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Anxiety Disorders

Dr. Yousif A. Yaseen Psychiatrist College of Medicine - University of Duhok 2016-2017

What is Anxiety? According to Kaplan and Sadock

Anxiety is : “a diffuse, unpleasant, vague sense of apprehension, often accompanied by autonomic symptoms such as headache, perspiration, palpitations, tightness in the chest, mild stomach discomfort, and restlessness, as indicated by an inability to sit or stand still for long.”

Fear, Anxiety and Worry

Normal emotional responses Clear adaptive purpose

Pathological Anxiety

Anxiety that is excessive, persistent, easily triggered.Degree of the person’s fear is out-of-proportion to actual danger.Disrupts the person’s life and functioning.Creates intense discomfort.Doesn’t respond to rational reassurance.in pathological anxiety, attention is focused also on the person's response to the threat.

So, in Anxiety Disorders,

the normal responses become: excessive, persistent, easily triggered, and disruptive to the person’s life.

Three Components of Anxiety

Physical Psychological (Cognition and Emotion) Behaviours

The Physical Component

Autonomic hyperactivity: Flushing and pallor Tachycardia, palpitation Sweating Cold hands Diarrhea Dry mouth (xerostomia) Urinary frequency Blurred Vision
Trembling, twitching ,Shaking Dizziness Numbness/Tingling Backache, headache Muscle tension Shortness of breath, hyperventilation Fatigability Startle response Difficulty swallowing

The Psychological Component

Anxious Thoughts Anxious Predictions Anxious Beliefs and Interpretations Difficulty in Attention and Memory Indecissiveness Mental Images Unreality/Detachment Hypervigilance Insomnia Decreased libido Lump in the throat

The Behavioral Component

Avoidance of Situations and Activities Subtle Avoidance Strategies, Safety Signals, and Overprotective Behaviours Alcohol, Drug, and Medication Use

Anxiety Disorders

Generalized anxiety disorder (GAD) Social Phobia ( Social Anxiety Disorder) Agoraphobia Specific Phobia Panic disorder Separation Anxiety Disorder Selective Mutism

Anxiety disorders

Continuous anxiety
Episodic anxiety
In defined situation
In any situation
Panic disorder
Phobias
Simple phobia
Social phobia
Agoraphobia
Generalized anxiety disorder
Separation
Mutism


Epidemiology
Overall, anxiety disorders are among the most prevalent of psychiatric disorders. Age; Earlier onset than depression Sex factor; More in females Frequency (Prevalence): 10-15% of general population 25% (life time prevalence) Strong genetic component

Shared features of Anxiety Disorders

Substantial proportion of aetiology is stress related. Difference with Psychosis - free of delusions and hallucinations !, good insight - Reality testing is intact. Symptoms are ego dystonic (distressing) Disorders are enduring or recurrent. Demonstrable organic factors are absent Note: Hierarchy of Diagnosis Precedence: Organic > Psychosis > Depression > Anxiety

Risk Factors/Etiology

Psychodynamic Theory posits that anxiety occurs when instinctual drives arc thwarted (dissatisfied). Anxiety is a signal that the ego is having a hard time mediating between reality, id and superego. ,.Different anxiety disorders are the result of different defense mechanisms used to cope. Attachment Theories : Bowlby = “anxious attachment”Behavioral Theory anxiety is a conditional response to specific environmental stimuli followed by its generalization, displacement, or transference. It may be learned through identification and imitation of anxiety pattern in parents (social learning theory).

Cognitive approach Selective attention and catastrophic thinking: Cognitive Appraisal (perceive threat)Stimulus--->Appraisal---> Response Albert Ellis identified basic irrational assumptions: e.g.. It is necessary for humans to be loved by everyone Aaron Beck :Those with GAD hold unrealistic silent assumptions that imply imminent danger: e.g., Any strange situation is dangerous Biologic Theories: implicate various neurotransmitters (especially: ↓ gamma-aminobutyric acid [GABA], & serotonin, ↑ norepinephrine & dopamine, and various CNS structures (elevated responsiveness in the amygdala, part of the fear circuit of the limbic system limbic system) HPA axis dys-regulation, in addition to Genetic Component. Other Theories: Social (Stressful events & lack of support network) and personality factors (e.g., avoidant, perfectionist

Treatment of Anxiety Disorders

The combination of pharmacologic therapy and psychotherapy is the most successful form of treatment.

