1. ANXIETY DISORDERS 1 AHMAD ALHADI, MD Psychiatrist and Psychotherapist KSU, KKUH AHMAD ALHADI, MD Psychiatrist and Psychotherapist KSU, KKUH

2. IntroductionIntroduction Normal vs Abnormal GAD, Panic Dis., Agoraphobia, Social Phobia, Specific Phobia (Part 1). OCD (Part 2). Acute & PTSD, Adjustment Dis., Grief (Part 3). Normal vs Abnormal GAD, Panic Dis., Agoraphobia, Social Phobia, Specific Phobia (Part 1). OCD (Part 2). Acute & PTSD, Adjustment Dis., Grief (Part 3).

3. ABNORMAL ANXIETY NORMAL ANXIETY Out of proportion body responses > External trigger Many – severe – prolonged & interfere with life. GAD-Panic-Phobias Acute &PTSD- …etc Proportional to the trigger (time & severity). External trigger > body responses. few - not severe - not prolonged & minimal effect on life. Trait (character) State (situational) 1-Apprehension 2- Attention 3- Features 4- Types

4. Anxiety Disorders

5. Features of Anxiety PhysicalPsychological Neuro: ENT: CVS & CHEST: GI: Genito-urin.: SKIN: MSS: Apprehension + hypervigilance Excessive worries + anticipation Difficulty concentrating Feeling of restlessness Sensitivity to noise Sleep disturbance

6. Vicious cycle of panic attack

7. Mental Disorders among Adults (18 and older), in the past year (2001)

8. William R Yates, Anxiety Disorders: Multimedia 2010

10. Fear network Fear network centered in the Amygdala which has interaction with : Hippocampus, hypothalamic and brainstem sites (observed signs of fear responses) Neuroanatomical Hypothesis of Panic Disorder, Revised, Jack M,2004

11. Anxiety Disorders 1.Generalized Anxiety Disorder (GAD) 2.Panic Disorder 3.Agoraphobia 4.Specific Phobia 5.Social Phobia. 6.Obsessive Compulsive Disorder (OCD) 7.Post Traumatic Stress Disorder (PTSD), Acute Stress Disorder 1.Generalized Anxiety Disorder (GAD) 2.Panic Disorder 3.Agoraphobia 4.Specific Phobia 5.Social Phobia. 6.Obsessive Compulsive Disorder (OCD) 7.Post Traumatic Stress Disorder (PTSD), Acute Stress Disorder

12. Criteria:  6 months duration – most of the time  Excessive worries about many events : ( routine themes, Difficult to control or relax, not productive, expect terrible events if not worry, worry about not being worried or when everything is going well in pt’s life).  Multiple physical & psychological features.  Significant impairment in function.  Not due to GMC, substance abuse or other axis I psychiatric disorder. Criteria:  6 months duration – most of the time  Excessive worries about many events : ( routine themes, Difficult to control or relax, not productive, expect terrible events if not worry, worry about not being worried or when everything is going well in pt’s life).  Multiple physical & psychological features.  Significant impairment in function.  Not due to GMC, substance abuse or other axis I psychiatric disorder. Generalized Anxiety Disorder

13. Associated features:  panic attacks (episodes of short severe anxiety).  Sadness +/- weeping  Overconcerned about body functions (heart, brain,...) MSE :  Tense posture, excessive movement e.g. hands (tremor) & head, excessive blinking  Sweating.  Difficulty in inhalation. Associated features:  panic attacks (episodes of short severe anxiety).  Sadness +/- weeping  Overconcerned about body functions (heart, brain,...) MSE :  Tense posture, excessive movement e.g. hands (tremor) & head, excessive blinking  Sweating.  Difficulty in inhalation. Generalized Anxiety Disorder

15. 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.  Co-morbidity is high ( panic d, depression, substance abuse…etc). 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.  Co-morbidity is high ( panic d, depression, substance abuse…etc). Generalized Anxiety Disorder

16. 90.4% of persons with GAD met criteria for another psychiatric disorder over the course of their lifetime. 90.4% of persons with GAD met criteria for another psychiatric disorder over the course of their lifetime.

17. D Dx :  Anxiety due to other physical problems: anemia –hyperthyroidism – hypoglycemia-BA - Rx – sub. Abuse.  Psychotic disorders.  Depressive disorders.  Panic disorder.  Hypochondriasis.  Mixed anxiety & depressive disorder.  Adjustment disorder with anxious mood.  Normal reaction to stress. D Dx :  Anxiety due to other physical problems: anemia –hyperthyroidism – hypoglycemia-BA - Rx – sub. Abuse.  Psychotic disorders.  Depressive disorders.  Panic disorder.  Hypochondriasis.  Mixed anxiety & depressive disorder.  Adjustment disorder with anxious mood.  Normal reaction to stress. Generalized Anxiety Disorder

18. Course & Prognosis If not properly treated :  chronic, fluctuating & worsens with stress.  Secondary depression.  Possible physical complications: e.g. HTN,DM.IHD Poor Prognostic Factors:  Very severe symptoms  Personality problems  Uncooperative patient.  Derealization Course & Prognosis If not properly treated :  chronic, fluctuating & worsens with stress.  Secondary depression.  Possible physical complications: e.g. HTN,DM.IHD Poor Prognostic Factors:  Very severe symptoms  Personality problems  Uncooperative patient.  Derealization Generalized Anxiety Disorder

