Transcript Anxiety Disorders

Anxiety Disorders
Dr. Yousif A. Yaseen
Psychiatrist
College of Medicine - University of Duhok
2016-2017
What is Anxiety?
According to Kaplan and Sadock
• Anxiety is :
“a diffuse, unpleasant, vague sense of
apprehension,
often accompanied by autonomic symptoms
such as headache, perspiration, palpitations, tightness in the
chest, mild stomach discomfort, and restlessness,
as indicated by an inability to sit or stand still
for long.”
Fear, Anxiety and Worry
• Normal emotional responses
• Clear adaptive purpose
Pathological Anxiety
• Anxiety that is excessive, persistent,
easily triggered.
• Degree of the person’s fear is out-ofproportion to actual danger.
• Disrupts the person’s life and
functioning.
• Creates intense discomfort.
• Doesn’t respond to rational
reassurance.
• in pathological anxiety, attention is
focused also on the person's response
to the threat.
So, in Anxiety Disorders,
• the normal responses
become:
• excessive,
• persistent,
• easily triggered, and
• disruptive to the
person’s life.
Three Components of Anxiety
• Physical
• Psychological (Cognition and Emotion)
• Behaviours
The Physical Component
Trembling, twitching ,Shaking
Dizziness
Numbness/Tingling
Backache, headache
Muscle tension
Shortness of breath, hyperventilation
Fatigability
Startle response
Difficulty swallowing
Autonomic hyperactivity:
Flushing and pallor
Tachycardia, palpitation
Sweating
Cold hands
Diarrhea
Dry mouth (xerostomia)
Urinary frequency
Blurred Vision
The Psychological Component
Anxious Thoughts
Anxious Predictions
Anxious Beliefs and Interpretations
Difficulty in Attention and Memory
Indecissiveness
Mental Images
Unreality/Detachment
Hypervigilance
Insomnia
Decreased libido
Lump in the throat
The Behavioral Component
Avoidance of Situations and Activities
Subtle Avoidance Strategies, Safety
Signals, and Overprotective Behaviours
Alcohol, Drug, and Medication Use
Anxiety Disorders
– Generalized anxiety disorder (GAD)
– Social Phobia ( Social Anxiety Disorder)
– Agoraphobia
– Specific Phobia
– Panic disorder
– Separation Anxiety Disorder
– Selective Mutism
Anxiety disorders
Continuous anxiety
Episodic anxiety
Generalized anxiety disorder
In any situation
In defined situation
Separation
Phobias
Simple
phobia
Social
phobia
Mutism
Agoraphobia
Panic
disorder
Epidemiology
• Overall, anxiety disorders are among the most
prevalent of psychiatric disorders.
• Age; Earlier onset than depression
• Sex factor; More in females
• Frequency (Prevalence):
10-15% of general population
25% (life time prevalence)
• Strong genetic component
Shared features of Anxiety Disorders
• Substantial proportion of aetiology is stress related.
• Difference with Psychosis
- free of delusions and hallucinations !, good insight
- Reality testing is intact.
• Symptoms are ego dystonic (distressing)
• Disorders are enduring or recurrent.
• Demonstrable organic factors are absent
• Note: Hierarchy of Diagnosis Precedence:
Organic > Psychosis
> Depression > Anxiety
Risk Factors/Etiology
 Psychodynamic Theory
posits that anxiety occurs when instinctual drives arc thwarted
(dissatisfied).
Anxiety is a signal that the ego is having a hard time
mediating between reality, id and superego.
,.Different anxiety disorders are the result of different defense
mechanisms used to cope.
Attachment Theories : Bowlby = “anxious attachment”
 Behavioral Theory
anxiety is a conditional response to specific environmental
stimuli followed by its generalization, displacement, or
transference.
It may be learned through identification and imitation of anxiety
pattern in parents (social learning theory).
 Cognitive approach
Selective attention and catastrophic thinking:
Cognitive Appraisal (perceive threat)
Stimulus--->Appraisal---> Response
Albert Ellis identified basic irrational assumptions: e.g.. It
is necessary for humans to be loved by everyone
Aaron Beck :Those with GAD hold unrealistic silent
assumptions that imply imminent danger: e.g., Any strange
situation is dangerous
 Biologic Theories: implicate various neurotransmitters
(especially: ↓ gamma-aminobutyric acid [GABA], &
serotonin, ↑ norepinephrine & dopamine, and various CNS
structures (elevated responsiveness in the amygdala, part of
the fear circuit of the limbic system limbic system) HPA axis
dys-regulation, in addition to Genetic Component.