I. Pharmacotherapy of Anxiety Disorders:

,Fluoxetine

A. Antidepressants

Tricyclic and related antidepressants (TCA) E.g. amitriptyline, imipramine, , Clomipramine , Nortriptyline doxepin, mianserin, trazodone. Selective serotonin reuptake inhibitors (SSRI) E.g. fluoxetine, paroxetine, sertraline, citalopram, escitalopram, fluvoxamine Monoamine-oxidase inhibitors (MAOI) E.g. moclobemide, phenelzine, isocarboxazid, tranylcypromine Other antidepressants E.g. mirtazapine, venlafaxine, duloxetine

B. Benzodiazepines Antianxiety drugs- Anxiolytics

Commonly & widely used Very effective Chosen based on onset of action, potency, side effects Ativan (lorazepam): most common Xanax (alprazolam): high risk of addiction Valium (diazepam)

II. Non-Drug Approaches to Anxiety

A. General measures: 1. Patients should stop drinking coffee and other caffeinated beverages, and avoid excessive alcohol consumption. 2. Patients should get adequate sleep, with the use of medication if necessary. Moderate exercise each day may help reduce the intensity of anxiety symptoms.

B. Psychotherapy a. Cognitive behavioral therapy, with emphasis on misinterpretation of physiologic symptoms, may improve functioning in mild cases. b. Behavioral therapy: - Exposure and response prevention - Systemic desensitization - flooding c. Supportive or insight oriented psychotherapy can be helpful in mild cases of anxiety. d. Other Psychological managements Education about nature of disorder Structured problem solving (Coping skills) Graded exposure to difficult situations Support (guidance, advice, development of coping strategies) Counseling Stress management (relaxation techniques , meditation, Yoga, exercise regimens that improve stress recovery)

Generalized Anxiety Disorder

Generalized anxiety disorder (GAD) is the most common of the anxiety disorders. It is characterized by unrealistic or excessive anxiety and worry about two or more life circumstances for at least six months.

Diagnosis of Generalized Anxiety Disorder

Excessive anxiety or worry is present most days during at least a six-month period and involves a number of life events. The anxiety is difficult to control. At least three of the following: 1. Restlessness or feeling on edge. 2. Easy fatigability. 3. Difficulty concentrating. 4. Irritability. 5. Muscle tension. 6. Sleep disturbance.

Clinical Features of Generalized Anxiety Disorder

A. Other features often include insomnia, irritability, trembling, muscle aches and soreness, muscle twitches, clammy hands, dry mouth, and a heightened startle reflex. Patients may also report palpitations, dizziness, difficulty breathing, urinary frequency, dysphagia, light-headedness, abdominal pain, and diarrhea.B. Patients often complain that they “can't stop worrying,” which may revolve around valid concerns about money, jobs, marriage, health, and the safety of children.

Epidemiology

A. Lifetime prevalence is 5%. B. The female-to-male sex ratio for GAD is 2:1. C. Most patients report excessive anxiety during childhood or adolescence; however, onset after age 20 may sometimes occur.

Course and prognosis

Course is chronic; symptoms may diminish as the patient get older. With time, secondary depression may develop. This is not uncommon if the condition is left untreated.

Treatment of Generalized Anxiety Disorder

The combination of pharmacologic therapy and psychotherapy is the most successful form of treatment.

I. Pharmacotherapy of Generalized Anxiety Disorder:

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,Fluoxetine

II. Non-Drug Approaches to Anxiety

1. Patients should stop drinking coffee and other caffeinated beverages, and avoid excessive alcohol consumption. 2. Patients should get adequate sleep, with the use of medication if necessary. Moderate exercise each day may help reduce the intensity of anxiety symptoms. 3. Psychotherapy a. Cognitive behavioral therapy, b. Supportive or insight oriented psychotherapy
4.Other Psychological managements: like Stress management

Panic Disorder

Patients with panic disorder report discrete periods of intense terror and fear of impending doom, which are almost intolerable

Diagnosis for Panic Disorder

Recurrent unexpected panic attacks occur, during which four of the following symptoms begin abruptly and reach a peak within 10 minutes in the presence of intense fear: a. Palpitations, increased heart rate. b. Sweating. c. Trembling or shaking. d. Sensation of shortness of breath. e. Feeling of choking. f. Chest pain or discomfort. g. Nausea or abdominal distress. h. Feeling dizzy, lightheaded or faint. i. Derealization or depersonalization. j. Fear of losing control or going crazy. k. Fear of dying. l. Paresthesias. m. Chills or hot flushes. 2. At least one of the attacks has been followed by one month of one of the following: A. Persistent concern about having additional attacks or Worry about the implications of the attack, such as fear of having a heart attack or going crazy. B. A significant change in behavior related to the attacks.

