Anxiety Disorders PDF

‫‪Anxiety disorders‬‬ ‫د‪.‬علي رياض شمخي‬ ‫)‪M.B.Ch.B – F.I.C.S (psych‬‬ ‫بكلوريوس طب وجراحة عامة‬  INTRODUCTION FEAR VS ANXIETY WHAT WE MEAN BY DISORDER Symptoms of anxiety Psychological arousal Fearful anticipation Irritability Sensitivity to noise Restlessness Poor...

‫‪Anxiety disorders‬‬ ‫د‪.‬علي رياض شمخي‬ ‫)‪M.B.Ch.B – F.I.C.S (psych‬‬ ‫بكلوريوس طب وجراحة عامة‬  INTRODUCTION FEAR VS ANXIETY WHAT WE MEAN BY DISORDER Symptoms of anxiety Psychological arousal Fearful anticipation Irritability Sensitivity to noise Restlessness Poor concentration Worrying thoughts Autonomic arousal Gastrointestinal Dry mouth Difficulty in swallowing Epigastric discomfort Excessive wind Frequent or loose motions Respiratory Constriction in the chest Difficulty inhaling Cardiovascular Palpitations Discomfort in the chest Awareness of missed beats Genitourinary Frequent or urgent micturition Failure of erection Menstrual discomfort Muscle tension Tremor Headache Aching muscles Hyperventilation Dizziness Tingling in the extremities Feeling of breathlessness Sleep disturbance Insomnia Night terror Classification of anxiety disorders Generalized anxiety disorder Clinical picture The symptoms of GAD are persistent and are not restricted to, or markedly increased in, any particular set of circumstances (in contrast to phobic anxiety disorders). All of the symptoms of anxiety can occur in GAD, but there is a characteristic pattern, which consists of the following features: Worry and apprehension that are more prolonged than in healthy people. The worries are widespread and are not focused on a specific issue as they are in panic disorder (i.e. on having a panic attack), social phobia (i.e. on being embarrassed), or OCD (i.e. on contamination). The person feels that these widespread worries are difficult to control. Psychological arousal, which may be manifested as irritability, poor concentration, and/or sensitivity to noise. Autonomic overactivity, which is most often experienced as sweating, palpitations, dry mouth, epigastric discomfort, and dizziness. Muscle tension, which may be experienced as restlessness, trembling, inability to relax, headache (usually bilateral and frontal or occipital), and aching of the shoulders and back. Hyperventilation, which may lead to dizziness, tingling in the extremities and a feeling of shortness of breath.  Sleep disturbances, which include difficulty in falling asleep and persistent worrying thoughts. Sleep is often intermittent, unrefreshing, and accompanied by unpleasant dreams. Some patients have night terrors and wake suddenly feeling extremely anxious. Early-morning waking is not a feature of GAD, and its presence strongly suggests a depressive disorder. Other features, which include tiredness, depressive symptoms, obsessional symptoms, and depersonalization. These symptoms are never the most prominent feature of GAD. If they are prominent, another diagnosis should be considered Clinical signs The face appears strained, the brow is furrowed, and the posture is tense. The person is restless and may tremble. The skin is pale, and sweating is common, especially from the hands, feet, and axillae. Being close to tears, which may at first suggest depression, reflects the generally apprehensive state. Epidemiology The Adult Psychiatric Morbidity Survey found a 12-month prevalence of 4.4% for GAD in England and a similar figure has been reported in US surveys, with rather lower prevalence figures in European countries around 2%. Rates in women are about twice as high as those in men. GAD is associated with several indices of social disadvantage, including lower household income and unemployment, as well as divorce and separation Prognosis One of the DSM-5 criteria for GAD is that the symptoms should have been present for 6 months. One of the reasons for this cut-off is that anxiety disorders that last for longer than 6 months have a poor prognosis. Thus most clinical studies suggest that GAD is typically a chronic condition with low rates of remission over the short and medium term. Evaluation of the prognosis is complicated by the frequent comorbidity with other anxiety disorders and depression, which worsen the long-term outcome and accompanying burden of disability. The average duration of illness in this group was about 20 years and, despite treatment, the outcome over the next 3 years was relatively poor, with only one in four patients showing symptomatic remission from GAD Social phobia Clinical picture In this disorder, inappropriate anxiety is experienced in social situations, in which the person feels observed by others and could be criticized by them. Socially phobic people attempt to avoid such situations. If they cannot avoid them, they try not to engage in them fully—for example, they avoid making conversation, or they sit in the place where they are least conspicuous. Even the prospect of encountering the situation may cause considerable anxiety, which is often misconstrued as shyness. Social phobia can be distinguished from shyness by the levels of personal distress and associated