 Other Theories: Social (Stressful events & lack of support
network) and personality factors (e.g., avoidant, perfectionist
Treatment of Anxiety Disorders
The combination of
pharmacologic therapy and psychotherapy
is the most successful form of treatment.
I. Pharmacotherapy of Anxiety Disorders:
,Fluoxetine
A. Antidepressants
• Tricyclic and related antidepressants (TCA)
– E.g. amitriptyline, imipramine, , Clomipramine ,
Nortriptyline doxepin, mianserin, trazodone.
• Selective serotonin reuptake inhibitors (SSRI)
– E.g. fluoxetine, paroxetine, sertraline, citalopram,
escitalopram, fluvoxamine
• Monoamine-oxidase inhibitors (MAOI)
– E.g. moclobemide, phenelzine, isocarboxazid,
tranylcypromine
• Other antidepressants
– E.g. mirtazapine, venlafaxine, duloxetine
B. Benzodiazepines
Antianxiety drugs- Anxiolytics
• Commonly & widely used
• Very effective
• Chosen based on onset of action, potency,
side effects
– Ativan (lorazepam): most common
– Xanax (alprazolam): high risk of addiction
– Valium (diazepam)
II. Non-Drug Approaches to Anxiety
• A. General measures:
• 1. Patients should stop drinking coffee and other
caffeinated beverages, and avoid excessive alcohol
consumption.
• 2. Patients should get adequate sleep, with the use of
medication if necessary. Moderate exercise each day
may help reduce the intensity of anxiety symptoms.
• B. Psychotherapy
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a. Cognitive behavioral therapy, with emphasis on misinterpretation of physiologic
symptoms, may improve functioning in mild cases.
• b. Behavioral therapy:
- Exposure and response prevention
- Systemic desensitization
- flooding
• c. Supportive or insight oriented psychotherapy can be helpful in mild cases of
anxiety.
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d. Other Psychological managements
Education about nature of disorder
Structured problem solving (Coping skills)
Graded exposure to difficult situations
Support (guidance, advice, development of coping strategies)
Counseling
Stress management (relaxation techniques , meditation, Yoga, exercise
regimens that improve stress recovery)
Generalized Anxiety Disorder
Generalized anxiety disorder (GAD) is the most common of the anxiety
disorders.
It is characterized by unrealistic or excessive anxiety and worry about two or
more life circumstances for at least six months.
Diagnosis of Generalized Anxiety Disorder
• Excessive anxiety or worry is present most days
during at least a six-month period and involves a
number of life events.
• The anxiety is difficult to control.
• At least three of the following:
1. Restlessness or feeling on edge.
2. Easy fatigability.
3. Difficulty concentrating.
4. Irritability.
5. Muscle tension.
6. Sleep disturbance.
Clinical Features of Generalized Anxiety Disorder
• A. Other features often include insomnia,
irritability, trembling, muscle aches and soreness,
muscle twitches, clammy hands, dry mouth, and a
heightened startle reflex.
• Patients may also report palpitations, dizziness,
difficulty breathing, urinary frequency, dysphagia,
light-headedness, abdominal pain, and diarrhea.
• B. Patients often complain that they “can't stop
worrying,” which may revolve around valid
concerns about money, jobs, marriage, health,
and the safety of children.
Epidemiology
• A. Lifetime prevalence is 5%.
• B. The female-to-male sex ratio for GAD is 2:1.
• C. Most patients report excessive anxiety during
childhood or adolescence; however, onset after
age 20 may sometimes occur.
Course and prognosis
• Course is chronic; symptoms may diminish
as the patient get older.
• With time, secondary depression may
develop. This is not uncommon if the
condition is left untreated.
Treatment of Generalized Anxiety Disorder
The combination of
pharmacologic therapy and psychotherapy
is the most successful form of treatment.
I. Pharmacotherapy of Generalized Anxiety
Disorder:
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,Fluoxetine
II. Non-Drug Approaches to Anxiety
• 1. Patients should stop drinking coffee and other caffeinated
beverages, and avoid excessive alcohol consumption.
• 2. Patients should get adequate sleep, with the use of medication if
necessary. Moderate exercise each day may help reduce the
intensity of anxiety symptoms.
