2. Anxiety Disorders By Dr seddigh HUMS

3. Anxiety Disorders Disorders to be discussed: –Panic disorder –Phobias –Obssessive compulsive disorder –Post-traumatic stress disorder –Generalized anxiety disorders

4. Panic Disorder introduction Agoraphobia Etiology Panic & MVP

5. Panic Attack Essential feature: a discrete period of intense fear or discomfort in the absence of real danger that is accompanied by at least four of 13 somatic or cognitive symptoms

6. Panic Attack Somatic or cognitive symptoms –Palpitations –Sweating –Feeling of choking –Chest pain or discomfort –Nausea or abdominal distress –Dizziness or lightheadedness –Derealization or depersonalization

7. –Fear of losing control or “going crazy” –Fear of dying –Paresthesias –Chills or hot flushes –Trembling/shaking –Shortness of breath Panic Attack Somatic and Cognitive Symptoms (cont’):

8. Panic Disorder Three types of panic attacks: –Uncued –Cued –Situationally predisposed

9. Panic Disorder Sudden onset Sense of imminent danger, doom, urge to escape Variability in frequency/severity of attack Concern for implications

10. Panic Disorder Age of onset –Median is 25 yrs, rare before age 15/after 40 Gender/Genetics –75-80% female –Relatives Life course

11. Panic Disorder Differential diagnosis

12. Panic Disorder Prevalence –Lifetime 1.5-5% –Clinical 10% in mental health setting 10-30% in vestibular, respiratory, neurology setting 60% in cardiology

13. Panic Disorder Treatment –Behavior therapy –Cognitive therapy –Medication Tricyclic antidepresssants, SSRIs, MAOIs, Benzodiazepines –Education

14. Serteraline,paroxetine, alprazolam SSRI BZD TCA MAO CARMAMAZEPIN, VALPORATE Na Ca.C.B BUSPIRONE

16. Phobias Specific Phobia Social Phobia

17. Phobias Epidemiology –Prevalence –Spicific phobia 11 % social 3-13% Age –Generally begins in childhood –Specific ph 5-9 y or 25-26 y –Social ph 12-15 y Gender –Female: Male 2:1

18. Phobias Specific Phobia –Diagnostic feature: Marked and persistent fear of clearly discernible objects or situations –Exposure evokes response –Patient avoids or endures stimulus –Diagnosis appropriate if interferes with routine life/patient stressed –No other mental disorder is present

19. Phobias Specific Phobia –Subtypes Animal type Natural environment type Blood-Injection-Injury type Situational type Other type

20. Phobias Specific Phobia – Acrophobia Agoraphobia Ailurophobia Hydrophobia Claustrophobia Pyrophobia Xenophobia Zoophobia

21. Phobias Epidemiology –Prevalence –Spicific phobia 11 % social 3-13% Age –Generally begins in childhood –Specific ph 5-9 y or 25-26 y –Social ph 12-15 y Gender –Female: Male 2:1

22. Phobias Specific Phobia-associated features and disorders: restricted lifestyle and social life May co-occur with other anxiety/mood/substance disorders

23. Phobias Social Phobia –Fears of social/performance situation in which embarrassment may occur –Diagnose if interferes with functioning, no other mental disorder present

24. Phobias Social Phobia Features –Hypersensitivity to criticism, rejection, low self-esteem –Poor social skills –Underachiever –Possible suicidal ideation

25. Phobias Progression –May increase in severity, debilitation –2 peak –continius

26. Phobias Treatment –Benzodiazepines –Begin low dosage, raise until symptoms gone –Abstain from alcohol –Patient may develop tolerance/dependence –Generally prescribed short-term –Beta Blocker’s

27. Social phobia SSRI BZD VENLAFAXINE BUSPIRONE MAO INH BETA BLOCKER’S

29. Obsessive-Compulsive Disorder Prevalence: 2-3 % fourth dx Gender: M=F Age of Onset: 20 Y

30. Obsessive-Compulsive Disorder A. Either obsessions or compulsions: Obsessions as defined by 1, 2, 3, and 4 1.Recurrent, persistent thoughts, impulses, or images that are experienced at some time during the disturbance, as intrusive and inappropriate and that cause marked anxiety or distress 2.The thoughts, impulses, or images are not simply excessive worries about real-life problems 3.The person attempts to ignore or suppress such thoughts, impulses, or images or tries to neutralize them with some other thought or action 4.The person recognizes that the obsessional thoughts, impulses, or images are a product of his or her own mind

