examples
Acrophobia fear of heights
Agoraphobia fear of open places
Claustrophobia fear of enclosed places
Ailurophobia fear of cats
Cynophobia fear of dogs
Pathophobia fear of disease
Mysophobia fear of dirt and germs
Arachnophobia fear of spiders
Hematophobia fear of blood
Xenophobia fear of strangers
Better-halfophobia fear of wife
PAN ndash The Greek God
Panic Attack ndash DSM IV
1 1048766 Palpitations
2 Sweating
3 Trembling or shaking
4 Shortness of breath
5 Feeling of choking
6 Chest pain or discomfort
7 Nausea or abd distress
8 Feeling dizzy fainty
9 Derealization (feelings of unreality)
10 Fear of going crazy
11 Fear of dying
12 Paresthesias
13 Chills or hot flushes
10487661048766A discrete period of intense fear or discomfort in which 4 (or more) of the above 13 symptoms develop abruptly and reach a peak within 10 minutes
Case 2
Mrs B co a long ho episodes of anxiety
SOB racing heart sweating CP and
fears that she is having a MI and will die
These last 30 minutes and are
unexpected She co anxiety while in
malls and traveling alone to new places
for fear of having another attack Despite
a negative wu she still worries about
having a MI during an attack
Panic Disorder with Agoraphobia
Recurrent unexpected panic attacks anxiety
associated with at least four physical andor
cognitive symptoms cognitive symptoms
At least 1 month of worry about having additional
attacks or the consequences of an attack (losing
control having a heart attack ldquogoing crazyrdquo)
Agoraphobia
Panic Disorder ndash Chest pain
Chest pain is a common symptom of panic
attacks
22 ndash 70 of panic attacks are associated with
CP
18 ndash 25 of all patients with chest pain have
PD
Rates of PD higher among cardiology
outpatients with chest pain
Such patients undergo expensive cardiac
workups but their PD remains undiagnosed amp
untreated
Obsessive Compulsive Disorder - OCD
Obsessions Recurrent and persistent thoughts impulses or
images
that are experienced during the disturbance as intrusive
and inappropriate and cause marked 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 to neutralize them with some other thought or action
The person recognizes that the obsessive thoughts
impulses or images are a product of his or her own mind
Obsessive Compulsive Disorder -OCD
Compulsions Repetitive behaviors (eg hand washing ordering
checking) or mental acts (eg praying counting repeating
words silently)
Heshe is driven to perform in response to an obsession
The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event
But these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent and are clearly excessive
Obsessive Compulsive Disorder -OCD
Putamen
Globus Pallidus
Caudate Nucleus
Thalamus
Orbital frontal
cortex
Post traumatic Stress Disorder- PTSD
Post traumatic Stress Disorder- PTSD
Experiential requirements The person has experienced a life-threatening
event and has responded with intense fear
hopelessness or horror The personrsquos response to the event occurred
more
than 4 weeks after it was experienced and lasted
more than one month The traumatic event is persistently re
experienced
in several ways eg by intrusive recollections
dreams illusions hallucinations or flashbacks
Post traumatic stress disorder PTSD
Post traumatic Stress Disorder- PTSD
Behavioral requirements Thought avoidance related-activities
andor People-avoidance behavior Feelings of detachment Blunted affect Sense of doom Insomnia Irritability Hyper vigilance Exaggerated startle response
Post traumatic Stress Disorder- PTSD
Subdivisions Acute ndash when PTSD is diagnosed between 1 and
3
months after the event occurs it is called acute Chronic - when PTSD continues longer than 3
months it is considered chronic and long term Delayed Onset PTSD-this term is used to
describe
those cases where the symptoms do not occur
immediately after the experience but rather
months or years later
Case 3
Mr A witnessed a friend die in a MVA six
weeks ago and co frequent nightmares
of the accident poor sleep fears of
driving anxiety around highways
anhedonia and decreased affection
highways towards his girlfriend His
girlfriend also notes that he has been
very irritable and startles easily since the
accident
Post traumatic Stress Disorder- PTSD
10487661048766Exposure to a traumatic event
10487661048766Response involving intense fear
Helplessness and horror
10487661048766Re-experiencing of the traumatic event
Avoidance of stimulipsychological numbing
10487661048766Increased arousal
10487661048766Symptoms greater than 1 month
Separation Anxiety Disorder - SAD
Medical conditions causing anxiety
10487661048766Endocrine conditions
10487661048766Cardiovascular conditions
10487661048766Respiratory conditions
10487661048766Metabolic conditions
10487661048766Neurological conditions
Substances causing anxiety
10487661048766Alcohol Alcohol
10487661048766Amphetamines
10487661048766Caffeine
10487661048766Cannabis
10487661048766Cocaine
10487661048766Hallucinogens
10487661048766Inhalants
10487661048766Phencyclidine
Substances that cause
anxiety (withdrawal)
10487661048766Alcohol
10487661048766Cocaine
10487661048766Sedatives
10487661048766Hypnotics
10487661048766Anxiolytics
Medications causing anxiety
Anesthetics
Analgesics
Sympathomimetics
Bronchodilators
Anti-cholinergics
1048766Insulin
Thyroid hormones
Oral contraceptives
Antihistamines
Anti-parkinsonians
1048766Corticosteroids
Antihypertensives
Cardiovascular drugs
Anticonvulsants
Anxiety Disorders
Current Management Strategies
Management of Anxiety Disorders
1048766 Pharmacotherapy (Medications)
Psycho-analytic therapy ndash PT
Behavior Therapy - BT
Cognitive Behavior Therapy ndash CBT
Computer therapy - CT
1048766 Virtual Realty ndash VR
Mood GYM
Drug Rx of Anxiety Disorders
Clonazepam
How do anxiolytics act
GABA and Glycine are inhibitory neurotransmitter
Serotonin and Noradrenaline are excitatory
Anxiety is increased excitatory transmitters
BZNs increase GABA and increase inhibition
SSRI decrease the serotonin levels and darrexcitation
TCAs act by darrboth serotonin and noradrenaline
Drug Rx of Anxiety Disorders
Disorder First Choice 2nd Choice Short (prn) Add on
GADBZN-
CZ CDZ ALZBeta-blockers Buspirone Carbamazp
Panic Disorder
Paroxetine
CitalopramTCA-
ClomipramineBZN-
ALZ CZ LZMAOI -
Phenelzine
Phobias Beta-blockers SSRIsBZN-
ALZ CZMAOI
OCD Clomipramine Fluoxetine CDZ Buspirone
PTSDTCA-
Imipra Amytrp
SSRI- FLX
Sertaline CPBZN MAOI
Comparison of Benzodiazepines
BZN Sedation Anxiolytic Half life Lipid solu Dose
Diazepam +++ + 20-80 h High 5 mg od
Alprazolam + +++ 6-20 h Low 05 mg qid
Clonazapam ++ +++ 22-50 h Low 05 mg bid
Lorazepam ++ ++ 10-20 h Med 1 mg tid
Chlordiazepx + + 7-30 h Med 15 mg bid
Different strategies of therapy
Behavior therapy
Desensitization
Behavior modification
Behavioral activation
Cognitive therapy
Rational-emotive therapy
Beckrsquos cognitive therapy
Newer approaches
Mindfulness meditation
Acceptance and commitment therapy
Dialectical Behavior Therapy (BPD)
Cognitive Behaviour Therapy - CBT
CBT is a method used to treat anxiety
Recognition of ldquodistorted thinkingrdquo
ldquoCognitive restructuringrdquo
It may also involve classical conditioning when used to treat Obsessive Compulsive Disorder
CBT ndash Obstacles - Restructuring
Hopelessness
Self-criticism
Fear of getting worse
Shame and embarrassment
Partial exposure
Blaming other people
Low motivation
Looking for complex solution
Depressing ruminations
There must be an easier way
Computer Therapy
Pts are ashamed to seek help and may fear the consequences at work and home
Therapy is expensive and beyond the reach of many patients
Computer therapy is very cheap and available by comparison
Computer Therapy ndash Softwares
Fearfighter - for phobiapanic
Cope - for depressionanxiety
Balance - for GAD
BTSteps - for OCD
These are PC based in a CD-Rom
or phone based or Web-based
MENTAL OUTSIDE
Virtual Reality - VR
VR therapy via SD (Systematic Desensitization) is becoming very popular
SD is a process of gradually introducing a disturbing stimulus (eg view from a high place) in otherwise pleasant surroundings
This process gradually suppresses the anxiety response
Virtual Reality ndash VR - Advantages
Patients often have difficulty imagining the stimulus themselves
They are often afraid of experiencing it directly ndash which may also be expensive and time-consuming
VR affords patient privacy and confidentiality during treatment
Very good for phobias
Virtual Reality ndash VR - Imagination
ldquoProjection in timerdquo ndash rationally reconstructing the future
ldquoDe-catastrophizing an imagerdquo ndash modifying a disturbing image
ldquoImage modeling and substitutionrdquo ndashinterrupting a negative train of images
ldquoCovert conditioningrdquo ndash subtle conditioning using imagined rather than real stimuli
Virtual Reality ndash VR - Hutchworld
Hutchworld is a virtual community attached to the Hutchison Cancer Research Center
Designed to provide social support for cancer patients and their families
Based on Microsoftrsquos Vworldrsquos system
Mood GYM on the Internet
Few GPs are trained in CBT
Clinical psychologists are expensive
Young people are not easily reached
They may not want them ndash embarrassment
The web is accessible convenient and popular
with young people
Deliver CBT via internet ndash 5 modules
Mood GYM Modules
5 Modules - analysis and results
1 Essentials of CBT with examples and interactive exercises
2 Warpy Thoughts Questionnaire Identifying dysfunctional thoughts Methods to contest such thoughts
3 Other methods for overcoming warpy thoughts
4 Life Event Stress Relaxation meditation music Pleasant Events Schedule parental style
5 Simple problem solving responses to relationship break-up
Web stats summary
Sessions
Take home points
10487661048766Anxiety disorders are very common
10487661048766Just as fevers these are of different types
10487661048766Accurate Dx and Rx by GP is essential
10487661048766Depression and substance abuse potential
Minimum of six weeks to see Rx effect
Prolonged Rx is necessary 6 m or more
Drug Rx is only a small part of management
SSRI TCAs BZNs MAOIs szlig-blockers etc
CBT Computer treatment VRs Mood GYM
Thank You All Visit us at
wwwdrsarmain
This is sponsored by Torrent ndash
Makers of Clonotril (Clonazepam)
Behavioral domain
10487661048766 Triggers many responses
10487661048766 Behavioral in nature
10487661048766 Concerned with diminishing
10487661048766 And even avoiding the distress
Regulation of locus ceruleus
10487661048766Alpha-noradrenergic auto receptors
10487661048766Serotonin receptors
10487661048766GABA-benzodiazepine receptors
10487661048766Opiate receptors
Dopamine receptors
The amygdala and locus ceruleus
Generalized Anxiety Disorder -GADPathological anxiety which
is
excessive chronic and
typically interferes with their ability to function in normal daily activities
GAD is distinguished from Phobic anxiety ndash as it is not triggered by a specific object
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
Excessive anxiety and worry occurring more days than not for at least 6 months about a number of events The person finds it difficult to control the anxiety and worry and has associated three (or more) of the above six symptoms
Case 1
Ms D has a chief co ldquoworrying about
everythingrdquo for the last year She also co
frequent headaches fatigue and
insomnia secondary to the anxiety
These symptoms have worsened to the
point where she has been distracted and
making mistakes at work
Worry that is 1048766 Excessive uncontrollable 1048766 Frequent multiple topics (not only
onetime) 1048766 More than one day out of two
3 out of 6 other associated physical symptoms
1048766 Muscle tension Restlessness 1048766 Fatigued easily Irritability 1048766 Sleep disturbance Concentration
difficulty
GAD ndash Mr Fisc
Acute fear state
10487661048766Response to life-threatening danger
10487661048766Terror helplessness
Sense of impending disasterdoom
10487661048766Urgency to flee or seek safety
10487661048766SympatheticNor-adrenergic activation
10487661048766Located in locus ceruleus
1048766 Corresponds to panic attacks
Agoraphobia
Anxiety in situations where escape might be
difficult (or embarrassing) or help might not be
available in the event of having a panic attack or
panic-like symptoms
Situations are avoided or endured with marked
distress
May not leave home or may need a companion
Can occur with and without panic disorder
Agoraphobia
Social Phobia
Marked persistent fear of social or performance
situations where a person is exposed to unfamiliar
situations or people or possible scrutiny by others
The individual fears acting in an embarrassing or
humiliating way
The Person recognizes fear as excessive
Exposure causes anxiety symptoms or panic
Situations are avoided or endured with anxiety
Specific Phobias
Marked and persistent fear that is excessive or unreasonable
cued by the presence or anticipation of a specific object or
situation (eg flying heights animals receiving an injection
seeing blood)
Exposure to the phobic stimulus almost invariably provokes an
immediate anxiety response which may take the form of a
Panic Attack
The person recognizes that hisher fear is excessive or
unreasonable The phobic situation is avoided or else is
endured with intense anxiety or distress
Specific Phobias - Examples
Acrophobia fear of heights
Agoraphobia fear of open places
Claustrophobia fear of enclosed places
Ailurophobia fear of cats
Cynophobia fear of dogs
Pathophobia fear of disease
Mysophobia fear of dirt and germs
Arachnophobia fear of spiders
Hematophobia fear of blood
Xenophobia fear of strangers
Better-halfophobia fear of wife
PAN ndash The Greek God
Panic Attack ndash DSM IV
1 1048766 Palpitations
2 Sweating
3 Trembling or shaking
4 Shortness of breath
5 Feeling of choking
6 Chest pain or discomfort
7 Nausea or abd distress
8 Feeling dizzy fainty
9 Derealization (feelings of unreality)
10 Fear of going crazy
11 Fear of dying
12 Paresthesias
13 Chills or hot flushes
10487661048766A discrete period of intense fear or discomfort in which 4 (or more) of the above 13 symptoms develop abruptly and reach a peak within 10 minutes
Case 2
Mrs B co a long ho episodes of anxiety
SOB racing heart sweating CP and
fears that she is having a MI and will die
These last 30 minutes and are
unexpected She co anxiety while in
malls and traveling alone to new places
for fear of having another attack Despite
a negative wu she still worries about
having a MI during an attack
Panic Disorder with Agoraphobia
Recurrent unexpected panic attacks anxiety
associated with at least four physical andor
cognitive symptoms cognitive symptoms
At least 1 month of worry about having additional
attacks or the consequences of an attack (losing
control having a heart attack ldquogoing crazyrdquo)
Agoraphobia
Panic Disorder ndash Chest pain
Chest pain is a common symptom of panic
attacks
22 ndash 70 of panic attacks are associated with
CP
18 ndash 25 of all patients with chest pain have
PD
Rates of PD higher among cardiology
outpatients with chest pain
Such patients undergo expensive cardiac
workups but their PD remains undiagnosed amp
untreated
Obsessive Compulsive Disorder - OCD
Obsessions Recurrent and persistent thoughts impulses or
images
that are experienced during the disturbance as intrusive
and inappropriate and cause marked 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 to neutralize them with some other thought or action
The person recognizes that the obsessive thoughts
impulses or images are a product of his or her own mind
Obsessive Compulsive Disorder -OCD
Compulsions Repetitive behaviors (eg hand washing ordering
checking) or mental acts (eg praying counting repeating
words silently)
Heshe is driven to perform in response to an obsession
The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event
But these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent and are clearly excessive
Obsessive Compulsive Disorder -OCD
Putamen
Globus Pallidus
Caudate Nucleus
Thalamus
Orbital frontal
cortex
Post traumatic Stress Disorder- PTSD
Post traumatic Stress Disorder- PTSD
Experiential requirements The person has experienced a life-threatening
event and has responded with intense fear
hopelessness or horror The personrsquos response to the event occurred
more
than 4 weeks after it was experienced and lasted
more than one month The traumatic event is persistently re
experienced
in several ways eg by intrusive recollections
dreams illusions hallucinations or flashbacks
Post traumatic stress disorder PTSD
Post traumatic Stress Disorder- PTSD
Behavioral requirements Thought avoidance related-activities
andor People-avoidance behavior Feelings of detachment Blunted affect Sense of doom Insomnia Irritability Hyper vigilance Exaggerated startle response
Post traumatic Stress Disorder- PTSD
Subdivisions Acute ndash when PTSD is diagnosed between 1 and
3
months after the event occurs it is called acute Chronic - when PTSD continues longer than 3
months it is considered chronic and long term Delayed Onset PTSD-this term is used to
describe
those cases where the symptoms do not occur
immediately after the experience but rather
months or years later
Case 3
Mr A witnessed a friend die in a MVA six
weeks ago and co frequent nightmares
of the accident poor sleep fears of
driving anxiety around highways
anhedonia and decreased affection
highways towards his girlfriend His
girlfriend also notes that he has been
very irritable and startles easily since the
accident
Post traumatic Stress Disorder- PTSD
10487661048766Exposure to a traumatic event
10487661048766Response involving intense fear
Helplessness and horror
10487661048766Re-experiencing of the traumatic event
Avoidance of stimulipsychological numbing
10487661048766Increased arousal
10487661048766Symptoms greater than 1 month
Separation Anxiety Disorder - SAD
Medical conditions causing anxiety
10487661048766Endocrine conditions
10487661048766Cardiovascular conditions
10487661048766Respiratory conditions
10487661048766Metabolic conditions
10487661048766Neurological conditions
Substances causing anxiety
10487661048766Alcohol Alcohol
10487661048766Amphetamines
10487661048766Caffeine
10487661048766Cannabis
10487661048766Cocaine
10487661048766Hallucinogens
10487661048766Inhalants
10487661048766Phencyclidine
Substances that cause
anxiety (withdrawal)
10487661048766Alcohol
10487661048766Cocaine
10487661048766Sedatives
10487661048766Hypnotics
10487661048766Anxiolytics
Medications causing anxiety
Anesthetics
Analgesics
Sympathomimetics
Bronchodilators
Anti-cholinergics
1048766Insulin
Thyroid hormones
Oral contraceptives
Antihistamines
Anti-parkinsonians
1048766Corticosteroids
Antihypertensives
Cardiovascular drugs
Anticonvulsants
Anxiety Disorders
Current Management Strategies
Management of Anxiety Disorders
1048766 Pharmacotherapy (Medications)
Psycho-analytic therapy ndash PT
Behavior Therapy - BT
Cognitive Behavior Therapy ndash CBT
Computer therapy - CT
1048766 Virtual Realty ndash VR
Mood GYM
Drug Rx of Anxiety Disorders
Clonazepam
How do anxiolytics act
GABA and Glycine are inhibitory neurotransmitter
Serotonin and Noradrenaline are excitatory
Anxiety is increased excitatory transmitters
BZNs increase GABA and increase inhibition
SSRI decrease the serotonin levels and darrexcitation
TCAs act by darrboth serotonin and noradrenaline
Drug Rx of Anxiety Disorders
Disorder First Choice 2nd Choice Short (prn) Add on
GADBZN-
CZ CDZ ALZBeta-blockers Buspirone Carbamazp
Panic Disorder
Paroxetine
CitalopramTCA-
ClomipramineBZN-
ALZ CZ LZMAOI -
Phenelzine
Phobias Beta-blockers SSRIsBZN-
ALZ CZMAOI
OCD Clomipramine Fluoxetine CDZ Buspirone
PTSDTCA-
Imipra Amytrp
SSRI- FLX
Sertaline CPBZN MAOI
Comparison of Benzodiazepines
BZN Sedation Anxiolytic Half life Lipid solu Dose
Diazepam +++ + 20-80 h High 5 mg od
Alprazolam + +++ 6-20 h Low 05 mg qid
Clonazapam ++ +++ 22-50 h Low 05 mg bid
Lorazepam ++ ++ 10-20 h Med 1 mg tid
Chlordiazepx + + 7-30 h Med 15 mg bid
Different strategies of therapy
Behavior therapy
Desensitization
Behavior modification
Behavioral activation
Cognitive therapy
Rational-emotive therapy
Beckrsquos cognitive therapy
Newer approaches
Mindfulness meditation
Acceptance and commitment therapy
Dialectical Behavior Therapy (BPD)
Cognitive Behaviour Therapy - CBT
CBT is a method used to treat anxiety
Recognition of ldquodistorted thinkingrdquo
ldquoCognitive restructuringrdquo
It may also involve classical conditioning when used to treat Obsessive Compulsive Disorder
CBT ndash Obstacles - Restructuring
Hopelessness
Self-criticism
Fear of getting worse
Shame and embarrassment
Partial exposure
Blaming other people
Low motivation
Looking for complex solution
Depressing ruminations
There must be an easier way
Computer Therapy
Pts are ashamed to seek help and may fear the consequences at work and home
Therapy is expensive and beyond the reach of many patients
Computer therapy is very cheap and available by comparison
Computer Therapy ndash Softwares
Fearfighter - for phobiapanic
Cope - for depressionanxiety
Balance - for GAD
BTSteps - for OCD
These are PC based in a CD-Rom
or phone based or Web-based
MENTAL OUTSIDE
Virtual Reality - VR
VR therapy via SD (Systematic Desensitization) is becoming very popular
SD is a process of gradually introducing a disturbing stimulus (eg view from a high place) in otherwise pleasant surroundings
This process gradually suppresses the anxiety response
Virtual Reality ndash VR - Advantages
Patients often have difficulty imagining the stimulus themselves
They are often afraid of experiencing it directly ndash which may also be expensive and time-consuming
VR affords patient privacy and confidentiality during treatment
Very good for phobias
Virtual Reality ndash VR - Imagination
ldquoProjection in timerdquo ndash rationally reconstructing the future
ldquoDe-catastrophizing an imagerdquo ndash modifying a disturbing image
ldquoImage modeling and substitutionrdquo ndashinterrupting a negative train of images
ldquoCovert conditioningrdquo ndash subtle conditioning using imagined rather than real stimuli
Virtual Reality ndash VR - Hutchworld
Hutchworld is a virtual community attached to the Hutchison Cancer Research Center
Designed to provide social support for cancer patients and their families
Based on Microsoftrsquos Vworldrsquos system
Mood GYM on the Internet
Few GPs are trained in CBT
Clinical psychologists are expensive
Young people are not easily reached
They may not want them ndash embarrassment
The web is accessible convenient and popular
with young people
Deliver CBT via internet ndash 5 modules
Mood GYM Modules
5 Modules - analysis and results
1 Essentials of CBT with examples and interactive exercises
2 Warpy Thoughts Questionnaire Identifying dysfunctional thoughts Methods to contest such thoughts
3 Other methods for overcoming warpy thoughts
4 Life Event Stress Relaxation meditation music Pleasant Events Schedule parental style
5 Simple problem solving responses to relationship break-up
Web stats summary
Sessions
Take home points
10487661048766Anxiety disorders are very common
10487661048766Just as fevers these are of different types
10487661048766Accurate Dx and Rx by GP is essential
10487661048766Depression and substance abuse potential
Minimum of six weeks to see Rx effect
Prolonged Rx is necessary 6 m or more
Drug Rx is only a small part of management
SSRI TCAs BZNs MAOIs szlig-blockers etc
CBT Computer treatment VRs Mood GYM
Thank You All Visit us at
wwwdrsarmain
This is sponsored by Torrent ndash
Makers of Clonotril (Clonazepam)
Regulation of locus ceruleus
10487661048766Alpha-noradrenergic auto receptors
10487661048766Serotonin receptors
10487661048766GABA-benzodiazepine receptors
10487661048766Opiate receptors
Dopamine receptors
The amygdala and locus ceruleus
Generalized Anxiety Disorder -GADPathological anxiety which
is
excessive chronic and
typically interferes with their ability to function in normal daily activities
GAD is distinguished from Phobic anxiety ndash as it is not triggered by a specific object
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
Excessive anxiety and worry occurring more days than not for at least 6 months about a number of events The person finds it difficult to control the anxiety and worry and has associated three (or more) of the above six symptoms
Case 1
Ms D has a chief co ldquoworrying about
everythingrdquo for the last year She also co
frequent headaches fatigue and
insomnia secondary to the anxiety
These symptoms have worsened to the
point where she has been distracted and
making mistakes at work
Worry that is 1048766 Excessive uncontrollable 1048766 Frequent multiple topics (not only
onetime) 1048766 More than one day out of two
3 out of 6 other associated physical symptoms
1048766 Muscle tension Restlessness 1048766 Fatigued easily Irritability 1048766 Sleep disturbance Concentration
difficulty
GAD ndash Mr Fisc
Acute fear state
10487661048766Response to life-threatening danger
10487661048766Terror helplessness
Sense of impending disasterdoom
10487661048766Urgency to flee or seek safety
10487661048766SympatheticNor-adrenergic activation
10487661048766Located in locus ceruleus
1048766 Corresponds to panic attacks
Agoraphobia
Anxiety in situations where escape might be
difficult (or embarrassing) or help might not be
available in the event of having a panic attack or
panic-like symptoms
Situations are avoided or endured with marked
distress
May not leave home or may need a companion
Can occur with and without panic disorder
Agoraphobia
Social Phobia
Marked persistent fear of social or performance
situations where a person is exposed to unfamiliar
situations or people or possible scrutiny by others
The individual fears acting in an embarrassing or
humiliating way
The Person recognizes fear as excessive
Exposure causes anxiety symptoms or panic
Situations are avoided or endured with anxiety
Specific Phobias
Marked and persistent fear that is excessive or unreasonable
cued by the presence or anticipation of a specific object or
situation (eg flying heights animals receiving an injection
seeing blood)
Exposure to the phobic stimulus almost invariably provokes an
immediate anxiety response which may take the form of a
Panic Attack
The person recognizes that hisher fear is excessive or
unreasonable The phobic situation is avoided or else is
endured with intense anxiety or distress
Specific Phobias - Examples
Acrophobia fear of heights
Agoraphobia fear of open places
Claustrophobia fear of enclosed places
Ailurophobia fear of cats
Cynophobia fear of dogs
Pathophobia fear of disease
Mysophobia fear of dirt and germs
Arachnophobia fear of spiders
Hematophobia fear of blood
Xenophobia fear of strangers
Better-halfophobia fear of wife
PAN ndash The Greek God
Panic Attack ndash DSM IV
1 1048766 Palpitations
2 Sweating
3 Trembling or shaking
4 Shortness of breath
5 Feeling of choking
6 Chest pain or discomfort
7 Nausea or abd distress
8 Feeling dizzy fainty
9 Derealization (feelings of unreality)
10 Fear of going crazy
11 Fear of dying
12 Paresthesias
13 Chills or hot flushes
10487661048766A discrete period of intense fear or discomfort in which 4 (or more) of the above 13 symptoms develop abruptly and reach a peak within 10 minutes
Case 2
Mrs B co a long ho episodes of anxiety
SOB racing heart sweating CP and
fears that she is having a MI and will die
These last 30 minutes and are
unexpected She co anxiety while in
malls and traveling alone to new places
for fear of having another attack Despite
a negative wu she still worries about
having a MI during an attack
Panic Disorder with Agoraphobia
Recurrent unexpected panic attacks anxiety
associated with at least four physical andor
cognitive symptoms cognitive symptoms
At least 1 month of worry about having additional
attacks or the consequences of an attack (losing
control having a heart attack ldquogoing crazyrdquo)
Agoraphobia
Panic Disorder ndash Chest pain
Chest pain is a common symptom of panic
attacks
22 ndash 70 of panic attacks are associated with
CP
18 ndash 25 of all patients with chest pain have
PD
Rates of PD higher among cardiology
outpatients with chest pain
Such patients undergo expensive cardiac
workups but their PD remains undiagnosed amp
untreated
Obsessive Compulsive Disorder - OCD
Obsessions Recurrent and persistent thoughts impulses or
images
that are experienced during the disturbance as intrusive
and inappropriate and cause marked 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 to neutralize them with some other thought or action
The person recognizes that the obsessive thoughts
impulses or images are a product of his or her own mind
Obsessive Compulsive Disorder -OCD
Compulsions Repetitive behaviors (eg hand washing ordering
checking) or mental acts (eg praying counting repeating
words silently)
Heshe is driven to perform in response to an obsession
The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event
But these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent and are clearly excessive
Obsessive Compulsive Disorder -OCD
Putamen
Globus Pallidus
Caudate Nucleus
Thalamus
Orbital frontal
cortex
Post traumatic Stress Disorder- PTSD
Post traumatic Stress Disorder- PTSD
Experiential requirements The person has experienced a life-threatening
event and has responded with intense fear
hopelessness or horror The personrsquos response to the event occurred
more
than 4 weeks after it was experienced and lasted
more than one month The traumatic event is persistently re
experienced
in several ways eg by intrusive recollections
dreams illusions hallucinations or flashbacks
Post traumatic stress disorder PTSD
Post traumatic Stress Disorder- PTSD
Behavioral requirements Thought avoidance related-activities
andor People-avoidance behavior Feelings of detachment Blunted affect Sense of doom Insomnia Irritability Hyper vigilance Exaggerated startle response
Post traumatic Stress Disorder- PTSD
Subdivisions Acute ndash when PTSD is diagnosed between 1 and
3
months after the event occurs it is called acute Chronic - when PTSD continues longer than 3
months it is considered chronic and long term Delayed Onset PTSD-this term is used to
describe
those cases where the symptoms do not occur
immediately after the experience but rather
months or years later
Case 3
Mr A witnessed a friend die in a MVA six
weeks ago and co frequent nightmares
of the accident poor sleep fears of
driving anxiety around highways
anhedonia and decreased affection
highways towards his girlfriend His
girlfriend also notes that he has been
very irritable and startles easily since the
accident
Post traumatic Stress Disorder- PTSD
10487661048766Exposure to a traumatic event
10487661048766Response involving intense fear
Helplessness and horror
10487661048766Re-experiencing of the traumatic event
Avoidance of stimulipsychological numbing
10487661048766Increased arousal
10487661048766Symptoms greater than 1 month
Separation Anxiety Disorder - SAD
Medical conditions causing anxiety
10487661048766Endocrine conditions
10487661048766Cardiovascular conditions
10487661048766Respiratory conditions
10487661048766Metabolic conditions
10487661048766Neurological conditions
Substances causing anxiety
10487661048766Alcohol Alcohol
10487661048766Amphetamines
10487661048766Caffeine
10487661048766Cannabis
10487661048766Cocaine
10487661048766Hallucinogens
10487661048766Inhalants
10487661048766Phencyclidine
Substances that cause
anxiety (withdrawal)
10487661048766Alcohol
10487661048766Cocaine
10487661048766Sedatives
10487661048766Hypnotics
10487661048766Anxiolytics
Medications causing anxiety
Anesthetics
Analgesics
Sympathomimetics
Bronchodilators
Anti-cholinergics
1048766Insulin
Thyroid hormones
Oral contraceptives
Antihistamines
Anti-parkinsonians
1048766Corticosteroids
Antihypertensives
Cardiovascular drugs
Anticonvulsants
Anxiety Disorders
Current Management Strategies
Management of Anxiety Disorders
1048766 Pharmacotherapy (Medications)
Psycho-analytic therapy ndash PT
Behavior Therapy - BT
Cognitive Behavior Therapy ndash CBT
Computer therapy - CT
1048766 Virtual Realty ndash VR
Mood GYM
Drug Rx of Anxiety Disorders
Clonazepam
How do anxiolytics act
GABA and Glycine are inhibitory neurotransmitter
Serotonin and Noradrenaline are excitatory
Anxiety is increased excitatory transmitters
BZNs increase GABA and increase inhibition
SSRI decrease the serotonin levels and darrexcitation
TCAs act by darrboth serotonin and noradrenaline
Drug Rx of Anxiety Disorders
Disorder First Choice 2nd Choice Short (prn) Add on
GADBZN-
CZ CDZ ALZBeta-blockers Buspirone Carbamazp
Panic Disorder
Paroxetine
CitalopramTCA-
ClomipramineBZN-
ALZ CZ LZMAOI -
Phenelzine
Phobias Beta-blockers SSRIsBZN-
ALZ CZMAOI
OCD Clomipramine Fluoxetine CDZ Buspirone
PTSDTCA-
Imipra Amytrp
SSRI- FLX
Sertaline CPBZN MAOI
Comparison of Benzodiazepines
BZN Sedation Anxiolytic Half life Lipid solu Dose
Diazepam +++ + 20-80 h High 5 mg od
Alprazolam + +++ 6-20 h Low 05 mg qid
Clonazapam ++ +++ 22-50 h Low 05 mg bid
Lorazepam ++ ++ 10-20 h Med 1 mg tid
Chlordiazepx + + 7-30 h Med 15 mg bid
Different strategies of therapy
Behavior therapy
Desensitization
Behavior modification
Behavioral activation
Cognitive therapy
Rational-emotive therapy
Beckrsquos cognitive therapy
Newer approaches
Mindfulness meditation
Acceptance and commitment therapy
Dialectical Behavior Therapy (BPD)
Cognitive Behaviour Therapy - CBT
CBT is a method used to treat anxiety
Recognition of ldquodistorted thinkingrdquo
ldquoCognitive restructuringrdquo
It may also involve classical conditioning when used to treat Obsessive Compulsive Disorder
CBT ndash Obstacles - Restructuring
Hopelessness
Self-criticism
Fear of getting worse
Shame and embarrassment
Partial exposure
Blaming other people
Low motivation
Looking for complex solution
Depressing ruminations
There must be an easier way
Computer Therapy
Pts are ashamed to seek help and may fear the consequences at work and home
Therapy is expensive and beyond the reach of many patients
Computer therapy is very cheap and available by comparison
Computer Therapy ndash Softwares
Fearfighter - for phobiapanic
Cope - for depressionanxiety
Balance - for GAD
BTSteps - for OCD
These are PC based in a CD-Rom
or phone based or Web-based
MENTAL OUTSIDE
Virtual Reality - VR
VR therapy via SD (Systematic Desensitization) is becoming very popular
SD is a process of gradually introducing a disturbing stimulus (eg view from a high place) in otherwise pleasant surroundings
This process gradually suppresses the anxiety response
Virtual Reality ndash VR - Advantages
Patients often have difficulty imagining the stimulus themselves
They are often afraid of experiencing it directly ndash which may also be expensive and time-consuming
VR affords patient privacy and confidentiality during treatment
Very good for phobias
Virtual Reality ndash VR - Imagination
ldquoProjection in timerdquo ndash rationally reconstructing the future
ldquoDe-catastrophizing an imagerdquo ndash modifying a disturbing image
ldquoImage modeling and substitutionrdquo ndashinterrupting a negative train of images
ldquoCovert conditioningrdquo ndash subtle conditioning using imagined rather than real stimuli
Virtual Reality ndash VR - Hutchworld
Hutchworld is a virtual community attached to the Hutchison Cancer Research Center
Designed to provide social support for cancer patients and their families
Based on Microsoftrsquos Vworldrsquos system
Mood GYM on the Internet
Few GPs are trained in CBT
Clinical psychologists are expensive
Young people are not easily reached
They may not want them ndash embarrassment
The web is accessible convenient and popular
with young people
Deliver CBT via internet ndash 5 modules
Mood GYM Modules
5 Modules - analysis and results
1 Essentials of CBT with examples and interactive exercises
2 Warpy Thoughts Questionnaire Identifying dysfunctional thoughts Methods to contest such thoughts
3 Other methods for overcoming warpy thoughts
4 Life Event Stress Relaxation meditation music Pleasant Events Schedule parental style
5 Simple problem solving responses to relationship break-up
Web stats summary
Sessions
Take home points
10487661048766Anxiety disorders are very common
10487661048766Just as fevers these are of different types
10487661048766Accurate Dx and Rx by GP is essential
10487661048766Depression and substance abuse potential
Minimum of six weeks to see Rx effect
Prolonged Rx is necessary 6 m or more
Drug Rx is only a small part of management
SSRI TCAs BZNs MAOIs szlig-blockers etc
CBT Computer treatment VRs Mood GYM
Thank You All Visit us at
wwwdrsarmain
This is sponsored by Torrent ndash
Makers of Clonotril (Clonazepam)
The amygdala and locus ceruleus
Generalized Anxiety Disorder -GADPathological anxiety which
is
excessive chronic and
typically interferes with their ability to function in normal daily activities
GAD is distinguished from Phobic anxiety ndash as it is not triggered by a specific object
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
Excessive anxiety and worry occurring more days than not for at least 6 months about a number of events The person finds it difficult to control the anxiety and worry and has associated three (or more) of the above six symptoms
Case 1
Ms D has a chief co ldquoworrying about
everythingrdquo for the last year She also co
frequent headaches fatigue and
insomnia secondary to the anxiety
These symptoms have worsened to the
point where she has been distracted and
making mistakes at work
Worry that is 1048766 Excessive uncontrollable 1048766 Frequent multiple topics (not only
onetime) 1048766 More than one day out of two
3 out of 6 other associated physical symptoms
1048766 Muscle tension Restlessness 1048766 Fatigued easily Irritability 1048766 Sleep disturbance Concentration
difficulty
GAD ndash Mr Fisc
Acute fear state
10487661048766Response to life-threatening danger
10487661048766Terror helplessness
Sense of impending disasterdoom
10487661048766Urgency to flee or seek safety
10487661048766SympatheticNor-adrenergic activation
10487661048766Located in locus ceruleus
1048766 Corresponds to panic attacks
Agoraphobia
Anxiety in situations where escape might be
difficult (or embarrassing) or help might not be
available in the event of having a panic attack or
panic-like symptoms
Situations are avoided or endured with marked
distress
May not leave home or may need a companion
Can occur with and without panic disorder
Agoraphobia
Social Phobia
Marked persistent fear of social or performance
situations where a person is exposed to unfamiliar
situations or people or possible scrutiny by others
The individual fears acting in an embarrassing or
humiliating way
The Person recognizes fear as excessive
Exposure causes anxiety symptoms or panic
Situations are avoided or endured with anxiety
Specific Phobias
Marked and persistent fear that is excessive or unreasonable
cued by the presence or anticipation of a specific object or
situation (eg flying heights animals receiving an injection
seeing blood)
Exposure to the phobic stimulus almost invariably provokes an
immediate anxiety response which may take the form of a
Panic Attack
The person recognizes that hisher fear is excessive or
unreasonable The phobic situation is avoided or else is
endured with intense anxiety or distress
Specific Phobias - Examples
Acrophobia fear of heights
Agoraphobia fear of open places
Claustrophobia fear of enclosed places
Ailurophobia fear of cats
Cynophobia fear of dogs
Pathophobia fear of disease
Mysophobia fear of dirt and germs
Arachnophobia fear of spiders
Hematophobia fear of blood
Xenophobia fear of strangers
Better-halfophobia fear of wife
PAN ndash The Greek God
Panic Attack ndash DSM IV
1 1048766 Palpitations
2 Sweating
3 Trembling or shaking
4 Shortness of breath
5 Feeling of choking
6 Chest pain or discomfort
7 Nausea or abd distress
8 Feeling dizzy fainty
9 Derealization (feelings of unreality)
10 Fear of going crazy
11 Fear of dying
12 Paresthesias
13 Chills or hot flushes
10487661048766A discrete period of intense fear or discomfort in which 4 (or more) of the above 13 symptoms develop abruptly and reach a peak within 10 minutes
Case 2
Mrs B co a long ho episodes of anxiety
SOB racing heart sweating CP and
fears that she is having a MI and will die
These last 30 minutes and are
unexpected She co anxiety while in
malls and traveling alone to new places
for fear of having another attack Despite
a negative wu she still worries about
having a MI during an attack
Panic Disorder with Agoraphobia
Recurrent unexpected panic attacks anxiety
associated with at least four physical andor
cognitive symptoms cognitive symptoms
At least 1 month of worry about having additional
attacks or the consequences of an attack (losing
control having a heart attack ldquogoing crazyrdquo)
Agoraphobia
Panic Disorder ndash Chest pain
Chest pain is a common symptom of panic
attacks
22 ndash 70 of panic attacks are associated with
CP
18 ndash 25 of all patients with chest pain have
PD
Rates of PD higher among cardiology
outpatients with chest pain
Such patients undergo expensive cardiac
workups but their PD remains undiagnosed amp
untreated
Obsessive Compulsive Disorder - OCD
Obsessions Recurrent and persistent thoughts impulses or
images
that are experienced during the disturbance as intrusive
and inappropriate and cause marked 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 to neutralize them with some other thought or action
The person recognizes that the obsessive thoughts
impulses or images are a product of his or her own mind
Obsessive Compulsive Disorder -OCD
Compulsions Repetitive behaviors (eg hand washing ordering
checking) or mental acts (eg praying counting repeating
words silently)
Heshe is driven to perform in response to an obsession
The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event
But these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent and are clearly excessive
Obsessive Compulsive Disorder -OCD
Putamen
Globus Pallidus
Caudate Nucleus
Thalamus
Orbital frontal
cortex
Post traumatic Stress Disorder- PTSD
Post traumatic Stress Disorder- PTSD
Experiential requirements The person has experienced a life-threatening
event and has responded with intense fear
hopelessness or horror The personrsquos response to the event occurred
more
than 4 weeks after it was experienced and lasted
more than one month The traumatic event is persistently re
experienced
in several ways eg by intrusive recollections
dreams illusions hallucinations or flashbacks
Post traumatic stress disorder PTSD
Post traumatic Stress Disorder- PTSD
Behavioral requirements Thought avoidance related-activities
andor People-avoidance behavior Feelings of detachment Blunted affect Sense of doom Insomnia Irritability Hyper vigilance Exaggerated startle response
Post traumatic Stress Disorder- PTSD
Subdivisions Acute ndash when PTSD is diagnosed between 1 and
3
months after the event occurs it is called acute Chronic - when PTSD continues longer than 3
months it is considered chronic and long term Delayed Onset PTSD-this term is used to
describe
those cases where the symptoms do not occur
immediately after the experience but rather
months or years later
Case 3
Mr A witnessed a friend die in a MVA six
weeks ago and co frequent nightmares
of the accident poor sleep fears of
driving anxiety around highways
anhedonia and decreased affection
highways towards his girlfriend His
girlfriend also notes that he has been
very irritable and startles easily since the
accident
Post traumatic Stress Disorder- PTSD
10487661048766Exposure to a traumatic event
10487661048766Response involving intense fear
Helplessness and horror
10487661048766Re-experiencing of the traumatic event
Avoidance of stimulipsychological numbing
10487661048766Increased arousal
10487661048766Symptoms greater than 1 month
