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Anxiety DisorderAnxiety DisorderTazeen Arif
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Anxiety Disorders
AnxietyDiffuse, unpleasant, sense of apprehensionaccompanied by autonomic symptoms to athreat that is unknown, vague and conflictual
Normal if Less severe, shorter duration, adaptive
response, no suffering, improve performanceand needs no treatment
Fear
As anxiety, alerting symptom but to known,external threat
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Anxiety Disorders
- Most prevalent psychiatric disorder
- Produce inordinate morbidity
- Use health services
- Produce impairment
- Must be treated
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Anxiety Disorders
1- Panic disorder and agoraphobia
2- Social and specific phobia
3- Obsessive compulsive disorder
4- Posttraumatic stress disorder and
Acute stress reaction
5- Generalized anxiety disorder
6- Other anxiety disorders
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Anxiety Disorders( Etiology )
1- Psychoanalytical theoriesAnxiety result from psychic conflict betweensexual or aggressive wishes and threats fromexternal reality
2- Behavioral theories
- Classical conditioning
- Social learning theory: patients learn to respondexcessively to stress e.g through modeling
3- Cognitive theories
- Patients misperceive situations as dangerouswhen they are not.
- Overestimation of danger or harm andunderestimation of their abilities
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Anxiety Disorders( Etiology )
4- Biological
A- Autonomic nervous system
Increased Sympathetic tone
B- Neurotransmitters
Dysregulation of monoamines e.g nor
epinephrine and serotonin.
- GABA
C- +ve link between streptococcalinfections and OCD
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Anxiety Disorders( Etiology )
D- Brain imaging studies
- CT ,MRI
Cerebral asymmetries
-PE
T,S
PECT
,EEG
Abnormalities in frontal, temporal and
occipital lobes
E- Genetics
Higher incidence in relatives indicate
positive genetic factors
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1- Panic disorderand agoraphobia
Definitions
Panic disorder
Spontaneous, unexpected occurrence of panicattacks
Panic attacks
Discrete periods of intense fear or discomfort,occurring over a short period develop abruptlyand reach a peak within 10 minutes not related tospecific situation or object that can vary fromonce/ day to few attacks / year
Agoraphobia
Fear of being alone in public places especially inplaces in which rapid exit is difficult
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Life time prevalence: 1-5%
Sex: Female: male = 3:1
Age: young adulthood( before 30 years)
Co morbidity = 90%
- Agoraphobia
- Depression
- Other anxiety disorders
- Other psychiatric disorders asHypochondriasis, personality disorders,substance abuse especially alcohol
Epidemiology
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- Commonly presents to the Emergency room
complain of somatic concern of death fromcardiac or respiratory problem
- 1st attack usually spontaneous, may be
precipitated by caffeine, alcohol, nicotine,
sleep exertion, unusual sleep pattern
- Onset: sudden
- Course: rapidly progress within 10 minutes
- In-between attacks : patient has anticipatory
anxiety
- +/- Associated symptoms: Depression, suicide,
substance intake, other anxiety disorder
Clinical picture ofpanic attack
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A discrete period of intense fear or discomfort inwhich 4 or more symptoms are present
Mental Symptoms
1- Fear of dying ( can't name source of fear )
2- Fear of losing control or going crazy
3- Depersonalization( detachment from self) andderealization (feeling of unreality)
Neurological symptoms
4- Parasthesia ( numbness or tingling sensation)5- Feeling dizzy, unsteady, or faint
6- Trembling or shaking
DSM IV Criteria ofpanic attack
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Physical symptoms
7- Palpitation, pounding heart, accelerated heartrate
8- Dyspnea and chest pain9- Chills or hot flushes
10- Sweating
11- Nausea or abdominal distress
12- feeling of choking
DSM IV Criteria ofpanic attack
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A- Both 1 and 2
1- Recurrent unexpected panic attacks
2- at least one attack followed 1 month by at least
