2 anxiety disorders mine

8/9/2019 2 Anxiety Disorders mine

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Anxiety disorders

Specific Phobia

Social Anxiety Disorder

OCD

Post-TraumaticStress Disorder

Panic Disorder

GAD

Anxiety is common normal response to a perceived threat, it is important to clinician to beable to distinguish normal from pathological anxiety.When anxiety is pathological :1- it is inappropriate2- there is either no real source of fear or the source is not sufficient to account for the

severity of the symptoms3- symptoms interfere with function and personal relationships


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Epidemiology& longitudinal course

• 25% of people in community will meet criteriafor an anxiety disorder at some time in theirlife.

• Woman have higher prevalence for all AD( 3-

2:1) exception for OCD & SAD( 1:1)


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Normal versus Pathologic Anxiety

• Normal anxiety is adaptive. It is an inbornresponse to threat

• Pathologic anxiety is anxiety that is excessive,impairs function.


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General considerations for anxiety disorder

• Often have an early onset- teens or earlytwenties

•

Show 2:1 female predominance• Have a waxing and waning course over lifetime• Similar to major depression and chronic

diseases such as diabetes in functionalimpairment and decreased quality of life


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Panic Disorder


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Panic attacksIntense fear with 4 or more :

• palpitations.

• sweating

• Shaking

• Shortness of breath

• feeling of choking

• chest pain or discomfort

• chills or hot flushes

• nausea

• dizzy, lightheaded, or faint

• feelings of unreality(derealization) or being detachedfrom oneself (depersonalization)

• fear of losing control or goingcrazy

• numbness or tingling sensations

Panic attacks are discrete periods of intense anxiety that occur to pt. With panic disorder/ other mental disordersIt peak in several min. And subside within 25 min.They rarely last > 1 hourAttack can be either unexpected or come about due to specifics trigger


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Panic disorder

• Recurrent unexpected panic attacks.(no obviousprecipitant)

• At least one of attacks are followed by 1 month by 1>=a. Continuous concern of having additional attacks.b. Worry about implication of attackc. Behavior will change due to attacks.

• Panic disorder is diagnosed in people who experience spontaneous out-of-the-blue panic attacks and are preoccupied with the fear of a recurringattack. Panic attacks occur unexpectedly, sometimes even during sleep.

DSM IV criteria


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Panic disorder epidemiology•

-1-3% of general population; 5-10% of primarycare patients ---Onset in teens or early 20 ’s • -Female:male 2-3:1

Prognosis :• Good with treatment.• Course is variable, but often chronic• Relapse are common

50% continue to have mild infrequent symptoms30-40% remain free of symptoms after treatment


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Treatment Panic disorder•

Up to70% treatment response• Education, reassurance, elimination of

caffeine, alcohol, drugs, OTC stimulants• Cognitive-behavioral therapy• Medications – SSRIs, venlafaxine,

Acute initial treatment with benzodiazepine( only for short period up to 5 weeks).SSRI :it is drug of choice for panic disorderSSRI takes 2 to 4 weeks to be effectiveTreatment should be For 1 year


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Panic disorder co morbidity

• 30-50% have agoraphobia – avoidance of situations where escape would be

difficult• 50-60% have lifetime major depression

– one third with current depression• 20-25% have history of substance dependence


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Treatment Agoraphobia:

• SSRI : first line treatment• Behavior therapy


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Social Anxiety Disorder


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Social anxiety disorderA. A marked fear of one or more social or performance situationsin which the person is exposed to unfamiliar people.

The individual fears that he or she will act in a way (or show anxietysymptoms) that will be humiliating or embarrassing.

B. Exposure provokes anxiety /panic attack.

C. The person recognizes that the fear is excessive orunreasonable.

D. situations are avoided or else are endured with intense anxietyor distress.

B. Exposure to the feared social situation almost invariably provokesanxiety /panic attack.


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SAD epidemiology

• 12% of general population• Age of onset teens; more common in women.•

Causes significant disability• Increased depressive disorders

Incidence of social anxiety disorders and the consistent risk for secondary depressionin the first three decades of life. Arch Gen Psychiatry 2007 Mar(4):221-232

Stein found half of SAD patients had onset of sx by age 13 and 90% by age 23.