Separation Anxiety Disorder - SAD
Medical conditions causing anxiety
10487661048766Endocrine conditions
10487661048766Cardiovascular conditions
10487661048766Respiratory conditions
10487661048766Metabolic conditions
10487661048766Neurological conditions
Substances causing anxiety
10487661048766Alcohol Alcohol
10487661048766Amphetamines
10487661048766Caffeine
10487661048766Cannabis
10487661048766Cocaine
10487661048766Hallucinogens
10487661048766Inhalants
10487661048766Phencyclidine
Substances that cause
anxiety (withdrawal)
10487661048766Alcohol
10487661048766Cocaine
10487661048766Sedatives
10487661048766Hypnotics
10487661048766Anxiolytics
Medications causing anxiety
Anesthetics
Analgesics
Sympathomimetics
Bronchodilators
Anti-cholinergics
1048766Insulin
Thyroid hormones
Oral contraceptives
Antihistamines
Anti-parkinsonians
1048766Corticosteroids
Antihypertensives
Cardiovascular drugs
Anticonvulsants
Anxiety Disorders
Current Management Strategies
Management of Anxiety Disorders
1048766 Pharmacotherapy (Medications)
Psycho-analytic therapy ndash PT
Behavior Therapy - BT
Cognitive Behavior Therapy ndash CBT
Computer therapy - CT
1048766 Virtual Realty ndash VR
Mood GYM
Drug Rx of Anxiety Disorders
Clonazepam
How do anxiolytics act
GABA and Glycine are inhibitory neurotransmitter
Serotonin and Noradrenaline are excitatory
Anxiety is increased excitatory transmitters
BZNs increase GABA and increase inhibition
SSRI decrease the serotonin levels and darrexcitation
TCAs act by darrboth serotonin and noradrenaline
Drug Rx of Anxiety Disorders
Disorder First Choice 2nd Choice Short (prn) Add on
GADBZN-
CZ CDZ ALZBeta-blockers Buspirone Carbamazp
Panic Disorder
Paroxetine
CitalopramTCA-
ClomipramineBZN-
ALZ CZ LZMAOI -
Phenelzine
Phobias Beta-blockers SSRIsBZN-
ALZ CZMAOI
OCD Clomipramine Fluoxetine CDZ Buspirone
PTSDTCA-
Imipra Amytrp
SSRI- FLX
Sertaline CPBZN MAOI
Comparison of Benzodiazepines
BZN Sedation Anxiolytic Half life Lipid solu Dose
Diazepam +++ + 20-80 h High 5 mg od
Alprazolam + +++ 6-20 h Low 05 mg qid
Clonazapam ++ +++ 22-50 h Low 05 mg bid
Lorazepam ++ ++ 10-20 h Med 1 mg tid
Chlordiazepx + + 7-30 h Med 15 mg bid
Different strategies of therapy
Behavior therapy
Desensitization
Behavior modification
Behavioral activation
Cognitive therapy
Rational-emotive therapy
Beckrsquos cognitive therapy
Newer approaches
Mindfulness meditation
Acceptance and commitment therapy
Dialectical Behavior Therapy (BPD)
Cognitive Behaviour Therapy - CBT
CBT is a method used to treat anxiety
Recognition of ldquodistorted thinkingrdquo
ldquoCognitive restructuringrdquo
It may also involve classical conditioning when used to treat Obsessive Compulsive Disorder
CBT ndash Obstacles - Restructuring
Hopelessness
Self-criticism
Fear of getting worse
Shame and embarrassment
Partial exposure
Blaming other people
Low motivation
Looking for complex solution
Depressing ruminations
There must be an easier way
Computer Therapy
Pts are ashamed to seek help and may fear the consequences at work and home
Therapy is expensive and beyond the reach of many patients
Computer therapy is very cheap and available by comparison
Computer Therapy ndash Softwares
Fearfighter - for phobiapanic
Cope - for depressionanxiety
Balance - for GAD
BTSteps - for OCD
These are PC based in a CD-Rom
or phone based or Web-based
MENTAL OUTSIDE
Virtual Reality - VR
VR therapy via SD (Systematic Desensitization) is becoming very popular
SD is a process of gradually introducing a disturbing stimulus (eg view from a high place) in otherwise pleasant surroundings
This process gradually suppresses the anxiety response
Virtual Reality ndash VR - Advantages
Patients often have difficulty imagining the stimulus themselves
They are often afraid of experiencing it directly ndash which may also be expensive and time-consuming
VR affords patient privacy and confidentiality during treatment
Very good for phobias
Virtual Reality ndash VR - Imagination
ldquoProjection in timerdquo ndash rationally reconstructing the future
ldquoDe-catastrophizing an imagerdquo ndash modifying a disturbing image
ldquoImage modeling and substitutionrdquo ndashinterrupting a negative train of images
ldquoCovert conditioningrdquo ndash subtle conditioning using imagined rather than real stimuli
Virtual Reality ndash VR - Hutchworld
Hutchworld is a virtual community attached to the Hutchison Cancer Research Center
Designed to provide social support for cancer patients and their families
Based on Microsoftrsquos Vworldrsquos system
Mood GYM on the Internet
Few GPs are trained in CBT
Clinical psychologists are expensive
Young people are not easily reached
They may not want them ndash embarrassment
The web is accessible convenient and popular
with young people
Deliver CBT via internet ndash 5 modules
Mood GYM Modules
5 Modules - analysis and results
1 Essentials of CBT with examples and interactive exercises
2 Warpy Thoughts Questionnaire Identifying dysfunctional thoughts Methods to contest such thoughts
3 Other methods for overcoming warpy thoughts
4 Life Event Stress Relaxation meditation music Pleasant Events Schedule parental style
5 Simple problem solving responses to relationship break-up
Web stats summary
Sessions
Take home points
10487661048766Anxiety disorders are very common
10487661048766Just as fevers these are of different types
10487661048766Accurate Dx and Rx by GP is essential
10487661048766Depression and substance abuse potential
Minimum of six weeks to see Rx effect
Prolonged Rx is necessary 6 m or more
Drug Rx is only a small part of management
SSRI TCAs BZNs MAOIs szlig-blockers etc
CBT Computer treatment VRs Mood GYM
Thank You All Visit us at
wwwdrsarmain
This is sponsored by Torrent ndash
Makers of Clonotril (Clonazepam)
Generalized Anxiety Disorder -GADPathological anxiety which
is
excessive chronic and
typically interferes with their ability to function in normal daily activities
GAD is distinguished from Phobic anxiety ndash as it is not triggered by a specific object
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
Excessive anxiety and worry occurring more days than not for at least 6 months about a number of events The person finds it difficult to control the anxiety and worry and has associated three (or more) of the above six symptoms
Case 1
Ms D has a chief co ldquoworrying about
everythingrdquo for the last year She also co
frequent headaches fatigue and
insomnia secondary to the anxiety
These symptoms have worsened to the
point where she has been distracted and
making mistakes at work
Worry that is 1048766 Excessive uncontrollable 1048766 Frequent multiple topics (not only
onetime) 1048766 More than one day out of two
3 out of 6 other associated physical symptoms
1048766 Muscle tension Restlessness 1048766 Fatigued easily Irritability 1048766 Sleep disturbance Concentration
difficulty
GAD ndash Mr Fisc
Acute fear state
10487661048766Response to life-threatening danger
10487661048766Terror helplessness
Sense of impending disasterdoom
10487661048766Urgency to flee or seek safety
10487661048766SympatheticNor-adrenergic activation
10487661048766Located in locus ceruleus
1048766 Corresponds to panic attacks
Agoraphobia
Anxiety in situations where escape might be
difficult (or embarrassing) or help might not be
available in the event of having a panic attack or
panic-like symptoms
Situations are avoided or endured with marked
distress
May not leave home or may need a companion
Can occur with and without panic disorder
Agoraphobia
Social Phobia
Marked persistent fear of social or performance
situations where a person is exposed to unfamiliar
situations or people or possible scrutiny by others
The individual fears acting in an embarrassing or
humiliating way
The Person recognizes fear as excessive
Exposure causes anxiety symptoms or panic
Situations are avoided or endured with anxiety
Specific Phobias
Marked and persistent fear that is excessive or unreasonable
cued by the presence or anticipation of a specific object or
situation (eg flying heights animals receiving an injection
seeing blood)
Exposure to the phobic stimulus almost invariably provokes an
immediate anxiety response which may take the form of a
Panic Attack
The person recognizes that hisher fear is excessive or
unreasonable The phobic situation is avoided or else is
endured with intense anxiety or distress
Specific Phobias - Examples
Acrophobia fear of heights
Agoraphobia fear of open places
Claustrophobia fear of enclosed places
Ailurophobia fear of cats
Cynophobia fear of dogs
Pathophobia fear of disease
Mysophobia fear of dirt and germs
Arachnophobia fear of spiders
Hematophobia fear of blood
Xenophobia fear of strangers
Better-halfophobia fear of wife
PAN ndash The Greek God
Panic Attack ndash DSM IV
1 1048766 Palpitations
2 Sweating
3 Trembling or shaking
4 Shortness of breath
5 Feeling of choking
6 Chest pain or discomfort
7 Nausea or abd distress
8 Feeling dizzy fainty
9 Derealization (feelings of unreality)
10 Fear of going crazy
11 Fear of dying
12 Paresthesias
13 Chills or hot flushes
10487661048766A discrete period of intense fear or discomfort in which 4 (or more) of the above 13 symptoms develop abruptly and reach a peak within 10 minutes
Case 2
Mrs B co a long ho episodes of anxiety
SOB racing heart sweating CP and
fears that she is having a MI and will die
These last 30 minutes and are
unexpected She co anxiety while in
malls and traveling alone to new places
for fear of having another attack Despite
a negative wu she still worries about
having a MI during an attack
Panic Disorder with Agoraphobia
Recurrent unexpected panic attacks anxiety
associated with at least four physical andor
cognitive symptoms cognitive symptoms
At least 1 month of worry about having additional
attacks or the consequences of an attack (losing
control having a heart attack ldquogoing crazyrdquo)
Agoraphobia
Panic Disorder ndash Chest pain
Chest pain is a common symptom of panic
attacks
22 ndash 70 of panic attacks are associated with
CP
18 ndash 25 of all patients with chest pain have
PD
Rates of PD higher among cardiology
outpatients with chest pain
Such patients undergo expensive cardiac
workups but their PD remains undiagnosed amp
untreated
Obsessive Compulsive Disorder - OCD
Obsessions Recurrent and persistent thoughts impulses or
images
that are experienced during the disturbance as intrusive
and inappropriate and cause marked 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 to neutralize them with some other thought or action
The person recognizes that the obsessive thoughts
impulses or images are a product of his or her own mind
Obsessive Compulsive Disorder -OCD
Compulsions Repetitive behaviors (eg hand washing ordering
checking) or mental acts (eg praying counting repeating
words silently)
Heshe is driven to perform in response to an obsession
The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event
But these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent and are clearly excessive
Obsessive Compulsive Disorder -OCD
Putamen
Globus Pallidus
Caudate Nucleus
Thalamus
Orbital frontal
cortex
Post traumatic Stress Disorder- PTSD
Post traumatic Stress Disorder- PTSD
Experiential requirements The person has experienced a life-threatening
event and has responded with intense fear
hopelessness or horror The personrsquos response to the event occurred
more
than 4 weeks after it was experienced and lasted
more than one month The traumatic event is persistently re
experienced
in several ways eg by intrusive recollections
dreams illusions hallucinations or flashbacks
Post traumatic stress disorder PTSD
Post traumatic Stress Disorder- PTSD
Behavioral requirements Thought avoidance related-activities
andor People-avoidance behavior Feelings of detachment Blunted affect Sense of doom Insomnia Irritability Hyper vigilance Exaggerated startle response
Post traumatic Stress Disorder- PTSD
Subdivisions Acute ndash when PTSD is diagnosed between 1 and
3
months after the event occurs it is called acute Chronic - when PTSD continues longer than 3
months it is considered chronic and long term Delayed Onset PTSD-this term is used to
describe
those cases where the symptoms do not occur
immediately after the experience but rather
months or years later
Case 3
Mr A witnessed a friend die in a MVA six
weeks ago and co frequent nightmares
of the accident poor sleep fears of
driving anxiety around highways
anhedonia and decreased affection
highways towards his girlfriend His
girlfriend also notes that he has been
very irritable and startles easily since the
accident
Post traumatic Stress Disorder- PTSD
10487661048766Exposure to a traumatic event
10487661048766Response involving intense fear
Helplessness and horror
10487661048766Re-experiencing of the traumatic event
Avoidance of stimulipsychological numbing
10487661048766Increased arousal
10487661048766Symptoms greater than 1 month
Separation Anxiety Disorder - SAD
Medical conditions causing anxiety
10487661048766Endocrine conditions
10487661048766Cardiovascular conditions
10487661048766Respiratory conditions
10487661048766Metabolic conditions
10487661048766Neurological conditions
Substances causing anxiety
10487661048766Alcohol Alcohol
10487661048766Amphetamines
10487661048766Caffeine
10487661048766Cannabis
10487661048766Cocaine
10487661048766Hallucinogens
10487661048766Inhalants
10487661048766Phencyclidine
Substances that cause
anxiety (withdrawal)
10487661048766Alcohol
10487661048766Cocaine
10487661048766Sedatives
10487661048766Hypnotics
10487661048766Anxiolytics
Medications causing anxiety
Anesthetics
Analgesics
Sympathomimetics
Bronchodilators
Anti-cholinergics
1048766Insulin
Thyroid hormones
Oral contraceptives
Antihistamines
Anti-parkinsonians
1048766Corticosteroids
Antihypertensives
Cardiovascular drugs
Anticonvulsants
Anxiety Disorders
Current Management Strategies
Management of Anxiety Disorders
1048766 Pharmacotherapy (Medications)
Psycho-analytic therapy ndash PT
Behavior Therapy - BT
Cognitive Behavior Therapy ndash CBT
Computer therapy - CT
1048766 Virtual Realty ndash VR
Mood GYM
Drug Rx of Anxiety Disorders
Clonazepam
How do anxiolytics act
GABA and Glycine are inhibitory neurotransmitter
Serotonin and Noradrenaline are excitatory
Anxiety is increased excitatory transmitters
BZNs increase GABA and increase inhibition
SSRI decrease the serotonin levels and darrexcitation
TCAs act by darrboth serotonin and noradrenaline
Drug Rx of Anxiety Disorders
Disorder First Choice 2nd Choice Short (prn) Add on
GADBZN-
CZ CDZ ALZBeta-blockers Buspirone Carbamazp
Panic Disorder
Paroxetine
CitalopramTCA-
ClomipramineBZN-
ALZ CZ LZMAOI -
Phenelzine
Phobias Beta-blockers SSRIsBZN-
ALZ CZMAOI
OCD Clomipramine Fluoxetine CDZ Buspirone
PTSDTCA-
Imipra Amytrp
SSRI- FLX
Sertaline CPBZN MAOI
Comparison of Benzodiazepines
BZN Sedation Anxiolytic Half life Lipid solu Dose
Diazepam +++ + 20-80 h High 5 mg od
Alprazolam + +++ 6-20 h Low 05 mg qid
Clonazapam ++ +++ 22-50 h Low 05 mg bid
Lorazepam ++ ++ 10-20 h Med 1 mg tid
Chlordiazepx + + 7-30 h Med 15 mg bid
Different strategies of therapy
Behavior therapy
Desensitization
Behavior modification
Behavioral activation
Cognitive therapy
Rational-emotive therapy
Beckrsquos cognitive therapy
Newer approaches
Mindfulness meditation
Acceptance and commitment therapy
Dialectical Behavior Therapy (BPD)
Cognitive Behaviour Therapy - CBT
CBT is a method used to treat anxiety
Recognition of ldquodistorted thinkingrdquo
ldquoCognitive restructuringrdquo
It may also involve classical conditioning when used to treat Obsessive Compulsive Disorder
CBT ndash Obstacles - Restructuring
Hopelessness
Self-criticism
Fear of getting worse
Shame and embarrassment
Partial exposure
Blaming other people
Low motivation
Looking for complex solution
Depressing ruminations
There must be an easier way
Computer Therapy
Pts are ashamed to seek help and may fear the consequences at work and home
Therapy is expensive and beyond the reach of many patients
Computer therapy is very cheap and available by comparison
Computer Therapy ndash Softwares
Fearfighter - for phobiapanic
Cope - for depressionanxiety
Balance - for GAD
BTSteps - for OCD
These are PC based in a CD-Rom
or phone based or Web-based
MENTAL OUTSIDE
Virtual Reality - VR
VR therapy via SD (Systematic Desensitization) is becoming very popular
SD is a process of gradually introducing a disturbing stimulus (eg view from a high place) in otherwise pleasant surroundings
This process gradually suppresses the anxiety response
Virtual Reality ndash VR - Advantages
Patients often have difficulty imagining the stimulus themselves
They are often afraid of experiencing it directly ndash which may also be expensive and time-consuming
VR affords patient privacy and confidentiality during treatment
Very good for phobias
Virtual Reality ndash VR - Imagination
ldquoProjection in timerdquo ndash rationally reconstructing the future
ldquoDe-catastrophizing an imagerdquo ndash modifying a disturbing image
ldquoImage modeling and substitutionrdquo ndashinterrupting a negative train of images
ldquoCovert conditioningrdquo ndash subtle conditioning using imagined rather than real stimuli
Virtual Reality ndash VR - Hutchworld
Hutchworld is a virtual community attached to the Hutchison Cancer Research Center
Designed to provide social support for cancer patients and their families
Based on Microsoftrsquos Vworldrsquos system
Mood GYM on the Internet
Few GPs are trained in CBT
Clinical psychologists are expensive
Young people are not easily reached
They may not want them ndash embarrassment
The web is accessible convenient and popular
with young people
Deliver CBT via internet ndash 5 modules
Mood GYM Modules
5 Modules - analysis and results
1 Essentials of CBT with examples and interactive exercises
2 Warpy Thoughts Questionnaire Identifying dysfunctional thoughts Methods to contest such thoughts
3 Other methods for overcoming warpy thoughts
4 Life Event Stress Relaxation meditation music Pleasant Events Schedule parental style
5 Simple problem solving responses to relationship break-up
Web stats summary
Sessions
Take home points
10487661048766Anxiety disorders are very common
10487661048766Just as fevers these are of different types
10487661048766Accurate Dx and Rx by GP is essential
10487661048766Depression and substance abuse potential
Minimum of six weeks to see Rx effect
Prolonged Rx is necessary 6 m or more
Drug Rx is only a small part of management
SSRI TCAs BZNs MAOIs szlig-blockers etc
CBT Computer treatment VRs Mood GYM
Thank You All Visit us at
wwwdrsarmain
This is sponsored by Torrent ndash
Makers of Clonotril (Clonazepam)
Case 1
Ms D has a chief co ldquoworrying about
everythingrdquo for the last year She also co
frequent headaches fatigue and
insomnia secondary to the anxiety
These symptoms have worsened to the
point where she has been distracted and
making mistakes at work
Worry that is 1048766 Excessive uncontrollable 1048766 Frequent multiple topics (not only
onetime) 1048766 More than one day out of two
3 out of 6 other associated physical symptoms
1048766 Muscle tension Restlessness 1048766 Fatigued easily Irritability 1048766 Sleep disturbance Concentration
difficulty
GAD ndash Mr Fisc
Acute fear state
10487661048766Response to life-threatening danger
10487661048766Terror helplessness
Sense of impending disasterdoom
10487661048766Urgency to flee or seek safety
10487661048766SympatheticNor-adrenergic activation
10487661048766Located in locus ceruleus
1048766 Corresponds to panic attacks
Agoraphobia
Anxiety in situations where escape might be
difficult (or embarrassing) or help might not be
available in the event of having a panic attack or
panic-like symptoms
Situations are avoided or endured with marked
distress
May not leave home or may need a companion
Can occur with and without panic disorder
Agoraphobia
Social Phobia
Marked persistent fear of social or performance
situations where a person is exposed to unfamiliar
situations or people or possible scrutiny by others
The individual fears acting in an embarrassing or
humiliating way
The Person recognizes fear as excessive
Exposure causes anxiety symptoms or panic
Situations are avoided or endured with anxiety
Specific Phobias
Marked and persistent fear that is excessive or unreasonable
cued by the presence or anticipation of a specific object or
situation (eg flying heights animals receiving an injection
seeing blood)
Exposure to the phobic stimulus almost invariably provokes an
immediate anxiety response which may take the form of a
Panic Attack
The person recognizes that hisher fear is excessive or
unreasonable The phobic situation is avoided or else is
endured with intense anxiety or distress
Specific Phobias - Examples
Acrophobia fear of heights
Agoraphobia fear of open places
Claustrophobia fear of enclosed places
Ailurophobia fear of cats
Cynophobia fear of dogs
Pathophobia fear of disease
Mysophobia fear of dirt and germs
Arachnophobia fear of spiders
Hematophobia fear of blood
Xenophobia fear of strangers
Better-halfophobia fear of wife
PAN ndash The Greek God
Panic Attack ndash DSM IV
1 1048766 Palpitations
2 Sweating
3 Trembling or shaking
4 Shortness of breath
5 Feeling of choking
6 Chest pain or discomfort
7 Nausea or abd distress
8 Feeling dizzy fainty
9 Derealization (feelings of unreality)
10 Fear of going crazy
11 Fear of dying
12 Paresthesias
13 Chills or hot flushes
10487661048766A discrete period of intense fear or discomfort in which 4 (or more) of the above 13 symptoms develop abruptly and reach a peak within 10 minutes
Case 2
Mrs B co a long ho episodes of anxiety
SOB racing heart sweating CP and
fears that she is having a MI and will die
These last 30 minutes and are
unexpected She co anxiety while in
malls and traveling alone to new places
for fear of having another attack Despite
a negative wu she still worries about
having a MI during an attack
Panic Disorder with Agoraphobia
Recurrent unexpected panic attacks anxiety
associated with at least four physical andor
cognitive symptoms cognitive symptoms
At least 1 month of worry about having additional
attacks or the consequences of an attack (losing
control having a heart attack ldquogoing crazyrdquo)
Agoraphobia
Panic Disorder ndash Chest pain
Chest pain is a common symptom of panic
attacks
22 ndash 70 of panic attacks are associated with
CP
18 ndash 25 of all patients with chest pain have
PD
Rates of PD higher among cardiology
outpatients with chest pain
Such patients undergo expensive cardiac
workups but their PD remains undiagnosed amp
untreated
Obsessive Compulsive Disorder - OCD
Obsessions Recurrent and persistent thoughts impulses or
images
that are experienced during the disturbance as intrusive
and inappropriate and cause marked 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 to neutralize them with some other thought or action
The person recognizes that the obsessive thoughts
impulses or images are a product of his or her own mind
Obsessive Compulsive Disorder -OCD
Compulsions Repetitive behaviors (eg hand washing ordering
checking) or mental acts (eg praying counting repeating
words silently)
Heshe is driven to perform in response to an obsession
The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event
But these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent and are clearly excessive
Obsessive Compulsive Disorder -OCD
Putamen
Globus Pallidus
Caudate Nucleus
Thalamus
Orbital frontal
cortex
Post traumatic Stress Disorder- PTSD
Post traumatic Stress Disorder- PTSD
Experiential requirements The person has experienced a life-threatening
event and has responded with intense fear
hopelessness or horror The personrsquos response to the event occurred
more
than 4 weeks after it was experienced and lasted
more than one month The traumatic event is persistently re
experienced
in several ways eg by intrusive recollections
dreams illusions hallucinations or flashbacks
Post traumatic stress disorder PTSD
Post traumatic Stress Disorder- PTSD
Behavioral requirements Thought avoidance related-activities
andor People-avoidance behavior Feelings of detachment Blunted affect Sense of doom Insomnia Irritability Hyper vigilance Exaggerated startle response
Post traumatic Stress Disorder- PTSD
Subdivisions Acute ndash when PTSD is diagnosed between 1 and
3
months after the event occurs it is called acute Chronic - when PTSD continues longer than 3
months it is considered chronic and long term Delayed Onset PTSD-this term is used to
describe
those cases where the symptoms do not occur
immediately after the experience but rather
months or years later
Case 3
Mr A witnessed a friend die in a MVA six
weeks ago and co frequent nightmares
of the accident poor sleep fears of
driving anxiety around highways
anhedonia and decreased affection
highways towards his girlfriend His
girlfriend also notes that he has been
very irritable and startles easily since the
accident
Post traumatic Stress Disorder- PTSD
10487661048766Exposure to a traumatic event
10487661048766Response involving intense fear
Helplessness and horror
10487661048766Re-experiencing of the traumatic event
Avoidance of stimulipsychological numbing
10487661048766Increased arousal
10487661048766Symptoms greater than 1 month
Separation Anxiety Disorder - SAD
Medical conditions causing anxiety
10487661048766Endocrine conditions
10487661048766Cardiovascular conditions
10487661048766Respiratory conditions
10487661048766Metabolic conditions
10487661048766Neurological conditions
Substances causing anxiety
10487661048766Alcohol Alcohol
10487661048766Amphetamines
10487661048766Caffeine
10487661048766Cannabis
10487661048766Cocaine
10487661048766Hallucinogens
10487661048766Inhalants
10487661048766Phencyclidine
Substances that cause
anxiety (withdrawal)
10487661048766Alcohol
10487661048766Cocaine
10487661048766Sedatives
10487661048766Hypnotics
10487661048766Anxiolytics
Medications causing anxiety
Anesthetics
Analgesics
Sympathomimetics
Bronchodilators
Anti-cholinergics
1048766Insulin
Thyroid hormones
Oral contraceptives
Antihistamines
Anti-parkinsonians
1048766Corticosteroids
Antihypertensives
Cardiovascular drugs
Anticonvulsants
Anxiety Disorders
Current Management Strategies
Management of Anxiety Disorders
1048766 Pharmacotherapy (Medications)
Psycho-analytic therapy ndash PT
Behavior Therapy - BT
Cognitive Behavior Therapy ndash CBT
Computer therapy - CT
1048766 Virtual Realty ndash VR
Mood GYM
Drug Rx of Anxiety Disorders
Clonazepam
How do anxiolytics act
GABA and Glycine are inhibitory neurotransmitter
Serotonin and Noradrenaline are excitatory
Anxiety is increased excitatory transmitters
BZNs increase GABA and increase inhibition
SSRI decrease the serotonin levels and darrexcitation
TCAs act by darrboth serotonin and noradrenaline
Drug Rx of Anxiety Disorders
Disorder First Choice 2nd Choice Short (prn) Add on
GADBZN-
CZ CDZ ALZBeta-blockers Buspirone Carbamazp
Panic Disorder
Paroxetine
CitalopramTCA-
ClomipramineBZN-
ALZ CZ LZMAOI -
Phenelzine
Phobias Beta-blockers SSRIsBZN-
ALZ CZMAOI
OCD Clomipramine Fluoxetine CDZ Buspirone
PTSDTCA-
Imipra Amytrp
SSRI- FLX
Sertaline CPBZN MAOI
Comparison of Benzodiazepines
BZN Sedation Anxiolytic Half life Lipid solu Dose
Diazepam +++ + 20-80 h High 5 mg od
Alprazolam + +++ 6-20 h Low 05 mg qid
Clonazapam ++ +++ 22-50 h Low 05 mg bid
Lorazepam ++ ++ 10-20 h Med 1 mg tid
Chlordiazepx + + 7-30 h Med 15 mg bid
Different strategies of therapy
Behavior therapy
Desensitization
Behavior modification
Behavioral activation
Cognitive therapy
Rational-emotive therapy
Beckrsquos cognitive therapy
Newer approaches
Mindfulness meditation
Acceptance and commitment therapy
Dialectical Behavior Therapy (BPD)
Cognitive Behaviour Therapy - CBT
CBT is a method used to treat anxiety
Recognition of ldquodistorted thinkingrdquo
ldquoCognitive restructuringrdquo
It may also involve classical conditioning when used to treat Obsessive Compulsive Disorder
CBT ndash Obstacles - Restructuring
Hopelessness
Self-criticism
Fear of getting worse
Shame and embarrassment
Partial exposure
Blaming other people
Low motivation
Looking for complex solution
Depressing ruminations
There must be an easier way
Computer Therapy
Pts are ashamed to seek help and may fear the consequences at work and home
Therapy is expensive and beyond the reach of many patients
Computer therapy is very cheap and available by comparison
Computer Therapy ndash Softwares
Fearfighter - for phobiapanic
Cope - for depressionanxiety
Balance - for GAD
BTSteps - for OCD
These are PC based in a CD-Rom
or phone based or Web-based
MENTAL OUTSIDE
Virtual Reality - VR
VR therapy via SD (Systematic Desensitization) is becoming very popular
SD is a process of gradually introducing a disturbing stimulus (eg view from a high place) in otherwise pleasant surroundings
This process gradually suppresses the anxiety response
Virtual Reality ndash VR - Advantages
Patients often have difficulty imagining the stimulus themselves
They are often afraid of experiencing it directly ndash which may also be expensive and time-consuming
VR affords patient privacy and confidentiality during treatment
Very good for phobias
Virtual Reality ndash VR - Imagination
ldquoProjection in timerdquo ndash rationally reconstructing the future
ldquoDe-catastrophizing an imagerdquo ndash modifying a disturbing image
ldquoImage modeling and substitutionrdquo ndashinterrupting a negative train of images
ldquoCovert conditioningrdquo ndash subtle conditioning using imagined rather than real stimuli
Virtual Reality ndash VR - Hutchworld
Hutchworld is a virtual community attached to the Hutchison Cancer Research Center
Designed to provide social support for cancer patients and their families
Based on Microsoftrsquos Vworldrsquos system
Mood GYM on the Internet
Few GPs are trained in CBT
Clinical psychologists are expensive
Young people are not easily reached
They may not want them ndash embarrassment
The web is accessible convenient and popular
with young people
Deliver CBT via internet ndash 5 modules
Mood GYM Modules
5 Modules - analysis and results
1 Essentials of CBT with examples and interactive exercises
2 Warpy Thoughts Questionnaire Identifying dysfunctional thoughts Methods to contest such thoughts
3 Other methods for overcoming warpy thoughts
4 Life Event Stress Relaxation meditation music Pleasant Events Schedule parental style
5 Simple problem solving responses to relationship break-up
Web stats summary
Sessions
Take home points
10487661048766Anxiety disorders are very common
10487661048766Just as fevers these are of different types
10487661048766Accurate Dx and Rx by GP is essential
10487661048766Depression and substance abuse potential
Minimum of six weeks to see Rx effect
Prolonged Rx is necessary 6 m or more
Drug Rx is only a small part of management
SSRI TCAs BZNs MAOIs szlig-blockers etc
CBT Computer treatment VRs Mood GYM
Thank You All Visit us at
wwwdrsarmain
This is sponsored by Torrent ndash
Makers of Clonotril (Clonazepam)
Worry that is 1048766 Excessive uncontrollable 1048766 Frequent multiple topics (not only
onetime) 1048766 More than one day out of two
3 out of 6 other associated physical symptoms
1048766 Muscle tension Restlessness 1048766 Fatigued easily Irritability 1048766 Sleep disturbance Concentration
difficulty
GAD ndash Mr Fisc
Acute fear state
10487661048766Response to life-threatening danger
10487661048766Terror helplessness
Sense of impending disasterdoom
10487661048766Urgency to flee or seek safety
10487661048766SympatheticNor-adrenergic activation
10487661048766Located in locus ceruleus
1048766 Corresponds to panic attacks
Agoraphobia
Anxiety in situations where escape might be
difficult (or embarrassing) or help might not be
available in the event of having a panic attack or
panic-like symptoms
Situations are avoided or endured with marked
distress
May not leave home or may need a companion
Can occur with and without panic disorder
Agoraphobia
Social Phobia
Marked persistent fear of social or performance
situations where a person is exposed to unfamiliar
situations or people or possible scrutiny by others
The individual fears acting in an embarrassing or
humiliating way
The Person recognizes fear as excessive
Exposure causes anxiety symptoms or panic
Situations are avoided or endured with anxiety
Specific Phobias
Marked and persistent fear that is excessive or unreasonable
cued by the presence or anticipation of a specific object or
situation (eg flying heights animals receiving an injection
seeing blood)
Exposure to the phobic stimulus almost invariably provokes an
immediate anxiety response which may take the form of a
Panic Attack
The person recognizes that hisher fear is excessive or
unreasonable The phobic situation is avoided or else is
endured with intense anxiety or distress
Specific Phobias - Examples
Acrophobia fear of heights
Agoraphobia fear of open places
Claustrophobia fear of enclosed places
Ailurophobia fear of cats
Cynophobia fear of dogs
Pathophobia fear of disease
Mysophobia fear of dirt and germs
Arachnophobia fear of spiders
Hematophobia fear of blood
Xenophobia fear of strangers
Better-halfophobia fear of wife
PAN ndash The Greek God
Panic Attack ndash DSM IV
1 1048766 Palpitations
2 Sweating
3 Trembling or shaking
4 Shortness of breath
5 Feeling of choking
6 Chest pain or discomfort
7 Nausea or abd distress
8 Feeling dizzy fainty
9 Derealization (feelings of unreality)
10 Fear of going crazy
11 Fear of dying
12 Paresthesias
13 Chills or hot flushes
10487661048766A discrete period of intense fear or discomfort in which 4 (or more) of the above 13 symptoms develop abruptly and reach a peak within 10 minutes
Case 2
Mrs B co a long ho episodes of anxiety
SOB racing heart sweating CP and
fears that she is having a MI and will die
These last 30 minutes and are
unexpected She co anxiety while in
malls and traveling alone to new places
for fear of having another attack Despite
a negative wu she still worries about
having a MI during an attack
Panic Disorder with Agoraphobia
Recurrent unexpected panic attacks anxiety
associated with at least four physical andor
cognitive symptoms cognitive symptoms
At least 1 month of worry about having additional
attacks or the consequences of an attack (losing
control having a heart attack ldquogoing crazyrdquo)
Agoraphobia
Panic Disorder ndash Chest pain
Chest pain is a common symptom of panic
attacks
22 ndash 70 of panic attacks are associated with
CP
18 ndash 25 of all patients with chest pain have
PD
Rates of PD higher among cardiology
outpatients with chest pain
Such patients undergo expensive cardiac
workups but their PD remains undiagnosed amp
untreated
Obsessive Compulsive Disorder - OCD
Obsessions Recurrent and persistent thoughts impulses or
images
that are experienced during the disturbance as intrusive
and inappropriate and cause marked 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 to neutralize them with some other thought or action
The person recognizes that the obsessive thoughts
impulses or images are a product of his or her own mind
Obsessive Compulsive Disorder -OCD
Compulsions Repetitive behaviors (eg hand washing ordering
checking) or mental acts (eg praying counting repeating
words silently)
Heshe is driven to perform in response to an obsession
The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event
But these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent and are clearly excessive
Obsessive Compulsive Disorder -OCD
Putamen
Globus Pallidus
Caudate Nucleus
Thalamus
Orbital frontal
cortex
Post traumatic Stress Disorder- PTSD
Post traumatic Stress Disorder- PTSD
Experiential requirements The person has experienced a life-threatening
event and has responded with intense fear
hopelessness or horror The personrsquos response to the event occurred
more
than 4 weeks after it was experienced and lasted
more than one month The traumatic event is persistently re
experienced
in several ways eg by intrusive recollections
dreams illusions hallucinations or flashbacks
Post traumatic stress disorder PTSD
Post traumatic Stress Disorder- PTSD
Behavioral requirements Thought avoidance related-activities
andor People-avoidance behavior Feelings of detachment Blunted affect Sense of doom Insomnia Irritability Hyper vigilance Exaggerated startle response
Post traumatic Stress Disorder- PTSD
Subdivisions Acute ndash when PTSD is diagnosed between 1 and
3
months after the event occurs it is called acute Chronic - when PTSD continues longer than 3
months it is considered chronic and long term Delayed Onset PTSD-this term is used to
describe
those cases where the symptoms do not occur
immediately after the experience but rather
months or years later
Case 3
Mr A witnessed a friend die in a MVA six
weeks ago and co frequent nightmares
of the accident poor sleep fears of
driving anxiety around highways
anhedonia and decreased affection
highways towards his girlfriend His
girlfriend also notes that he has been
very irritable and startles easily since the
accident
Post traumatic Stress Disorder- PTSD
10487661048766Exposure to a traumatic event
10487661048766Response involving intense fear
Helplessness and horror
10487661048766Re-experiencing of the traumatic event
Avoidance of stimulipsychological numbing
10487661048766Increased arousal
10487661048766Symptoms greater than 1 month
Separation Anxiety Disorder - SAD
Medical conditions causing anxiety
10487661048766Endocrine conditions
10487661048766Cardiovascular conditions
10487661048766Respiratory conditions
10487661048766Metabolic conditions
10487661048766Neurological conditions
Substances causing anxiety
10487661048766Alcohol Alcohol
10487661048766Amphetamines
10487661048766Caffeine
10487661048766Cannabis
10487661048766Cocaine
10487661048766Hallucinogens
10487661048766Inhalants
10487661048766Phencyclidine
Substances that cause
anxiety (withdrawal)
10487661048766Alcohol
10487661048766Cocaine
10487661048766Sedatives
10487661048766Hypnotics
10487661048766Anxiolytics
Medications causing anxiety
Anesthetics
Analgesics
Sympathomimetics
Bronchodilators
Anti-cholinergics
1048766Insulin
Thyroid hormones
Oral contraceptives
Antihistamines
Anti-parkinsonians
1048766Corticosteroids
Antihypertensives
Cardiovascular drugs
Anticonvulsants
Anxiety Disorders
Current Management Strategies
Management of Anxiety Disorders
1048766 Pharmacotherapy (Medications)
Psycho-analytic therapy ndash PT
Behavior Therapy - BT
Cognitive Behavior Therapy ndash CBT
Computer therapy - CT
1048766 Virtual Realty ndash VR
Mood GYM
Drug Rx of Anxiety Disorders
Clonazepam
How do anxiolytics act
GABA and Glycine are inhibitory neurotransmitter
Serotonin and Noradrenaline are excitatory
Anxiety is increased excitatory transmitters
BZNs increase GABA and increase inhibition
SSRI decrease the serotonin levels and darrexcitation
TCAs act by darrboth serotonin and noradrenaline
Drug Rx of Anxiety Disorders
Disorder First Choice 2nd Choice Short (prn) Add on
GADBZN-
CZ CDZ ALZBeta-blockers Buspirone Carbamazp
Panic Disorder
Paroxetine
CitalopramTCA-
ClomipramineBZN-
ALZ CZ LZMAOI -
Phenelzine
Phobias Beta-blockers SSRIsBZN-
ALZ CZMAOI
OCD Clomipramine Fluoxetine CDZ Buspirone
PTSDTCA-
Imipra Amytrp
SSRI- FLX
Sertaline CPBZN MAOI
Comparison of Benzodiazepines
BZN Sedation Anxiolytic Half life Lipid solu Dose
Diazepam +++ + 20-80 h High 5 mg od
Alprazolam + +++ 6-20 h Low 05 mg qid
Clonazapam ++ +++ 22-50 h Low 05 mg bid
Lorazepam ++ ++ 10-20 h Med 1 mg tid
Chlordiazepx + + 7-30 h Med 15 mg bid
Different strategies of therapy
Behavior therapy
Desensitization
Behavior modification
Behavioral activation
Cognitive therapy
Rational-emotive therapy
Beckrsquos cognitive therapy
Newer approaches
Mindfulness meditation
Acceptance and commitment therapy
Dialectical Behavior Therapy (BPD)
Cognitive Behaviour Therapy - CBT
CBT is a method used to treat anxiety
Recognition of ldquodistorted thinkingrdquo
ldquoCognitive restructuringrdquo
It may also involve classical conditioning when used to treat Obsessive Compulsive Disorder
CBT ndash Obstacles - Restructuring
Hopelessness
Self-criticism
Fear of getting worse
Shame and embarrassment
Partial exposure
Blaming other people
Low motivation
Looking for complex solution
Depressing ruminations
There must be an easier way
Computer Therapy
Pts are ashamed to seek help and may fear the consequences at work and home
Therapy is expensive and beyond the reach of many patients
Computer therapy is very cheap and available by comparison
Computer Therapy ndash Softwares
Fearfighter - for phobiapanic
Cope - for depressionanxiety
Balance - for GAD
BTSteps - for OCD
These are PC based in a CD-Rom
or phone based or Web-based
MENTAL OUTSIDE
Virtual Reality - VR
VR therapy via SD (Systematic Desensitization) is becoming very popular
SD is a process of gradually introducing a disturbing stimulus (eg view from a high place) in otherwise pleasant surroundings
This process gradually suppresses the anxiety response
Virtual Reality ndash VR - Advantages
Patients often have difficulty imagining the stimulus themselves
They are often afraid of experiencing it directly ndash which may also be expensive and time-consuming
VR affords patient privacy and confidentiality during treatment
Very good for phobias
Virtual Reality ndash VR - Imagination
ldquoProjection in timerdquo ndash rationally reconstructing the future
ldquoDe-catastrophizing an imagerdquo ndash modifying a disturbing image
ldquoImage modeling and substitutionrdquo ndashinterrupting a negative train of images
ldquoCovert conditioningrdquo ndash subtle conditioning using imagined rather than real stimuli
Virtual Reality ndash VR - Hutchworld
Hutchworld is a virtual community attached to the Hutchison Cancer Research Center
Designed to provide social support for cancer patients and their families
Based on Microsoftrsquos Vworldrsquos system
Mood GYM on the Internet
Few GPs are trained in CBT
Clinical psychologists are expensive
Young people are not easily reached
They may not want them ndash embarrassment
The web is accessible convenient and popular
with young people
Deliver CBT via internet ndash 5 modules
Mood GYM Modules
5 Modules - analysis and results
1 Essentials of CBT with examples and interactive exercises
2 Warpy Thoughts Questionnaire Identifying dysfunctional thoughts Methods to contest such thoughts
3 Other methods for overcoming warpy thoughts
4 Life Event Stress Relaxation meditation music Pleasant Events Schedule parental style
5 Simple problem solving responses to relationship break-up
Web stats summary
Sessions
Take home points
10487661048766Anxiety disorders are very common
10487661048766Just as fevers these are of different types
10487661048766Accurate Dx and Rx by GP is essential
10487661048766Depression and substance abuse potential
Minimum of six weeks to see Rx effect
Prolonged Rx is necessary 6 m or more
Drug Rx is only a small part of management
SSRI TCAs BZNs MAOIs szlig-blockers etc
CBT Computer treatment VRs Mood GYM
Thank You All Visit us at
wwwdrsarmain
This is sponsored by Torrent ndash
Makers of Clonotril (Clonazepam)
Acute fear state
10487661048766Response to life-threatening danger
10487661048766Terror helplessness
Sense of impending disasterdoom
10487661048766Urgency to flee or seek safety
10487661048766SympatheticNor-adrenergic activation
10487661048766Located in locus ceruleus
1048766 Corresponds to panic attacks
Agoraphobia
Anxiety in situations where escape might be
difficult (or embarrassing) or help might not be
available in the event of having a panic attack or
panic-like symptoms
Situations are avoided or endured with marked
distress
May not leave home or may need a companion
Can occur with and without panic disorder
Agoraphobia
Social Phobia
Marked persistent fear of social or performance
situations where a person is exposed to unfamiliar
situations or people or possible scrutiny by others
