PROF. MUHAMMAD RIAZ BHATTI MBBS(K.E.), DPM., RCP&RCS(Dublin), MCCEE (Canada) FRSH(Lond), MRCPsych,(Lond) FRCPsych.,(Lond) Chairperson Academic Department of Psychiatry & Behavioural Sciences, Continental Medical College, Lahore President, Psychiatric Welfare Association Ex-President, Pakistan Psychiatric Society Advisor on Mental Health Government of the Punjab Former Chairperson Academic Department of Psychiatry & Behavioral Sciences, King Edward Medical University/Mayo Hospital, Lahore.
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PROF. MUHAMMAD RIAZ BHATTIMBBS(K.E.), DPM., RCP&RCS(Dublin), MCCEE (Canada)
FRSH(Lond), MRCPsych,(Lond) FRCPsych.,(Lond)
Chairperson Academic Department of Psychiatry & Behavioural Sciences,
Continental Medical College, Lahore
President,Psychiatric Welfare Association
Ex-President, Pakistan Psychiatric SocietyAdvisor on Mental Health Government of the Punjab
Former Chairperson Academic Department of Psychiatry & Behavioral Sciences,
King Edward Medical University/Mayo Hospital, Lahore.
Types of Anxiety Disorders
Generalized Anxiety Disorder
Panic Disorder
Obsessive-Compulsive Disorder
Post-Traumatic Stress Disorder
Phobias
Definition of Anxiety Anxiety is a feeling of apprehension or fear.
The source of this uneasiness is not always
known or recognized, which can add to the
distress you feel.
Anxiety disorders are a group of psychiatric
conditions that involve excessive anxiety.
Anxiety as a Normal & An Abnormal Response
Some amount of anxiety is“normal” and is associated withoptimal levels of functioning.
Only when anxiety begins tointerfere with social oroccupational functioning is itconsidered “abnormal.”
Cardiovascular Effects Increase in heart rate and strength of heartbeat to
speed up blood flow.
Blood is redirected from places it is not needed (skin,
fingers and toes) to places where it is more needed
(large muscle groups like thighs and biceps).
Respiratory Effects-increase in speed and dept of
breathing.
Sweat Gland Effects-increased sweating.
Behavioral System
Fight/flight response prepares the
body for action-to attack or run.
When not possible behaviors such
as foot tapping, pacing, or snapping
at people.
Cognitive System Shift in attention to search surroundings for
potential threat.
Can’t concentrate on daily tasks.
Anxious people complain that they are easily
distracted from daily chores, cannot
concentrate, and have trouble with memory.
Introduction
Generalized anxiety disorder (GAD) is
a chronic disturbance characterized
by excessive worry and apprehension
accompanied by psychic and somatic
symptoms of stress and anxiety.
Generalized Anxiety Disorder: Neurotransmitters
Finding that benzodiazepines provide relief
from anxiety (e.g. valium).
Benzodiazepine receptors ordinarily receive
GABA (gamma-aminobutyric acid).
GABA causes neuron to stop firing (calms
things down).
Symptoms of GAD Worry and apprehension
Muscle tension
Autonomic over activity
Psychological arousal
Sleep disturbance
OTHER FEATURES
Depression
Obsessions
depersonalization
Clinical signs Face appears strained, the brow is furrowed, and
posture is tense.
Person is restless and may tremble.
The skin is pale and sweating is common.
Readiness to tears which reflects the generallyapprehensive state.
Important messages to share with people with Generalized Anxiety Disorder
Anxiety disorders are common chronic the cause of considerable distress and disability often unrecognized and untreated
If left untreated they are costly to both the individual and society.
A range of effective interventions is available to treat anxiety disorders, including medication, psychological therapies and self-help.
NICE: Clinical Guidelines for the Management of Anxiety. Management of anxiety (panic disorder, with or without agoraphobia, and generalised
anxiety disorder) in adults in primary, secondary and community care
Treatment
The most effective treatment of GAD isprobably one that combinepsychotherapeutic, pharmacotherapeutic,and supportive approaches.
Psychotherapy:
The major approaches to GAD are CBT,supportive therapy and insight orientedtherapy
Cognitive Behavioral Therapy This treatment combines relaxation with
cognitive procedures designed to helppatient to control worrying thoughts.
