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Anxiety Anxiety & Anxiety Disorders Anxiety Disorders

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Page 1: Anxiety Anxiety & Anxiety Disorders Anxiety Disorders
Page 2: Anxiety Anxiety & Anxiety Disorders Anxiety Disorders

AnxietyAnxiety

& &

Anxiety Anxiety DisordersDisorders

Page 3: Anxiety Anxiety & Anxiety Disorders Anxiety Disorders

Anxiety DisordersAnxiety DisordersAnxietyAnxietyDiffuse, unpleasant, sense of apprehension Diffuse, unpleasant, sense of apprehension accompanied by autonomic symptoms to a accompanied by autonomic symptoms to a threat that is unknown, vague and threat that is unknown, vague and conflictualconflictualNormal if Less severe, shorter duration, Normal if Less severe, shorter duration, adaptive response, no suffering, improve adaptive response, no suffering, improve performance and needs no treatmentperformance and needs no treatmentFearFearAs anxiety, alerting symptom but to known, As anxiety, alerting symptom but to known,

external threatexternal threat

Page 4: Anxiety Anxiety & Anxiety Disorders Anxiety Disorders

Anxiety DisordersAnxiety Disorders are the most prevalent psychiatric conditionsare the most prevalent psychiatric conditions

produce morbidity , excessive use of health produce morbidity , excessive use of health services & functional impairmentservices & functional impairment

may increase cardiovascular - related mortalitymay increase cardiovascular - related mortality

are due to abnormal genes & traumatic life ventsare due to abnormal genes & traumatic life vents

treatment are among the most effective in treatment are among the most effective in psychiatric medicinepsychiatric medicine

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Epidemiology of anxiety Epidemiology of anxiety disordersdisorders: :

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Epidemiology of anxiety Epidemiology of anxiety disordersdisorders: :

are prevalent in 25% of total populationare prevalent in 25% of total population

women > menwomen > men

low socioeconomics > high low socioeconomics > high socioeconomicssocioeconomics

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Anxiety DisordersAnxiety Disorders

11 - -Panic disorder and agoraphobiaPanic disorder and agoraphobia

22 - -Social and specific phobiaSocial and specific phobia

33 - -Obsessive compulsive disorderObsessive compulsive disorder

44 - -Posttraumatic stress disorder and Posttraumatic stress disorder and Acute stress reactionAcute stress reaction

55 - -Generalized anxiety disorderGeneralized anxiety disorder

66 - -Other anxiety disordersOther anxiety disorders

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Anxiety Disorders( Etiology )Anxiety Disorders( Etiology )11 - -Psychoanalytical theoriesPsychoanalytical theories

Anxiety result from psychic conflict between sexual Anxiety result from psychic conflict between sexual or aggressive wishes and threats from external or aggressive wishes and threats from external realityreality

22 - -Behavioral theoriesBehavioral theories - -Classical conditioningClassical conditioning

- -Social learning theory: patients learn to respond Social learning theory: patients learn to respond excessively to stress e.g through modelingexcessively to stress e.g through modeling

33 - -Cognitive theoriesCognitive theories - -Patients misperceive situations as dangerous when Patients misperceive situations as dangerous when

they are notthey are not.. - -Overestimation of danger or harm and Overestimation of danger or harm and

underestimation of their abilitiesunderestimation of their abilities

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Anxiety Disorders( Etiology )Anxiety Disorders( Etiology )44 - -BiologicalBiological

A- Autonomic nervousA- Autonomic nervous

Increased Sympathetic toneIncreased Sympathetic tone

Adapt slowly to repeated stimuliAdapt slowly to repeated stimuli

Respond excessively to moderate stimuliRespond excessively to moderate stimuli

B- NeurotransmittersB- Neurotransmitters

Dysregulation of monoamines e.g nor epinephrine and Dysregulation of monoamines e.g nor epinephrine and serotoninserotonin..