The individual fears acting in an embarrassing or
humiliating way
The Person recognizes fear as excessive
Exposure causes anxiety symptoms or panic
Situations are avoided or endured with anxiety
Specific Phobias
Marked and persistent fear that is excessive or unreasonable
cued by the presence or anticipation of a specific object or
situation (eg flying heights animals receiving an injection
seeing blood)
Exposure to the phobic stimulus almost invariably provokes an
immediate anxiety response which may take the form of a
Panic Attack
The person recognizes that hisher fear is excessive or
unreasonable The phobic situation is avoided or else is
endured with intense anxiety or distress
Specific Phobias - Examples
Acrophobia fear of heights
Agoraphobia fear of open places
Claustrophobia fear of enclosed places
Ailurophobia fear of cats
Cynophobia fear of dogs
Pathophobia fear of disease
Mysophobia fear of dirt and germs
Arachnophobia fear of spiders
Hematophobia fear of blood
Xenophobia fear of strangers
Better-halfophobia fear of wife
PAN ndash The Greek God
Panic Attack ndash DSM IV
1 1048766 Palpitations
2 Sweating
3 Trembling or shaking
4 Shortness of breath
5 Feeling of choking
6 Chest pain or discomfort
7 Nausea or abd distress
8 Feeling dizzy fainty
9 Derealization (feelings of unreality)
10 Fear of going crazy
11 Fear of dying
12 Paresthesias
13 Chills or hot flushes
10487661048766A discrete period of intense fear or discomfort in which 4 (or more) of the above 13 symptoms develop abruptly and reach a peak within 10 minutes
Case 2
Mrs B co a long ho episodes of anxiety
SOB racing heart sweating CP and
fears that she is having a MI and will die
These last 30 minutes and are
unexpected She co anxiety while in
malls and traveling alone to new places
for fear of having another attack Despite
a negative wu she still worries about
having a MI during an attack
Panic Disorder with Agoraphobia
Recurrent unexpected panic attacks anxiety
associated with at least four physical andor
cognitive symptoms cognitive symptoms
At least 1 month of worry about having additional
attacks or the consequences of an attack (losing
control having a heart attack ldquogoing crazyrdquo)
Agoraphobia
Panic Disorder ndash Chest pain
Chest pain is a common symptom of panic
attacks
22 ndash 70 of panic attacks are associated with
CP
18 ndash 25 of all patients with chest pain have
PD
Rates of PD higher among cardiology
outpatients with chest pain
Such patients undergo expensive cardiac
workups but their PD remains undiagnosed amp
untreated
Obsessive Compulsive Disorder - OCD
Obsessions Recurrent and persistent thoughts impulses or
images
that are experienced during the disturbance as intrusive
and inappropriate and cause marked 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 to neutralize them with some other thought or action
The person recognizes that the obsessive thoughts
impulses or images are a product of his or her own mind
Obsessive Compulsive Disorder -OCD
Compulsions Repetitive behaviors (eg hand washing ordering
checking) or mental acts (eg praying counting repeating
words silently)
Heshe is driven to perform in response to an obsession
The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event
But these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent and are clearly excessive
Obsessive Compulsive Disorder -OCD
Putamen
Globus Pallidus
Caudate Nucleus
Thalamus
Orbital frontal
cortex
Post traumatic Stress Disorder- PTSD
Post traumatic Stress Disorder- PTSD
Experiential requirements The person has experienced a life-threatening
event and has responded with intense fear
hopelessness or horror The personrsquos response to the event occurred
more
than 4 weeks after it was experienced and lasted
more than one month The traumatic event is persistently re
experienced
in several ways eg by intrusive recollections
dreams illusions hallucinations or flashbacks
Post traumatic stress disorder PTSD
Post traumatic Stress Disorder- PTSD
Behavioral requirements Thought avoidance related-activities
andor People-avoidance behavior Feelings of detachment Blunted affect Sense of doom Insomnia Irritability Hyper vigilance Exaggerated startle response
Post traumatic Stress Disorder- PTSD
Subdivisions Acute ndash when PTSD is diagnosed between 1 and
3
months after the event occurs it is called acute Chronic - when PTSD continues longer than 3
months it is considered chronic and long term Delayed Onset PTSD-this term is used to
describe
those cases where the symptoms do not occur
immediately after the experience but rather
months or years later
Case 3
Mr A witnessed a friend die in a MVA six
weeks ago and co frequent nightmares
of the accident poor sleep fears of
driving anxiety around highways
anhedonia and decreased affection
highways towards his girlfriend His
girlfriend also notes that he has been
very irritable and startles easily since the
accident
Post traumatic Stress Disorder- PTSD
10487661048766Exposure to a traumatic event
10487661048766Response involving intense fear
Helplessness and horror
10487661048766Re-experiencing of the traumatic event
Avoidance of stimulipsychological numbing
10487661048766Increased arousal
10487661048766Symptoms greater than 1 month
Separation Anxiety Disorder - SAD
Medical conditions causing anxiety
10487661048766Endocrine conditions
10487661048766Cardiovascular conditions
10487661048766Respiratory conditions
10487661048766Metabolic conditions
10487661048766Neurological conditions
Substances causing anxiety
10487661048766Alcohol Alcohol
10487661048766Amphetamines
10487661048766Caffeine
10487661048766Cannabis
10487661048766Cocaine
10487661048766Hallucinogens
10487661048766Inhalants
10487661048766Phencyclidine
Substances that cause
anxiety (withdrawal)
10487661048766Alcohol
10487661048766Cocaine
10487661048766Sedatives
10487661048766Hypnotics
10487661048766Anxiolytics
Medications causing anxiety
Anesthetics
Analgesics
Sympathomimetics
Bronchodilators
Anti-cholinergics
1048766Insulin
Thyroid hormones
Oral contraceptives
Antihistamines
Anti-parkinsonians
1048766Corticosteroids
Antihypertensives
Cardiovascular drugs
Anticonvulsants
Anxiety Disorders
Current Management Strategies
Management of Anxiety Disorders
1048766 Pharmacotherapy (Medications)
Psycho-analytic therapy ndash PT
Behavior Therapy - BT
Cognitive Behavior Therapy ndash CBT
Computer therapy - CT
1048766 Virtual Realty ndash VR
Mood GYM
Drug Rx of Anxiety Disorders
Clonazepam
How do anxiolytics act
GABA and Glycine are inhibitory neurotransmitter
Serotonin and Noradrenaline are excitatory
Anxiety is increased excitatory transmitters
BZNs increase GABA and increase inhibition
SSRI decrease the serotonin levels and darrexcitation
TCAs act by darrboth serotonin and noradrenaline
Drug Rx of Anxiety Disorders
Disorder First Choice 2nd Choice Short (prn) Add on
GADBZN-
CZ CDZ ALZBeta-blockers Buspirone Carbamazp
Panic Disorder
Paroxetine
CitalopramTCA-
ClomipramineBZN-
ALZ CZ LZMAOI -
Phenelzine
Phobias Beta-blockers SSRIsBZN-
ALZ CZMAOI
OCD Clomipramine Fluoxetine CDZ Buspirone
PTSDTCA-
Imipra Amytrp
SSRI- FLX
Sertaline CPBZN MAOI
Comparison of Benzodiazepines
BZN Sedation Anxiolytic Half life Lipid solu Dose
Diazepam +++ + 20-80 h High 5 mg od
Alprazolam + +++ 6-20 h Low 05 mg qid
Clonazapam ++ +++ 22-50 h Low 05 mg bid
Lorazepam ++ ++ 10-20 h Med 1 mg tid
Chlordiazepx + + 7-30 h Med 15 mg bid
Different strategies of therapy
Behavior therapy
Desensitization
Behavior modification
Behavioral activation
Cognitive therapy
Rational-emotive therapy
Beckrsquos cognitive therapy
Newer approaches
Mindfulness meditation
Acceptance and commitment therapy
Dialectical Behavior Therapy (BPD)
Cognitive Behaviour Therapy - CBT
CBT is a method used to treat anxiety
Recognition of ldquodistorted thinkingrdquo
ldquoCognitive restructuringrdquo
It may also involve classical conditioning when used to treat Obsessive Compulsive Disorder
CBT ndash Obstacles - Restructuring
Hopelessness
Self-criticism
Fear of getting worse
Shame and embarrassment
Partial exposure
Blaming other people
Low motivation
Looking for complex solution
Depressing ruminations
There must be an easier way
Computer Therapy
Pts are ashamed to seek help and may fear the consequences at work and home
Therapy is expensive and beyond the reach of many patients
Computer therapy is very cheap and available by comparison
Computer Therapy ndash Softwares
Fearfighter - for phobiapanic
Cope - for depressionanxiety
Balance - for GAD
BTSteps - for OCD
These are PC based in a CD-Rom
or phone based or Web-based
MENTAL OUTSIDE
Virtual Reality - VR
VR therapy via SD (Systematic Desensitization) is becoming very popular
SD is a process of gradually introducing a disturbing stimulus (eg view from a high place) in otherwise pleasant surroundings
This process gradually suppresses the anxiety response
Virtual Reality ndash VR - Advantages
Patients often have difficulty imagining the stimulus themselves
They are often afraid of experiencing it directly ndash which may also be expensive and time-consuming
VR affords patient privacy and confidentiality during treatment
Very good for phobias
Virtual Reality ndash VR - Imagination
ldquoProjection in timerdquo ndash rationally reconstructing the future
ldquoDe-catastrophizing an imagerdquo ndash modifying a disturbing image
ldquoImage modeling and substitutionrdquo ndashinterrupting a negative train of images
ldquoCovert conditioningrdquo ndash subtle conditioning using imagined rather than real stimuli
Virtual Reality ndash VR - Hutchworld
Hutchworld is a virtual community attached to the Hutchison Cancer Research Center
Designed to provide social support for cancer patients and their families
Based on Microsoftrsquos Vworldrsquos system
Mood GYM on the Internet
Few GPs are trained in CBT
Clinical psychologists are expensive
Young people are not easily reached
They may not want them ndash embarrassment
The web is accessible convenient and popular
with young people
Deliver CBT via internet ndash 5 modules
Mood GYM Modules
5 Modules - analysis and results
1 Essentials of CBT with examples and interactive exercises
2 Warpy Thoughts Questionnaire Identifying dysfunctional thoughts Methods to contest such thoughts
3 Other methods for overcoming warpy thoughts
4 Life Event Stress Relaxation meditation music Pleasant Events Schedule parental style
5 Simple problem solving responses to relationship break-up
Web stats summary
Sessions
Take home points
10487661048766Anxiety disorders are very common
10487661048766Just as fevers these are of different types
10487661048766Accurate Dx and Rx by GP is essential
10487661048766Depression and substance abuse potential
Minimum of six weeks to see Rx effect
Prolonged Rx is necessary 6 m or more
Drug Rx is only a small part of management
SSRI TCAs BZNs MAOIs szlig-blockers etc
CBT Computer treatment VRs Mood GYM
Thank You All Visit us at
wwwdrsarmain
This is sponsored by Torrent ndash
Makers of Clonotril (Clonazepam)
Agoraphobia
Anxiety in situations where escape might be
difficult (or embarrassing) or help might not be
available in the event of having a panic attack or
panic-like symptoms
Situations are avoided or endured with marked
distress
May not leave home or may need a companion
Can occur with and without panic disorder
Agoraphobia
Social Phobia
Marked persistent fear of social or performance
situations where a person is exposed to unfamiliar
situations or people or possible scrutiny by others
The individual fears acting in an embarrassing or
humiliating way
The Person recognizes fear as excessive
Exposure causes anxiety symptoms or panic
Situations are avoided or endured with anxiety
Specific Phobias
Marked and persistent fear that is excessive or unreasonable
cued by the presence or anticipation of a specific object or
situation (eg flying heights animals receiving an injection
seeing blood)
Exposure to the phobic stimulus almost invariably provokes an
immediate anxiety response which may take the form of a
Panic Attack
The person recognizes that hisher fear is excessive or
unreasonable The phobic situation is avoided or else is
endured with intense anxiety or distress
Specific Phobias - Examples
Acrophobia fear of heights
Agoraphobia fear of open places
Claustrophobia fear of enclosed places
Ailurophobia fear of cats
Cynophobia fear of dogs
Pathophobia fear of disease
Mysophobia fear of dirt and germs
Arachnophobia fear of spiders
Hematophobia fear of blood
Xenophobia fear of strangers
Better-halfophobia fear of wife
PAN ndash The Greek God
Panic Attack ndash DSM IV
1 1048766 Palpitations
2 Sweating
3 Trembling or shaking
4 Shortness of breath
5 Feeling of choking
6 Chest pain or discomfort
7 Nausea or abd distress
8 Feeling dizzy fainty
9 Derealization (feelings of unreality)
10 Fear of going crazy
11 Fear of dying
12 Paresthesias
13 Chills or hot flushes
10487661048766A discrete period of intense fear or discomfort in which 4 (or more) of the above 13 symptoms develop abruptly and reach a peak within 10 minutes
Case 2
Mrs B co a long ho episodes of anxiety
SOB racing heart sweating CP and
fears that she is having a MI and will die
These last 30 minutes and are
unexpected She co anxiety while in
malls and traveling alone to new places
for fear of having another attack Despite
a negative wu she still worries about
having a MI during an attack
Panic Disorder with Agoraphobia
Recurrent unexpected panic attacks anxiety
associated with at least four physical andor
cognitive symptoms cognitive symptoms
At least 1 month of worry about having additional
attacks or the consequences of an attack (losing
control having a heart attack ldquogoing crazyrdquo)
Agoraphobia
Panic Disorder ndash Chest pain
Chest pain is a common symptom of panic
attacks
22 ndash 70 of panic attacks are associated with
CP
18 ndash 25 of all patients with chest pain have
PD
Rates of PD higher among cardiology
outpatients with chest pain
Such patients undergo expensive cardiac
workups but their PD remains undiagnosed amp
untreated
Obsessive Compulsive Disorder - OCD
Obsessions Recurrent and persistent thoughts impulses or
images
that are experienced during the disturbance as intrusive
and inappropriate and cause marked 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 to neutralize them with some other thought or action
The person recognizes that the obsessive thoughts
impulses or images are a product of his or her own mind
Obsessive Compulsive Disorder -OCD
Compulsions Repetitive behaviors (eg hand washing ordering
checking) or mental acts (eg praying counting repeating
words silently)
Heshe is driven to perform in response to an obsession
The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event
But these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent and are clearly excessive
Obsessive Compulsive Disorder -OCD
Putamen
Globus Pallidus
Caudate Nucleus
Thalamus
Orbital frontal
cortex
Post traumatic Stress Disorder- PTSD
Post traumatic Stress Disorder- PTSD
Experiential requirements The person has experienced a life-threatening
event and has responded with intense fear
hopelessness or horror The personrsquos response to the event occurred
more
than 4 weeks after it was experienced and lasted
more than one month The traumatic event is persistently re
experienced
in several ways eg by intrusive recollections
dreams illusions hallucinations or flashbacks
Post traumatic stress disorder PTSD
Post traumatic Stress Disorder- PTSD
Behavioral requirements Thought avoidance related-activities
andor People-avoidance behavior Feelings of detachment Blunted affect Sense of doom Insomnia Irritability Hyper vigilance Exaggerated startle response
Post traumatic Stress Disorder- PTSD
Subdivisions Acute ndash when PTSD is diagnosed between 1 and
3
months after the event occurs it is called acute Chronic - when PTSD continues longer than 3
months it is considered chronic and long term Delayed Onset PTSD-this term is used to
describe
those cases where the symptoms do not occur
immediately after the experience but rather
months or years later
Case 3
Mr A witnessed a friend die in a MVA six
weeks ago and co frequent nightmares
of the accident poor sleep fears of
driving anxiety around highways
anhedonia and decreased affection
highways towards his girlfriend His
girlfriend also notes that he has been
very irritable and startles easily since the
accident
Post traumatic Stress Disorder- PTSD
10487661048766Exposure to a traumatic event
10487661048766Response involving intense fear
Helplessness and horror
10487661048766Re-experiencing of the traumatic event
Avoidance of stimulipsychological numbing
10487661048766Increased arousal
10487661048766Symptoms greater than 1 month
Separation Anxiety Disorder - SAD
Medical conditions causing anxiety
10487661048766Endocrine conditions
10487661048766Cardiovascular conditions
10487661048766Respiratory conditions
10487661048766Metabolic conditions
10487661048766Neurological conditions
Substances causing anxiety
10487661048766Alcohol Alcohol
10487661048766Amphetamines
10487661048766Caffeine
10487661048766Cannabis
10487661048766Cocaine
10487661048766Hallucinogens
10487661048766Inhalants
10487661048766Phencyclidine
Substances that cause
anxiety (withdrawal)
10487661048766Alcohol
10487661048766Cocaine
10487661048766Sedatives
10487661048766Hypnotics
10487661048766Anxiolytics
Medications causing anxiety
Anesthetics
Analgesics
Sympathomimetics
Bronchodilators
Anti-cholinergics
1048766Insulin
Thyroid hormones
Oral contraceptives
Antihistamines
Anti-parkinsonians
1048766Corticosteroids
Antihypertensives
Cardiovascular drugs
Anticonvulsants
Anxiety Disorders
Current Management Strategies
Management of Anxiety Disorders
1048766 Pharmacotherapy (Medications)
Psycho-analytic therapy ndash PT
Behavior Therapy - BT
Cognitive Behavior Therapy ndash CBT
Computer therapy - CT
1048766 Virtual Realty ndash VR
Mood GYM
Drug Rx of Anxiety Disorders
Clonazepam
How do anxiolytics act
GABA and Glycine are inhibitory neurotransmitter
Serotonin and Noradrenaline are excitatory
Anxiety is increased excitatory transmitters
BZNs increase GABA and increase inhibition
SSRI decrease the serotonin levels and darrexcitation
TCAs act by darrboth serotonin and noradrenaline
Drug Rx of Anxiety Disorders
Disorder First Choice 2nd Choice Short (prn) Add on
GADBZN-
CZ CDZ ALZBeta-blockers Buspirone Carbamazp
Panic Disorder
Paroxetine
CitalopramTCA-
ClomipramineBZN-
ALZ CZ LZMAOI -
Phenelzine
Phobias Beta-blockers SSRIsBZN-
ALZ CZMAOI
OCD Clomipramine Fluoxetine CDZ Buspirone
PTSDTCA-
Imipra Amytrp
SSRI- FLX
Sertaline CPBZN MAOI
Comparison of Benzodiazepines
BZN Sedation Anxiolytic Half life Lipid solu Dose
Diazepam +++ + 20-80 h High 5 mg od
Alprazolam + +++ 6-20 h Low 05 mg qid
Clonazapam ++ +++ 22-50 h Low 05 mg bid
Lorazepam ++ ++ 10-20 h Med 1 mg tid
Chlordiazepx + + 7-30 h Med 15 mg bid
Different strategies of therapy
Behavior therapy
Desensitization
Behavior modification
Behavioral activation
Cognitive therapy
Rational-emotive therapy
Beckrsquos cognitive therapy
Newer approaches
Mindfulness meditation
Acceptance and commitment therapy
Dialectical Behavior Therapy (BPD)
Cognitive Behaviour Therapy - CBT
CBT is a method used to treat anxiety
Recognition of ldquodistorted thinkingrdquo
ldquoCognitive restructuringrdquo
It may also involve classical conditioning when used to treat Obsessive Compulsive Disorder
CBT ndash Obstacles - Restructuring
Hopelessness
Self-criticism
Fear of getting worse
Shame and embarrassment
Partial exposure
Blaming other people
Low motivation
Looking for complex solution
Depressing ruminations
There must be an easier way
Computer Therapy
Pts are ashamed to seek help and may fear the consequences at work and home
Therapy is expensive and beyond the reach of many patients
Computer therapy is very cheap and available by comparison
Computer Therapy ndash Softwares
Fearfighter - for phobiapanic
Cope - for depressionanxiety
Balance - for GAD
BTSteps - for OCD
These are PC based in a CD-Rom
or phone based or Web-based
MENTAL OUTSIDE
Virtual Reality - VR
VR therapy via SD (Systematic Desensitization) is becoming very popular
SD is a process of gradually introducing a disturbing stimulus (eg view from a high place) in otherwise pleasant surroundings
This process gradually suppresses the anxiety response
Virtual Reality ndash VR - Advantages
Patients often have difficulty imagining the stimulus themselves
They are often afraid of experiencing it directly ndash which may also be expensive and time-consuming
VR affords patient privacy and confidentiality during treatment
Very good for phobias
Virtual Reality ndash VR - Imagination
ldquoProjection in timerdquo ndash rationally reconstructing the future
ldquoDe-catastrophizing an imagerdquo ndash modifying a disturbing image
ldquoImage modeling and substitutionrdquo ndashinterrupting a negative train of images
ldquoCovert conditioningrdquo ndash subtle conditioning using imagined rather than real stimuli
Virtual Reality ndash VR - Hutchworld
Hutchworld is a virtual community attached to the Hutchison Cancer Research Center
Designed to provide social support for cancer patients and their families
Based on Microsoftrsquos Vworldrsquos system
Mood GYM on the Internet
Few GPs are trained in CBT
Clinical psychologists are expensive
Young people are not easily reached
They may not want them ndash embarrassment
The web is accessible convenient and popular
with young people
Deliver CBT via internet ndash 5 modules
Mood GYM Modules
5 Modules - analysis and results
1 Essentials of CBT with examples and interactive exercises
2 Warpy Thoughts Questionnaire Identifying dysfunctional thoughts Methods to contest such thoughts
3 Other methods for overcoming warpy thoughts
4 Life Event Stress Relaxation meditation music Pleasant Events Schedule parental style
5 Simple problem solving responses to relationship break-up
Web stats summary
Sessions
Take home points
10487661048766Anxiety disorders are very common
10487661048766Just as fevers these are of different types
10487661048766Accurate Dx and Rx by GP is essential
10487661048766Depression and substance abuse potential
Minimum of six weeks to see Rx effect
Prolonged Rx is necessary 6 m or more
Drug Rx is only a small part of management
SSRI TCAs BZNs MAOIs szlig-blockers etc
CBT Computer treatment VRs Mood GYM
Thank You All Visit us at
wwwdrsarmain
This is sponsored by Torrent ndash
Makers of Clonotril (Clonazepam)
Agoraphobia
Social Phobia
Marked persistent fear of social or performance
situations where a person is exposed to unfamiliar
situations or people or possible scrutiny by others
The individual fears acting in an embarrassing or
humiliating way
The Person recognizes fear as excessive
Exposure causes anxiety symptoms or panic
Situations are avoided or endured with anxiety
Specific Phobias
Marked and persistent fear that is excessive or unreasonable
cued by the presence or anticipation of a specific object or
situation (eg flying heights animals receiving an injection
seeing blood)
Exposure to the phobic stimulus almost invariably provokes an
immediate anxiety response which may take the form of a
Panic Attack
The person recognizes that hisher fear is excessive or
unreasonable The phobic situation is avoided or else is
endured with intense anxiety or distress
Specific Phobias - Examples
Acrophobia fear of heights
Agoraphobia fear of open places
Claustrophobia fear of enclosed places
Ailurophobia fear of cats
Cynophobia fear of dogs
Pathophobia fear of disease
Mysophobia fear of dirt and germs
Arachnophobia fear of spiders
Hematophobia fear of blood
Xenophobia fear of strangers
Better-halfophobia fear of wife
PAN ndash The Greek God
Panic Attack ndash DSM IV
1 1048766 Palpitations
2 Sweating
3 Trembling or shaking
4 Shortness of breath
5 Feeling of choking
6 Chest pain or discomfort
7 Nausea or abd distress
8 Feeling dizzy fainty
9 Derealization (feelings of unreality)
10 Fear of going crazy
11 Fear of dying
12 Paresthesias
13 Chills or hot flushes
10487661048766A discrete period of intense fear or discomfort in which 4 (or more) of the above 13 symptoms develop abruptly and reach a peak within 10 minutes
Case 2
Mrs B co a long ho episodes of anxiety
SOB racing heart sweating CP and
fears that she is having a MI and will die
These last 30 minutes and are
unexpected She co anxiety while in
malls and traveling alone to new places
for fear of having another attack Despite
a negative wu she still worries about
having a MI during an attack
Panic Disorder with Agoraphobia
Recurrent unexpected panic attacks anxiety
associated with at least four physical andor
cognitive symptoms cognitive symptoms
At least 1 month of worry about having additional
attacks or the consequences of an attack (losing
control having a heart attack ldquogoing crazyrdquo)
Agoraphobia
Panic Disorder ndash Chest pain
Chest pain is a common symptom of panic
attacks
22 ndash 70 of panic attacks are associated with
CP
18 ndash 25 of all patients with chest pain have
PD
Rates of PD higher among cardiology
outpatients with chest pain
Such patients undergo expensive cardiac
workups but their PD remains undiagnosed amp
untreated
Obsessive Compulsive Disorder - OCD
Obsessions Recurrent and persistent thoughts impulses or
images
that are experienced during the disturbance as intrusive
and inappropriate and cause marked 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 to neutralize them with some other thought or action
The person recognizes that the obsessive thoughts
impulses or images are a product of his or her own mind
Obsessive Compulsive Disorder -OCD
Compulsions Repetitive behaviors (eg hand washing ordering
checking) or mental acts (eg praying counting repeating
words silently)
Heshe is driven to perform in response to an obsession
The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event
But these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent and are clearly excessive
Obsessive Compulsive Disorder -OCD
Putamen
Globus Pallidus
Caudate Nucleus
Thalamus
Orbital frontal
cortex
Post traumatic Stress Disorder- PTSD
Post traumatic Stress Disorder- PTSD
Experiential requirements The person has experienced a life-threatening
event and has responded with intense fear
hopelessness or horror The personrsquos response to the event occurred
more
than 4 weeks after it was experienced and lasted
more than one month The traumatic event is persistently re
experienced
in several ways eg by intrusive recollections
dreams illusions hallucinations or flashbacks
Post traumatic stress disorder PTSD
Post traumatic Stress Disorder- PTSD
Behavioral requirements Thought avoidance related-activities
andor People-avoidance behavior Feelings of detachment Blunted affect Sense of doom Insomnia Irritability Hyper vigilance Exaggerated startle response
Post traumatic Stress Disorder- PTSD
Subdivisions Acute ndash when PTSD is diagnosed between 1 and
3
months after the event occurs it is called acute Chronic - when PTSD continues longer than 3
months it is considered chronic and long term Delayed Onset PTSD-this term is used to
describe
those cases where the symptoms do not occur
immediately after the experience but rather
months or years later
Case 3
Mr A witnessed a friend die in a MVA six
weeks ago and co frequent nightmares
of the accident poor sleep fears of
driving anxiety around highways
anhedonia and decreased affection
highways towards his girlfriend His
girlfriend also notes that he has been
very irritable and startles easily since the
accident
Post traumatic Stress Disorder- PTSD
10487661048766Exposure to a traumatic event
10487661048766Response involving intense fear
Helplessness and horror
10487661048766Re-experiencing of the traumatic event
Avoidance of stimulipsychological numbing
10487661048766Increased arousal
10487661048766Symptoms greater than 1 month
Separation Anxiety Disorder - SAD
Medical conditions causing anxiety
10487661048766Endocrine conditions
10487661048766Cardiovascular conditions
10487661048766Respiratory conditions
10487661048766Metabolic conditions
10487661048766Neurological conditions
Substances causing anxiety
10487661048766Alcohol Alcohol
10487661048766Amphetamines
10487661048766Caffeine
10487661048766Cannabis
10487661048766Cocaine
10487661048766Hallucinogens
10487661048766Inhalants
10487661048766Phencyclidine
Substances that cause
anxiety (withdrawal)
10487661048766Alcohol
10487661048766Cocaine
10487661048766Sedatives
10487661048766Hypnotics
10487661048766Anxiolytics
Medications causing anxiety
Anesthetics
Analgesics
Sympathomimetics
Bronchodilators
Anti-cholinergics
1048766Insulin
Thyroid hormones
Oral contraceptives
Antihistamines
Anti-parkinsonians
1048766Corticosteroids
Antihypertensives
Cardiovascular drugs
Anticonvulsants
Anxiety Disorders
Current Management Strategies
Management of Anxiety Disorders
1048766 Pharmacotherapy (Medications)
Psycho-analytic therapy ndash PT
Behavior Therapy - BT
Cognitive Behavior Therapy ndash CBT
Computer therapy - CT
1048766 Virtual Realty ndash VR
Mood GYM
Drug Rx of Anxiety Disorders
Clonazepam
How do anxiolytics act
GABA and Glycine are inhibitory neurotransmitter
Serotonin and Noradrenaline are excitatory
Anxiety is increased excitatory transmitters
BZNs increase GABA and increase inhibition
SSRI decrease the serotonin levels and darrexcitation
TCAs act by darrboth serotonin and noradrenaline
Drug Rx of Anxiety Disorders
Disorder First Choice 2nd Choice Short (prn) Add on
GADBZN-
CZ CDZ ALZBeta-blockers Buspirone Carbamazp
Panic Disorder
Paroxetine
CitalopramTCA-
ClomipramineBZN-
ALZ CZ LZMAOI -
Phenelzine
Phobias Beta-blockers SSRIsBZN-
ALZ CZMAOI
OCD Clomipramine Fluoxetine CDZ Buspirone
PTSDTCA-
Imipra Amytrp
SSRI- FLX
Sertaline CPBZN MAOI
Comparison of Benzodiazepines
BZN Sedation Anxiolytic Half life Lipid solu Dose
Diazepam +++ + 20-80 h High 5 mg od
Alprazolam + +++ 6-20 h Low 05 mg qid
Clonazapam ++ +++ 22-50 h Low 05 mg bid
Lorazepam ++ ++ 10-20 h Med 1 mg tid
Chlordiazepx + + 7-30 h Med 15 mg bid
Different strategies of therapy
Behavior therapy
Desensitization
Behavior modification
Behavioral activation
Cognitive therapy
Rational-emotive therapy
Beckrsquos cognitive therapy
Newer approaches
Mindfulness meditation
Acceptance and commitment therapy
Dialectical Behavior Therapy (BPD)
Cognitive Behaviour Therapy - CBT
CBT is a method used to treat anxiety
Recognition of ldquodistorted thinkingrdquo
ldquoCognitive restructuringrdquo
It may also involve classical conditioning when used to treat Obsessive Compulsive Disorder
CBT ndash Obstacles - Restructuring
Hopelessness
Self-criticism
Fear of getting worse
Shame and embarrassment
Partial exposure
Blaming other people
Low motivation
Looking for complex solution
Depressing ruminations
There must be an easier way
Computer Therapy
Pts are ashamed to seek help and may fear the consequences at work and home
Therapy is expensive and beyond the reach of many patients
Computer therapy is very cheap and available by comparison
Computer Therapy ndash Softwares
Fearfighter - for phobiapanic
Cope - for depressionanxiety
Balance - for GAD
BTSteps - for OCD
These are PC based in a CD-Rom
or phone based or Web-based
MENTAL OUTSIDE
Virtual Reality - VR
VR therapy via SD (Systematic Desensitization) is becoming very popular
SD is a process of gradually introducing a disturbing stimulus (eg view from a high place) in otherwise pleasant surroundings
This process gradually suppresses the anxiety response
Virtual Reality ndash VR - Advantages
Patients often have difficulty imagining the stimulus themselves
They are often afraid of experiencing it directly ndash which may also be expensive and time-consuming
VR affords patient privacy and confidentiality during treatment
Very good for phobias
Virtual Reality ndash VR - Imagination
ldquoProjection in timerdquo ndash rationally reconstructing the future
ldquoDe-catastrophizing an imagerdquo ndash modifying a disturbing image
ldquoImage modeling and substitutionrdquo ndashinterrupting a negative train of images
ldquoCovert conditioningrdquo ndash subtle conditioning using imagined rather than real stimuli
Virtual Reality ndash VR - Hutchworld
Hutchworld is a virtual community attached to the Hutchison Cancer Research Center
Designed to provide social support for cancer patients and their families
Based on Microsoftrsquos Vworldrsquos system
Mood GYM on the Internet
Few GPs are trained in CBT
Clinical psychologists are expensive
Young people are not easily reached
They may not want them ndash embarrassment
The web is accessible convenient and popular
with young people
Deliver CBT via internet ndash 5 modules
Mood GYM Modules
5 Modules - analysis and results
1 Essentials of CBT with examples and interactive exercises
2 Warpy Thoughts Questionnaire Identifying dysfunctional thoughts Methods to contest such thoughts
3 Other methods for overcoming warpy thoughts
4 Life Event Stress Relaxation meditation music Pleasant Events Schedule parental style
5 Simple problem solving responses to relationship break-up
Web stats summary
Sessions
Take home points
10487661048766Anxiety disorders are very common
10487661048766Just as fevers these are of different types
10487661048766Accurate Dx and Rx by GP is essential
10487661048766Depression and substance abuse potential
Minimum of six weeks to see Rx effect
Prolonged Rx is necessary 6 m or more
Drug Rx is only a small part of management
SSRI TCAs BZNs MAOIs szlig-blockers etc
CBT Computer treatment VRs Mood GYM
Thank You All Visit us at
wwwdrsarmain
This is sponsored by Torrent ndash
Makers of Clonotril (Clonazepam)
Social Phobia
Marked persistent fear of social or performance
situations where a person is exposed to unfamiliar
situations or people or possible scrutiny by others
The individual fears acting in an embarrassing or
humiliating way
The Person recognizes fear as excessive
Exposure causes anxiety symptoms or panic
Situations are avoided or endured with anxiety
Specific Phobias
Marked and persistent fear that is excessive or unreasonable
cued by the presence or anticipation of a specific object or
situation (eg flying heights animals receiving an injection
seeing blood)
Exposure to the phobic stimulus almost invariably provokes an
immediate anxiety response which may take the form of a
Panic Attack
The person recognizes that hisher fear is excessive or
unreasonable The phobic situation is avoided or else is
endured with intense anxiety or distress
Specific Phobias - Examples
Acrophobia fear of heights
Agoraphobia fear of open places
Claustrophobia fear of enclosed places
Ailurophobia fear of cats
Cynophobia fear of dogs
Pathophobia fear of disease
Mysophobia fear of dirt and germs
Arachnophobia fear of spiders
Hematophobia fear of blood
Xenophobia fear of strangers
Better-halfophobia fear of wife
PAN ndash The Greek God
Panic Attack ndash DSM IV
1 1048766 Palpitations
2 Sweating
3 Trembling or shaking
4 Shortness of breath
5 Feeling of choking
6 Chest pain or discomfort
7 Nausea or abd distress
8 Feeling dizzy fainty
9 Derealization (feelings of unreality)
10 Fear of going crazy
11 Fear of dying
12 Paresthesias
13 Chills or hot flushes
10487661048766A discrete period of intense fear or discomfort in which 4 (or more) of the above 13 symptoms develop abruptly and reach a peak within 10 minutes
Case 2
Mrs B co a long ho episodes of anxiety
SOB racing heart sweating CP and
fears that she is having a MI and will die
These last 30 minutes and are
unexpected She co anxiety while in
malls and traveling alone to new places
for fear of having another attack Despite
a negative wu she still worries about
having a MI during an attack
Panic Disorder with Agoraphobia
Recurrent unexpected panic attacks anxiety
associated with at least four physical andor
cognitive symptoms cognitive symptoms
At least 1 month of worry about having additional
attacks or the consequences of an attack (losing
control having a heart attack ldquogoing crazyrdquo)
Agoraphobia
Panic Disorder ndash Chest pain
Chest pain is a common symptom of panic
attacks
22 ndash 70 of panic attacks are associated with
CP
18 ndash 25 of all patients with chest pain have
PD
Rates of PD higher among cardiology
outpatients with chest pain
Such patients undergo expensive cardiac
workups but their PD remains undiagnosed amp
untreated
Obsessive Compulsive Disorder - OCD
Obsessions Recurrent and persistent thoughts impulses or
images
that are experienced during the disturbance as intrusive
and inappropriate and cause marked 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 to neutralize them with some other thought or action
The person recognizes that the obsessive thoughts
impulses or images are a product of his or her own mind
Obsessive Compulsive Disorder -OCD
Compulsions Repetitive behaviors (eg hand washing ordering
checking) or mental acts (eg praying counting repeating
words silently)
Heshe is driven to perform in response to an obsession
The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event
But these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent and are clearly excessive
Obsessive Compulsive Disorder -OCD
Putamen
Globus Pallidus
Caudate Nucleus
Thalamus
Orbital frontal
cortex
Post traumatic Stress Disorder- PTSD
Post traumatic Stress Disorder- PTSD
Experiential requirements The person has experienced a life-threatening
event and has responded with intense fear
hopelessness or horror The personrsquos response to the event occurred
more
than 4 weeks after it was experienced and lasted
more than one month The traumatic event is persistently re
experienced
in several ways eg by intrusive recollections
dreams illusions hallucinations or flashbacks
Post traumatic stress disorder PTSD
Post traumatic Stress Disorder- PTSD
Behavioral requirements Thought avoidance related-activities
andor People-avoidance behavior Feelings of detachment Blunted affect Sense of doom Insomnia Irritability Hyper vigilance Exaggerated startle response
Post traumatic Stress Disorder- PTSD
Subdivisions Acute ndash when PTSD is diagnosed between 1 and
3
months after the event occurs it is called acute Chronic - when PTSD continues longer than 3
months it is considered chronic and long term Delayed Onset PTSD-this term is used to
describe
those cases where the symptoms do not occur
immediately after the experience but rather
months or years later
Case 3
Mr A witnessed a friend die in a MVA six
weeks ago and co frequent nightmares
of the accident poor sleep fears of
driving anxiety around highways
anhedonia and decreased affection
highways towards his girlfriend His
girlfriend also notes that he has been
very irritable and startles easily since the
accident
Post traumatic Stress Disorder- PTSD
10487661048766Exposure to a traumatic event
10487661048766Response involving intense fear
Helplessness and horror
10487661048766Re-experiencing of the traumatic event
Avoidance of stimulipsychological numbing
10487661048766Increased arousal
10487661048766Symptoms greater than 1 month
Separation Anxiety Disorder - SAD
Medical conditions causing anxiety
10487661048766Endocrine conditions
10487661048766Cardiovascular conditions
10487661048766Respiratory conditions
10487661048766Metabolic conditions
10487661048766Neurological conditions
Substances causing anxiety
10487661048766Alcohol Alcohol
10487661048766Amphetamines
10487661048766Caffeine
10487661048766Cannabis
10487661048766Cocaine
10487661048766Hallucinogens
10487661048766Inhalants
10487661048766Phencyclidine
Substances that cause
anxiety (withdrawal)
10487661048766Alcohol
10487661048766Cocaine
10487661048766Sedatives
10487661048766Hypnotics
10487661048766Anxiolytics
Medications causing anxiety
Anesthetics
Analgesics
Sympathomimetics
Bronchodilators
Anti-cholinergics
1048766Insulin
Thyroid hormones
Oral contraceptives
Antihistamines
Anti-parkinsonians
1048766Corticosteroids
Antihypertensives
Cardiovascular drugs
Anticonvulsants
Anxiety Disorders
Current Management Strategies
Management of Anxiety Disorders
1048766 Pharmacotherapy (Medications)
Psycho-analytic therapy ndash PT
Behavior Therapy - BT
Cognitive Behavior Therapy ndash CBT
Computer therapy - CT
1048766 Virtual Realty ndash VR
Mood GYM
Drug Rx of Anxiety Disorders
Clonazepam
How do anxiolytics act
GABA and Glycine are inhibitory neurotransmitter
Serotonin and Noradrenaline are excitatory
Anxiety is increased excitatory transmitters
BZNs increase GABA and increase inhibition
SSRI decrease the serotonin levels and darrexcitation
TCAs act by darrboth serotonin and noradrenaline
Drug Rx of Anxiety Disorders
Disorder First Choice 2nd Choice Short (prn) Add on
GADBZN-
CZ CDZ ALZBeta-blockers Buspirone Carbamazp
Panic Disorder
Paroxetine
CitalopramTCA-
ClomipramineBZN-
ALZ CZ LZMAOI -
Phenelzine
Phobias Beta-blockers SSRIsBZN-
ALZ CZMAOI
OCD Clomipramine Fluoxetine CDZ Buspirone
PTSDTCA-
Imipra Amytrp
SSRI- FLX
Sertaline CPBZN MAOI
Comparison of Benzodiazepines
BZN Sedation Anxiolytic Half life Lipid solu Dose
Diazepam +++ + 20-80 h High 5 mg od
Alprazolam + +++ 6-20 h Low 05 mg qid
Clonazapam ++ +++ 22-50 h Low 05 mg bid
Lorazepam ++ ++ 10-20 h Med 1 mg tid
Chlordiazepx + + 7-30 h Med 15 mg bid
Different strategies of therapy
Behavior therapy
Desensitization
Behavior modification
Behavioral activation
Cognitive therapy
Rational-emotive therapy
Beckrsquos cognitive therapy
Newer approaches
Mindfulness meditation
Acceptance and commitment therapy
Dialectical Behavior Therapy (BPD)
Cognitive Behaviour Therapy - CBT
CBT is a method used to treat anxiety
Recognition of ldquodistorted thinkingrdquo
ldquoCognitive restructuringrdquo
It may also involve classical conditioning when used to treat Obsessive Compulsive Disorder
CBT ndash Obstacles - Restructuring
Hopelessness
Self-criticism
Fear of getting worse
Shame and embarrassment
Partial exposure
Blaming other people
Low motivation
Looking for complex solution
Depressing ruminations
There must be an easier way
Computer Therapy
Pts are ashamed to seek help and may fear the consequences at work and home
Therapy is expensive and beyond the reach of many patients
Computer therapy is very cheap and available by comparison
Computer Therapy ndash Softwares
Fearfighter - for phobiapanic
Cope - for depressionanxiety
Balance - for GAD
BTSteps - for OCD
These are PC based in a CD-Rom
or phone based or Web-based
MENTAL OUTSIDE
Virtual Reality - VR
VR therapy via SD (Systematic Desensitization) is becoming very popular
SD is a process of gradually introducing a disturbing stimulus (eg view from a high place) in otherwise pleasant surroundings
This process gradually suppresses the anxiety response
Virtual Reality ndash VR - Advantages
Patients often have difficulty imagining the stimulus themselves
They are often afraid of experiencing it directly ndash which may also be expensive and time-consuming
VR affords patient privacy and confidentiality during treatment
Very good for phobias
Virtual Reality ndash VR - Imagination
ldquoProjection in timerdquo ndash rationally reconstructing the future
ldquoDe-catastrophizing an imagerdquo ndash modifying a disturbing image
ldquoImage modeling and substitutionrdquo ndashinterrupting a negative train of images
ldquoCovert conditioningrdquo ndash subtle conditioning using imagined rather than real stimuli
Virtual Reality ndash VR - Hutchworld
Hutchworld is a virtual community attached to the Hutchison Cancer Research Center
Designed to provide social support for cancer patients and their families
Based on Microsoftrsquos Vworldrsquos system
Mood GYM on the Internet
Few GPs are trained in CBT
Clinical psychologists are expensive
Young people are not easily reached
They may not want them ndash embarrassment
The web is accessible convenient and popular
with young people
Deliver CBT via internet ndash 5 modules
Mood GYM Modules
5 Modules - analysis and results
