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. 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 Normal Anxiety : advantageous response to a threatening situation Pathological Anxiety: inappropriate response to a given stimulus. Pathological Anxiety: inappropriate response to a given stimulus. Fear: A response to a known, external, definite threat Fear: A response to a known, external, definite threat

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

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

PANIC DISORDER Epidemiology: PD:1.5-5%,PA: 3-5.6% A: 0.6-6% Epidemiology: PD:1.5-5%,PA: 3-5.6% A: 0.6-6% DSM 5 CRITERIA FOR PANIC DISORDER DSM 5 CRITERIA FOR PANIC DISORDER 1- Recurrent unexpected panic attacks 1- Recurrent unexpected panic attacks 2- Persistent concern about having additional attacks 2- Persistent concern about having additional attacks 3- Worry about its consequences ( going crazy..) 3- Worry about its consequences ( going crazy..) 4- Significant change in behaviour 4- Significant change in behaviour 5- Panic attacks are not due to a substance or a medical condition or another mental disorder 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: 4 or more of the following symtoms: * palpitations * palpitations * sweating * sweating * trembling or shaking * trembling or shaking * shortness of breath * shortness of breath * feeling of choking * feeling of choking * chest pain * chest pain * nausea or abdominal discomfort * nausea or abdominal discomfort * feeling dizzy, lightheaded, faint * feeling dizzy, lightheaded, faint * derealization- depersonalization * derealization- depersonalization * fear of losing control or going crazy * fear of losing control or going crazy * fear of dying * fear of dying * numbness or tingling sensations * numbness or tingling sensations * chills or hot flushes * chills or hot flushes

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

COURSE AND PROGNOSIS Onset: early adulthood Onset: early adulthood %30-40 → long term symptom free %30-40 → long term symptom free %50 → mild symptoms %50 → mild symptoms %10-20 → significant symptoms %10-20 → significant symptoms %40-80 → depression develops %40-80 → depression develops %20-40 → alcohol adn substance dependance %20-40 → alcohol adn substance dependance TREATMENT: TREATMENT: Benzodiazepines ( alprazolam, lorazepam ) Benzodiazepines ( alprazolam, lorazepam ) SSRI’s ( paroxetine, sertraline, citalopram ) SSRI’s ( paroxetine, sertraline, citalopram ) Cognitive behaviour therapy 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. 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 ) 5-10% ( most common anxiety disorder ) Early beginning Early beginning Animals ( ailurophobia-cats, cynophobia-dogs) Animals ( ailurophobia-cats, cynophobia-dogs) Natural enviroment( storms,acrophobia-height) Natural enviroment( storms,acrophobia-height) Blood-injection-injury Blood-injection-injury Situational ( elevators, airoplane ) Situational ( elevators, airoplane ) Other ( mysophobia-germs,nasophobia-illness, death) Other ( mysophobia-germs,nasophobia-illness, death) Treatment: Treatment: Exposure therapy Exposure therapy benzodiazepines benzodiazepines

SOCIAL PHOBIA 3-13%, teens 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. 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 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 person recognizes that the fear is excessive or unreasonable. The feared social or performance situations are avoided The feared social or performance situations are avoided Treatment: Treatment: SSRI’s, benzodiazepines SSRI’s, benzodiazepines Behavioral and cognitive therapy Behavioral and cognitive therapy

GENERALIZED ANXIETY DISORDER Prevalance: ~ % 5 Prevalance: ~ % 5 More likely to occur in people with «behavioral inhibition» More likely to occur in people with «behavioral inhibition» Excessive anxiety and worry about a number of events or activities. 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. 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: Treatment: Cognitive and behavioral therapy Cognitive and behavioral therapy SSRI’s, benzodiazepines SSRI’s, benzodiazepines

1. Feeling nervous, anxious, or on edge Not being able to stop or control worrying Worrying too much about different things Trouble relaxing Being so restless that it is hard to sit still Becoming easily annoyed or irritable 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. 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. The event is persistantly reexperienced as images, flashbacks, thoughts, dreams. Intense psychological distress at exposure to cues that symbolize or resemble the event Intense psychological distress at exposure to cues that symbolize or resemble the event Persistance avoidance of the stimuli and numbing of general responsiveness Persistance avoidance of the stimuli and numbing of general responsiveness Sleep disturbances, irritability, hypervigilance, difficulty concentrating, exaggerated startle response Sleep disturbances, irritability, hypervigilance, difficulty concentrating, exaggerated startle response 1 week-30 years 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 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 A subjective sense of numbing, detachment, absence of emotions Derealization, depersonalization, Derealization, depersonalization, Dissociative amnesia Dissociative amnesia The event is persistantly reexperienced as images, flashbacks, thoughts, dreams The event is persistantly reexperienced as images, flashbacks, thoughts, dreams Sleep disturbances, irritability, hypervigilance, difficulty concentrating, exaggerated startle response Sleep disturbances, irritability, hypervigilance, difficulty concentrating, exaggerated startle response

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

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