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

2. ABNORMAL ANXIETY NORMAL ANXIETY Out of proportion < 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

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

4. 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

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

6. 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.

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

8. 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

9. 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-

11. Panic Disorder 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 concern about another attack or implication of the attack. 3- Not due to other disorders

12. Panic Attacks Unexpected Situationally bound Situationally predisposed 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

13. Epidemiology Women > men Prevalence : 1– 3 % Age at onset : 20 --- 35 years Etiology Genetic predisposition Disturbance of neurotransmitters NE & 5 HT in the locus ceruleus ( alarm system in the brain ) Behavioral conditioning Mitral valve prolapse 2x ?

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

15. Phobic Disorders Irrational excessive f ear on exposure + avoidance Agoraphobia Social Specific Crowded places difficult to escape : fainting/ vomiting diarrhea e.g. mosques main roads public transport malls / markets airports /queues 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 closed spaces/lifts darkness

16. 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 : 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: M = F common in children Etiology : ? Modeling cont. of childhood fears Treatment : behavior therapy: exp. + / - B- blockers / BNZ

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