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Social anxiety disorder

Prognosis:

Chronic disorder.

Can disturb patient academic achievement, job& social development.


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treatment Social phobia:

• SSRI• Beta blocked ( control symptoms of

performance anxiety)• Cognitive behavior therapy


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Specific Phobia

• Marked or persistent fear that is excessive orunreasonable cued by the presence or anticipation ofa specific object or situation – The person recognizes the fear is excessive or

unreasonable – It interferes significantly with the persons routine or

function


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Specific Phobia

• Epidemiology

-Up to 20% of general population-Onset early in life-Female:male=2-3:1

Case of wasp phobia. Told of results…cured. Not social phobia.


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Common specific phobia

flying , heights, animal, blood or needles, death.

Treatment : systemic desensitizationGradual exposure to feared object / situation

while teaching relaxation and breathingtechniques.

Simple phobia Intense fears induced by presence /anticipation of a specific object or situation


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OCD

Obsessions as defined by (1), (2), (3), and (4):

(1) recurrent, persistent and intrusiv e thoughts, impulses, orimages that cause marked anxiety

(2) They are not simply excessive worries about real-lifeproblems ( senseless)

(3) the person attempts to ignore them or to neutralize them

with some other thought or action(4) the person realizes thoughts are a product of his or her

own mind

http://www.behavenet.com/capsules/disorders/anxiety.htmhttp://www.behavenet.com/capsules/disorders/anxiety.htmhttp://www.behavenet.com/capsules/disorders/anxiety.htm


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Compulsions as defined by (1) and (2): •

(1) Repetitive behaviors or mental act that theperson feels driven to perform in response to anobsession.

•

(2) the behaviors or mental acts are aimed atpreventing or reducing anxiety

• They are aimed at lowering distress or preventing some

dreaded event or situation; however, these behaviors ormental acts either are not connected in a realistic waywith what they are designed to neutralize or prevent orare clearly excessive.


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• At some point the person has recognized thatthe obsessions or compulsions are excessive

• The obsessions or compulsions cause markeddistress, take > 1 hour/day or interfere withthe person’s normal routine or function


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Examples of OCD

• Common pattern of OCD:• Obsession about contamination ------excessive

hand washing/ aviodance of feardcontamination

• Obsession of doubt- ----- repeated checking• Obsession of symmetry- ------slow

performance at task


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Obsessive-Compulsive DisorderEpidemiology

• 2-3% of generalpopulation

• Onset in childhood or

teens in men, 20 ’s inwomen

• Female:Male Ratio 1:1• Comorbidities: 70-80%

recurrent depression


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Etiology of OCD

• Neurochemical :Abnormal regulation of serotonin

•

Genetic :Rate are higher in first –degree relativesmonozygotic twins than in general population

•

Psychosocial :OCD is triggered by stressful life event


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OCD Treatment

• 40-60% treatment response• Serotonergic antidepressants•

Behavior therapy• Adjunctive antipsychotics


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Pharmacological:SSRI : first drug of choice

Higher than normal doses may be neededIt require 1 to 2 months to have an effect

Clomipramine a TCA with high serotonergic properties

Antipsychotic : adjunct therapy with serotonergicagent_ Risperidal , Aripiprazole


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Treatment of OCD

Behavioral treatment:

Exposure and relapse prevention

Prolong exposure to the obsesstional idea andprevention of the relieving compulsion

Relaxation training


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Generalized Anxiety Disorder ( GAD)


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GAD

•

Excessive anxiety and worry about daily events and activities for at least 6months• B. It Is Difficult to control the worry.• C. The anxiety associated with 3>= of the following

(1) restlessness(2) fatigued .