- -GABAGABA

--Neuropeptide Y(counter regulatory effect on CRH and LC-NE Neuropeptide Y(counter regulatory effect on CRH and LC-NE

systemsystem))

--Galanin (an immunoreactive fiber system Galanin (an immunoreactive fiber system originating in the LCoriginating in the LC ……… ………

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Anxiety Disorders( Etiology )Anxiety Disorders( Etiology )D- Brain imaging studiesD- Brain imaging studies

- -CT ,MRICT ,MRI

Cerebral asymmetriesCerebral asymmetries

- -PET,SPECT,EEGPET,SPECT,EEG

Abnormalities in frontal, temporal and Abnormalities in frontal, temporal and occipital lobesoccipital lobes

E- GeneticsE- Genetics

Higher incidence in relatives indicate positive Higher incidence in relatives indicate positive genetic factorsgenetic factors

F-CRH and HPA-AxisF-CRH and HPA-Axis..

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11 - -Panic disorder and agoraphobiaPanic disorder and agoraphobiaDefinitionsDefinitionsPanic disorderPanic disorderSpontaneous, unexpected occurrence of panic Spontaneous, unexpected occurrence of panic attacksattacksPanic attacksPanic attacksDiscrete periods of intense fear or discomfort, Discrete periods of intense fear or discomfort, occurring over a short period develop abruptly occurring over a short period develop abruptly and reach a peak within 10 minutes not related to and reach a peak within 10 minutes not related to specific situation or object that can vary from specific situation or object that can vary from once/ day to few attacks / yearonce/ day to few attacks / yearAgoraphobiaAgoraphobiaFear of being alone in public places especially in Fear of being alone in public places especially in places in which rapid exit is difficultplaces in which rapid exit is difficult

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EpidemiologyEpidemiology

Life time prevalence: 1-5%Life time prevalence: 1-5%

Sex: Female: male = 3:1Sex: Female: male = 3:1

Age: young adulthood( before 30 years)Age: young adulthood( before 30 years)

Co morbidity = 90%Co morbidity = 90%

- -AgoraphobiaAgoraphobia

- -DepressionDepression

- -Other anxiety disordersOther anxiety disorders

- -Other psychiatric disorders as Other psychiatric disorders as Hypochondriasis, personality disorders, Hypochondriasis, personality disorders, substance abuse especially alcoholsubstance abuse especially alcohol

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Clinical picture of panic disorderClinical picture of panic disorder - -Commonly presents to the Emergency room Commonly presents to the Emergency room

complain of somatic concern of death from complain of somatic concern of death from cardiac or respiratory problemcardiac or respiratory problem

- -11stst attack usually spontaneous, may be precipitated attack usually spontaneous, may be precipitated by caffeine, alcohol, nicotine, sleep exertion, by caffeine, alcohol, nicotine, sleep exertion, unusual sleep patternunusual sleep pattern

- -Onset: suddenOnset: sudden

- -Course: rapidly progress within 10 minutesCourse: rapidly progress within 10 minutes

- -In-between attacks : patient has anticipatory In-between attacks : patient has anticipatory anxietyanxiety

-/+ - -/+ -Associated symptoms: Depression, suicide, Associated symptoms: Depression, suicide, substance intake, other anxiety disordersubstance intake, other anxiety disorder

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Panic disorderPanic disorder

Spontaneous , unexpected Spontaneous , unexpected periods of intense fearperiods of intense fear

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DSM IV Criteria of panic attackDSM IV Criteria of panic attackA discrete period of intense fear or discomfort A discrete period of intense fear or discomfort in which 4 or more symptoms are presentin which 4 or more symptoms are presentMental SymptomsMental Symptoms

11 - -Fear of dying ( can't name source of fear )Fear of dying ( can't name source of fear )22 - -Fear of losing control or going crazyFear of losing control or going crazy

33 - -Depersonalization( detachment from self) Depersonalization( detachment from self) and derealization (feeling of unreality)and derealization (feeling of unreality)Neurological symptomsNeurological symptoms

44 - -Parasthesia ( numbness or tingling Parasthesia ( numbness or tingling sensation)sensation)

55 - -Feeling dizzy, unsteady, or faintFeeling dizzy, unsteady, or faint66 - -Trembling or shakingTrembling or shaking

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Physical symptomsPhysical symptoms

77 - -Palpitation, pounding heart, Palpitation, pounding heart, accelerated heart rateaccelerated heart rate