social and occupational impairment The situations in which social phobia occurs include restaurants, canteens, dinner parties, seminars, board meetings, and other places where the person feels observed by other people. Some patients become anxious in a wide range of social situations (generalized social phobia), whereas others are anxious only in specific situations, such as public speaking, writing in front of others, or playing a musical instrument in public. In DSM-5 ‘performance only’ social phobia, anxiety is restricted to speaking or performing in public. People with social phobia may experience any of the anxiety symptoms , but complaints of blushing and trembling are particularly frequent. The cognitions centre around a fear of being evaluated critically by others. Other problems. Some patients take alcohol to relieve the symptoms of anxiety, and alcohol misuse is more common in social phobia than in other phobias. Social phobia is also a predictor of alcohol misuse. Comorbid depressive disorders as well as other anxiety disorders are also common. Epidemiology The National Comorbidity Survey Replication reported a lifetime prevalence rate of social phobia in the community of around 12%. Social phobias are about equally frequent among the men and women who seek treatment, but in community surveys they are reported rather more frequently by women. Neural mechanisms Functional neuroimaging studies have found that patients with social phobia have increased amygdala responses to presentation of faces with expressions of negative affect. The anticipation of public speaking in individuals with social phobia produced activation in limbic and associated regions, including the amygdala, hippocampus, and insula, while activation of cortical regulatory areas such as the prefrontal cortex was diminished. The insula is thought to represent interoceptive cues, and increased insula activity in patients with social phobia may underpin the preoccupation of patients with bodily autonomic changes; for example, flushing and sweating. Course and prognosis Social phobia has an early onset, usually in childhood or adolescence, and can persist over many years, sometimes even into old age. Only about 50% of people with the disorder seek treatment, usually after many years of symptoms  Agoraphobia: Anxiety about being in places or situations such as in a crowd or in open spaces, outside the home, from which escape or egress is feared to be impossible. The situation is avoided or endured with marked distress, sometimes including the fear of having a panic attack. Agoraphobic patients may become housebound and never leave the home or go outside only with a companion The anxiety symptoms that are experienced by agoraphobic patients in the phobic situations are similar to those of other anxiety disorders although two features are particularly important: panic attacks, whether in response to environmental stimuli or arising spontaneously anxious cognitions about fainting and loss of control. there are three common themes, namely distance from home, crowding, and confinement. The situations include buses and trains, shops and supermarkets, and places that cannot be left suddenly without attracting attention, such as the hairdresser’s chair or a seat in the middle row of a theatre or cinema. As the condition progresses, the individual increasingly avoids these situations until in severe cases they may be more or less confined to their home. For example, most patients are less anxious when accompanied by a trusted companion, and some are helped by the presence of a child or pet dog. Panic disorder Although the diagnosis of panic disorder did not appear in the nomenclature until 1980. The central feature is the occurrence of panic attacks. These are sudden attacks of anxiety in which physical symptoms predominate, and they are accompanied by fear of a serious medical consequence such as a heart attack. Clinical features Not every patient has all of these symptoms during the panic attack and, for a diagnosis of panic disorder, DSM-5 requires the presence of only four or more symptoms. The important features of panic attacks are that: anxiety builds up quickly the symptoms are severe the person fears a catastrophic outcome. Symptoms caused by hyperventilation Dizziness Tinnitus Headache Feeling of weakness Faintness Numbness Tingling in the hands, feet, and face Carpopedal spasms Precordial discomfort Feeling of breathlessness Epidemiology The National Comorbidity Survey Replication found a 12-month prevalence rate of DSM-IV panic disorder of 2.7% and a lifetime risk of 4.7% These figures include panic disorder with agoraphobia, which accounts for about 50% of the cases in the general population In most studies, the prevalence in women is about twice that in men. Patients with panic disorder have increased rates of other anxiety disorders, major depression, and alcohol misuse. Panic disorder is familial, with about a fivefold increase in risk in first degree relatives , with a heritability of about 40% Course and prognosis Earlier studies that used categories