1 of the following ( anticipatory anxiety)i- Concern about having additional attacks
ii- Worry about the consequences
iii- a significant change in behavior related to theattacks
B- +/- Agoraphobia
DSM IV Criteria ofpanic disorder
with or without agoraphobia
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C- The panic attacks are not due to direct
physiological effect of substance or
general medical condition
D- The panic attacks are not due to other
mental disorder
E- Frequency
Moderate = 3 attacks/ 3 weeks
Severe = 4 attacks/4 weeks
DSM IV Criteria ofpanic disorder
with or without agoraphobia
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A- Anxiety about being in place or situation ( busystreets, closed spaces, crowded stores ) fromwhich escape may be difficult or in which helpmay not be available
B- The situations are avoided, done with anxiety, orrequire the presence of a companion
C- The anxiety is not due to substance, generalmedical condition, or other mental disorder
D- Complications: Psychosocial consequences
DSM IV Criteria of agoraphobia
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Medical disorders1- Cardiovascular disorder
Angina, mitral valve prolapse, myocardialinfarction, hypertension, cardiac
dysrhythmias
2- Pulmonary diseases
Bronchial asthma, pulmonary embolus
3- Neurological disease
Migraine, temporal lobe epilepsy, multiplesclerosis, transient ischemic attack
Differential diagnosis
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4- Endocrinal disordersHypoglycemia( insulinomas),pheochromocytoma, diabetes, hyperthyroid,hypo parathyroid
5- Drug intoxication
Amphetamines, hallucinogens, theophylline,nicotine, cannabis, caffeine
6- Drug withdrawal
Alcohol, sedatives hypnotics, antihypertensive
7- Psychiatric disorders
Malingering, hypochondriasis, specific and socialphobia
Differential diagnosis
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Workup to assess
Thyroid
Parathyroid
AdrenalSubstance intake
Chest X- ray
ECG
Cardiac enzymes
EEG
MRI
Investigations
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Duration of therapy= 8-12 months
Combined pharmacotherapy+ Psychotherapy
I) Pharmacotherapy
A- Selective Serotonin Reuptake Inhibitor( SSRI)
Best approved for panic is paroxetine
Dose= 5-10 mg and titrate up to 20-60 mg/day2nd choice is fluvoxamine or sertraline
B- Tricyclic Antidepressant (TCA)
Clomipramine( anafranil) or imiprammine ( tofranil)( 100-150 mg/day)
Less widely used d.t side effects
Treatment
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C- Benzodiazepines (BDZ)Given only 4- 6 weeks
Advantage: rapid onset of action
Mostly used is Alprazolam( Xanax)
D- Non benzodiazepines
Buspirone ( 10 mg /day )
E- Beta blockers
Propranolol 10 mg tablet, up to 30 mg/day.
Treatment
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II) Psychotherapy
A- Cognitive therapyAim: Change false beliefs and information about panicattacks
- Patient's of bodily sensation as indicating impendingdeath
- Explain that when panic attack occurs it is time limitedand not life threatening
B- Behavioral therapy
- Applied relaxation
Aim: Instill in patients a sense of control over theirlevels of anxiety
- Respiratory training
Train patient to control urge to hyperventillation
C- Supportive psychotherapy to assure the patient
D- patient education
E- Environmental and societal manipulation
Treatment
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2- Specific Phobiaand Social PhobiaDefinitions
Phobia
Fear of a specific object, circumstances, or
situation that is excessive, irrational result in
avoidance of the feared object
Social Phobia (Social Anxiety Disorder)
Excessive fears of humiliation or embarrassment
in various social settings e.g Speaking in public
Specific Phobia
Marked and persistent fear that is excessive andunreasonable, cued by the presence of specific
object or situation
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Epidemiology
- Most common mental disorder = 5-10% up to
25%
- Sex: Female > Male- Age: Teenagers can occur in childhood
- In specific Phobia, most common feared object:
Animals, storms, Heights, illness, injury, and
death
Co morbidity
- Other anxiety disorder
- Mood disorders esp. depression
- Substance related disorders( i.e way to cope )- Bulimia nervosa
- Avoidant personality disorder
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Clinical picture
