Anxiety Disorders (8-9-1442-1) PDF

2  Definitions Fear: A response to a known, external, definite threat. Anxiety: An alerting signal; it warns of impeding danger and enables a person to take measures to deal with a threat. 3  Definitions Phobia: Irrational...

2  Definitions Fear: A response to a known, external, definite threat. Anxiety: An alerting signal; it warns of impeding danger and enables a person to take measures to deal with a threat. 3  Definitions Phobia: Irrational fear, avoidance, recognized as excessive, causes distress and dysfunction. 4  Between Normal and Abnormal Anxiety NORMAL ANXIETY ABNORMAL ANXIETY Proportional apprehension Apprehension is out of to the external stimulus. proportion to the external Features of anxiety are few. stimulus. Anxiety is not severe and not Features are multiple. prolonged. Anxiety is prolonged or severe Attention is focused on the (or both). external threat rather than on Attention is focused also on the person’s feelings. the person’s response to the threat (e.g. palpitation). 5  Features of Anxiety PSYCHOLOGICAL PHYSICAL Excessive apprehension Chest: Fearful anticipation -- chest discomfort Feeling of dread -- difficulty in inhalation Worrying thoughts Cardiovascular: Hypervigilance -- palpitation Feeling of restlessness -- awareness of missed beats Sensitivity to noise -- cold extremities Difficulty concentrating Neurological: Subjective report of memory -- headache -- dizziness deficit -- tinnitus -- numbness -- tremor -- blurred vision 6 Table 11 – 2 Features of Anxiety PHYSICAL Gastrointestinal: -- disturbed appetite -- dysphagia -- epigastric discomfort -- nausea -- vomiting -- disturbed bowel habit Genitourinary: -- ↑ urine frequency and urgency -- ↓ libido -- impotence -- dysmenorrheoea Musculoskeletal: -- muscle and joint pain 7 Table 11 – 2 Features of Anxiety PHYSICAL Sleep: -- insomnia -- bad dreams Skin: -- sweating -- itching -- hot / cold skin 8 Anxiety disorders include: 1. Generalized Anxiety Disorder (GAD). 2. Panic disorder with or without agoraphobia. 3. Social phobia. 4. Specific phobia. 9 Anxiety disorders include: 5. Anxiety Disorder due to General Medical Conditions. 6. Substance-Induced Anxiety Disorder. 10. Obsessive Compulsive Disorder (OCD).. Acute Stress Disorder.. Post-Traumatic Stress Disorder (PTSD). 11  Anxiety Disorders Epidemiology: 1 in 4 F M (2-3X) Age at onset: mean age: 25 Aetiology: Genetic factor: 4-8 X more in first degree relatives Biological factors: a) neurotransmitters: noradrenaline, serotonin & GABA 36  Cognitive – behaviour theory: = modeling parental behaviour (learning) = classic conditioning 37 DDx: 1. Medical causes 2. Phobias 3. PTSD 4. Somatoform disorder 38 Treatment: R/O organic causes Support and reassurance Cognitive therapy Behaviour therapy: – Relaxation & – Respiratory training – Exposure @@Cognitive-behaviour therapy (CBT) 39 Drugs: (GRADUALLY) – Tricyclic antidepressants – Imipramine – Clomipramine – Selective serotonin reuptake inhibitors( 1st choice) – Paroxetine – Fluvoxamine – Citalopram – Escitalopram – Sertraline 40  _ SNRI : Venlafaxine – Benzodiazepine( 2 – 4 wks ) * Alprazolam * lorazepam 41 Course and Prognosis: Chronic but waxing and waning Some patients recover within weeks Others have a prolonged course (those symptoms persist for 6 months or more) Prognosis is excellent with therapy 42  ‫للتأمل‪....‬‬ ‫”التقوى أساس كل توفيق‬ ‫وفالح يف الدنيا واآلخرة“‬ ‫‪43‬‬ AGORAPHOBIA 44  Fear of open spaces ??? Anxiety about being in places or situations from which escape seems difficult or help may not be available 2– 6 % Chronic & very disabling 45 A. Marked fear or anxiety about two (or more) of the following five situations: 1. Using public transportation (e.g., automobiles, buses, trains, ships, planes). 2. Being in open spaces (e.g., parking lots, marketplaces, bridges). 3. Being in enclosed places (e.g., shops, theaters, cinemas). 4. Standing in line or being in a crowd. 5. Being outside of the home alone. 46 B. The individual fears or avoids these situations because of thoughts that escape might be difficult or help might not be available in the event of developing panic- like symptoms 47 C. The agoraphobic situations almost always provoke fear or anxiety. D. The agoraphobic situations are actively avoided, require the presence of a companion, or are endured with intense fear or anxiety. 48  E. The fear or anxiety is out of proportion to the actual danger  F. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more.  