Anxiety Disorders PDF

ANXIETY DISORDERS KRISHNEEL KAVITESH CHAND S160275  WHAT IS ANXIETY? It is characterized most commonly as a diffuse, unpleasant, vague sense of apprehension, often accompanied by autonomic symptoms. It is an alerting signal that warns of impending dang...

ANXIETY DISORDERS KRISHNEEL KAVITESH CHAND S160275  WHAT IS ANXIETY? It is characterized most commonly as a diffuse, unpleasant, vague sense of apprehension, often accompanied by autonomic symptoms. It is an alerting signal that warns of impending danger and enables the person to take measures to deal with the threat (fight or flight) Normal response unless it becomes exaggerated, frequent, chronic and starts affecting function. Symptoms of Anxiety  CLASSIFICATION 1. Generalized Anxiety Disorder 2. Panic Disorder 3. Agoraphobia 4. Specific Phobia 5. Social Anxiety Disorder 6. Obsessive-Compulsive Disorder 7. Post-Traumatic Stress Disorder  EPIDEMIOLOGY Global population with anxiety disorders in 2015 was estimated to be 3.6%. Anxiety disorders are more common among females than males (2:1)  GENERALIZED ANXIETY DISORDER Generalized anxiety disorder (GAD) is usually characterized by chronic anxiety unrealistic and excessive anxiety and worry, that is uncomfortable to the point of interfering with daily life. GAD is a common chronic disorder characterized by long-lasting anxiety that is not focused on any one objects or situation. A person with GAD worries excessively and feels highly anxious at least 50 per cent of the time for six months or more.  Diagnostic Criteria The following criteria must be met for a person to be Diagnosed with GAD A. Excessive anxiety and worry , occurring more than six months. B. The person finds it difficult to control the worry The following criteria must be met for a person to be Diagnosed with GAD C. The anxiety and worry are associated with three of the following six symptoms. (Only one item is required in children). 1. Restlessness or feeling keyed up. 2. Being easily fatigued 3. Irritability 4. Muscle tension 5. Difficulty falling or staying asleep, or restless unsatisfying sleep 6. Difficulty in concentrating or the mind going blank.  PANIC DISORDER An individual is diagnosed with panic disorder when he/she experiences repeated unexpected panic attack. At lease one of the attack is followed by a month period of one or more of the following: - Persistent concern about having more attack - Its consequences - Significant changes in behavior related to attacks. Panic attack last no more than 30 min. peaks at 10 min ( intense symptoms) Not better accounted for any other mental disorder. Not caused by general medical condition or substance abuse  PANIC ATTACK SYMPTOMS Panic attack has 4 or more of the following: 1. Palpitation or tachycardia 2. sweating 3. Tremors 4. Dyspnea 5. Feeling of choking 6. Chest pain or discomfort 7. Nausea or abdominal distress 8. Fear of loosing control 9. Fear of dying 10. Paresthsia 11. Chills or hot flushes 12. Dizziness or faint  AGORAPHOBIA Agoraphobia is a type of anxiety disorder in which the sufferer doesn’t only fear crowded situations, as is commonly believed, but rather, the individual fears having a panic attack in general in any place at any time. Anxiety about being in unfamiliar places or situations in which it might be difficult to escape or in situations where no help is available if needed. Can cause significant interference to a person's ability to function in work or social situations  Anxiety Causing Situations Marked fear and anxiety in the following 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 DIAGNOSTIC CRITERIA  SPECIFIC PHOBIA A specific phobia is any kind of anxiety disorder that amounts to an unreasonable or irrational fear related to exposure to specific objects or situations. As a result, the affected person tends to avoid contact with the objects or situations and, in severe cases, any mention or depiction of them. Marked, persistent, unreasonable fear of an object or situation: i. Animals ii. Environment (storms, heights) iii. Blood and injection iv. Situations (airplanes, closed spaces) Most common mental disorder in women. DIAGNOSTIC CRITERIA  SOCIAL ANXIETY DISORDER The defining feature of social anxiety disorder, also called social phobia, is intense anxiety or fear of being judged, negatively evaluated, or rejected in a social or performance situation. Persistent/ marked anxiety in social situation. Situations that involve scrutiny and contact with strangers Fear of embarrassment Social gatherings and oral presentations Main concern: about being observed critically by others. DIAGNOSTIC CRITERIA  OTHER ANXIETY DISORDERS Anxiety disorders attribute to another medical conditions e.g. cardiovascular disease, endocrine disturbances. Substance Induced Anxiety Disorder – cocaine, marijuana Mixed Anxiety-Depressive Disorder – patients that have both anxiety and depressive symptoms but do not meet the diagnostic criteria or an anxiety and mood disorder Obsessive-Compulsive Disorder Post Traumatic Stress Disorder  MANAGEMENT Non-Pharmacological – Specific Phobias and Social Anxiety Disorders Psych Education- patient is familiarized with their disorder. Applied Relaxation- Two strategies often used: Calm Breathing, which involves consciously slowing down the breath, and Progressive Muscle Relaxation, which involves systematically tensing and relaxing different muscle group. Behavior Therapy – desensitizing the patient by slowly exposing to all the anxiety causing stimuli Visual Therapy – computer-generated images of simulations of the phobic disorders. Patients are exposed and made to interact with the phobic object.  PHARMACOLOGICAL TREATMENT Targets 3 main neurotransmitters: GABA- benzodiazepine SE: cognitive impairment, sedation, depression Serotonin – SSRIs ( fluoxetine 10-20mg) SE: insomnia , agitation, ↑activity level, tremor, nausea, vomiting Norepinephrine – SNRIs ( venlafaxine) Initially started with low dose. Have longer period of treatment. Usually for 8-12 weeks. TCA, beta blocker(phobic disorder), antipsychotic (OCD, PTSD) can also be given.  