1. ANXIETY DISORDERS 1 AHMAD ALHADI, MD Psychiatrist and Psychotherapist KSU, KKUH

2. Introduction • Normal vs Abnormal • GAD, Panic Dis., Agoraphobia, Social Phobia, Specific Phobia (Part 1). • OCD (Part 2). • Acute & PTSD, Adjustment Dis., Grief (Part 3).

4. Anxiety Disorders THREAT COPING

5. Features of Anxiety

6. Vicious cycle of panic attack

7. Mental Disorders among Adults (18 and older), in the past year (2001)

8. William R Yates, Anxiety Disorders: Multimedia 2010

9. William R Yates, Anxiety Disorders: Multimedia 2010

10. Fear network • Fear network centered inthe Amygdalawhich has interaction with : • Hippocampus,hypothalamic and brainstem sites (observedsigns of fear responses) • Neuroanatomical Hypothesis of Panic Disorder, Revised, Jack M,2004

11. Anxiety Disorders • Generalized Anxiety Disorder (GAD) • Panic Disorder • Agoraphobia • Specific Phobia • Social Phobia. • Obsessive Compulsive Disorder (OCD) • Post Traumatic Stress Disorder (PTSD), Acute Stress Disorder

12. Generalized Anxiety Disorder Criteria: • 6 months duration – most of the time • Excessiveworries about many events : ( routine themes, Difficult to control or relax, not productive, expect terrible events if not worry, worry about not being worried or when everything is going well in pt’s life). • Multiple physical & psychological features. • Significant impairment in function. • Not due to GMC , substance abuse or other axis I psychiatric disorder.

13. Generalized Anxiety Disorder Associated features: • panic attacks (episodes of short severe anxiety). • Sadness +/- weeping • Overconcerned about body functions (heart, brain,...) MSE : • Tense posture, excessive movement e.g. hands (tremor) & head, excessive blinking • Sweating. • Difficulty in inhalation.

15. Generalized Anxiety Disorder Epidemiology: • women > menPrevalence : 3 – 5 %. • Age of onset vary , range : 20 – 55 years. • Pt. usually consults medical (non-psychiatric) specialties, and/or faith-healers first. • Co-morbidity is high ( panic d, depression, substance abuse…etc).

16. 90.4% of persons with GAD met criteria for another psychiatric disorder over the course of their lifetime. 

17. Generalized Anxiety Disorder D Dx : • Anxiety due to other physical problems: anemia –hyperthyroidism – hypoglycemia-BA - Rx – sub. Abuse. • Psychotic disorders. • Depressive disorders. • Panic disorder. • Hypochondriasis. • Mixed anxiety & depressive disorder. • Adjustment disorder with anxious mood. • Normal reaction to stress.

18. Generalized Anxiety Disorder Course & Prognosis If not properly treated : • chronic, fluctuating & worsens with stress. • Secondary depression . • Possible physical complications: e.g. HTN,DM.IHD Poor Prognostic Factors: • Very severe symptoms • Personality problems • Uncooperative patient. • Derealization

19. Generalized Anxiety Disorder • Rule out common physical reasons. • Explain the nature of the illness & symptoms. • Reassure that symptoms are not due to a physical disease. • Reduction of caffeine intake. • Draw attention to psychological factors (connect with his affect). • Behavioral Therapies (CBT, Relaxation training, Meditation….). • Short course(2/52) BDZ e.g. lorazepam. • Long term Rx: SSRI-SNRI-TCA- buspirone

20. Any Qs? Panic

21. تخيّل !! Video 1

22. Panic Disorder Panic Disorder: Disorder with specific criteria: 1- unexpected recurrent panic attacks (+/- situationally bound). 2- one month period (or more) of persistent concerns about another attack or implications of the attack or changes in behavior. 3- Not due to other disorders Panic attack : • a symptom not a disorder. • episodic sudden intense fear (of dying, going mad, or loosing self-control). • Can be part of many disorders: panic disorder, GAD, phobias, sub. Abuse, acute & PTSD. 3 types: 1- unexpected. 2- situationally bound. 3- situationally predisposed.

23. Spontaneous Essential to diagnose Panic Disorder Occur on anticipation Or immediately on exposure to the trigger e.g. specific phobia can be ass./with panic disorder Exposure is likely but not always trigger them e.g. social phobia

24. Epidemiology Women > men Prevalence : 1– 3 % Age at onset : 20 --- 35 years Etiology • Genetic predisposition • Disturbance of neurotransmitters NE & 5 HT in the locus ceruleus (alarm system in the brain ) • Behavioral conditioning • Mitral valve prolapse 2x ?..% not increased in Echo. MVP

25. Course & Prognosis • With treatment : good • Some pts recover within weeks even with no treatment. • Others have chronic fluctuating course. Management • Rule out physical causes. • Support & reassurance • Relaxation & CBT • Medications: BNZ SSRIs TCAs

26. Any Qs So far? Phobia s

27. Phobic Disorders Irrational excessivefear ± panic attack on exposure + avoidance or endured with +++ discomfort

28. Video 2&3

30. Video 4 (therapy)

31. Normal vs Abnormal • GAD, Panic Dis., Agoraphobia, Social Phobia, Specific Phobia (Part 1). • OCD (Part 2). • Acute & PTSD, Adjustment Dis., Grief (Part 3).

32. Thank you