izben c. williams, md, mph instructor. lecture # 12 anxiety, somatoform and factitious disordres,...
TRANSCRIPT
BEHAVIORAL SCIENCE
IzBen C. Williams, MD, MPHInstructor
Lecture # 12
ANXIETY, SOMATOFORM and
FACTITIOUS DISORDRES,
and MALINGERING
Anxiety DisordersDefinition: Anxiety is abnormal fear that is out of
proportion to any external stimulus Fear is a normal reaction to a known,
external source of dangerThe physiologic manifestations of anxiety
(qv), are similar to those of fear Anxiety is essentially unconscious
symptom formation in response to stress
Anxiety DisordersDefinition: Anxiety Disorder: A chronic condition
characterized by an excessive and persistent sense of apprehension, with physical symptoms such assweating, palpitations, irritability, muscle
tension, restlessness, GI and urinary disturbances,
It is essentially, unconscious symptom formation in response to stress
Anxiety Disorders
“The Scream”
Edvard Munch
The Vise
.
Anxiety DisordersDefinition: The boundary between normal and
pathologic anxiety cannot be drawn with great precision or confidence.
However, it is generally agreed that when anxiety substantially impairs work style or social adjustment, careful assessment is indicated, and treatment is likely to be worthwhile.
Anxiety DisordersTypes of Anxiety disorders:
Phobic disorder (specific and social)Panic disorderObsessive compulsive disorderPosttraumatic stress disorderGeneralized anxiety disorder
Anxiety DisordersI. Phobic Disorder:Def.: A phobia is a type of anxiety disorder, characterized by a persistent, intense and irrational fear and avoidance of a situation or object, to which the sufferer commits great lengths in avoiding, disproportional to any actual danger posed.
Anxiety DisordersI. Phobic Disorder:There are different types of phobias. Agoraphobia: (one of the most familiar) the
fear of being in public places, often stems from panic disorder as a result of trying to avoid places that have triggered past panic attacks.
Social phobia: is characterized by an undue fear of embarrassment in social situations; sometimes accompanied by panic attacks
Anxiety DisordersI. Phobic Disorder: (cont’d) Specific Phobias: Excessive or irrational fear in
response to the presence or anticipation of a specific object or situation (eg. Height, spiders, blood) Subtypes:
Animal type Natural environment type Blood-injection-injury type Situational type Other type (illness phobia, space phobia
Anxiety DisordersII. Panic Disorder:Panic attacks are unprovoked , sudden episodes
of anxiety that usually reach their peak within a few minutes and subside within an hour.
A sense of dread, which is the most prominent psychological symptom may be masked by, or seem to be in reaction to, the physical symptoms that frequently accompany panic attacks: palpitations, chest pain, sweating, dyspnea, tremors, dizziness, ……..
Anxiety DisordersII. Panic Disorder:Panic disorder: consists of recurrent panic
attacks characterized by sudden apprehension or fear and usually accompanied by autonomic arousal that is not a reaction to physical exertion, a life-threatening situation, a substance , a medical factor, or another disorder
May be accompanied by agoraphobia
Anxiety DisordersIII.Obsessive-Compulsive Disorder:Symptoms include persistent, intrusive, recurrent
ideas, thoughts, feelings, images, or impulses (obsessions), which are experienced as senseless and repugnant and which the patient tries to ignore or resist.
Repetitive stereotyped physical and mental actions (compulsions), which the patient recognizes as senseless and tries to resist, nay also occur
Compulsions are performed with a subjective sense of necessity
Anxiety DisordersIV. Post Traumatic Stress Disorder: describes……A syndrome of distress, re-experiencing, avoidance,
and arousal that develops after exposure to events or circumstances that involved actual death or injury or a threat to the physical integrity of oneself or others and that evoked intense fear, helplessness, or horror
Symptoms may appear immediately after the trauma or may be delayed
Symptoms of excessive arousal include insomnia, angry outbursts, difficulty concentrating, exaggerated startle response
Anxiety DisordersIV. Post Traumatic Stress Disorder:Treatment involves:
Discussion of the trauma as a means of achieving retroactive mastery
At times, confrontation of the perpetrators can help Group therapy often very helpful Adjunctive techniques (eg biofeedback) and
medication (esp. SSRIs and Carbamazepine)
Anxiety DisordersV. Generalized Anxiety Disorder:Symptoms include:
At least six months of unrealistic worry about a number of life circumstances accompanied by at least 3 of 6 additional symptoms of anxiety, including, insomnia irritability, restlessness, easy fatigability, difficulty concentrating, muscle tension
Treatment:Benzodiazepines, buspirone, and
antidepressants are drugs used. Relaxation training, hypnosis, biofeedback and related treatments are also useful
Anxiety Disorders
.
