Anxiety disorders Dr. Eman Abahussain psychiatry consultant,kkuh,kauh.

Normal vs. Abnormal anxiety Anxiety Disorders: 1- GAD 2-Panic disorder 3- Agoraphobia 4- Social phobia 5- Specific phobia 6- Acute & PTSD 7- OCD

fear: is a response to a known external definite threat Anxiety: is a response to a threat that is unknown internal vague or conflictual.

ABNORMAL ANXIETY NORMAL ANXIETY Out of proportion body responses < Many – severe – prolonged & interfere with life. Proportional to the trigger ( time & severity). External trigger > body responses. few - not severe - not prolonged & minimal effect on life. -Apprehension - Attention - Features

: features of anxiety PhysicalPsychological CVS & CHEST: GI: GUT & RS: SKIN: CNS: MSS: Apprehension+ hypervigilance Excessive worries+ anticipation Difficulty concentrating Feeling of restlessness Sensitivity to noise Sleep disturbance

Generalized Anxiety Disorder Criteria: 6 months duration – most of the time Excessive worries about many events Multiple physical & psychological features Difficult to control Significant impairment in function Not due to GMC, substance abuse or other axis I psychiatric disorder

: COMORBIDITY: 50-90% other mental disorders. Epidemiology: women > men Prevalence : 3 – 5 %. Age of onset vary, range : 20 – 55 years. Pt. usually consults medical (non-psychiatric) specialties, and / or faith-healers first. MSE : Tense posture, excessive movement e.g. hands (tremor) & head, excessive blinking Sweating Difficulty in inhalation.

D Dx : Normal reaction to stress. Anxiety due to physical problems: anemia –hyperhyroidism - BA - Rx – sub. A. Panic disorder. Adjustment disorder with anxious mood. Somatization disorder. Hypochondriasis. Mixed anxiety & depressive disorder. Depressive disorders. Psychotic disorders.

Course & Prognosis chronic, fluctuating & worsens with stress. it may cause Secondary depression. Poor Prognostic Factors: Very severe symptoms Personality problems Uncooperative patient.

Management of GAD Rule out common physical causes. Explain the nature of the illness & symptoms. Reassure that symptoms are not due to a physical disease. Draw attention to psychological factors. Cognitive-Behavioral Treatment (CBT). Short course(2/52) BDZ e.g. lorazepam. Long term Rx: SSRI-SNRI-TCA - 6 months after initial response to treatment,(NICE guidelines),few studies examine relapse prevention.

Panic attack : a symptom not a disorder. Can be part of many disorders: panic disorder, GAD, phobias, sub. Abuse acute & PTSD It is adiscreate period of intense fear or discomfort,in which 4 of the anxiety symptoms developed abruptly and reached apeak within 10 min. Panic Disorder

Symptoms of panic attack : Palpitation Sweating Trembling Shortness of breath Feeling of choking Chest pain Feeling dizzy Fear of dying paresthesias

Panic Disorder: Disorder with specific criteria: 1- unexpected recurrent panic attacks (+/- situationally bound). 2- one month period (or more) of persistent concern about having another attack or worry about the implications of the attack, or change in behavior related to the attacks. 3- Not due to other disorders

Epidemiology Women > men Prevalence : 1– 3 % Age at onset : years Etiology Genetic predisposition Disturbance of neurotransmitters NE & 5 HT in the locus ceruleus ( alarm system in the brain ) Behavioral conditioning

Prognosis: 30-40% became symptoms free 50%have mild symptoms 10-20%continue to have significant symptoms

Management Rule out physical causes. Support & reassurance CBT: cognitive therapy( instructions about a patient false beliefs and information about panic attack) behavioral therapy (relaxation, breathing training, in vivo exposure) Medications: BNZ, SSRIs, TCAs Treatment should continue for 12 months or more.

Phobic Disorders Agoraphobia Social Specific Fear of being in places or situations from which escape might be difficult or embarrassing or help may not be available in the event of having panic or panic like attack. e.g. mosques public transport Functional impair. Embarrassment when observed performing e.g. speaking in public, leading prayer serving guests Sweating / tremor palpitation / SOB Functional impair. Objects or situations e.g. blood ex. dental clinic hospital airplane (height) animals insects thunder storms lifts darkness

Agoraphobia Social Specific Epidemiology: F : M = 2 : 1 Prevalence : 2 – 10%. Onset : 2o – 35 y. Etiology: Personality predis. Psychosocial trigger. Treatment : CBT with graded exp. Medications : Either; SSRIs, TCAs, or MAOIs +/- BNZ Epidemiology: M : F = ? Cultural F. prevalence : %. only 10 % come. Etiology: genetic predis. ( shyness ) psychosocial (shame – criticism ). Treatment: CBT, Assertiveness training. Medications : PRN : B-blockers, BNZ SSRIs, MAOIs, or TCA Epidemiology: M = F common in children Etiology : ? Modeling cont. of childhood fears Treatment : behavior therapy: exp. + / - BNZ

OCD 1-obsessions: Recurrent persistent intrusive thoughts impulses or images from his own mind, that cause marked distress and anxiety, pt tries to suppress them with some other thoughts or actions. 2-compulsions: Repetitive behaviors or mental acts that pt feels driven to do. 3- they are excessive or unreasonable 4- cause marked distress or time consuming or interfer with function.

-Contamination & washing - pathological doubt, Checking & counting Ablution, prayers… -intrusive thoughts: Images of aggression, Self- harm,Sexual act. -symmetry, and slowness -other symptoms: religious obsessions

Males = Females Lifetime prevalence = 2-3 % Mean age of onset = 20 – 25 yeas

the course is usually long but variable,some have fluctuating course and others constant one %have significant improvement 40-50% moderate improvement %remain ill or even worse.

D 1. Anxiety, panic and phobia. 2. Depressive disorders. 3. Hypochondriasis 4. Schizophrenia. 5. Organic mental disorders. 6. OCPD: perfectionism, orderliness…

Treatment Pharmacobehavioral : 1- Pharmacological: - SSRIs : fluoxetine - paroxetine clomipramine Duration of treatment 12 months and more. 2- Behavioral : exposure & response prevention others

Non – severe No OCPD Depressed / anxious mood Compliance with T Family support Good p. FactorsBad p. Factors  very – severe  OCPD  No Depressed / anxious mood  Non- Compliance with treatment.  No Family support

Thanks