88 - -Dyspnea and chest painDyspnea and chest pain

99 - -Chills or hot flushesChills or hot flushes

1010 - -SweatingSweating

1111 - -Nausea or abdominal distressNausea or abdominal distress

1212 - -feeling of chokingfeeling of choking

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DSM IV Criteria of panic disorder with or DSM IV Criteria of panic disorder with or without agoraphobiawithout agoraphobiaA- Both 1 and 2A- Both 1 and 2

11 - -Recurrent unexpected panic attacksRecurrent unexpected panic attacks22 - -at least one attack followed 1 month by at at least one attack followed 1 month by at

least 1 of the following ( anticipatory least 1 of the following ( anticipatory anxiety)anxiety)i- Concern about having additional attacksi- Concern about having additional attacksii- Worry about the consequencesii- Worry about the consequencesiii- a significant change in behavior related to iii- a significant change in behavior related to the attacksthe attacksB- +/- AgoraphobiaB- +/- Agoraphobia

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C- The panic attacks are not due to direct C- The panic attacks are not due to direct physiological effect of substance or general physiological effect of substance or general medical conditionmedical condition

D- The panic attacks are not due to other D- The panic attacks are not due to other mental disordermental disorder

E- FrequencyE- Frequency

Moderate = 3 attacks/ 3 weeksModerate = 3 attacks/ 3 weeks

Severe = 4 attacks/4 weeksSevere = 4 attacks/4 weeks

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DSM IV Criteria of agoraphobiaDSM IV Criteria of agoraphobiaA- Anxiety about being in place or situation A- Anxiety about being in place or situation ( Busy streets, closed spaces, crowded ( Busy streets, closed spaces, crowded stores ) from which escape may be difficult stores ) from which escape may be difficult or in which help may not be availableor in which help may not be availableB- The situations are avoided, done with B- The situations are avoided, done with anxiety, or require the presence of a anxiety, or require the presence of a companioncompanionC- The anxiety is not due to substance, C- The anxiety is not due to substance, general medical condition, or other mental general medical condition, or other mental disorderdisorderD- Complications: Psychosocial D- Complications: Psychosocial consequencesconsequences

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Differential diagnosisDifferential diagnosisMedical disordersMedical disorders

11 - -Cardiovascular disorderCardiovascular disorder

Angina, mitral valve prolapse, myocardial Angina, mitral valve prolapse, myocardial infarction, hypertension, cardiac infarction, hypertension, cardiac dysrhythmiasdysrhythmias

22 - -Pulmonary diseasesPulmonary diseases

Bronchial asthma, pulmonary embolusBronchial asthma, pulmonary embolus

33 - -Neurological diseaseNeurological disease

Migraine, temporal lobe epilepsy, multiple Migraine, temporal lobe epilepsy, multiple sclerosis, transient ischemic attacksclerosis, transient ischemic attack

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44 - -Endocrinal disordersEndocrinal disordersHypoglycemia( insulinomas), Hypoglycemia( insulinomas), pheochromocytoma, diabetes, pheochromocytoma, diabetes, hyperthyroid, hypo parathyroidhyperthyroid, hypo parathyroid

55 - -Drug intoxicationDrug intoxicationAmphetamines, hallucinogens, theophylline, Amphetamines, hallucinogens, theophylline, nicotine, cannabis, caffeinenicotine, cannabis, caffeine

66 - -Drug withdrawalDrug withdrawalAlcohol, sedatives hypnotics, Alcohol, sedatives hypnotics, antihypertensiveantihypertensive

Psychiatric disordersPsychiatric disordersMalingering, hypochondriasis, specific and Malingering, hypochondriasis, specific and social phobiasocial phobia

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InvestigationsInvestigations

Workup to assess thyroid, parathyroid, Workup to assess thyroid, parathyroid, adrenal, substance intake, chest X- ray, adrenal, substance intake, chest X- ray, ECG, cardiac enzymes, EEG, MRIECG, cardiac enzymes, EEG, MRI

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TreatmentTreatmentDuration of therapy= 8-12 monthsDuration of therapy= 8-12 monthsCombined pharmacotherapy+ PsychotherapyCombined pharmacotherapy+ PsychotherapyI) PharmacotherapyI) PharmacotherapyA- Selective Serotonin Reuptake A- Selective Serotonin Reuptake Inhibitor( SSRI)Inhibitor( SSRI)