CBT in the optimal range of duration (16–20 hours in total) should be offered.
It has following stages:
1. Ask patient to keep a diary record of:
The frequency and severity of symptoms
The situations in which they occur
Avoidance behavior
CBT cont:2. Provide information about the physiology of anxiety
and other matters that correct misconceptions.
3. Explanation of the various vicious circles of anxiety.
4. Relaxation training as a means of controlling of anxiety.
5. Graded exposure to situations that provoke anxiety
6. Distraction to reduce the impact of anxiety provoking thoughts.
Psychotherapy cont:
Supportive therapy offers patients reassurance
and comfort, although its long term efficacy is
doubtful.
Insight-orientated psychotherapy focuses on
uncovering unconscious conflicts and identify
ego strengths
Pharmacotherapy Placebo response rate with GAD is about 40%
(Fossey and Lydiard, 1990).
Because of the long term nature of the disorder, a treatment plan must be carefully thought out.
Drug treatment of GAD is sometimes seen as a 6 to 12 months treatment, some evidence indicates that treatment should be long term, perhaps life long.
About 25% of patients relapse in the first month after the discontinuation of therapy and 60 to 80% relapse over the course of next year.
Pharmacotherapy cont:
Three major drug groups to be considered for the treatment of GAD
Benzodiazepines
Antidepressants
Buspirone
Others e.g. beta blockers
What is Phobia?
Irrational Fear
Avoidance
Anticipatory Anxiety
Phobic Disorders:
Phobias
1. Specific phobias
2. Social phobia
3. Agoraphobia
Phobias: Disruptive fear of a particular object or
situation Fear out of proportion to actual threat
Awareness that fear is excessive
Must be severe enough to cause distress or interfere with job or social life Avoidance
Two types: Specific
Social
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Specific Phobia: Social and Cultural Factors
Predominantly female
Unacceptable in cultures around the
world for men to express fears.
Specific Phobia: Treatment
Exposure Treatment
Systematic Desensitization
Social Phobia
Fearful Apprehension
Social Situations
Social Phobia General characteristics:
Fear of being in social situations inwhich one will be embarrassed or humiliated.
Social Phobia/Anxiety
Common anxiety provoking social situations include: public speaking talking with people in authority dating and developing close relationships making a phone call or answering the phone interviewing attending and participating in class speaking with strangers meeting new people eating, drinking, or writing in public using public bathrooms driving shopping
Social Phobia Interaction of psychosocial and biological causal
factors
Genetic and temperamental factors
Perceptions of uncontrollability
Cognitive variables
Social Phobia Persistent, intense fear of social situations. Fear of negative evaluation or scrutiny.
More intense and extensive than shynessMore appropriate diagnostic label?
Social anxiety disorder
Exposure to trigger leads to anxiety about beinghumiliated or embarrassed socially.
Onset often adolescence.
Diagnosed as either generalized or specific.
33% also diagnosed with Avoidant PersonalityDisorder.Overlap in genetic vulnerability for both disorders.
Social Phobia: Prevalence
13% of the general population.
About equally distributed in males and females,
however, males more often seek treatment .
Usually begins around age 15.
Equally distributed among ethnic groups.
Social Phobia: TreatmentCognitive-Behavioral Therapy
Assess which social situations
are problematic.
Assess their behavior in these
situations.
Assess their thoughts in these
situations.
Teaches more effective
strategies.
Rehearse or role play feared
social situations in a group
setting.
Medication
Tricyclic antidepressants
Monoamine oxidase inhibitors
SSRI (Paxil) approved for
treatment.
Relapse is common with
medications are discontinued.
Panic Disorder With and Without Agoraphobia
Panic Disorder
Panic versus Anxiety
Agoraphobia
Agoraphobia without Panic
Panic Disorder The abrupt onset of an episode of intense fear or
discomfort, which peaks in approximately 10 minutes, and
includes at least four of the following symptoms:
• A feeling of imminent danger
or doom
• The need to escape
• Palpitations
• Sweating
• Trembling
• Shortness of breath or a
smothering
feeling
• A feeling of choking
• Chest pain or discomfort
• Nausea or abdominal
discomfort
• Dizziness or lightheadedness
• A sense of things being
unreal,
depersonalization
• A fear of losing control or
"going crazy"
• A fear of dying
• Tingling sensations
• Chills or hot flushes
TREATMENTS
Drugs:(Davison & Neale, 1998)
Benzodiazepines:
example: alprazolam
these have been found to have some success, but must becontinued otherwise symptoms will return if stopped
However, studies show that these have less long lastingeffects on patients than cognitive-behavioral treatments(Brown & Barlow, 1995).