such as ‘effort syndrome’ found that most patients still had symptoms 20 years later, although most had a good social outcome. More recent studies of patients diagnosed with panic disorder also reveal a lengthy course, with fluctuating anxiety and depression. About 30% of patients remit without subsequent relapse, and a similar proportion show useful improvement, although with persistent symptomatology. The prognosis of panic disorder without agoraphobia is somewhat better, and results from controlled trials suggests effective treatment can improve the prognosis of both panic disorder and panic disorder with agoraphobia. Mortality rates from unnatural causes and, among men, from cardiovascular disorders are higher than average, and may be linked to changes in the regulation of the sympathetic nervous system Specific phobia A person with a specific phobia is inappropriately anxious in the presence of a particular object or situation. In the presence of that object or situation, the person experiences the symptoms of anxiety. Anticipatory anxiety is common, and the person usually seeks to escape from and avoid the feared situation. Specific phobias can be characterized further by adding the name of the stimulus (e.g. spider phobia). In DSM-5, five general types of specific phobia are recognized, which are concerned with: animals aspects of the natural environment blood, injection, medical care, and injury situations (for example, aeroplanes, lifts, enclosed spaces). other provoking agents (for example, fears of choking or vomiting).  Etiology Of anxiety disorders A. Biologic 1. Anxiety involves an excessive autonomic reaction with increased sympathetic tone. 2. The release of catecholamines is increased with the increased production of norepinephrine metabolites (e.g., 3-methoxy-4- hydroxyphenylglycol). 3. Decreased rapid eye movement (REM) latency and stage IV sleep (similar to depression) may develop. 4. Decreased levels of γ-aminobutyric acid (GABA) cause central nervous system (CNS) hyperactivity (GABA inhibits CNS irritability and is widespread throughout the brain). 5. Alterations in serotonergic system and increased dopaminergic activity are associated with anxiety. 6. Activity in the temporal cerebral cortex is increased. 7. The locus coeruleus, a brain center of noradrenergic neurons, is hyperactive in anxiety states, especially panic attacks. 8. Recent studies also suggest a role for neuropeptides (substance P, CRF, and cholecystokinin), but currently there are no agents available for these targets. 9. Hyperactivity and dysregulation in the amygdala may be associated with social anxiety. Psychoanalytic According to Freud, unconscious impulses (e.g., sex or aggression) threaten to burst into consciousness and produce anxiety. Anxiety is related developmentally to childhood fears of disintegration that derive from the fear of an actual or imagined loss of a love object or the fear of bodily harm (e.g., castration). Freud used the term signal anxiety to describe anxiety not consciously experienced but that triggers defense mechanisms used by the person to deal with a potentially threatening situation. Learning theory 1. Anxiety is produced by continued or severe frustration or stress. The anxiety then becomes a conditioned response to other situations that are less severely frustrating or stressful. 2. It may be learned through identification and imitation of anxiety patterns in parents (social learning theory). 3. Anxiety is associated with a naturally frightening stimulus (e.g., accident). Subsequent displacement or transference to another stimulus through conditioning produces a phobia to a new and different object or situation. 4. Anxiety disorders involve faulty, distorted, or counterproductive patterns of cognitive thinking. Laboratory Tests A. No specific laboratory tests for anxiety. B. Experimental infusion of lactate increases norepinephrine levels and produces anxiety in patients with panic disorder. Pathophysiology and Brain-Imaging Studies A. No consistent pathognomonic changes. B. In obsessive–compulsive disorder, positron emission tomography (PET) reveals decreased metabolism in the orbital gyrus, caudate nuclei, and cingulate gyrus. C. In generalized anxiety disorder and panic states, PET reveals increased blood flow in the right parahippocampus in the frontal lobe. D. Magnetic resonance imaging (MRI) has shown increased ventricular size in some cases, but findings are not consistent. E. Right temporal atrophy is seen in some panic disorder patients, and cerebral vasoconstriction is often present in anxiety.). F. Mitral valve prolapse is present in 50% of patients with panic disorder, but clinical significance unknown. G. Nonspecific electroencephalogram (EEG) changes may be noted. H. Dexamethasone suppression test does not suppress cortisol in some obsessive–compulsive patients. I. Panic-inducing substances include carbon dioxide, sodium lactate, methyl-chlorophenyl-piperazine (mCPP), carbolines, GABAB receptor antagonists, caffeine, isoproterenol, and yohimbine (Yocon  Managements of anxiety disorders Thank you