Anxiety DisordersAcute Stress Disorder (ASD).A traumatic event defined exactly as for PTSD,
produces anxiety or arousal, avoidance, re-experiencing, and acute or delayed dissociative symptoms
ASD begins within one month of the event and lasts up to 4 weeks
This may be followed by PTSD
Anxiety DisordersIllnesses that cause anxiety:Before investigating a psychological cause of anxiety, it is important to exclude the possibility of physical disordersCardiovascular disordersPulmonary disordersDisorders of the endocrine system and metabolismTumorsNeurologic disordersInfectionsDrug related disorders
Anxiety DisordersPsychological components of anxiety:Many patients display anxiety symptoms
that don’t meet the criteria for specific disorders:
Situational anxietyAnxiety about deathAnxiety about mutilation, loss of prowess or
attractivenessAnxiety about loss of self esteemSeparation anxiety
Anxiety DisordersPsychological components of anxiety:Many patients display anxiety symptoms
that don’t meet the criteria for specific disorders:
Stranger anxietyAnxiety about loss of controlAnxiety about dependency Anxiety about intimacyAnxiety about being punishedSignal anxiety
Anxiety DisordersThe organic basis of anxiety:Neurotransmitters involved in the
development of anxiety include:Gamma-aminobutyric acid (GABA)Serotonin Norepinephrine
Anxiety DisordersThe organic basis of anxiety:Brain areas likely involved in anxiety:
The locus ceruleus (site of noradrenergic neurons)
Raphe nucleus (site of serotonergic neurons)
Caudate nucleus (role in OCD)Temporal cortexFrontal cortex
Anxiety DisordersThe organic basis of anxiety:
Anxiety Disorders.
Anxiety DisordersThe organic basis of anxiety:Organic causes of anxiety symptoms
include:XS caffeine intake, Substance abuseHyperthyroidismVit B₁₂ deficiencyHypo or hyperglycemiaPulmonary disease, Cardiac arrhythmiaPheochromocytoma (adrenal medullary
tumor)
Anxiety DisordersTreatment of anxiety disorders:A. Psychotherapy
Effective in situational anxiety and anxiety related to identifiable intra-psychic conflict. May be facilitated by medication and behavioral techniques
B. Behavior therapyEffective in phobias; anticipatory, situational, and
generalized anxiety; some forms of panic, OCD
C. Pharmacotherapy: Broadly effective in anxiety disorders
Anxiety DisordersTreatment of anxiety disorders:A. Psychotherapy
Supportive therapySupport of defenses Reality testingAdviceAdaptive behavior
Expressive psychotherapyClarification, confrontation, interpretation
Anxiety DisordersTreatment of anxiety disorders:B. Behavior therapy
i. Systematic desensitizationii. Graduated in vivo exposureiii. Panic control therapyiv. Response preventionv. Stop thinkingvi. Adjunctive behavioral techniques (relaxation
techniques, hypnosis, biofeedback)
Anxiety DisordersTreatment of anxiety disorders:C. Psychopharmacology
i. Benzodiazepines – the most effective anxiolytics. Uses: panic anxiety, generalized and situational anxiety, insomnia.
ii. Heterocyclic antidepressants: (used in Panic disorder, GAD, OCD, PTSD, insomnia
iii. MAO inhibitors: in atypical depression with reverse vegetative symptoms, but also in panic and social phobia
iv. Buspirone (BuSpar): is a non-benzodiazepine anxiolytic; it is a partial agonist of serotonin receptor; no sedation, no dependence. Not use with MAO (fatal serotonin syndrome)
Anxiety DisordersTreatment of anxiety disorders:C. Psychopharmacology
v. Barbiturates: to be avoided in treating anxiety or insomnia
vi. Antihistamines: diphenhydramine (Benadryl)
vii. Neuroleptics: psychotic features, personality disorders
viii.β-blocking agents: eg propanalol. Not as predictably effective but useful
Somatoform DisordersSomatoform disorders:
The essential feature of these disorders is the presence of symptoms that suggest a physical cause, including pain, but the symptoms can't be traced back to any physical cause and they are not the result of substance abuse or another mental disorder
Somatoform DisordersSomatoform disorders:
a. Somatization disorder: Multiple physical symptoms recurring over a period of several years and are either unrelated to an identifiable physical disorder, or grossly in excess of physical findings
b. Conversion disorder: Loss or alteration of physical functioning that suggests physical disorder, but which instead is apparently an expression of psychologic conflict or need
Somatoform DisordersSomatoform disorders:
c. Somatoform Pain Disorder: essentially same as conversion disorder with physical pain being the primary symptom.
d. Hypochondriasis: The fear of having, or the belief that one has, a serious physical illness.
e. Body Dysmorphic Disorder: Preoccupations with imagined defect(s) in one’s physical appearance, that is out of proportion to any physical characteristic or abnormality
Somatoform DisordersTreatment include:
Individual and group psychotherapy, with strategies such asEstablishing a good therapeutic relationship Providing a multidisciplinary approach
including other medical professionalsIdentifying and decreasing social difficulties
on which the symptoms may ‘feed’Anxiolytic and antidepressant agents,
hypnosis, behavioral relaxation therapy
Factitious DisordersFeigning illness: A factitious disorder is a condition in which a
person acts as if they have an illness by deliberately producing, feigning, or exaggerating symptoms
Patients feign mental or physical illness, or actually induce physical illness in themselves or others for:Psychological gain (as in factitious disorder)Tangible gain (as in malingering)
Factitious DisordersFeigning illness:
Patients with factitious disorder often have some medical knowledge or have worked in the health field
Feigned symptoms commonly includeAbdominal pains, fever, blood in the urine,
induction of tachycardia, skin lesions and seizures