• 3. Psychotherapy
• a. Cognitive behavioral therapy,
• b. Supportive or insight oriented psychotherapy
4.Other Psychological managements: like Stress management
Panic Disorder
Patients with panic disorder report discrete
periods of intense terror and fear of impending
doom, which are almost intolerable
Diagnosis for Panic Disorder
1. Recurrent unexpected panic attacks occur, during which four of the following symptoms
begin abruptly and reach a peak within 10 minutes in the presence of intense fear:
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a. Palpitations, increased heart rate.
b. Sweating.
c. Trembling or shaking.
d. Sensation of shortness of breath.
e. Feeling of choking.
f. Chest pain or discomfort.
g. Nausea or abdominal distress.
h. Feeling dizzy, lightheaded or faint.
i. Derealization or depersonalization.
j. Fear of losing control or going crazy.
k. Fear of dying.
l. Paresthesias.
m. Chills or hot flushes.
2. At least one of the attacks has been followed by one month of one of the following:
A. Persistent concern about having additional attacks or Worry about the implications of
the attack, such as fear of having a heart attack or going crazy.
B. A significant change in behavior related to the attacks.
Clinical Features of Panic Disorder
• A. Patients often believe that they have a serious medical
condition. Marked anxiety about having future panic attacks
(anticipatory anxiety) is common.
• B. In agoraphobia, the most common fears are of being
outside alone or of being in crowds or traveling.
The first panic attack often occurs without an acute stressor or
warning.
Later in the disorder, panic attacks may occur in relation to
specific situations, and phobic avoidance to these situations
can occur.
• C. Major Depression occurs in over fifty percent of patients.
Agoraphobia may develop in patients with simple panic
attacks.
Elevation of blood pressure an tachycardia may occur during a
panic attack.
Epidemiology of Panic Disorder
• A. The lifetime prevalence of panic disorder is
between 1.5% and 3.5%. The female-to-male ratio is
3:1. Up to one-half of panic disorder patients have
agoraphobia.
• B. Panic disorder usually develops in early adulthood
with a peak onset in the mid twenties. Onset after
age 45 years is unusual.
• C. The suicide risk is markedly increased, especially
in untreated patients. Substance abuse, especially of
alcohol, may occur in up to 40% of patients.
Treatment of Panic Disorder
A. Mild cases of panic disorder can be effectively treated with cognitive
behavioral psychotherapy with an emphasis on relaxation and instruction
on misinterpretation of physiologic symptoms.
B. Pharmacotherapy is indicated when patients have marked distress from
panic attacks or are experiencing impairment in work or social functioning.
1. SSRI=Serotonin-specific reuptake inhibitors and tricyclic antidepressants
are most often used.
2. Benzodiazepines may be used adjunctively with TCAs or SSRIs during the
first few weeks of treatment
3. Monoamine oxidase inhibitors (MAOIs) may be the most effective agents
available for panic disorder, but these agents are not often used because
of concern over hypertensive crisis.
4. Buspirone (BuSpar) is not effective for panic disorder.
5.
Medication should be combined with cognitive behavioral therapy
for optimal outcome.
What is Phobia?
An extreme, irrational fear of a
specific object or situation that the
person trying to avoid.
Phobias
• General characteristics of phobias
– Fear sensations
– Avoidance behavior
– Cognitive recognition that the fear is out of
proportion to the stimulus
Agoraphobia
Agoraphobia
The presence of agoraphobia that has the following three
components:
• 1. Anxiety about being in places or situations where
escape might be difficult or embarrassing, or in which
help might not be available.
• 2. Situations are avoided or endured with marked
distress, or these situations are endured with anxiety
about developing panic symptoms, or these situations
require the presence of a companion.
• 3. The anxiety is not better accounted for by another
disorder, such as social phobia, where phobic avoidance
is only limited to social situations.
Agoraphobia
• Literally fear of market place or open
spaces
• Anxiety about being in situations from
which escape might be difficult
• Often secondary to panic attacks
• Avoided situations include: driving,
bridges, malls, long lines, sitting in middle
of row, etc.
Treatment of Agoraphobia
A. Psychotherapy : cognitive behavioral psychotherapy with an emphasis on
relaxation and instruction on misinterpretation of physiologic symptoms.
B. Pharmacotherapy is indicated when patients have marked distress from
panic attacks or are experiencing impairment in work or social functioning.
1. SSRI=Serotonin-specific reuptake inhibitors and tricyclic antidepressants
are most often used.
2. Benzodiazepines may be used adjunctively with TCAs or SSRIs during the
first few weeks of treatment
3. Monoamine oxidase inhibitors (MAOIs)
Medication should be combined with cognitive behavioral therapy
for optimal outcome.
Social Phobia
Diagnosis of Social Phobia
(Social Anxiety Disorder)
• Marked and persistent fear of social or
performance situations in which the person is
exposed to unfamiliar people or to scrutiny by
others. The individual often fears that he will act
in a way that will be humiliating or embarrassing.
• The person recognizes that the fear is excessive
or unreasonable.