31. Typical Obsessions Doubts (e.g. Did I turn off the stove? Did I lock the door? Did I hurt someone?) Fears that someone else has been hurt or killed Fears that one has done something criminal Fears that one may accidentally injure someone Worry that one has become dirty or contaminated Blasphemous or obscene thoughts NOT just excessive worries about real-life problems

32. Obsessive-Compulsive Disorder Compulsions as defined by 1 and 2 1.Repetitive behaviors or mental acts that the person feels driven to perform in response to an obsession or according to rules that must be applied rigidly 2.The compulsions are aimed at preventing or reducing distress or preventing some dreaded event or situation; however, these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent or are clearly excessive

33. Typical Compulsions Checking Cleaning/washing Doing things a certain number of times in a row Doing and then undoing things Doing things in a certain order, with symmetry Mental acts such as praying, counting, etc.

34. Obsessive-Compulsive Disorder B. The person has recognized that the obsessions or compulsions are excessive or unreasonable C. There is significant distress or an impairment in functioning due to the obsessions or compulsions D. If another Axis I disorder is present, the content of the obsessions or compulsions is not restricted to the other Axis I disorder E. The disturbance is not due to a GMC or substance

35. Obsessions and Compulsions Two Possibilities No relationship Relationship

36. OCD – Potential Causes Behavioral Perspective –Compulsions Cognitive Perspective –Obsessions

37. OCD – Potential Causes Genetic Perspective 35 % 1 st degree Biological Perspective –Serotonin dysfunction –Abnormal brain functioning – Beta hemolytic streptococci

38. OCD - Treatment Cognitive Behavioral Therapies –“Exposure and Response Prevention” (ERP) –SYSTEMATIC DESENSITIZATION Medications SSRI, CLOMIPRAMINE 50 – 70 % AUGMENTED : Li, VAL, CAR

39. Generalized Anxiety Disorder Criteria: –Excessive anxiety and worry for at least 6 months –Difficult to control the worry –Focus is not confined to specific other anxiety disorders, substance abuse or medical condition

40. Generalized Anxiety Disorder Symptoms –Anxiety and worry are associated with three (or more) of six symptoms: Restlessness Being easily fatigued Difficulty concentrating or mind “going blank”

41. Generalized Anxiety Disorder Symptoms (con’t) –Irritability –Muscle tension –Sleep disturbance

42. Generalized Anxiety Disorder May also experience: –Nausea –Sweating –Diarrhea –Exaggerated startle response

43. Generalized Anxiety Disorder The anxiety, worry or physical symptoms cause clinically significant distress or impairment in social, occupational or other important areas of functioning

44. Generalized Anxiety Disorder Associated disorders –Mood Disorders –Anxiety Disorders –Other stress-related conditions

45. Generalized Anxiety Disorder Specific features –Culture –Age –Gender –Familial pattern

46. Generalized Anxiety Disorder Treatment: –Anxiety management –Cognitive-behavioral therapy –Medication Benzodiazepines Buspirone [generic] SSRIs, tricyclic anti-depressants & MAOIs

47. Post-Traumatic Stress Disorder Clinical Description –Pathological emotional and behavioral condition than can follow exposure to traumatic stressor severe enough to lie outside range of usual human experience –Direct or witnessed experience of possible death, injury

48. Post-Traumatic Stress Disorder Traumatic Events examples –Direct experiences: Military combat/POW Personal assault Kidnapping Terrorist attack

49. Post-Traumatic Stress Disorder Traumatic Events examples –Torture –Natural/man-made disasters –Auto accidents –Life-threatening illness

50. Post-Traumatic Stress Disorder –Witnessed experiences: Observing death/injury/assault

51. Post-Traumatic Stress Disorder Clinical Description –May relive trauma/sleep problems –Lose interest/irritable/aggressive –Greater in females –Age non-specific –May be depressed/abuse substances/have other anxiety disorder

52. Post-Traumatic Stress Disorder Specifiers –Acute –Chronic –With delayed onset

53. Post-Traumatic Stress Disorder Prevalence –8% of U.S. adult population Course –Age non-specific Familial pattern

54. Post-Traumatic Stress Disorder Clinical intervention –Treatment –Referral for psychiatric evaluation Immediate intervention