A- intense fear of an object or situation .The fearis:
- Out of proportion with the situation
- Cannot be reasoned or explained
- Is beyond voluntary control
- Leads to avoidance
B- Psychological symptoms
Fear, anticipatory anxiety
C- Pysiological, somatic symptoms
Autonomic manifestations on exposure to theobject, palpitation, sweating, trembling, drymouth, breathing difficulty, hot flushes,numbnessetc
D- Behavioral
Avoidance
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Other forms of specific phobia
- Agoraphobia: fear of open spaces
- Claustrophobia: fear of closed spaces
- Acrophobia : fear of heights
- Nosophobia: fear of illness
- Xantophobia: fear of death
-Zoophobia: fear of animals
- Fear of blood injection injury
- School phobia
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Clinical picture of social phobia
Fear of social situations in which:
- Fear of being the focus of attention or being
negative evaluated in social situations
- The affected patient is exposed to the gaze of
others, is being criticized by others , or has to talk
in front of others
- Fear of doing something embarrassing
- Social situations are avoided
- Patient develops intense anxiety with autonomic
manifestations on exposure to the phobic
situations
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Psychotherapy and pharmacotherapy
I- Behavioral therapy
A- Systemic desensitization
The patient is exposed serially to apredetermined list of anxiety provoking stimuliunder relaxation, hypnosis, or tranquilizingdrugs
B- Flooding ( in vivo or imaginary )
C- Relaxation techniques and breathingexercises
D- Rehearsal during sessions
E- Homework assignments
F-
social skill training in social phobia
Treatment
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II-Cognitive therapy
Correct cognitive distortion
III- social and environmental manipulations
IV- PharmacotherapyA-1st line= SSRI( fluoxetine, citalopram, sertraline,
fluvoxamine, paroxetine).
-Other approved (TCA,SNRI)
B- Initial BDZ, alprazolam ( Xanax 0.25-0.5mg) 1 to2 tab./day, then taper after 4-6 weeks
C- Beta blockers esp. if associated with panicattacks e.g propranolol( Inderal 10 mg/day): upto 30 mg/day.
Treatment
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3-Obsessive compulsive disorder
Definition
Recurrent occurrence of obsessions andcompulsions severe to cause marked distress tothe person
Obsessions is a mental event
Compulsion is a behavior
Epidemiology
- Life time prevalence:2-3 %
- 4th common psychiatric diagnosis
- Mean age:25 years
- Sex: equal
- More in single person
Co morbidity
- 2/3 has major depressive disoder, alcohol use
- Other anxiety disorders: Social phobia, GAD
- Tics
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Obsessions1- Recurrent and persistent thoughts,
impulses, or images that areexperienced as intrusive andinappropriate causing markedanxiety or distress
2- they are not simply excessiveworries
3- The person tries to neutralize themwith some thought or action
4- the person realizes that thesethoughts are the product of his mind
Clinical features
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Compulsions1- Repetitive behaviors, or mental acts that
person feels driven to perform them
2- Aimed to relieve anxiety
Obsessions and compulsions are excessive,
unreasonable, time consuming, and
significantly interferes with the patient
routine and function
Specify: if with poor insight
Clinical features
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1- Contamination
CommonestFollowed by washing or avoidance of contaminatedobject
2- Pathological doubt
Followed by compulsion of checking
3- Intrusive thoughts
Usually sexual or aggressive
May report themselves to police
4- Symmetry
Result in compulsive of slowness
5- Others
Religious obsessions
Compulsions of hoarding
Depression, psychosocial factors, insight
Symptom patterns
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1- Hospitalize
Remove external stressors, ECT, depressed, andsuicidal risk
2- Pharmacotherapy +Behavioral therapy
a- SSRI orTCA + behavioral therapy ( 12 weeks )
b- AnotherSSRI orTCA +Behavioral therapy (12weeks)
c- Combine 2 SSRI or (SSRI +TCA) +Behavioral
therapy ( 12 weeks )
d- Augment ( Valproate , Lithium , or
Carbamazepine)e- ECT
f- Surgery ( Cingulotomy )
Treatment
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3- Psychotherapy
A- Behavioral therapy