Clinical Features of Panic Disorder

A. Patients often believe that they have a serious medical condition. Marked anxiety about having future panic attacks (anticipatory anxiety) is common. B. In agoraphobia, the most common fears are of being outside alone or of being in crowds or traveling. The first panic attack often occurs without an acute stressor or warning. Later in the disorder, panic attacks may occur in relation to specific situations, and phobic avoidance to these situations can occur. C. Major Depression occurs in over fifty percent of patients. Agoraphobia may develop in patients with simple panic attacks. Elevation of blood pressure an tachycardia may occur during a panic attack.

Epidemiology of Panic Disorder

A. The lifetime prevalence of panic disorder is between 1.5% and 3.5%. The female-to-male ratio is 3:1. Up to one-half of panic disorder patients have agoraphobia. B. Panic disorder usually develops in early adulthood with a peak onset in the mid twenties. Onset after age 45 years is unusual. C. The suicide risk is markedly increased, especially in untreated patients. Substance abuse, especially of alcohol, may occur in up to 40% of patients.

Treatment of Panic Disorder

Mild cases of panic disorder can be effectively treated with cognitive behavioral psychotherapy with an emphasis on relaxation and instruction on misinterpretation of physiologic symptoms. B. Pharmacotherapy is indicated when patients have marked distress from panic attacks or are experiencing impairment in work or social functioning. 1. SSRI=Serotonin-specific reuptake inhibitors and tricyclic antidepressants are most often used. 2. Benzodiazepines may be used adjunctively with TCAs or SSRIs during the first few weeks of treatment 3. Monoamine oxidase inhibitors (MAOIs) may be the most effective agents available for panic disorder, but these agents are not often used because of concern over hypertensive crisis. 4. Buspirone (BuSpar) is not effective for panic disorder. 5. Medication should be combined with cognitive behavioral therapy for optimal outcome.

What is Phobia?

An extreme, irrational fear of a specific object or situation that the person trying to avoid.

Phobias

General characteristics of phobias Fear sensations Avoidance behavior Cognitive recognition that the fear is out of proportion to the stimulus

Agoraphobia


Agoraphobia
The presence of agoraphobia that has the following three components: 1. Anxiety about being in places or situations where escape might be difficult or embarrassing, or in which help might not be available. 2. Situations are avoided or endured with marked distress, or these situations are endured with anxiety about developing panic symptoms, or these situations require the presence of a companion. 3. The anxiety is not better accounted for by another disorder, such as social phobia, where phobic avoidance is only limited to social situations.

Agoraphobia

Literally fear of market place or open spaces Anxiety about being in situations from which escape might be difficult Often secondary to panic attacks Avoided situations include: driving, bridges, malls, long lines, sitting in middle of row, etc.

Treatment of Agoraphobia

Psychotherapy : cognitive behavioral psychotherapy with an emphasis on relaxation and instruction on misinterpretation of physiologic symptoms. B. Pharmacotherapy is indicated when patients have marked distress from panic attacks or are experiencing impairment in work or social functioning. 1. SSRI=Serotonin-specific reuptake inhibitors and tricyclic antidepressants are most often used. 2. Benzodiazepines may be used adjunctively with TCAs or SSRIs during the first few weeks of treatment 3. Monoamine oxidase inhibitors (MAOIs) Medication should be combined with cognitive behavioral therapy for optimal outcome.

Social Phobia

Diagnosis of Social Phobia (Social Anxiety Disorder)
Marked and persistent fear of social or performance situations in which the person is exposed to unfamiliar people or to scrutiny by others. The individual often fears that he will act in a way that will be humiliating or embarrassing. The person recognizes that the fear is excessive or unreasonable. The feared situations are avoided or endured with intense distress. The duration of symptoms is at least six months

Clinical Features of Social Phobia

A. Patients often display hypersensitivity to criticism, difficulty being assertive, low self-esteem, and inadequate social skills. B. Avoidance of speaking in front of groups may lead to work or school difficulties. Most patients with social phobia fear public speaking, while less than half fear meeting new people. C. Less common fears include fear of eating, drinking, or writing in public, or of using a public restroom.