Best approved for panic is paroxetineBest approved for panic is paroxetineDose= 5-10 mg and titrate up to 20-60 mg/dayDose= 5-10 mg and titrate up to 20-60 mg/day22ndnd choice is fluvoxamine or sertraline choice is fluvoxamine or sertralineB- Tricyclic Antidepressant (TCA)B- Tricyclic Antidepressant (TCA)Clomipramine( anafranil) or imiprammine Clomipramine( anafranil) or imiprammine ( tofranil) ( 100-150 mg/day)( tofranil) ( 100-150 mg/day)Less widely used d.t side effectsLess widely used d.t side effects

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C- Benzodiazepines (BDZ) Given only 4- 6 weeksC- Benzodiazepines (BDZ) Given only 4- 6 weeks

Advantage: rapid onset of actionAdvantage: rapid onset of action

Mostly used is Alprazolam( Xanax)Mostly used is Alprazolam( Xanax)

D- Non benzodiazepines : Buspirone ( 10 mg /day )D- Non benzodiazepines : Buspirone ( 10 mg /day )

E- Beta blockers: Propranolol 10 mg tablet, up to 30 E- Beta blockers: Propranolol 10 mg tablet, up to 30 mg/daymg/day..

II) PsychotherapyII) Psychotherapy

A- Cognitive therapyA- Cognitive therapy

Aim: Change false beliefs and information about Aim: Change false beliefs and information about panic attackspanic attacks

- -Patient's misinterpretation of bodily sensation as Patient's misinterpretation of bodily sensation as indicating impending deathindicating impending death

- -Explain that when panic attack occurs it is time Explain that when panic attack occurs it is time limited and not life threateninglimited and not life threatening

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B- Behavioral therapyB- Behavioral therapy

- -Applied relaxationApplied relaxation

Aim: Instill in patients a sense of control over Aim: Instill in patients a sense of control over their levels of anxietytheir levels of anxiety

- -Respiratory trainingRespiratory training

Train patient to control urge to Train patient to control urge to hyperventillationhyperventillation

C- Supportive psychotherapy to assure the C- Supportive psychotherapy to assure the patientpatient

D- patient educationD- patient education

E- Environmental and societal manipulationE- Environmental and societal manipulation

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22 - -Specific Phobia and Social PhobiaSpecific Phobia and Social PhobiaDefinitionsDefinitions

PhobiaPhobia

Fear of a specific object, circumstances, or situation Fear of a specific object, circumstances, or situation that is excessive, irrational result in avoidance of that is excessive, irrational result in avoidance of the feared objectthe feared object

Social Phobia (Social Anxiety Disorder)Social Phobia (Social Anxiety Disorder)

Excessive fears of humiliation or embarrassment in Excessive fears of humiliation or embarrassment in various social settings e.g Speaking in publicvarious social settings e.g Speaking in public

Specific PhobiaSpecific Phobia

Marked and persistent fear that is excessive and Marked and persistent fear that is excessive and unreasonable, cued by the presence of specific unreasonable, cued by the presence of specific object or situationobject or situation

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EpidemiologyEpidemiology - -Most common mental disorder = 5-10% up to 25%Most common mental disorder = 5-10% up to 25%

- -Sex: Female > MaleSex: Female > Male

- -Age: Teenagers can occur in childhoodAge: Teenagers can occur in childhood

- -In specific Phobia, most common feared object: In specific Phobia, most common feared object: Animals, storms, Heights, illness, injury, and deathAnimals, storms, Heights, illness, injury, and death

Co morbidityCo morbidity - -Other anxiety disorderOther anxiety disorder

- -Mood disorders esp. depressionMood disorders esp. depression

- -Substance related disorders( i.e way to cope )Substance related disorders( i.e way to cope )

- -Bulimia nervosaBulimia nervosa

- -Avoidant personality disorderAvoidant personality disorder

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Specific Phobia(Clinical picture)Specific Phobia(Clinical picture)A- intense fear of an object or situation .The fear isA- intense fear of an object or situation .The fear is::

- -Out of proportion with the situationOut of proportion with the situation - -Cannot be reasoned or explainedCannot be reasoned or explained

- -Is beyond voluntary controlIs beyond voluntary control - -Leads to avoidanceLeads to avoidance