19.  Rule out common physical reasons.  Explain the nature of the illness & symptoms.  Reassure that symptoms are not due to a physical disease.  Reduction of caffeine intake.  Draw attention to psychological factors (connect with his affect).  Behavioral Therapies (CBT, Relaxation training, Meditation….).  Short course(2/52) BDZ e.g. lorazepam.  Long term Rx: SSRI-SNRI-TCA- buspirone  Rule out common physical reasons.  Explain the nature of the illness & symptoms.  Reassure that symptoms are not due to a physical disease.  Reduction of caffeine intake.  Draw attention to psychological factors (connect with his affect).  Behavioral Therapies (CBT, Relaxation training, Meditation….).  Short course(2/52) BDZ e.g. lorazepam.  Long term Rx: SSRI-SNRI-TCA- buspirone Generalized Anxiety Disorder

20. PANIC Any Qs?

22. Panic attack :  a symptom not a disorder.  episodic sudden intense fear (of dying, going mad, or loosing self-control).  Can be part of many disorders: panic disorder, GAD, phobias, sub. Abuse, acute & PTSD. 3 types: 1- unexpected. 2- situationally bound. 3- situationally predisposed. Panic attack :  a symptom not a disorder.  episodic sudden intense fear (of dying, going mad, or loosing self-control).  Can be part of many disorders: panic disorder, GAD, phobias, sub. Abuse, acute & PTSD. 3 types: 1- unexpected. 2- situationally bound. 3- situationally predisposed. Panic Disorder: Disorder with specific criteria: 1- unexpected recurrent panic attacks (+/- situationally bound). 2- one month period (or more) of persistent concerns about another attack or implications of the attack or changes in behavior. 3- Not due to other disorders Panic Disorder

23. Spontaneous Essential to diagnose Panic Disorder Occur on anticipation Or immediately on exposure to the trigger e.g. specific phobia can be ass./with panic disorder Exposure is likely but not always trigger them e.g. social phobia Panic Attacks Unexpected Situationally bound Situationally predisposed

24. Epidemiology Epidemiology Women > men Prevalence : 1– 3 % Age at onset : 20 --- 35 years Epidemiology Epidemiology Women > men Prevalence : 1– 3 % Age at onset : 20 --- 35 years Etiology Etiology  Genetic predisposition  Disturbance of neurotransmitters NE & 5 HT NE & 5 HT in the locus ceruleus (alarm system (alarm system in the brain ) in the brain )  Behavioral conditioning  Mitral valve prolapse 2x ?..% not increased in Echo. MVP

25. Course & Prognosis Course & Prognosis  With treatment : good  Some pts recover within weeks even with no treatment.  Others have chronic fluctuating course. Course & Prognosis Course & Prognosis  With treatment : good  Some pts recover within weeks even with no treatment.  Others have chronic fluctuating course. Management Management  Rule out physical causes.  Support & reassurance  Relaxation & CBT  Medications: BNZ BNZ SSRIs SSRIs TCAs TCAs

26. PHOBIA S Any Qs So far?

27. Phobic Disorders Irrational excessive fear ± panic attack on exposure + avoidance or endured with +++ discomfort Agoraphobia Social Specific 1)Away from home, 2) Crowded places, or 3)confinement (in- closed spaces e.g. bridges or in-closed vehicles ( e.g. bus) *where it is difficult or embarrassing to escape or get help. *Anxiety about fainting and / or loss of control Functional impair. Embarrassment when observed performing badly or showing anxiety features) e.g. speaking in public, leading prayer serving guests *Functional impair. Objects or situations e.g. blood ex. dental clinic hospital airplane (height) animals insects thunder storms closed spaces/lifts darkness

28. VIDEO 2&3

29. Agoraphobia SocialSpecific Epidemiology: F : M = 2 : 1 Prevalence : 2–10%. Onset : 20–35 y. Etiology: Personality predis. Psychosocial trigger. Treatment : CBT with graded exp. Medications : Either; SSRIs, TCAs, or MAOIs +/- BNZ Epidemiology: M : F = ? Cultural F. prevalence : 3-13% only 10 % come. Etiology: Genetic predis. (shyness) psychosocial (shame – criticism) Treatment: CBT, Ass. T. & SST Medications : PRN : B-blockers, BNZ SSRIs, MAOIs, or TCA Epidemiology: F>M common in children Etiology : ? Modeling cont. of childhood fears Conditioning. Genetics (blood phobia) Treatment : Behavior therapy: ERP +/- B blockers / BNZ

30. Video 4 (therapy)

31. Normal vs Abnormal GAD, Panic Dis., Agoraphobia, Social Phobia, Specific Phobia (Part 1). OCD (Part 2). Acute & PTSD, Adjustment Dis., Grief (Part 3). Normal vs Abnormal GAD, Panic Dis., Agoraphobia, Social Phobia, Specific Phobia (Part 1). OCD (Part 2). Acute & PTSD, Adjustment Dis., Grief (Part 3).