(3) difficulty concentrating(4) irritability (5) muscle tension(6) sleep disturbance (difficulty falling or staying asleep, or unsatisfyingsleep)

1. Pt have excessive worry about general daily events.2. Other symptoms palpitation trembling, sweating dry mouth, abdominal

discomfort: low mood , obsession thoughts hypochondriasis3. Most pt. first seek out general doctors because of their somatic complaints (

fatigue, muscle tension)4. sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying

sleep

Criteria DSM V

http://www.behavenet.com/capsules/path/irritable.htmhttp://www.behavenet.com/capsules/path/irritable.htm


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Generalized Anxiety Disorder ( GAD)Epidemiology

• 2-4% of general population• Female:male

2 to 1 – Start early adult life ( present 35-45 years of age)

•

Prognosis:• Chronic illness, with low probability of achieving

recovery


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Case

• A 36 years old office clerk state she isconstantly wonders if she is capable of doingher job, and feels as if she is not good enough. She constantly worry about the school bills,telephone bills, and her children health andfuture .this has been going on for several years

.


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Treatment of GAD

Pharmacological:SSRIEffexore XR Adjunct treatment withBenzodiazepine (Clonazepam, Diazepam )Others:

PsychotherapyRelaxation


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Post Traumatic Stress Disorder


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A. The person has been exposed to a traumatic event(actual or threatened death or serious injury )

Recurrent re-experiencing of the traumatic event(indreams , flashbacks)

Severe anxiety when exposed to internal or external

cues that symbolize or resemble an aspect of thetraumatic event/ avoid stimuli associated withtrauma.

Clinical presentation:


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PTSD clinical pic.

• Numbing of responsiveness ( feelingdetachment , shallow affect)

• Symptoms must be present for at least ONE

Month• Increased arousal as indicated by 2>=:

(1) Difficulty falling or staying asleep(2) Irritability or outbursts of anger(3) Difficulty concentrating(4) Exaggerated startle response

http://www.behavenet.com/capsules/path/irritable.htmhttp://www.behavenet.com/capsules/nrml/startleresponse.htmhttp://www.behavenet.com/capsules/nrml/startleresponse.htmhttp://www.behavenet.com/capsules/path/irritable.htm


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Symptomatology: Key featuresAttacks of intense fear, No trigger, duration10-30 min.Panic Disorder

Fear of embarrassment-panic attacks in socialsituations

Social phobia

Worry++++++,about daily activitiesGAD

Nightmares, flash backs after major traumaPTSD

obsessions and compulsionsOCD

Irrational fear of specific object /situationSpecific phobia


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Take home points• Anxiety disorders are common, common, common!• There are significant comorbid psychiatric conditions

associated with anxiety disorders!•

Screening questions can help identify or rule outdiagnoses• There are many effective treatments including

psychotherapy and psychopharmacology•

There is a huge amount of suffering associated withanxiety disorders!


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Treatment of anxiety disorders

SSRIFirst line for the treatment (broad spectrum ofefficacy, favorable SE profile and lack ofcardiotoxicity. ( Prozac,paroxetine,,FevarinCipralex, lustral )

SNRI : ( Effexor XR)


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Points for treatment of anxietydisorders

• At start of Treatment ( SSRI or SNRI) : Restlessness,insomnia, increased anxiety.

• Panic patients are very sensitive to somaticsensations: the starting dose should be low andtypically half the usual starting dose.

• There is delay 2-3 weeks in response

• No clear evidence of different efficacy betweenSSRI &SNRI class to guide selection.


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Tricyclic Antidepressant ( TCA)

• Imipramine( Tofranil) – clomipramine• Have potency for serotonergic uptake• Not used as much due to it’s greater side

effect profile : anticholinergic effect,orthostasis , wieght gain, cardiac conductiondelays, lethality in overdose, drop out rate upfrom 30%-70% in most studies

• Start low to avoid activation syndrome


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Benzodiazepines

• Rivotril, Xanax, Ativan• Not appropriate to use it as a monotherapy.• effective, tolerable , use at beginning of

treatment , rapid action• SE: sedation, ataxia & memory impairment


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psychotherapy

• Reassurance• Cognitive behavior therapy• Behavior therapy (flooding, desensitization)


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Medical causes of anxiety disorders

HyperthyrodismVitamin B12 deficiencyNeurological disorder( epilepsy,braintumors,MS,ect)Cardiovascular

Hypoglycemia


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medication or substance- inducedanxiety disorder:

• Caffeine• Amphetamine• Alcohol and sedative withdrawal• Other ilicit drug withdrawal• Antidepressant•

Penicillin

2 anxiety disorders mine

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