B- Psychological symptomsB- Psychological symptomsFear, anticipatory anxietyFear, anticipatory anxiety

C- Pysiological, somatic symptomsC- Pysiological, somatic symptomsAutonomic manifestations on exposure to the object, Autonomic manifestations on exposure to the object, palpitation, sweating, trembling, dry mouth, breathing palpitation, sweating, trembling, dry mouth, breathing difficulty, hot flushes, numbness…etcdifficulty, hot flushes, numbness…etc

D- BehavioralD- BehavioralAvoidanceAvoidance

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Other forms of specific phobiaOther forms of specific phobia - -Agoraphobia: fear of open spacesAgoraphobia: fear of open spaces

- -Claustrophobia: fear of closed spacesClaustrophobia: fear of closed spaces

- -Acrophobia : fear of heightsAcrophobia : fear of heights

- -Nosophobia: fear of illnessNosophobia: fear of illness

- -Xantophobia: fear of deathXantophobia: fear of death

- -Zoophobia: fear of animalsZoophobia: fear of animals

- -Fear of blood injection injuryFear of blood injection injury

- -School phobiaSchool phobia

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Clinical picture of social phobiaClinical picture of social phobiaFear of social situations in whichFear of social situations in which::

- -Fear of being the focus of attention or being Fear of being the focus of attention or being negative evaluated in social situationsnegative evaluated in social situations

- -The affected patient is exposed to the gaze The affected patient is exposed to the gaze of others, is being criticized by others , or of others, is being criticized by others , or has to talk in front of othershas to talk in front of others

- -Fear of doing something embarrassingFear of doing something embarrassing

- -Social situations are avoidedSocial situations are avoided

- -Patient develops intense anxiety with Patient develops intense anxiety with autonomic manifestations on exposure to autonomic manifestations on exposure to the phobic situationsthe phobic situations

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AgoraphobiaAgoraphobia

Social phobiaSocial phobia

Specific phobiasSpecific phobias

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Specific phobias :Specific phobias :

animal typeanimal type

Specific ias (animal type)

natural environment typenatural environment type

situational typesituational type

blood , injection , injury typeblood , injection , injury type

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TreatmentTreatmentPsychotherapy and pharmacotherapyPsychotherapy and pharmacotherapyI- Behavioral therapyI- Behavioral therapyTechniquesTechniquesA- Systemic desensitizationA- Systemic desensitizationThe patient is exposed serially to a predetermined The patient is exposed serially to a predetermined list of anxiety provoking stimuli under relaxation, list of anxiety provoking stimuli under relaxation, hypnosis, or tranquilizing drugshypnosis, or tranquilizing drugsB- Flooding ( in vivo or imaginary )B- Flooding ( in vivo or imaginary )C- Relaxation techniques and breathing exercisesC- Relaxation techniques and breathing exercisesD- Rehearsal during sessionsD- Rehearsal during sessionsE- Homework assignmentsE- Homework assignmentsF- social skill training in social phobiaF- social skill training in social phobia

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II-Cognitive therapyII-Cognitive therapyCorrect cognitive distortionCorrect cognitive distortionIII- social and environmental manipulationsIII- social and environmental manipulationsIV- PharmacotherapyIV- PharmacotherapyA-1A-1stst line= SSRI( fluoxetine, citalopram, line= SSRI( fluoxetine, citalopram, sertraline, fluvoxamine, paroxetine)sertraline, fluvoxamine, paroxetine)..

--Other approvedOther approved))TCA,SNRITCA,SNRI ( (

B- Initial BDZ,alprazolam ( Xanax 0.25-0.5mg) B- Initial BDZ,alprazolam ( Xanax 0.25-0.5mg) 1 to 2 tab./day, then taper after 4-6 weeks1 to 2 tab./day, then taper after 4-6 weeksC- Beta blockers esp. if associated with panic C- Beta blockers esp. if associated with panic attacks e.g propranolol( Inderal 10 mg/day): attacks e.g propranolol( Inderal 10 mg/day):

up to 30 mg/dayup to 30 mg/day . .