1 Essentials of CBT with examples and interactive exercises
2 Warpy Thoughts Questionnaire Identifying dysfunctional thoughts Methods to contest such thoughts
3 Other methods for overcoming warpy thoughts
4 Life Event Stress Relaxation meditation music Pleasant Events Schedule parental style
5 Simple problem solving responses to relationship break-up
Web stats summary
Sessions
Take home points
10487661048766Anxiety disorders are very common
10487661048766Just as fevers these are of different types
10487661048766Accurate Dx and Rx by GP is essential
10487661048766Depression and substance abuse potential
Minimum of six weeks to see Rx effect
Prolonged Rx is necessary 6 m or more
Drug Rx is only a small part of management
SSRI TCAs BZNs MAOIs szlig-blockers etc
CBT Computer treatment VRs Mood GYM
Thank You All Visit us at
wwwdrsarmain
This is sponsored by Torrent ndash
Makers of Clonotril (Clonazepam)
Specific Phobias
Marked and persistent fear that is excessive or unreasonable
cued by the presence or anticipation of a specific object or
situation (eg flying heights animals receiving an injection
seeing blood)
Exposure to the phobic stimulus almost invariably provokes an
immediate anxiety response which may take the form of a
Panic Attack
The person recognizes that hisher fear is excessive or
unreasonable The phobic situation is avoided or else is
endured with intense anxiety or distress
Specific Phobias - Examples
Acrophobia fear of heights
Agoraphobia fear of open places
Claustrophobia fear of enclosed places
Ailurophobia fear of cats
Cynophobia fear of dogs
Pathophobia fear of disease
Mysophobia fear of dirt and germs
Arachnophobia fear of spiders
Hematophobia fear of blood
Xenophobia fear of strangers
Better-halfophobia fear of wife
PAN ndash The Greek God
Panic Attack ndash DSM IV
1 1048766 Palpitations
2 Sweating
3 Trembling or shaking
4 Shortness of breath
5 Feeling of choking
6 Chest pain or discomfort
7 Nausea or abd distress
8 Feeling dizzy fainty
9 Derealization (feelings of unreality)
10 Fear of going crazy
11 Fear of dying
12 Paresthesias
13 Chills or hot flushes
10487661048766A discrete period of intense fear or discomfort in which 4 (or more) of the above 13 symptoms develop abruptly and reach a peak within 10 minutes
Case 2
Mrs B co a long ho episodes of anxiety
SOB racing heart sweating CP and
fears that she is having a MI and will die
These last 30 minutes and are
unexpected She co anxiety while in
malls and traveling alone to new places
for fear of having another attack Despite
a negative wu she still worries about
having a MI during an attack
Panic Disorder with Agoraphobia
Recurrent unexpected panic attacks anxiety
associated with at least four physical andor
cognitive symptoms cognitive symptoms
At least 1 month of worry about having additional
attacks or the consequences of an attack (losing
control having a heart attack ldquogoing crazyrdquo)
Agoraphobia
Panic Disorder ndash Chest pain
Chest pain is a common symptom of panic
attacks
22 ndash 70 of panic attacks are associated with
CP
18 ndash 25 of all patients with chest pain have
PD
Rates of PD higher among cardiology
outpatients with chest pain
Such patients undergo expensive cardiac
workups but their PD remains undiagnosed amp
untreated
Obsessive Compulsive Disorder - OCD
Obsessions Recurrent and persistent thoughts impulses or
images
that are experienced during the disturbance as intrusive
and inappropriate and cause marked 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 to neutralize them with some other thought or action
The person recognizes that the obsessive thoughts
impulses or images are a product of his or her own mind
Obsessive Compulsive Disorder -OCD
Compulsions Repetitive behaviors (eg hand washing ordering
checking) or mental acts (eg praying counting repeating
words silently)
Heshe is driven to perform in response to an obsession
The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event
But these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent and are clearly excessive
Obsessive Compulsive Disorder -OCD
Putamen
Globus Pallidus
Caudate Nucleus
Thalamus
Orbital frontal
cortex
Post traumatic Stress Disorder- PTSD
Post traumatic Stress Disorder- PTSD
Experiential requirements The person has experienced a life-threatening
event and has responded with intense fear
hopelessness or horror The personrsquos response to the event occurred
more
than 4 weeks after it was experienced and lasted
more than one month The traumatic event is persistently re
experienced
in several ways eg by intrusive recollections
dreams illusions hallucinations or flashbacks
Post traumatic stress disorder PTSD
Post traumatic Stress Disorder- PTSD
Behavioral requirements Thought avoidance related-activities
andor People-avoidance behavior Feelings of detachment Blunted affect Sense of doom Insomnia Irritability Hyper vigilance Exaggerated startle response
Post traumatic Stress Disorder- PTSD
Subdivisions Acute ndash when PTSD is diagnosed between 1 and
3
months after the event occurs it is called acute Chronic - when PTSD continues longer than 3
months it is considered chronic and long term Delayed Onset PTSD-this term is used to
describe
those cases where the symptoms do not occur
immediately after the experience but rather
months or years later
Case 3
Mr A witnessed a friend die in a MVA six
weeks ago and co frequent nightmares
of the accident poor sleep fears of
driving anxiety around highways
anhedonia and decreased affection
highways towards his girlfriend His
girlfriend also notes that he has been
very irritable and startles easily since the
accident
Post traumatic Stress Disorder- PTSD
10487661048766Exposure to a traumatic event
10487661048766Response involving intense fear
Helplessness and horror
10487661048766Re-experiencing of the traumatic event
Avoidance of stimulipsychological numbing
10487661048766Increased arousal
10487661048766Symptoms greater than 1 month
Separation Anxiety Disorder - SAD
Medical conditions causing anxiety
10487661048766Endocrine conditions
10487661048766Cardiovascular conditions
10487661048766Respiratory conditions
10487661048766Metabolic conditions
10487661048766Neurological conditions
Substances causing anxiety
10487661048766Alcohol Alcohol
10487661048766Amphetamines
10487661048766Caffeine
10487661048766Cannabis
10487661048766Cocaine
10487661048766Hallucinogens
10487661048766Inhalants
10487661048766Phencyclidine
Substances that cause
anxiety (withdrawal)
10487661048766Alcohol
10487661048766Cocaine
10487661048766Sedatives
10487661048766Hypnotics
10487661048766Anxiolytics
Medications causing anxiety
Anesthetics
Analgesics
Sympathomimetics
Bronchodilators
Anti-cholinergics
1048766Insulin
Thyroid hormones
Oral contraceptives
Antihistamines
Anti-parkinsonians
1048766Corticosteroids
Antihypertensives
Cardiovascular drugs
Anticonvulsants
Anxiety Disorders
Current Management Strategies
Management of Anxiety Disorders
1048766 Pharmacotherapy (Medications)
Psycho-analytic therapy ndash PT
Behavior Therapy - BT
Cognitive Behavior Therapy ndash CBT
Computer therapy - CT
1048766 Virtual Realty ndash VR
Mood GYM
Drug Rx of Anxiety Disorders
Clonazepam
How do anxiolytics act
GABA and Glycine are inhibitory neurotransmitter
Serotonin and Noradrenaline are excitatory
Anxiety is increased excitatory transmitters
BZNs increase GABA and increase inhibition
SSRI decrease the serotonin levels and darrexcitation
TCAs act by darrboth serotonin and noradrenaline
Drug Rx of Anxiety Disorders
Disorder First Choice 2nd Choice Short (prn) Add on
GADBZN-
CZ CDZ ALZBeta-blockers Buspirone Carbamazp
Panic Disorder
Paroxetine
CitalopramTCA-
ClomipramineBZN-
ALZ CZ LZMAOI -
Phenelzine
Phobias Beta-blockers SSRIsBZN-
ALZ CZMAOI
OCD Clomipramine Fluoxetine CDZ Buspirone
PTSDTCA-
Imipra Amytrp
SSRI- FLX
Sertaline CPBZN MAOI
Comparison of Benzodiazepines
BZN Sedation Anxiolytic Half life Lipid solu Dose
Diazepam +++ + 20-80 h High 5 mg od
Alprazolam + +++ 6-20 h Low 05 mg qid
Clonazapam ++ +++ 22-50 h Low 05 mg bid
Lorazepam ++ ++ 10-20 h Med 1 mg tid
Chlordiazepx + + 7-30 h Med 15 mg bid
Different strategies of therapy
Behavior therapy
Desensitization
Behavior modification
Behavioral activation
Cognitive therapy
Rational-emotive therapy
Beckrsquos cognitive therapy
Newer approaches
Mindfulness meditation
Acceptance and commitment therapy
Dialectical Behavior Therapy (BPD)
Cognitive Behaviour Therapy - CBT
CBT is a method used to treat anxiety
Recognition of ldquodistorted thinkingrdquo
ldquoCognitive restructuringrdquo
It may also involve classical conditioning when used to treat Obsessive Compulsive Disorder
CBT ndash Obstacles - Restructuring
Hopelessness
Self-criticism
Fear of getting worse
Shame and embarrassment
Partial exposure
Blaming other people
Low motivation
Looking for complex solution
Depressing ruminations
There must be an easier way
Computer Therapy
Pts are ashamed to seek help and may fear the consequences at work and home
Therapy is expensive and beyond the reach of many patients
Computer therapy is very cheap and available by comparison
Computer Therapy ndash Softwares
Fearfighter - for phobiapanic
Cope - for depressionanxiety
Balance - for GAD
BTSteps - for OCD
These are PC based in a CD-Rom
or phone based or Web-based
MENTAL OUTSIDE
Virtual Reality - VR
VR therapy via SD (Systematic Desensitization) is becoming very popular
SD is a process of gradually introducing a disturbing stimulus (eg view from a high place) in otherwise pleasant surroundings
This process gradually suppresses the anxiety response
Virtual Reality ndash VR - Advantages
Patients often have difficulty imagining the stimulus themselves
They are often afraid of experiencing it directly ndash which may also be expensive and time-consuming
VR affords patient privacy and confidentiality during treatment
Very good for phobias
Virtual Reality ndash VR - Imagination
ldquoProjection in timerdquo ndash rationally reconstructing the future
ldquoDe-catastrophizing an imagerdquo ndash modifying a disturbing image
ldquoImage modeling and substitutionrdquo ndashinterrupting a negative train of images
ldquoCovert conditioningrdquo ndash subtle conditioning using imagined rather than real stimuli
Virtual Reality ndash VR - Hutchworld
Hutchworld is a virtual community attached to the Hutchison Cancer Research Center
Designed to provide social support for cancer patients and their families
Based on Microsoftrsquos Vworldrsquos system
Mood GYM on the Internet
Few GPs are trained in CBT
Clinical psychologists are expensive
Young people are not easily reached
They may not want them ndash embarrassment
The web is accessible convenient and popular
with young people
Deliver CBT via internet ndash 5 modules
Mood GYM Modules
5 Modules - analysis and results
1 Essentials of CBT with examples and interactive exercises
2 Warpy Thoughts Questionnaire Identifying dysfunctional thoughts Methods to contest such thoughts
3 Other methods for overcoming warpy thoughts
4 Life Event Stress Relaxation meditation music Pleasant Events Schedule parental style
5 Simple problem solving responses to relationship break-up
Web stats summary
Sessions
Take home points
10487661048766Anxiety disorders are very common
10487661048766Just as fevers these are of different types
10487661048766Accurate Dx and Rx by GP is essential
10487661048766Depression and substance abuse potential
Minimum of six weeks to see Rx effect
Prolonged Rx is necessary 6 m or more
Drug Rx is only a small part of management
SSRI TCAs BZNs MAOIs szlig-blockers etc
CBT Computer treatment VRs Mood GYM
Thank You All Visit us at
wwwdrsarmain
This is sponsored by Torrent ndash
Makers of Clonotril (Clonazepam)
Specific Phobias - Examples
Acrophobia fear of heights
Agoraphobia fear of open places
Claustrophobia fear of enclosed places
Ailurophobia fear of cats
Cynophobia fear of dogs
Pathophobia fear of disease
Mysophobia fear of dirt and germs
Arachnophobia fear of spiders
Hematophobia fear of blood
Xenophobia fear of strangers
Better-halfophobia fear of wife
PAN ndash The Greek God
Panic Attack ndash DSM IV
1 1048766 Palpitations
2 Sweating
3 Trembling or shaking
4 Shortness of breath
5 Feeling of choking
6 Chest pain or discomfort
7 Nausea or abd distress
8 Feeling dizzy fainty
9 Derealization (feelings of unreality)
10 Fear of going crazy
11 Fear of dying
12 Paresthesias
13 Chills or hot flushes
10487661048766A discrete period of intense fear or discomfort in which 4 (or more) of the above 13 symptoms develop abruptly and reach a peak within 10 minutes
Case 2
Mrs B co a long ho episodes of anxiety
SOB racing heart sweating CP and
fears that she is having a MI and will die
These last 30 minutes and are
unexpected She co anxiety while in
malls and traveling alone to new places
for fear of having another attack Despite
a negative wu she still worries about
having a MI during an attack
Panic Disorder with Agoraphobia
Recurrent unexpected panic attacks anxiety
associated with at least four physical andor
cognitive symptoms cognitive symptoms
At least 1 month of worry about having additional
attacks or the consequences of an attack (losing
control having a heart attack ldquogoing crazyrdquo)
Agoraphobia
Panic Disorder ndash Chest pain
Chest pain is a common symptom of panic
attacks
22 ndash 70 of panic attacks are associated with
CP
18 ndash 25 of all patients with chest pain have
PD
Rates of PD higher among cardiology
outpatients with chest pain
Such patients undergo expensive cardiac
workups but their PD remains undiagnosed amp
untreated
Obsessive Compulsive Disorder - OCD
Obsessions Recurrent and persistent thoughts impulses or
images
that are experienced during the disturbance as intrusive
and inappropriate and cause marked 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 to neutralize them with some other thought or action
The person recognizes that the obsessive thoughts
impulses or images are a product of his or her own mind
Obsessive Compulsive Disorder -OCD
Compulsions Repetitive behaviors (eg hand washing ordering
checking) or mental acts (eg praying counting repeating
words silently)
Heshe is driven to perform in response to an obsession
The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event
But these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent and are clearly excessive
Obsessive Compulsive Disorder -OCD
Putamen
Globus Pallidus
Caudate Nucleus
Thalamus
Orbital frontal
cortex
Post traumatic Stress Disorder- PTSD
Post traumatic Stress Disorder- PTSD
Experiential requirements The person has experienced a life-threatening
event and has responded with intense fear
hopelessness or horror The personrsquos response to the event occurred
more
than 4 weeks after it was experienced and lasted
more than one month The traumatic event is persistently re
experienced
in several ways eg by intrusive recollections
dreams illusions hallucinations or flashbacks
Post traumatic stress disorder PTSD
Post traumatic Stress Disorder- PTSD
Behavioral requirements Thought avoidance related-activities
andor People-avoidance behavior Feelings of detachment Blunted affect Sense of doom Insomnia Irritability Hyper vigilance Exaggerated startle response
Post traumatic Stress Disorder- PTSD
Subdivisions Acute ndash when PTSD is diagnosed between 1 and
3
months after the event occurs it is called acute Chronic - when PTSD continues longer than 3
months it is considered chronic and long term Delayed Onset PTSD-this term is used to
describe
those cases where the symptoms do not occur
immediately after the experience but rather
months or years later
Case 3
Mr A witnessed a friend die in a MVA six
weeks ago and co frequent nightmares
of the accident poor sleep fears of
driving anxiety around highways
anhedonia and decreased affection
highways towards his girlfriend His
girlfriend also notes that he has been
very irritable and startles easily since the
accident
Post traumatic Stress Disorder- PTSD
10487661048766Exposure to a traumatic event
10487661048766Response involving intense fear
Helplessness and horror
10487661048766Re-experiencing of the traumatic event
Avoidance of stimulipsychological numbing
10487661048766Increased arousal
10487661048766Symptoms greater than 1 month
Separation Anxiety Disorder - SAD
Medical conditions causing anxiety
10487661048766Endocrine conditions
10487661048766Cardiovascular conditions
10487661048766Respiratory conditions
10487661048766Metabolic conditions
10487661048766Neurological conditions
Substances causing anxiety
10487661048766Alcohol Alcohol
10487661048766Amphetamines
10487661048766Caffeine
10487661048766Cannabis
10487661048766Cocaine
10487661048766Hallucinogens
10487661048766Inhalants
10487661048766Phencyclidine
Substances that cause
anxiety (withdrawal)
10487661048766Alcohol
10487661048766Cocaine
10487661048766Sedatives
10487661048766Hypnotics
10487661048766Anxiolytics
Medications causing anxiety
Anesthetics
Analgesics
Sympathomimetics
Bronchodilators
Anti-cholinergics
1048766Insulin
Thyroid hormones
Oral contraceptives
Antihistamines
Anti-parkinsonians
1048766Corticosteroids
Antihypertensives
Cardiovascular drugs
Anticonvulsants
Anxiety Disorders
Current Management Strategies
Management of Anxiety Disorders
1048766 Pharmacotherapy (Medications)
Psycho-analytic therapy ndash PT
Behavior Therapy - BT
Cognitive Behavior Therapy ndash CBT
Computer therapy - CT
1048766 Virtual Realty ndash VR
Mood GYM
Drug Rx of Anxiety Disorders
Clonazepam
How do anxiolytics act
GABA and Glycine are inhibitory neurotransmitter
Serotonin and Noradrenaline are excitatory
Anxiety is increased excitatory transmitters
BZNs increase GABA and increase inhibition
SSRI decrease the serotonin levels and darrexcitation
TCAs act by darrboth serotonin and noradrenaline
Drug Rx of Anxiety Disorders
Disorder First Choice 2nd Choice Short (prn) Add on
GADBZN-
CZ CDZ ALZBeta-blockers Buspirone Carbamazp
Panic Disorder
Paroxetine
CitalopramTCA-
ClomipramineBZN-
ALZ CZ LZMAOI -
Phenelzine
Phobias Beta-blockers SSRIsBZN-
ALZ CZMAOI
OCD Clomipramine Fluoxetine CDZ Buspirone
PTSDTCA-
Imipra Amytrp
SSRI- FLX
Sertaline CPBZN MAOI
Comparison of Benzodiazepines
BZN Sedation Anxiolytic Half life Lipid solu Dose
Diazepam +++ + 20-80 h High 5 mg od
Alprazolam + +++ 6-20 h Low 05 mg qid
Clonazapam ++ +++ 22-50 h Low 05 mg bid
Lorazepam ++ ++ 10-20 h Med 1 mg tid
Chlordiazepx + + 7-30 h Med 15 mg bid
Different strategies of therapy
Behavior therapy
Desensitization
Behavior modification
Behavioral activation
Cognitive therapy
Rational-emotive therapy
Beckrsquos cognitive therapy
Newer approaches
Mindfulness meditation
Acceptance and commitment therapy
Dialectical Behavior Therapy (BPD)
Cognitive Behaviour Therapy - CBT
CBT is a method used to treat anxiety
Recognition of ldquodistorted thinkingrdquo
ldquoCognitive restructuringrdquo
It may also involve classical conditioning when used to treat Obsessive Compulsive Disorder
CBT ndash Obstacles - Restructuring
Hopelessness
Self-criticism
Fear of getting worse
Shame and embarrassment
Partial exposure
Blaming other people
Low motivation
Looking for complex solution
Depressing ruminations
There must be an easier way
Computer Therapy
Pts are ashamed to seek help and may fear the consequences at work and home
Therapy is expensive and beyond the reach of many patients
Computer therapy is very cheap and available by comparison
Computer Therapy ndash Softwares
Fearfighter - for phobiapanic
Cope - for depressionanxiety
Balance - for GAD
BTSteps - for OCD
These are PC based in a CD-Rom
or phone based or Web-based
MENTAL OUTSIDE
Virtual Reality - VR
VR therapy via SD (Systematic Desensitization) is becoming very popular
SD is a process of gradually introducing a disturbing stimulus (eg view from a high place) in otherwise pleasant surroundings
This process gradually suppresses the anxiety response
Virtual Reality ndash VR - Advantages
Patients often have difficulty imagining the stimulus themselves
They are often afraid of experiencing it directly ndash which may also be expensive and time-consuming
VR affords patient privacy and confidentiality during treatment
Very good for phobias
Virtual Reality ndash VR - Imagination
ldquoProjection in timerdquo ndash rationally reconstructing the future
ldquoDe-catastrophizing an imagerdquo ndash modifying a disturbing image
ldquoImage modeling and substitutionrdquo ndashinterrupting a negative train of images
ldquoCovert conditioningrdquo ndash subtle conditioning using imagined rather than real stimuli
Virtual Reality ndash VR - Hutchworld
Hutchworld is a virtual community attached to the Hutchison Cancer Research Center
Designed to provide social support for cancer patients and their families
Based on Microsoftrsquos Vworldrsquos system
Mood GYM on the Internet
Few GPs are trained in CBT
Clinical psychologists are expensive
Young people are not easily reached
They may not want them ndash embarrassment
The web is accessible convenient and popular
with young people
Deliver CBT via internet ndash 5 modules
Mood GYM Modules
5 Modules - analysis and results
1 Essentials of CBT with examples and interactive exercises
2 Warpy Thoughts Questionnaire Identifying dysfunctional thoughts Methods to contest such thoughts
3 Other methods for overcoming warpy thoughts
4 Life Event Stress Relaxation meditation music Pleasant Events Schedule parental style
5 Simple problem solving responses to relationship break-up
Web stats summary
Sessions
Take home points
10487661048766Anxiety disorders are very common
10487661048766Just as fevers these are of different types
10487661048766Accurate Dx and Rx by GP is essential
10487661048766Depression and substance abuse potential
Minimum of six weeks to see Rx effect
Prolonged Rx is necessary 6 m or more
Drug Rx is only a small part of management
SSRI TCAs BZNs MAOIs szlig-blockers etc
CBT Computer treatment VRs Mood GYM
Thank You All Visit us at
wwwdrsarmain
This is sponsored by Torrent ndash
Makers of Clonotril (Clonazepam)
PAN ndash The Greek God
Panic Attack ndash DSM IV
1 1048766 Palpitations
2 Sweating
3 Trembling or shaking
4 Shortness of breath
5 Feeling of choking
6 Chest pain or discomfort
7 Nausea or abd distress
8 Feeling dizzy fainty
9 Derealization (feelings of unreality)
10 Fear of going crazy
11 Fear of dying
12 Paresthesias
13 Chills or hot flushes
10487661048766A discrete period of intense fear or discomfort in which 4 (or more) of the above 13 symptoms develop abruptly and reach a peak within 10 minutes
Case 2
Mrs B co a long ho episodes of anxiety
SOB racing heart sweating CP and
fears that she is having a MI and will die
These last 30 minutes and are
unexpected She co anxiety while in
malls and traveling alone to new places
for fear of having another attack Despite
a negative wu she still worries about
having a MI during an attack
Panic Disorder with Agoraphobia
Recurrent unexpected panic attacks anxiety
associated with at least four physical andor
cognitive symptoms cognitive symptoms
At least 1 month of worry about having additional
attacks or the consequences of an attack (losing
control having a heart attack ldquogoing crazyrdquo)
Agoraphobia
Panic Disorder ndash Chest pain
Chest pain is a common symptom of panic
attacks
22 ndash 70 of panic attacks are associated with
CP
18 ndash 25 of all patients with chest pain have
PD
Rates of PD higher among cardiology
outpatients with chest pain
Such patients undergo expensive cardiac
workups but their PD remains undiagnosed amp
untreated
Obsessive Compulsive Disorder - OCD
Obsessions Recurrent and persistent thoughts impulses or
images
that are experienced during the disturbance as intrusive
and inappropriate and cause marked 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 to neutralize them with some other thought or action
The person recognizes that the obsessive thoughts
impulses or images are a product of his or her own mind
Obsessive Compulsive Disorder -OCD
Compulsions Repetitive behaviors (eg hand washing ordering
checking) or mental acts (eg praying counting repeating
words silently)
Heshe is driven to perform in response to an obsession
The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event
But these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent and are clearly excessive
Obsessive Compulsive Disorder -OCD
Putamen
Globus Pallidus
Caudate Nucleus
Thalamus
Orbital frontal
cortex
Post traumatic Stress Disorder- PTSD
Post traumatic Stress Disorder- PTSD
Experiential requirements The person has experienced a life-threatening
event and has responded with intense fear
hopelessness or horror The personrsquos response to the event occurred
more
than 4 weeks after it was experienced and lasted
more than one month The traumatic event is persistently re
experienced
in several ways eg by intrusive recollections
dreams illusions hallucinations or flashbacks
Post traumatic stress disorder PTSD
Post traumatic Stress Disorder- PTSD
Behavioral requirements Thought avoidance related-activities
andor People-avoidance behavior Feelings of detachment Blunted affect Sense of doom Insomnia Irritability Hyper vigilance Exaggerated startle response
Post traumatic Stress Disorder- PTSD
Subdivisions Acute ndash when PTSD is diagnosed between 1 and
3
months after the event occurs it is called acute Chronic - when PTSD continues longer than 3
months it is considered chronic and long term Delayed Onset PTSD-this term is used to
describe
those cases where the symptoms do not occur
immediately after the experience but rather
months or years later
Case 3
Mr A witnessed a friend die in a MVA six
weeks ago and co frequent nightmares
of the accident poor sleep fears of
driving anxiety around highways
anhedonia and decreased affection
highways towards his girlfriend His
girlfriend also notes that he has been
very irritable and startles easily since the
accident
Post traumatic Stress Disorder- PTSD
10487661048766Exposure to a traumatic event
10487661048766Response involving intense fear
Helplessness and horror
10487661048766Re-experiencing of the traumatic event
Avoidance of stimulipsychological numbing
10487661048766Increased arousal
10487661048766Symptoms greater than 1 month
Separation Anxiety Disorder - SAD
Medical conditions causing anxiety
10487661048766Endocrine conditions
10487661048766Cardiovascular conditions
10487661048766Respiratory conditions
10487661048766Metabolic conditions
10487661048766Neurological conditions
Substances causing anxiety
10487661048766Alcohol Alcohol
10487661048766Amphetamines
10487661048766Caffeine
10487661048766Cannabis
10487661048766Cocaine
10487661048766Hallucinogens
10487661048766Inhalants
10487661048766Phencyclidine
Substances that cause
anxiety (withdrawal)
10487661048766Alcohol
10487661048766Cocaine
10487661048766Sedatives
10487661048766Hypnotics
10487661048766Anxiolytics
Medications causing anxiety
Anesthetics
Analgesics
Sympathomimetics
Bronchodilators
Anti-cholinergics
1048766Insulin
Thyroid hormones
Oral contraceptives
Antihistamines
Anti-parkinsonians
1048766Corticosteroids
Antihypertensives
Cardiovascular drugs
Anticonvulsants
Anxiety Disorders
Current Management Strategies
Management of Anxiety Disorders
1048766 Pharmacotherapy (Medications)
Psycho-analytic therapy ndash PT
Behavior Therapy - BT
Cognitive Behavior Therapy ndash CBT
Computer therapy - CT
1048766 Virtual Realty ndash VR
Mood GYM
Drug Rx of Anxiety Disorders
Clonazepam
How do anxiolytics act
GABA and Glycine are inhibitory neurotransmitter
Serotonin and Noradrenaline are excitatory
Anxiety is increased excitatory transmitters
BZNs increase GABA and increase inhibition
SSRI decrease the serotonin levels and darrexcitation
TCAs act by darrboth serotonin and noradrenaline
Drug Rx of Anxiety Disorders
Disorder First Choice 2nd Choice Short (prn) Add on
GADBZN-
CZ CDZ ALZBeta-blockers Buspirone Carbamazp
Panic Disorder
Paroxetine
CitalopramTCA-
ClomipramineBZN-
ALZ CZ LZMAOI -
Phenelzine
Phobias Beta-blockers SSRIsBZN-
ALZ CZMAOI
OCD Clomipramine Fluoxetine CDZ Buspirone
PTSDTCA-
Imipra Amytrp
SSRI- FLX
Sertaline CPBZN MAOI
Comparison of Benzodiazepines
BZN Sedation Anxiolytic Half life Lipid solu Dose
Diazepam +++ + 20-80 h High 5 mg od
Alprazolam + +++ 6-20 h Low 05 mg qid
Clonazapam ++ +++ 22-50 h Low 05 mg bid
Lorazepam ++ ++ 10-20 h Med 1 mg tid
Chlordiazepx + + 7-30 h Med 15 mg bid
Different strategies of therapy
Behavior therapy
Desensitization
Behavior modification
Behavioral activation
Cognitive therapy
Rational-emotive therapy
Beckrsquos cognitive therapy
Newer approaches
Mindfulness meditation
Acceptance and commitment therapy
Dialectical Behavior Therapy (BPD)
Cognitive Behaviour Therapy - CBT
CBT is a method used to treat anxiety
Recognition of ldquodistorted thinkingrdquo
ldquoCognitive restructuringrdquo
It may also involve classical conditioning when used to treat Obsessive Compulsive Disorder
CBT ndash Obstacles - Restructuring
Hopelessness
Self-criticism
Fear of getting worse
Shame and embarrassment
Partial exposure
Blaming other people
Low motivation
Looking for complex solution
Depressing ruminations
There must be an easier way
Computer Therapy
Pts are ashamed to seek help and may fear the consequences at work and home
Therapy is expensive and beyond the reach of many patients
Computer therapy is very cheap and available by comparison
Computer Therapy ndash Softwares
Fearfighter - for phobiapanic
Cope - for depressionanxiety
Balance - for GAD
BTSteps - for OCD
These are PC based in a CD-Rom
or phone based or Web-based
MENTAL OUTSIDE
Virtual Reality - VR
VR therapy via SD (Systematic Desensitization) is becoming very popular
SD is a process of gradually introducing a disturbing stimulus (eg view from a high place) in otherwise pleasant surroundings
This process gradually suppresses the anxiety response
Virtual Reality ndash VR - Advantages
Patients often have difficulty imagining the stimulus themselves
They are often afraid of experiencing it directly ndash which may also be expensive and time-consuming
VR affords patient privacy and confidentiality during treatment
Very good for phobias
Virtual Reality ndash VR - Imagination
ldquoProjection in timerdquo ndash rationally reconstructing the future
ldquoDe-catastrophizing an imagerdquo ndash modifying a disturbing image
ldquoImage modeling and substitutionrdquo ndashinterrupting a negative train of images
ldquoCovert conditioningrdquo ndash subtle conditioning using imagined rather than real stimuli
Virtual Reality ndash VR - Hutchworld
Hutchworld is a virtual community attached to the Hutchison Cancer Research Center
Designed to provide social support for cancer patients and their families
Based on Microsoftrsquos Vworldrsquos system
Mood GYM on the Internet
Few GPs are trained in CBT
Clinical psychologists are expensive
Young people are not easily reached
They may not want them ndash embarrassment
The web is accessible convenient and popular
with young people
Deliver CBT via internet ndash 5 modules
Mood GYM Modules
5 Modules - analysis and results
1 Essentials of CBT with examples and interactive exercises
2 Warpy Thoughts Questionnaire Identifying dysfunctional thoughts Methods to contest such thoughts
3 Other methods for overcoming warpy thoughts
4 Life Event Stress Relaxation meditation music Pleasant Events Schedule parental style
5 Simple problem solving responses to relationship break-up
Web stats summary
Sessions
Take home points
10487661048766Anxiety disorders are very common
10487661048766Just as fevers these are of different types
10487661048766Accurate Dx and Rx by GP is essential
10487661048766Depression and substance abuse potential
Minimum of six weeks to see Rx effect
Prolonged Rx is necessary 6 m or more
Drug Rx is only a small part of management
SSRI TCAs BZNs MAOIs szlig-blockers etc
CBT Computer treatment VRs Mood GYM
Thank You All Visit us at
wwwdrsarmain
This is sponsored by Torrent ndash
Makers of Clonotril (Clonazepam)
Panic Attack ndash DSM IV
1 1048766 Palpitations
2 Sweating
3 Trembling or shaking
4 Shortness of breath
5 Feeling of choking
6 Chest pain or discomfort
7 Nausea or abd distress
8 Feeling dizzy fainty
9 Derealization (feelings of unreality)
10 Fear of going crazy
11 Fear of dying
12 Paresthesias
13 Chills or hot flushes
10487661048766A discrete period of intense fear or discomfort in which 4 (or more) of the above 13 symptoms develop abruptly and reach a peak within 10 minutes
Case 2
Mrs B co a long ho episodes of anxiety
SOB racing heart sweating CP and
fears that she is having a MI and will die
These last 30 minutes and are
unexpected She co anxiety while in
malls and traveling alone to new places
for fear of having another attack Despite
a negative wu she still worries about
having a MI during an attack
Panic Disorder with Agoraphobia
Recurrent unexpected panic attacks anxiety
associated with at least four physical andor
cognitive symptoms cognitive symptoms
At least 1 month of worry about having additional
attacks or the consequences of an attack (losing
control having a heart attack ldquogoing crazyrdquo)
Agoraphobia
Panic Disorder ndash Chest pain
Chest pain is a common symptom of panic
attacks
22 ndash 70 of panic attacks are associated with
CP
18 ndash 25 of all patients with chest pain have
PD
Rates of PD higher among cardiology
outpatients with chest pain
Such patients undergo expensive cardiac
workups but their PD remains undiagnosed amp
untreated
Obsessive Compulsive Disorder - OCD
Obsessions Recurrent and persistent thoughts impulses or
images
that are experienced during the disturbance as intrusive
and inappropriate and cause marked 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 to neutralize them with some other thought or action
The person recognizes that the obsessive thoughts
impulses or images are a product of his or her own mind
Obsessive Compulsive Disorder -OCD
Compulsions Repetitive behaviors (eg hand washing ordering
checking) or mental acts (eg praying counting repeating
words silently)
Heshe is driven to perform in response to an obsession
The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event
But these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent and are clearly excessive
Obsessive Compulsive Disorder -OCD
Putamen
Globus Pallidus
Caudate Nucleus
Thalamus
Orbital frontal
cortex
Post traumatic Stress Disorder- PTSD
Post traumatic Stress Disorder- PTSD
Experiential requirements The person has experienced a life-threatening
event and has responded with intense fear
hopelessness or horror The personrsquos response to the event occurred
more
than 4 weeks after it was experienced and lasted
more than one month The traumatic event is persistently re
experienced
in several ways eg by intrusive recollections
dreams illusions hallucinations or flashbacks
Post traumatic stress disorder PTSD
Post traumatic Stress Disorder- PTSD
Behavioral requirements Thought avoidance related-activities
andor People-avoidance behavior Feelings of detachment Blunted affect Sense of doom Insomnia Irritability Hyper vigilance Exaggerated startle response
Post traumatic Stress Disorder- PTSD
Subdivisions Acute ndash when PTSD is diagnosed between 1 and
3
months after the event occurs it is called acute Chronic - when PTSD continues longer than 3
months it is considered chronic and long term Delayed Onset PTSD-this term is used to
describe
those cases where the symptoms do not occur
immediately after the experience but rather
months or years later
Case 3
Mr A witnessed a friend die in a MVA six
weeks ago and co frequent nightmares
of the accident poor sleep fears of
driving anxiety around highways
anhedonia and decreased affection
highways towards his girlfriend His
girlfriend also notes that he has been
very irritable and startles easily since the
accident
Post traumatic Stress Disorder- PTSD
10487661048766Exposure to a traumatic event
10487661048766Response involving intense fear
Helplessness and horror
10487661048766Re-experiencing of the traumatic event
Avoidance of stimulipsychological numbing
10487661048766Increased arousal
10487661048766Symptoms greater than 1 month
Separation Anxiety Disorder - SAD
Medical conditions causing anxiety
10487661048766Endocrine conditions
10487661048766Cardiovascular conditions
10487661048766Respiratory conditions
10487661048766Metabolic conditions
10487661048766Neurological conditions
Substances causing anxiety
10487661048766Alcohol Alcohol
10487661048766Amphetamines
10487661048766Caffeine
10487661048766Cannabis
10487661048766Cocaine
10487661048766Hallucinogens
10487661048766Inhalants
10487661048766Phencyclidine
Substances that cause
anxiety (withdrawal)
10487661048766Alcohol
10487661048766Cocaine
10487661048766Sedatives
10487661048766Hypnotics
10487661048766Anxiolytics
Medications causing anxiety
Anesthetics
Analgesics
Sympathomimetics
Bronchodilators
Anti-cholinergics
1048766Insulin
Thyroid hormones
Oral contraceptives
Antihistamines
Anti-parkinsonians
1048766Corticosteroids
Antihypertensives
Cardiovascular drugs
Anticonvulsants
Anxiety Disorders
Current Management Strategies
Management of Anxiety Disorders
1048766 Pharmacotherapy (Medications)
Psycho-analytic therapy ndash PT
Behavior Therapy - BT
Cognitive Behavior Therapy ndash CBT
Computer therapy - CT
1048766 Virtual Realty ndash VR
Mood GYM
Drug Rx of Anxiety Disorders
Clonazepam
How do anxiolytics act
GABA and Glycine are inhibitory neurotransmitter
Serotonin and Noradrenaline are excitatory
Anxiety is increased excitatory transmitters
BZNs increase GABA and increase inhibition
SSRI decrease the serotonin levels and darrexcitation
TCAs act by darrboth serotonin and noradrenaline
Drug Rx of Anxiety Disorders
Disorder First Choice 2nd Choice Short (prn) Add on
GADBZN-
CZ CDZ ALZBeta-blockers Buspirone Carbamazp
Panic Disorder
Paroxetine
CitalopramTCA-
ClomipramineBZN-
ALZ CZ LZMAOI -
Phenelzine
Phobias Beta-blockers SSRIsBZN-
ALZ CZMAOI
OCD Clomipramine Fluoxetine CDZ Buspirone
PTSDTCA-
Imipra Amytrp
SSRI- FLX
Sertaline CPBZN MAOI
Comparison of Benzodiazepines
BZN Sedation Anxiolytic Half life Lipid solu Dose
Diazepam +++ + 20-80 h High 5 mg od
Alprazolam + +++ 6-20 h Low 05 mg qid
Clonazapam ++ +++ 22-50 h Low 05 mg bid
Lorazepam ++ ++ 10-20 h Med 1 mg tid
Chlordiazepx + + 7-30 h Med 15 mg bid
Different strategies of therapy
Behavior therapy
Desensitization
Behavior modification
Behavioral activation
Cognitive therapy
Rational-emotive therapy
Beckrsquos cognitive therapy
Newer approaches
Mindfulness meditation
Acceptance and commitment therapy
Dialectical Behavior Therapy (BPD)
Cognitive Behaviour Therapy - CBT
CBT is a method used to treat anxiety
Recognition of ldquodistorted thinkingrdquo
ldquoCognitive restructuringrdquo
It may also involve classical conditioning when used to treat Obsessive Compulsive Disorder
CBT ndash Obstacles - Restructuring
Hopelessness
Self-criticism
Fear of getting worse
Shame and embarrassment
Partial exposure
Blaming other people
Low motivation
Looking for complex solution
Depressing ruminations
There must be an easier way
Computer Therapy
Pts are ashamed to seek help and may fear the consequences at work and home
Therapy is expensive and beyond the reach of many patients
Computer therapy is very cheap and available by comparison
Computer Therapy ndash Softwares
Fearfighter - for phobiapanic
Cope - for depressionanxiety
Balance - for GAD
BTSteps - for OCD
These are PC based in a CD-Rom
or phone based or Web-based
MENTAL OUTSIDE
Virtual Reality - VR
VR therapy via SD (Systematic Desensitization) is becoming very popular
SD is a process of gradually introducing a disturbing stimulus (eg view from a high place) in otherwise pleasant surroundings
This process gradually suppresses the anxiety response
Virtual Reality ndash VR - Advantages
Patients often have difficulty imagining the stimulus themselves
They are often afraid of experiencing it directly ndash which may also be expensive and time-consuming
VR affords patient privacy and confidentiality during treatment
Very good for phobias
Virtual Reality ndash VR - Imagination
ldquoProjection in timerdquo ndash rationally reconstructing the future
ldquoDe-catastrophizing an imagerdquo ndash modifying a disturbing image
ldquoImage modeling and substitutionrdquo ndashinterrupting a negative train of images
ldquoCovert conditioningrdquo ndash subtle conditioning using imagined rather than real stimuli
Virtual Reality ndash VR - Hutchworld
Hutchworld is a virtual community attached to the Hutchison Cancer Research Center
Designed to provide social support for cancer patients and their families
Based on Microsoftrsquos Vworldrsquos system
Mood GYM on the Internet
Few GPs are trained in CBT
Clinical psychologists are expensive
Young people are not easily reached
They may not want them ndash embarrassment
The web is accessible convenient and popular
with young people
Deliver CBT via internet ndash 5 modules
Mood GYM Modules
5 Modules - analysis and results
1 Essentials of CBT with examples and interactive exercises
2 Warpy Thoughts Questionnaire Identifying dysfunctional thoughts Methods to contest such thoughts
3 Other methods for overcoming warpy thoughts
4 Life Event Stress Relaxation meditation music Pleasant Events Schedule parental style
5 Simple problem solving responses to relationship break-up
Web stats summary
Sessions
Take home points
10487661048766Anxiety disorders are very common
10487661048766Just as fevers these are of different types
10487661048766Accurate Dx and Rx by GP is essential
10487661048766Depression and substance abuse potential
Minimum of six weeks to see Rx effect
Prolonged Rx is necessary 6 m or more
Drug Rx is only a small part of management
SSRI TCAs BZNs MAOIs szlig-blockers etc
CBT Computer treatment VRs Mood GYM
Thank You All Visit us at
wwwdrsarmain
This is sponsored by Torrent ndash
Makers of Clonotril (Clonazepam)
Case 2
Mrs B co a long ho episodes of anxiety
SOB racing heart sweating CP and
fears that she is having a MI and will die
These last 30 minutes and are
unexpected She co anxiety while in
malls and traveling alone to new places
for fear of having another attack Despite
a negative wu she still worries about
having a MI during an attack
Panic Disorder with Agoraphobia
Recurrent unexpected panic attacks anxiety
associated with at least four physical andor
cognitive symptoms cognitive symptoms
At least 1 month of worry about having additional
attacks or the consequences of an attack (losing
control having a heart attack ldquogoing crazyrdquo)
Agoraphobia
Panic Disorder ndash Chest pain
Chest pain is a common symptom of panic
attacks
22 ndash 70 of panic attacks are associated with
CP
18 ndash 25 of all patients with chest pain have
PD
Rates of PD higher among cardiology
outpatients with chest pain
Such patients undergo expensive cardiac
workups but their PD remains undiagnosed amp
untreated
Obsessive Compulsive Disorder - OCD
Obsessions Recurrent and persistent thoughts impulses or
images
that are experienced during the disturbance as intrusive
and inappropriate and cause marked 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 to neutralize them with some other thought or action
The person recognizes that the obsessive thoughts
impulses or images are a product of his or her own mind
Obsessive Compulsive Disorder -OCD
Compulsions Repetitive behaviors (eg hand washing ordering
checking) or mental acts (eg praying counting repeating
words silently)
Heshe is driven to perform in response to an obsession
The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event
But these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent and are clearly excessive
Obsessive Compulsive Disorder -OCD
Putamen
Globus Pallidus
Caudate Nucleus
Thalamus
Orbital frontal
cortex
Post traumatic Stress Disorder- PTSD
Post traumatic Stress Disorder- PTSD
Experiential requirements The person has experienced a life-threatening
event and has responded with intense fear