• The feared situations are avoided or endured
with intense distress.
• The duration of symptoms is at least six months
Clinical Features of Social Phobia
A. Patients often display hypersensitivity to criticism,
difficulty being assertive, low self-esteem, and
inadequate social skills.
B. Avoidance of speaking in front of groups may lead to
work or school difficulties. Most patients with social
phobia fear public speaking, while less than half fear
meeting new people.
C. Less common fears include fear of eating, drinking, or
writing in public, or of using a public restroom.
Epidemiology and Etiology of Social Phobia
A. Lifetime prevalence is 3-13%.
B. Social phobia is more frequent (up to tenfold) in firstdegree relatives of patients with generalized
social phobia.
C. Onset usually occurs in adolescence, with a
childhood history of shyness.
D. Social phobia is often a lifelong problem, but the
disorder may remit or improve in adulthood.
Treatment of Social Phobia
A. Pharmacotherapy:
- SSRIs, such as paroxetine or sertraline, are first-line medications for
social phobia.
- Benzodiazepines, may be used if antidepressants are ineffective
(short course).
- Social phobia with Performance Anxiety (for specific situations
known to be anxiety provoking) responds well to beta-blockers,
such as propranolol. The effective dosage can be very low, such as
10-20 mg qid. It may also be used on a prn basis; 20-40 mg given
30-60 minutes prior to the anxiety provoking event.
B. Psychotherapy:
Cognitive/behavioral therapies are effective and should focus on
cognitive retraining, desensitization, and relaxation techniques.
C. Combined pharmacotherapy and cognitive or behavioral
therapies is the most effective treatment.
Specific Phobia
Diagnosis of Specific Phobia

Marked and persistent fear that is excessive or
unreasonable, which is caused by the presence or
anticipation of a specific object or situation.
 Exposure to the feared stimulus provokes an immediate
anxiety response, which may take the form of a panic
attack.
 Recognition by the patient that the fear is excessive or
unreasonable.
 The phobic situation is avoided or endured with intense
anxiety.
Specify Types of Phobias
1. Animal (e.g., dogs).
2. Natural Environmental (e.g.,
heights, storms, water).
3. Blood-injection injury.
4. Situational (e.g., airplanes,
elevators, enclosed
places)..
5. Other (e.g., situations that
may lead to choking,
vomiting).
Epidemiology of Specific Phobia
A. The lifetime prevalence of phobias is
10%.
Most do not cause clinically significant
impairment or distress.
B. Age of onset is variable, and females
with the disorder far outnumber males.
Treatment of Specific Phobia
A. The primary treatment is Behavioral Therapy.
 Commonly used technique is Systemic
Desensitization, consisting of gradually
increasing exposure to the feared situation,
combined with a relaxation technique such as
deep breathing.
 Other technique like flooding can be used.
B. Beta-blockers may also be useful prior to
confronting the specific feared situation.
Selective Mutism
• A. Consistent failure to speak in specific social situations in which
there is an expectation for speaking (e.g., at school) despite speaking in
other situations.
• B. The disturbance interferes with educational or occupational
achievement or with social communication.
• C. The duration of the disturbance is at least 1 month (not limited to
the first month of school).
• D. The failure to speak is not attributable to a lack of knowledge of, or
comfort with, the spoken language required in the social situation.
• E. The disturbance is not better explained by a communication
disorder (e.g., childhood onset fluency disorder) and does not occur
exclusively during the course of autism spectrum disorder,
schizophrenia, or another psychotic disorder.
Separation Anxiety Disorder
Developmentally inappropriate and excessive fear or anxiety concerning separation from those to
whom the individual is attached, as evidenced by at least three of the following:
• 1. Recurrent excessive distress when anticipating or experiencing separation from home or
from major attachment figures.
• 2. Persistent and excessive worry about losing major attachment figures or about possible
harm to them, such as illness, injury, disasters, or death.
• 3. Persistent and excessive worry about experiencing an untoward event (e.g., getting lost,
being kidnapped, having an accident, becoming ill) that causes separation from a major
attachment figure.
• 4. Persistent reluctance or refusal to go out, away from home, to school, to work, or elsewhere
because of fear of separation.
• 5. Persistent and excessive fear of or reluctance about being alone or without major
attachment figures at home or in other settings.
• 6. Persistent reluctance or refusal to sleep away from home or to go to sleep without being
near a major attachment figure.
• 7. Repeated nightmares involving the theme of separation.
• 8. Repeated complaints of physical symptoms (e.g., headaches, stomachaches, nausea,
vomiting) when separation from major attachment figures occurs or is anticipated.