Epidemiology and Etiology of Social Phobia

A. Lifetime prevalence is 3-13%. B. Social phobia is more frequent (up to tenfold) in first-degree relatives of patients with generalized social phobia. C. Onset usually occurs in adolescence, with a childhood history of shyness. D. Social phobia is often a lifelong problem, but the disorder may remit or improve in adulthood.

Treatment of Social Phobia

A. Pharmacotherapy: - SSRIs, such as paroxetine or sertraline, are first-line medications for social phobia. - Benzodiazepines, may be used if antidepressants are ineffective (short course). - Social phobia with Performance Anxiety (for specific situations known to be anxiety provoking) responds well to beta-blockers, such as propranolol. The effective dosage can be very low, such as 10-20 mg qid. It may also be used on a prn basis; 20-40 mg given 30-60 minutes prior to the anxiety provoking event. B. Psychotherapy: Cognitive/behavioral therapies are effective and should focus on cognitive retraining, desensitization, and relaxation techniques. C. Combined pharmacotherapy and cognitive or behavioral therapies is the most effective treatment.

Specific Phobia

Diagnosis of Specific Phobia
Marked and persistent fear that is excessive or unreasonable, which is caused by the presence or anticipation of a specific object or situation. Exposure to the feared stimulus provokes an immediate anxiety response, which may take the form of a panic attack. Recognition by the patient that the fear is excessive or unreasonable. The phobic situation is avoided or endured with intense anxiety.

Specify Types of Phobias

1. Animal (e.g., dogs). 2. Natural Environmental (e.g., heights, storms, water). 3. Blood-injection injury. 4. Situational (e.g., airplanes, elevators, enclosed places).. 5. Other (e.g., situations that may lead to choking, vomiting).

Epidemiology of Specific Phobia

The lifetime prevalence of phobias is 10%. Most do not cause clinically significant impairment or distress. B. Age of onset is variable, and females with the disorder far outnumber males.

Treatment of Specific Phobia

A. The primary treatment is Behavioral Therapy. Commonly used technique is Systemic Desensitization, consisting of gradually increasing exposure to the feared situation, combined with a relaxation technique such as deep breathing. Other technique like flooding can be used. B. Beta-blockers may also be useful prior to confronting the specific feared situation.

Selective Mutism

A. Consistent failure to speak in specific social situations in which there is an expectation for speaking (e.g., at school) despite speaking in other situations. B. The disturbance interferes with educational or occupational achievement or with social communication. C. The duration of the disturbance is at least 1 month (not limited to the first month of school). D. The failure to speak is not attributable to a lack of knowledge of, or comfort with, the spoken language required in the social situation. E. The disturbance is not better explained by a communication disorder (e.g., childhood onset fluency disorder) and does not occur exclusively during the course of autism spectrum disorder, schizophrenia, or another psychotic disorder.

Separation Anxiety Disorder

Developmentally inappropriate and excessive fear or anxiety concerning separation from those to whom the individual is attached, as evidenced by at least three of the following: 1. Recurrent excessive distress when anticipating or experiencing separation from home or from major attachment figures. 2. Persistent and excessive worry about losing major attachment figures or about possible harm to them, such as illness, injury, disasters, or death. 3. Persistent and excessive worry about experiencing an untoward event (e.g., getting lost, being kidnapped, having an accident, becoming ill) that causes separation from a major attachment figure. 4. Persistent reluctance or refusal to go out, away from home, to school, to work, or elsewhere because of fear of separation. 5. Persistent and excessive fear of or reluctance about being alone or without major attachment figures at home or in other settings. 6. Persistent reluctance or refusal to sleep away from home or to go to sleep without being near a major attachment figure. 7. Repeated nightmares involving the theme of separation. 8. Repeated complaints of physical symptoms (e.g., headaches, stomachaches, nausea, vomiting) when separation from major attachment figures occurs or is anticipated.





رفعت المحاضرة من قبل: Bayar Garagary
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