Anxiety Disorders

1. Anxiety Disorders Anxiety Diffuse, unpleasant, sense of apprehension accompanied by autonomic symptoms to a threat that is unknown, vague and conflictual Normal if Less severe, shorter duration, adaptive response, no suffering, improve performance and needs no treatment Fear As anxiety, alerting symptom but to known, external threat

2. Anxiety Disorders Most prevalent psychiatric disorder Produce inordinate morbidity Use health services Produce impairment Must be treated

3. Anxiety Disorders 1- Panic disorder and agoraphobia 2- Social and specific phobia 3- Obsessive compulsive disorder 4- Posttraumatic stress disorder and Acute stress reaction 5- Generalized anxiety disorder 6- Other anxiety disorders

4. Anxiety Disorders( Etiology ) 1- Psychoanalytical theories Anxiety result from psychic conflict between sexual or aggressive wishes and threats from external reality 2- Behavioral theories - Classical conditioning - Social learning theory: patients learn to respond excessively to stress e.g through modeling 3- Cognitive theories - Patients misperceive situations as dangerous when they are not. - Overestimation of danger or harm and underestimation of their abilities

5. Anxiety Disorders( Etiology ) 4- Biological A- Autonomic nervous Increased Sympathetic tone B- Neurotransmitters Dysregulation of monoamines e.g nor epinephrine and serotonin. - GABA C- +ve link between streptococcal infections and OCD

6. Anxiety Disorders( Etiology ) D- Brain imaging studies - CT ,MRI Cerebral asymmetries - PET,SPECT,EEG Abnormalities in frontal, temporal and occipital lobes E- Genetics Higher incidence in relatives indicate positive genetic factors

7. 1- Panic disorder and agoraphobia Definitions Panic disorder Spontaneous, unexpected occurrence of panic attacks Panic attacks Discrete periods of intense fear or discomfort, occurring over a short period develop abruptly and reach a peak within 10 minutes not related to specific situation or object that can vary from once/ day to few attacks / year Agoraphobia Fear of being alone in public places especially in places in which rapid exit is difficult

8. Epidemiology Life time prevalence: 1-5% Sex: Female: male = 3:1 Age: young adulthood( before 30 years) Co morbidity = 90% - Agoraphobia - Depression - Other anxiety disorders - Other psychiatric disorders as Hypochondriasis, personality disorders, substance abuse especially alcohol

9. Clinical picture of panic attack - Commonly presents to the Emergency room complain of somatic concern of death from cardiac or respiratory problem - 1st attack usually spontaneous, may be precipitated by caffeine, alcohol, nicotine, sleep exertion, unusual sleep pattern - Onset: sudden - Course: rapidly progress within 10 minutes - In-between attacks : patient has anticipatory anxiety - +/- Associated symptoms: Depression, suicide, substance intake, other anxiety disorder

10. DSM IV Criteria of panic attack A discrete period of intense fear or discomfort in which 4 or more symptoms are present Mental Symptoms 1- Fear of dying ( can't name source of fear ) 2- Fear of losing control or going crazy 3- Depersonalization( detachment from self) and derealization (feeling of unreality) Neurological symptoms 4- Parasthesia ( numbness or tingling sensation) 5- Feeling dizzy, unsteady, or faint 6- Trembling or shaking

11. Physical symptoms 7- Palpitation, pounding heart, accelerated heart rate 8- Dyspnea and chest pain 9- Chills or hot flushes 10- Sweating 11- Nausea or abdominal distress 12- feeling of choking

12. DSM IV Criteria of panic disorder with or without agoraphobia A- Both 1 and 2 1- Recurrent unexpected panic attacks 2- at least one attack followed 1 month by at least 1 of the following ( anticipatory anxiety) i- Concern about having additional attacks ii- Worry about the consequences iii- a significant change in behavior related to the attacks B- +/- Agoraphobia

13. C- The panic attacks are not due to direct physiological effect of substance or general medical condition D- The panic attacks are not due to other mental disorder E- Frequency Moderate = 3 attacks/ 3 weeks Severe = 4 attacks/4 weeks

14. DSM IV Criteria of agoraphobia A- Anxiety about being in place or situation ( Busy streets, closed spaces, crowded stores ) from which escape may be difficult or in which help may not be available B- The situations are avoided, done with anxiety, or require the presence of a companion C- The anxiety is not due to substance, general medical condition, or other mental disorder D- Complications: Psychosocial consequences

15. Differential diagnosis Medical disorders 1- Cardiovascular disorder Angina, mitral valve prolapse, myocardial infarction, hypertension, cardiac dysrhythmias 2- Pulmonary diseases Bronchial asthma, pulmonary embolus 3- Neurological disease Migraine, temporal lobe epilepsy, multiple sclerosis, transient ischemic attack

16. 4- Endocrinal disorders Hypoglycemia( insulinomas), pheochromocytoma, diabetes, hyperthyroid, hypo parathyroid 5- Drug intoxication Amphetamines, hallucinogens, theophylline, nicotine, cannabis, caffeine 6- Drug withdrawal Alcohol, sedatives hypnotics, antihypertensive Psychiatric disorders Malingering, hypochondriasis, specific and social phobia

