2 anxiety disorders mine
TRANSCRIPT
-
8/9/2019 2 Anxiety Disorders mine
1/46
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
-
8/9/2019 2 Anxiety Disorders mine
2/46
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)
-
8/9/2019 2 Anxiety Disorders mine
3/46
Normal versus Pathologic Anxiety
• Normal anxiety is adaptive. It is an inbornresponse to threat
• Pathologic anxiety is anxiety that is excessive,impairs function.
-
8/9/2019 2 Anxiety Disorders mine
4/46
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
-
8/9/2019 2 Anxiety Disorders mine
5/46
-
8/9/2019 2 Anxiety Disorders mine
6/46
Panic Disorder
-
8/9/2019 2 Anxiety Disorders mine
7/46
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
-
8/9/2019 2 Anxiety Disorders mine
8/46
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
-
8/9/2019 2 Anxiety Disorders mine
9/46
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
-
8/9/2019 2 Anxiety Disorders mine
10/46
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
-
8/9/2019 2 Anxiety Disorders mine
11/46
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
-
8/9/2019 2 Anxiety Disorders mine
12/46
Treatment Agoraphobia:
• SSRI : first line treatment• Behavior therapy
-
8/9/2019 2 Anxiety Disorders mine
13/46
Social Anxiety Disorder
-
8/9/2019 2 Anxiety Disorders mine
14/46
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.
-
8/9/2019 2 Anxiety Disorders mine
15/46
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.
-
8/9/2019 2 Anxiety Disorders mine
16/46
Social anxiety disorder
Prognosis:
Chronic disorder.
Can disturb patient academic achievement, job& social development.
-
8/9/2019 2 Anxiety Disorders mine
17/46
treatment Social phobia:
• SSRI• Beta blocked ( control symptoms of
performance anxiety)• Cognitive behavior therapy
-
8/9/2019 2 Anxiety Disorders mine
18/46
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
-
8/9/2019 2 Anxiety Disorders mine
19/46
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.
-
8/9/2019 2 Anxiety Disorders mine
20/46
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
-
8/9/2019 2 Anxiety Disorders mine
21/46
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
-
8/9/2019 2 Anxiety Disorders mine
22/46
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.
-
8/9/2019 2 Anxiety Disorders mine
23/46
• 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
-
8/9/2019 2 Anxiety Disorders mine
24/46
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
-
8/9/2019 2 Anxiety Disorders mine
25/46
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
-
8/9/2019 2 Anxiety Disorders mine
26/46
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
-
8/9/2019 2 Anxiety Disorders mine
27/46
OCD Treatment
• 40-60% treatment response• Serotonergic antidepressants•
Behavior therapy• Adjunctive antipsychotics
-
8/9/2019 2 Anxiety Disorders mine
28/46
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
-
8/9/2019 2 Anxiety Disorders mine
29/46
Treatment of OCD
Behavioral treatment:
Exposure and relapse prevention
Prolong exposure to the obsesstional idea andprevention of the relieving compulsion
Relaxation training
-
8/9/2019 2 Anxiety Disorders mine
30/46
Generalized Anxiety Disorder ( GAD)
-
8/9/2019 2 Anxiety Disorders mine
31/46
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
-
8/9/2019 2 Anxiety Disorders mine
32/46
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
-
8/9/2019 2 Anxiety Disorders mine
33/46
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
.
-
8/9/2019 2 Anxiety Disorders mine
34/46
Treatment of GAD
Pharmacological:SSRIEffexore XR Adjunct treatment withBenzodiazepine (Clonazepam, Diazepam )Others:
PsychotherapyRelaxation
-
8/9/2019 2 Anxiety Disorders mine
35/46
Post Traumatic Stress Disorder
-
8/9/2019 2 Anxiety Disorders mine
36/46
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:
-
8/9/2019 2 Anxiety Disorders mine
37/46
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
-
8/9/2019 2 Anxiety Disorders mine
38/46
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
-
8/9/2019 2 Anxiety Disorders mine
39/46
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!
-
8/9/2019 2 Anxiety Disorders mine
40/46
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)
-
8/9/2019 2 Anxiety Disorders mine
41/46
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.
-
8/9/2019 2 Anxiety Disorders mine
42/46
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
-
8/9/2019 2 Anxiety Disorders mine
43/46
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
-
8/9/2019 2 Anxiety Disorders mine
44/46
psychotherapy
• Reassurance• Cognitive behavior therapy• Behavior therapy (flooding, desensitization)
-
8/9/2019 2 Anxiety Disorders mine
45/46
Medical causes of anxiety disorders
HyperthyrodismVitamin B12 deficiencyNeurological disorder( epilepsy,braintumors,MS,ect)Cardiovascular
Hypoglycemia
-
8/9/2019 2 Anxiety Disorders mine
46/46
medication or substance- inducedanxiety disorder:
• Caffeine• Amphetamine• Alcohol and sedative withdrawal• Other ilicit drug withdrawal• Antidepressant•
Penicillin