TREATMENTS- continued Tricyclic antidepressants:(Chambless & Goldstein,
1982)
antidepressants block spontaneous panic attacks.
as of 1982, the FDA had not accepted panic attacks as anindication for antidepressants
Example: imipramine (Mavissakalian, 1992).
dosage should be carefully monitored since panic disorderpatients are sometimes very sensitive to drug use (Swinson,1992).
Along with use of this drug, persuasion, support, or minortranquilizers are often required to help extinguishanticipatory anxiety.
TREATMENTS- continued Systematic desensitization: (Chambless &
Goldstein, 1982)
patients are trained in muscular relaxation
they gradually move up a hierarchy of anxiety arousingsituations while remaining relaxed.
Either imagination or in vivo can be used.
in vivo tends to be most successful.
Flooding:(Chambless & Goldstein, 1982)
maximize anxiety throughout treatment.
this leads to extinction.
TREATMENTS- continued Self-management Procedure: (Jacobson and
Hollon, 1996)
a combination of flooding followed by self-observation.
this is more effective than any single treatment.
a viable alternative to drugs.
Relaxation Training (Barlow, 1988)
combination of cognitive and behavioral intervention andexposure to internal cues that trigger panic.
After two years, this was shown to have great success.
Treating Panic Disorder and Agoraphobia
Medications
Behavioral and cognitive-
behavioral treatments
Range of Mood and Emotion
severe mania
mild to moderate mania (hypomania)
normal-balanced mood
mild to moderate depression
severe depression
Depressive Disorders
Major Depressive Disorder (single, recurrent)
Dysthymic Disorder
Double Depression
Major Depressive Disorder: Diagnostic Criteria
5 of following symptoms, must include one of first
• Poor concentration of difficulties making decision
• Feelings of hopelessness
C. Present for two year period (one year in children and adolescents)
D. No evidence of a Major Depressive Episode during the first two years (one year for
children)
E. No manic or hypomanic episode
F. No chronic psychotic disorder
G. Not related to organic factors
Manic Episode: Diagnostic CriteriaA. A distinct period of abnormally and persistently elevated, expansive,
or irritable mood.B. Mood disturbance plus three of the following symptoms (four if the
mood is only irritable): Inflated self esteem or grandiosity Decreased need for sleep More talkative than usual or pressure to keep talking Flight of ideas, or racing thoughts Distractibility Increase in goal directed activity Excessive involvement in pleasurable activitiesC. Marked impairmentD. No psychosisE. Not organic
Rate of suicide is increasing in adolescents and elderly
Males are more likely to commit suicide
Females are more likely to attempt suicide (except China)
Suicide: A Sociological TypologyEmile Durkeim
Formalized or altruistic suicide
Egoistic suicide
Anomic suicides
Fatalistic suicide
Sanctioned suicide
Disintegration of social support
Major disruption
Loss of control of one’s destiny (mass suicide’s)
5 Myths and Facts About Suicide
Myth #1:
People who talk about killing themselves rarely commit suicide.
Fact:
Most people who commit suicide have given some verbal clues or warnings of their intentions
5 Myths and Facts About SuicideMyth #2:
The suicidal person wants to die and feels there is no turning back.
Fact:
Suicidal people are usually ambivalent about dying; they may desperately want to live but can not see alternatives to problems.
5 Myths and Facts About SuicideMyth # 3:
If you ask someone about their suicidal intentions, you will only encourage them to kill themselves.
Fact:
The opposite is true. Asking lowers their anxiety and helps deter suicidal behavior. Discussion of suicidal feelings allow for accurate risk assessment.
5 Myths and Facts About SuicideMyth # 4:
All suicidal people are deeply depressed.
Fact:
Although depression is usually associated with depression, not all suicidal people are obviously depressed. Once they make the decision, they may appear happier/carefree.
5 Myths and Facts About Suicide
Myths # 5:
Suicidal people rarely seek medical attention.
Fact:
75% of suicidal individuals will visit a physician within the month before they kill themselves.