17. Investigations Workup to assess thyroid, parathyroid, adrenal, substance intake, chest X- ray, ECG, cardiac enzymes, EEG, MRI

18. Treatment Duration of therapy= 8-12 months Combined pharmacotherapy+ Psychotherapy I) Pharmacotherapy A- Selective Serotonin Reuptake Inhibitor( SSRI) Best approved for panic is paroxetine Dose= 5-10 mg and titrate up to 20-60 mg/day 2nd choice is fluvoxamine or sertraline B- Tricyclic Antidepressant (TCA) Clomipramine( anafranil) or imiprammine ( tofranil) ( 100-150 mg/day) Less widely used d.t side effects

19. C- Benzodiazepines (BDZ) Given only 4- 6 weeks Advantage: rapid onset of action Mostly used is Alprazolam( Xanax) D- Non benzodiazepines : Buspirone ( 10 mg /day ) E- Beta blockers: Propranolol 10 mg tablet, up to 30 mg/day. II) Psychotherapy A- Cognitive therapy Aim: Change false beliefs and information about panic attacks - Patient's misinterpretation of bodily sensation as indicating impending death - Explain that when panic attack occurs it is time limited and not life threatening

20. B- Behavioral therapy - Applied relaxation Aim: Instill in patients a sense of control over their levels of anxiety - Respiratory training Train patient to control urge to hyperventillation C- Supportive psychotherapy to assure the patient D- patient education E- Environmental and societal manipulation

21. 2- Specific Phobia and Social Phobia Definitions Phobia Fear of a specific object, circumstances, or situation that is excessive, irrational result in avoidance of the feared object Social Phobia (Social Anxiety Disorder) Excessive fears of humiliation or embarrassment in various social settings e.g Speaking in public Specific Phobia Marked and persistent fear that is excessive and unreasonable, cued by the presence of specific object or situation

22. Epidemiology - Most common mental disorder = 5-10% up to 25% - Sex: Female > Male - Age: Teenagers can occur in childhood - In specific Phobia, most common feared object: Animals, storms, Heights, illness, injury, and death Co morbidity - Other anxiety disorder - Mood disorders esp. depression - Substance related disorders( i.e way to cope ) - Bulimia nervosa - Avoidant personality disorder

23. Clinical picture A- intense fear of an object or situation .The fear is: - Out of proportion with the situation - Cannot be reasoned or explained - Is beyond voluntary control - Leads to avoidance B- Psychological symptoms Fear, anticipatory anxiety C- Pysiological, somatic symptoms Autonomic manifestations on exposure to the object, palpitation, sweating, trembling, dry mouth, breathing difficulty, hot flushes, numbness�etc D- Behavioral Avoidance

24. Other forms of specific phobia - Agoraphobia: fear of open spaces - Claustrophobia: fear of closed spaces - Acrophobia : fear of heights - Nosophobia: fear of illness - Xantophobia: fear of death - Zoophobia: fear of animals - Fear of blood injection injury - School phobia

25. Clinical picture of social phobia Fear of social situations in which: - Fear of being the focus of attention or being negative evaluated in social situations - The affected patient is exposed to the gaze of others, is being criticized by others , or has to talk in front of others - Fear of doing something embarrassing - Social situations are avoided - Patient develops intense anxiety with autonomic manifestations on exposure to the phobic situations

26. Treatment Psychotherapy and pharmacotherapy I- Behavioral therapy Techniques A- Systemic desensitization The patient is exposed serially to a predetermined list of anxiety provoking stimuli under relaxation, hypnosis, or tranquilizing drugs B- Flooding ( in vivo or imaginary ) C- Relaxation techniques and breathing exercises D- Rehearsal during sessions E- Homework assignments F- social skill training in social phobia

27. II-Cognitive therapy Correct cognitive distortion III- social and environmental manipulations IV- Pharmacotherapy A-1st line= SSRI( fluoxetine, citalopram, sertraline, fluvoxamine, paroxetine). -Other approved (TCA,SNRI) B- Initial BDZ,alprazolam ( Xanax 0.25-0.5mg) 1 to 2 tab./day, then taper after 4-6 weeks C- Beta blockers esp. if associated with panic attacks e.g propranolol( Inderal 10 mg/day): up to 30 mg/day.