- Exposure and response prevention
- Desensitization- Thought stoppage
- Implosion therapy
- Aversion conditioning
B- Family therapy
C- Supportive therapy
D- Group therapy
Treatment
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DefinitionSyndrome occurs to person when sees ,involved in, or hears of an extreme traumaticstress
Epidemiology- Prevalence
30% in traumatic event
25 % sub clinical form
- Women > Men
- Age: young adults- High risk : Severe trauma, long duration,high proximity of person to the actualtrauma, stressful life changes, 1st degreerelatives have depression, inadequate family
support
4- Posttraumatic stress disorder ( PTSD )and acute stress reaction
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A- A person has been exposed to a traumaticevent in which both of the following werepresent
1- Experience, witnessed or confronted with anevent involved actual death or serious injurye.g torture, wars, rape, and brain washing
2- Person's has intense fear, helplessness, orhorror
B- Re-experience of the traumatic event
1- Distressing images, thoughts or perceptions
2- Distressing dreams
3- Flashbacks
4- Psychological distress on exposure to internal
or external cues5- Physiological distress on exposure to internal
or external cues
Clinical features (1 Month)
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C- Avoidance of stimuli associated with the trauma
1- Avoidance of thoughts, feelings or conversation
associated with the trauma2- Avoidance of activities, places, or people that
arouse recollection of the trauma
3- inability to recall important aspect of the trauma
4-diminished interest in activities
5- Feeling of detachment from others
6- unable to have lovely feelings7- Sense of foreshortened future
D- Hyper arousal
1- Difficulty in falling asleep
2- Irritability or outbursts of anger
3- Difficult concentration4- Hyper vigilance
5- Exaggerated startle response
Acute stress reaction = Less than one month
Clinical features ( cont. )
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I- Prophylaxis
Aim: Develop more mature copingmechanisms and acceptance of theevent through psychotherapy
- Crisis intervention
- Education and support
II- Hospitalize if
Symptoms are severe, suicide, orviolence
III- Psychotherapy ( individual or group )
A- Exposure therapy
B- Stress management ( Relaxationtechniques, cognitive approaches )
Treatment
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C- Support through relatives and friends
D- Abreaction- Experiencing the emotionsassociated with event
IV- Pharmacotherapy (duration = 1 year)
A- Induction of sleep by sedative hypnotics butno more than 1 month
B- SSRI -Sertraline, paroxetine
Or TCA as imipramine or amitriptyline
Dose = antidepressant dose
Each trial = 8 weeks
C- Others as alpha agonist and beta blockers
Treatment
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DefinitionChronic condition characterized bysubjective experience of apprehensionwithout objective reasons, excessiveanxiety and worry about several events
or activities can't be controlled for mostof the day
Epidemiology
Common = 3-8 %
Female : Male = 2:1
25% ofGAD in anxiety clinics
5- Generalized anxiety disorder
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- Somatic symptoms( cardiopulmonary
symptoms, easy fatigability, restlessness,
shakiness, GIT symptoms, tension headache,
muscle pain, parathesia and hyperreflexia)
- Psychological,anxiety difficult to control ( worry,
apprehension, fear, sense of insecurity,irritable, restless, hypersenstivity, easy loss of
temper,and breaking down in tears)
- Autonomic hyperactivity ( pallor or flushing,
blurred vision, dry mouth, sweating,palpitation)
- Cognitive symptoms ( irritable, difficult
concentration, difficult recall )
Clinical picture ( 6 months duration)
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Combined pharmacotherapy andPsychotherapy
A- Psychotherapy
- Cognitive behavioral therapy
- Environmental and social manipulation
- Biofeedback training
- Encourage patient to engage inpleasurable activities
Treatment
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B- Pharmacotherapy
Duration = 6-12 months
1- benzodiazepine
Not more than 1 month
2- Buspirone
Non BDZ anxiolytic
3- SSRI( Fluvoxamine, Sertraline,
Escitalopram, Paroxetine, Fluoxetine)
4- SNRI (Venlafaxine ) for cognitive
impairment and insomnia
Treatment