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33--Obsessive compulsive disorderObsessive compulsive disorderDefinitionDefinitionRecurrent occurrence of obsessions and compulsions severe Recurrent occurrence of obsessions and compulsions severe to cause marked distress to the personto cause marked distress to the personObsessions is a mental eventObsessions is a mental eventCompulsion is a behaviorCompulsion is a behavior

EpidemiologyEpidemiology - -Life time prevalence:2-3Life time prevalence:2-3% %

- -44thth common psychiatric diagnosis common psychiatric diagnosis - -Mean age:25 yearsMean age:25 years

- Sex: equal(M>F in children)- Sex: equal(M>F in children)- More in single person- More in single person

Co morbidityCo morbidity - -2/32/3 has MDD, alcohol usehas MDD, alcohol use

- -Other anxiety disorders: Social phobia, GADOther anxiety disorders: Social phobia, GAD - -TicsTics

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Clinical featuresClinical featuresA- Either obsessions or compulsionsA- Either obsessions or compulsionsObsessionsObsessions

11 - -Recurrent and persistent thoughts, impulses, or images Recurrent and persistent thoughts, impulses, or images that are experienced as intrusive and inappropriate that are experienced as intrusive and inappropriate causing marked anxiety or distresscausing marked anxiety or distress

22 - -they are not simply excessive worriesthey are not simply excessive worries33 - -The person tries to neutralize them with some thought or The person tries to neutralize them with some thought or

actionaction44 - -the person realizes that these thoughts are the product of the person realizes that these thoughts are the product of

his mindhis mindCompulsionsCompulsions

11 - -Repetitive behaviors, or mental acts that person feels Repetitive behaviors, or mental acts that person feels driven to perform themdriven to perform them

22 - -Aimed to relieve anxietyAimed to relieve anxiety

B- Obsessions and compulsions are excessive, B- Obsessions and compulsions are excessive, unreasonable, time consuming, and significantly unreasonable, time consuming, and significantly interferes with the patient routine and functioninterferes with the patient routine and functionSpecify: if with poor insightSpecify: if with poor insight

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Symptom patternsSymptom patterns11 - -ContaminationContamination

CommonestCommonest Followed by washing or avoidance of contaminated objectFollowed by washing or avoidance of contaminated object

22 - -Pathological doubtPathological doubt Followed by compulsion of checkingFollowed by compulsion of checking

33 - -Intrusive thoughtsIntrusive thoughtsUsually sexual or aggressiveUsually sexual or aggressiveMay report themselves to policeMay report themselves to police

44 - -SymmetrySymmetryResult in compulsive of slownessResult in compulsive of slowness

55 - -OthersOthersReligious obsessionsReligious obsessions

Compulsions of hoardingCompulsions of hoardingMSEMSE

Depression, psychosocial factors, insightDepression, psychosocial factors, insight

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OCDOCD ( counting )

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Obsessive - Compulsive Disorder (OCD)Obsessive - Compulsive Disorder (OCD)

Recurrent obsessions or compulsions that cause marked distress

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OCDOCD ( symmetry )( symmetry )

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Treatment ( Algorithm )Treatment ( Algorithm )

11 - -Hospitalize ifHospitalize if;;

Remove external stressors, ECT, depressed, and Remove external stressors, ECT, depressed, and suicidal risksuicidal risk

22 - -Pharmacotherapy + Behavioral therapyPharmacotherapy + Behavioral therapy

a- SSRI or TCA + behavioral therapy ( 12 weeks )a- SSRI or TCA + behavioral therapy ( 12 weeks )

b- Another SSRI or TCA +Behavioral therapy (12 b- Another SSRI or TCA +Behavioral therapy (12 weeks)weeks)

c- Combine 2 SSRI or (SSRI + TCA) + Behavioral c- Combine 2 SSRI or (SSRI + TCA) + Behavioral therapy ( 12 weeks )therapy ( 12 weeks )

d- Augment ( Valproate , Lithium , or d- Augment ( Valproate , Lithium , or Carbamazepine)Carbamazepine)

e- ECTe- ECT

f- Surgery ( Cingulotomy )f- Surgery ( Cingulotomy )

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33 - -PsychotherapyPsychotherapy