28. 3-Obsessive compulsive disorder Definition Recurrent occurrence of obsessions and compulsions severe to cause marked distress to the person Obsessions is a mental event Compulsion is a behavior Epidemiology - Life time prevalence:2-3 % - 4th common psychiatric diagnosis - Mean age:25 years - Sex: equal - More in single person Co morbidity - 2/3 has MDD, alcohol use - Other anxiety disorders: Social phobia, GAD - Tics

29. Clinical features A- Either obsessions or compulsions Obsessions 1- Recurrent and persistent thoughts, impulses, or images that are experienced as intrusive and inappropriate causing marked anxiety or distress 2- they are not simply excessive worries 3- The person tries to neutralize them with some thought or action 4- the person realizes that these thoughts are the product of his mind Compulsions 1- Repetitive behaviors, or mental acts that person feels driven to perform them 2- Aimed to relieve anxiety B- Obsessions and compulsions are excessive, unreasonable, time consuming, and significantly interferes with the patient routine and function Specify: if with poor insight

30. Symptom patterns 1- Contamination Commonest Followed by washing or avoidance of contaminated object 2- Pathological doubt Followed by compulsion of checking 3- Intrusive thoughts Usually sexual or aggressive May report themselves to police 4- Symmetry Result in compulsive of slowness 5- Others Religious obsessions Compulsions of hoarding MSE Depression, psychosocial factors, insight

31. Treatment ( Algorithm ) 1- Hospitalize if; Remove external stressors, ECT, depressed, and suicidal risk 2- Pharmacotherapy + Behavioral therapy a- SSRI or TCA + behavioral therapy ( 12 weeks ) b- Another SSRI or TCA +Behavioral therapy (12 weeks) c- Combine 2 SSRI or (SSRI + TCA) + Behavioral therapy ( 12 weeks ) d- Augment ( Valproate , Lithium , or Carbamazepine) e- ECT f- Surgery ( Cingulotomy )

32. 3- Psychotherapy A- Behavioral therapy - Exposure and response prevention - Desensitization - Thought stoppage - Implosion therapy - Aversion conditioning B- Family therapy C- Supportive therapy D- Group therapy

33. 4- Posttraumatic stress disorder ( PTSD ) and acute stress reaction Definition Syndrome occurs to person when sees , involved in, or hears of an extreme traumatic stress Epidemiology - Prevalence 30% in traumatic event 25 % sub clinical form - Women > Men - Age: young adults - High risk : Severe trauma, long duration, high proximity of person to the actual trauma, stressful life changes, 1st degree relatives have depression, inadequate family support

34. Clinical features (1 Month) A- A person has been exposed to a traumatic event in which both of the following were present 1- Experience, witnessed or confronted with an event involved actual death or serious injury e.g torture, wars, rape, and brain washing 2- Person's has intense fear, helplessness, or horror B- Re-experience of the traumatic event 1- Distressing images, thoughts or perceptions 2- Distressing dreams 3- Flashbacks 4- Psychological distress on exposure to internal or external cues 5- Physiological distress on exposure to internal or external cues

35. Clinical features ( cont. ) C- Avoidance of stimuli associated with the trauma 1- Avoidance of thoughts, feelings or conversation associated with the trauma 2- Avoidance of activities, places, or people that arouse recollection of the trauma 3- inability to recall important aspect of the trauma 4-diminished interest in activities 5- Feeling of detachment from others 6- unable to have lovely feelings 7- Sense of foreshortened future D- Hyper arousal 1- Difficulty in falling asleep 2- Irritability or outbursts of anger 3- Difficult concentration 4- Hyper vigilance 5- Exaggerated startle response Acute stress reaction = Less than one month

36. Treatment I- Prophylaxis Aim: Develop more mature coping mechanisms and acceptance of the event Through psychotherapy - Crisis intervention - Education and support II- Hospitalize if Symptoms are severe, suicide, or violence III- Psychotherapy ( individual or group ) A- Exposure therapy B- Stress management ( Relaxation techniques, cognitive approaches )

37. C- Support through relatives and friends D- Abreaction Experiencing the emotions associated with event IV- Pharmacotherapy (duration = 1 year) A- Induction of sleep by sedative hypnotics but no more than 1 month B- SSRI Sertraline, paroxetine Or TCA as imipramine or amitriptyline Dose = antidepressant dose Each trial = 8 weeks C- Others as alpha agonist and beta blockers

38. 5- Generalized anxiety disorder Definition Chronic condition characterized by subjective experience of apprehension without objective reasons, excessive anxiety and worry about several events or activities can't be controlled for most of the day Epidemiology Common = 3-8 % Female : Male = 2:1 25% of GAD in anxiety clinics

39. Clinical picture ( 6 months duration) - Somatic symptoms( cardiopulmonary symptoms, easy fatigability, restlessness, shakiness, GIT symptoms, tension headache, muscle pain, parathesia and hyperreflexia) - Psychological,anxiety difficult to control ( worry, apprehension, fear, sense of insecurity, irritable, restless, hypersenstivity, easy loss of temper,and breaking down in tears) - Autonomic hyperactivity ( pallor or flushing, blurred vision, dry mouth, sweating, palpitation) - Cognitive symptoms ( irritable, difficult concentration, difficult recall )

40. Treatment Combined pharmacotherapy and Psychotherapy A- Psychotherapy - Cognitive behavioral therapy - Environmental and social manipulation - Biofeedback training - Encourage patient to engage in pleasurable activities B- Pharmacotherapy Duration = 6-12 months 1- Benzodiazepines Not more than 1 month 2- Buspirone Non BDZ anxiolytic 3- SSRI( Fluvoxamine, Sertraline, Escitalopram, Paroxetine, Fluoxetine) 4- SNRI (Venlafaxine ) for cognitive impairment and insomnia