ANXIETY DISORDERS Yard. Doç. Dr. Berfu Akbaş

A diffuse, unpleasant, vague sensation of apprehension, often accompanied by autonomic symptoms; palpitations, perspiration, headache, tightness in the chest, mild stomach discomfort, restlessness, dizziness, diarrhea, tremors, urinary frequency, hesitancy. Normal Anxiety : advantageous response to a threatening situation Pathological Anxiety: inappropriate response to a given stimulus. Fear: A response to a known, external, definite threat

Epidemiology: women life-time prevalence: % 30.5 Men : % 17.7 Autonomic Nervous System Neurotransmitters: Norepinephrine, serotonin, GABA Neuroanatomy:Locus cereleus, raphe nuclei, limbic system, temporal lobes Genetics:

Anxiety Disorders Panic Disorder Specific Phobia Social Phobia Posttraumatic Stress Disorder ( PTSD ) Acute Stress Disorder Generalized Anxiety Disorder

PANIC DISORDER Epidemiology: PD:1.5-5%,PA: 3-5.6% A: 0.6-6% DSM 5 CRITERIA FOR PANIC DISORDER 1- Recurrent unexpected panic attacks 2- Persistent concern about having additional attacks 3- Worry about its consequences ( going crazy..) 4- Significant change in behaviour 5- Panic attacks are not due to a substance or a medical condition or another mental disorder

PANIC ATTACK 4 or more of the following symtoms: * palpitations * sweating * trembling or shaking * shortness of breath * feeling of choking * chest pain * nausea or abdominal discomfort * feeling dizzy, lightheaded, faint * derealization- depersonalization * fear of losing control or going crazy * fear of dying * numbness or tingling sensations * chills or hot flushes

MEDİCAL CONDITIONS THAT CAN MIMIC A PANIC ATTACK Angina pectoris Arrithmias COPD Temporal lobe epilepsy Pulmonary Embolism Asthma Hyperthyroidism Hypoglycemia Pheochromacytoma

COURSE AND PROGNOSIS Onset: early adulthood %30-40→long term symptom free %50→mild symptoms %10-20→significant symptoms %40-80→depression develops %20-40→alcohol adn substance dependance TREATMENT: Benzodiazepines ( alprazolam, lorazepam ) SSRI’s ( paroxetine, sertraline, citalopram ) Cognitive behaviour therapy

SPECIFIC PHOBIAS

SPECIFIC PHOBIA A phobia is defined as an irrational fear that produces conscious avoidance of the fearred subject, activity or situation. 5-10% ( most common anxiety disorder ) Early beginning Animals ( ailurophobia-cats, cynophobia-dogs) Natural enviroment( storms,acrophobia-height) Blood-injection-injury Situational ( elevators, airoplane ) Other ( mysophobia-germs,nasophobia-illness, death) Treatment: Exposure therapy benzodiazepines

SOCIAL PHOBIA 3-13%, teens hyperactivation of the amygdala and insula in fMRI A marked fear of social or performance situations in which the person is exposed to unfamiliar people. The individual fears that he will act in a way that will be humiliating or embarrassing. Exposure to the feared social situation provokes anxiety which may take the form of panic attack The person recognizes that the fear is excessive or unreasonable. The feared social or performance situations are avoided Treatment: SSRI’s, benzodiazepines Behavioral and cognitive therapy

GENERALIZED ANXIETY DISORDER Prevalance: ~ % 5 More likely to occur in people with «behavioral inhibition» Excessive anxiety and worry about a number of events or activities. Anxiety and worry is associated with at least 3 of the followings: restlessness, being easily fatiqued, difficulty in concentrating, irritability, muscle tenion, sleep disturbance. Treatment: Cognitive and behavioral therapy SSRI’s, benzodiazepines

1. Feeling nervous, anxious, or on edge 1 2 3 2. Not being able to stop or control worrying 3. Worrying too much about different things 4. Trouble relaxing 5. Being so restless that it is hard to sit still 6. Becoming easily annoyed or irritable 7. Feeling afraid as if something awful might happen