hopelessness or horror The personrsquos response to the event occurred
more
than 4 weeks after it was experienced and lasted
more than one month The traumatic event is persistently re
experienced
in several ways eg by intrusive recollections
dreams illusions hallucinations or flashbacks
Post traumatic stress disorder PTSD
Post traumatic Stress Disorder- PTSD
Behavioral requirements Thought avoidance related-activities
andor People-avoidance behavior Feelings of detachment Blunted affect Sense of doom Insomnia Irritability Hyper vigilance Exaggerated startle response
Post traumatic Stress Disorder- PTSD
Subdivisions Acute ndash when PTSD is diagnosed between 1 and
3
months after the event occurs it is called acute Chronic - when PTSD continues longer than 3
months it is considered chronic and long term Delayed Onset PTSD-this term is used to
describe
those cases where the symptoms do not occur
immediately after the experience but rather
months or years later
Case 3
Mr A witnessed a friend die in a MVA six
weeks ago and co frequent nightmares
of the accident poor sleep fears of
driving anxiety around highways
anhedonia and decreased affection
highways towards his girlfriend His
girlfriend also notes that he has been
very irritable and startles easily since the
accident
Post traumatic Stress Disorder- PTSD
10487661048766Exposure to a traumatic event
10487661048766Response involving intense fear
Helplessness and horror
10487661048766Re-experiencing of the traumatic event
Avoidance of stimulipsychological numbing
10487661048766Increased arousal
10487661048766Symptoms greater than 1 month
Separation Anxiety Disorder - SAD
Medical conditions causing anxiety
10487661048766Endocrine conditions
10487661048766Cardiovascular conditions
10487661048766Respiratory conditions
10487661048766Metabolic conditions
10487661048766Neurological conditions
Substances causing anxiety
10487661048766Alcohol Alcohol
10487661048766Amphetamines
10487661048766Caffeine
10487661048766Cannabis
10487661048766Cocaine
10487661048766Hallucinogens
10487661048766Inhalants
10487661048766Phencyclidine
Substances that cause
anxiety (withdrawal)
10487661048766Alcohol
10487661048766Cocaine
10487661048766Sedatives
10487661048766Hypnotics
10487661048766Anxiolytics
Medications causing anxiety
Anesthetics
Analgesics
Sympathomimetics
Bronchodilators
Anti-cholinergics
1048766Insulin
Thyroid hormones
Oral contraceptives
Antihistamines
Anti-parkinsonians
1048766Corticosteroids
Antihypertensives
Cardiovascular drugs
Anticonvulsants
Anxiety Disorders
Current Management Strategies
Management of Anxiety Disorders
1048766 Pharmacotherapy (Medications)
Psycho-analytic therapy ndash PT
Behavior Therapy - BT
Cognitive Behavior Therapy ndash CBT
Computer therapy - CT
1048766 Virtual Realty ndash VR
Mood GYM
Drug Rx of Anxiety Disorders
Clonazepam
How do anxiolytics act
GABA and Glycine are inhibitory neurotransmitter
Serotonin and Noradrenaline are excitatory
Anxiety is increased excitatory transmitters
BZNs increase GABA and increase inhibition
SSRI decrease the serotonin levels and darrexcitation
TCAs act by darrboth serotonin and noradrenaline
Drug Rx of Anxiety Disorders
Disorder First Choice 2nd Choice Short (prn) Add on
GADBZN-
CZ CDZ ALZBeta-blockers Buspirone Carbamazp
Panic Disorder
Paroxetine
CitalopramTCA-
ClomipramineBZN-
ALZ CZ LZMAOI -
Phenelzine
Phobias Beta-blockers SSRIsBZN-
ALZ CZMAOI
OCD Clomipramine Fluoxetine CDZ Buspirone
PTSDTCA-
Imipra Amytrp
SSRI- FLX
Sertaline CPBZN MAOI
Comparison of Benzodiazepines
BZN Sedation Anxiolytic Half life Lipid solu Dose
Diazepam +++ + 20-80 h High 5 mg od
Alprazolam + +++ 6-20 h Low 05 mg qid
Clonazapam ++ +++ 22-50 h Low 05 mg bid
Lorazepam ++ ++ 10-20 h Med 1 mg tid
Chlordiazepx + + 7-30 h Med 15 mg bid
Different strategies of therapy
Behavior therapy
Desensitization
Behavior modification
Behavioral activation
Cognitive therapy
Rational-emotive therapy
Beckrsquos cognitive therapy
Newer approaches
Mindfulness meditation
Acceptance and commitment therapy
Dialectical Behavior Therapy (BPD)
Cognitive Behaviour Therapy - CBT
CBT is a method used to treat anxiety
Recognition of ldquodistorted thinkingrdquo
ldquoCognitive restructuringrdquo
It may also involve classical conditioning when used to treat Obsessive Compulsive Disorder
CBT ndash Obstacles - Restructuring
Hopelessness
Self-criticism
Fear of getting worse
Shame and embarrassment
Partial exposure
Blaming other people
Low motivation
Looking for complex solution
Depressing ruminations
There must be an easier way
Computer Therapy
Pts are ashamed to seek help and may fear the consequences at work and home
Therapy is expensive and beyond the reach of many patients
Computer therapy is very cheap and available by comparison
Computer Therapy ndash Softwares
Fearfighter - for phobiapanic
Cope - for depressionanxiety
Balance - for GAD
BTSteps - for OCD
These are PC based in a CD-Rom
or phone based or Web-based
MENTAL OUTSIDE
Virtual Reality - VR
VR therapy via SD (Systematic Desensitization) is becoming very popular
SD is a process of gradually introducing a disturbing stimulus (eg view from a high place) in otherwise pleasant surroundings
This process gradually suppresses the anxiety response
Virtual Reality ndash VR - Advantages
Patients often have difficulty imagining the stimulus themselves
They are often afraid of experiencing it directly ndash which may also be expensive and time-consuming
VR affords patient privacy and confidentiality during treatment
Very good for phobias
Virtual Reality ndash VR - Imagination
ldquoProjection in timerdquo ndash rationally reconstructing the future
ldquoDe-catastrophizing an imagerdquo ndash modifying a disturbing image
ldquoImage modeling and substitutionrdquo ndashinterrupting a negative train of images
ldquoCovert conditioningrdquo ndash subtle conditioning using imagined rather than real stimuli
Virtual Reality ndash VR - Hutchworld
Hutchworld is a virtual community attached to the Hutchison Cancer Research Center
Designed to provide social support for cancer patients and their families
Based on Microsoftrsquos Vworldrsquos system
Mood GYM on the Internet
Few GPs are trained in CBT
Clinical psychologists are expensive
Young people are not easily reached
They may not want them ndash embarrassment
The web is accessible convenient and popular
with young people
Deliver CBT via internet ndash 5 modules
Mood GYM Modules
5 Modules - analysis and results
1 Essentials of CBT with examples and interactive exercises
2 Warpy Thoughts Questionnaire Identifying dysfunctional thoughts Methods to contest such thoughts
3 Other methods for overcoming warpy thoughts
4 Life Event Stress Relaxation meditation music Pleasant Events Schedule parental style
5 Simple problem solving responses to relationship break-up
Web stats summary
Sessions
Take home points
10487661048766Anxiety disorders are very common
10487661048766Just as fevers these are of different types
10487661048766Accurate Dx and Rx by GP is essential
10487661048766Depression and substance abuse potential
Minimum of six weeks to see Rx effect
Prolonged Rx is necessary 6 m or more
Drug Rx is only a small part of management
SSRI TCAs BZNs MAOIs szlig-blockers etc
CBT Computer treatment VRs Mood GYM
Thank You All Visit us at
wwwdrsarmain
This is sponsored by Torrent ndash
Makers of Clonotril (Clonazepam)
Panic Disorder with Agoraphobia
Recurrent unexpected panic attacks anxiety
associated with at least four physical andor
cognitive symptoms cognitive symptoms
At least 1 month of worry about having additional
attacks or the consequences of an attack (losing
control having a heart attack ldquogoing crazyrdquo)
Agoraphobia
Panic Disorder ndash Chest pain
Chest pain is a common symptom of panic
attacks
22 ndash 70 of panic attacks are associated with
CP
18 ndash 25 of all patients with chest pain have
PD
Rates of PD higher among cardiology
outpatients with chest pain
Such patients undergo expensive cardiac
workups but their PD remains undiagnosed amp
untreated
Obsessive Compulsive Disorder - OCD
Obsessions Recurrent and persistent thoughts impulses or
images
that are experienced during the disturbance as intrusive
and inappropriate and cause marked 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 to neutralize them with some other thought or action
The person recognizes that the obsessive thoughts
impulses or images are a product of his or her own mind
Obsessive Compulsive Disorder -OCD
Compulsions Repetitive behaviors (eg hand washing ordering
checking) or mental acts (eg praying counting repeating
words silently)
Heshe is driven to perform in response to an obsession
The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event
But these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent and are clearly excessive
Obsessive Compulsive Disorder -OCD
Putamen
Globus Pallidus
Caudate Nucleus
Thalamus
Orbital frontal
cortex
Post traumatic Stress Disorder- PTSD
Post traumatic Stress Disorder- PTSD
Experiential requirements The person has experienced a life-threatening
event and has responded with intense fear
hopelessness or horror The personrsquos response to the event occurred
more
than 4 weeks after it was experienced and lasted
more than one month The traumatic event is persistently re
experienced
in several ways eg by intrusive recollections
dreams illusions hallucinations or flashbacks
Post traumatic stress disorder PTSD
Post traumatic Stress Disorder- PTSD
Behavioral requirements Thought avoidance related-activities
andor People-avoidance behavior Feelings of detachment Blunted affect Sense of doom Insomnia Irritability Hyper vigilance Exaggerated startle response
Post traumatic Stress Disorder- PTSD
Subdivisions Acute ndash when PTSD is diagnosed between 1 and
3
months after the event occurs it is called acute Chronic - when PTSD continues longer than 3
months it is considered chronic and long term Delayed Onset PTSD-this term is used to
describe
those cases where the symptoms do not occur
immediately after the experience but rather
months or years later
Case 3
Mr A witnessed a friend die in a MVA six
weeks ago and co frequent nightmares
of the accident poor sleep fears of
driving anxiety around highways
anhedonia and decreased affection
highways towards his girlfriend His
girlfriend also notes that he has been
very irritable and startles easily since the
accident
Post traumatic Stress Disorder- PTSD
10487661048766Exposure to a traumatic event
10487661048766Response involving intense fear
Helplessness and horror
10487661048766Re-experiencing of the traumatic event
Avoidance of stimulipsychological numbing
10487661048766Increased arousal
10487661048766Symptoms greater than 1 month
Separation Anxiety Disorder - SAD
Medical conditions causing anxiety
10487661048766Endocrine conditions
10487661048766Cardiovascular conditions
10487661048766Respiratory conditions
10487661048766Metabolic conditions
10487661048766Neurological conditions
Substances causing anxiety
10487661048766Alcohol Alcohol
10487661048766Amphetamines
10487661048766Caffeine
10487661048766Cannabis
10487661048766Cocaine
10487661048766Hallucinogens
10487661048766Inhalants
10487661048766Phencyclidine
Substances that cause
anxiety (withdrawal)
10487661048766Alcohol
10487661048766Cocaine
10487661048766Sedatives
10487661048766Hypnotics
10487661048766Anxiolytics
Medications causing anxiety
Anesthetics
Analgesics
Sympathomimetics
Bronchodilators
Anti-cholinergics
1048766Insulin
Thyroid hormones
Oral contraceptives
Antihistamines
Anti-parkinsonians
1048766Corticosteroids
Antihypertensives
Cardiovascular drugs
Anticonvulsants
Anxiety Disorders
Current Management Strategies
Management of Anxiety Disorders
1048766 Pharmacotherapy (Medications)
Psycho-analytic therapy ndash PT
Behavior Therapy - BT
Cognitive Behavior Therapy ndash CBT
Computer therapy - CT
1048766 Virtual Realty ndash VR
Mood GYM
Drug Rx of Anxiety Disorders
Clonazepam
How do anxiolytics act
GABA and Glycine are inhibitory neurotransmitter
Serotonin and Noradrenaline are excitatory
Anxiety is increased excitatory transmitters
BZNs increase GABA and increase inhibition
SSRI decrease the serotonin levels and darrexcitation
TCAs act by darrboth serotonin and noradrenaline
Drug Rx of Anxiety Disorders
Disorder First Choice 2nd Choice Short (prn) Add on
GADBZN-
CZ CDZ ALZBeta-blockers Buspirone Carbamazp
Panic Disorder
Paroxetine
CitalopramTCA-
ClomipramineBZN-
ALZ CZ LZMAOI -
Phenelzine
Phobias Beta-blockers SSRIsBZN-
ALZ CZMAOI
OCD Clomipramine Fluoxetine CDZ Buspirone
PTSDTCA-
Imipra Amytrp
SSRI- FLX
Sertaline CPBZN MAOI
Comparison of Benzodiazepines
BZN Sedation Anxiolytic Half life Lipid solu Dose
Diazepam +++ + 20-80 h High 5 mg od
Alprazolam + +++ 6-20 h Low 05 mg qid
Clonazapam ++ +++ 22-50 h Low 05 mg bid
Lorazepam ++ ++ 10-20 h Med 1 mg tid
Chlordiazepx + + 7-30 h Med 15 mg bid
Different strategies of therapy
Behavior therapy
Desensitization
Behavior modification
Behavioral activation
Cognitive therapy
Rational-emotive therapy
Beckrsquos cognitive therapy
Newer approaches
Mindfulness meditation
Acceptance and commitment therapy
Dialectical Behavior Therapy (BPD)
Cognitive Behaviour Therapy - CBT
CBT is a method used to treat anxiety
Recognition of ldquodistorted thinkingrdquo
ldquoCognitive restructuringrdquo
It may also involve classical conditioning when used to treat Obsessive Compulsive Disorder
CBT ndash Obstacles - Restructuring
Hopelessness
Self-criticism
Fear of getting worse
Shame and embarrassment
Partial exposure
Blaming other people
Low motivation
Looking for complex solution
Depressing ruminations
There must be an easier way
Computer Therapy
Pts are ashamed to seek help and may fear the consequences at work and home
Therapy is expensive and beyond the reach of many patients
Computer therapy is very cheap and available by comparison
Computer Therapy ndash Softwares
Fearfighter - for phobiapanic
Cope - for depressionanxiety
Balance - for GAD
BTSteps - for OCD
These are PC based in a CD-Rom
or phone based or Web-based
MENTAL OUTSIDE
Virtual Reality - VR
VR therapy via SD (Systematic Desensitization) is becoming very popular
SD is a process of gradually introducing a disturbing stimulus (eg view from a high place) in otherwise pleasant surroundings
This process gradually suppresses the anxiety response
Virtual Reality ndash VR - Advantages
Patients often have difficulty imagining the stimulus themselves
They are often afraid of experiencing it directly ndash which may also be expensive and time-consuming
VR affords patient privacy and confidentiality during treatment
Very good for phobias
Virtual Reality ndash VR - Imagination
ldquoProjection in timerdquo ndash rationally reconstructing the future
ldquoDe-catastrophizing an imagerdquo ndash modifying a disturbing image
ldquoImage modeling and substitutionrdquo ndashinterrupting a negative train of images
ldquoCovert conditioningrdquo ndash subtle conditioning using imagined rather than real stimuli
Virtual Reality ndash VR - Hutchworld
Hutchworld is a virtual community attached to the Hutchison Cancer Research Center
Designed to provide social support for cancer patients and their families
Based on Microsoftrsquos Vworldrsquos system
Mood GYM on the Internet
Few GPs are trained in CBT
Clinical psychologists are expensive
Young people are not easily reached
They may not want them ndash embarrassment
The web is accessible convenient and popular
with young people
Deliver CBT via internet ndash 5 modules
Mood GYM Modules
5 Modules - analysis and results
1 Essentials of CBT with examples and interactive exercises
2 Warpy Thoughts Questionnaire Identifying dysfunctional thoughts Methods to contest such thoughts
3 Other methods for overcoming warpy thoughts
4 Life Event Stress Relaxation meditation music Pleasant Events Schedule parental style
5 Simple problem solving responses to relationship break-up
Web stats summary
Sessions
Take home points
10487661048766Anxiety disorders are very common
10487661048766Just as fevers these are of different types
10487661048766Accurate Dx and Rx by GP is essential
10487661048766Depression and substance abuse potential
Minimum of six weeks to see Rx effect
Prolonged Rx is necessary 6 m or more
Drug Rx is only a small part of management
SSRI TCAs BZNs MAOIs szlig-blockers etc
CBT Computer treatment VRs Mood GYM
Thank You All Visit us at
wwwdrsarmain
This is sponsored by Torrent ndash
Makers of Clonotril (Clonazepam)
Panic Disorder ndash Chest pain
Chest pain is a common symptom of panic
attacks
22 ndash 70 of panic attacks are associated with
CP
18 ndash 25 of all patients with chest pain have
PD
Rates of PD higher among cardiology
outpatients with chest pain
Such patients undergo expensive cardiac
workups but their PD remains undiagnosed amp
untreated
Obsessive Compulsive Disorder - OCD
Obsessions Recurrent and persistent thoughts impulses or
images
that are experienced during the disturbance as intrusive
and inappropriate and cause marked 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 to neutralize them with some other thought or action
The person recognizes that the obsessive thoughts
impulses or images are a product of his or her own mind
Obsessive Compulsive Disorder -OCD
Compulsions Repetitive behaviors (eg hand washing ordering
checking) or mental acts (eg praying counting repeating
words silently)
Heshe is driven to perform in response to an obsession
The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event
But these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent and are clearly excessive
Obsessive Compulsive Disorder -OCD
Putamen
Globus Pallidus
Caudate Nucleus
Thalamus
Orbital frontal
cortex
Post traumatic Stress Disorder- PTSD
Post traumatic Stress Disorder- PTSD
Experiential requirements The person has experienced a life-threatening
event and has responded with intense fear
hopelessness or horror The personrsquos response to the event occurred
more
than 4 weeks after it was experienced and lasted
more than one month The traumatic event is persistently re
experienced
in several ways eg by intrusive recollections
dreams illusions hallucinations or flashbacks
Post traumatic stress disorder PTSD
Post traumatic Stress Disorder- PTSD
Behavioral requirements Thought avoidance related-activities
andor People-avoidance behavior Feelings of detachment Blunted affect Sense of doom Insomnia Irritability Hyper vigilance Exaggerated startle response
Post traumatic Stress Disorder- PTSD
Subdivisions Acute ndash when PTSD is diagnosed between 1 and
3
months after the event occurs it is called acute Chronic - when PTSD continues longer than 3
months it is considered chronic and long term Delayed Onset PTSD-this term is used to
describe
those cases where the symptoms do not occur
immediately after the experience but rather
months or years later
Case 3
Mr A witnessed a friend die in a MVA six
weeks ago and co frequent nightmares
of the accident poor sleep fears of
driving anxiety around highways
anhedonia and decreased affection
highways towards his girlfriend His
girlfriend also notes that he has been
very irritable and startles easily since the
accident
Post traumatic Stress Disorder- PTSD
10487661048766Exposure to a traumatic event
10487661048766Response involving intense fear
Helplessness and horror
10487661048766Re-experiencing of the traumatic event
Avoidance of stimulipsychological numbing
10487661048766Increased arousal
10487661048766Symptoms greater than 1 month
Separation Anxiety Disorder - SAD
Medical conditions causing anxiety
10487661048766Endocrine conditions
10487661048766Cardiovascular conditions
10487661048766Respiratory conditions
10487661048766Metabolic conditions
10487661048766Neurological conditions
Substances causing anxiety
10487661048766Alcohol Alcohol
10487661048766Amphetamines
10487661048766Caffeine
10487661048766Cannabis
10487661048766Cocaine
10487661048766Hallucinogens
10487661048766Inhalants
10487661048766Phencyclidine
Substances that cause
anxiety (withdrawal)
10487661048766Alcohol
10487661048766Cocaine
10487661048766Sedatives
10487661048766Hypnotics
10487661048766Anxiolytics
Medications causing anxiety
Anesthetics
Analgesics
Sympathomimetics
Bronchodilators
Anti-cholinergics
1048766Insulin
Thyroid hormones
Oral contraceptives
Antihistamines
Anti-parkinsonians
1048766Corticosteroids
Antihypertensives
Cardiovascular drugs
Anticonvulsants
Anxiety Disorders
Current Management Strategies
Management of Anxiety Disorders
1048766 Pharmacotherapy (Medications)
Psycho-analytic therapy ndash PT
Behavior Therapy - BT
Cognitive Behavior Therapy ndash CBT
Computer therapy - CT
1048766 Virtual Realty ndash VR
Mood GYM
Drug Rx of Anxiety Disorders
Clonazepam
How do anxiolytics act
GABA and Glycine are inhibitory neurotransmitter
Serotonin and Noradrenaline are excitatory
Anxiety is increased excitatory transmitters
BZNs increase GABA and increase inhibition
SSRI decrease the serotonin levels and darrexcitation
TCAs act by darrboth serotonin and noradrenaline
Drug Rx of Anxiety Disorders
Disorder First Choice 2nd Choice Short (prn) Add on
GADBZN-
CZ CDZ ALZBeta-blockers Buspirone Carbamazp
Panic Disorder
Paroxetine
CitalopramTCA-
ClomipramineBZN-
ALZ CZ LZMAOI -
Phenelzine
Phobias Beta-blockers SSRIsBZN-
ALZ CZMAOI
OCD Clomipramine Fluoxetine CDZ Buspirone
PTSDTCA-
Imipra Amytrp
SSRI- FLX
Sertaline CPBZN MAOI
Comparison of Benzodiazepines
BZN Sedation Anxiolytic Half life Lipid solu Dose
Diazepam +++ + 20-80 h High 5 mg od
Alprazolam + +++ 6-20 h Low 05 mg qid
Clonazapam ++ +++ 22-50 h Low 05 mg bid
Lorazepam ++ ++ 10-20 h Med 1 mg tid
Chlordiazepx + + 7-30 h Med 15 mg bid
Different strategies of therapy
Behavior therapy
Desensitization
Behavior modification
Behavioral activation
Cognitive therapy
Rational-emotive therapy
Beckrsquos cognitive therapy
Newer approaches
Mindfulness meditation
Acceptance and commitment therapy
Dialectical Behavior Therapy (BPD)
Cognitive Behaviour Therapy - CBT
CBT is a method used to treat anxiety
Recognition of ldquodistorted thinkingrdquo
ldquoCognitive restructuringrdquo
It may also involve classical conditioning when used to treat Obsessive Compulsive Disorder
CBT ndash Obstacles - Restructuring
Hopelessness
Self-criticism
Fear of getting worse
Shame and embarrassment
Partial exposure
Blaming other people
Low motivation
Looking for complex solution
Depressing ruminations
There must be an easier way
Computer Therapy
Pts are ashamed to seek help and may fear the consequences at work and home
Therapy is expensive and beyond the reach of many patients
Computer therapy is very cheap and available by comparison
Computer Therapy ndash Softwares
Fearfighter - for phobiapanic
Cope - for depressionanxiety
Balance - for GAD
BTSteps - for OCD
These are PC based in a CD-Rom
or phone based or Web-based
MENTAL OUTSIDE
Virtual Reality - VR
VR therapy via SD (Systematic Desensitization) is becoming very popular
SD is a process of gradually introducing a disturbing stimulus (eg view from a high place) in otherwise pleasant surroundings
This process gradually suppresses the anxiety response
Virtual Reality ndash VR - Advantages
Patients often have difficulty imagining the stimulus themselves
They are often afraid of experiencing it directly ndash which may also be expensive and time-consuming
VR affords patient privacy and confidentiality during treatment
Very good for phobias
Virtual Reality ndash VR - Imagination
ldquoProjection in timerdquo ndash rationally reconstructing the future
ldquoDe-catastrophizing an imagerdquo ndash modifying a disturbing image
ldquoImage modeling and substitutionrdquo ndashinterrupting a negative train of images
ldquoCovert conditioningrdquo ndash subtle conditioning using imagined rather than real stimuli
Virtual Reality ndash VR - Hutchworld
Hutchworld is a virtual community attached to the Hutchison Cancer Research Center
Designed to provide social support for cancer patients and their families
Based on Microsoftrsquos Vworldrsquos system
Mood GYM on the Internet
Few GPs are trained in CBT
Clinical psychologists are expensive
Young people are not easily reached
They may not want them ndash embarrassment
The web is accessible convenient and popular
with young people
Deliver CBT via internet ndash 5 modules
Mood GYM Modules
5 Modules - analysis and results
1 Essentials of CBT with examples and interactive exercises
2 Warpy Thoughts Questionnaire Identifying dysfunctional thoughts Methods to contest such thoughts
3 Other methods for overcoming warpy thoughts
4 Life Event Stress Relaxation meditation music Pleasant Events Schedule parental style
5 Simple problem solving responses to relationship break-up
Web stats summary
Sessions
Take home points
10487661048766Anxiety disorders are very common
10487661048766Just as fevers these are of different types
10487661048766Accurate Dx and Rx by GP is essential
10487661048766Depression and substance abuse potential
Minimum of six weeks to see Rx effect
Prolonged Rx is necessary 6 m or more
Drug Rx is only a small part of management
SSRI TCAs BZNs MAOIs szlig-blockers etc
CBT Computer treatment VRs Mood GYM
Thank You All Visit us at
wwwdrsarmain
This is sponsored by Torrent ndash
Makers of Clonotril (Clonazepam)
Obsessive Compulsive Disorder - OCD
Obsessions Recurrent and persistent thoughts impulses or
images
that are experienced during the disturbance as intrusive
and inappropriate and cause marked 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 to neutralize them with some other thought or action
The person recognizes that the obsessive thoughts
impulses or images are a product of his or her own mind
Obsessive Compulsive Disorder -OCD
Compulsions Repetitive behaviors (eg hand washing ordering
checking) or mental acts (eg praying counting repeating
words silently)
Heshe is driven to perform in response to an obsession
The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event
But these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent and are clearly excessive
Obsessive Compulsive Disorder -OCD
Putamen
Globus Pallidus
Caudate Nucleus
Thalamus
Orbital frontal
cortex
Post traumatic Stress Disorder- PTSD
Post traumatic Stress Disorder- PTSD
Experiential requirements The person has experienced a life-threatening
event and has responded with intense fear
hopelessness or horror The personrsquos response to the event occurred
more
than 4 weeks after it was experienced and lasted
more than one month The traumatic event is persistently re
experienced
in several ways eg by intrusive recollections
dreams illusions hallucinations or flashbacks
Post traumatic stress disorder PTSD
Post traumatic Stress Disorder- PTSD
Behavioral requirements Thought avoidance related-activities
andor People-avoidance behavior Feelings of detachment Blunted affect Sense of doom Insomnia Irritability Hyper vigilance Exaggerated startle response
Post traumatic Stress Disorder- PTSD
Subdivisions Acute ndash when PTSD is diagnosed between 1 and
3
months after the event occurs it is called acute Chronic - when PTSD continues longer than 3
months it is considered chronic and long term Delayed Onset PTSD-this term is used to
describe
those cases where the symptoms do not occur
immediately after the experience but rather
months or years later
Case 3
Mr A witnessed a friend die in a MVA six
weeks ago and co frequent nightmares
of the accident poor sleep fears of
driving anxiety around highways
anhedonia and decreased affection
highways towards his girlfriend His
girlfriend also notes that he has been
very irritable and startles easily since the
accident
Post traumatic Stress Disorder- PTSD
10487661048766Exposure to a traumatic event
10487661048766Response involving intense fear
Helplessness and horror
10487661048766Re-experiencing of the traumatic event
Avoidance of stimulipsychological numbing
10487661048766Increased arousal
10487661048766Symptoms greater than 1 month
Separation Anxiety Disorder - SAD
Medical conditions causing anxiety
10487661048766Endocrine conditions
10487661048766Cardiovascular conditions
10487661048766Respiratory conditions
10487661048766Metabolic conditions
10487661048766Neurological conditions
Substances causing anxiety
10487661048766Alcohol Alcohol
10487661048766Amphetamines
10487661048766Caffeine
10487661048766Cannabis
10487661048766Cocaine
10487661048766Hallucinogens
10487661048766Inhalants
10487661048766Phencyclidine
Substances that cause
anxiety (withdrawal)
10487661048766Alcohol
10487661048766Cocaine
10487661048766Sedatives
10487661048766Hypnotics
10487661048766Anxiolytics
Medications causing anxiety
Anesthetics
Analgesics
Sympathomimetics
Bronchodilators
Anti-cholinergics
1048766Insulin
Thyroid hormones
Oral contraceptives
Antihistamines
Anti-parkinsonians
1048766Corticosteroids
Antihypertensives
Cardiovascular drugs
Anticonvulsants
Anxiety Disorders
Current Management Strategies
Management of Anxiety Disorders
1048766 Pharmacotherapy (Medications)
Psycho-analytic therapy ndash PT
Behavior Therapy - BT
Cognitive Behavior Therapy ndash CBT
Computer therapy - CT
1048766 Virtual Realty ndash VR
Mood GYM
Drug Rx of Anxiety Disorders
Clonazepam
How do anxiolytics act
GABA and Glycine are inhibitory neurotransmitter
Serotonin and Noradrenaline are excitatory
Anxiety is increased excitatory transmitters
BZNs increase GABA and increase inhibition
SSRI decrease the serotonin levels and darrexcitation
TCAs act by darrboth serotonin and noradrenaline
Drug Rx of Anxiety Disorders
Disorder First Choice 2nd Choice Short (prn) Add on
GADBZN-
CZ CDZ ALZBeta-blockers Buspirone Carbamazp
Panic Disorder
Paroxetine
CitalopramTCA-
ClomipramineBZN-
ALZ CZ LZMAOI -
Phenelzine
Phobias Beta-blockers SSRIsBZN-
ALZ CZMAOI
OCD Clomipramine Fluoxetine CDZ Buspirone
PTSDTCA-
Imipra Amytrp
SSRI- FLX
Sertaline CPBZN MAOI
Comparison of Benzodiazepines
BZN Sedation Anxiolytic Half life Lipid solu Dose
Diazepam +++ + 20-80 h High 5 mg od
Alprazolam + +++ 6-20 h Low 05 mg qid
Clonazapam ++ +++ 22-50 h Low 05 mg bid
Lorazepam ++ ++ 10-20 h Med 1 mg tid
Chlordiazepx + + 7-30 h Med 15 mg bid
Different strategies of therapy
Behavior therapy
Desensitization
Behavior modification
Behavioral activation
Cognitive therapy
Rational-emotive therapy
Beckrsquos cognitive therapy
Newer approaches
Mindfulness meditation
Acceptance and commitment therapy
Dialectical Behavior Therapy (BPD)
Cognitive Behaviour Therapy - CBT
CBT is a method used to treat anxiety
Recognition of ldquodistorted thinkingrdquo
ldquoCognitive restructuringrdquo
It may also involve classical conditioning when used to treat Obsessive Compulsive Disorder
CBT ndash Obstacles - Restructuring
Hopelessness
Self-criticism
Fear of getting worse
Shame and embarrassment
Partial exposure
Blaming other people
Low motivation
Looking for complex solution
Depressing ruminations
There must be an easier way
Computer Therapy
Pts are ashamed to seek help and may fear the consequences at work and home
Therapy is expensive and beyond the reach of many patients
Computer therapy is very cheap and available by comparison
Computer Therapy ndash Softwares
Fearfighter - for phobiapanic
Cope - for depressionanxiety
Balance - for GAD
BTSteps - for OCD
These are PC based in a CD-Rom
or phone based or Web-based
MENTAL OUTSIDE
Virtual Reality - VR
VR therapy via SD (Systematic Desensitization) is becoming very popular
SD is a process of gradually introducing a disturbing stimulus (eg view from a high place) in otherwise pleasant surroundings
This process gradually suppresses the anxiety response
Virtual Reality ndash VR - Advantages
Patients often have difficulty imagining the stimulus themselves
They are often afraid of experiencing it directly ndash which may also be expensive and time-consuming
VR affords patient privacy and confidentiality during treatment
Very good for phobias
Virtual Reality ndash VR - Imagination
ldquoProjection in timerdquo ndash rationally reconstructing the future
ldquoDe-catastrophizing an imagerdquo ndash modifying a disturbing image
ldquoImage modeling and substitutionrdquo ndashinterrupting a negative train of images
ldquoCovert conditioningrdquo ndash subtle conditioning using imagined rather than real stimuli
Virtual Reality ndash VR - Hutchworld
Hutchworld is a virtual community attached to the Hutchison Cancer Research Center
Designed to provide social support for cancer patients and their families
Based on Microsoftrsquos Vworldrsquos system
Mood GYM on the Internet
Few GPs are trained in CBT
Clinical psychologists are expensive
Young people are not easily reached
They may not want them ndash embarrassment
The web is accessible convenient and popular
with young people
Deliver CBT via internet ndash 5 modules
Mood GYM Modules
5 Modules - analysis and results
1 Essentials of CBT with examples and interactive exercises
2 Warpy Thoughts Questionnaire Identifying dysfunctional thoughts Methods to contest such thoughts
3 Other methods for overcoming warpy thoughts
4 Life Event Stress Relaxation meditation music Pleasant Events Schedule parental style
5 Simple problem solving responses to relationship break-up
Web stats summary
Sessions
Take home points
10487661048766Anxiety disorders are very common
10487661048766Just as fevers these are of different types
10487661048766Accurate Dx and Rx by GP is essential
10487661048766Depression and substance abuse potential
Minimum of six weeks to see Rx effect
Prolonged Rx is necessary 6 m or more
Drug Rx is only a small part of management
SSRI TCAs BZNs MAOIs szlig-blockers etc
CBT Computer treatment VRs Mood GYM
Thank You All Visit us at
wwwdrsarmain
This is sponsored by Torrent ndash
Makers of Clonotril (Clonazepam)
Obsessive Compulsive Disorder -OCD
Compulsions Repetitive behaviors (eg hand washing ordering
checking) or mental acts (eg praying counting repeating
words silently)
Heshe is driven to perform in response to an obsession
The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event
But these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent and are clearly excessive
Obsessive Compulsive Disorder -OCD
Putamen
Globus Pallidus
Caudate Nucleus
Thalamus
Orbital frontal
cortex
Post traumatic Stress Disorder- PTSD
Post traumatic Stress Disorder- PTSD
Experiential requirements The person has experienced a life-threatening
event and has responded with intense fear
hopelessness or horror The personrsquos response to the event occurred
more
than 4 weeks after it was experienced and lasted
more than one month The traumatic event is persistently re
experienced
in several ways eg by intrusive recollections
dreams illusions hallucinations or flashbacks
Post traumatic stress disorder PTSD
Post traumatic Stress Disorder- PTSD
Behavioral requirements Thought avoidance related-activities
andor People-avoidance behavior Feelings of detachment Blunted affect Sense of doom Insomnia Irritability Hyper vigilance Exaggerated startle response
Post traumatic Stress Disorder- PTSD
Subdivisions Acute ndash when PTSD is diagnosed between 1 and
3
months after the event occurs it is called acute Chronic - when PTSD continues longer than 3
months it is considered chronic and long term Delayed Onset PTSD-this term is used to
describe
those cases where the symptoms do not occur
immediately after the experience but rather
months or years later
Case 3
Mr A witnessed a friend die in a MVA six
weeks ago and co frequent nightmares
of the accident poor sleep fears of
driving anxiety around highways
anhedonia and decreased affection
highways towards his girlfriend His
girlfriend also notes that he has been
very irritable and startles easily since the
accident
Post traumatic Stress Disorder- PTSD
10487661048766Exposure to a traumatic event
10487661048766Response involving intense fear
Helplessness and horror
10487661048766Re-experiencing of the traumatic event
Avoidance of stimulipsychological numbing
10487661048766Increased arousal
10487661048766Symptoms greater than 1 month
Separation Anxiety Disorder - SAD
Medical conditions causing anxiety
10487661048766Endocrine conditions
10487661048766Cardiovascular conditions
10487661048766Respiratory conditions
10487661048766Metabolic conditions
10487661048766Neurological conditions
Substances causing anxiety
10487661048766Alcohol Alcohol
10487661048766Amphetamines
10487661048766Caffeine
10487661048766Cannabis
10487661048766Cocaine
10487661048766Hallucinogens
10487661048766Inhalants
10487661048766Phencyclidine
Substances that cause
anxiety (withdrawal)
10487661048766Alcohol
10487661048766Cocaine
10487661048766Sedatives
10487661048766Hypnotics
10487661048766Anxiolytics
Medications causing anxiety
Anesthetics
Analgesics
Sympathomimetics
Bronchodilators
Anti-cholinergics
1048766Insulin
Thyroid hormones
Oral contraceptives
Antihistamines
Anti-parkinsonians
1048766Corticosteroids
Antihypertensives
Cardiovascular drugs
Anticonvulsants
Anxiety Disorders
Current Management Strategies
Management of Anxiety Disorders
1048766 Pharmacotherapy (Medications)
Psycho-analytic therapy ndash PT
Behavior Therapy - BT
Cognitive Behavior Therapy ndash CBT
Computer therapy - CT
1048766 Virtual Realty ndash VR
Mood GYM
Drug Rx of Anxiety Disorders
Clonazepam
How do anxiolytics act
GABA and Glycine are inhibitory neurotransmitter
Serotonin and Noradrenaline are excitatory
Anxiety is increased excitatory transmitters
BZNs increase GABA and increase inhibition
SSRI decrease the serotonin levels and darrexcitation
TCAs act by darrboth serotonin and noradrenaline
Drug Rx of Anxiety Disorders
Disorder First Choice 2nd Choice Short (prn) Add on
GADBZN-
CZ CDZ ALZBeta-blockers Buspirone Carbamazp
Panic Disorder
Paroxetine
CitalopramTCA-
ClomipramineBZN-
ALZ CZ LZMAOI -
Phenelzine
Phobias Beta-blockers SSRIsBZN-
ALZ CZMAOI
OCD Clomipramine Fluoxetine CDZ Buspirone
PTSDTCA-
Imipra Amytrp
SSRI- FLX
Sertaline CPBZN MAOI
Comparison of Benzodiazepines
BZN Sedation Anxiolytic Half life Lipid solu Dose
Diazepam +++ + 20-80 h High 5 mg od
Alprazolam + +++ 6-20 h Low 05 mg qid
Clonazapam ++ +++ 22-50 h Low 05 mg bid
Lorazepam ++ ++ 10-20 h Med 1 mg tid
Chlordiazepx + + 7-30 h Med 15 mg bid
Different strategies of therapy
Behavior therapy
Desensitization
Behavior modification
Behavioral activation
Cognitive therapy
Rational-emotive therapy
Beckrsquos cognitive therapy
Newer approaches
Mindfulness meditation
Acceptance and commitment therapy
Dialectical Behavior Therapy (BPD)
Cognitive Behaviour Therapy - CBT
CBT is a method used to treat anxiety
Recognition of ldquodistorted thinkingrdquo
ldquoCognitive restructuringrdquo
It may also involve classical conditioning when used to treat Obsessive Compulsive Disorder
CBT ndash Obstacles - Restructuring
Hopelessness
Self-criticism
Fear of getting worse
Shame and embarrassment
Partial exposure
Blaming other people
Low motivation
Looking for complex solution
Depressing ruminations
There must be an easier way
Computer Therapy
Pts are ashamed to seek help and may fear the consequences at work and home
Therapy is expensive and beyond the reach of many patients
Computer therapy is very cheap and available by comparison
Computer Therapy ndash Softwares
Fearfighter - for phobiapanic
Cope - for depressionanxiety
Balance - for GAD
BTSteps - for OCD
These are PC based in a CD-Rom
or phone based or Web-based
MENTAL OUTSIDE
Virtual Reality - VR
VR therapy via SD (Systematic Desensitization) is becoming very popular
SD is a process of gradually introducing a disturbing stimulus (eg view from a high place) in otherwise pleasant surroundings
This process gradually suppresses the anxiety response
Virtual Reality ndash VR - Advantages
Patients often have difficulty imagining the stimulus themselves
They are often afraid of experiencing it directly ndash which may also be expensive and time-consuming
VR affords patient privacy and confidentiality during treatment
Very good for phobias
Virtual Reality ndash VR - Imagination
ldquoProjection in timerdquo ndash rationally reconstructing the future
ldquoDe-catastrophizing an imagerdquo ndash modifying a disturbing image
ldquoImage modeling and substitutionrdquo ndashinterrupting a negative train of images
ldquoCovert conditioningrdquo ndash subtle conditioning using imagined rather than real stimuli
Virtual Reality ndash VR - Hutchworld
Hutchworld is a virtual community attached to the Hutchison Cancer Research Center
Designed to provide social support for cancer patients and their families
Based on Microsoftrsquos Vworldrsquos system
Mood GYM on the Internet
Few GPs are trained in CBT
Clinical psychologists are expensive
Young people are not easily reached
They may not want them ndash embarrassment
The web is accessible convenient and popular
with young people
Deliver CBT via internet ndash 5 modules
Mood GYM Modules
5 Modules - analysis and results
1 Essentials of CBT with examples and interactive exercises
2 Warpy Thoughts Questionnaire Identifying dysfunctional thoughts Methods to contest such thoughts
3 Other methods for overcoming warpy thoughts
4 Life Event Stress Relaxation meditation music Pleasant Events Schedule parental style
5 Simple problem solving responses to relationship break-up
Web stats summary
Sessions
Take home points
10487661048766Anxiety disorders are very common
10487661048766Just as fevers these are of different types
10487661048766Accurate Dx and Rx by GP is essential
10487661048766Depression and substance abuse potential
Minimum of six weeks to see Rx effect
Prolonged Rx is necessary 6 m or more
Drug Rx is only a small part of management
SSRI TCAs BZNs MAOIs szlig-blockers etc
CBT Computer treatment VRs Mood GYM
Thank You All Visit us at
wwwdrsarmain
This is sponsored by Torrent ndash
Makers of Clonotril (Clonazepam)
Obsessive Compulsive Disorder -OCD
Putamen
Globus Pallidus
Caudate Nucleus
Thalamus
Orbital frontal
cortex
Post traumatic Stress Disorder- PTSD
Post traumatic Stress Disorder- PTSD
Experiential requirements The person has experienced a life-threatening
event and has responded with intense fear
hopelessness or horror The personrsquos response to the event occurred
more
than 4 weeks after it was experienced and lasted
more than one month The traumatic event is persistently re
experienced
in several ways eg by intrusive recollections
dreams illusions hallucinations or flashbacks
Post traumatic stress disorder PTSD
Post traumatic Stress Disorder- PTSD
Behavioral requirements Thought avoidance related-activities
andor People-avoidance behavior Feelings of detachment Blunted affect Sense of doom Insomnia Irritability Hyper vigilance Exaggerated startle response
Post traumatic Stress Disorder- PTSD
Subdivisions Acute ndash when PTSD is diagnosed between 1 and
3
months after the event occurs it is called acute Chronic - when PTSD continues longer than 3
months it is considered chronic and long term Delayed Onset PTSD-this term is used to
describe
those cases where the symptoms do not occur
immediately after the experience but rather
months or years later
Case 3
Mr A witnessed a friend die in a MVA six
weeks ago and co frequent nightmares
of the accident poor sleep fears of
driving anxiety around highways
anhedonia and decreased affection
highways towards his girlfriend His
girlfriend also notes that he has been
very irritable and startles easily since the
accident
Post traumatic Stress Disorder- PTSD
10487661048766Exposure to a traumatic event
10487661048766Response involving intense fear
Helplessness and horror
10487661048766Re-experiencing of the traumatic event
Avoidance of stimulipsychological numbing
10487661048766Increased arousal
10487661048766Symptoms greater than 1 month
Separation Anxiety Disorder - SAD
Medical conditions causing anxiety
10487661048766Endocrine conditions
10487661048766Cardiovascular conditions
10487661048766Respiratory conditions
10487661048766Metabolic conditions
10487661048766Neurological conditions
Substances causing anxiety
10487661048766Alcohol Alcohol
10487661048766Amphetamines
