1. ANXIETY DISORDERS
Yard. Doç. Dr. Berfu Akbaş

2. 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

3. 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:

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

6. 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

7. 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

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

9. 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

10. SPECIFIC PHOBIAS

11. 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

12. 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

13. 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

14. 1. Feeling nervous, anxious, or on edge1 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

15. 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

16. 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

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

18. 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

19. Obsessive Compulsive Disorder

20. 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

21. 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).

22. 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

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

24. 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)

25. 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

26. 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”)

27. 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