PHARMACOLOGICAL TREATMENT GAD – benzodiazepines, SSRI, Buspirone and venlafaxine Panic Disorders – SSRI, Tricyclic Antidepressants, Monoamine oxidase inhibitors Agoraphobia – Benzodiazepines, SSRI, TCA Social Anxiety Disorder – SSRI, Benzodiazepines, Venlafaxine ANXIETY DISORDERS OCD & PTSD  OBSESSIVE-COMPULSIVE DISORDER The DSM-IV-TR describes obsessive-compulsive disorder (OCD) as recurrent obsessions or compulsions that are severe enough to be time consuming or to cause marked distress or significant impairment The person has recurring thoughts or images(obsessions) and/or repetitive, ritualistic-type behaviors that the individual is unable to keep from doing(compulsions). The person may try to suppress these thoughts or behaviors but is unable to do so. The individual knows that the thoughts or behaviors are irrational but feels powerless to stop. Obsessions It is defined as unwanted, intrusive, persistent ideas, thoughts, impulses or images that cause marked distress. Compulsions It denote unwanted repetitive behavior patterns or mental acts that are intended to reduce anxiety, not to provide pleasure or gratification.  ETIOLOGY Biological Factors Serotonergic System - The many clinical drug trials that have been conducted support the hypothesis that dysregulation of serotonin is involved in the symptom formation of obsessions and compulsions in the disorder. Noradrenergic System - less evidence exists for dysfunction in the noradrenergic system in OCD but anecdotal reports show some improvement in OCD symptoms with use of oral clonidine (Catapres). Neuroimmunology - Group A/3-hemolytic streptococcal infection can cause rheumatic fever, and approximately 10 to 30 percent of the patients develop Sydenham's chorea and show obsessive-compulsive symptoms.  ETIOLOGY Brain-Imaging Studies – PET scans show increased activity in the frontal lobes, basal ganglia and the cingulum of patients with OCD OCD appears more associated with corticostriatal pathways CT & MRI scans show bilaterally smaller caudate Genetics – 3-5 times more likely if immediate family has OCD Associated with depressive disorders.  SYMPTOMS Obsessions Compulsion o Washing and cleaning(e.g. excessive Repeated thoughts about hand washing or house cleaning). contamination(e.g. may lead to fear o Counting (e.g. counting number of of shaking hands or touching times that something is done) objects). o Checking (e.g. checking something that Repeated doubts(e.g. repeatedly one has done, over and over). wondering if they locked the door o Requesting or demanding assurances or turned off an appliance). from others. A need to have things in a certain o Repeating actions(e.g. going in and out order(e.g. feels intense anxiety of door or up and down from a chair). o Ordering(e.g. arranging and when things are out of place). rearranging cloths or other items). OCD Inducing Images  DIAGNOSTIC CRITERIA A. Anxiety disorder with presence of obsessions or compulsions B. Realize thoughts and actions are irrational or excessive C. Must take up more than 1 hour a day D. Must disrupt daily routine E. Symptoms can’t result from effects of other medical conditions or substances  TREATMENT Rarely curable Treatment depends of the problems of the patient Most common treatments: Behavioral Therapy Cognitive Therapy Medication  Cognitive: change the way they think to deal with their fears Behavioral: change the way they react to “anxiety-provoking” situations Exposure and Response Prevention - Slowly learning to tolerate anxiety associated with not performing ritual behavior Psychotherapy - Talking with therapist to discover what causes the anxiety and how to deal with symptoms Systematic Desensitization - Learning cognitive strategies to deal with anxiety then gradual exposure to feared object  PHARMACOLOGICAL Selective Serotonin Reuptake Inhibitors (SSRIs) TCA’s Anxiolytic benzodiazepine such as chloradiazepoxide or diazepam -> give temporary relief from anxiety but not really effective on obsessions and compulsions Antidepressants because of common depression  POST TRAUMATIC STRESS DISORDER Marked by increased stress and anxiety following exposure to a traumatic or stressful event. The person reacts to the experience with fear and helplessness, persistently relives the event, and tries to avoid being reminded of it. The event may be relived in dreams and waking thoughts (flashbacks) Common events: being a witness to or being involved in a violent accident or crime, military combat, or assault, being kidnapped, being involved in a natural disaster, being diagnosed with a life-threatening illness, or experiencing physical or sexual abuse  ETIOLOGY Stressor is the prime causative factor in the development of PTSD. The response to the traumatic event must involve intense fear or horror. Noradrenergic and endogenous opiate systems, as well as the HPA axis, are hyperactive Genetics  TREATMENT Selective serotonin reuptake inhibitors (SSRI) - sertraline and paroxetineare considered first-line treatments for PTSD Tricyclic antidepressants (TCA) - Imipramine and amitriptyline Monoamine oxidase inhibitors (MAOI) - phenelzine, trazodoneare effective in reducing re experiencing symptoms and insomnia. Anticonvulsants - carbamazepine, valproate Benzodiazepines  NON-PHARMACOLOGICAL Exposure - going to the site of the traumatic event e.g. driving again after a road traffic accident (repeated until patient is no longer distressed) Cognitive therapy - For anxiety disorder focus on identification and modification of misinterpretations that lead to overestimation of threat and under estimation of their coping abilities (stop negative interpretation) Psychodynamic therapy - The goal of the treatment is to work through and resolve an unconscious conflict which the traumatic event is thought to have provoked. THANK YOU  REFERENCE Kaplan And Sadock's Synopsis Of Psychiatry 11th Edition Toronto notes https://ar.pinterest.com/pin/23573598033232872/ http://integral-options.blogspot.com/2009/12/ptsd-shadow-of-millenial-decade-part-ii.html Slideshare Lectures