10487661048766Caffeine
10487661048766Cannabis
10487661048766Cocaine
10487661048766Hallucinogens
10487661048766Inhalants
10487661048766Phencyclidine
Substances that cause
anxiety (withdrawal)
10487661048766Alcohol
10487661048766Cocaine
10487661048766Sedatives
10487661048766Hypnotics
10487661048766Anxiolytics
Medications causing anxiety
Anesthetics
Analgesics
Sympathomimetics
Bronchodilators
Anti-cholinergics
1048766Insulin
Thyroid hormones
Oral contraceptives
Antihistamines
Anti-parkinsonians
1048766Corticosteroids
Antihypertensives
Cardiovascular drugs
Anticonvulsants
Anxiety Disorders
Current Management Strategies
Management of Anxiety Disorders
1048766 Pharmacotherapy (Medications)
Psycho-analytic therapy ndash PT
Behavior Therapy - BT
Cognitive Behavior Therapy ndash CBT
Computer therapy - CT
1048766 Virtual Realty ndash VR
Mood GYM
Drug Rx of Anxiety Disorders
Clonazepam
How do anxiolytics act
GABA and Glycine are inhibitory neurotransmitter
Serotonin and Noradrenaline are excitatory
Anxiety is increased excitatory transmitters
BZNs increase GABA and increase inhibition
SSRI decrease the serotonin levels and darrexcitation
TCAs act by darrboth serotonin and noradrenaline
Drug Rx of Anxiety Disorders
Disorder First Choice 2nd Choice Short (prn) Add on
GADBZN-
CZ CDZ ALZBeta-blockers Buspirone Carbamazp
Panic Disorder
Paroxetine
CitalopramTCA-
ClomipramineBZN-
ALZ CZ LZMAOI -
Phenelzine
Phobias Beta-blockers SSRIsBZN-
ALZ CZMAOI
OCD Clomipramine Fluoxetine CDZ Buspirone
PTSDTCA-
Imipra Amytrp
SSRI- FLX
Sertaline CPBZN MAOI
Comparison of Benzodiazepines
BZN Sedation Anxiolytic Half life Lipid solu Dose
Diazepam +++ + 20-80 h High 5 mg od
Alprazolam + +++ 6-20 h Low 05 mg qid
Clonazapam ++ +++ 22-50 h Low 05 mg bid
Lorazepam ++ ++ 10-20 h Med 1 mg tid
Chlordiazepx + + 7-30 h Med 15 mg bid
Different strategies of therapy
Behavior therapy
Desensitization
Behavior modification
Behavioral activation
Cognitive therapy
Rational-emotive therapy
Beckrsquos cognitive therapy
Newer approaches
Mindfulness meditation
Acceptance and commitment therapy
Dialectical Behavior Therapy (BPD)
Cognitive Behaviour Therapy - CBT
CBT is a method used to treat anxiety
Recognition of ldquodistorted thinkingrdquo
ldquoCognitive restructuringrdquo
It may also involve classical conditioning when used to treat Obsessive Compulsive Disorder
CBT ndash Obstacles - Restructuring
Hopelessness
Self-criticism
Fear of getting worse
Shame and embarrassment
Partial exposure
Blaming other people
Low motivation
Looking for complex solution
Depressing ruminations
There must be an easier way
Computer Therapy
Pts are ashamed to seek help and may fear the consequences at work and home
Therapy is expensive and beyond the reach of many patients
Computer therapy is very cheap and available by comparison
Computer Therapy ndash Softwares
Fearfighter - for phobiapanic
Cope - for depressionanxiety
Balance - for GAD
BTSteps - for OCD
These are PC based in a CD-Rom
or phone based or Web-based
MENTAL OUTSIDE
Virtual Reality - VR
VR therapy via SD (Systematic Desensitization) is becoming very popular
SD is a process of gradually introducing a disturbing stimulus (eg view from a high place) in otherwise pleasant surroundings
This process gradually suppresses the anxiety response
Virtual Reality ndash VR - Advantages
Patients often have difficulty imagining the stimulus themselves
They are often afraid of experiencing it directly ndash which may also be expensive and time-consuming
VR affords patient privacy and confidentiality during treatment
Very good for phobias
Virtual Reality ndash VR - Imagination
ldquoProjection in timerdquo ndash rationally reconstructing the future
ldquoDe-catastrophizing an imagerdquo ndash modifying a disturbing image
ldquoImage modeling and substitutionrdquo ndashinterrupting a negative train of images
ldquoCovert conditioningrdquo ndash subtle conditioning using imagined rather than real stimuli
Virtual Reality ndash VR - Hutchworld
Hutchworld is a virtual community attached to the Hutchison Cancer Research Center
Designed to provide social support for cancer patients and their families
Based on Microsoftrsquos Vworldrsquos system
Mood GYM on the Internet
Few GPs are trained in CBT
Clinical psychologists are expensive
Young people are not easily reached
They may not want them ndash embarrassment
The web is accessible convenient and popular
with young people
Deliver CBT via internet ndash 5 modules
Mood GYM Modules
5 Modules - analysis and results
1 Essentials of CBT with examples and interactive exercises
2 Warpy Thoughts Questionnaire Identifying dysfunctional thoughts Methods to contest such thoughts
3 Other methods for overcoming warpy thoughts
4 Life Event Stress Relaxation meditation music Pleasant Events Schedule parental style
5 Simple problem solving responses to relationship break-up
Web stats summary
Sessions
Take home points
10487661048766Anxiety disorders are very common
10487661048766Just as fevers these are of different types
10487661048766Accurate Dx and Rx by GP is essential
10487661048766Depression and substance abuse potential
Minimum of six weeks to see Rx effect
Prolonged Rx is necessary 6 m or more
Drug Rx is only a small part of management
SSRI TCAs BZNs MAOIs szlig-blockers etc
CBT Computer treatment VRs Mood GYM
Thank You All Visit us at
wwwdrsarmain
This is sponsored by Torrent ndash
Makers of Clonotril (Clonazepam)
Post traumatic Stress Disorder- PTSD
Post traumatic Stress Disorder- PTSD
Experiential requirements The person has experienced a life-threatening
event and has responded with intense fear
hopelessness or horror The personrsquos response to the event occurred
more
than 4 weeks after it was experienced and lasted
more than one month The traumatic event is persistently re
experienced
in several ways eg by intrusive recollections
dreams illusions hallucinations or flashbacks
Post traumatic stress disorder PTSD
Post traumatic Stress Disorder- PTSD
Behavioral requirements Thought avoidance related-activities
andor People-avoidance behavior Feelings of detachment Blunted affect Sense of doom Insomnia Irritability Hyper vigilance Exaggerated startle response
Post traumatic Stress Disorder- PTSD
Subdivisions Acute ndash when PTSD is diagnosed between 1 and
3
months after the event occurs it is called acute Chronic - when PTSD continues longer than 3
months it is considered chronic and long term Delayed Onset PTSD-this term is used to
describe
those cases where the symptoms do not occur
immediately after the experience but rather
months or years later
Case 3
Mr A witnessed a friend die in a MVA six
weeks ago and co frequent nightmares
of the accident poor sleep fears of
driving anxiety around highways
anhedonia and decreased affection
highways towards his girlfriend His
girlfriend also notes that he has been
very irritable and startles easily since the
accident
Post traumatic Stress Disorder- PTSD
10487661048766Exposure to a traumatic event
10487661048766Response involving intense fear
Helplessness and horror
10487661048766Re-experiencing of the traumatic event
Avoidance of stimulipsychological numbing
10487661048766Increased arousal
10487661048766Symptoms greater than 1 month
Separation Anxiety Disorder - SAD
Medical conditions causing anxiety
10487661048766Endocrine conditions
10487661048766Cardiovascular conditions
10487661048766Respiratory conditions
10487661048766Metabolic conditions
10487661048766Neurological conditions
Substances causing anxiety
10487661048766Alcohol Alcohol
10487661048766Amphetamines
10487661048766Caffeine
10487661048766Cannabis
10487661048766Cocaine
10487661048766Hallucinogens
10487661048766Inhalants
10487661048766Phencyclidine
Substances that cause
anxiety (withdrawal)
10487661048766Alcohol
10487661048766Cocaine
10487661048766Sedatives
10487661048766Hypnotics
10487661048766Anxiolytics
Medications causing anxiety
Anesthetics
Analgesics
Sympathomimetics
Bronchodilators
Anti-cholinergics
1048766Insulin
Thyroid hormones
Oral contraceptives
Antihistamines
Anti-parkinsonians
1048766Corticosteroids
Antihypertensives
Cardiovascular drugs
Anticonvulsants
Anxiety Disorders
Current Management Strategies
Management of Anxiety Disorders
1048766 Pharmacotherapy (Medications)
Psycho-analytic therapy ndash PT
Behavior Therapy - BT
Cognitive Behavior Therapy ndash CBT
Computer therapy - CT
1048766 Virtual Realty ndash VR
Mood GYM
Drug Rx of Anxiety Disorders
Clonazepam
How do anxiolytics act
GABA and Glycine are inhibitory neurotransmitter
Serotonin and Noradrenaline are excitatory
Anxiety is increased excitatory transmitters
BZNs increase GABA and increase inhibition
SSRI decrease the serotonin levels and darrexcitation
TCAs act by darrboth serotonin and noradrenaline
Drug Rx of Anxiety Disorders
Disorder First Choice 2nd Choice Short (prn) Add on
GADBZN-
CZ CDZ ALZBeta-blockers Buspirone Carbamazp
Panic Disorder
Paroxetine
CitalopramTCA-
ClomipramineBZN-
ALZ CZ LZMAOI -
Phenelzine
Phobias Beta-blockers SSRIsBZN-
ALZ CZMAOI
OCD Clomipramine Fluoxetine CDZ Buspirone
PTSDTCA-
Imipra Amytrp
SSRI- FLX
Sertaline CPBZN MAOI
Comparison of Benzodiazepines
BZN Sedation Anxiolytic Half life Lipid solu Dose
Diazepam +++ + 20-80 h High 5 mg od
Alprazolam + +++ 6-20 h Low 05 mg qid
Clonazapam ++ +++ 22-50 h Low 05 mg bid
Lorazepam ++ ++ 10-20 h Med 1 mg tid
Chlordiazepx + + 7-30 h Med 15 mg bid
Different strategies of therapy
Behavior therapy
Desensitization
Behavior modification
Behavioral activation
Cognitive therapy
Rational-emotive therapy
Beckrsquos cognitive therapy
Newer approaches
Mindfulness meditation
Acceptance and commitment therapy
Dialectical Behavior Therapy (BPD)
Cognitive Behaviour Therapy - CBT
CBT is a method used to treat anxiety
Recognition of ldquodistorted thinkingrdquo
ldquoCognitive restructuringrdquo
It may also involve classical conditioning when used to treat Obsessive Compulsive Disorder
CBT ndash Obstacles - Restructuring
Hopelessness
Self-criticism
Fear of getting worse
Shame and embarrassment
Partial exposure
Blaming other people
Low motivation
Looking for complex solution
Depressing ruminations
There must be an easier way
Computer Therapy
Pts are ashamed to seek help and may fear the consequences at work and home
Therapy is expensive and beyond the reach of many patients
Computer therapy is very cheap and available by comparison
Computer Therapy ndash Softwares
Fearfighter - for phobiapanic
Cope - for depressionanxiety
Balance - for GAD
BTSteps - for OCD
These are PC based in a CD-Rom
or phone based or Web-based
MENTAL OUTSIDE
Virtual Reality - VR
VR therapy via SD (Systematic Desensitization) is becoming very popular
SD is a process of gradually introducing a disturbing stimulus (eg view from a high place) in otherwise pleasant surroundings
This process gradually suppresses the anxiety response
Virtual Reality ndash VR - Advantages
Patients often have difficulty imagining the stimulus themselves
They are often afraid of experiencing it directly ndash which may also be expensive and time-consuming
VR affords patient privacy and confidentiality during treatment
Very good for phobias
Virtual Reality ndash VR - Imagination
ldquoProjection in timerdquo ndash rationally reconstructing the future
ldquoDe-catastrophizing an imagerdquo ndash modifying a disturbing image
ldquoImage modeling and substitutionrdquo ndashinterrupting a negative train of images
ldquoCovert conditioningrdquo ndash subtle conditioning using imagined rather than real stimuli
Virtual Reality ndash VR - Hutchworld
Hutchworld is a virtual community attached to the Hutchison Cancer Research Center
Designed to provide social support for cancer patients and their families
Based on Microsoftrsquos Vworldrsquos system
Mood GYM on the Internet
Few GPs are trained in CBT
Clinical psychologists are expensive
Young people are not easily reached
They may not want them ndash embarrassment
The web is accessible convenient and popular
with young people
Deliver CBT via internet ndash 5 modules
Mood GYM Modules
5 Modules - analysis and results
1 Essentials of CBT with examples and interactive exercises
2 Warpy Thoughts Questionnaire Identifying dysfunctional thoughts Methods to contest such thoughts
3 Other methods for overcoming warpy thoughts
4 Life Event Stress Relaxation meditation music Pleasant Events Schedule parental style
5 Simple problem solving responses to relationship break-up
Web stats summary
Sessions
Take home points
10487661048766Anxiety disorders are very common
10487661048766Just as fevers these are of different types
10487661048766Accurate Dx and Rx by GP is essential
10487661048766Depression and substance abuse potential
Minimum of six weeks to see Rx effect
Prolonged Rx is necessary 6 m or more
Drug Rx is only a small part of management
SSRI TCAs BZNs MAOIs szlig-blockers etc
CBT Computer treatment VRs Mood GYM
Thank You All Visit us at
wwwdrsarmain
This is sponsored by Torrent ndash
Makers of Clonotril (Clonazepam)
Post traumatic Stress Disorder- PTSD
Experiential requirements The person has experienced a life-threatening
event and has responded with intense fear
hopelessness or horror The personrsquos response to the event occurred
more
than 4 weeks after it was experienced and lasted
more than one month The traumatic event is persistently re
experienced
in several ways eg by intrusive recollections
dreams illusions hallucinations or flashbacks
Post traumatic stress disorder PTSD
Post traumatic Stress Disorder- PTSD
Behavioral requirements Thought avoidance related-activities
andor People-avoidance behavior Feelings of detachment Blunted affect Sense of doom Insomnia Irritability Hyper vigilance Exaggerated startle response
Post traumatic Stress Disorder- PTSD
Subdivisions Acute ndash when PTSD is diagnosed between 1 and
3
months after the event occurs it is called acute Chronic - when PTSD continues longer than 3
months it is considered chronic and long term Delayed Onset PTSD-this term is used to
describe
those cases where the symptoms do not occur
immediately after the experience but rather
months or years later
Case 3
Mr A witnessed a friend die in a MVA six
weeks ago and co frequent nightmares
of the accident poor sleep fears of
driving anxiety around highways
anhedonia and decreased affection
highways towards his girlfriend His
girlfriend also notes that he has been
very irritable and startles easily since the
accident
Post traumatic Stress Disorder- PTSD
10487661048766Exposure to a traumatic event
10487661048766Response involving intense fear
Helplessness and horror
10487661048766Re-experiencing of the traumatic event
Avoidance of stimulipsychological numbing
10487661048766Increased arousal
10487661048766Symptoms greater than 1 month
Separation Anxiety Disorder - SAD
Medical conditions causing anxiety
10487661048766Endocrine conditions
10487661048766Cardiovascular conditions
10487661048766Respiratory conditions
10487661048766Metabolic conditions
10487661048766Neurological conditions
Substances causing anxiety
10487661048766Alcohol Alcohol
10487661048766Amphetamines
10487661048766Caffeine
10487661048766Cannabis
10487661048766Cocaine
10487661048766Hallucinogens
10487661048766Inhalants
10487661048766Phencyclidine
Substances that cause
anxiety (withdrawal)
10487661048766Alcohol
10487661048766Cocaine
10487661048766Sedatives
10487661048766Hypnotics
10487661048766Anxiolytics
Medications causing anxiety
Anesthetics
Analgesics
Sympathomimetics
Bronchodilators
Anti-cholinergics
1048766Insulin
Thyroid hormones
Oral contraceptives
Antihistamines
Anti-parkinsonians
1048766Corticosteroids
Antihypertensives
Cardiovascular drugs
Anticonvulsants
Anxiety Disorders
Current Management Strategies
Management of Anxiety Disorders
1048766 Pharmacotherapy (Medications)
Psycho-analytic therapy ndash PT
Behavior Therapy - BT
Cognitive Behavior Therapy ndash CBT
Computer therapy - CT
1048766 Virtual Realty ndash VR
Mood GYM
Drug Rx of Anxiety Disorders
Clonazepam
How do anxiolytics act
GABA and Glycine are inhibitory neurotransmitter
Serotonin and Noradrenaline are excitatory
Anxiety is increased excitatory transmitters
BZNs increase GABA and increase inhibition
SSRI decrease the serotonin levels and darrexcitation
TCAs act by darrboth serotonin and noradrenaline
Drug Rx of Anxiety Disorders
Disorder First Choice 2nd Choice Short (prn) Add on
GADBZN-
CZ CDZ ALZBeta-blockers Buspirone Carbamazp
Panic Disorder
Paroxetine
CitalopramTCA-
ClomipramineBZN-
ALZ CZ LZMAOI -
Phenelzine
Phobias Beta-blockers SSRIsBZN-
ALZ CZMAOI
OCD Clomipramine Fluoxetine CDZ Buspirone
PTSDTCA-
Imipra Amytrp
SSRI- FLX
Sertaline CPBZN MAOI
Comparison of Benzodiazepines
BZN Sedation Anxiolytic Half life Lipid solu Dose
Diazepam +++ + 20-80 h High 5 mg od
Alprazolam + +++ 6-20 h Low 05 mg qid
Clonazapam ++ +++ 22-50 h Low 05 mg bid
Lorazepam ++ ++ 10-20 h Med 1 mg tid
Chlordiazepx + + 7-30 h Med 15 mg bid
Different strategies of therapy
Behavior therapy
Desensitization
Behavior modification
Behavioral activation
Cognitive therapy
Rational-emotive therapy
Beckrsquos cognitive therapy
Newer approaches
Mindfulness meditation
Acceptance and commitment therapy
Dialectical Behavior Therapy (BPD)
Cognitive Behaviour Therapy - CBT
CBT is a method used to treat anxiety
Recognition of ldquodistorted thinkingrdquo
ldquoCognitive restructuringrdquo
It may also involve classical conditioning when used to treat Obsessive Compulsive Disorder
CBT ndash Obstacles - Restructuring
Hopelessness
Self-criticism
Fear of getting worse
Shame and embarrassment
Partial exposure
Blaming other people
Low motivation
Looking for complex solution
Depressing ruminations
There must be an easier way
Computer Therapy
Pts are ashamed to seek help and may fear the consequences at work and home
Therapy is expensive and beyond the reach of many patients
Computer therapy is very cheap and available by comparison
Computer Therapy ndash Softwares
Fearfighter - for phobiapanic
Cope - for depressionanxiety
Balance - for GAD
BTSteps - for OCD
These are PC based in a CD-Rom
or phone based or Web-based
MENTAL OUTSIDE
Virtual Reality - VR
VR therapy via SD (Systematic Desensitization) is becoming very popular
SD is a process of gradually introducing a disturbing stimulus (eg view from a high place) in otherwise pleasant surroundings
This process gradually suppresses the anxiety response
Virtual Reality ndash VR - Advantages
Patients often have difficulty imagining the stimulus themselves
They are often afraid of experiencing it directly ndash which may also be expensive and time-consuming
VR affords patient privacy and confidentiality during treatment
Very good for phobias
Virtual Reality ndash VR - Imagination
ldquoProjection in timerdquo ndash rationally reconstructing the future
ldquoDe-catastrophizing an imagerdquo ndash modifying a disturbing image
ldquoImage modeling and substitutionrdquo ndashinterrupting a negative train of images
ldquoCovert conditioningrdquo ndash subtle conditioning using imagined rather than real stimuli
Virtual Reality ndash VR - Hutchworld
Hutchworld is a virtual community attached to the Hutchison Cancer Research Center
Designed to provide social support for cancer patients and their families
Based on Microsoftrsquos Vworldrsquos system
Mood GYM on the Internet
Few GPs are trained in CBT
Clinical psychologists are expensive
Young people are not easily reached
They may not want them ndash embarrassment
The web is accessible convenient and popular
with young people
Deliver CBT via internet ndash 5 modules
Mood GYM Modules
5 Modules - analysis and results
1 Essentials of CBT with examples and interactive exercises
2 Warpy Thoughts Questionnaire Identifying dysfunctional thoughts Methods to contest such thoughts
3 Other methods for overcoming warpy thoughts
4 Life Event Stress Relaxation meditation music Pleasant Events Schedule parental style
5 Simple problem solving responses to relationship break-up
Web stats summary
Sessions
Take home points
10487661048766Anxiety disorders are very common
10487661048766Just as fevers these are of different types
10487661048766Accurate Dx and Rx by GP is essential
10487661048766Depression and substance abuse potential
Minimum of six weeks to see Rx effect
Prolonged Rx is necessary 6 m or more
Drug Rx is only a small part of management
SSRI TCAs BZNs MAOIs szlig-blockers etc
CBT Computer treatment VRs Mood GYM
Thank You All Visit us at
wwwdrsarmain
This is sponsored by Torrent ndash
Makers of Clonotril (Clonazepam)
Post traumatic stress disorder PTSD
Post traumatic Stress Disorder- PTSD
Behavioral requirements Thought avoidance related-activities
andor People-avoidance behavior Feelings of detachment Blunted affect Sense of doom Insomnia Irritability Hyper vigilance Exaggerated startle response
Post traumatic Stress Disorder- PTSD
Subdivisions Acute ndash when PTSD is diagnosed between 1 and
3
months after the event occurs it is called acute Chronic - when PTSD continues longer than 3
months it is considered chronic and long term Delayed Onset PTSD-this term is used to
describe
those cases where the symptoms do not occur
immediately after the experience but rather
months or years later
Case 3
Mr A witnessed a friend die in a MVA six
weeks ago and co frequent nightmares
of the accident poor sleep fears of
driving anxiety around highways
anhedonia and decreased affection
highways towards his girlfriend His
girlfriend also notes that he has been
very irritable and startles easily since the
accident
Post traumatic Stress Disorder- PTSD
10487661048766Exposure to a traumatic event
10487661048766Response involving intense fear
Helplessness and horror
10487661048766Re-experiencing of the traumatic event
Avoidance of stimulipsychological numbing
10487661048766Increased arousal
10487661048766Symptoms greater than 1 month
Separation Anxiety Disorder - SAD
Medical conditions causing anxiety
10487661048766Endocrine conditions
10487661048766Cardiovascular conditions
10487661048766Respiratory conditions
10487661048766Metabolic conditions
10487661048766Neurological conditions
Substances causing anxiety
10487661048766Alcohol Alcohol
10487661048766Amphetamines
10487661048766Caffeine
10487661048766Cannabis
10487661048766Cocaine
10487661048766Hallucinogens
10487661048766Inhalants
10487661048766Phencyclidine
Substances that cause
anxiety (withdrawal)
10487661048766Alcohol
10487661048766Cocaine
10487661048766Sedatives
10487661048766Hypnotics
10487661048766Anxiolytics
Medications causing anxiety
Anesthetics
Analgesics
Sympathomimetics
Bronchodilators
Anti-cholinergics
1048766Insulin
Thyroid hormones
Oral contraceptives
Antihistamines
Anti-parkinsonians
1048766Corticosteroids
Antihypertensives
Cardiovascular drugs
Anticonvulsants
Anxiety Disorders
Current Management Strategies
Management of Anxiety Disorders
1048766 Pharmacotherapy (Medications)
Psycho-analytic therapy ndash PT
Behavior Therapy - BT
Cognitive Behavior Therapy ndash CBT
Computer therapy - CT
1048766 Virtual Realty ndash VR
Mood GYM
Drug Rx of Anxiety Disorders
Clonazepam
How do anxiolytics act
GABA and Glycine are inhibitory neurotransmitter
Serotonin and Noradrenaline are excitatory
Anxiety is increased excitatory transmitters
BZNs increase GABA and increase inhibition
SSRI decrease the serotonin levels and darrexcitation
TCAs act by darrboth serotonin and noradrenaline
Drug Rx of Anxiety Disorders
Disorder First Choice 2nd Choice Short (prn) Add on
GADBZN-
CZ CDZ ALZBeta-blockers Buspirone Carbamazp
Panic Disorder
Paroxetine
CitalopramTCA-
ClomipramineBZN-
ALZ CZ LZMAOI -
Phenelzine
Phobias Beta-blockers SSRIsBZN-
ALZ CZMAOI
OCD Clomipramine Fluoxetine CDZ Buspirone
PTSDTCA-
Imipra Amytrp
SSRI- FLX
Sertaline CPBZN MAOI
Comparison of Benzodiazepines
BZN Sedation Anxiolytic Half life Lipid solu Dose
Diazepam +++ + 20-80 h High 5 mg od
Alprazolam + +++ 6-20 h Low 05 mg qid
Clonazapam ++ +++ 22-50 h Low 05 mg bid
Lorazepam ++ ++ 10-20 h Med 1 mg tid
Chlordiazepx + + 7-30 h Med 15 mg bid
Different strategies of therapy
Behavior therapy
Desensitization
Behavior modification
Behavioral activation
Cognitive therapy
Rational-emotive therapy
Beckrsquos cognitive therapy
Newer approaches
Mindfulness meditation
Acceptance and commitment therapy
Dialectical Behavior Therapy (BPD)
Cognitive Behaviour Therapy - CBT
CBT is a method used to treat anxiety
Recognition of ldquodistorted thinkingrdquo
ldquoCognitive restructuringrdquo
It may also involve classical conditioning when used to treat Obsessive Compulsive Disorder
CBT ndash Obstacles - Restructuring
Hopelessness
Self-criticism
Fear of getting worse
Shame and embarrassment
Partial exposure
Blaming other people
Low motivation
Looking for complex solution
Depressing ruminations
There must be an easier way
Computer Therapy
Pts are ashamed to seek help and may fear the consequences at work and home
Therapy is expensive and beyond the reach of many patients
Computer therapy is very cheap and available by comparison
Computer Therapy ndash Softwares
Fearfighter - for phobiapanic
Cope - for depressionanxiety
Balance - for GAD
BTSteps - for OCD
These are PC based in a CD-Rom
or phone based or Web-based
MENTAL OUTSIDE
Virtual Reality - VR
VR therapy via SD (Systematic Desensitization) is becoming very popular
SD is a process of gradually introducing a disturbing stimulus (eg view from a high place) in otherwise pleasant surroundings
This process gradually suppresses the anxiety response
Virtual Reality ndash VR - Advantages
Patients often have difficulty imagining the stimulus themselves
They are often afraid of experiencing it directly ndash which may also be expensive and time-consuming
VR affords patient privacy and confidentiality during treatment
Very good for phobias
Virtual Reality ndash VR - Imagination
ldquoProjection in timerdquo ndash rationally reconstructing the future
ldquoDe-catastrophizing an imagerdquo ndash modifying a disturbing image
ldquoImage modeling and substitutionrdquo ndashinterrupting a negative train of images
ldquoCovert conditioningrdquo ndash subtle conditioning using imagined rather than real stimuli
Virtual Reality ndash VR - Hutchworld
Hutchworld is a virtual community attached to the Hutchison Cancer Research Center
Designed to provide social support for cancer patients and their families
Based on Microsoftrsquos Vworldrsquos system
Mood GYM on the Internet
Few GPs are trained in CBT
Clinical psychologists are expensive
Young people are not easily reached
They may not want them ndash embarrassment
The web is accessible convenient and popular
with young people
Deliver CBT via internet ndash 5 modules
Mood GYM Modules
5 Modules - analysis and results
1 Essentials of CBT with examples and interactive exercises
2 Warpy Thoughts Questionnaire Identifying dysfunctional thoughts Methods to contest such thoughts
3 Other methods for overcoming warpy thoughts
4 Life Event Stress Relaxation meditation music Pleasant Events Schedule parental style
5 Simple problem solving responses to relationship break-up
Web stats summary
Sessions
Take home points
10487661048766Anxiety disorders are very common
10487661048766Just as fevers these are of different types
10487661048766Accurate Dx and Rx by GP is essential
10487661048766Depression and substance abuse potential
Minimum of six weeks to see Rx effect
Prolonged Rx is necessary 6 m or more
Drug Rx is only a small part of management
SSRI TCAs BZNs MAOIs szlig-blockers etc
CBT Computer treatment VRs Mood GYM
Thank You All Visit us at
wwwdrsarmain
This is sponsored by Torrent ndash
Makers of Clonotril (Clonazepam)
Post traumatic Stress Disorder- PTSD
Behavioral requirements Thought avoidance related-activities
andor People-avoidance behavior Feelings of detachment Blunted affect Sense of doom Insomnia Irritability Hyper vigilance Exaggerated startle response
Post traumatic Stress Disorder- PTSD
Subdivisions Acute ndash when PTSD is diagnosed between 1 and
3
months after the event occurs it is called acute Chronic - when PTSD continues longer than 3
months it is considered chronic and long term Delayed Onset PTSD-this term is used to
describe
those cases where the symptoms do not occur
immediately after the experience but rather
months or years later
Case 3
Mr A witnessed a friend die in a MVA six
weeks ago and co frequent nightmares
of the accident poor sleep fears of
driving anxiety around highways
anhedonia and decreased affection
highways towards his girlfriend His
girlfriend also notes that he has been
very irritable and startles easily since the
accident
Post traumatic Stress Disorder- PTSD
10487661048766Exposure to a traumatic event
10487661048766Response involving intense fear
Helplessness and horror
10487661048766Re-experiencing of the traumatic event
Avoidance of stimulipsychological numbing
10487661048766Increased arousal
10487661048766Symptoms greater than 1 month
Separation Anxiety Disorder - SAD
Medical conditions causing anxiety
10487661048766Endocrine conditions
10487661048766Cardiovascular conditions
10487661048766Respiratory conditions
10487661048766Metabolic conditions
10487661048766Neurological conditions
Substances causing anxiety
10487661048766Alcohol Alcohol
10487661048766Amphetamines
10487661048766Caffeine
10487661048766Cannabis
10487661048766Cocaine
10487661048766Hallucinogens
10487661048766Inhalants
10487661048766Phencyclidine
Substances that cause
anxiety (withdrawal)
10487661048766Alcohol
10487661048766Cocaine
10487661048766Sedatives
10487661048766Hypnotics
10487661048766Anxiolytics
Medications causing anxiety
Anesthetics
Analgesics
Sympathomimetics
Bronchodilators
Anti-cholinergics
1048766Insulin
Thyroid hormones
Oral contraceptives
Antihistamines
Anti-parkinsonians
1048766Corticosteroids
Antihypertensives
Cardiovascular drugs
Anticonvulsants
Anxiety Disorders
Current Management Strategies
Management of Anxiety Disorders
1048766 Pharmacotherapy (Medications)
Psycho-analytic therapy ndash PT
Behavior Therapy - BT
Cognitive Behavior Therapy ndash CBT
Computer therapy - CT
1048766 Virtual Realty ndash VR
Mood GYM
Drug Rx of Anxiety Disorders
Clonazepam
How do anxiolytics act
GABA and Glycine are inhibitory neurotransmitter
Serotonin and Noradrenaline are excitatory
Anxiety is increased excitatory transmitters
BZNs increase GABA and increase inhibition
SSRI decrease the serotonin levels and darrexcitation
TCAs act by darrboth serotonin and noradrenaline
Drug Rx of Anxiety Disorders
Disorder First Choice 2nd Choice Short (prn) Add on
GADBZN-
CZ CDZ ALZBeta-blockers Buspirone Carbamazp
Panic Disorder
Paroxetine
CitalopramTCA-
ClomipramineBZN-
ALZ CZ LZMAOI -
Phenelzine
Phobias Beta-blockers SSRIsBZN-
ALZ CZMAOI
OCD Clomipramine Fluoxetine CDZ Buspirone
PTSDTCA-
Imipra Amytrp
SSRI- FLX
Sertaline CPBZN MAOI
Comparison of Benzodiazepines
BZN Sedation Anxiolytic Half life Lipid solu Dose
Diazepam +++ + 20-80 h High 5 mg od
Alprazolam + +++ 6-20 h Low 05 mg qid
Clonazapam ++ +++ 22-50 h Low 05 mg bid
Lorazepam ++ ++ 10-20 h Med 1 mg tid
Chlordiazepx + + 7-30 h Med 15 mg bid
Different strategies of therapy
Behavior therapy
Desensitization
Behavior modification
Behavioral activation
Cognitive therapy
Rational-emotive therapy
Beckrsquos cognitive therapy
Newer approaches
Mindfulness meditation
Acceptance and commitment therapy
Dialectical Behavior Therapy (BPD)
Cognitive Behaviour Therapy - CBT
CBT is a method used to treat anxiety
Recognition of ldquodistorted thinkingrdquo
ldquoCognitive restructuringrdquo
It may also involve classical conditioning when used to treat Obsessive Compulsive Disorder
CBT ndash Obstacles - Restructuring
Hopelessness
Self-criticism
Fear of getting worse
Shame and embarrassment
Partial exposure
Blaming other people
Low motivation
Looking for complex solution
Depressing ruminations
There must be an easier way
Computer Therapy
Pts are ashamed to seek help and may fear the consequences at work and home
Therapy is expensive and beyond the reach of many patients
Computer therapy is very cheap and available by comparison
Computer Therapy ndash Softwares
Fearfighter - for phobiapanic
Cope - for depressionanxiety
Balance - for GAD
BTSteps - for OCD
These are PC based in a CD-Rom
or phone based or Web-based
MENTAL OUTSIDE
Virtual Reality - VR
VR therapy via SD (Systematic Desensitization) is becoming very popular
SD is a process of gradually introducing a disturbing stimulus (eg view from a high place) in otherwise pleasant surroundings
This process gradually suppresses the anxiety response
Virtual Reality ndash VR - Advantages
Patients often have difficulty imagining the stimulus themselves
They are often afraid of experiencing it directly ndash which may also be expensive and time-consuming
VR affords patient privacy and confidentiality during treatment
Very good for phobias
Virtual Reality ndash VR - Imagination
ldquoProjection in timerdquo ndash rationally reconstructing the future
ldquoDe-catastrophizing an imagerdquo ndash modifying a disturbing image
ldquoImage modeling and substitutionrdquo ndashinterrupting a negative train of images
ldquoCovert conditioningrdquo ndash subtle conditioning using imagined rather than real stimuli
Virtual Reality ndash VR - Hutchworld
Hutchworld is a virtual community attached to the Hutchison Cancer Research Center
Designed to provide social support for cancer patients and their families
Based on Microsoftrsquos Vworldrsquos system
Mood GYM on the Internet
Few GPs are trained in CBT
Clinical psychologists are expensive
Young people are not easily reached
They may not want them ndash embarrassment
The web is accessible convenient and popular
with young people
Deliver CBT via internet ndash 5 modules
Mood GYM Modules
5 Modules - analysis and results
1 Essentials of CBT with examples and interactive exercises
2 Warpy Thoughts Questionnaire Identifying dysfunctional thoughts Methods to contest such thoughts
3 Other methods for overcoming warpy thoughts
4 Life Event Stress Relaxation meditation music Pleasant Events Schedule parental style
5 Simple problem solving responses to relationship break-up
Web stats summary
Sessions
Take home points
10487661048766Anxiety disorders are very common
10487661048766Just as fevers these are of different types
10487661048766Accurate Dx and Rx by GP is essential
10487661048766Depression and substance abuse potential
Minimum of six weeks to see Rx effect
Prolonged Rx is necessary 6 m or more
Drug Rx is only a small part of management
SSRI TCAs BZNs MAOIs szlig-blockers etc
CBT Computer treatment VRs Mood GYM
Thank You All Visit us at
wwwdrsarmain
This is sponsored by Torrent ndash
Makers of Clonotril (Clonazepam)
Post traumatic Stress Disorder- PTSD
Subdivisions Acute ndash when PTSD is diagnosed between 1 and
3
months after the event occurs it is called acute Chronic - when PTSD continues longer than 3
months it is considered chronic and long term Delayed Onset PTSD-this term is used to
describe
those cases where the symptoms do not occur
immediately after the experience but rather
months or years later
Case 3
Mr A witnessed a friend die in a MVA six
weeks ago and co frequent nightmares
of the accident poor sleep fears of
driving anxiety around highways
anhedonia and decreased affection
highways towards his girlfriend His
girlfriend also notes that he has been
very irritable and startles easily since the
accident
Post traumatic Stress Disorder- PTSD
10487661048766Exposure to a traumatic event
10487661048766Response involving intense fear
Helplessness and horror
10487661048766Re-experiencing of the traumatic event
Avoidance of stimulipsychological numbing
10487661048766Increased arousal
10487661048766Symptoms greater than 1 month
Separation Anxiety Disorder - SAD
Medical conditions causing anxiety
10487661048766Endocrine conditions
10487661048766Cardiovascular conditions
10487661048766Respiratory conditions
10487661048766Metabolic conditions
10487661048766Neurological conditions
Substances causing anxiety
10487661048766Alcohol Alcohol
10487661048766Amphetamines
10487661048766Caffeine
10487661048766Cannabis
10487661048766Cocaine
10487661048766Hallucinogens
10487661048766Inhalants
10487661048766Phencyclidine
Substances that cause
anxiety (withdrawal)
10487661048766Alcohol
10487661048766Cocaine
10487661048766Sedatives
10487661048766Hypnotics
10487661048766Anxiolytics
Medications causing anxiety
Anesthetics
Analgesics
Sympathomimetics
Bronchodilators
Anti-cholinergics
1048766Insulin
Thyroid hormones
Oral contraceptives
Antihistamines
Anti-parkinsonians
1048766Corticosteroids
Antihypertensives
Cardiovascular drugs
Anticonvulsants
Anxiety Disorders
Current Management Strategies
Management of Anxiety Disorders
1048766 Pharmacotherapy (Medications)
Psycho-analytic therapy ndash PT
Behavior Therapy - BT
Cognitive Behavior Therapy ndash CBT
Computer therapy - CT
1048766 Virtual Realty ndash VR
Mood GYM
Drug Rx of Anxiety Disorders
Clonazepam
How do anxiolytics act
GABA and Glycine are inhibitory neurotransmitter
Serotonin and Noradrenaline are excitatory
Anxiety is increased excitatory transmitters
BZNs increase GABA and increase inhibition
SSRI decrease the serotonin levels and darrexcitation
TCAs act by darrboth serotonin and noradrenaline
Drug Rx of Anxiety Disorders
Disorder First Choice 2nd Choice Short (prn) Add on
GADBZN-
CZ CDZ ALZBeta-blockers Buspirone Carbamazp
Panic Disorder
Paroxetine
CitalopramTCA-
ClomipramineBZN-
ALZ CZ LZMAOI -
Phenelzine
Phobias Beta-blockers SSRIsBZN-
ALZ CZMAOI
OCD Clomipramine Fluoxetine CDZ Buspirone
PTSDTCA-
Imipra Amytrp
SSRI- FLX
Sertaline CPBZN MAOI
Comparison of Benzodiazepines
BZN Sedation Anxiolytic Half life Lipid solu Dose
Diazepam +++ + 20-80 h High 5 mg od
Alprazolam + +++ 6-20 h Low 05 mg qid
Clonazapam ++ +++ 22-50 h Low 05 mg bid
Lorazepam ++ ++ 10-20 h Med 1 mg tid
Chlordiazepx + + 7-30 h Med 15 mg bid
Different strategies of therapy
Behavior therapy
Desensitization
Behavior modification
Behavioral activation
Cognitive therapy
Rational-emotive therapy
Beckrsquos cognitive therapy
Newer approaches
Mindfulness meditation
Acceptance and commitment therapy
Dialectical Behavior Therapy (BPD)
Cognitive Behaviour Therapy - CBT
CBT is a method used to treat anxiety
Recognition of ldquodistorted thinkingrdquo
ldquoCognitive restructuringrdquo
It may also involve classical conditioning when used to treat Obsessive Compulsive Disorder
CBT ndash Obstacles - Restructuring
Hopelessness
Self-criticism
Fear of getting worse
Shame and embarrassment
Partial exposure
Blaming other people
Low motivation
Looking for complex solution
Depressing ruminations
There must be an easier way
Computer Therapy
Pts are ashamed to seek help and may fear the consequences at work and home
Therapy is expensive and beyond the reach of many patients
Computer therapy is very cheap and available by comparison
Computer Therapy ndash Softwares
Fearfighter - for phobiapanic
Cope - for depressionanxiety
Balance - for GAD
BTSteps - for OCD
These are PC based in a CD-Rom
or phone based or Web-based
MENTAL OUTSIDE
Virtual Reality - VR
VR therapy via SD (Systematic Desensitization) is becoming very popular
SD is a process of gradually introducing a disturbing stimulus (eg view from a high place) in otherwise pleasant surroundings
This process gradually suppresses the anxiety response
Virtual Reality ndash VR - Advantages
Patients often have difficulty imagining the stimulus themselves
They are often afraid of experiencing it directly ndash which may also be expensive and time-consuming
VR affords patient privacy and confidentiality during treatment
Very good for phobias
Virtual Reality ndash VR - Imagination
ldquoProjection in timerdquo ndash rationally reconstructing the future
ldquoDe-catastrophizing an imagerdquo ndash modifying a disturbing image
ldquoImage modeling and substitutionrdquo ndashinterrupting a negative train of images
ldquoCovert conditioningrdquo ndash subtle conditioning using imagined rather than real stimuli
Virtual Reality ndash VR - Hutchworld
Hutchworld is a virtual community attached to the Hutchison Cancer Research Center
Designed to provide social support for cancer patients and their families
Based on Microsoftrsquos Vworldrsquos system
Mood GYM on the Internet
Few GPs are trained in CBT
Clinical psychologists are expensive
Young people are not easily reached
They may not want them ndash embarrassment
The web is accessible convenient and popular
with young people
Deliver CBT via internet ndash 5 modules
Mood GYM Modules
5 Modules - analysis and results
1 Essentials of CBT with examples and interactive exercises
2 Warpy Thoughts Questionnaire Identifying dysfunctional thoughts Methods to contest such thoughts
3 Other methods for overcoming warpy thoughts
4 Life Event Stress Relaxation meditation music Pleasant Events Schedule parental style
5 Simple problem solving responses to relationship break-up
Web stats summary
Sessions
Take home points
10487661048766Anxiety disorders are very common
10487661048766Just as fevers these are of different types
10487661048766Accurate Dx and Rx by GP is essential
10487661048766Depression and substance abuse potential
Minimum of six weeks to see Rx effect
Prolonged Rx is necessary 6 m or more
Drug Rx is only a small part of management
SSRI TCAs BZNs MAOIs szlig-blockers etc
CBT Computer treatment VRs Mood GYM
Thank You All Visit us at
wwwdrsarmain
This is sponsored by Torrent ndash
Makers of Clonotril (Clonazepam)
Case 3
Mr A witnessed a friend die in a MVA six
weeks ago and co frequent nightmares
of the accident poor sleep fears of
driving anxiety around highways
anhedonia and decreased affection
highways towards his girlfriend His
girlfriend also notes that he has been
very irritable and startles easily since the
accident
Post traumatic Stress Disorder- PTSD
10487661048766Exposure to a traumatic event
10487661048766Response involving intense fear
Helplessness and horror
10487661048766Re-experiencing of the traumatic event
Avoidance of stimulipsychological numbing
10487661048766Increased arousal
10487661048766Symptoms greater than 1 month
Separation Anxiety Disorder - SAD
Medical conditions causing anxiety
10487661048766Endocrine conditions
10487661048766Cardiovascular conditions
10487661048766Respiratory conditions
10487661048766Metabolic conditions
10487661048766Neurological conditions
Substances causing anxiety
10487661048766Alcohol Alcohol
10487661048766Amphetamines
10487661048766Caffeine
10487661048766Cannabis
10487661048766Cocaine
10487661048766Hallucinogens
10487661048766Inhalants
10487661048766Phencyclidine
Substances that cause
anxiety (withdrawal)
10487661048766Alcohol
10487661048766Cocaine
10487661048766Sedatives
10487661048766Hypnotics
10487661048766Anxiolytics
Medications causing anxiety
Anesthetics
Analgesics
Sympathomimetics
Bronchodilators
Anti-cholinergics
1048766Insulin
Thyroid hormones
Oral contraceptives
Antihistamines
Anti-parkinsonians
1048766Corticosteroids
Antihypertensives
Cardiovascular drugs
Anticonvulsants
Anxiety Disorders
Current Management Strategies
Management of Anxiety Disorders
1048766 Pharmacotherapy (Medications)
Psycho-analytic therapy ndash PT
Behavior Therapy - BT
Cognitive Behavior Therapy ndash CBT
Computer therapy - CT
1048766 Virtual Realty ndash VR
Mood GYM
Drug Rx of Anxiety Disorders
Clonazepam
How do anxiolytics act
GABA and Glycine are inhibitory neurotransmitter
Serotonin and Noradrenaline are excitatory
Anxiety is increased excitatory transmitters
BZNs increase GABA and increase inhibition
SSRI decrease the serotonin levels and darrexcitation
TCAs act by darrboth serotonin and noradrenaline
Drug Rx of Anxiety Disorders
Disorder First Choice 2nd Choice Short (prn) Add on
GADBZN-
CZ CDZ ALZBeta-blockers Buspirone Carbamazp
Panic Disorder
Paroxetine
CitalopramTCA-
ClomipramineBZN-
ALZ CZ LZMAOI -
Phenelzine
Phobias Beta-blockers SSRIsBZN-
ALZ CZMAOI
OCD Clomipramine Fluoxetine CDZ Buspirone
PTSDTCA-
Imipra Amytrp
SSRI- FLX
Sertaline CPBZN MAOI