G. The fear, anxiety, or avoidance causes clinically significant distress or impairment 49  ** Complications: Function disabilities ( House – Bound Syndrome ) Being dependent: e.g.: in driving, shopping… Depressive symptoms (> 30%) 50  COMORBIDITY: Panic disorder ( 90% ) Depressive symptoms (> 30%) 51 Treatment: A) Cognitive – Behaviour Therapy: Detailed inquiry about the situations that provoke anxiety Hierarchy (from the least – to the most) Relaxation training Exposure 52 B) Antidepressant: _ SSRI _ TCA: impiramine – clomipramin – MAOI, (e.g. moclebemide) C) Anxiolytics: e.g. alprazolam 53 SOCIAL PHOBIA (Social Anxiety Disorder) 54 A marked persistent inappropriate fear and anxiety (with physical and psychological features) WHEN: * unfamiliar people * in social or performance situations Anticipatory anxiety Avoidance Significant dysfunctioning 55 Features: The same as GAD Common complaints: palpitation, trembling, sweating and flushing (physical more) The response may take a form of panic attack Negative thoughts about performance 56 DIAGNOSTIC CRITERIA 57 A. Marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others. B. The individual fears that he or she will act in a way or show anxiety symptoms that will be negatively evaluated (i.e., will be humiliating or embarrassing: will lead to rejection or offend others). 58 C. The social situations are avoided or endured with intense fear or anxiety. D. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more. E. clinically significant distress or impairment 59 Epidemiology: Age: 5 - 35 Late teenage or early twenties: peak May occur in children Lifetime prevalence: 13% F>M 60 Aetiology: Genetic factors Biological Social factors: excessive demands for social conformity and concerns about impression a person is making on others, (high cultural superego increases shame feelings), some Arab cultures are judgmental and impressionistic. 61 Aetiology: Behavioural factors: sudden episode of anxiety in a social situation followed by avoidance. Cognitive factors: exaggerated fear of negative evaluation and feelings that other people will be critical. 62 Complications: Secondary depression Alcohol or stimulant abuse Deterioration in functioning 63 Treatment: A. Psychological: 1. Cognitive-Behaviour Therapy: – Exposure – Relaxation training – It is the treatment of choice for social phobia 2. Social Skill Training: 3. Assertiveness Training 64 B. Drugs: 1. Beta-adrenergic antagonists 2. Benzodiazepines (e.g. alprazolam- clonazepam) 3. Antidepressants: a. SSRIs : best choice eg: fluoxetine – paroxetine – sertraline – citalopram- escitalopram Or b. Monoamine oxidase inhibitors (e.g. moclobemide) c. SNRI e.g: venlafaxine 65 66  Marked Irrational persistent fear of a specific object or situation ( 1 )  Avoidance  Impairment  absence of other psychiatric problems 6 months 67  Animals (including spiders) Storms and thunder. Heights (acrophobia), flying Closed spaces (claustrophobia) Injury, blood, hospitals Illness, death 68  It is common in the general population 7-9% in children 5%, adolescent 16% M:F=1:2 Usually start as childhood phobias A minority begins in adult life 69 Treatment: Behaviour therapy (exposure technique) : the best Drugs (e.g. benzodiazepines, beta adrenergic antagonists) before exposure sessions 70 Prognosis: If started in adult life after stressful events the prognosis is usually good If started in childhood, it usually disappears in adolescence but may continue for many years 71 Obsessive Compulsive Disorder ( OCD ) 72 Obsessions: Recurrent, persistent ideas, images or impulses Against patient’s resistance A silly product of his own mind Intense anxiety Compulsions: Repeated compelling acts done in response to obsessions 73 OCD is: A psychiatric disorder characterized by: Recurrent obsessions or compulsions Time consuming (> 1 hour a day) Causes marked distress or significant impairment Recognized as excessive and unreasonable 74 Epidemiology:  Lifetime prevalence: 2 – 3% of the population  Sex: equal  Mean age at onset = 20 – 25 years 75  Etiology: A) Genetic: B) Biological: Neurobiological Hypothesis * Serotonergic dysfunction abnormalities in the frontal lobe, basal ganglia, and cingulum C) Learning Theory: avoidance responses 76  The Main Types of OCD 1. Contamination and washing 2. Repeated doubts (e.g. ablutions, prayers, gas checking) 3. Symmetry 4. Intrusive thoughts: sexual, blasphemous 77 78 79 Treatment: Explain the nature of the illness Providing hope The most effective treatment is pharmaco-behavioural approach Drugs Antiobsessional drugs Clomipramine SSRIs (e.g. fluvoxamine- paroxetine-sertraline- fluoxetine) Anxiolytics 80 Behaviour Therapy: Exposure + response prevention Thought stopping Thought distraction Family therapy: Cotherapist Support conflicts 81  IN RESISTANT CASES: ECT Psychosurgery: (cingulotomy) 25 – 30 % seizures 82 Course and Prognosis:  Gradual onset usually  Chronic but waxing and waning  Exacerbated with stresses 83  ‫د‪.‬موسى يودعكم‬ ‫ويدعو لكم بالسعادة‬ ‫والتوفيق‬ ‫يف الدنيا واآلخرة‬ ‫‪84‬‬