A- Behavioral therapyA- Behavioral therapy

- -Exposure and response preventionExposure and response prevention

- -DesensitizationDesensitization

- -Thought stoppageThought stoppage

- -Implosion therapyImplosion therapy

- -Aversion conditioningAversion conditioning

B- Family therapyB- Family therapy

C- Supportive therapyC- Supportive therapy

D- Group therapyD- Group therapy

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44 - -Posttraumatic stress disorder ( PTSD ) Posttraumatic stress disorder ( PTSD ) and acute stress reactionand acute stress reactionDefinitionDefinitionSyndrome occurs to person when sees , involved Syndrome occurs to person when sees , involved in, or hears of an extreme traumatic stressin, or hears of an extreme traumatic stressEpidemiologyEpidemiology

- -PrevalencePrevalence 30%30% in traumatic eventin traumatic event2525 % % sub clinical formsub clinical form

- -Women > MenWomen > Men - -Age: young adultsAge: young adults

- -High risk : Severe trauma, long duration, high High risk : Severe trauma, long duration, high proximity of person to the actual trauma, stressful proximity of person to the actual trauma, stressful life changes, 1life changes, 1stst degree relatives have depression, degree relatives have depression, inadequate family supportinadequate family support

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Clinical features (Clinical features (1 Month1 Month)) A- A person has been exposed to a traumatic event A- A person has been exposed to a traumatic event in which both of the following were presentin which both of the following were present

11 - -Experience, witnessed or confronted with an Experience, witnessed or confronted with an event involved actual death or serious injury e.g event involved actual death or serious injury e.g torture, wars, rape, and brain washingtorture, wars, rape, and brain washing

22 - -Person's has intense fear, helplessness, or horrorPerson's has intense fear, helplessness, or horror

B- Re-experience of the traumatic eventB- Re-experience of the traumatic event11 - -Distressing images, thoughts or perceptionsDistressing images, thoughts or perceptions

22 - -Distressing dreamsDistressing dreams33 - -FlashbacksFlashbacks

44 - -Psychological distress on exposure to internal or Psychological distress on exposure to internal or external cuesexternal cues

55 - -Physiological distress on exposure to internal or Physiological distress on exposure to internal or external cuesexternal cues

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Clinical features ( cont. )Clinical features ( cont. )C- Avoidance of stimuli associated with the traumaC- Avoidance of stimuli associated with the trauma

11 - -Avoidance of thoughts, feelings or conversation Avoidance of thoughts, feelings or conversation associated with the traumaassociated with the trauma

22 - -Avoidance of activities, places, or people that arouse Avoidance of activities, places, or people that arouse recollection of the traumarecollection of the trauma

33 - -inability to recall important aspect of the traumainability to recall important aspect of the trauma44--diminished interest in activitiesdiminished interest in activities

55 - -Feeling of detachment from othersFeeling of detachment from others66 - -unable to have lovely feelingsunable to have lovely feelings77 - -Sense of foreshortened futureSense of foreshortened future

D- Hyper arousalD- Hyper arousal11 - -Difficulty in falling asleepDifficulty in falling asleep

22 - -Irritability or outbursts of angerIrritability or outbursts of anger33 - -Difficult concentrationDifficult concentration

44 - -Hyper vigilanceHyper vigilance55 - -Exaggerated startle responseExaggerated startle response

Acute stress reaction = Less than one monthAcute stress reaction = Less than one month

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A syndrome that develops after a person sees , is involved in , or hears of an

extreme traumatic stressor

Posttraumatic stress disorder (PTSD)Posttraumatic stress disorder (PTSD)

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A syndrome that develops after a person sees , is involved in , or hears of an

extreme traumatic stressor

Posttraumatic stress disorder (PTSD)Posttraumatic stress disorder (PTSD)

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TreatmentTreatmentI- ProphylaxisI- ProphylaxisAim: Develop more mature coping Aim: Develop more mature coping mechanisms and acceptance of the eventmechanisms and acceptance of the eventThrough psychotherapyThrough psychotherapy

- -Crisis interventionCrisis intervention - -Education and supportEducation and support

II- Hospitalize ifII- Hospitalize ifSymptoms are severe, suicide, or violenceSymptoms are severe, suicide, or violenceIII- Psychotherapy ( individual or group )III- Psychotherapy ( individual or group )A- Exposure therapyA- Exposure therapyB- Stress management ( Relaxation B- Stress management ( Relaxation techniques, cognitive approaches )techniques, cognitive approaches )