Comparison of Benzodiazepines
BZN Sedation Anxiolytic Half life Lipid solu Dose
Diazepam +++ + 20-80 h High 5 mg od
Alprazolam + +++ 6-20 h Low 05 mg qid
Clonazapam ++ +++ 22-50 h Low 05 mg bid
Lorazepam ++ ++ 10-20 h Med 1 mg tid
Chlordiazepx + + 7-30 h Med 15 mg bid
Different strategies of therapy
Behavior therapy
Desensitization
Behavior modification
Behavioral activation
Cognitive therapy
Rational-emotive therapy
Beckrsquos cognitive therapy
Newer approaches
Mindfulness meditation
Acceptance and commitment therapy
Dialectical Behavior Therapy (BPD)
Cognitive Behaviour Therapy - CBT
CBT is a method used to treat anxiety
Recognition of ldquodistorted thinkingrdquo
ldquoCognitive restructuringrdquo
It may also involve classical conditioning when used to treat Obsessive Compulsive Disorder
CBT ndash Obstacles - Restructuring
Hopelessness
Self-criticism
Fear of getting worse
Shame and embarrassment
Partial exposure
Blaming other people
Low motivation
Looking for complex solution
Depressing ruminations
There must be an easier way
Computer Therapy
Pts are ashamed to seek help and may fear the consequences at work and home
Therapy is expensive and beyond the reach of many patients
Computer therapy is very cheap and available by comparison
Computer Therapy ndash Softwares
Fearfighter - for phobiapanic
Cope - for depressionanxiety
Balance - for GAD
BTSteps - for OCD
These are PC based in a CD-Rom
or phone based or Web-based
MENTAL OUTSIDE
Virtual Reality - VR
VR therapy via SD (Systematic Desensitization) is becoming very popular
SD is a process of gradually introducing a disturbing stimulus (eg view from a high place) in otherwise pleasant surroundings
This process gradually suppresses the anxiety response
Virtual Reality ndash VR - Advantages
Patients often have difficulty imagining the stimulus themselves
They are often afraid of experiencing it directly ndash which may also be expensive and time-consuming
VR affords patient privacy and confidentiality during treatment
Very good for phobias
Virtual Reality ndash VR - Imagination
ldquoProjection in timerdquo ndash rationally reconstructing the future
ldquoDe-catastrophizing an imagerdquo ndash modifying a disturbing image
ldquoImage modeling and substitutionrdquo ndashinterrupting a negative train of images
ldquoCovert conditioningrdquo ndash subtle conditioning using imagined rather than real stimuli
Virtual Reality ndash VR - Hutchworld
Hutchworld is a virtual community attached to the Hutchison Cancer Research Center
Designed to provide social support for cancer patients and their families
Based on Microsoftrsquos Vworldrsquos system
Mood GYM on the Internet
Few GPs are trained in CBT
Clinical psychologists are expensive
Young people are not easily reached
They may not want them ndash embarrassment
The web is accessible convenient and popular
with young people
Deliver CBT via internet ndash 5 modules
Mood GYM Modules
5 Modules - analysis and results
1 Essentials of CBT with examples and interactive exercises
2 Warpy Thoughts Questionnaire Identifying dysfunctional thoughts Methods to contest such thoughts
3 Other methods for overcoming warpy thoughts
4 Life Event Stress Relaxation meditation music Pleasant Events Schedule parental style
5 Simple problem solving responses to relationship break-up
Web stats summary
Sessions
Take home points
10487661048766Anxiety disorders are very common
10487661048766Just as fevers these are of different types
10487661048766Accurate Dx and Rx by GP is essential
10487661048766Depression and substance abuse potential
Minimum of six weeks to see Rx effect
Prolonged Rx is necessary 6 m or more
Drug Rx is only a small part of management
SSRI TCAs BZNs MAOIs szlig-blockers etc
CBT Computer treatment VRs Mood GYM
Thank You All Visit us at
wwwdrsarmain
This is sponsored by Torrent ndash
Makers of Clonotril (Clonazepam)
Post traumatic Stress Disorder- PTSD
10487661048766Exposure to a traumatic event
10487661048766Response involving intense fear
Helplessness and horror
10487661048766Re-experiencing of the traumatic event
Avoidance of stimulipsychological numbing
10487661048766Increased arousal
10487661048766Symptoms greater than 1 month
Separation Anxiety Disorder - SAD
Medical conditions causing anxiety
10487661048766Endocrine conditions
10487661048766Cardiovascular conditions
10487661048766Respiratory conditions
10487661048766Metabolic conditions
10487661048766Neurological conditions
Substances causing anxiety
10487661048766Alcohol Alcohol
10487661048766Amphetamines
10487661048766Caffeine
10487661048766Cannabis
10487661048766Cocaine
10487661048766Hallucinogens
10487661048766Inhalants
10487661048766Phencyclidine
Substances that cause
anxiety (withdrawal)
10487661048766Alcohol
10487661048766Cocaine
10487661048766Sedatives
10487661048766Hypnotics
10487661048766Anxiolytics
Medications causing anxiety
Anesthetics
Analgesics
Sympathomimetics
Bronchodilators
Anti-cholinergics
1048766Insulin
Thyroid hormones
Oral contraceptives
Antihistamines
Anti-parkinsonians
1048766Corticosteroids
Antihypertensives
Cardiovascular drugs
Anticonvulsants
Anxiety Disorders
Current Management Strategies
Management of Anxiety Disorders
1048766 Pharmacotherapy (Medications)
Psycho-analytic therapy ndash PT
Behavior Therapy - BT
Cognitive Behavior Therapy ndash CBT
Computer therapy - CT
1048766 Virtual Realty ndash VR
Mood GYM
Drug Rx of Anxiety Disorders
Clonazepam
How do anxiolytics act
GABA and Glycine are inhibitory neurotransmitter
Serotonin and Noradrenaline are excitatory
Anxiety is increased excitatory transmitters
BZNs increase GABA and increase inhibition
SSRI decrease the serotonin levels and darrexcitation
TCAs act by darrboth serotonin and noradrenaline
Drug Rx of Anxiety Disorders
Disorder First Choice 2nd Choice Short (prn) Add on
GADBZN-
CZ CDZ ALZBeta-blockers Buspirone Carbamazp
Panic Disorder
Paroxetine
CitalopramTCA-
ClomipramineBZN-
ALZ CZ LZMAOI -
Phenelzine
Phobias Beta-blockers SSRIsBZN-
ALZ CZMAOI
OCD Clomipramine Fluoxetine CDZ Buspirone
PTSDTCA-
Imipra Amytrp
SSRI- FLX
Sertaline CPBZN MAOI
Comparison of Benzodiazepines
BZN Sedation Anxiolytic Half life Lipid solu Dose
Diazepam +++ + 20-80 h High 5 mg od
Alprazolam + +++ 6-20 h Low 05 mg qid
Clonazapam ++ +++ 22-50 h Low 05 mg bid
Lorazepam ++ ++ 10-20 h Med 1 mg tid
Chlordiazepx + + 7-30 h Med 15 mg bid
Different strategies of therapy
Behavior therapy
Desensitization
Behavior modification
Behavioral activation
Cognitive therapy
Rational-emotive therapy
Beckrsquos cognitive therapy
Newer approaches
Mindfulness meditation
Acceptance and commitment therapy
Dialectical Behavior Therapy (BPD)
Cognitive Behaviour Therapy - CBT
CBT is a method used to treat anxiety
Recognition of ldquodistorted thinkingrdquo
ldquoCognitive restructuringrdquo
It may also involve classical conditioning when used to treat Obsessive Compulsive Disorder
CBT ndash Obstacles - Restructuring
Hopelessness
Self-criticism
Fear of getting worse
Shame and embarrassment
Partial exposure
Blaming other people
Low motivation
Looking for complex solution
Depressing ruminations
There must be an easier way
Computer Therapy
Pts are ashamed to seek help and may fear the consequences at work and home
Therapy is expensive and beyond the reach of many patients
Computer therapy is very cheap and available by comparison
Computer Therapy ndash Softwares
Fearfighter - for phobiapanic
Cope - for depressionanxiety
Balance - for GAD
BTSteps - for OCD
These are PC based in a CD-Rom
or phone based or Web-based
MENTAL OUTSIDE
Virtual Reality - VR
VR therapy via SD (Systematic Desensitization) is becoming very popular
SD is a process of gradually introducing a disturbing stimulus (eg view from a high place) in otherwise pleasant surroundings
This process gradually suppresses the anxiety response
Virtual Reality ndash VR - Advantages
Patients often have difficulty imagining the stimulus themselves
They are often afraid of experiencing it directly ndash which may also be expensive and time-consuming
VR affords patient privacy and confidentiality during treatment
Very good for phobias
Virtual Reality ndash VR - Imagination
ldquoProjection in timerdquo ndash rationally reconstructing the future
ldquoDe-catastrophizing an imagerdquo ndash modifying a disturbing image
ldquoImage modeling and substitutionrdquo ndashinterrupting a negative train of images
ldquoCovert conditioningrdquo ndash subtle conditioning using imagined rather than real stimuli
Virtual Reality ndash VR - Hutchworld
Hutchworld is a virtual community attached to the Hutchison Cancer Research Center
Designed to provide social support for cancer patients and their families
Based on Microsoftrsquos Vworldrsquos system
Mood GYM on the Internet
Few GPs are trained in CBT
Clinical psychologists are expensive
Young people are not easily reached
They may not want them ndash embarrassment
The web is accessible convenient and popular
with young people
Deliver CBT via internet ndash 5 modules
Mood GYM Modules
5 Modules - analysis and results
1 Essentials of CBT with examples and interactive exercises
2 Warpy Thoughts Questionnaire Identifying dysfunctional thoughts Methods to contest such thoughts
3 Other methods for overcoming warpy thoughts
4 Life Event Stress Relaxation meditation music Pleasant Events Schedule parental style
5 Simple problem solving responses to relationship break-up
Web stats summary
Sessions
Take home points
10487661048766Anxiety disorders are very common
10487661048766Just as fevers these are of different types
10487661048766Accurate Dx and Rx by GP is essential
10487661048766Depression and substance abuse potential
Minimum of six weeks to see Rx effect
Prolonged Rx is necessary 6 m or more
Drug Rx is only a small part of management
SSRI TCAs BZNs MAOIs szlig-blockers etc
CBT Computer treatment VRs Mood GYM
Thank You All Visit us at
wwwdrsarmain
This is sponsored by Torrent ndash
Makers of Clonotril (Clonazepam)
Separation Anxiety Disorder - SAD
Medical conditions causing anxiety
10487661048766Endocrine conditions
10487661048766Cardiovascular conditions
10487661048766Respiratory conditions
10487661048766Metabolic conditions
10487661048766Neurological conditions
Substances causing anxiety
10487661048766Alcohol Alcohol
10487661048766Amphetamines
10487661048766Caffeine
10487661048766Cannabis
10487661048766Cocaine
10487661048766Hallucinogens
10487661048766Inhalants
10487661048766Phencyclidine
Substances that cause
anxiety (withdrawal)
10487661048766Alcohol
10487661048766Cocaine
10487661048766Sedatives
10487661048766Hypnotics
10487661048766Anxiolytics
Medications causing anxiety
Anesthetics
Analgesics
Sympathomimetics
Bronchodilators
Anti-cholinergics
1048766Insulin
Thyroid hormones
Oral contraceptives
Antihistamines
Anti-parkinsonians
1048766Corticosteroids
Antihypertensives
Cardiovascular drugs
Anticonvulsants
Anxiety Disorders
Current Management Strategies
Management of Anxiety Disorders
1048766 Pharmacotherapy (Medications)
Psycho-analytic therapy ndash PT
Behavior Therapy - BT
Cognitive Behavior Therapy ndash CBT
Computer therapy - CT
1048766 Virtual Realty ndash VR
Mood GYM
Drug Rx of Anxiety Disorders
Clonazepam
How do anxiolytics act
GABA and Glycine are inhibitory neurotransmitter
Serotonin and Noradrenaline are excitatory
Anxiety is increased excitatory transmitters
BZNs increase GABA and increase inhibition
SSRI decrease the serotonin levels and darrexcitation
TCAs act by darrboth serotonin and noradrenaline
Drug Rx of Anxiety Disorders
Disorder First Choice 2nd Choice Short (prn) Add on
GADBZN-
CZ CDZ ALZBeta-blockers Buspirone Carbamazp
Panic Disorder
Paroxetine
CitalopramTCA-
ClomipramineBZN-
ALZ CZ LZMAOI -
Phenelzine
Phobias Beta-blockers SSRIsBZN-
ALZ CZMAOI
OCD Clomipramine Fluoxetine CDZ Buspirone
PTSDTCA-
Imipra Amytrp
SSRI- FLX
Sertaline CPBZN MAOI
Comparison of Benzodiazepines
BZN Sedation Anxiolytic Half life Lipid solu Dose
Diazepam +++ + 20-80 h High 5 mg od
Alprazolam + +++ 6-20 h Low 05 mg qid
Clonazapam ++ +++ 22-50 h Low 05 mg bid
Lorazepam ++ ++ 10-20 h Med 1 mg tid
Chlordiazepx + + 7-30 h Med 15 mg bid
Different strategies of therapy
Behavior therapy
Desensitization
Behavior modification
Behavioral activation
Cognitive therapy
Rational-emotive therapy
Beckrsquos cognitive therapy
Newer approaches
Mindfulness meditation
Acceptance and commitment therapy
Dialectical Behavior Therapy (BPD)
Cognitive Behaviour Therapy - CBT
CBT is a method used to treat anxiety
Recognition of ldquodistorted thinkingrdquo
ldquoCognitive restructuringrdquo
It may also involve classical conditioning when used to treat Obsessive Compulsive Disorder
CBT ndash Obstacles - Restructuring
Hopelessness
Self-criticism
Fear of getting worse
Shame and embarrassment
Partial exposure
Blaming other people
Low motivation
Looking for complex solution
Depressing ruminations
There must be an easier way
Computer Therapy
Pts are ashamed to seek help and may fear the consequences at work and home
Therapy is expensive and beyond the reach of many patients
Computer therapy is very cheap and available by comparison
Computer Therapy ndash Softwares
Fearfighter - for phobiapanic
Cope - for depressionanxiety
Balance - for GAD
BTSteps - for OCD
These are PC based in a CD-Rom
or phone based or Web-based
MENTAL OUTSIDE
Virtual Reality - VR
VR therapy via SD (Systematic Desensitization) is becoming very popular
SD is a process of gradually introducing a disturbing stimulus (eg view from a high place) in otherwise pleasant surroundings
This process gradually suppresses the anxiety response
Virtual Reality ndash VR - Advantages
Patients often have difficulty imagining the stimulus themselves
They are often afraid of experiencing it directly ndash which may also be expensive and time-consuming
VR affords patient privacy and confidentiality during treatment
Very good for phobias
Virtual Reality ndash VR - Imagination
ldquoProjection in timerdquo ndash rationally reconstructing the future
ldquoDe-catastrophizing an imagerdquo ndash modifying a disturbing image
ldquoImage modeling and substitutionrdquo ndashinterrupting a negative train of images
ldquoCovert conditioningrdquo ndash subtle conditioning using imagined rather than real stimuli
Virtual Reality ndash VR - Hutchworld
Hutchworld is a virtual community attached to the Hutchison Cancer Research Center
Designed to provide social support for cancer patients and their families
Based on Microsoftrsquos Vworldrsquos system
Mood GYM on the Internet
Few GPs are trained in CBT
Clinical psychologists are expensive
Young people are not easily reached
They may not want them ndash embarrassment
The web is accessible convenient and popular
with young people
Deliver CBT via internet ndash 5 modules
Mood GYM Modules
5 Modules - analysis and results
1 Essentials of CBT with examples and interactive exercises
2 Warpy Thoughts Questionnaire Identifying dysfunctional thoughts Methods to contest such thoughts
3 Other methods for overcoming warpy thoughts
4 Life Event Stress Relaxation meditation music Pleasant Events Schedule parental style
5 Simple problem solving responses to relationship break-up
Web stats summary
Sessions
Take home points
10487661048766Anxiety disorders are very common
10487661048766Just as fevers these are of different types
10487661048766Accurate Dx and Rx by GP is essential
10487661048766Depression and substance abuse potential
Minimum of six weeks to see Rx effect
Prolonged Rx is necessary 6 m or more
Drug Rx is only a small part of management
SSRI TCAs BZNs MAOIs szlig-blockers etc
CBT Computer treatment VRs Mood GYM
Thank You All Visit us at
wwwdrsarmain
This is sponsored by Torrent ndash
Makers of Clonotril (Clonazepam)
Medical conditions causing anxiety
10487661048766Endocrine conditions
10487661048766Cardiovascular conditions
10487661048766Respiratory conditions
10487661048766Metabolic conditions
10487661048766Neurological conditions
Substances causing anxiety
10487661048766Alcohol Alcohol
10487661048766Amphetamines
10487661048766Caffeine
10487661048766Cannabis
10487661048766Cocaine
10487661048766Hallucinogens
10487661048766Inhalants
10487661048766Phencyclidine
Substances that cause
anxiety (withdrawal)
10487661048766Alcohol
10487661048766Cocaine
10487661048766Sedatives
10487661048766Hypnotics
10487661048766Anxiolytics
Medications causing anxiety
Anesthetics
Analgesics
Sympathomimetics
Bronchodilators
Anti-cholinergics
1048766Insulin
Thyroid hormones
Oral contraceptives
Antihistamines
Anti-parkinsonians
1048766Corticosteroids
Antihypertensives
Cardiovascular drugs
Anticonvulsants
Anxiety Disorders
Current Management Strategies
Management of Anxiety Disorders
1048766 Pharmacotherapy (Medications)
Psycho-analytic therapy ndash PT
Behavior Therapy - BT
Cognitive Behavior Therapy ndash CBT
Computer therapy - CT
1048766 Virtual Realty ndash VR
Mood GYM
Drug Rx of Anxiety Disorders
Clonazepam
How do anxiolytics act
GABA and Glycine are inhibitory neurotransmitter
Serotonin and Noradrenaline are excitatory
Anxiety is increased excitatory transmitters
BZNs increase GABA and increase inhibition
SSRI decrease the serotonin levels and darrexcitation
TCAs act by darrboth serotonin and noradrenaline
Drug Rx of Anxiety Disorders
Disorder First Choice 2nd Choice Short (prn) Add on
GADBZN-
CZ CDZ ALZBeta-blockers Buspirone Carbamazp
Panic Disorder
Paroxetine
CitalopramTCA-
ClomipramineBZN-
ALZ CZ LZMAOI -
Phenelzine
Phobias Beta-blockers SSRIsBZN-
ALZ CZMAOI
OCD Clomipramine Fluoxetine CDZ Buspirone
PTSDTCA-
Imipra Amytrp
SSRI- FLX
Sertaline CPBZN MAOI
Comparison of Benzodiazepines
BZN Sedation Anxiolytic Half life Lipid solu Dose
Diazepam +++ + 20-80 h High 5 mg od
Alprazolam + +++ 6-20 h Low 05 mg qid
Clonazapam ++ +++ 22-50 h Low 05 mg bid
Lorazepam ++ ++ 10-20 h Med 1 mg tid
Chlordiazepx + + 7-30 h Med 15 mg bid
Different strategies of therapy
Behavior therapy
Desensitization
Behavior modification
Behavioral activation
Cognitive therapy
Rational-emotive therapy
Beckrsquos cognitive therapy
Newer approaches
Mindfulness meditation
Acceptance and commitment therapy
Dialectical Behavior Therapy (BPD)
Cognitive Behaviour Therapy - CBT
CBT is a method used to treat anxiety
Recognition of ldquodistorted thinkingrdquo
ldquoCognitive restructuringrdquo
It may also involve classical conditioning when used to treat Obsessive Compulsive Disorder
CBT ndash Obstacles - Restructuring
Hopelessness
Self-criticism
Fear of getting worse
Shame and embarrassment
Partial exposure
Blaming other people
Low motivation
Looking for complex solution
Depressing ruminations
There must be an easier way
Computer Therapy
Pts are ashamed to seek help and may fear the consequences at work and home
Therapy is expensive and beyond the reach of many patients
Computer therapy is very cheap and available by comparison
Computer Therapy ndash Softwares
Fearfighter - for phobiapanic
Cope - for depressionanxiety
Balance - for GAD
BTSteps - for OCD
These are PC based in a CD-Rom
or phone based or Web-based
MENTAL OUTSIDE
Virtual Reality - VR
VR therapy via SD (Systematic Desensitization) is becoming very popular
SD is a process of gradually introducing a disturbing stimulus (eg view from a high place) in otherwise pleasant surroundings
This process gradually suppresses the anxiety response
Virtual Reality ndash VR - Advantages
Patients often have difficulty imagining the stimulus themselves
They are often afraid of experiencing it directly ndash which may also be expensive and time-consuming
VR affords patient privacy and confidentiality during treatment
Very good for phobias
Virtual Reality ndash VR - Imagination
ldquoProjection in timerdquo ndash rationally reconstructing the future
ldquoDe-catastrophizing an imagerdquo ndash modifying a disturbing image
ldquoImage modeling and substitutionrdquo ndashinterrupting a negative train of images
ldquoCovert conditioningrdquo ndash subtle conditioning using imagined rather than real stimuli
Virtual Reality ndash VR - Hutchworld
Hutchworld is a virtual community attached to the Hutchison Cancer Research Center
Designed to provide social support for cancer patients and their families
Based on Microsoftrsquos Vworldrsquos system
Mood GYM on the Internet
Few GPs are trained in CBT
Clinical psychologists are expensive
Young people are not easily reached
They may not want them ndash embarrassment
The web is accessible convenient and popular
with young people
Deliver CBT via internet ndash 5 modules
Mood GYM Modules
5 Modules - analysis and results
1 Essentials of CBT with examples and interactive exercises
2 Warpy Thoughts Questionnaire Identifying dysfunctional thoughts Methods to contest such thoughts
3 Other methods for overcoming warpy thoughts
4 Life Event Stress Relaxation meditation music Pleasant Events Schedule parental style
5 Simple problem solving responses to relationship break-up
Web stats summary
Sessions
Take home points
10487661048766Anxiety disorders are very common
10487661048766Just as fevers these are of different types
10487661048766Accurate Dx and Rx by GP is essential
10487661048766Depression and substance abuse potential
Minimum of six weeks to see Rx effect
Prolonged Rx is necessary 6 m or more
Drug Rx is only a small part of management
SSRI TCAs BZNs MAOIs szlig-blockers etc
CBT Computer treatment VRs Mood GYM
Thank You All Visit us at
wwwdrsarmain
This is sponsored by Torrent ndash
Makers of Clonotril (Clonazepam)
Substances causing anxiety
10487661048766Alcohol Alcohol
10487661048766Amphetamines
10487661048766Caffeine
10487661048766Cannabis
10487661048766Cocaine
10487661048766Hallucinogens
10487661048766Inhalants
10487661048766Phencyclidine
Substances that cause
anxiety (withdrawal)
10487661048766Alcohol
10487661048766Cocaine
10487661048766Sedatives
10487661048766Hypnotics
10487661048766Anxiolytics
Medications causing anxiety
Anesthetics
Analgesics
Sympathomimetics
Bronchodilators
Anti-cholinergics
1048766Insulin
Thyroid hormones
Oral contraceptives
Antihistamines
Anti-parkinsonians
1048766Corticosteroids
Antihypertensives
Cardiovascular drugs
Anticonvulsants
Anxiety Disorders
Current Management Strategies
Management of Anxiety Disorders
1048766 Pharmacotherapy (Medications)
Psycho-analytic therapy ndash PT
Behavior Therapy - BT
Cognitive Behavior Therapy ndash CBT
Computer therapy - CT
1048766 Virtual Realty ndash VR
Mood GYM
Drug Rx of Anxiety Disorders
Clonazepam
How do anxiolytics act
GABA and Glycine are inhibitory neurotransmitter
Serotonin and Noradrenaline are excitatory
Anxiety is increased excitatory transmitters
BZNs increase GABA and increase inhibition
SSRI decrease the serotonin levels and darrexcitation
TCAs act by darrboth serotonin and noradrenaline
Drug Rx of Anxiety Disorders
Disorder First Choice 2nd Choice Short (prn) Add on
GADBZN-
CZ CDZ ALZBeta-blockers Buspirone Carbamazp
Panic Disorder
Paroxetine
CitalopramTCA-
ClomipramineBZN-
ALZ CZ LZMAOI -
Phenelzine
Phobias Beta-blockers SSRIsBZN-
ALZ CZMAOI
OCD Clomipramine Fluoxetine CDZ Buspirone
PTSDTCA-
Imipra Amytrp
SSRI- FLX
Sertaline CPBZN MAOI
Comparison of Benzodiazepines
BZN Sedation Anxiolytic Half life Lipid solu Dose
Diazepam +++ + 20-80 h High 5 mg od
Alprazolam + +++ 6-20 h Low 05 mg qid
Clonazapam ++ +++ 22-50 h Low 05 mg bid
Lorazepam ++ ++ 10-20 h Med 1 mg tid
Chlordiazepx + + 7-30 h Med 15 mg bid
Different strategies of therapy
Behavior therapy
Desensitization
Behavior modification
Behavioral activation
Cognitive therapy
Rational-emotive therapy
Beckrsquos cognitive therapy
Newer approaches
Mindfulness meditation
Acceptance and commitment therapy
Dialectical Behavior Therapy (BPD)
Cognitive Behaviour Therapy - CBT
CBT is a method used to treat anxiety
Recognition of ldquodistorted thinkingrdquo
ldquoCognitive restructuringrdquo
It may also involve classical conditioning when used to treat Obsessive Compulsive Disorder
CBT ndash Obstacles - Restructuring
Hopelessness
Self-criticism
Fear of getting worse
Shame and embarrassment
Partial exposure
Blaming other people
Low motivation
Looking for complex solution
Depressing ruminations
There must be an easier way
Computer Therapy
Pts are ashamed to seek help and may fear the consequences at work and home
Therapy is expensive and beyond the reach of many patients
Computer therapy is very cheap and available by comparison
Computer Therapy ndash Softwares
Fearfighter - for phobiapanic
Cope - for depressionanxiety
Balance - for GAD
BTSteps - for OCD
These are PC based in a CD-Rom
or phone based or Web-based
MENTAL OUTSIDE
Virtual Reality - VR
VR therapy via SD (Systematic Desensitization) is becoming very popular
SD is a process of gradually introducing a disturbing stimulus (eg view from a high place) in otherwise pleasant surroundings
This process gradually suppresses the anxiety response
Virtual Reality ndash VR - Advantages
Patients often have difficulty imagining the stimulus themselves
They are often afraid of experiencing it directly ndash which may also be expensive and time-consuming
VR affords patient privacy and confidentiality during treatment
Very good for phobias
Virtual Reality ndash VR - Imagination
ldquoProjection in timerdquo ndash rationally reconstructing the future
ldquoDe-catastrophizing an imagerdquo ndash modifying a disturbing image
ldquoImage modeling and substitutionrdquo ndashinterrupting a negative train of images
ldquoCovert conditioningrdquo ndash subtle conditioning using imagined rather than real stimuli
Virtual Reality ndash VR - Hutchworld
Hutchworld is a virtual community attached to the Hutchison Cancer Research Center
Designed to provide social support for cancer patients and their families
Based on Microsoftrsquos Vworldrsquos system
Mood GYM on the Internet
Few GPs are trained in CBT
Clinical psychologists are expensive
Young people are not easily reached
They may not want them ndash embarrassment
The web is accessible convenient and popular
with young people
Deliver CBT via internet ndash 5 modules
Mood GYM Modules
5 Modules - analysis and results
1 Essentials of CBT with examples and interactive exercises
2 Warpy Thoughts Questionnaire Identifying dysfunctional thoughts Methods to contest such thoughts
3 Other methods for overcoming warpy thoughts
4 Life Event Stress Relaxation meditation music Pleasant Events Schedule parental style
5 Simple problem solving responses to relationship break-up
Web stats summary
Sessions
Take home points
10487661048766Anxiety disorders are very common
10487661048766Just as fevers these are of different types
10487661048766Accurate Dx and Rx by GP is essential
10487661048766Depression and substance abuse potential
Minimum of six weeks to see Rx effect
Prolonged Rx is necessary 6 m or more
Drug Rx is only a small part of management
SSRI TCAs BZNs MAOIs szlig-blockers etc
CBT Computer treatment VRs Mood GYM
Thank You All Visit us at
wwwdrsarmain
This is sponsored by Torrent ndash
Makers of Clonotril (Clonazepam)
Medications causing anxiety
Anesthetics
Analgesics
Sympathomimetics
Bronchodilators
Anti-cholinergics
1048766Insulin
Thyroid hormones
Oral contraceptives
Antihistamines
Anti-parkinsonians
1048766Corticosteroids
Antihypertensives
Cardiovascular drugs
Anticonvulsants
Anxiety Disorders
Current Management Strategies
Management of Anxiety Disorders
1048766 Pharmacotherapy (Medications)
Psycho-analytic therapy ndash PT
Behavior Therapy - BT
Cognitive Behavior Therapy ndash CBT
Computer therapy - CT
1048766 Virtual Realty ndash VR
Mood GYM
Drug Rx of Anxiety Disorders
Clonazepam
How do anxiolytics act
GABA and Glycine are inhibitory neurotransmitter
Serotonin and Noradrenaline are excitatory
Anxiety is increased excitatory transmitters
BZNs increase GABA and increase inhibition
SSRI decrease the serotonin levels and darrexcitation
TCAs act by darrboth serotonin and noradrenaline
Drug Rx of Anxiety Disorders
Disorder First Choice 2nd Choice Short (prn) Add on
GADBZN-
CZ CDZ ALZBeta-blockers Buspirone Carbamazp
Panic Disorder
Paroxetine
CitalopramTCA-
ClomipramineBZN-
ALZ CZ LZMAOI -
Phenelzine
Phobias Beta-blockers SSRIsBZN-
ALZ CZMAOI
OCD Clomipramine Fluoxetine CDZ Buspirone
PTSDTCA-
Imipra Amytrp
SSRI- FLX
Sertaline CPBZN MAOI
Comparison of Benzodiazepines
BZN Sedation Anxiolytic Half life Lipid solu Dose
Diazepam +++ + 20-80 h High 5 mg od
Alprazolam + +++ 6-20 h Low 05 mg qid
Clonazapam ++ +++ 22-50 h Low 05 mg bid
Lorazepam ++ ++ 10-20 h Med 1 mg tid
Chlordiazepx + + 7-30 h Med 15 mg bid
Different strategies of therapy
Behavior therapy
Desensitization
Behavior modification
Behavioral activation
Cognitive therapy
Rational-emotive therapy
Beckrsquos cognitive therapy
Newer approaches
Mindfulness meditation
Acceptance and commitment therapy
Dialectical Behavior Therapy (BPD)
Cognitive Behaviour Therapy - CBT
CBT is a method used to treat anxiety
Recognition of ldquodistorted thinkingrdquo
ldquoCognitive restructuringrdquo
It may also involve classical conditioning when used to treat Obsessive Compulsive Disorder
CBT ndash Obstacles - Restructuring
Hopelessness
Self-criticism
Fear of getting worse
Shame and embarrassment
Partial exposure
Blaming other people
Low motivation
Looking for complex solution
Depressing ruminations
There must be an easier way
Computer Therapy
Pts are ashamed to seek help and may fear the consequences at work and home
Therapy is expensive and beyond the reach of many patients
Computer therapy is very cheap and available by comparison
Computer Therapy ndash Softwares
Fearfighter - for phobiapanic
Cope - for depressionanxiety
Balance - for GAD
BTSteps - for OCD
These are PC based in a CD-Rom
or phone based or Web-based
MENTAL OUTSIDE
Virtual Reality - VR
VR therapy via SD (Systematic Desensitization) is becoming very popular
SD is a process of gradually introducing a disturbing stimulus (eg view from a high place) in otherwise pleasant surroundings
This process gradually suppresses the anxiety response
Virtual Reality ndash VR - Advantages
Patients often have difficulty imagining the stimulus themselves
They are often afraid of experiencing it directly ndash which may also be expensive and time-consuming
VR affords patient privacy and confidentiality during treatment
Very good for phobias
Virtual Reality ndash VR - Imagination
ldquoProjection in timerdquo ndash rationally reconstructing the future
ldquoDe-catastrophizing an imagerdquo ndash modifying a disturbing image
ldquoImage modeling and substitutionrdquo ndashinterrupting a negative train of images
ldquoCovert conditioningrdquo ndash subtle conditioning using imagined rather than real stimuli
Virtual Reality ndash VR - Hutchworld
Hutchworld is a virtual community attached to the Hutchison Cancer Research Center
Designed to provide social support for cancer patients and their families
Based on Microsoftrsquos Vworldrsquos system
Mood GYM on the Internet
Few GPs are trained in CBT
Clinical psychologists are expensive
Young people are not easily reached
They may not want them ndash embarrassment
The web is accessible convenient and popular
with young people
Deliver CBT via internet ndash 5 modules
Mood GYM Modules
5 Modules - analysis and results
1 Essentials of CBT with examples and interactive exercises
2 Warpy Thoughts Questionnaire Identifying dysfunctional thoughts Methods to contest such thoughts
3 Other methods for overcoming warpy thoughts
4 Life Event Stress Relaxation meditation music Pleasant Events Schedule parental style
5 Simple problem solving responses to relationship break-up
Web stats summary
Sessions
Take home points
10487661048766Anxiety disorders are very common
10487661048766Just as fevers these are of different types
10487661048766Accurate Dx and Rx by GP is essential
10487661048766Depression and substance abuse potential
Minimum of six weeks to see Rx effect
Prolonged Rx is necessary 6 m or more
Drug Rx is only a small part of management
SSRI TCAs BZNs MAOIs szlig-blockers etc
CBT Computer treatment VRs Mood GYM
Thank You All Visit us at
wwwdrsarmain
This is sponsored by Torrent ndash
Makers of Clonotril (Clonazepam)
Anxiety Disorders
Current Management Strategies
Management of Anxiety Disorders
1048766 Pharmacotherapy (Medications)
Psycho-analytic therapy ndash PT
Behavior Therapy - BT
Cognitive Behavior Therapy ndash CBT
Computer therapy - CT
1048766 Virtual Realty ndash VR
Mood GYM
Drug Rx of Anxiety Disorders
Clonazepam
How do anxiolytics act
GABA and Glycine are inhibitory neurotransmitter
Serotonin and Noradrenaline are excitatory
Anxiety is increased excitatory transmitters
BZNs increase GABA and increase inhibition
SSRI decrease the serotonin levels and darrexcitation
TCAs act by darrboth serotonin and noradrenaline
Drug Rx of Anxiety Disorders
Disorder First Choice 2nd Choice Short (prn) Add on
GADBZN-
CZ CDZ ALZBeta-blockers Buspirone Carbamazp
Panic Disorder
Paroxetine
CitalopramTCA-
ClomipramineBZN-
ALZ CZ LZMAOI -
Phenelzine
Phobias Beta-blockers SSRIsBZN-
ALZ CZMAOI
OCD Clomipramine Fluoxetine CDZ Buspirone
PTSDTCA-
Imipra Amytrp
SSRI- FLX
Sertaline CPBZN MAOI
Comparison of Benzodiazepines
BZN Sedation Anxiolytic Half life Lipid solu Dose
Diazepam +++ + 20-80 h High 5 mg od
Alprazolam + +++ 6-20 h Low 05 mg qid
Clonazapam ++ +++ 22-50 h Low 05 mg bid
Lorazepam ++ ++ 10-20 h Med 1 mg tid
Chlordiazepx + + 7-30 h Med 15 mg bid
Different strategies of therapy
Behavior therapy
Desensitization
Behavior modification
Behavioral activation
Cognitive therapy
Rational-emotive therapy
Beckrsquos cognitive therapy
Newer approaches
Mindfulness meditation
Acceptance and commitment therapy
Dialectical Behavior Therapy (BPD)
Cognitive Behaviour Therapy - CBT
CBT is a method used to treat anxiety
Recognition of ldquodistorted thinkingrdquo
ldquoCognitive restructuringrdquo
It may also involve classical conditioning when used to treat Obsessive Compulsive Disorder
CBT ndash Obstacles - Restructuring
Hopelessness
Self-criticism
Fear of getting worse
Shame and embarrassment
Partial exposure
Blaming other people
Low motivation
Looking for complex solution
Depressing ruminations
There must be an easier way
Computer Therapy
Pts are ashamed to seek help and may fear the consequences at work and home
Therapy is expensive and beyond the reach of many patients
Computer therapy is very cheap and available by comparison
Computer Therapy ndash Softwares
Fearfighter - for phobiapanic
Cope - for depressionanxiety
Balance - for GAD
BTSteps - for OCD
These are PC based in a CD-Rom
or phone based or Web-based
MENTAL OUTSIDE
Virtual Reality - VR
VR therapy via SD (Systematic Desensitization) is becoming very popular
SD is a process of gradually introducing a disturbing stimulus (eg view from a high place) in otherwise pleasant surroundings
This process gradually suppresses the anxiety response
Virtual Reality ndash VR - Advantages
Patients often have difficulty imagining the stimulus themselves
They are often afraid of experiencing it directly ndash which may also be expensive and time-consuming
VR affords patient privacy and confidentiality during treatment
Very good for phobias
Virtual Reality ndash VR - Imagination
ldquoProjection in timerdquo ndash rationally reconstructing the future
ldquoDe-catastrophizing an imagerdquo ndash modifying a disturbing image
ldquoImage modeling and substitutionrdquo ndashinterrupting a negative train of images
ldquoCovert conditioningrdquo ndash subtle conditioning using imagined rather than real stimuli
Virtual Reality ndash VR - Hutchworld
Hutchworld is a virtual community attached to the Hutchison Cancer Research Center
Designed to provide social support for cancer patients and their families
Based on Microsoftrsquos Vworldrsquos system
Mood GYM on the Internet
Few GPs are trained in CBT
Clinical psychologists are expensive
Young people are not easily reached
They may not want them ndash embarrassment
The web is accessible convenient and popular
with young people
Deliver CBT via internet ndash 5 modules
Mood GYM Modules
5 Modules - analysis and results
1 Essentials of CBT with examples and interactive exercises
2 Warpy Thoughts Questionnaire Identifying dysfunctional thoughts Methods to contest such thoughts
3 Other methods for overcoming warpy thoughts
4 Life Event Stress Relaxation meditation music Pleasant Events Schedule parental style
5 Simple problem solving responses to relationship break-up
Web stats summary
Sessions
Take home points
10487661048766Anxiety disorders are very common
10487661048766Just as fevers these are of different types
10487661048766Accurate Dx and Rx by GP is essential
10487661048766Depression and substance abuse potential
Minimum of six weeks to see Rx effect
Prolonged Rx is necessary 6 m or more
Drug Rx is only a small part of management
SSRI TCAs BZNs MAOIs szlig-blockers etc
CBT Computer treatment VRs Mood GYM
Thank You All Visit us at
wwwdrsarmain
This is sponsored by Torrent ndash
Makers of Clonotril (Clonazepam)
Management of Anxiety Disorders
1048766 Pharmacotherapy (Medications)
Psycho-analytic therapy ndash PT
Behavior Therapy - BT
Cognitive Behavior Therapy ndash CBT
Computer therapy - CT
1048766 Virtual Realty ndash VR
Mood GYM
Drug Rx of Anxiety Disorders
Clonazepam
How do anxiolytics act
GABA and Glycine are inhibitory neurotransmitter
Serotonin and Noradrenaline are excitatory
Anxiety is increased excitatory transmitters
BZNs increase GABA and increase inhibition
SSRI decrease the serotonin levels and darrexcitation
TCAs act by darrboth serotonin and noradrenaline
Drug Rx of Anxiety Disorders
Disorder First Choice 2nd Choice Short (prn) Add on
GADBZN-
CZ CDZ ALZBeta-blockers Buspirone Carbamazp
Panic Disorder
Paroxetine
CitalopramTCA-
ClomipramineBZN-
ALZ CZ LZMAOI -
Phenelzine
Phobias Beta-blockers SSRIsBZN-
ALZ CZMAOI
OCD Clomipramine Fluoxetine CDZ Buspirone
PTSDTCA-
Imipra Amytrp
SSRI- FLX
Sertaline CPBZN MAOI
Comparison of Benzodiazepines
BZN Sedation Anxiolytic Half life Lipid solu Dose
Diazepam +++ + 20-80 h High 5 mg od
Alprazolam + +++ 6-20 h Low 05 mg qid
Clonazapam ++ +++ 22-50 h Low 05 mg bid
Lorazepam ++ ++ 10-20 h Med 1 mg tid
Chlordiazepx + + 7-30 h Med 15 mg bid
Different strategies of therapy
Behavior therapy
Desensitization
Behavior modification
Behavioral activation
Cognitive therapy
Rational-emotive therapy
Beckrsquos cognitive therapy
Newer approaches
Mindfulness meditation
Acceptance and commitment therapy
Dialectical Behavior Therapy (BPD)
Cognitive Behaviour Therapy - CBT
CBT is a method used to treat anxiety
Recognition of ldquodistorted thinkingrdquo
ldquoCognitive restructuringrdquo
It may also involve classical conditioning when used to treat Obsessive Compulsive Disorder
CBT ndash Obstacles - Restructuring
Hopelessness
Self-criticism
Fear of getting worse
Shame and embarrassment
Partial exposure
Blaming other people
Low motivation
Looking for complex solution
Depressing ruminations
There must be an easier way
Computer Therapy
Pts are ashamed to seek help and may fear the consequences at work and home
Therapy is expensive and beyond the reach of many patients
Computer therapy is very cheap and available by comparison
Computer Therapy ndash Softwares
Fearfighter - for phobiapanic
Cope - for depressionanxiety
Balance - for GAD
BTSteps - for OCD
These are PC based in a CD-Rom
or phone based or Web-based
MENTAL OUTSIDE
Virtual Reality - VR
VR therapy via SD (Systematic Desensitization) is becoming very popular
SD is a process of gradually introducing a disturbing stimulus (eg view from a high place) in otherwise pleasant surroundings
This process gradually suppresses the anxiety response
Virtual Reality ndash VR - Advantages
Patients often have difficulty imagining the stimulus themselves
They are often afraid of experiencing it directly ndash which may also be expensive and time-consuming
VR affords patient privacy and confidentiality during treatment
Very good for phobias
Virtual Reality ndash VR - Imagination
ldquoProjection in timerdquo ndash rationally reconstructing the future
ldquoDe-catastrophizing an imagerdquo ndash modifying a disturbing image
ldquoImage modeling and substitutionrdquo ndashinterrupting a negative train of images
ldquoCovert conditioningrdquo ndash subtle conditioning using imagined rather than real stimuli
Virtual Reality ndash VR - Hutchworld
Hutchworld is a virtual community attached to the Hutchison Cancer Research Center
Designed to provide social support for cancer patients and their families
Based on Microsoftrsquos Vworldrsquos system
Mood GYM on the Internet
Few GPs are trained in CBT
Clinical psychologists are expensive
Young people are not easily reached
They may not want them ndash embarrassment
The web is accessible convenient and popular
with young people
Deliver CBT via internet ndash 5 modules
Mood GYM Modules
5 Modules - analysis and results
1 Essentials of CBT with examples and interactive exercises
2 Warpy Thoughts Questionnaire Identifying dysfunctional thoughts Methods to contest such thoughts
3 Other methods for overcoming warpy thoughts
4 Life Event Stress Relaxation meditation music Pleasant Events Schedule parental style
5 Simple problem solving responses to relationship break-up
Web stats summary
Sessions
Take home points
10487661048766Anxiety disorders are very common
10487661048766Just as fevers these are of different types
10487661048766Accurate Dx and Rx by GP is essential
10487661048766Depression and substance abuse potential
Minimum of six weeks to see Rx effect
Prolonged Rx is necessary 6 m or more
Drug Rx is only a small part of management
SSRI TCAs BZNs MAOIs szlig-blockers etc
CBT Computer treatment VRs Mood GYM
Thank You All Visit us at
wwwdrsarmain
This is sponsored by Torrent ndash
Makers of Clonotril (Clonazepam)
Drug Rx of Anxiety Disorders
Clonazepam
How do anxiolytics act
GABA and Glycine are inhibitory neurotransmitter
Serotonin and Noradrenaline are excitatory
Anxiety is increased excitatory transmitters
BZNs increase GABA and increase inhibition
SSRI decrease the serotonin levels and darrexcitation
TCAs act by darrboth serotonin and noradrenaline
Drug Rx of Anxiety Disorders
Disorder First Choice 2nd Choice Short (prn) Add on
GADBZN-
CZ CDZ ALZBeta-blockers Buspirone Carbamazp
Panic Disorder
Paroxetine
CitalopramTCA-
ClomipramineBZN-
ALZ CZ LZMAOI -
Phenelzine
Phobias Beta-blockers SSRIsBZN-
ALZ CZMAOI
OCD Clomipramine Fluoxetine CDZ Buspirone
PTSDTCA-
Imipra Amytrp
SSRI- FLX
Sertaline CPBZN MAOI
Comparison of Benzodiazepines
BZN Sedation Anxiolytic Half life Lipid solu Dose
Diazepam +++ + 20-80 h High 5 mg od
Alprazolam + +++ 6-20 h Low 05 mg qid
Clonazapam ++ +++ 22-50 h Low 05 mg bid
Lorazepam ++ ++ 10-20 h Med 1 mg tid
Chlordiazepx + + 7-30 h Med 15 mg bid
Different strategies of therapy
Behavior therapy
Desensitization
Behavior modification
Behavioral activation
Cognitive therapy
Rational-emotive therapy
Beckrsquos cognitive therapy
Newer approaches
Mindfulness meditation
Acceptance and commitment therapy
Dialectical Behavior Therapy (BPD)
Cognitive Behaviour Therapy - CBT
CBT is a method used to treat anxiety
Recognition of ldquodistorted thinkingrdquo
ldquoCognitive restructuringrdquo
It may also involve classical conditioning when used to treat Obsessive Compulsive Disorder
CBT ndash Obstacles - Restructuring
Hopelessness
Self-criticism
Fear of getting worse
Shame and embarrassment
Partial exposure
Blaming other people
Low motivation
Looking for complex solution
Depressing ruminations
There must be an easier way
Computer Therapy
Pts are ashamed to seek help and may fear the consequences at work and home
Therapy is expensive and beyond the reach of many patients
Computer therapy is very cheap and available by comparison
Computer Therapy ndash Softwares
Fearfighter - for phobiapanic
Cope - for depressionanxiety
Balance - for GAD
BTSteps - for OCD
These are PC based in a CD-Rom
or phone based or Web-based
MENTAL OUTSIDE
Virtual Reality - VR
VR therapy via SD (Systematic Desensitization) is becoming very popular