POSTRAUMATIC STRESS DISORDER Develops after a person sees, is involved in or hears of an extreme traumatic stressor. The persons response involves intense fear, helplessness or horror. The event is persistantly reexperienced as images, flashbacks, thoughts, dreams. Intense psychological distress at exposure to cues that symbolize or resemble the event Persistance avoidance of the stimuli and numbing of general responsiveness Sleep disturbances, irritability, hypervigilance, difficulty concentrating, exaggerated startle response 1 week-30 years

ACUTE STRESS DISORDER Develops after a person sees, is involved in or hears of an extreme traumatic stressor. The persons response involves intense fear, helplessness or horror A subjective sense of numbing, detachment, absence of emotions Derealization, depersonalization, Dissociative amnesia The event is persistantly reexperienced as images, flashbacks, thoughts, dreams Sleep disturbances, irritability, hypervigilance, difficulty concentrating, exaggerated startle response

Pharmacotherapy Benzodiazepines: GABA A agonist SSRI’s TCI’s MAO inhibitors B- adrenergic receptor antagonists ( propranolol Antihistaminics Buspirone ( HT1a agonist) Ca channel blockers

ANXIETY DISORDER DUE TO A GENERAL MEDICAL CONDITION Thyroid disorders ( hyper-hypothyroidism ) Hypoglycemia Neurological Disorders ( MS, epilepsy, CVD, Parkinson) Anemia Cardiomyopathies, hypoxia, cardiac arrytmias SLE, RA, PAN ALCOHOL – DRUG WITHDRAWAL caffeine

Obsessive Compulsive Disorder

Facts and Figures Prevalence Originally believed to be rare >0.1% Recent evidence suggests 1-3% Onset / Characteristics: Males:, high prevalence of checking Females:, high prevalence of washing

OCD Diagnosis (1): DSM IV Obsessions defined by all of the following: Recurrent and persistent thoughts, impulses or images experience at some time during the disturbance, as intrusive and inappropriate and that cause marked anxiety or distress. The thoughts/impulses/images are not simply excessive worries about real life problems. The person attempts to ignore or suppress such thoughts/impulses/images, or neutralize them with some other thought or action. The person recognizes that the obsessional thoughts/impulses/images are a product of their own mind (not imposed from without).

OCD Diagnosis (2): DSM IV Compulsions defined by: Repetitive behaviors or mental acts that the person feels driven to perform in response to an obsession, or according to rules which must be applied rigidly The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation; however, these behaviors or mental acts either are not connected in a realistic way with what they are designed to neutralize or prevent, or are clearly excessive Not better accounted for by other diagnosis

What is an Obsession? Involuntary intrusive cognition Types Doubts (74%) Thinking (34%) Fears (26%) Impulses (17%) Images (7%) Other (2%)

Themes in Obsessions Obsessions often have common themes Contamination, dirt, disease, illness (46%) Violence and aggression (29%) Moral and religious topics (11%) Symmetry and sequence (27%) Sex (10%) Other (22%) The themes often reflect contemporary concerns (the devil, germs, AIDS)

Causes of OCD Elevated activity in the Frontal Lobe and Basal Ganglia Activity is not typical in people without mental illness PET (Positron emission Tomography) scan used in brain imaging

Pharmacotherapy SSRI’s Clomipramine First line, no major difference in class Higher doses than for MDD (ex. 80 mg fluoxetine) 10-12 weeks before switching Clomipramine first FDA approved, most serotonin specific of TCA’s, side effects Augmentation, no to Li, atypical antipsychotics, e.g. risperidone (5HT2A blockade suggests there’s more to it than just “low serotonin”)

Treatment Refractory Psychosurgery For patient’s who have failed meds and therapy Response rate approx. 50% Four surgical prodecures Cingulotomy, subcaudate tractotomy, limbic leukotomy, capsulotomy Interrupt signals from OFC to basal ganglia Gamma Knife Anterior limb of internal capsule