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C- Support through relatives and friendsC- Support through relatives and friendsD- AbreactionD- Abreaction

Experiencing the emotions associated with Experiencing the emotions associated with eventeventIV- Pharmacotherapy (duration = 1 year)IV- Pharmacotherapy (duration = 1 year)A- Induction of sleep by sedative hypnotics A- Induction of sleep by sedative hypnotics but no more than 1 monthbut no more than 1 monthB- SSRIB- SSRISertraline, paroxetineSertraline, paroxetineOr TCA as imipramine or amitriptylineOr TCA as imipramine or amitriptylineDose = antidepressant doseDose = antidepressant doseEach trial = 8 weeksEach trial = 8 weeksC- Others as alpha agonist and beta blockersC- Others as alpha agonist and beta blockers

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55 - -Generalized anxiety disorderGeneralized anxiety disorderDefinitionDefinitionChronic condition characterized by subjective Chronic condition characterized by subjective experience of apprehension without experience of apprehension without objective reasons, excessive anxiety and objective reasons, excessive anxiety and worry about several events or activities worry about several events or activities can't be controlled for most of the daycan't be controlled for most of the day

EpidemiologyEpidemiologyCommon = 3-8Common = 3-8% %

Female : Male = 2:1Female : Male = 2:1

25%25% of GAD in anxiety clinicsof GAD in anxiety clinics

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Clinical picture ( 6 months duration)Clinical picture ( 6 months duration) - -Somatic symptoms( cardiopulmonary symptoms, Somatic symptoms( cardiopulmonary symptoms,

easy fatigability, restlessness, shakiness, GIT easy fatigability, restlessness, shakiness, GIT symptoms, tension headache, muscle pain, symptoms, tension headache, muscle pain, parathesia and hyperreflexia)parathesia and hyperreflexia)

- -Psychological,anxiety difficult to control ( worry, Psychological,anxiety difficult to control ( worry, apprehension, fear, sense of insecurity, irritable, apprehension, fear, sense of insecurity, irritable, restless, hypersenstivity, easy loss of temper,and restless, hypersenstivity, easy loss of temper,and breaking down in tears)breaking down in tears)

- -Autonomic hyperactivity ( pallor or flushing, Autonomic hyperactivity ( pallor or flushing, blurred vision, dry mouth, sweating, palpitation)blurred vision, dry mouth, sweating, palpitation)

- -Cognitive symptoms ( irritable, difficult Cognitive symptoms ( irritable, difficult concentration, difficult recall )concentration, difficult recall )

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TreatmentTreatmentCombined pharmacotherapy and PsychotherapyCombined pharmacotherapy and PsychotherapyA- PsychotherapyA- Psychotherapy

- -Cognitive behavioral therapyCognitive behavioral therapy - -Environmental and social manipulationEnvironmental and social manipulation

- -Biofeedback trainingBiofeedback training - -Encourage patient to engage in pleasurable activitiesEncourage patient to engage in pleasurable activities

B- PharmacotherapyB- PharmacotherapyDuration = 6-12 monthsDuration = 6-12 months

11 - -BenzodiazepinesBenzodiazepines Not more than 1 monthNot more than 1 month

22 - -BuspironeBuspironeNon BDZ anxiolyticNon BDZ anxiolytic

33 - -SSRI( Fluvoxamine, Sertraline, Escitalopram, Paroxetine, SSRI( Fluvoxamine, Sertraline, Escitalopram, Paroxetine, Fluoxetine)Fluoxetine)

44 - -SNRI (Venlafaxine ) for cognitive impairment and insomniaSNRI (Venlafaxine ) for cognitive impairment and insomnia

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Generalized Anxiety Disorder Generalized Anxiety Disorder (GAD)(GAD)

BuspironBenzodiazepinsSSRIsTCAsMAOIsAntihistaminicsBete-blockersAntipsychotics

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Anxiety disorder Anxiety disorder due to adue to aGGeneral eneral MMedical edical CConditionondition

Anxiety symptoms Anxiety symptoms will be due to the will be due to the direct physiological direct physiological effect of a medical effect of a medical conditioncondition

Substance-induced Substance-induced anxiety disorderanxiety disorder

Anxiety symptomsAnxiety symptoms are the direct resultare the direct result of a substanceof a substance

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