Anxiety disorder

ANXIETY DISORDERS

Dr. Sami Adil Al-Badri / Psychiatrist
5th October 2015
5th year lectures

References

Kaplan medical lectures from youtube.com
IMHS
Numan S. Ali, Hayder Abdulmhsin. A Family Study of Panic Disorder in Iraq. THE ARAB JOURNAL OF PSYCHIATRY. 2006, No.12, Autumn
Panic study in kerbala
Basheer Fadel Homady Al-Mashedany. Prevalence Study of Social Phobia Amon Secondary School Students in Baghdad. 2004. A non-published thesis.

DSM-5 (Diagnostic and Statistical manual) classification:

Panic disorder
Phobias
Generalized Anxiety Disorder (GAD)
Separation anxiety disorder
Selective mutism


Risk Factors/Etiology
Psychodynamic Theory
Behavioral Theory (CBT for phobia)
Biological Theory.

Anxiety disorders are the most common anxiety disorders. IMHS lifetime prevalence of all anxiety disorders to be about 10% (1).

Female to male ration

All anxiety disorders 2:1

Panic Disorder

A classic example of panic disorder would be a female who repeatedly visits the emergency room with episodes of racing heart, sweating, shortness of breath, and a fear of "going crazy" or of dying.

Definition: Recurrent unexpected panic attacks are present. These typically occur out of the blue and cause intense distress to the patient.

Panic Attacks Vs. Panic Disorder

Panic attacks can occur in mental disorders other than panic disorder, particularly specific phobia, social phobia, and PTSD.

Panic and agoraphobia

Risk Factors/ Etiology
Separation during childhood
"Panicogens": e.g. flumazenil.
Genetic components. Many studies confirm this including a study done in Iraq where the prevalence of panic disorder in first degree relatives of patients with panic disorder was found to be 17.3% while in the control its prevalence was 3.1% (2).


In the USA the lifetime prevalence is 1-4 %. Mean age of patients is 25 years. In the Iraqi study mentioned above it was found to occur with female to male ratio of 2:1; and that most patients were married and living in urban areas and were of good educational status (2).

These finding goes well with other studies done outside Iraq. In the Iraqi Mental Health Survey (IMHS) the life time prevalence of panic disorder was found to be 0.6% with female to male ration 2-3:1 (1).

DSM 5 diagnostic criteria of panic disorder:

A. Recurrent unexpected panic attacks
B. At least one of the attacks has been followed by 1 month (or more) of one or both of the following:
1. Persistent concern or worry about additional panic attacks or their consequences (e.g., losing control, having a heart attack, going crazy).
2. Significant maladaptive change in behavior
C. The Panic Attacks are not restricted to the direct physiological effects of a substance or a general medical condition
D. The Panic Attacks are not restricted to the symptoms of another mental disorder

DDx.:

Cardiovascular: anemia, mitral valve prolapse, angina, others.
Respiratory: asthma, pulmonary embolism, others.
Neurological: epilepsy, TIA, MS, others.
Endocrine: hyperthyroidism, menopausal disorders, hypoparathyroidism, hypoglycemia and others.
Drug intoxications or withdrawal.
Others: anaphylaxis, electrolyte disturbance, uremia, and others.
Other mental disorders: specific phobia, social phobia, PTSD, and others.


Treatment
Pharmacotherapy: BNZ, SSRIs
Alprazolam and Paroxetine
Psychotherapy: CBT
Systemic desensitization for agoraphobic symptoms if associated.

BNZ and SSRI

How to start?
When the effect begin?
Side effects?
For how long?

FDA approval??? paroxetine

PHOBIC DISORDERS
Irrational fear and avoidance of objects and situations.
When confronted with the feared object, patients typically experience anxiety.

Agoraphobia is fear or avoidance of places from which escape would be difficult in the event of panic symptoms.

Specific phobia: is fear or avoidance of objects or situations other than agoraphobia or social phobia. The IMHS found the lifetime prevalence of specific phobia to be about 5% of the general population (1). In the USA the lifetime prevalence of specific phobia is 10%.


Social phobia: fear of humiliation or embarrassment in either general or specific social situations. In an Iraqi study on the prevalence of social phobia among a big sample secondary school students (1080 persons) in Baghdad it was found to be of 1.67% with female to male ration 3.5:1 (3). The IMHS found the lifetime prevalence of social phobia to be about 1% of the general population (1).

Treatment:

CBT which include systematic desensitization.
Systematic Desensitization: Anxiety and relaxation are physiologically opposite. Purpose of therapy is to replace anxiety with relaxation. Begin with low levels of anxiety. Use relaxation techniques.

Example of desensitization

E.g. Fear of Heights: ask the patient to make a list of his fears, e.g.:
1. Thinking of a tall building, 2. Seeing a picture of a tall building, 3. Standing outside a tall building…. Etc… we start the desensitization with the 1, till the patient is no more afraid of it, then goes to 2 and etc..

Pharmacotherapy (especially for social phobia): SSRIs, Buspirone, or Beta-blockers (particularly for stage ساحة المسرح fright. Stage fright occurs when those who need to talk to a public. Sometimes they regard it as part of social phobia)

GENERALIZED ANXIETY DISORDER

Definition: excessive, poorly controlled anxiety about life circumstances that continues for longer than 6 months. There are psychological and physiological symptoms.
DSM-5 criteria for GAD:
Excessive anxiety or worry, occuring most of the days at least for 6 months.
Difficulty controlling worry.
Associated with three of the following six symptoms: Muscle tension, Fatigue, Concentration difficulty, Restlessness or feeling on edge, Irritability, and Sleep disturbance. (Mnemonic: Macbeth Frets يقلق Constantly Regarding Illicitمحظور Sins)

Risk Factors / Etiology: Genetic predisposition for anxiety trait.

Presenting Symptoms:
Prevalence: 5% of the population. Occurs at a 2:3 male-to-female ratio.
Course: chronic, symptoms worsen with stress.
Associated problems: depression, somatic symptoms, and substance abuse.
.


Treatment
Behavioral psychotherapy: relaxation training, and biofeedback.
Pharmacotherapy: Venlafaxine, other antidepressants, buspirone, benzodiazepines. (Buspirone is better than benzodiazepines). (SSRIs are better than Buspirone). The choice is dependent on response and on the individual

Thank you