SD is a process of gradually introducing a disturbing stimulus (eg view from a high place) in otherwise pleasant surroundings
This process gradually suppresses the anxiety response
Virtual Reality ndash VR - Advantages
Patients often have difficulty imagining the stimulus themselves
They are often afraid of experiencing it directly ndash which may also be expensive and time-consuming
VR affords patient privacy and confidentiality during treatment
Very good for phobias
Virtual Reality ndash VR - Imagination
ldquoProjection in timerdquo ndash rationally reconstructing the future
ldquoDe-catastrophizing an imagerdquo ndash modifying a disturbing image
ldquoImage modeling and substitutionrdquo ndashinterrupting a negative train of images
ldquoCovert conditioningrdquo ndash subtle conditioning using imagined rather than real stimuli
Virtual Reality ndash VR - Hutchworld
Hutchworld is a virtual community attached to the Hutchison Cancer Research Center
Designed to provide social support for cancer patients and their families
Based on Microsoftrsquos Vworldrsquos system
Mood GYM on the Internet
Few GPs are trained in CBT
Clinical psychologists are expensive
Young people are not easily reached
They may not want them ndash embarrassment
The web is accessible convenient and popular
with young people
Deliver CBT via internet ndash 5 modules
Mood GYM Modules
5 Modules - analysis and results
1 Essentials of CBT with examples and interactive exercises
2 Warpy Thoughts Questionnaire Identifying dysfunctional thoughts Methods to contest such thoughts
3 Other methods for overcoming warpy thoughts
4 Life Event Stress Relaxation meditation music Pleasant Events Schedule parental style
5 Simple problem solving responses to relationship break-up
Web stats summary
Sessions
Take home points
10487661048766Anxiety disorders are very common
10487661048766Just as fevers these are of different types
10487661048766Accurate Dx and Rx by GP is essential
10487661048766Depression and substance abuse potential
Minimum of six weeks to see Rx effect
Prolonged Rx is necessary 6 m or more
Drug Rx is only a small part of management
SSRI TCAs BZNs MAOIs szlig-blockers etc
CBT Computer treatment VRs Mood GYM
Thank You All Visit us at
wwwdrsarmain
This is sponsored by Torrent ndash
Makers of Clonotril (Clonazepam)
How do anxiolytics act
GABA and Glycine are inhibitory neurotransmitter
Serotonin and Noradrenaline are excitatory
Anxiety is increased excitatory transmitters
BZNs increase GABA and increase inhibition
SSRI decrease the serotonin levels and darrexcitation
TCAs act by darrboth serotonin and noradrenaline
Drug Rx of Anxiety Disorders
Disorder First Choice 2nd Choice Short (prn) Add on
GADBZN-
CZ CDZ ALZBeta-blockers Buspirone Carbamazp
Panic Disorder
Paroxetine
CitalopramTCA-
ClomipramineBZN-
ALZ CZ LZMAOI -
Phenelzine
Phobias Beta-blockers SSRIsBZN-
ALZ CZMAOI
OCD Clomipramine Fluoxetine CDZ Buspirone
PTSDTCA-
Imipra Amytrp
SSRI- FLX
Sertaline CPBZN MAOI
Comparison of Benzodiazepines
BZN Sedation Anxiolytic Half life Lipid solu Dose
Diazepam +++ + 20-80 h High 5 mg od
Alprazolam + +++ 6-20 h Low 05 mg qid
Clonazapam ++ +++ 22-50 h Low 05 mg bid
Lorazepam ++ ++ 10-20 h Med 1 mg tid
Chlordiazepx + + 7-30 h Med 15 mg bid
Different strategies of therapy
Behavior therapy
Desensitization
Behavior modification
Behavioral activation
Cognitive therapy
Rational-emotive therapy
Beckrsquos cognitive therapy
Newer approaches
Mindfulness meditation
Acceptance and commitment therapy
Dialectical Behavior Therapy (BPD)
Cognitive Behaviour Therapy - CBT
CBT is a method used to treat anxiety
Recognition of ldquodistorted thinkingrdquo
ldquoCognitive restructuringrdquo
It may also involve classical conditioning when used to treat Obsessive Compulsive Disorder
CBT ndash Obstacles - Restructuring
Hopelessness
Self-criticism
Fear of getting worse
Shame and embarrassment
Partial exposure
Blaming other people
Low motivation
Looking for complex solution
Depressing ruminations
There must be an easier way
Computer Therapy
Pts are ashamed to seek help and may fear the consequences at work and home
Therapy is expensive and beyond the reach of many patients
Computer therapy is very cheap and available by comparison
Computer Therapy ndash Softwares
Fearfighter - for phobiapanic
Cope - for depressionanxiety
Balance - for GAD
BTSteps - for OCD
These are PC based in a CD-Rom
or phone based or Web-based
MENTAL OUTSIDE
Virtual Reality - VR
VR therapy via SD (Systematic Desensitization) is becoming very popular
SD is a process of gradually introducing a disturbing stimulus (eg view from a high place) in otherwise pleasant surroundings
This process gradually suppresses the anxiety response
Virtual Reality ndash VR - Advantages
Patients often have difficulty imagining the stimulus themselves
They are often afraid of experiencing it directly ndash which may also be expensive and time-consuming
VR affords patient privacy and confidentiality during treatment
Very good for phobias
Virtual Reality ndash VR - Imagination
ldquoProjection in timerdquo ndash rationally reconstructing the future
ldquoDe-catastrophizing an imagerdquo ndash modifying a disturbing image
ldquoImage modeling and substitutionrdquo ndashinterrupting a negative train of images
ldquoCovert conditioningrdquo ndash subtle conditioning using imagined rather than real stimuli
Virtual Reality ndash VR - Hutchworld
Hutchworld is a virtual community attached to the Hutchison Cancer Research Center
Designed to provide social support for cancer patients and their families
Based on Microsoftrsquos Vworldrsquos system
Mood GYM on the Internet
Few GPs are trained in CBT
Clinical psychologists are expensive
Young people are not easily reached
They may not want them ndash embarrassment
The web is accessible convenient and popular
with young people
Deliver CBT via internet ndash 5 modules
Mood GYM Modules
5 Modules - analysis and results
1 Essentials of CBT with examples and interactive exercises
2 Warpy Thoughts Questionnaire Identifying dysfunctional thoughts Methods to contest such thoughts
3 Other methods for overcoming warpy thoughts
4 Life Event Stress Relaxation meditation music Pleasant Events Schedule parental style
5 Simple problem solving responses to relationship break-up
Web stats summary
Sessions
Take home points
10487661048766Anxiety disorders are very common
10487661048766Just as fevers these are of different types
10487661048766Accurate Dx and Rx by GP is essential
10487661048766Depression and substance abuse potential
Minimum of six weeks to see Rx effect
Prolonged Rx is necessary 6 m or more
Drug Rx is only a small part of management
SSRI TCAs BZNs MAOIs szlig-blockers etc
CBT Computer treatment VRs Mood GYM
Thank You All Visit us at
wwwdrsarmain
This is sponsored by Torrent ndash
Makers of Clonotril (Clonazepam)
Drug Rx of Anxiety Disorders
Disorder First Choice 2nd Choice Short (prn) Add on
GADBZN-
CZ CDZ ALZBeta-blockers Buspirone Carbamazp
Panic Disorder
Paroxetine
CitalopramTCA-
ClomipramineBZN-
ALZ CZ LZMAOI -
Phenelzine
Phobias Beta-blockers SSRIsBZN-
ALZ CZMAOI
OCD Clomipramine Fluoxetine CDZ Buspirone
PTSDTCA-
Imipra Amytrp
SSRI- FLX
Sertaline CPBZN MAOI
Comparison of Benzodiazepines
BZN Sedation Anxiolytic Half life Lipid solu Dose
Diazepam +++ + 20-80 h High 5 mg od
Alprazolam + +++ 6-20 h Low 05 mg qid
Clonazapam ++ +++ 22-50 h Low 05 mg bid
Lorazepam ++ ++ 10-20 h Med 1 mg tid
Chlordiazepx + + 7-30 h Med 15 mg bid
Different strategies of therapy
Behavior therapy
Desensitization
Behavior modification
Behavioral activation
Cognitive therapy
Rational-emotive therapy
Beckrsquos cognitive therapy
Newer approaches
Mindfulness meditation
Acceptance and commitment therapy
Dialectical Behavior Therapy (BPD)
Cognitive Behaviour Therapy - CBT
CBT is a method used to treat anxiety
Recognition of ldquodistorted thinkingrdquo
ldquoCognitive restructuringrdquo
It may also involve classical conditioning when used to treat Obsessive Compulsive Disorder
CBT ndash Obstacles - Restructuring
Hopelessness
Self-criticism
Fear of getting worse
Shame and embarrassment
Partial exposure
Blaming other people
Low motivation
Looking for complex solution
Depressing ruminations
There must be an easier way
Computer Therapy
Pts are ashamed to seek help and may fear the consequences at work and home
Therapy is expensive and beyond the reach of many patients
Computer therapy is very cheap and available by comparison
Computer Therapy ndash Softwares
Fearfighter - for phobiapanic
Cope - for depressionanxiety
Balance - for GAD
BTSteps - for OCD
These are PC based in a CD-Rom
or phone based or Web-based
MENTAL OUTSIDE
Virtual Reality - VR
VR therapy via SD (Systematic Desensitization) is becoming very popular
SD is a process of gradually introducing a disturbing stimulus (eg view from a high place) in otherwise pleasant surroundings
This process gradually suppresses the anxiety response
Virtual Reality ndash VR - Advantages
Patients often have difficulty imagining the stimulus themselves
They are often afraid of experiencing it directly ndash which may also be expensive and time-consuming
VR affords patient privacy and confidentiality during treatment
Very good for phobias
Virtual Reality ndash VR - Imagination
ldquoProjection in timerdquo ndash rationally reconstructing the future
ldquoDe-catastrophizing an imagerdquo ndash modifying a disturbing image
ldquoImage modeling and substitutionrdquo ndashinterrupting a negative train of images
ldquoCovert conditioningrdquo ndash subtle conditioning using imagined rather than real stimuli
Virtual Reality ndash VR - Hutchworld
Hutchworld is a virtual community attached to the Hutchison Cancer Research Center
Designed to provide social support for cancer patients and their families
Based on Microsoftrsquos Vworldrsquos system
Mood GYM on the Internet
Few GPs are trained in CBT
Clinical psychologists are expensive
Young people are not easily reached
They may not want them ndash embarrassment
The web is accessible convenient and popular
with young people
Deliver CBT via internet ndash 5 modules
Mood GYM Modules
5 Modules - analysis and results
1 Essentials of CBT with examples and interactive exercises
2 Warpy Thoughts Questionnaire Identifying dysfunctional thoughts Methods to contest such thoughts
3 Other methods for overcoming warpy thoughts
4 Life Event Stress Relaxation meditation music Pleasant Events Schedule parental style
5 Simple problem solving responses to relationship break-up
Web stats summary
Sessions
Take home points
10487661048766Anxiety disorders are very common
10487661048766Just as fevers these are of different types
10487661048766Accurate Dx and Rx by GP is essential
10487661048766Depression and substance abuse potential
Minimum of six weeks to see Rx effect
Prolonged Rx is necessary 6 m or more
Drug Rx is only a small part of management
SSRI TCAs BZNs MAOIs szlig-blockers etc
CBT Computer treatment VRs Mood GYM
Thank You All Visit us at
wwwdrsarmain
This is sponsored by Torrent ndash
Makers of Clonotril (Clonazepam)
Comparison of Benzodiazepines
BZN Sedation Anxiolytic Half life Lipid solu Dose
Diazepam +++ + 20-80 h High 5 mg od
Alprazolam + +++ 6-20 h Low 05 mg qid
Clonazapam ++ +++ 22-50 h Low 05 mg bid
Lorazepam ++ ++ 10-20 h Med 1 mg tid
Chlordiazepx + + 7-30 h Med 15 mg bid
Different strategies of therapy
Behavior therapy
Desensitization
Behavior modification
Behavioral activation
Cognitive therapy
Rational-emotive therapy
Beckrsquos cognitive therapy
Newer approaches
Mindfulness meditation
Acceptance and commitment therapy
Dialectical Behavior Therapy (BPD)
Cognitive Behaviour Therapy - CBT
CBT is a method used to treat anxiety
Recognition of ldquodistorted thinkingrdquo
ldquoCognitive restructuringrdquo
It may also involve classical conditioning when used to treat Obsessive Compulsive Disorder
CBT ndash Obstacles - Restructuring
Hopelessness
Self-criticism
Fear of getting worse
Shame and embarrassment
Partial exposure
Blaming other people
Low motivation
Looking for complex solution
Depressing ruminations
There must be an easier way
Computer Therapy
Pts are ashamed to seek help and may fear the consequences at work and home
Therapy is expensive and beyond the reach of many patients
Computer therapy is very cheap and available by comparison
Computer Therapy ndash Softwares
Fearfighter - for phobiapanic
Cope - for depressionanxiety
Balance - for GAD
BTSteps - for OCD
These are PC based in a CD-Rom
or phone based or Web-based
MENTAL OUTSIDE
Virtual Reality - VR
VR therapy via SD (Systematic Desensitization) is becoming very popular
SD is a process of gradually introducing a disturbing stimulus (eg view from a high place) in otherwise pleasant surroundings
This process gradually suppresses the anxiety response
Virtual Reality ndash VR - Advantages
Patients often have difficulty imagining the stimulus themselves
They are often afraid of experiencing it directly ndash which may also be expensive and time-consuming
VR affords patient privacy and confidentiality during treatment
Very good for phobias
Virtual Reality ndash VR - Imagination
ldquoProjection in timerdquo ndash rationally reconstructing the future
ldquoDe-catastrophizing an imagerdquo ndash modifying a disturbing image
ldquoImage modeling and substitutionrdquo ndashinterrupting a negative train of images
ldquoCovert conditioningrdquo ndash subtle conditioning using imagined rather than real stimuli
Virtual Reality ndash VR - Hutchworld
Hutchworld is a virtual community attached to the Hutchison Cancer Research Center
Designed to provide social support for cancer patients and their families
Based on Microsoftrsquos Vworldrsquos system
Mood GYM on the Internet
Few GPs are trained in CBT
Clinical psychologists are expensive
Young people are not easily reached
They may not want them ndash embarrassment
The web is accessible convenient and popular
with young people
Deliver CBT via internet ndash 5 modules
Mood GYM Modules
5 Modules - analysis and results
1 Essentials of CBT with examples and interactive exercises
2 Warpy Thoughts Questionnaire Identifying dysfunctional thoughts Methods to contest such thoughts
3 Other methods for overcoming warpy thoughts
4 Life Event Stress Relaxation meditation music Pleasant Events Schedule parental style
5 Simple problem solving responses to relationship break-up
Web stats summary
Sessions
Take home points
10487661048766Anxiety disorders are very common
10487661048766Just as fevers these are of different types
10487661048766Accurate Dx and Rx by GP is essential
10487661048766Depression and substance abuse potential
Minimum of six weeks to see Rx effect
Prolonged Rx is necessary 6 m or more
Drug Rx is only a small part of management
SSRI TCAs BZNs MAOIs szlig-blockers etc
CBT Computer treatment VRs Mood GYM
Thank You All Visit us at
wwwdrsarmain
This is sponsored by Torrent ndash
Makers of Clonotril (Clonazepam)
Different strategies of therapy
Behavior therapy
Desensitization
Behavior modification
Behavioral activation
Cognitive therapy
Rational-emotive therapy
Beckrsquos cognitive therapy
Newer approaches
Mindfulness meditation
Acceptance and commitment therapy
Dialectical Behavior Therapy (BPD)
Cognitive Behaviour Therapy - CBT
CBT is a method used to treat anxiety
Recognition of ldquodistorted thinkingrdquo
ldquoCognitive restructuringrdquo
It may also involve classical conditioning when used to treat Obsessive Compulsive Disorder
CBT ndash Obstacles - Restructuring
Hopelessness
Self-criticism
Fear of getting worse
Shame and embarrassment
Partial exposure
Blaming other people
Low motivation
Looking for complex solution
Depressing ruminations
There must be an easier way
Computer Therapy
Pts are ashamed to seek help and may fear the consequences at work and home
Therapy is expensive and beyond the reach of many patients
Computer therapy is very cheap and available by comparison
Computer Therapy ndash Softwares
Fearfighter - for phobiapanic
Cope - for depressionanxiety
Balance - for GAD
BTSteps - for OCD
These are PC based in a CD-Rom
or phone based or Web-based
MENTAL OUTSIDE
Virtual Reality - VR
VR therapy via SD (Systematic Desensitization) is becoming very popular
SD is a process of gradually introducing a disturbing stimulus (eg view from a high place) in otherwise pleasant surroundings
This process gradually suppresses the anxiety response
Virtual Reality ndash VR - Advantages
Patients often have difficulty imagining the stimulus themselves
They are often afraid of experiencing it directly ndash which may also be expensive and time-consuming
VR affords patient privacy and confidentiality during treatment
Very good for phobias
Virtual Reality ndash VR - Imagination
ldquoProjection in timerdquo ndash rationally reconstructing the future
ldquoDe-catastrophizing an imagerdquo ndash modifying a disturbing image
ldquoImage modeling and substitutionrdquo ndashinterrupting a negative train of images
ldquoCovert conditioningrdquo ndash subtle conditioning using imagined rather than real stimuli
Virtual Reality ndash VR - Hutchworld
Hutchworld is a virtual community attached to the Hutchison Cancer Research Center
Designed to provide social support for cancer patients and their families
Based on Microsoftrsquos Vworldrsquos system
Mood GYM on the Internet
Few GPs are trained in CBT
Clinical psychologists are expensive
Young people are not easily reached
They may not want them ndash embarrassment
The web is accessible convenient and popular
with young people
Deliver CBT via internet ndash 5 modules
Mood GYM Modules
5 Modules - analysis and results
1 Essentials of CBT with examples and interactive exercises
2 Warpy Thoughts Questionnaire Identifying dysfunctional thoughts Methods to contest such thoughts
3 Other methods for overcoming warpy thoughts
4 Life Event Stress Relaxation meditation music Pleasant Events Schedule parental style
5 Simple problem solving responses to relationship break-up
Web stats summary
Sessions
Take home points
10487661048766Anxiety disorders are very common
10487661048766Just as fevers these are of different types
10487661048766Accurate Dx and Rx by GP is essential
10487661048766Depression and substance abuse potential
Minimum of six weeks to see Rx effect
Prolonged Rx is necessary 6 m or more
Drug Rx is only a small part of management
SSRI TCAs BZNs MAOIs szlig-blockers etc
CBT Computer treatment VRs Mood GYM
Thank You All Visit us at
wwwdrsarmain
This is sponsored by Torrent ndash
Makers of Clonotril (Clonazepam)
Cognitive Behaviour Therapy - CBT
CBT is a method used to treat anxiety
Recognition of ldquodistorted thinkingrdquo
ldquoCognitive restructuringrdquo
It may also involve classical conditioning when used to treat Obsessive Compulsive Disorder
CBT ndash Obstacles - Restructuring
Hopelessness
Self-criticism
Fear of getting worse
Shame and embarrassment
Partial exposure
Blaming other people
Low motivation
Looking for complex solution
Depressing ruminations
There must be an easier way
Computer Therapy
Pts are ashamed to seek help and may fear the consequences at work and home
Therapy is expensive and beyond the reach of many patients
Computer therapy is very cheap and available by comparison
Computer Therapy ndash Softwares
Fearfighter - for phobiapanic
Cope - for depressionanxiety
Balance - for GAD
BTSteps - for OCD
These are PC based in a CD-Rom
or phone based or Web-based
MENTAL OUTSIDE
Virtual Reality - VR
VR therapy via SD (Systematic Desensitization) is becoming very popular
SD is a process of gradually introducing a disturbing stimulus (eg view from a high place) in otherwise pleasant surroundings
This process gradually suppresses the anxiety response
Virtual Reality ndash VR - Advantages
Patients often have difficulty imagining the stimulus themselves
They are often afraid of experiencing it directly ndash which may also be expensive and time-consuming
VR affords patient privacy and confidentiality during treatment
Very good for phobias
Virtual Reality ndash VR - Imagination
ldquoProjection in timerdquo ndash rationally reconstructing the future
ldquoDe-catastrophizing an imagerdquo ndash modifying a disturbing image
ldquoImage modeling and substitutionrdquo ndashinterrupting a negative train of images
ldquoCovert conditioningrdquo ndash subtle conditioning using imagined rather than real stimuli
Virtual Reality ndash VR - Hutchworld
Hutchworld is a virtual community attached to the Hutchison Cancer Research Center
Designed to provide social support for cancer patients and their families
Based on Microsoftrsquos Vworldrsquos system
Mood GYM on the Internet
Few GPs are trained in CBT
Clinical psychologists are expensive
Young people are not easily reached
They may not want them ndash embarrassment
The web is accessible convenient and popular
with young people
Deliver CBT via internet ndash 5 modules
Mood GYM Modules
5 Modules - analysis and results
1 Essentials of CBT with examples and interactive exercises
2 Warpy Thoughts Questionnaire Identifying dysfunctional thoughts Methods to contest such thoughts
3 Other methods for overcoming warpy thoughts
4 Life Event Stress Relaxation meditation music Pleasant Events Schedule parental style
5 Simple problem solving responses to relationship break-up
Web stats summary
Sessions
Take home points
10487661048766Anxiety disorders are very common
10487661048766Just as fevers these are of different types
10487661048766Accurate Dx and Rx by GP is essential
10487661048766Depression and substance abuse potential
Minimum of six weeks to see Rx effect
Prolonged Rx is necessary 6 m or more
Drug Rx is only a small part of management
SSRI TCAs BZNs MAOIs szlig-blockers etc
CBT Computer treatment VRs Mood GYM
Thank You All Visit us at
wwwdrsarmain
This is sponsored by Torrent ndash
Makers of Clonotril (Clonazepam)
CBT ndash Obstacles - Restructuring
Hopelessness
Self-criticism
Fear of getting worse
Shame and embarrassment
Partial exposure
Blaming other people
Low motivation
Looking for complex solution
Depressing ruminations
There must be an easier way
Computer Therapy
Pts are ashamed to seek help and may fear the consequences at work and home
Therapy is expensive and beyond the reach of many patients
Computer therapy is very cheap and available by comparison
Computer Therapy ndash Softwares
Fearfighter - for phobiapanic
Cope - for depressionanxiety
Balance - for GAD
BTSteps - for OCD
These are PC based in a CD-Rom
or phone based or Web-based
MENTAL OUTSIDE
Virtual Reality - VR
VR therapy via SD (Systematic Desensitization) is becoming very popular
SD is a process of gradually introducing a disturbing stimulus (eg view from a high place) in otherwise pleasant surroundings
This process gradually suppresses the anxiety response
Virtual Reality ndash VR - Advantages
Patients often have difficulty imagining the stimulus themselves
They are often afraid of experiencing it directly ndash which may also be expensive and time-consuming
VR affords patient privacy and confidentiality during treatment
Very good for phobias
Virtual Reality ndash VR - Imagination
ldquoProjection in timerdquo ndash rationally reconstructing the future
ldquoDe-catastrophizing an imagerdquo ndash modifying a disturbing image
ldquoImage modeling and substitutionrdquo ndashinterrupting a negative train of images
ldquoCovert conditioningrdquo ndash subtle conditioning using imagined rather than real stimuli
Virtual Reality ndash VR - Hutchworld
Hutchworld is a virtual community attached to the Hutchison Cancer Research Center
Designed to provide social support for cancer patients and their families
Based on Microsoftrsquos Vworldrsquos system
Mood GYM on the Internet
Few GPs are trained in CBT
Clinical psychologists are expensive
Young people are not easily reached
They may not want them ndash embarrassment
The web is accessible convenient and popular
with young people
Deliver CBT via internet ndash 5 modules
Mood GYM Modules
5 Modules - analysis and results
1 Essentials of CBT with examples and interactive exercises
2 Warpy Thoughts Questionnaire Identifying dysfunctional thoughts Methods to contest such thoughts
3 Other methods for overcoming warpy thoughts
4 Life Event Stress Relaxation meditation music Pleasant Events Schedule parental style
5 Simple problem solving responses to relationship break-up
Web stats summary
Sessions
Take home points
10487661048766Anxiety disorders are very common
10487661048766Just as fevers these are of different types
10487661048766Accurate Dx and Rx by GP is essential
10487661048766Depression and substance abuse potential
Minimum of six weeks to see Rx effect
Prolonged Rx is necessary 6 m or more
Drug Rx is only a small part of management
SSRI TCAs BZNs MAOIs szlig-blockers etc
CBT Computer treatment VRs Mood GYM
Thank You All Visit us at
wwwdrsarmain
This is sponsored by Torrent ndash
Makers of Clonotril (Clonazepam)
Computer Therapy
Pts are ashamed to seek help and may fear the consequences at work and home
Therapy is expensive and beyond the reach of many patients
Computer therapy is very cheap and available by comparison
Computer Therapy ndash Softwares
Fearfighter - for phobiapanic
Cope - for depressionanxiety
Balance - for GAD
BTSteps - for OCD
These are PC based in a CD-Rom
or phone based or Web-based
MENTAL OUTSIDE
Virtual Reality - VR
VR therapy via SD (Systematic Desensitization) is becoming very popular
SD is a process of gradually introducing a disturbing stimulus (eg view from a high place) in otherwise pleasant surroundings
This process gradually suppresses the anxiety response
Virtual Reality ndash VR - Advantages
Patients often have difficulty imagining the stimulus themselves
They are often afraid of experiencing it directly ndash which may also be expensive and time-consuming
VR affords patient privacy and confidentiality during treatment
Very good for phobias
Virtual Reality ndash VR - Imagination
ldquoProjection in timerdquo ndash rationally reconstructing the future
ldquoDe-catastrophizing an imagerdquo ndash modifying a disturbing image
ldquoImage modeling and substitutionrdquo ndashinterrupting a negative train of images
ldquoCovert conditioningrdquo ndash subtle conditioning using imagined rather than real stimuli
Virtual Reality ndash VR - Hutchworld
Hutchworld is a virtual community attached to the Hutchison Cancer Research Center
Designed to provide social support for cancer patients and their families
Based on Microsoftrsquos Vworldrsquos system
Mood GYM on the Internet
Few GPs are trained in CBT
Clinical psychologists are expensive
Young people are not easily reached
They may not want them ndash embarrassment
The web is accessible convenient and popular
with young people
Deliver CBT via internet ndash 5 modules
Mood GYM Modules
5 Modules - analysis and results
1 Essentials of CBT with examples and interactive exercises
2 Warpy Thoughts Questionnaire Identifying dysfunctional thoughts Methods to contest such thoughts
3 Other methods for overcoming warpy thoughts
4 Life Event Stress Relaxation meditation music Pleasant Events Schedule parental style
5 Simple problem solving responses to relationship break-up
Web stats summary
Sessions
Take home points
10487661048766Anxiety disorders are very common
10487661048766Just as fevers these are of different types
10487661048766Accurate Dx and Rx by GP is essential
10487661048766Depression and substance abuse potential
Minimum of six weeks to see Rx effect
Prolonged Rx is necessary 6 m or more
Drug Rx is only a small part of management
SSRI TCAs BZNs MAOIs szlig-blockers etc
CBT Computer treatment VRs Mood GYM
Thank You All Visit us at
wwwdrsarmain
This is sponsored by Torrent ndash
Makers of Clonotril (Clonazepam)
Computer Therapy ndash Softwares
Fearfighter - for phobiapanic
Cope - for depressionanxiety
Balance - for GAD
BTSteps - for OCD
These are PC based in a CD-Rom
or phone based or Web-based
MENTAL OUTSIDE
Virtual Reality - VR
VR therapy via SD (Systematic Desensitization) is becoming very popular
SD is a process of gradually introducing a disturbing stimulus (eg view from a high place) in otherwise pleasant surroundings
This process gradually suppresses the anxiety response
Virtual Reality ndash VR - Advantages
Patients often have difficulty imagining the stimulus themselves
They are often afraid of experiencing it directly ndash which may also be expensive and time-consuming
VR affords patient privacy and confidentiality during treatment
Very good for phobias
Virtual Reality ndash VR - Imagination
ldquoProjection in timerdquo ndash rationally reconstructing the future
ldquoDe-catastrophizing an imagerdquo ndash modifying a disturbing image
ldquoImage modeling and substitutionrdquo ndashinterrupting a negative train of images
ldquoCovert conditioningrdquo ndash subtle conditioning using imagined rather than real stimuli
Virtual Reality ndash VR - Hutchworld
Hutchworld is a virtual community attached to the Hutchison Cancer Research Center
Designed to provide social support for cancer patients and their families
Based on Microsoftrsquos Vworldrsquos system
Mood GYM on the Internet
Few GPs are trained in CBT
Clinical psychologists are expensive
Young people are not easily reached
They may not want them ndash embarrassment
The web is accessible convenient and popular
with young people
Deliver CBT via internet ndash 5 modules
Mood GYM Modules
5 Modules - analysis and results
1 Essentials of CBT with examples and interactive exercises
2 Warpy Thoughts Questionnaire Identifying dysfunctional thoughts Methods to contest such thoughts
3 Other methods for overcoming warpy thoughts
4 Life Event Stress Relaxation meditation music Pleasant Events Schedule parental style
5 Simple problem solving responses to relationship break-up
Web stats summary
Sessions
Take home points
10487661048766Anxiety disorders are very common
10487661048766Just as fevers these are of different types
10487661048766Accurate Dx and Rx by GP is essential
10487661048766Depression and substance abuse potential
Minimum of six weeks to see Rx effect
Prolonged Rx is necessary 6 m or more
Drug Rx is only a small part of management
SSRI TCAs BZNs MAOIs szlig-blockers etc
CBT Computer treatment VRs Mood GYM
Thank You All Visit us at
wwwdrsarmain
This is sponsored by Torrent ndash
Makers of Clonotril (Clonazepam)
MENTAL OUTSIDE
Virtual Reality - VR
VR therapy via SD (Systematic Desensitization) is becoming very popular
SD is a process of gradually introducing a disturbing stimulus (eg view from a high place) in otherwise pleasant surroundings
This process gradually suppresses the anxiety response
Virtual Reality ndash VR - Advantages
Patients often have difficulty imagining the stimulus themselves
They are often afraid of experiencing it directly ndash which may also be expensive and time-consuming
VR affords patient privacy and confidentiality during treatment
Very good for phobias
Virtual Reality ndash VR - Imagination
ldquoProjection in timerdquo ndash rationally reconstructing the future
ldquoDe-catastrophizing an imagerdquo ndash modifying a disturbing image
ldquoImage modeling and substitutionrdquo ndashinterrupting a negative train of images
ldquoCovert conditioningrdquo ndash subtle conditioning using imagined rather than real stimuli
Virtual Reality ndash VR - Hutchworld
Hutchworld is a virtual community attached to the Hutchison Cancer Research Center
Designed to provide social support for cancer patients and their families
Based on Microsoftrsquos Vworldrsquos system
Mood GYM on the Internet
Few GPs are trained in CBT
Clinical psychologists are expensive
Young people are not easily reached
They may not want them ndash embarrassment
The web is accessible convenient and popular
with young people
Deliver CBT via internet ndash 5 modules
Mood GYM Modules
5 Modules - analysis and results
1 Essentials of CBT with examples and interactive exercises
2 Warpy Thoughts Questionnaire Identifying dysfunctional thoughts Methods to contest such thoughts
3 Other methods for overcoming warpy thoughts
4 Life Event Stress Relaxation meditation music Pleasant Events Schedule parental style
5 Simple problem solving responses to relationship break-up
Web stats summary
Sessions
Take home points
10487661048766Anxiety disorders are very common
10487661048766Just as fevers these are of different types
10487661048766Accurate Dx and Rx by GP is essential
10487661048766Depression and substance abuse potential
Minimum of six weeks to see Rx effect
Prolonged Rx is necessary 6 m or more
Drug Rx is only a small part of management
SSRI TCAs BZNs MAOIs szlig-blockers etc
CBT Computer treatment VRs Mood GYM
Thank You All Visit us at
wwwdrsarmain
This is sponsored by Torrent ndash
Makers of Clonotril (Clonazepam)
Virtual Reality - VR
VR therapy via SD (Systematic Desensitization) is becoming very popular
SD is a process of gradually introducing a disturbing stimulus (eg view from a high place) in otherwise pleasant surroundings
This process gradually suppresses the anxiety response
Virtual Reality ndash VR - Advantages
Patients often have difficulty imagining the stimulus themselves
They are often afraid of experiencing it directly ndash which may also be expensive and time-consuming
VR affords patient privacy and confidentiality during treatment
Very good for phobias
Virtual Reality ndash VR - Imagination
ldquoProjection in timerdquo ndash rationally reconstructing the future
ldquoDe-catastrophizing an imagerdquo ndash modifying a disturbing image
ldquoImage modeling and substitutionrdquo ndashinterrupting a negative train of images
ldquoCovert conditioningrdquo ndash subtle conditioning using imagined rather than real stimuli
Virtual Reality ndash VR - Hutchworld
Hutchworld is a virtual community attached to the Hutchison Cancer Research Center
Designed to provide social support for cancer patients and their families
Based on Microsoftrsquos Vworldrsquos system
Mood GYM on the Internet
Few GPs are trained in CBT
Clinical psychologists are expensive
Young people are not easily reached
They may not want them ndash embarrassment
The web is accessible convenient and popular
with young people
Deliver CBT via internet ndash 5 modules
Mood GYM Modules
5 Modules - analysis and results
1 Essentials of CBT with examples and interactive exercises
2 Warpy Thoughts Questionnaire Identifying dysfunctional thoughts Methods to contest such thoughts
3 Other methods for overcoming warpy thoughts
4 Life Event Stress Relaxation meditation music Pleasant Events Schedule parental style
5 Simple problem solving responses to relationship break-up
Web stats summary
Sessions
Take home points
10487661048766Anxiety disorders are very common
10487661048766Just as fevers these are of different types
10487661048766Accurate Dx and Rx by GP is essential
10487661048766Depression and substance abuse potential
Minimum of six weeks to see Rx effect
Prolonged Rx is necessary 6 m or more
Drug Rx is only a small part of management
SSRI TCAs BZNs MAOIs szlig-blockers etc
CBT Computer treatment VRs Mood GYM
Thank You All Visit us at
wwwdrsarmain
This is sponsored by Torrent ndash
Makers of Clonotril (Clonazepam)
Virtual Reality ndash VR - Advantages
Patients often have difficulty imagining the stimulus themselves
They are often afraid of experiencing it directly ndash which may also be expensive and time-consuming
VR affords patient privacy and confidentiality during treatment
Very good for phobias
Virtual Reality ndash VR - Imagination
ldquoProjection in timerdquo ndash rationally reconstructing the future
ldquoDe-catastrophizing an imagerdquo ndash modifying a disturbing image
ldquoImage modeling and substitutionrdquo ndashinterrupting a negative train of images
ldquoCovert conditioningrdquo ndash subtle conditioning using imagined rather than real stimuli
Virtual Reality ndash VR - Hutchworld
Hutchworld is a virtual community attached to the Hutchison Cancer Research Center
Designed to provide social support for cancer patients and their families
Based on Microsoftrsquos Vworldrsquos system
Mood GYM on the Internet
Few GPs are trained in CBT
Clinical psychologists are expensive
Young people are not easily reached
They may not want them ndash embarrassment
The web is accessible convenient and popular
with young people
Deliver CBT via internet ndash 5 modules
Mood GYM Modules
5 Modules - analysis and results
1 Essentials of CBT with examples and interactive exercises
2 Warpy Thoughts Questionnaire Identifying dysfunctional thoughts Methods to contest such thoughts
3 Other methods for overcoming warpy thoughts
4 Life Event Stress Relaxation meditation music Pleasant Events Schedule parental style
5 Simple problem solving responses to relationship break-up
Web stats summary
Sessions
Take home points
10487661048766Anxiety disorders are very common
10487661048766Just as fevers these are of different types
10487661048766Accurate Dx and Rx by GP is essential
10487661048766Depression and substance abuse potential
Minimum of six weeks to see Rx effect
Prolonged Rx is necessary 6 m or more
Drug Rx is only a small part of management
SSRI TCAs BZNs MAOIs szlig-blockers etc
CBT Computer treatment VRs Mood GYM
Thank You All Visit us at
wwwdrsarmain
This is sponsored by Torrent ndash
Makers of Clonotril (Clonazepam)
Virtual Reality ndash VR - Imagination
ldquoProjection in timerdquo ndash rationally reconstructing the future
ldquoDe-catastrophizing an imagerdquo ndash modifying a disturbing image
ldquoImage modeling and substitutionrdquo ndashinterrupting a negative train of images
ldquoCovert conditioningrdquo ndash subtle conditioning using imagined rather than real stimuli
Virtual Reality ndash VR - Hutchworld
Hutchworld is a virtual community attached to the Hutchison Cancer Research Center
Designed to provide social support for cancer patients and their families
Based on Microsoftrsquos Vworldrsquos system
Mood GYM on the Internet
Few GPs are trained in CBT
Clinical psychologists are expensive
Young people are not easily reached
They may not want them ndash embarrassment
The web is accessible convenient and popular
with young people
Deliver CBT via internet ndash 5 modules
Mood GYM Modules
5 Modules - analysis and results
1 Essentials of CBT with examples and interactive exercises
2 Warpy Thoughts Questionnaire Identifying dysfunctional thoughts Methods to contest such thoughts
3 Other methods for overcoming warpy thoughts
4 Life Event Stress Relaxation meditation music Pleasant Events Schedule parental style
5 Simple problem solving responses to relationship break-up
Web stats summary
Sessions
Take home points
10487661048766Anxiety disorders are very common
10487661048766Just as fevers these are of different types
10487661048766Accurate Dx and Rx by GP is essential
10487661048766Depression and substance abuse potential
Minimum of six weeks to see Rx effect
Prolonged Rx is necessary 6 m or more
Drug Rx is only a small part of management
SSRI TCAs BZNs MAOIs szlig-blockers etc
CBT Computer treatment VRs Mood GYM
Thank You All Visit us at
wwwdrsarmain
This is sponsored by Torrent ndash
Makers of Clonotril (Clonazepam)
Virtual Reality ndash VR - Hutchworld
Hutchworld is a virtual community attached to the Hutchison Cancer Research Center
Designed to provide social support for cancer patients and their families
Based on Microsoftrsquos Vworldrsquos system
Mood GYM on the Internet
Few GPs are trained in CBT
Clinical psychologists are expensive
Young people are not easily reached
They may not want them ndash embarrassment
The web is accessible convenient and popular
with young people
Deliver CBT via internet ndash 5 modules
Mood GYM Modules
5 Modules - analysis and results
1 Essentials of CBT with examples and interactive exercises
2 Warpy Thoughts Questionnaire Identifying dysfunctional thoughts Methods to contest such thoughts
3 Other methods for overcoming warpy thoughts
4 Life Event Stress Relaxation meditation music Pleasant Events Schedule parental style
5 Simple problem solving responses to relationship break-up
Web stats summary
Sessions
Take home points
10487661048766Anxiety disorders are very common
10487661048766Just as fevers these are of different types
10487661048766Accurate Dx and Rx by GP is essential
10487661048766Depression and substance abuse potential
Minimum of six weeks to see Rx effect
Prolonged Rx is necessary 6 m or more
Drug Rx is only a small part of management
SSRI TCAs BZNs MAOIs szlig-blockers etc
CBT Computer treatment VRs Mood GYM
Thank You All Visit us at
wwwdrsarmain
This is sponsored by Torrent ndash
Makers of Clonotril (Clonazepam)
Mood GYM on the Internet
Few GPs are trained in CBT
Clinical psychologists are expensive
Young people are not easily reached
They may not want them ndash embarrassment
The web is accessible convenient and popular
with young people
Deliver CBT via internet ndash 5 modules
Mood GYM Modules
5 Modules - analysis and results
1 Essentials of CBT with examples and interactive exercises
2 Warpy Thoughts Questionnaire Identifying dysfunctional thoughts Methods to contest such thoughts
3 Other methods for overcoming warpy thoughts
4 Life Event Stress Relaxation meditation music Pleasant Events Schedule parental style
5 Simple problem solving responses to relationship break-up
Web stats summary
Sessions
Take home points
10487661048766Anxiety disorders are very common
10487661048766Just as fevers these are of different types
10487661048766Accurate Dx and Rx by GP is essential
10487661048766Depression and substance abuse potential
Minimum of six weeks to see Rx effect
Prolonged Rx is necessary 6 m or more
Drug Rx is only a small part of management
SSRI TCAs BZNs MAOIs szlig-blockers etc
CBT Computer treatment VRs Mood GYM
Thank You All Visit us at
wwwdrsarmain
This is sponsored by Torrent ndash
Makers of Clonotril (Clonazepam)
Mood GYM Modules
5 Modules - analysis and results
1 Essentials of CBT with examples and interactive exercises
2 Warpy Thoughts Questionnaire Identifying dysfunctional thoughts Methods to contest such thoughts
3 Other methods for overcoming warpy thoughts
4 Life Event Stress Relaxation meditation music Pleasant Events Schedule parental style
5 Simple problem solving responses to relationship break-up
Web stats summary
Sessions
Take home points
10487661048766Anxiety disorders are very common
10487661048766Just as fevers these are of different types
10487661048766Accurate Dx and Rx by GP is essential
10487661048766Depression and substance abuse potential
Minimum of six weeks to see Rx effect
Prolonged Rx is necessary 6 m or more
Drug Rx is only a small part of management
SSRI TCAs BZNs MAOIs szlig-blockers etc
CBT Computer treatment VRs Mood GYM
Thank You All Visit us at
wwwdrsarmain
This is sponsored by Torrent ndash
Makers of Clonotril (Clonazepam)
Web stats summary
Sessions
Take home points
10487661048766Anxiety disorders are very common
10487661048766Just as fevers these are of different types
10487661048766Accurate Dx and Rx by GP is essential
10487661048766Depression and substance abuse potential
Minimum of six weeks to see Rx effect
Prolonged Rx is necessary 6 m or more
Drug Rx is only a small part of management
SSRI TCAs BZNs MAOIs szlig-blockers etc
CBT Computer treatment VRs Mood GYM
Thank You All Visit us at
wwwdrsarmain
This is sponsored by Torrent ndash
Makers of Clonotril (Clonazepam)
Take home points
10487661048766Anxiety disorders are very common
10487661048766Just as fevers these are of different types
10487661048766Accurate Dx and Rx by GP is essential
10487661048766Depression and substance abuse potential
Minimum of six weeks to see Rx effect
Prolonged Rx is necessary 6 m or more
Drug Rx is only a small part of management
SSRI TCAs BZNs MAOIs szlig-blockers etc
CBT Computer treatment VRs Mood GYM
Thank You All Visit us at
wwwdrsarmain
This is sponsored by Torrent ndash
Makers of Clonotril (Clonazepam)
Thank You All Visit us at
wwwdrsarmain
This is sponsored by Torrent ndash
Makers of Clonotril (Clonazepam)
